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On examination, she had no swelling, no erythema and no tenderness. She was unable to flex her DIPJ of the right little finger; otherwise, her movement was normal. X-ray showed no fracture. An ultrasound scan was suggestive of a complete rupture of the FDP tendon within the flexor sheath.
The FDP tendon was explored under WALANT, and no tendon rupture was found within the sheath. The distal end was found in mid-palm level, and the proximal end was found in the wrist. There was evidence of attrition rupture of the FDP tendon on the very prominent hook of the hamate bone in addition to a tight carpal tunnel (Fig. 1).
A decision was taken for primary reconstruction by palmaris longus graft and release of the carpal tunnel. A Pulvertaft weave with 3-0 prolene was used at both ends. The repair was strong and was tested on table. The patient then was referred to hand therapy as per protocol.
She returned 8 months later to our hand clinic with a problematic restriction of full extension, which particularly affected her ability to perform yoga. When extending the finger, she was unable to fully straighten it, and after sustained exertions, the MCP extended and the PIP flexed to compensate. A tight repair was suspected, and she was scheduled for tendon lengthening.
After reexploration under local anesthesia, a longitudinal incision was done over the volar aspect of the forearm aiming at tendon lengthening by tenotomy at the musclo-tendinous junction. Three tendinous cuts were made, and the tendon looked very lax, but still the patient failed to extend her DIPJ. After consideration, the A1 pulley was released. Tendinitis was found without an apparent cause of the obstruction. The tendon graft seemed to be fully healed and functioning. Brunner incisions were used to connect the forearm to the A1 pulley incision. A bulk of scar tissue was found diverting the pathway of the tendon and acting as a pulley effect. It was changing the direction of the pull and causing this flexion deformity. Once released, the patient was able to full extend the DIPJ on table (Fig. 2; Supplementary Videos 1 and 2).
Three cases had underlying fracture of the hamate bone, two cases had degenerative diseases and one did not have any underlying cause and could be considered as a spontaneous rupture with an exact similar mechanism of injury to our case.
Jeong et al. (2012)  reported rupture to the flexors of the left ring and little fingers secondary to fracture of the hook of hamate, which was reconstructed in a two-stage operation by silicone tendon rods and then two palmaris longus grafts.
Hosokawa et al.  reported a similar case in 2016 of FDP of little finger rupture after insufficiency fracture in a systemic lupus erythematosus (SLE) patient. A tendon transfer was performed with excision of the hamate bone.
In the same year, Lee and Yeo  reported a case of FDP rupture of FDP to the little finger in addition to attrition to flexors of the ring finger in a patient with acromegaly. The rough bony edge of the hook of hamate was smoothened, and a flap of the transverse carpal ligament was used to cover the bony surface in addition to the PL graft.
One patient had chronic non-union hook of the hamate fracture. The second had piso-triquetral osteoarthritis. However, the third patient did not have any underlying etiology for the attrition rupture.
The author identified this patient by the letter (B). He was a 61-year-old bricklayer with no related past medical history. He reported opening a wide doorknob with the small finger while holding a wine glass stem using the remaining digits. Suddenly he felt an episode of severe pain and loss of small finger flexion.
Intra-operatively, the tendon was ruptured within the carpal tunnel. On palpation, there was a rough surface to ulnar border of the carpal tunnel over the hook of hamate with no evidence of fracture. Interpostion graft using palmaris longus tendon was used for reconstruction.
In our case, there was no history of underlying degenerative disease or evidence of hamate fracture. So, the rupture is considered to be spontaneous. We noticed an exact similar pattern to the mode of injury that was reported by Grant in his case series which was forcefully opening a doorknob.
Among the six reported cases, there were four males and two females. Three cases had underlying degenerative conditions. The mechanism of injury was almost the same in all cases; forceful wrist twisting against resistance. Two cases had a typical mode of injury; forceful opening of doorknob. Three of the six cases had an underlying fracture of the hamate bone.
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Description: In this talk, we bring new evidence from learning to bear the question of whether personal and locative indexicals have a common semantic basis. We present three artificial language learning experiments where we test whether learners assume that new partitions of person and spatial indexicals share the same set of features. We find that learners tend to generalize a non-native person partition from a pronominal system to a new locative system, but do not extrapolate to the same extent in the opposite direction. Moreover, learners are sensitive to the naturalness of these systems, showing a general dispreference for non-natural person and locative systems. 041b061a72