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LETTER TO EDITOR
Year : 2020  |  Volume : 1  |  Issue : 1  |  Page : 16-17

“Sign of Horns” following sickle injury: An uncommon rural spot diagnosis


Department of Orthopaedics, Government Medical College, Haldwani, Uttarakhand, India

Date of Submission16-Dec-2020
Date of Acceptance17-Dec-2020
Date of Web Publication31-Dec-2020

Correspondence Address:
Ganesh Singh Dharmshaktu
C/O Dr Y.P.S. Pangtey, Ganga Vihar, Malli Bamori, Haldwani - 263 139, Uttarakhand
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jssrp.jssrp_4_20

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How to cite this article:
Dharmshaktu GS. “Sign of Horns” following sickle injury: An uncommon rural spot diagnosis. J Surg Spec Rural Pract 2020;1:16-7

How to cite this URL:
Dharmshaktu GS. “Sign of Horns” following sickle injury: An uncommon rural spot diagnosis. J Surg Spec Rural Pract [serial online] 2020 [cited 2021 Apr 18];1:16-7. Available from: http://www.jssrp.com/text.asp?2020/1/1/16/305920



Dear Editor,

A 28-year-old male patient came to us with history of accidental injury to his right hand from a sickle while cutting grass and crop shoots in rural farmland. He was taken to local practitioner for first aid and tetanus injection before referral. On examination, third and fourth fingers were dropped and flexed as he could extend all fingers except these two [Figure 1]a. There was crescent shaped wound over dorsum of hand and white cut structures, suggestive of tendon ends, were visible from the wound [Figure 1]b. There was no clinico-radiological evidence of underlying bony injury. The characteristic hand posture was similar to 'sign of horns' as described in medical literature. The primary tendon end to end repair was successfully done under wrist block following which deformity was corrected with all fingers appearing and functioning as normal [Figure 1]c. A short period of plaster splint was given till tendon healing and the later physiotherapy ensured pre-injury return of function with no immediate or remote complication noted.
Figure 1: The clinical image of the injured hand with flexed middle and ring finger and extended index and little finger forming a “sign of horns” (a) The lacerated wound by a sickle (b) showing whitish tendon ends peeping through the wound (denoted by arrows). The extended wound after repair and normal finger attitude regained following tendon repair (c)

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“Sign of horns” deformity has been atributed to injury to extensor digitorum communis (EDC) tendon as traumatic or post surgical complication.[1] It consists of flexion of middle and ring finger while simultaneous extension of index and little finger suggesting normal extensor indicis propius and extensor digiti quinti. This peculiar clinical sign was first described by Furnas and Spencer.[2] The sign may also be recalled as “Rock on” hand sign or Devil's hand sign. The extensor tendon injuries (ETIs) are complex ijuries and require optimal reconstruction to preserve hand function and mobility. Careful history and clinical assessment to accurately isolate extensor tendon injury and its location or zone is important for the management.[3]

The injury in our patient belonged to zone 6 of the extensor tendon injury classification as per Kleinert and Verdan classification and injury at this level fortunately has less chance of adhesion and tendon imbalance.[4] Out of two groups of extrinsic extensor tendons, superficial and deep, the EDC is part of superficial extrinsic group.[5] Being superficial may risk the injuries from sharp objects leading to laceration injuries to these tendons. Early repair of tendon injuries may obviate the need for extensive surgeries with tendon graft or transfer in chronic or neglected cases. Fortunately our case had no bony injury to complicate the treatment. Results of extensor tendon injuries have been better than those of flexor tendon injuries when tendon length is restored optimaly.[6] This case snippet highlights importance of anticipation and early recognition of these injuries in rural settings. It also underlines importance of basic knowledge of simple finger and wrist block techniques for injury management and suturing of wounds in rural settings. These techniques are easy to learn and require no advanced paraphernalia. Apart from it, training regarding basic tendon suturing techniques given to primary care practitioners shall be important for many simple cases for the benefit of rural population and will also reduce burden of neglected or mismanaged cases.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Rushnaiwala F, Hussain N, Kulkarni A. The “Sign of horns” deformity following Thompson's approach to the proximal radius: A rare case report and literature review. J Orthop Trauma Reha 2019;26:29-33.  Back to cited text no. 1
    
2.
Furnas DW, Spinner M. The “Sign of horns” in the diagnosis of injury or disease of the extensor digitorum communis of the hand. Br J Plast Surg 1978;31:263-5.  Back to cited text no. 2
    
3.
Colzani G, Tos P, Battiston B, Merolla G, Porcellini G, Artiaco S. Traumatic extensor tendon injuries to the hand: Clinical anatomy, biomechanics, and surgical procedure review. J Hand Microsurg 2016;8:2-12.  Back to cited text no. 3
    
4.
Kleinert HE, Verdan C. Report of the Committee on Tendon injuries (International Federation of Societies for Surgery of the Hand. J Hand Surg Am 1983;8:794-8.  Back to cited text no. 4
    
5.
Amirtharajah M, Lattanza L. Open extrinsic tendon injuries. J Hand Surg Am 2015;40:391-7.  Back to cited text no. 5
    
6.
Mehdinasa SA, Pipelzadeh MR, Sarrafan N. Results of primary extensor tendon repair of the hand with respect to the zone of injury. Arch Trauma Res 2012;1:131-4.  Back to cited text no. 6
    


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