Estimation of Injury Limits at Vulnerable Impact Locations Along the Forearm Via THUMS AM50 Finite Element Model at Airbag Loading Rates

Side and frontal airbag deployment represents the main injury mechanism to the upper extremity during automotive collisions. Previous dynamic injury limit research has been limited to testing the forearm at either the assumed most vulnerable location to fracture, the distal 1/3rd, or the midpoint. Studies have varied the surface to which impacts were applied, with no clear consensus on the site of greatest vulnerability. The unpredictability of airbag impact location, especially with altered hand positioning, limits the effectiveness of existing forearm injury limits determined from impacts at only one location. The current study quantified the effect of impacts at alternative locations on injury risk along the forearm using the THUMS FE model. Airbag-level impacts were simulated along the forearm on all four anatomical surfaces. Results showed the distal 1/3rd is not the most vulnerable location (for any side), indicating forearm fracture is not solely driven by area moment of inertia (as previously assumed). The posterior forearm was the weakest, suggesting that current test standards underestimate the fracture risk of the forearm. Linear regression models showed strong correlation between forearm fracture risk and bone geometry (cross-sectional area and area moment of inertia) as well as soft-tissue depth, potentially providing the ability to predict forearm injury tolerances for any location or forearm size. This study demonstrated the forearm's vulnerability to fracture from airbag deployments, indicating the need for safety systems to better address injury mechanisms for the upper limb to effectively protect drivers.

Anterior radial head subluxation in primary elbow osteoarthritis

PURPOSE

To investigate elbows with primary osteoarthritis (OA) for the presence of anterior radial head subluxation.

METHODS

A total of 71 patients with elbow osteoarthritis and 45 with lateral epicondylitis were initially identified. The baseline characteristics and preoperative elbow X-rays of consecutive patients that had been clinically confirmed with elbow OA or lateral epicondylitis between March 2011 and January 2020 were then retrospectively reviewed. The radiocapitellar ratio (RCR; the ratio of the displacement of the radial head about the diameter of the capitulum) was calculated using lateral views. These RCR values were compared between the OA and lateral epicondylitis cases.

RESULT

A significant increase was detected in RCR values between patients in elbow OA and the control group (13.2% (± 10.6) vs -1.2% (± 6.8), P<0.001). Based on receiver operating characteristic curves, RCR values had an excellent area under the curve (0.89) for the detection of elbow OA (Youden index, 0.69; sensitivity, 89%; specificity, 80%). Based on the ROC curve, the cutoff value of RCR was 0.04. Patients with RCR ≥ 0.04 had a significantly higher proportion of cases with elbow OA (risk ratio, 31.50 [95% CI, 11.17-88.82]) than those with RCR ˂ 0.04 (P ˂ 0.001).

CONCLUSION

Radial head subluxation is a radiographic finding associated with elbow OA and RCR ≥ 0.04 could be used as an aetiological factor for elbow OA diagnosis.

Intramedullary Nailing of Forearm Fractures

The primary goal in operative fixation of forearm fractures is to restore length, rotational stability, and maintenance of the radial bow. Plate osteosynthesis is well regarded as the gold standard of treatment though often necessitates soft tissue injury, periosteal stripping, and risk of refracture after hardware removal. While intramedullary nails have been utilized for forearm fixation since the early 1900s, technological advancements including locked intramedullary nails have lead to improved outcomes in intramedullary nail forearm fixation. In select patients, intramedullary nail fixation is an appropriate treatment option. For example, patients with mangled extremities, comminuted or segmental fractures, or soft tissue injury may benefit from this approach as it allows for smaller incisions and limits further soft tissue compromise.

Surgical site infection following fasciotomy in patients with acute forearm compartment syndrome: a retrospective analysis of risk factors

PURPOSE

Fasciotomy, a standard therapy for acute forearm compartment syndrome (AFCS), can prevent serious complications, but there may be significant postoperative consequences. Surgical site infection (SSI) may cause fever, discomfort, and potentially fatal sepsis. This study aimed to identify risk factors for SSI in AFCS patients who had undergone fasciotomy.

MATERIALS AND METHODS

Patients with AFCS who had fasciotomies between November 2013 and January 2021 were recruited. We collected demographic information, comorbidities, and admission laboratory results. Analyses of continuous data were conducted using the t-test, the Mann-Whitney U test, and logistic regression analysis, while analyses of categorical data were conducted using the Chi-square and Fisher's exact tests.

RESULTS

Sixteen AFCS patients (13.9%) suffered infections that need further therapy. Using the logistic regression analysis, we identified that patients with a history of diabetes (p = 0.028, OR = 16.353, 95% CI (1.357, 197.001)), open fractures (p = 0.026, OR = 5.239, 95% CI (1.223, 22.438)), and a higher level of TC (p = 0.004, OR = 4.871, 95% CI (1.654-14.350)) were the best predictors of SSI, while ALB levels (p = 0.004, OR = 0.776, 95% CI (0.653-0.924)) were protective for SSI in AFCS patients.

CONCLUSIONS

Our results showed that open fractures, diabetes, and TC levels were relevent risk factors for SSI following fasciotomy in patients with AFCS, allowing us to personalize the risk assessment and apply early targeted interventions.

Community Water Fluoridation and Rate of Pediatric Fractures

BACKGROUND

The effect of community water fluoridation on bone fragility and fracture has been inconclusive in the literature. The null hypothesis of this study was that no association was observed between water fluoride level and risk of fracture in children.

METHODS

Community fluoridation data were obtained from the Centers for Disease Control and Prevention while data on fracture rates were obtained from the PearlDiver database. The rate of fracture type for each state was then compared with state-level fluoridation data using Pearson correlation coefficients and Wilcoxon rank-sum tests.

RESULTS

Positive correlations were found between the percentage of state water fluoridation and fracture rates for both bone forearm fracture (BBFFx) and femur fracture. Fluoride levels had positive correlations with fracture rates for all fracture types. Increased fracture rates were found between states in the highest quartiles of percentage of state water fluoridation and fluoride water levels for supracondylar humerus fracture and BBFFx.

CONCLUSIONS

A higher level of water fluoridation was associated with higher rates of supracondylar humerus fracture and BBFFx in children aged 4 to 10 years. These findings do not imply causality, but they suggest that additional investigation into the effect of fluoride on pediatric bone health may be indicated.

Comparison of the clinical and radiographic outcomes of plate fixation versus new-generation locked intramedullary nail in the management of adult forearm diaphyseal fractures

OBJECTIVE

This study aimed to compare functional and radiographical outcomes following intramedullary nailing (IMN) versus plate and screw osteosynthesis in managing patients with diaphyseal forearm fractures.

METHODS

Forty-six patients (27 male, 19 female) were included in this retrospective study. Of these, 25 were treated with plate osteosynthesis and 21 with IMN. The mean age was 32.4 (range, 19-67) years in the plate group and 28.8 (range, 18-64) years in the IMN group. The mean follow-up was 22.3 (range, 12-36) months in the IMN group and 24.8 (range, 12-48) months in the plate group. Functional outcomes were evaluated based on the forearm pronation/supination range of motion, grip strength, Disabilities of the Arm, Shoulder, and Hand (DASH) score, and Grace-Eversmann scoring criteria.

RESULTS

The median time to union was 13.6 weeks in the plate group and 10.9 weeks in the IMN group (p<0.05). Union was achieved in 24 of 25 patients in the plate group (96%) and all patients in the IMN group (100%). The mean operative time was 69.7 (range, 45-110) minutes in the IMN group and 88.2 (range, 50-130) minutes in the plate group. The mean fluoroscopy time was 2.7 seconds in the plate group and 21.3 seconds in the IMN group. The mean length of hospital stay was five (range, 3-9) days in the plate group and four (range, 3-10) days in the IMN group. The mean operative time was significantly shorter in the IMN group (p < 0.05), while the mean fluoroscopy time was longer in the IMN group (p < 0.05). There was no significant difference between the groups in forearm pronation and supination, grip strength, DASH score, and Grace-Eversmann scoring criteria.

CONCLUSION

Locked IMNs seem a viable alternative to ORIF with plate osteosynthesis for adult diaphyseal forearm fractures with similar healing rates, functional scores, and shorter operative times.

LEVEL OF EVIDENCE

Level III, Therapeutic Study.

Does a Good Cast Index Always Reflect a Good Cast?

OBJECTIVES

The cast index is the most commonly used measurement of cast quality in pediatric forearm fractures, with low values representing a good quality cast and higher values suggesting poor technique. However, in some instances the cast index may not accurately reflect cast quality. The purpose of this study was to critically evaluate the quality of casts deemed "good" or "bad" based on the cast index against other measurements in order to identify these examples.

METHODS

Pediatric patients casted for a distal or midshaft forearm fracture were identified from a prospectively gathered database. There were 121 casts on 97 forearms. Measurements were made on forearm or wrist x-rays to calculate the cast index, gap index, and the anatomic dimensions of the forearm at the level of the fracture. Fisher's exact test was used to assess the likelihood of a good cast index (< 0.75) to also have an acceptable gap index (< 0.15). Pearson's correlation compared the anatomic measurements of the forearm and the cast index.

RESULTS

There were 65 casts with a good cast index, and 58% also had an acceptable gap index (< 0.15). Among the 56 casts with a bad cast index, 20% had an acceptable gap index (p < 0.001). The anatomic measurements of the forearm and the cast index were strongly correlated (r = 0.96).

CONCLUSION

Many casts with a good cast index have an unacceptable gap index. Forearm measurements and cast index are highly correlated, suggesting that a well-molded cast may have a higher cast index due to the shape of the forearm. While the cast index is a useful tool, "good" or "bad" casts are not uniformly captured by this measurement.

Flexor Pollicis Longus Tendon Rupture and Carpal Tunnel Syndrome due to Scaphoid Nonunion Advanced Collapse: A Case Report

CASE

We report a case of flexor pollicis longus (FPL) tendon rupture and carpal tunnel syndrome due to scaphoid nonunion advanced collapse deformity. Intraoperative findings showed disruption of the palmar joint capsule and a sharp proximal bone fragment protruding into the carpal tunnel. Removal of this proximal fragment and tendon grafting were performed. At the postoperative 2-year follow-up, the patient had no wrist pain, finger numbness, or restriction of thumb motion.

CONCLUSION

Our results suggest that minimally invasive surgical procedures, such as proximal pole or osteophyte resection, might be optimal choices for early rehabilitation after tendon repair in cases of FPL tendon rupture due to asymptomatic scaphoid nonunion.

Assessment of Ethno-racial and Insurance-based Disparities in Pediatric Forearm and Tibial Fracture Care in the United States

INTRODUCTION

Despite growing attention to healthcare disparities and interventions to improve inequalities, additional identification of disparities is needed, particularly in the pediatric population. We used state and nationwide databases to identify factors associated with the surgical treatment of pediatric forearm and tibial fractures.

METHODS

The Healthcare Cost and Utilization Project State Inpatient, Emergency Department, and Ambulatory Surgery and Services Databases from four US states and the Nationwide Emergency Department Sample database were quarried using International Classification of Diseases codes to identify patients from 2006 to 2015. Multivariable regression models were used to determine factors associated with surgical treatment.

RESULTS

State databases identified 130,006 forearm (1575 open) and 51,979 tibial fractures (1339 open). Surgical treatment was done in 2.6% of closed and 37.5% of open forearm fractures and 7.9% of closed and 60.5% of open tibial fractures. A national estimated total of 3,312,807 closed and 46,569 open forearm fractures were included, 59,024 (1.8%) of which were treated surgically. A total of 719,374 closed and 26,144 open tibial fractures were identified; 52,506 (7.0%) were treated surgically. Multivariable regression revealed that race and/or insurance status were independent predictors for the lower likelihood of surgery in 3 of 4 groups: Black patients were 43% and 35% less likely to have surgery after closed and open forearm fractures, respectively, and patients with Medicaid were less often treated surgically for open tibial fractures in state (17%) and nationwide (20%) databases.

CONCLUSIONS

Disparities in pediatric forearm and tibial fracture care persist, especially for Black patients and those with Medicaid; identification of influencing factors and interventions to address them are important in improving equality and value of care.

Trends and epidemiology of radial head subluxation in the United States from 2004 to 2018

BACKGROUND

Increased body mass may predispose children to a greater risk for radial head subluxation (RHS). Recent studies in the literature have reported a plateau in obesity prevalence among infants and toddlers. This study sought to examine recent epidemiological trends in RHS incidence from 2004 to 2018 using the National Electronic Injury Surveillance System database to determine how obesity patterns may affect RHS incidence.

METHODS

The National Electronic Injury Surveillance System (NEISS) database was queried for patients 6 years of age or younger presenting with radial head subluxation between January 1, 2004 and December 31, 2018. Patient demographics, mechanisms of injury, and location of injury were recorded.

RESULTS

An estimated total 253,578 children 6 years or younger were treated for RHS with 14,204 (95% CI = 8124-20,284) in 2004 to 21,408 (95% CI = 12,882-29,934) in 2018. The overall annual rate of RHS per 10,000 children ≤ 6 years was 6.03 (95% CI = 4.85-7.58). The annual rate of RHS per 10,000 children ≤ 6 years increased (m = 0.200, ß = 0.802, p < 0.001) from 5.18 (95% CI 2.96-7.39) in 2004 to 7.69 (95% CI = 4.63-10.75) in 2018. The most common mechanism associated with RHS was falls (39.4%) with 103,466 (95% CI 74,806-132,125) cases. Pulls accounted for the second most common mechanism of injury, accounting for 90,146 (95% CI 68,274-112,018) cases or 36.2%. Yearly RHS incidence was compared to obesity prevalence for ages 2-5 children provided by the National Health and Nutritional Examination Survey (NHANES) surveys. Changes in obesity prevalence may visually reflect RHS incidence trends, but no causality between obesity prevalence and RHS incidence could be confirmed.

CONCLUSION

This study corroborated previous findings that falls and arm pulling contribute to the vast majority of RHS cases. The nonsignificant rise in RHS cases may reflect a possible plateau in obesity prevalence of children aged 2-5 years in recent years.

LEVEL OF EVIDENCE

III.

Sedoanalgesia Versus Infraclavicular Block for Closed Reduction of Pediatric Forearm Fracture in Emergency Department: Prospective Randomized Study

OBJECTIVE

Procedural sedoanalgesia is commonly used in pediatric patients in the emergency department (ED) for interventional procedures, diagnosis, and treatment. However, this method causes serious systemic complications, such as respiratory and cardiac depression. To minimize these complications, ultrasound-guided regional anesthesia methods have been used in recent years. We aimed to compare the use of procedural sedoanalgesia (PSA) and infraclavicular block (ICB) in the pain management of pediatric patients who underwent closed reductions of forearm fractures.

MATERIALS AND METHODS

This prospective, randomized, clinical study included patients aged 3 to 15 years who presented to the ED with forearm fractures. The patients were divided into 2 groups: the procedural sedoanalgesia group (group PSA, n = 30) and ultrasound-guided ICB group (group ICB, n = 30). Pain scores of the patients were evaluated using the Wong-Baker FACES Scale before and during the procedure. Pain scores and parental and operator satisfaction were compared between the groups.

RESULTS

There was no statistical significance in terms of demographic data. The pain scores observed during the procedures were significantly higher in the group PSA than in the group ICB (3.07 ± 1.55 vs 0.47 ± 0.86, respectively; P < 0.001). The parental and operator satisfaction of the ICB group was significantly higher than that of the PSA group (P < 0.001).

CONCLUSIONS

Ultrasound-guided ICB is a safe and effective method in the management of pain during closed reduction of forearm fracture in pediatric patients in EDs. It can be used safely in emergency rooms and has a high level of both parental and operator satisfaction.

Neonatal Forearm Compartment Syndrome Secondary to Intrauterine Brachiocephalic Arterial Thrombosis: A Case Report

CASE

A newborn presented with necrotic skin lesions and contractures of the right upper extremity. Ultrasonography indicated the presence of a brachiocephalic artery thrombosis, and clinical examination demonstrated a neonatal forearm compartment syndrome. Surgical treatment included decompressive fasciotomy of the right forearm. The right-sided brachiocephalic thrombosis resulted in left hemiplegic cerebral palsy. At the 3-year follow-up, the patient had near-normal function of the right upper extremity. This case has detailed preoperative video and follow-up to illustrate this rare but modifiable condition.

CONCLUSION

This case demonstrates a unique cause of neonatal forearm compartment syndrome (brachiocephalic arterial thrombosis) and the results of prompt surgical treatment.

The "floating ulna" injury in adults: a case report, literature review and proposed injury classification

BACKGROUND

Ipsilateral Galeazzi fracture with elbow dislocation, namely the "floating ulna" injury, is a rare injury pattern. A few reports have described this type of injury and its treatment.

CASE PRESENTATION

A 33-year-old female at 38+ weeks gestational age presented with Galeazzi fracture and posterolateral elbow dislocation of the left upper extremity. The patient was treated with closed reduction of the elbow, open reduction, and internal fixation of the radial shaft fracture with a dynamic compression plate and K-wire stabilization of the unstable distal radioulnar joint. At the 12-month follow-up, the patient had no pain or signs of instability. Range of motion was 0-135° at the elbow, 70° extension and 80° flexion at the wrist, and 80° supination and 80° pronation at the forearm.

CONCLUSION

The "floating ulna" injury is a rare and special injury pattern with ipsilateral Galeazzi fracture and elbow dislocation. This type of injury was likely caused by significant amount of deforming force and the unique position of upper limb when the patient fell from a height of 1-2 m in high-energy trauma.

Quantitative Computed Tomography (QCT) of the Distal Forearm in Men Using a Spiral Whole-Body CT Scanner - Description of a Method and Reliability Assessment of the QCT Pro Software

The Mr F study investigates the pathogenesis of low trauma distal forearm fractures in men and includes volumetric bone mineral density (vBMD) measurements at the ultradistal forearm as there are no current data. A standard 64 slice CT scanner was used to determine if it was possible to adapt the existing Mindways quantitative computed tomography Pro software for measuring vBMD values at the hip and spine sites. For calculation of intra- and interobserver reliability 40 forearm scans out of the 300 available were chosen randomly. The images were analyzed using the Slice Pick module and Bone Investigational Toolkit. The 4% length of the radius was chosen by measuring the length of the radius from the scaphoid fossa distally to the radial head. The acquired image then underwent extraction, isolation, rotation, and selection of region of interest in order to generate a report on vBMD. A cross-sectional image was created to allow the generation of data on the cortical and trabecular components separately. Repeat analyses were undertaken by 3 independent observers who were blinded as to whether the image was from a participant with or without fracture. The images were presented in random order at each time point. The following parameters were recorded: cortical cross sectional area, total vBMD, trabecular vBMD, and cortical vBMD (CvBMD). Data were analyzed by calculating intraclass correlation coefficients for intra- and interobserver reliability. The lowest values occurred at the CvBMD with intraobserver reliability of 0.92 (95% confidence interval [CI] of 0.86-0.96) and interobserver reliability of 0.92 (95% CI 0.89-0.96). All other parameters had reliability values between 0.97 and 0.99 with tighter 95% CI than for CvBMD. The method of adapting the Mindways Pro software using a standard CT to produce vBMD and structural data at the ultradistal radius is reliable.

Proton pump inhibitors and fracture risk. The HUNT study, Norway

Proton pump inhibitors (PPIs) have been linked to increased risk of fracture; the data have, however, been diverging. We did not find any increased risk of fractures among users of PPIs in a Norwegian population of 15,017 women and 13,241 men aged 50-85 years with detailed information about lifestyle and comorbidity.

INTRODUCTION

Proton pump inhibitors (PPIs) are widely prescribed and have been linked to increased risk of fracture.

METHODS

We used data from the Nord-Trøndelag Health Study (HUNT3), The Fracture registry in Nord-Trøndelag, and the Norwegian Prescription Database, including 15,017 women and 13,241 men aged 50-85 years. The study population was followed from the date of participating in HUNT3 (2006-2008) until the date of first fracture (forearm or hip), death, or end of study (31 December 2012). The Cox proportional hazards model with time-dependent exposure to PPIs was applied, and each individual was considered as unexposed until the first prescriptions was filled. To be included, the prescription of PPIs should minimum be equivalent to 90 defined daily doses (DDD) in the period. Individuals were defined as exposed until 6 months after end of drug supply.

RESULTS

The proportion of women and men using PPIs was 17.9% and 15.5%, respectively. During a median of 5.2 years follow-up, 266 women and 134 men had a first hip fracture and 662 women and 127 men, a first forearm fracture. The combined rate/1000 patient-years for forearm and hip fractures in women was 49.2 for users of PPIs compared with 64.1 among non-users; for men 18.6 and 19.8, respectively. The hazard ratios with 95% confidence interval for the first forearm or hip fracture among users of PPIs in the age-adjusted analysis were 0.82 (0.67-1.01) for women and 1.05 (0.72-1.52) for men. Adjusting for age, use of anti-osteoporotic drugs, and FRAX, the HR declined to 0.80 (0.65-0.98) in women and 1.00 (0.69-1.45) in men.

CONCLUSIONS

Use of PPIs was not associated with an increased risk of fractures.

Management of Pediatric Forearm Fractures After Failed Closed Reduction

Pediatric and adolescent forearm fractures account for nearly 40% of all fractures in childhood. The incidence of these fractures has increased over the past decade with a 10-fold increase in surgical intervention. A thorough physical examination of the upper extremity, with plain radiographs of the forearm, should be obtained to make the diagnosis. The primary modality of management for closed both-bone forearm fractures is a closed reduction if needed and long arm immobilization. Patients should be followed up weekly, for at least 3 weeks, to ensure maintenance of fracture alignment. Failure of closed management is a known complication of nonsurgical management, and providers should have a management algorithm to treat these patients. Re-manipulation and casting, or cast wedging, is warranted if the loss of reduction is noted early in the postreduction period. If closed reduction cannot be achieved, elastic stable intramedullary nailing is the management of choice with either single- or both-bone fixation. Potential complications of elastic stable intramedullary nailing include acute compartment syndrome, nonunion, dorsal radial sensory nerve neuritis, and extensor pollicis longus tendon rupture. In older children and adolescents with less remodeling potential, osteosynthesis with plate-and-screw fixation or hybrid fixation should be used.

Challenges in Pediatric Trauma: What We All Need to Know About Diaphyseal Forearm Fractures

Diaphyseal fractures of the radius and ulna are common injuries in children and often result from a fall on an outstretched hand. Fractures are classified by completeness, angular and rotational deformity, and displacement. The goal of management is to correct the deformity to the anatomic position or within acceptable alignment parameters as defined in the literature. This is primarily achieved by closed reduction and immobilization. Greenstick fractures are reduced by rotation of the palm toward the apex of the deformity. Complete fractures are reduced with sustained traction and manipulation. All fractures are immobilized in a cast, applied with the proper molding technique to ensure adequate stabilization, and maintained until healing is evident. Follow-up radiographs should be obtained weekly during the first 3 weeks after reduction to assess loss of reduction. Generally, postreduction malalignment greater than 20° is unacceptable, but these parameters vary based on age, fracture pattern, and the location and plane of angulation. Surgical intervention, with intramedullary nailing or plate fixation, is indicated for open fractures, for those with substantial soft-tissue injury, and when acceptable alignment cannot be achieved or maintained. Successful outcomes are seen in most forearm fractures in children, based on bone healing and restoration of functional forearm range of motion.

[Forearm diaphyseal fractures in pediatric patients. Review of treatment results]

OBJECTIVE

To describe the most common types of fractures in patients under 16 years of age at the forearm level, and to evaluate depending on the level of the fracture, the treatment with better results.

MATERIAL AND METHODS

We perform a retrospective analysis to determine the frequency of forearm fractures in patients under 16 years, in the period from January 2013-July 2017. The following diagnoses were entered into the system: forearm fracture, radius fracture, ulnar fracture and bilateral fracture.

RESULTS

We included 573 patients: 413 male, 160 females; right affected side: 230, left: 338, bilateral 5. Affected level: 438 distal, 102 mid-shaft and 33 proximal. The peak age of presentation was eight years. The initial treatment was conservative in 92%, followed by closed reduction and percutaneous fixation with 4.71 and 2.4% for open reduction and internal fixation with plates. There was a failed initial treatment at 3.83% when an inadequate reduction was found.

DISCUSSION

We found that the treatment of this fractures in our institution is conservative in 92%, closed reduction and percutaneous fixation in 4.71% and open reduction and internal fixation in a 2.4% being The highest prevalence in patients older than 12 years with bilateral mid-shaft fractures.

[APPLICATION OF DIGITAL TECHNOLOGY IN ANTEROLATERAL THIGH FLAP FOR REPAIRING WOUNDS OF HAND AND FOOT]

OBJECTIVE

To investigate the effectiveness of digital technology in repairing wounds of the hand and foot with anterolateral thigh flap.

METHODS

Between September 2013 and September 2014, 16 cases of wounds of the hand and foot were treated with the anterolateral thigh flap. There were 10 males and 6 females, with an average age of 31 years (range, 20-52 years). The causes included traffic accident injury in 8 cases, crushing injury by machine in 6 cases, burning injury in 1 case, and animal biting injury in 1 case. The locations of soft tissue defect were the dorsum of the foot in 5 cases, the ankle in 4 cases, the planta pedis in 1 case, and the hand and forearm in 6 cases. The time was 2 hours to 45 days from injury to hospitalization (mean, 14.3 days). All defects were associated with exposure of bone and tendon. The size of wound was from 9.0 cmx4.0 cm to 29.0 cmx8.5 cm. CT angiography (CTA) was performed before operation, and the appropriate perforator as well as the donor site was selected. Then the Mimics l5.0 software was used to reconstruct the data of CTA so as to locate the main perforators, design the three-dimensional models of the anterolateral thigh flap, and simulate operation. The flap was obtained according to preoperative plan during operation. The size of flaps varied from 11 cm x 5 cm to 31 cm x 10 cm. The donor sites were sutured directly in 14 cases and were repaired by free skin graft in 2 cases.

RESULTS

The lateral femoral circumflex artery identified by Mimics l5.0 software before operation, as well as the starting position of its descending branch, the blood vessel diameter at start site, vascular distribution, the maximum cutting length of the vascular pedicle were consistent with the actual observation during operation. All flaps were harvested and were used to repair defect smoothly. Vascular crisis occurred in 1 flap after operation, and the other flaps survived successfully. The wounds and the incisions obtained healing by first intention, and grafted skin survived completely. All cases were followed up 6-17 months (mean, 9 months). Fifteen flaps had good shape; but a second- stage operation was performed to make the flap thinner in 1 case. At last follow-up, the results were excellent in 3 cases, good in 2 cases, and fair in 1 case according to total active motion (TAM) in 6 cases of hand and forearm injury; the results were excellent in 5 cases, good in 3 cases, and fair in 2 cases according to American Orthopaedic Foot and Ankle Society (AOFAS) in 10 cases of foot injury. The total excellent and good rate was 81.25%.

CONCLUSION

The preoperative individualization design of the flap can be realized through CTA digital technology and Mimics 15.0 software; it can reduce the operation risk.

[Thoracic and abdominal and limb wounds by gun shot]

In Japan, we are permitted to own fire arms only for hunting and clay pigeon shooting, but gunshot wound victims have neen rarely seen due to the strict laws against owing guns, and the lack of related crimes. Therefore, surgeons should be familiar with ballistics, practical gunshot wound management, and the possibility of delayed lead poisoning ssociated with bullet residue. A 69-year-old man was brought to our hospital because he was accidentally shot by his companion's shotgun during hunting. On admission, although he had stable vital sign and multiple gunshot wounds on his right forearm and femur, chest X-ray and computed tomography (CT) revealed a few of bullets and its flagments on his back, into spleen and pericardium. Following local debridment after removal of the bullets in his right forearm and femur at an emergency room, broken heart muscle and diaphragm were repaired and hematoma in the anterior mediastinum was removed at the operating room. The patient was discharged on the 25th post-operative day and his post-operative course was uneventful. In case of gunshot injuries, in addition to prompt diagnosis and evaluation of organ injuries, careful follow up for possible delayed lead poisoning is important.

[Treatment of old radial head dislocation in children]

OBJECTIVE

To evaluate the short-term effectiveness of transarticular fixation of humeroradial joint by Kirschner wire (or combined with proximal ulnar osteotomy) for old radial head dislocation after open reduction of the radial head in children.

METHODS

A retrospective analysis was made on the clinical data of 25 children with old radial head dislocation between January 2008 and December 2010. There were 18 boys and 7 girls, aged 2 years and 5 months to 9 years and 5 months (mean, 5 years and 11 months). The left side was involved in 13 cases, and the right side in 12 cases. The interval of injury and operation was 3 weeks to 30 months (median, 14 months). The main presentations were abnormal mass in the anterior elbow, motion limitation of forearm pronation, and dorsiflexion inability of wrist and thumb. Three patients had radial nerve lesion. In 23 patients with simple radial head dislocation, transarticular fixation of humeroradial joint by Kirschner wire was used after open reduction of the radial head; in 2 patients with Monteggia fracture, transarticular fixation by Kirschner wire and additional proximal ulnar osteostomy were used.

RESULTS

A primary healing of incision was obtained, without complication of infection, joint stiffness, or radial head necrosis. Twenty-four patients were followed up 29-58 months (mean, 44.3 months); one case had re-dislocation, failed to be followed up at 2.5 months postoperatively. In 3 patients with radial nerve injury, neural function recovery was obtained in 2 cases, and no improvement was observed in 1 case. Twenty-three had no pain, no deformity, and no motion limitation of elbow and forearm except 1 patient with no improvement of neural function. The mean range of montion (ROM) of elbow flexion was 134 degrees (range, 125 - 140 degrees), and the mean ROM of extension was -4 degrees (range, - 8-0 degrees); the mean ROM of forearm pronation was 74 degrees (range, 65-80 degrees ), and the ROM of supination was 90 degrees. According to Mackay's criteria, the results were excellent in 22 cases, good in 1 case, and poor in 1 case at 2 years after operation.

CONCLUSION

The transarticular fixation of humeroradial joint by Kirschner wire (or combined with proximal ulnar osteotomy) is a feasible and effective method to treat old radial head dislocation in children based on a short-term follow-up.

Interchangeable skin grafting to camouflage self-inflicted wound scars on the dorsal and volar forearm: a case report

Scars from self-inflicted wounds to the upper extremities are the hallmark of self-mutilation. They are easy to recognize and difficult to hide. Camouflaging these scars can be an onerous task. In this case study, a 23-year-old woman who has major depressive disorder with comorbid borderline personality disorder presented for scar repair of self-inflicted wounds on the volar and dorsal forearm (each approximately 10 cm2 x 15 cm2). Following a psychological and physical evaluation, split-thickness skin grafts (10/1,000 inches in thickness) were obtained from both areas and switched. The grafts were fixed with staples, immobilized with a short arm splint, and dressed daily with gauze and neomycin ointment. Staples were removed after 10 days; at the 6-month follow up, the wounds resembled burn wound scars. The patient was satisfied with this more socially acceptable result. This method might offer a simple camouflage option in appropriately selected cases.

Effort-related compression of median and ulnar nerves as a result of reversed three-headed and hypertrophied palmaris longus muscle with extension of Guyon's canal

We explored a swelling on the anterior surface of the right distal forearm of a 21-year-old right-handed male soldier and effort-induced symptoms of median and ulnar nerve compression that showed a reversed, three-headed and hypertrophied palmaris longus muscle with extension of Guyon's canal.

Selective screw placement in forearm compression plating: results of 75 consecutive fractures stabilized with 4 cortices of screw fixation on either side of the fracture

OBJECTIVES

To (1) assess the effectiveness of an alternative plate and screw construct for all diaphyseal forearm fracture patterns and (2) test the hypothesis that as the working length (WL) to plate length (PL) ratio increases, so does the construct instability and therefore likelihood of failure.

DESIGN

Retrospective.

SETTING

Level 1 trauma center.

PATIENTS/PARTICIPANTS

Sixty-three patients were operatively treated and 53 were available for follow-up, totaling 75 diaphyseal fractures (19 ulna, 12 radius, and 22 radius/ulna). Average follow-up was 14.6 months (8-26).

MAIN OUTCOME MEASUREMENTS

Patients were followed postoperatively at 1 to 2 weeks, 6 weeks, 10 weeks, 4 months, and then at 3 month intervals. Radiographs were analyzed for changes in fracture alignment, loose or broken hardware, and fracture-healing characteristics. Fracture union was defined when a fracture was radiographically healed and clinically asymptomatic, and the patient was able to return to all activities without restrictions.

RESULTS

No fractures showed radiographic evidence of changes in alignment after fixation. There were no refractures, no infections, and one nonunion. The overall union rate after the index procedure was 97.1% for the radius and 97.6% for the ulna. WL:PL ratio averaged 0.17 (range 0-0.57) and the most frequently used PL was 7 holes (n=43). Patients with closed fractures did have a significantly reduced time to union when compared to those with open fractures (P=0.002). Overall union rate averaged 9.8 weeks (range 6-32 weeks).

CONCLUSIONS

Fixation with a standard length compression plate and four cortices of screw fixation on either side of the fracture seems to be a stable construct for diaphyseal forearm fractures and may result in union rates equivalent to those cited in the literature.

Automatic top loader washing machine related injury. A report of four cases with serious injury

We are reporting four cases of serious washing machine related injury that presented within a period of 5 months. All patients were young children with the mean age of 9 year-old and three had their dominant hand injured. The washing machines involved were the automatic top loader type and all injuries occurred during the spinning phase. Serious automatic washing machine injury is not uncommon in Malaysia. We feel that there is a need to improve the safety features especially during the spinning phase. The operating instructions and safety precautions on the washing machine should be displayed in different languages that can be understood well. Parents should also aware of the potential risks of this seemingly benign household appliance.

Rare combination of seven fractures in the same forearm and wrist

A rare combination of a segmental ulnar fracture with fracture dislocation of the head of the radius and intraarticular fracture of the distal radius concomitant with an ipsilateral scaphoid, lunate and coronoid process fractures is presented. The mechanism of injury could possibly be a tremendous impact on the outstretched hand with a dorsiflexed wrist, fracturing the carpal bones and the distal radius. Transmitted axial forces on the ulna in a pronating forearm resulted in the other fractures. To the best of our knowledge, no such case has been reported. Open reduction with screw fixation of the scaphoid, plating of the proximal ulna and Kirschner wiring of the distal radius and radial head dislocation were done.

Elbow, forearm and wrist injuries in the athlete

Competitive and recreational athletes sustain a wide variety of soft tissue, bone, ligament, tendon and nerve damage to their upper extremities. Most such injuries are related to direct trauma or repetitive stress, and account for a significant amount of 'down time' for athletes participating in a wide range of sports, particularly those in which the arm is utilised for throwing, catching or swinging. Overuse injuries to the elbow include musculotendinous injuries, ulnar nerve injuries and ligamentous injuries. Osteochondrol lesions of the capitellum and posterior impingement injuries in the joint are frequently seen in athletes as well. Acute traumatic injuries to the elbow include tendon ruptures, elbow dislocations and intra-articular fractures. Forearm overuse injuries in athletes include fracture of the carpal scaphold, fracture of the hook of the hamate, Kienbock's syndrome and pisoquetral syndromes. ligamentous injuries include scapholunate, lunotriquetral and midcarpal instability injuries. Injuries to the distal radio-ulnar joint and triangular fibrocartilage are also quite common in athletes, and require careful evaluation and treatment.

Ultrasound, densitometry, and extraskeletal appendicular fracture risk factors: a cross-sectional report on the Saunders County Bone Quality Study

The Saunders Bone Quality Study was designed to determine the feasibility of ultrasonic bone measurement, at the patella, as a predictor of low-trauma fractures in a rural population-based study. At the first visit of this 4-year longitudinal study, anthropometric and clinical measurements and medical, surgical and fracture histories were obtained for the 1428 participants 9899 women and 529 men). Explored risk factors for low-trauma fractures included age, sex, calcium intake, alcohol and caffeine ingestion, tobacco use, body mass and grip strength, age of menopause, estrogen replacement therapy, propensity to fall, distal radius and ulna bone mineral content, and bone density. Forward multivariate logistic regression analysis showed that lower ultrasound values are more consistently associated with reported low-trauma appendicular fractures than the commonly reported forearm absorptiometry measures of radius mineral content and density. When ultrasound, age, and the extra skeletal risk factors were included in an additional multivariate model, only age and ultrasound were significantly associated with appendicular fracture history in women (P = 0.0003), whereas only ultrasound was associated in the men (P = 0.001). We conclude that ultrasound is a better measure as association with reported low-trauma fractures than the commonly reported forearm SPA measures. Even after adjustment for many of the extra skeletal risk factors, low AVU is highly associated with low-trauma fracture status for both men and women.

[Forum: cover flaps of the upper limb. In practice: indications of pedicled flaps of the upper limb]

The author analyses the historical development and disadvantages of pedicled island flaps of the upper limb. The various procedures for skin cover of the upper limb are described region by region: shoulder, arm, elbow, forearm, wrist, hand and fingers. The large number of these procedures means that the reconstructive surgeon would have to be able to master all techniques and indications. Adopting an eclectic approach, the author proposes two main flaps: the latissimus dorsi muscle to cover the proximal region of the upper limb and the pedicled inguinal flap for the distal upper limb.

Fracture of the distal forearm as a forecaster of subsequent hip fracture: a population-based cohort study with 24 years of follow-up

OBJECTIVE

To determine the long-term risk of hip fracture following fracture of the distal forearm.

DESIGN

Registry-based cohort study comparing patients with a fracture of the distal forearm with a population-based cohort. FRACTURE COHORT: All women and men above 40 years of age with a radiologically verified fracture of the distal forearm during a 5-year period, 1968-1972, in all 1,126 women and 212 men. CONTROL COHORT: An equal number of population-based, age- and sex-matched control persons selected from a population register.

MEASUREMENTS

All cohort members were followed up individually through record linkage until the first hip fracture, emigration, death, or the end of 1991. The cohort members contributed a total of 40,832 person-years of observation, and altogether 365 cases of hip fractures were observed.

RESULTS

Both women and men with a fracture of the distal forearm ran an increased risk of sustaining a subsequent hip fracture. The overall relative hazard for the women was 1.54 and for men 2.27. The increased risk in the women was independent of age at inclusion, but that in the men was more pronounced in the younger age groups.

CONCLUSIONS

Patients with a fracture of the distal forearm run an increased risk of sustaining a subsequent hip fracture. They therefore appear to constitute a group in which appropriate prophylactic measures against osteoporosis and fractures should be considered.

Lower limb salvage using an extended free radial forearm flap

A case is reported of an unusual double injury, in which a lower limb salvage procedure employed a free radial forearm flap from an amputated upper limb. The use of amputated parts for salvage procedures is well documented but none has previously involved a free forearm flap. This clinical case shows that the entire forearm and hand skin can be adequately perfused on the radial artery along with the superficial palmar arch.

Displaced forearm fractures in children treated with AO plates

Internal fixation with AO compression plates was carried out in 8 per cent of all children with displaced diaphyseal fractures of the forearm. Primary treatment for 23 of these 43 fractures consisted of primary fixation. All fractures healed in anatomical alignment. Deep infection was observed in 1 child. All fractures united but 1 refractured . Of 29 children, 27 were reexamined after a mean observation time of 5 years; 22 had obtained normal function of the arm, and nobody had restriction of rotation of the forearm exceeding 20 degrees. The mean overgrowth of the bones was 2.4 mm. Fifty-six per cent of the children had discrepancies in the linear growth between the radius and the ulna in the fractured arms. These disturbances had no influence on the functional results. We conclude that internal fixation with AO plates is preferable when closed reduction fails or when secondary displacement cannot be corrected by repeated gentle manipulation.

The forearm flap

We present our experimental and clinical experiences with the free neurovascular forearm flap. The flap is based on the radial artery, one of the great veins of the forearm (cephalic, basilic, or interconnecting vein), and one or two cutaneous forearm nerves (ulnar, median, or lateral). Because of the standard anatomy, the large caliber of blood vessels, the good sensory supply, the quality and quantity of the forearm skin, and the thin layer of subcutaneous fat, the free forearm flap is a technically easy and safe flap for reconstruction of soft-tissue defects, especially those in the head and neck and those areas of the extremities where sensitive skin is desired.

Free muscle transplantation to provide active finger flexion

Free muscle transplatation is a procedure which involves the transfer of a skeletal muscle from one location in the body to another. Viability is maintained by microvascular anastomoses of the muscle's artery and vein to a suitable artery and vein in the recipient site. Voluntary muscle contraction is obtained by suturing of the muscle's motor nerve to an appropriate motor nerve in the recipient site. Two cases are presented; one using the gracilis and the other using the pectoralis major muscle. The indication for each transplantation was the traumatic loss of long flexor musculature to the digits. In both cases transplanted muscles survived and are functioning well. Excellent grip strength and nearly a full range of finger movement were provided by the transplanted muscle.

Decompression of forearm compartment syndromes

The diagnosis of forearm compartment syndrome by clinical findings alone has been difficult and inconsistent. This study was designed to assist in the diagnosis and treatment of forearm compartment syndromes. We evaluated several forearm incisions and determined their effectiveness by measuring compartment pressures using the wick catheter. The wick catheter is a simple, safe, and effective means of determining forearm compartment pressures. Preoperative and intraoperative measurements of the dorsal as well as the volar compartment pressures should be performed. Volar fasciotomy is effective in decompressing the volar compartment and may be effective in lowering the dorsal compartment pressure as well. Dorsal fasciotomy should be performed when that pressure remains elevated following volar decompression. The curvilinear volar and volar-ulnar incisions were equally effective in lowering compartment pressures experimentally, but the curved incision allowed beteer exposure to nerves and vessels and is preferred.