Search

Introduction: Acute plastic deformation refers to a traumatic bending or bowing without a detectable cortical defect., Case Presentation and Discussion: We describe a rare case from an individual that was exhumed from the Hispano-Mudejar necropolis in Uceda (Guadalajara, Spain) dated between the 13th and 14th centuries AD. The case corresponds to an adult woman, with a bowing involvement of the left ulna and radius. After making the differential diagnosis with various pathologies likely to present with this alteration, we reached the diagnosis of acute plastic deformation of the forearm through external and radiological examination and comparison with the healthy contralateral forearm., Conclusions: Acute plastic deformation is a rare traumatic injury, not described until the last century and only rarely described in palaeopathological contexts. We contribute a new case, the first being sufficiently documented, contributing to the knowledge and diagnosis of this type of trauma in the ancient bone, while deepening the knowledge of the living conditions of the medieval Mudejar population of Uceda., (© 2022 S. Karger AG, Basel.)

Background: Bone parameters derived from HR-pQCT have been investigated on a parameter-by-parameter basis for different clinical conditions. However, little is known regarding the interrelationships of bone parameters and the spatial distribution of these interrelationships. In this work: 1) we investigate compartmental interrelationships of bone parameters; 2) assess the spatial distribution of interrelationships of bone parameters; and 3) compare interrelationships of bone parameters between postmenopausal women with and without a recent Colles' fracture., Methods: Images from the unaffected radius in fracture cases (n=84), and from the non-dominant radius of controls (n=98) were obtained using HR-pQCT. Trabecular voxel-based maps of local bone volume fraction (L.Tb.BV/TV), homogenized volumetric bone mineral density (H.Tb.BMD), homogenized μFEA-derived strain energy density (H.Tb.SED), and homogenized inter-trabecular distances (H.Tb.1/N) were generated; as well as surface-based maps of apparent cortical bone thickness (Surf.app.Ct.Th), porosity-weighted cortical bone thickness (Surf.Ct.SIT), mean cortical BMD (Surf.Ct.BMD), and mean cortical SED (Surf.Ct.SED). Anatomical correspondences across the parametric maps in the study were established via spatial normalization to a common template. Mean values of the parametric maps before spatial normalization were used to assess compartmental Spearman's rank partial correlations of bone parameters (e.g., between H.Tb.BMD and L.Tb.BV/TV or between Surf.Ct.BMD and Surf.app.Ct.Th). Spearman's rank partial correlations were also assessed for each voxel and vertex of the spatially normalized parametric maps, thus generating maps of Spearman's rank partial correlation coefficients. Correlations were performed independently within each group, and compared between groups using the Fisher's Z transformation., Results: All within-group global trabecular and cortical Spearman's rank partial correlations were significant; and the correlations of H.Tb.BMD-L.Tb.BV/TV, H.Tb.BMD-H.Tb.1/N, L.Tb.BV/TV-H.Tb.1/N, Surf.Ct.BMD-Surf.Ct.SED and Surf.Ct.SIT-Surf.Ct.SED were significantly different between controls and fracture cases. The spatial analyses revealed significant heterogeneous voxel- and surface-based correlation coefficient maps across the distal radius for both groups; and the correlation maps of H.Tb.BMD-L.Tb.BV/TV, H.Tb.BMD-H.Tb.1/N, L.Tb.BV/TV-H.Tb.1/N, H.Tb.1/N-H.Tb.SED and Surf.app.Ct.Th - Surf.Ct.SIT yielded small clusters of significant correlation differences between groups., Discussion: The heterogeneous spatial distribution of interrelationships of bone parameters assessing density, microstructure, geometry and biomechanics, along with their global and local differences between controls and fracture cases, may help us further understand different bone mechanisms of bone fracture., Competing Interests: The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest., (Copyright © 2021 Shiraishi, Burghardt, Osaki, Khosla and Carballido-Gamio.)

Background and Objective: Burns are a serious health problem leading to several thousand deaths annually, and despite the growth of science and technology, automated burns diagnosis still remains a major challenge. Researchers have been exploring visual images-based automated approaches for burn diagnosis. Noting that the impact of a burn on a particular body part can be related to the skin thickness factor, we propose a deep convolutional neural network based body part-specific burns severity assessment model (BPBSAM)., Method: Considering skin anatomy, BPBSAM estimates burn severity using body part-specific support vector machines trained with CNN features extracted from burnt body part images. Thus BPBSAM first identifies the body part of the burn images using a convolutional neural network in training of which the challenge of limited availability of burnt body part images is successfully addressed by using available larger-size datasets of non-burn images of different body parts considered (face, hand, back, and inner forearm). We prepared a rich labelled burn images datasets: BI & UBI and trained several deep learning models with existing models as pipeline for body part classification and feature extraction for severity estimation., Results: The proposed novel BPBSAM method classified the severity of burn from color images of burn injury with an overall average F1 score of 77.8% and accuracy of 84.85% for the test BI dataset and 87.2% and 91.53% for the UBI dataset, respectively. For burn images body part classification, the average accuracy of around 93% is achieved, and for burn severity assessment, the proposed BPBSAM outperformed the generic method in terms of overall average accuracy by 10.61%, 4.55%, and 3.03% with pipelines ResNet50, VGG16, and VGG19, respectively., Conclusions: The main contributions of this work along with burn images labelled datasets creation is that the proposed customized body part-specific burn severity assessment model can significantly improve the performance in spite of having small burn images dataset. This highly innovative customized body part-specific approach could also be used to deal with the burn region segmentation problem. Moreover, fine tuning on pre-trained non-burn body part images network has proven to be robust and reliable., (Copyright © 2020 Elsevier Ltd and ISBI. All rights reserved.)

Aim: To study the visibility of standardized inflicted bruises by using an alternate ('forensic') light source compared to a white light source., Methods: Bruises were inflicted on the flexor site of the forearm (halfway in the middle) in 76 adults, by suddenly allowing a cylindrical metal object (400g) with rounded edges to drop for 1m in a vertically positioned tube. At 0.25, 1, 2, 7 and 14days after this blunt force impact, the impact site on the forearm was photographed with a white light source and subsequently with an alternate light source at 415nm. Visibility of bruises on 170 randomized photographs was assessed on a calibrated monitor by 10 forensic medical specialists (physicians and pathologists) independently in two sessions: (1) with white light source photographs, and (2) after a mean of 11days with greyscale converted alternate light source photographs. Bruise visibility was expressed as a report mark between 1 (very bad) and 10 (excellent), or as 'no visible bruise'. To determine intra-rater agreement, 10 of 170 photographs were assessed twice (untold to the assessors). In total 3600 (180×10×2) photographs were assessed., Results: 39 of 73 (53%) participants who completed the study, developed a visible bruise (women more often than men, p<0.001). Inter-rater agreement between assessors was high (mean inter-class coefficient, ICC, for white light source 0.66 (SD 0.14) and for alternate light source ICC 0.73 (0.09)). Intra-rater agreement was excellent (mean ICC 0.88 (SD 0.09)). Mean report marks for bruise visibility, recorded independently by 10 assessors on 170 unique photographs per light source, were significantly higher with an alternate light source than with a white light source, at 1 and 2days after impact: 4.4 (SD 2.0) vs 3.8 (1.8) (p<0.01) and 4.9 (2.1) vs 4.5 (2.0) (p<0.05), respectively. However, these differences were small, as the mean difference (effect size) in report marks were 0.6 (0.5) and 0.4 (0.3), at 1 and 2days after impact, respectively. The other time points showed no statistical significant differences in report marks., Conclusions: Bruises after standardized blunt force impact were slightly better visible with an alternate light source than with a white light source after 1 and 2 days, but not after 0.25, 7 and 14 days. The value of using an alternate light source at 415nm to improve bruise visibility was limited in this study., (Copyright © 2018 Elsevier B.V. All rights reserved.)

The Longobard necropolis of Povegliano Veronese dates from the 6th to the 8th centuries AD. Among the 164 tombs excavated, the skeleton of an older male shows a well-healed amputated right forearm. The orientation of the forearm fracture suggests an angled cut by a single blow. Reasons why a forearm might be amputated include combat, medical intervention, and judicial punishment. As with other amputation cases reported in literature, this one exhibits both healing and osteoblastic response. We argue that the forelimb stump morphology suggests the use of a prosthesis. Moreover, dental modification of RI2 shows considerable wear and smoothing of the occlusal surface, which points to dental use in attaching the prosthesis to the limb. Other indications of how this individual adjusted to his amputated condition includes a slight change in the orientation of the right glenoid fossa surface, and thinning of right humeral cortical bone. This is a remarkable example in which an older male survived the loss of a forelimb in pre-antibiotic era. We link archaeological remains found in the tomb (buckle and knife) with the biological evidence to show how a combined bioarchaeological approach can provide a clearer interpretation of the life history of an individual.

Despite various options for the reconstruction of soft tissue defects in the distal forearm, perforator-based propeller flap is rarely used. Here, we presented 2 cases of distal forearm injuries that were repaired using the recurrent branch of anterior interosseous artery perforator-based propeller flap. Patients in these cases were 57 and 67 years of age. Wounds resulting from farming machine injury and pyogenic extensor tenosynovitis following cat bite wounds were localized to the distal forearm and dorsum of the hand. Defect dimensions were 5 cm × 10 cm and 5 cm × 8 cm. The 12 cm × 7 cm and 21 cm × 4 cm sized recurrent branch of anterior interosseous artery perforator-based propeller flap was designed adjacent to the wounds. In the latter case, the absence of the posterior interosseous artery in the distal forearm was observed. One perforator from the recurrent branch of the anterior interosseous artery emerged through the septum between the extensor digiti minimi and extensor carpi ulnaris 7.5 cm and 6.0 cm proximal to the ulnar head in cases 1 and 2, respectively. Perforators were identified using multidetector computed tomographic angiography and handheld Doppler. Extending to two-thirds or almost the full length of the forearm, the flaps were raised and rotated by 90° and 120° to cover the defect. The donor sites were closed using free skin graft. Both flaps survived. Except for minor wound dehiscence and hemarthrosis, no other postoperative complications occurred. Patients returned to work or daily activities at 3- and 4-month follow-up after surgery., (© 2018 Wiley Periodicals, Inc.)

Pediatric emergency physicians at Kaplan Medical Center regularly reduce forearm fractures under point-of-care ultrasound guidance in the pediatric emergency department. We present 3 children who arrived at our department with shortened, angulated forearm fractures within the span of a single week. We report on the successful reduction of these fractures under point-of-care ultrasound and on the maintenance of anatomic alignment at follow-up 1 week postreduction.

Objectives: Children with public insurance are less likely than children with private insurance to obtain follow-up care after emergency department (ED) care. This study aimed to determine if specific demographic and clinical factors are associated with aftercare compliance in a population of publicly insured pediatric ED patients with orthopedic injuries., Methods: This was a retrospective case-control study of Washington, DC, children aged 0 to 17 years with public insurance discharged with isolated forearm fractures from the Children's National Medical Center ED from 2003 to 2006. Bivariable analyses and multivariable logistic regression were performed to measure the association between sociodemographic variables and failure to follow up., Results: Six hundred children met the inclusion criteria. The overall cohort was 63.7% male and 81.7% African American, with a mean age of 8.8 (SE, 0.2) years. Overall, 85.7% of patients went to a follow-up orthopedic appointment, and 68.2% of patients had timely orthopedic follow-up, defined as 14 days or less after discharge from the ED. Treatment with orthopedic reduction (adjusted odds ratio [OR], 2.0 [1.33-2.93]) was positively associated with timely orthopedic follow-up, whereas older age (adjusted OR, 0.9 [0.88-0.97]) was significantly associated with failure to follow up. In the subset of patients who required orthopedic reduction in the ED, older age was significantly associated with failure to follow up (adjusted OR, 0.80 [0.74-0.94])., Conclusions: Mild fracture severity is associated with lack of orthopedic follow-up for patients with public insurance. Older age was associated with lack of follow-up, even in the subgroup with severe fractures. Targeted interventions to improve orthopedic aftercare compliance should focus on older patients with severe forearm fractures.

There is extensive literature on metal fragments from improvised explosive devices being embedded in patients but there are no reports describing the clinical and radiological appearances of embedded home-made explosive (HME). We present a case of partially detonated HME being found inside a patient's forearm. We discuss the medical management of the injury, the ongoing risk to the patient and surgical team associated with the explosive and the safe disposal of the substance., (Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://group.bmj.com/group/rights-licensing/permissions.)

We report this 47-year-old man who presented with polytrauma following a fall from a roof in March 2011. He sustained a head injury and a complex, comminuted forearm fracture. He underwent an open reduction and internal fixation of the fracture at the time of injury, but later developed a rigid type 2 diaphyseal radioulnar synostosis, with loss of forearm rotation. Synostosis excision and a radial artery perforator-based adipofascial interposition flap to prevent recurrence has resulted in a good functional outcome and no recurrence at 2.5 years follow-up., (2015 BMJ Publishing Group Ltd.)

A 55-year-old woman taking warfarin for previous deep venous thrombosis (DVT), presented with an acutely swollen and painful forearm after forcefully contracting her forearm flexor compartment while using a car hand brake and later, an axe. Compartment syndrome was diagnosed and emergency fasciotomy performed, with a haematoma discovered between the flexor compartments of flexor digitorum superficialis (FDS) and flexor digitorum profundus (FDP). After evacuation and resolution of symptoms, the wounds were closed 4 days later. Following discharge on the fifth day, symptoms recurred without warning, prompting re-exploration and discovery of further haematoma. Symptoms again resolved and in due course a skin graft was applied to close the wound without tension., (2015 BMJ Publishing Group Ltd.)

A 2½ year old girl attended our facility following attack by a tapir at a city zoo. She sustained multiple injuries including a forearm laceration and multiple perforating wounds to her abdominal wall. She had several procedures, including bowel resection, performed under the care of the General Paediatric Surgery and Plastic Surgery teams and was treated with a course of IV antibiotics. She recovered well and to date has suffered no long-term adverse outcome.

Background: Both-bone diaphyseal forearm fractures constitute up to 5.4% of all fractures in children in the United Kingdom. Most can be managed with closed reduction and cast immobilisation. Surgical fixation options include flexible intramedullary nailing and plating. However, the optimal method is controversial. The main purpose of this study was to systematically search for and critically appraise articles comparing functional outcomes, radiographic outcomes and complications of nailing and plating for both-bone diaphyseal forearm fractures in children under 18 years., Methods: A comprehensive search of Medline, Embase and Cochrane databases using specific search terms and limits was conducted. Articles identified were thoroughly screened using strict eligibility criteria and eight retrospective non-randomised comparative studies were identified and reviewed., Results: There were no statistically significant differences in functional outcome or time to fracture union between plating and IM nailing. No consistent difference was found in complication rate, fracture angulation, shortening or rotation. Better cosmesis and shorter duration of surgery was noted in the IM nailing group. Post-operative radial bow was significantly abnormal in the IM nailing groups, but did not affect forearm movement., Conclusion: Based on similar functional and radiographic outcomes, nailing seems to be a safe and effective option when compared to plating for paediatric forearm fractures. However, critical appraisal of the studies in this review identified some methodological deficiencies and further prospective, randomised trials are recommended., (Copyright © 2014 Elsevier Ltd. All rights reserved.)

Introduction: Non-union rate in forearm fractures is generally less than 2% when a proper technique is used; this rate increases when ulnar lesions are involved., Patients and Methods: We present a case series of seven young patients whose average age was 14 years (range 11-19 years) at the time of surgery and who presented with a forearm post-traumatic non-union that was previously treated in different ways (three isolated ulnar non-union, two isolated radial non-union and two combined). Average follow-up was 34 months (range 9-72 months). Surgical treatment began with the removal of the previous synthesis and with curettage of the non-union area. The Acumed ulnar rod, Acumed radial rod and Thalon elastic nail (all of them are unreamed and locked nails) together with autologous platelet-rich plasma (PRP) obtained with the Biomet System (concentration of 158.2×10(4) platelets/μL) were chosen to treat the patients. X-rays and clinical controls were conducted every 30 days until recovery., Results: All patients recovered: average recovery was 23 weeks from operation (range 16-36 weeks) and nails were removed 3 months after complete healing. Six patients had excellent results and one patient had a good result (Patient 2, forearm pronosupination 60-0-40 degrees)., Discussion: The purpose of the case series was to establish a better way of treatment and to find a technique that could avoid the use of bone grafts, because obtaining autologous bone requires a further surgical procedure that can be really invasive depending on the amount of bone needed., Conclusion: All patients in the study showed complete recovery, with excellent clinical outcomes. Although there were only seven patients in this case series, and there is a need to analyse more patients, this study showed that the use of a specific locking nail system can provide proper stability to ulnar or radial atrophic non-union despite rotational forces, and when combined with autologous growth factors (PRP) is sufficient to promote bone healing in young patients without the necessity to take autologous bone grafts., (Copyright © 2013 Elsevier Ltd. All rights reserved.)

Introduction: There is no classification for acquired forearm deformities. A clinical-radiographic study was conducted to classify these deformities and evaluate the results., Materials and Methods: Thirteen patients with forearm deformities following traumas or their treatment were included (11 men and two women, from 2000 to 2010). Mean age was 31 years (range 10-75 years). Initial treatment was conservative in five patients and surgical in eight patients. One segment was affected in seven patients (the radius in four patients, the ulna in three), and both segments were affected in six patients. Location assessment: 2 projections X-rays, including wrist and elbow. Deformity location: proximal, diaphisary, distal, defined with the abbreviation, in distal sense, R1, R2, R3 for the radius, and U1, U2, U3 for the ulna. Primary and secondary deformities were distinguished: secondary deformities occurred later in a different location than the primary one. Six patients were treated with plate and screws. An external fixator was used in six patients. One patient was treated with bone resection. Iliac crest bone graft was used in 10 patients, and vascularised fibula graft in one patient., Results: The primary deformity affecting the radial diaphysis (R2) determined a secondary deformity in four patients: in the distal ulna (U3) with ulnocarpal dislocation in three patients and in the distal radius (R3) in one patient. Results of osteosynthesis treatment were excellent in one patient, satisfactory in four and unsatisfactory in one. External fixation was excellent in one patient and satisfactory in five. Bone resection was satisfactory in one patient., Discussion: Surgical treatments with osteosynthesis are the major cause of acquired forearm deformities in adults. Location and aetiology of the deformities are essential for the surgical indication and the result. It is important to restore the length of the deformed segment, realigning the anatomical axis. X-rays enable clinicians to distinguish between primary and secondary forearm deformities., Conclusion: Characteristics and locations of post-traumatic deformities were identified. The major location is diaphisary and distal, the elbow is rarely affected. The functional consequence is a limitation in the range of motion of the hand. The best results are achieved with short-term treatment., (Copyright © 2013 Elsevier Ltd. All rights reserved.)

Assessment of individuals with injuries that may have been caused by intentional self-harm is part of routine work of forensic physicians. We present a case of deliberate self-harm of a 19 years old woman who claimed she had been cut by her partner during a quarrel while her partner claimed that she had injured herself. No forensic examination was performed. The case was first reviewed several months after the incident by experts giving consultations for the defense (the authors) by that time the only documentation of injury available were scant medical records and photos of very low quality. This case shows the importance of recognizing self-inflicted injuries even when only scant documentation is available, by comparing the injuries described to the different accounts of the incident as described by the complainant and defendant. Also the importance of availability of access of defense lawyers to forensic medical consultations is stressed., (Copyright © 2013. Published by Elsevier Ltd.)

Background: Flexible intramedullary nailing (IMN) has become a popular technique for the management of unstable or open forearm fractures. Recent publications have suggested an increased incidence of delayed union and poor outcomes in older children and adolescents. The objective of this study was to review forearm fractures treated with IMN, comparing the rate of complications and outcomes between the 2 age groups. Our hypothesis was that IMN is an effective technique with a similar rate of complications in both age groups., Methods: An Institutional Review Board-approved retrospective review was conducted of pediatric forearm fractures treated from 1998 to 2008 at a single institution. Over the study time period, 4161 pediatric forearm fractures were managed nonoperatively (92%) and 353 were treated operatively with plate, cross-pin, or intramedullary fixation (8%). Patients with inadequate follow-up, cross-pin, or plate fixation were excluded. Medical records were reviewed for indications and complications. Complications were graded with a modification of the Clavien-Dindo classification. Outcomes were judged by a new grading system., Results: A total of 205 forearm fractures treated with IMN in 203 patients were identified. The mean age was 9.7 years (range, 1.7 to 16.2 y) and mean follow-up was 42 weeks. Operative indications were failure of closed treatment in 165 (80%) and open fracture in 40 (20%). Mean time from injury to IMN was 5.9 days (range, 0 to 25 d). Single bone IMN was performed in 40 of 185 both bone fractures (26%); there were 20 single-bone forearm fractures treated with IMN. Open reduction was required in 61/165 (37%) of closed fractures. Asymptomatic delayed union (grade 1 complication) was observed in 9 fractures (4%). More severe complications were noted in 17% (grade 2 to 4 complications). Postoperative compartment syndrome occurred in 3 isolated forearm fractures with a significant younger mean age (6.0 vs. 10 y, P=0.031). Overall, complications were significantly more frequent in children older than 10 years of age (25/101) as compared with younger children (13/104, P=0.031). In particular, delayed union was more common in children over the age of 10 years (9/101 vs. 1/104, OR=9.99, P=0.009). Outcomes were good or excellent in 91% of fractures. There was no statistical association of patient age with a fair or poor outcome., Conclusions: IMN is an effective technique for pediatric forearm fractures with good to excellent outcomes in 91%. Complications are not infrequent with this technique, with complications of grade 2 to 4 severity in 17%. There was a 2-fold increase in the rate of complications in children over the age of 10 years. Compartment syndrome was more common in younger children. Patients and families should be counseled about the risks preoperatively.

Background: The aim of this study was to identify the optimal cast index (CI) level that reduces the risk of fracture redisplacement. The CI is the ratio of sagittal to coronal width from the inside edges of the cast at the fracture site. Previous studies have used 0.7 as the standard., Methods: Case records and radiographs of 1001 children who underwent a manipulation under anesthesia for a displaced fracture of the distal forearm were studied. Redisplacement was defined as > 15 degrees of angulation and/or > 80% of translational displacement on check radiographs at 2 weeks. Angulation (degrees) and translational displacement (%) were measured on the initial and check radiographs. The CI was measured on the check radiographs. The CI has previously been validated in an experimental study., Results: The adequacy of reduction after manipulation was determined by translation and angulation of the radius and ulna in anteroposterior and lateral plain film radiographs. From the 1001 patients who qualified for the study, fracture redisplacement was seen in 107 (10.6%) cases at the 2-week follow-up. A total of 752 (75%) patients had CIs of ≤ 0.8, whereas 249 (25%) had casting indices of ≥ 0.81. In patients with CIs of ≤ 0.8, the displacement rate was only 5.58%. However, in patients with CIs of ≥ 0.81, the displacement rate was 26%. A high CI was the sole factor that was significantly higher in the redisplacement group. No statistically significant difference was seen for age, sex, or surgeon seniority. Statistical differences were not noted in initial angular deformity or initial displacement., Discussion: The CI is a simple reliable radiographic measurement to predict the redisplacement of forearm fractures in children. A plaster with a CI of > 0.81 is prone to redisplacement. High CIs are associated with redisplacement of fractures and should be avoided when molding casts in distal forearm fractures., Levels of Evidence: Level III--retrospective comparative study.

Introduction: Although there are three distinct compartments of the forearm, the typical approach for decompression of forearm compartment syndrome is a single incision fasciotomy of the volar compartment. This study had two purposes. The first purpose of this study was to investigate the compartment pressure changes within the forearm compartments following the creation of an acute compartment pressure using fresh-frozen cadaver forearm specimens. The second purpose was to compare the compartment pressure changes of the volar, dorsal, and mobile wad compartments at frequent intervals following a compartment fasciotomy of the forearm., Materials and Methods: An experimental study of a laboratory model of acute forearm compartment syndrome was performed at a level-one, university-based trauma centre. Eight non-embalmed human forearms from 5 male and 3 female donors with an average age of 71 years (range, 51-91) were used. Compartment pressures in the volar, dorsal, and mobile wad compartments were recorded both before fasciotomy and 1, 10, 20, and 30 min after fasciotomy., Results: A single incision volar fasciotomy was sufficient to decrease the elevated compartment pressures in the volar, dorsal and mobile wad compartments to near-baseline levels after 10 min. The mean compartment pressures 30 min post-fasciotomy in the volar, dorsal, and wad compartments were 2, 4, and 3 mmHg, respectively., Discussion: In a laboratory model of an acute forearm compartment syndrome, a single compartment fasciotomy may be sufficient to decrease compartment pressures in the non-released compartments (dorsal and mobile wad). Further study is necessary before changes in clinical management can be recommended., (Copyright © 2012 Elsevier Ltd. All rights reserved.)

Background: Fractures of the distal forearm and distal radius represent the most common types of fracture in the pediatric population, with the majority treated by closed reduction and cast. Redisplacement has been known to occur in up to 39% of cases. There have been numerous risk factors and radiologic indices put forward as methods of predicting redisplacement, but this topic remains a matter of debate. This retrospective study aims to further assess the significance of the many factors in redisplacement after treatment with closed reduction., Methods: This retrospective study included 155 children with distal radius and forearm fractures. Age, sex, location of fracture, angulation, displacement, an associated ulna fracture, obliquity of fracture, and accuracy of reduction were measured for assessment as potential risk factors. In addition, the cast index, padding index, Canterbury index, second metacarpal-radius index, gap index, and 3-point index were measured on postreduction radiographs., Results: Redisplacement occurred in 33 of the 155 cases (21.3%). Initial displacement and accuracy of the reduction were identified as significant risk factors for redisplacement. Initial displacement of >50% (of the radius width) was significantly associated with redisplacement (odds ratio of 5.4). Failure to achieve anatomic reduction was significantly higher in the redisplacement group (odds ratio 3.9). The only radiologic index that differed significantly between groups was the cast index, with more patients without redisplacement meeting the cut-off value (60% vs. 32%, P=0.010)., Discussion: Initial displacement of >50% and inability to achieve anatomic reduction are major risk factors for redisplacement. Given its effectiveness and ease of clinical application, the cast index remains the most useful measure of cast molding., Level of Evidence: Level II--Retrospective prognostic study.

Fluid increases resulting in higher MRI signal intensities in T(2) -weighted and short tau inversion recovery (STIR) sequences can be used to diagnose nerve injury. By comparing the signal intensities over time, MRI may become a new method for monitoring the healing process. Muscle edema is assessed by comparing the signal intensity of affected muscle with that of nonaffected muscle. However, in severe forearm trauma, the signal of nondenervated muscle may also be increased by wound edema, thus masking the effect of denervation. Hence, the purpose of this study was to investigate the influence of wound edema on muscle signal intensity in 29 consecutive patients examined on a 1.5-T MRI scanner at 1, 3, 6, 9 and 12 months after severe forearm trauma. The long-term course of wound edema and the influence of wound distance were thus investigated using a standardized imaging, calibration and post-processing protocol. The signal intensities of nondenervated intrinsic hand muscles were measured in the affected and contralateral sides. Muscle signal intensities were increased on the trauma side at 1 and 3 months (18% and 7.4%, respectively; p < 0.001) and normalized thereafter. In the contralateral hand, no significant signal changes were seen. No relationship was found between wound distance and the severity of wound edema. This study shows that wound edema influences muscle signal intensity comparisons in patients with forearm trauma. When comparing denervated muscle with nondenervated muscle, an additional scan of the contralateral side is indicated during the first 6 months after trauma to assess the extent of wound edema. After 6 months, the ipsilateral side can be used for muscle signal intensity comparisons., (Copyright © 2011 John Wiley & Sons, Ltd.)

Individual variability in skin reactivity and healing capacity after trauma are important clinical issues. The aims were to develop an in vivo, human wound model based on a standardised minimal skin injury and to demonstrate therapeutic effect of simple wound therapies in terms of morphological wound outcome with changes in skin blood perfusion as a quantified indicator of wound healing. In a series of experiments, wounds were induced on the normal forearm skin of volunteers using a blood collection lancet. This was well tolerated. Wounds were assessed by naked eye examination or laser Doppler perfusion imaging (LDPI) at baseline and at up to 6 further time points up to 96 h in control wounds and wounds treated by commonly used occlusive dressing options. Assessment by clinical observation with 10x magnification showed over 96 h a progression of erythema, surface crust, a new keratinisation layer and finally healed areas. LDPI quantifying wound erythema showed a peak at 24 h and near normal levels at 96 h. Inter-individual variability was evident but intra-individual variability was much less pronounced. Wounds treated with occlusion showed a statistically significant more rapid return to baseline blood perfusion as measured by LDPI compared to controls supported by favourable healing parameters in the clinical assessment. The paper exemplifies use of non-invasive, bioengineering technique for quantification of individual innate variability in skin reactivity, wound healing capacity and therapeutic effect in a well-tolerated in vivo, human, minimal skin trauma model.

Flexor carpi ulnaris (FCU) is an ever-present muscle of the anterior flexor compartment of the forearm. Variations of FCU are uncommon, with additional slips or heads of muscles described, and only one reported case of an accessory muscle. We describe a unique clinical case report in which an accessory FCU was identified and describe the findings of 5,000 cadaveric dissections of the forearm, performed as part of an ongoing institutional study of anatomical variations. An aberrant accessory forearm flexor muscle was identified incidentally at the wrist during surgery for an anterior interosseous to ulnar nerve transfer for management of ulnar nerve palsy. This muscle was seen running superficial to the ulnar nerve and radial to the FCU proper, arising from the common flexor origin and inserting at the triquetral carpal bone. This was therefore suitably acknowledged as an "accessory FCU". The anomaly was identified as bilateral using ultrasound imaging, and was found to be anomalously innervated by the median nerve with nerve conduction studies. A subsequent review of 5,000 cadaveric dissections of the forearm did not identify any such variations related to FCU, despite identifying a range of variations of the other forearm flexor musculature. While the scarcity of this anomaly is thus highlighted, consideration of an accessory FCU, and its aberrant innervation is important in a range of surgical approaches., (2010 Wiley-Liss, Inc.)

Introduction: The purpose of this prospective study was to demonstrate the findings of MRI in motocross racers with chronic exertional compartment syndrome (CECS) of the forearm., Materials and Methods: Racers with proven CECS and without CECS and male individuals not involved in strenuous activities with the forearm were included. Signal intensity (SI) and signal-to-noise ratio (SNR) obtained before and after exercise were compared (D-SNR)., Results: Magnetic resonance imaging after exercise showed an increase in SI and SNR in the muscles on T2-WI. The SI increase was obvious in the flexor digitorum superficialis (FDS) and profundus (FDP) in all CECS patients. In addition, a minor SI and SNR increase in the extensor carpi radialis longus (ECRL) was noted. In the non-symptomatic group of motocross racers, there was only a minor increase in SI and the SNR, which was similar in the FDP and ECRL muscles. In the untrained individuals a remarkable increase in the SI and SNR of the FDS/FDP-ECRL was noted. This increased SI and SNR was not present in the majority of non-symptomatic racers., Conclusion: Post-exertional MRI produces significant findings in CECS of the forearm. The motocross racers without post-exertional oedema in the FDP/FDS had no CECS.

An industrial worker in his early 20s sustained a severe injury to the right dominant upper extremity: fracture, inversion, and complete devascularization of the ulna; transection of the median nerve, the radial artery, and almost all flexor tendons of the hand and fingers; loss of all extensor muscles; and transection of the biceps and brachialis muscles at the elbow. Treatment consisted of conversion to one-bone forearm, immediate reconstruction of the biceps and brachialis muscles and of all flexor tendons of the hand, repair of the radial artery and median nerve and late tendon transfer for extension of the wrist and fingers. Two and a half years after injury, the patient had full flexion and extension of the elbow, full extension but limited flexion of the wrist, and full flexion and extension of the fingers.

We report a case of a 24-year-old patient who sustained a mutilating crush injury to the left forearm. After thorough debridement and stabilization of the skeletal injury, the dorsal thoracic fascial flap was used to resurface the circumferential wound, protect the underlying structures, and provide a gliding surface for the exposed tendons. The flap was safely transected during revision surgery, and at 6-months follow-up, excellent functional and cosmetic results were achieved. The dorsal thoracic fascia is a thin, durable, and pliable tissue that is based on a long vascular pedicle. We consider the dorsal thoracic fascial flap as a valuable option for coverage of complex upper extremity injuries and highly recommend its use., ((c) 2008 Wiley-Liss, Inc.)

An old man was found dead in a rice paddy with his face down in the water. His right forearm and hand were severely injured and the shapes of injuries were unusual. It was initially suspected that the injuries had been caused by a cultivator placed at the site. However, they proved to be postmortem injuries because vital reactions were not observed. The skin was widely torn away. Some edges of the injuries looked like a bite mark and other parts looked like scratches. There were many parallel injuries on the right forearm and hand and footmark-like injuries on the right hand. They were probably caused by wild animals. Judging from the sizes and shapes of the footprint, bite marks and scratches, we estimated that the animal which caused the injuries was weasels.

Isolated dislocation of the distal radio-ulnar joint and isolated dislocation of the radial head in adults are not common injuries. A simultaneous dislocation of the radial head and distal radio-ulnar joint with no other injury seems to be extremely rare since only one report was found in the English literature. A similar case, but with some differences in presentation and treatment is reported.

A 63-year-old man was admitted to hospital. He had a history of splenectomy secondary to trauma, previous alcohol abuse, cirrhosis and oesophagus varices. The patient had been bitten by a dog three days before admittance. He rapidly developed disseminated intravascular coagulation and multiple organ dysfunction. Six days after the bite, the patient died despite antibiotic treatment. The gram-negative rod Capnocytophaga canimorsus was found in the blood culture. This case emphasizes the importance of early diagnosis and prompt treatment of infections in post-splenectomy patients as they carry a greater-than-normal risk of serious complications.

The antibrachial interosseous membrane (IOM) is taught over an average length of 10.6cm between the diaphyses of the radius and ulna bone. It looks like a stitch with fibers running from the ulna to the radius and from proximal to distal and fibers running from distal to proximal. The central band, which is the middle part of the fibers directed from distal to proximal has mechanical properties similar to those of a ligament and act as a ligamentous structure embedded in the larger membranous complex of the IOM. The interosseous membrane has a double function: it stabilizes transversally the forearm's two bones and stabilizes longitudinally the two bones by transferring loads from the radius to the ulna. Load transmission varies according to the prono-supination position, the varus-valgus constraints on the elbow and the inclination of the wrist, making interpretation of the experimental data difficult. One should consider the forearm as a whole and the interosseous membrane with the two diaphyses should be regarded as a middle radio-ulnar joint, intercalated between the proximal and distal radio-ulnar joint. Those three articulations or links between radius and ulna act synergistically to stabilize and optimize repartition of loads. Functional loss of one of these links, and of course of more than one, will severely modify the forearm function. Essex-Lopresti lesion, which represents the functional loss of all three links, is the most destabilizing forearm lesion. Imaging of the interosseous membrane is difficult. MRI allows for static imaging of the interosseous membrane but there are often artifacts due to previous trauma or surgical procedures. Dynamic sonography helps to visualize all the lesions and will probably be part of the evaluation of every severe forearm injury. Surgical treatment depends on the gravity of the lesions of the different links. Interosseous membrane reconstruction is still the most difficult technique and most of the previously reported ligamentoplasties cannot answer all the biomechanical constraints. We describe a ligamentoplasty based on the biomechanics whose technique has been validated by cadaveric experiments. First surgical cases are promising.

Plastic deformation of the forearm is a rare and frequently missed injury in adults that can result in significant loss of forearm rotation. We report on a skeletally mature 19-year-old man with traumatic plastic deformation of the radius and ulna resulting in complete loss of forearm pronation. The patient was treated with multiple-level osteotomies of the radius and ulna 7 months postinjury. The patient had full forearm pronation at 4 months followup.

Objective: To study injuries involving brachial plexus and its branches., Methods: 66 cases collected from 2003 to 2005 in our department were analyzed statistically., Results: 94% of injuries involved young adult males; 94% were blunt force injuries; 34% involved both nerve and bone mainly involving ulnar nerve and ulnar bone (50%); 40% of the injured nerves received electromyogram and 15 nerves were diagnosed with injuries clinically., Conclusion: Forensic determination on severity of brachial plexus injuries mainly depends on movement recovery of limb. The best time for forensic appraisal is 20 d post operation+L (length of nerve severed distally)/R (growth rate)+90 d.

This study assessed the accuracy of doctors in estimating fracture angulation. Radiographs of fractured wrist and forearm of varying angulations were shown to all grades of doctors in the speciality of trauma and orthopaedics. They were asked to estimate the angulation at the fracture site without using a goniometer. The estimates were analysed for accuracy and variability. This study showed that doctors have a mean error of 8-9 degrees and had poor agreement with themselves and others. We recommend the use of a goniometer to assess fracture angulation.

Soft-tissue complications in the replantation wound, either septic or non-septic, are the main cause of failure in major extremity replantations. In the presence of necrosis or infection, vascular errosion or thrombosis readily develops and can lead to limb loss. Very aggressive surgical treatment has been recommended to salvage the replanted limb in these highly unstable clinical situations. Over a 10-year period, 423 amputated parts were replanted, 56 of which were replants proximal to the wrist. The experience of the author in treating 11 cases of critical soft-tissue necrosis (four septic and seven non-septic) after major replantation of the upper extremity with aggressive debridement and flap coverage, is reported. All flaps and limbs survived.

Many patients with burn injuries have various complications and emotional problems due to scars. Although various modalities to improve burn scars have been attempted, such as excision of scars, skin grafts, laser abrasion and silicone product usage, the cosmetic outcomes have not been satisfactory for a large portion of patients. Herein, we describe two cases which showed satisfactory cosmetic results after treatment of burns scars with the pinhole method using a carbon dioxide (CO(2)) laser that allowed us to make deep, closely set holes reaching down to the upper dermis. A 20-year-old female patient with a scar on her neck and a 25-year-old female patient with a scar on her right forearm after burn injuries are presented. As early as only a few weeks after the treatment, the scars showed relaxation of contracture, reduction of wrinkles and improvement of texture and color compared to before the treatment. Treatment of burn scars with the pinhole method can be easily performed and results in dramatic improvement in scar quality with only a few side-effects.

The injury findings in 58 perpetrators and 158 victims surviving bodily injuries due to sharp force are presented here. Defence injuries were found in 45.9% of the victims without any significant differences between males and females. There was no clear predominance of defence injuries on the left forearm and hand, as is known from autopsy studies; the right and the left hands were affected with an almost identical frequency. Regarding other parts of the victims' bodies, the topographic distribution of injuries showed a marked concentration on the left side (63.7%). The thorax, head and neck were frequently affected (45.9%, 15.3% and 15.3%, respectively), and less often the abdomen (11.1%), the lumbar and gluteal region (6.3%) and the lower extremities (6.1%). In surviving victims with only one singular stab apart from the upper limbs, the incidence of additional defence injuries on the hands and/or forearms was significantly higher (28.3%) than in fatalities. When the perpetrators had unintentionally cut their own hands, the frequency of these injuries on the right and left hands was almost equal.

Objective: Define criteria for interosseous membrane (IOM) injury diagnosis using MRI, and characterize patterns of IOM disruption following forearm trauma. Our hypothesis is that most IOM injuries occur along the ulnar insertion, and MRI should be obtained following forearm trauma to assess IOM competency., Design: Sixteen cadaver forearms were subjected to longitudinal impact trauma. Prior to and following injury, MR images were examined by a board-certified musculoskeletal radiologist using pre-defined criteria for determining IOM integrity. Each specimen was dissected and the viability/pattern of injury examined. The MRI and dissection results were compared using a double-blinded methodology., Results: Eight of the 16 specimens demonstrated IOM trauma. Seven specimens demonstrated complete IOM disruption from the ulnar insertion, and one revealed a mid-substance tear with intact origin and insertion. The dorsal oblique bundle was disrupted in four specimens. MRI analysis identified IOM injury in seven of the eight forearms. The injury location was correctly identified in six specimens when compared to dissection observations. MRI determination of IOM injury demonstrated a positive predictive value of 100%, a negative predictive value of 89%, a sensitivity of 87.5% and a specificity of 100%., Conclusion: Our findings demonstrate the accuracy of MRI in identifying IOM disruption, and its ability to localize specific injuries in a clinically relevant model of forearm trauma. The injury patterns demonstrated most lesions occurred along the IOM's ulnar insertion, and in half of the injured specimens there was concomitant dorsal oblique bundle disruption.

Objectives: We evaluated vascular problems in patients who were planned to receive posterior interosseous artery (PIA) flap for soft tissue defects in the dorsal hand, thumb, and the first web., Methods: The study included 25 male patients (mean age 27 years; range 12 to 54 years) in whom reconstruction was planned with the use of the reverse PIA flap. The defects were in the following localizations: the dorsal hand (n=15), the first web (n=5), hypothenar region (n=3), and the palmar aspect of the wrist (n=2). The frequency of anatomic variations and complications were evaluated., Results: The use of the PIA flap was cancelled in one patient (4%) due to an anatomic variation of the PIA in the forearm. The vascular pedicle of the flap was removed because of insufficient arterial perfusion due to the absence of distal carpal anastomosis and the donor tissue was used as a free flap in two patients (8.3%). The remaining 22 patients who received pedicled flaps were followed-up for a mean of 3.2 months (range 1.5 to 6.5 months), during which six patients (27.3%) developed venous insufficiency. A superficial vein anastomosis was performed in five patients within the first 24 hours, which resulted in complete improvement. One patient was not available for venous anastomosis and developed flap necrosis. The occurrence of venous insufficiency was not correlated with the timing of flap surgery, the size of the flap, and the placement of the flap pedicle (p>0.05)., Conclusion: The use of the reverse PIA flap is appropriate for soft tissue defects in the dorsal hand, thumb, and the first web. However, the frequency of anatomic variations and vascular complications is higher compared to other reverse pedicled flaps.

This research utilized biplanar radiographs to estimate cross-sectional biomechanical properties for the skeletal remains of two elite individuals from the Early Classic period (ca. AD 400-600) of Copan, Honduras: K'inich Yax K'uk' Mo' (Hunal Burial 95-2), founder of the Early Classic Dynasty at Copan, and the primary female interment (Burial 37-8) from the Motmot tomb. Both individuals survived severe blunt-force insults to the right forearm. Gross skeletal examination and evaluation of the radiographs for K'inich Yax K'uk' Mo' suggest that these traumas resulted from, at least in part, disuse atrophy of the affected forearm skeletal elements. Gross and radiologic evaluation of the Motmot remains countered the possibility that she suffered from a metabolic bone disease, and confirmed the presence of a well-healed parry fracture of the right ulna. The degree of asymmetry in cross-sectional biomechanical properties reported here for K'inich Yax K'uk' Mo' is likely the secondary result of the described blunt-force trauma. The results obtained for the principal Motmot interment are not as dramatic, but suggest subtle changes to humeral cross-sectional geometry subsequent to trauma., (2005 Wiley-Liss, Inc.)

Fourteen adult burials in a large (N = 224) prehistoric central California cemetery (CA-SCL-674) lack forearm bones. Twelve of these otherwise well-articulated primary interments have distal humeri bearing cutmarks with a distribution like that seen in fur seals butchered by Native Californians. Most of the burials with missing forearms are young adult males, a demographic profile that differs significantly from the full sample. Three of these males show evidence of perimortem trauma in addition to forearm amputation. Drilled and polished human radii and ulnae were recovered from the CA-SCL-674 cemetery in archaeological contexts separate from burials with missing forearms. A warfare-related trophy-taking practice is strongly suggested by these bioarchaeological data. Based on these data, it seems likely that 20% (N = 10) or more of the adult males (N = 59) in this population were victims of violence. Evidence of perimortem violence was much less common among women, with only about 2% (N = 2) of adult females (N = 86) subjected to trophy-taking. Examination of museum collections produced further evidence for perimortem forearm amputation among the Native American inhabitants of this area during the transition between the Early and Middle periods. The emergence of more hierarchical social systems during this period may have fostered warfare-related trophy-taking as a symbolic tool for enhancing the power and prestige of individuals within competing social groups., ((c) 2005 Wiley-Liss, Inc.)

Arterial injuries of the forearm account for an important fraction of peripheral vascular injuries. Early diagnosis and treatment are important for both function and viability of the extremity. Arterial injuries of the forearm mostly occur as a result of glass or knife cuts and gunshot wounds and the presence of accompanying injuries may facilitate the diagnosis. However, in this case (50-year-old male patient), a piece of nail behaved like a high-energy particle and injured the radial artery without any accompanying lesion. Detection of normal pulses in the radial and ulnar arteries delayed the diagnosis and treatment. This case report aimed to address difficulties in establishing the diagnosis of isolated radial artery injuries.

Objectives: In this study, we aimed to evaluate the functional results of nerve repair (median and/or ulnar) in patients with forearm clean-cut injuries and investigated the effect of injury level, associated injuries, the type of repair (primary or secondary), and age on the prognosis., Methods: The study included 42 patients (34 males, 8 females; mean age 31 years; range 9 to 62 years) who were treated for forearm clean-cut injuries. Involvement was in the proximal forearm in four, mid-forearm in 11, and distal forearm in 27 cases. There were 51 nerve injuries affecting the median nerve (n=30) and the ulnar nerve (n=21). Nerve injuries were isolated in 12 patients, associated with tendon injuries in nine patients, and with tendon and artery injuries in 21 patients. The patients were evaluated in four age groups including 0-15, 16-30, 31-45 years, and 46 years or above. Functional evaluations were made using the Seddon classification. The effect of injury level, associated injuries, the type of repair, and age on the prognosis was assessed. The mean follow-up was 39 months (range 11 to 57 months)., Results: Although the clinical and functional results of primary and late-primary repairs were less favorable than those of secondary repairs, the difference did not reach a significant level (p>0.05). The injury level, associated injuries, and age did not influence the Seddon scores significantly (p>0.05). In the age group of 0-15 years, the results were very good in all the patients (100%), but good and very good results accounted for only 20% in the age group of 46 years or above., Conclusion: In appropriate cases with clean-cut nerve injuries, primary repair must be the first choice. Taking the low regeneration capacity into consideration, priority should be given to reconstructive procedures in patients at older ages.

Objectives: We evaluated the effect of long- or short-arm casting on the stability of reduction and bone mineral density (BMD) in the forearm in patients treated conservatively for Colles' fractures (CF)., Methods: Eighty-three patients (48 females, 35 males; mean age 53 years; range 30 to 76 years) with an isolated unilateral CF underwent closed reduction followed by a randomly assigned long-arm (n=44) or short-arm (n=39) casting. Fractures were classified according to the Frykman's system. After reduction, radiographs of both forearms were taken, on which radial height and inclination, and volar tilt were measured and assessed according to the criteria by Sarmiento et al. In the first week, BMD measurements were made on the unaffected side to obtain reference values from four sites of the forearm, namely ultradistal, 1/3 proximal, middle diaphysis, and total. Following removal of the casts (mean 45.3 days; range 40 to 55 days), radiographic and BMD assessments were repeated. Osteoporosis was defined according to the criteria of the World Health Organization., Results: The two casting groups were similar with respect to age, sex, Frykman's classification, involved side, and the dominant extremity. Osteoporosis was detected in 20% according to the T scores. All the sites in the fractured forearm showed density losses, but the difference was significant only in the middle diaphysis (p<0.05). No significant relationship was found between BMD losses and the cast type. Angular measurements showed significant deterioration after union; however, none was found to be related to the cast type (p>0.05)., Conclusion: Our results show that BMD losses and deterioration in reduction following treatment of CF occur irrespective of which type of casting is used.