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Introduction: Pseudoaneurysms develop when all three layers of the artery wall are damaged, which causes blood to extravagate from the vessel and connect with the vessel lumen. Adventitia creates the fake sac's inner lining; over time, the hematoma is replaced by fibrous scar tissue, developing a false aneurysm. The fake aneurysm may grow and invade nearby structures, potentially rupturing later. Upper limb peripheral artery pseudoaneurysms are rare, with only a few case reports described in the literature and the most infrequent location being the radial artery. Presentation of Case: A 42-year-old male patient was admitted to our hospital with a chief complaint of pain and an open wound on his left hand after a motorcycle accident. The patient underwent debridement and primary closure for the wound. Eleven days later, the patient returned with a chief complaint of swelling on the injured side with vulnus punctum and bloody discharge at first web. Forearm MRI with contrast revealed a pocket-shaped lesion with internal hi-flow (flow void) in the left volar side associated with the left radial artery. The patient was diagnosed with a rupture of pseudoaneurysm from the left superficial branch of the radial artery and underwent evacuation of pseudoaneurysm and hematoma and ligation of the superficial branch of the radial artery. Conclusion: Despite being relatively uncommon, post-traumatic pseudoaneurysm of the superficial branch of the radial artery can put patients in severe danger and discomfort after hand trauma. Both emergency physicians and surgeons should be aware of the risk for pseudoaneurysm if a patient appears with a pulsatile mass following trauma.

BACKGROUND The rehabilitation intervention for upper extremity fracture varies from shoulder to finger, obtained from physical modalities and exercise. Physical modality and exercise rehabilitation intervention effectively reduce pain, increase range of motion (ROM), hand function and improve quality of life. This systematic review aims to synthesize current scientific knowledge on rehabilitative interventions with a specific focus on upper extremity fractures and the effect of all interventions on the patient. METHODS Three scholarly databases (PubMed, Google Scholar, Science Direct) were systematically searched. Literature published before 10 January 2022 focused on upper extremity fracture and rehabilitation treatment patients. Quality assessment was completed with CEBM tools by Oxford University. For PICO, The Population was upper extremity fractures, and the intervention was rehabilitation intervention, both physical modality and exercise. The comparation was other rehabilitation interventions or without rehabilitation, and the outcome in this study were measured with the visual analogue scale (VAS), ROM, hand function, and quality of life (QoL). RESULTS Eight studies were included in this review among 18.326 reference titles founded and screened. All of the studies had various sample sizes followed by bias analysis with CEBM tools. Rehabilitation for elbow fracture was dynamic fixation using rigid tape and proprioceptive neuromuscular facilitation stretching. Rehabilitation for distal radius fracture was scapular exercise, graded motor imagery, hot pack on hand volume, illusory kinesthesia, and wrist exercise. These interventions can reduce the pain, improve strength, range of motion, hand function and quality of life in upper extremity fracture patients. CONCLUSIONS Exercise and physical modality rehabilitation intervention have proven to reduce pain, improve strength, range of motion, hand function and quality of life in upper extremity fracture patients.

Background: Trans-scaphoid lunate dislocation is an orthopaedic injury, mostly because of high energy trauma. Due to subtle clinical and radiological findings, it might be easily left undiagnosed, with estimated 25% cases are missed at initial assessment in emergency department. Non-union scaphoid, which accounts for 5-10% of all scaphoid fractures treated with K-wires fixation, mostly occurs in young and active individual. Case Presentation: Thirty-seven-years-old right-handed man complained pain, and restricted range of motion (ROM) on his right wrist after fell from 2m height. Loss of symmetry and parallelism of joint space in Gilula's line shown in X-ray, possible for a trans-scaphoid lunate dislocation. We performed dorsal approach and internal fixation using Kirschner wire (1.0). The patient had a short arm cast for 4 weeks. The K-wires were removed 5 weeks postoperatively. We achieved good result clinically in 3, 9, and 36 months of follow up (Mayo Wrist Score of 70, 80, 90, respectively). The ROM of wrist is preferable than pre-surgery (RD 20o, UD 20o, and WF-WE 60o) with avascular necrosis of scaphoid in 9th month follow up (in 2019). Unfortunately, at 3 years of follow up, X-ray showed non-union scaphoid, avascular necrosis, and osteophytes between scaphoid and radius. Discussion: Unless it is asymptomatic, surgery is the recommended treatment for scaphoid non-union in order to limit further morbidity from pain, weakness, and stiffness of the wrist joint. However, in this case, the patient has been doing any activities with his right hand normally and never felt any pain in the last 2 years, eventhough the X-ray shows fracture line at distal of scaphoid. Thus, we choose not to do any treatment for it. Conclusion: In the case of trans-scaphoid lunate dislocation, the use of K-wire fixation shows excellent clinical outcome, but radiological finding shows non-union scaphoid with osteophytes, thus it has possibility to develop degenerative disease in the future. Keywords: Trans-scaphoid Lunate dislocation; Non-union; K-wire Fixation

Background: Osteoporosis is an increasing health problem in Indonesia. Fractures that occur in the spine and pelvis are considered to be the most common fracture sites for osteoporosis. Aim: to determine the differences in bone mineral density values in postmenopausal women with fracture and non-fracture. Methods: Survey was carried out in postmenopausal female patients with fractures and without fractures who were included in the inclusion criteria with a case-control study approach and had bone mass density data. For the group of cases with fracture, the amount of vertebral compression was measured using Gennant's measurement criteria. Interviews were conducted regarding the characteristics of patients with and without fracture. The differences in BMD values ​​were analyzed in postmenpausal female patients with fracture and without fracture by using unpaired T test on normal data distribution and Mann-Whitney test on abnormal data distribution. The measured BMD value is the T-score. The analysis result was considered significant if p 0.5). Conclusion: BMD L4 and femoral neck values ​​differ significantly in female patients with postmenopausal osteopenia with fracture and non-fracture.

Introduction: A tourniquet is a typical equipment used in the orthopedics surgery to decrease blood loss and create a better operating environment. Ischemic-reperfusion damage, which happens when the tourniquet is deflated, is one of the tourniquet's negative effects. Antioxidants can be used to minimize oxidative stress, which is one strategy to mitigate ischemic-reperfusion injury. Aloe vera, for example, is widely known for its antioxidant and anti-inflammatory properties. Method: The tibias of male Wistar strain rats (Rattus norvegicus) were fractured in this experiment, and Aloe vera gel was given orally as an antioxidant. A total of 18 rats were utilized in this research, which were separated into 6 groups. Varying amounts of Aloe vera extract were given to the treatment groups: 40 mg/kgBW, 60 mg/kgBW, and 80 mg/kgBW. The tourniquet would be inflated for two hours then deflated after application of the Aloe vera extract. Superoxide dismutase (SOD) and malondialdehyde levels were measured in the tibia (MDA). Result: Application of tourniquet increased oxidative stress marker in fracture state, marked by reduction of SOD and increase of MDA. After administration of Aloe vera extract, the oxidative stress parameters (SOD and MDA) were reduced significantly. Conclusion: The result of this study suggests that tourniquet increased oxidative stress marker in fracture state and Aloe vera extract could be used to ameliorate this ischemic-reperfusion injury.

Introduction: Osteomyelitis is a serious infection of the bone. One of the therapies for osteomyelitis is antibiotic treatment. Antibiotic treatment has evolved substantially, but bone infections are still a challenge. Antimicrobial therapy is also difficult, caused by antibiotic-resistant organisms. Therefore, a systematic review is needed to assess antibiotic use in osteomyelitis infection. Method: Articles were searched using Pubmed with keywords “antibiotics”, “osteomyelitis”, and its combination. The authors used five years publication date and English language to select the appropriate journal. Result: The author identified 13 relevant articles with antibiotics use in osteomyelitis. All of the cases were about chronic osteomyelitis and osteomyelitis in diabetic foot ulcers. Osteomyelitis in other sites of long bones needs longer duration treatment than long bone osteomyelitis. In acute osteomyelitis in children, antibiotic treatment can switch from IV to oral antibiotics. Furthermore, chronic osteomyelitis needs longer treatment to resolve than acute osteomyelitis. Conclusion: Antibiotics still mainstay treatment with surgery for osteomyelitis treatment. With acute, children, and long bone only need shorter treatment than chronic, adult, and non-long bone osteomyelitis.

BACKGROUND: Surgery for large joint areas can increase risk of venous thromboembolism, which can be in the form of pulmonary embolism or deep vein thrombosis (DVT). As much as, 40–60% of hemostasis abnormalities, specifically hypercoagulable diseases, are suspected of causing this condition. The risk of developing DVT can be assessed using a physiological examination such as Wells score, Caprini score, and Padua score. The scoring systems assess some of the patient’s symptoms and risk factors for increasing the incidence of DVT. Hypercoagulation conditions can be assessed using D-dimer, which is often considered a gold standard in measuring hypercoagulation conditions or as an indicator of DVT. AIM: We aimed to investigate correlation of Wells Score, Caprine Score, and Padua Score with risk of hypercoagulation condition based on d-dimer in intra-articular, periarticular, and degenerative fracture patients of inferior extremity. METHODS: This study used a cross-sectional design and was conducted on 34 participants that undergoing periarticular surgery. This study compared the Wells, Caprini, and Padua scores test against hypercoagulation conditions confirmed by the D-dimer examination. RESULTS: The correlation between Wells, Padua, Caprini scores, and D-dimer was 0.676, 0.023, and 0.395, respectively. CONCLUSION: There was a significant relationship between the Padua scores and the D-dimer.

Diabetes mellitus is one of the most common chronic metabolic diseases. Diabetes mellitus can cause many complications such as obesity, stroke, coronary heart disease, diabetic retinopathy, diabetic nephropathy, and diabetic neuropathy. Studies show that compared to the cost of treating diabetes, more costs are incurred for the treatment of complications of diabetes. One of the most common chronic complications is diabetic foot ulcers (DFU), which are disabling and affect about 15% of diabetic patients which leading to infection, gangrene, and eventually leading to amputation. DFU care requires a cross-disciplinary and systematic approach consisting of blood glucose control, surgical debridement, vascular recanalization, decompression, and supportive treatment. Controlling wound infection and performing tissue repair is very important to prevent or reduce amputation rates. The concept of negative pressure wound therapy (NPWT) was first established and applied in clinical practice by a German physician, Fleischmann, in 1993 and has been recognized for its remarkable effects in increasing perfusion, improving wound drainage, and promoting the growth of granulation tissue. Currently, NPWT is widely used for various acute and chronic wounds, such as DFU and considered effective to reduce limb amputation rates. NPWT is safe for the treatment of neuropathic, nonischemic, and noninfected plantar ulceration in patients with diabetes mellitus. However, special attention should be given to proper patient selection and intraoperative assessment to ensure wound closure and avoid undue complications.

The World Health Organization (WHO) has subsequently designated this ongoing disease as Coronavirus Disease 2019 (COVID-19). One month later, the COVID-19 outbreak was declared a pandemic. The rapid global spread of viral infections and diseases led to the introduction of broad containment and reduction strategies in affected countries worldwide. Since the early phase of the pandemic, operating rooms have been converted into additional ICUs to support critically ill patients, and non-urgent and non-cancerous surgical procedures have been cancelled or postponed to a later date. The impact of COVID-19 on surgical practice is widespread, ranging from labor and staff issues, procedure priorities, the risk of intraoperative virus transmission and the impact on surgical education. The impact on surgical practice includes the use of surgical facilities, redeploying staff, staff preparation, national referral procedure and preoperative phase. The impact of COVID-19 on surgeons' daily practice and surgeon education is enormous. The cancellation of elective and non-urgent surgeries has allowed surgeons to become an important staff resource for the health system to deal with the COVID-19 pandemic. Surgeons are considering safe, non-surgical alternative options for treating their patients during COVID-19.

Highlights • Three case of radial head fracture treated with radial head arthroplasty. • Evaluation of the functional outcomes after operative treatment of radial head arthroplasty. • Functional outcomes assessment with active and passive range of motion. • Satisfying result on pain and a fair result on functional outcome on patient follow-up. • Good follow up is important to minimize the complications of radial head arthroplasty., Introduction Radial head arthroplasty (RHA) has become one of the mainstay surgical treatment for radial head fracture in certain conditions. Many previous studies compared the superiority of either open reduction and internal fixation (ORIF) and RHA with inconclusive result. Our case series aim to evaluate the functional outcome of the patients treated with RHA in our institution. Presentation of case We evaluated three patients who had RHA in 2018 and 2019. The function of flexion, extension, supination and pronation of the elbow was evaluated. The range of motion (ROM) was assessed in both active and passive way. Discussion An abundant of literatures stated that RHA result is superior than radial head resection and ORIF. Our case series present a satisfying result on pain and a fair result on functional outcome from the range of motion (ROM) evaluation on patient follow-up. Conclusion A good follow up for post-operative care plays an important role in management of RHA to minimize the rate of complications. In this case series, the functional outcomes after RHA is good, but a larger number of patient and longer follow up duration is needed for a better analysis.

Background Fracture is a discontinuity of bone tissue, growth plates and/or cartilage which generally caused by trauma. Fracture healing is influenced by many things, including patient condition, age, comorbidity, lifestyle, medication and management. The use of tourniquets in medical cases reached 20.000 cases per day around the world. In Norway between 2005 and 2006, the use of tourniquets on orthopedic surgery reached 63.484 cases. The goal of using a tourniquet is to obtain a blood-free operation field to achieve maximum operating results. However, deflation of tourniquets can lead to reperfusion mechanisms that cause injuries resulting from the production of Reactive Oxygen Species (ROS). This study aims to measure the level of malondialdehyde (MDA) and the osteoblast count after tourniquet application in murine mode. Methods Thirty-two male Wistar strain rats were divided into two groups and tibial fracture with consequence casting was performed. The rats were divided into two groups, one control group (n = 16) and one treatment group (n = 16). Both groups' rats’ right tibia was fractured and immobilized with a long-leg cast. The tourniquet (4.5 oz orthodontic rubber) was applied to the treatment group for two hours. The evaluation of the osteoblast count and the malondialdehyde (MDA) level was done on day 14. The quantitative osteoblast count was done under light microscopy within 10 high power fields in 4000x magnification. The MDA level was measured by using Thiobarbituric Acid Reactive Substances (TBARS) assay. Data analysis was done by using independent t-test. Results There was elevated MDA levels (0,126 in group 1 compared to 8763 in group 2) with p Conclusions The use of tourniquets can increase MDA levels due to oxidative stress arising from ischemic-reperfusion injury, as well as decreasing the number of osteoblasts.

Introduction: A Monteggia fracture was described initially as a fracture of the proximal third ulna and anterior dislocation of the proximal epiphysis radius.[1] In 1967, Bado discovered “true Monteggia lesions” and classified them into 4 groups.[2] He also used the term “equivalents” or “Monteggia-like-lesions” to describe specific injuries with similar radiographic patterns.[3] This type of fracture is rare and frequently associated with complications, poor functional results, and further operations.[4] Patient concerns: A 16-year-old girl was admitted to our emergency department after a single motorcycle accident. Her main complaint was the pain and swollen of her left elbow. She was reluctant to move her arm due to pain. Diagnosis: Radiograph examination showed a displaced fracture of the left proximal third ulna accompanied by displacement of the left proximal radius. This fracture was similar to the Monteggia type III fracture except for proximal radial disruption that occurred laterally through a Salter-Harris type II fracture. Interventions: The patient underwent surgical debridement, and the forearm was immobilized using a backslap in a supine position and elbow flexion 90o. Open reduction and internal fixation were performed 5 days later. The ulna was reduced and stabilized first using a 3.5 mm one-third tubular plate (ORMED), and internal fixation of the radial epiphysis was done using a 1.6 mm miniplate (Prohealth). Outcomes: After 3 months, the patient showed improvement with the Mayo Elbow Performance Score (MEPS) of 85. She did not complain of any pain and decreased strength. The patient regained 0 to 125o of elbow flexion and 0 to 165o of supination and pronation. Conclusion: Monteggia-like-lesion has many variations in physical and radiograph appearance. Careful evaluation of fracture pattern, identification of injury mechanism, and appropriate treatment planning based on Monteggia fracture treatment principles are mandatory to achieve the patient's best outcome.

Unicameral bone cyst (UBC) or simple bone cyst (SBC) is a benign cystic lesion commonly found in the humerus and femur that is mainly encountered during childhood. The currently available treatments for UBC of the hand commonly involve curettage, bone grafting, partial resection with or without grafting, multiple drilling, fracture immobilization and observation alone, and steroid injection. We herein report a case treated with total resection of the cyst and non-vascularized fibular graft in a 9-year-old right-handed female patient. The patient presented with a chief complaint of a large, fast growing lump over the first metacarpal of the left hand. Flexion of the first metacarpophalangeal joint was limited. After the diagnosis was established with plain radiographs followed by biopsy, the cyst was completely removed by resecting the shaft of the metacarpal bone with preservation of the epiphyseal plate. A bone graft was obtained from the fibula and inserted in the gap, distally attached to the epiphyseal plate of the metacarpal and fixed with a Kirshner wire proximally. Radiographs revealed solid union of the bone graft to the epiphyseal plate at the head after 7 weeks, with improving function of the thumb. SBC or UBC of the metacarpal bone is very rare. A more aggressive method, such as in the case presented herein, may be necessary to treat this condition.

BACKGROUND: Tourniquet use is prevalent in the orthopaedic field to achieve a bloodless operating field, but it poses risks of local and systemic complications, including lung injury. This study aims to examine the effect of tourniquet application on the hindlimb of a rat to its lung. MATERIALS AND METHODS: This is an experimental study with 48 male Wistar strain rats as samples. The rats were divided into group A (n = 24), killed directly after fracturization and tourniquet application, and group B (n = 24), killed 14 days post-procedure. Each group was divided into four: group A1/B1 (control group, three hours tourniquet application without reperfusion interval), A2/B2 (5-min reperfusion between 2-h and 1-h tourniquet application), A3/B3 (10-min reperfusion), and A4/B4 (15-min reperfusion). The lung tissue was examined histologically within ten high-power fields (400 × magnification). The severity of lung injury was measured using the Lung Injury Score (LIS). The oxidative damage was measured by determining the malondialdehyde (MDA) level, using the TBARS (thiobarbituric acid reactive substance assay) method. RESULTS: There was a dose-dependent decrease of LIS and MDA in groups A and B with increasing reperfusion interval. Fifteen-minute reperfusion interval caused a 54.55% and 45.33% LIS reduction in groups A and B, respectively. All pair-wise group comparisons (p

Rheumatoid arthritis (RA) is mainly treated with immunosuppressive drugs, which affects the immunological system. Therefore, the risk of tuberculosis was increased two to ten times in RA patients. Moreover, immunosuppressant is contraindicated in patients with tuberculosis arthritis. A 51-year-old male was presented with pain in his left elbow after he slipped on the floor. He was diagnosed with RA for 16 years and only took prednisone for six years. Six months before, he came to a rheumatologist and was given corticosteroid for six months for RA. The left elbow radiograph and joint aspiration revealed a tuberculosis infection. The patient treated with chloroquine and oral antituberculosis for one year and showed good clinical outcomes. Other diseases should be suspected in RA with uncommon symptoms. Chloroquine is the drug of choice in RA patients with tuberculosis who are contraindicated in immunosuppressant therapy because chloroquine has no immunosuppressant effect.