Presence of anomalous flexor carpi radialis brevis (FCRB) in Madelung's deformity.

An anomalous flexor carpi radialis brevis (FCRB) muscle was present in four of nine patients undergoing surgery for Madelung's deformity. This disproportionately frequent finding suggests an embryologic dysgenesis of forearm formation rather than a developmental tethering of Vicker's ligament.Level of evidence: IV (case series).

Reliability of the Masada Classification for Forearm Involvement in Patients With Hereditary Multiple Osteochondromas (HMO).

BACKGROUND: Classifications describing forearm lesions in patients with Hereditary Multiple Osteochondromatosis (HMO) have been used to recommend surgical intervention and stratify outcomes; however, there is no consensus on which classification offers greater reliability. The purpose of this study was to determine the reliability of the Masada classification and newer classifications among pediatric hand surgeons. METHODS: One hundred one patients with HMO between June 2014 and October 2019 were enrolled in the Congenital Upper Limb Differences (CoULD) Registry. Of those, 67 patients with 101 forearms were included. Four pediatric hand surgeons from the CoULD study group undertook an online evaluation. Each rater classified radiographs according to the Masada classification. Six weeks later, raters were asked to reclassify images according to the Masada, Gottschalk, and Jo classifications. Rater agreement for these classifications was assessed by estimating Fleiss kappa along with a 95% CI. RESULTS: Interrater agreement for Masada classification after the first reading was poor (κ=0.35; 95% CI=0.30-0.41) across all raters. Interrater agreement across the 4 raters decreased for the Masada classification from the first to the second reading (κ=0.35 vs 0.21; P <0.001). Intrarater agreement for the Masada classification ranged from 0.32 to 0.63 from the first to the second study reading. Gottschalk and Jo classifications yielded significantly better interrater agreement compared with Masada (κ=0.43 vs 0.21; P <0.001). Unclassifiable cases were highest in the Masada classification (34% to 44%) and lower in the Jo (17%) and Gottschalk (14%) classifications. CONCLUSION: Despite wide use, the Masada classification was found to have low reliability when classifying forearm deformities in HMO. Gottschalk offered more options for location, yet lacked deformity description including radial head dislocation. Jo classification offered more locations than Masada and incorporated radial head dislocation in some patterns. Based on the shortcomings in all 3 classification systems, the development of a more inclusive and reliable classification is warranted. LEVEL OF EVIDENCE: Level II; Diagnostic.

Manufacture and clinical application of the forearm pronation's assistant tableware in the severely burned.

INTRODUCTION: Even after reconstructive surgery, it is still difficult for patients with severe burns to achieve independent eating activity. In this project, we customized the forearm pronation's assistant tableware to assist in improvement with eating activities. METHODS: From January 2017 to December 2018, 28 patients with severe burns including the hands were recruited. For the patient's independent eating activities, we customized forearm pronation's tableware (forks and spoons). We compared modified Barthel index (MBI) and Visual analogue scale (VAS) of satisfaction under three conditions: no auxiliary tableware, ADL universal cuff, or forearm pronation tableware; to compare the duration and the weight of food spilled during lunch when the patients wore the ADL universal cuff or the forearm pronation's tableware. Differences in MBI (rank data) were tested by the Friedman test, differences in VAS (normal distribution) were tested with One-way ANOVA (Bonferroni), differences in the duration and the weight (normal distribution data) were tested by paired sample t test. RESULTS: After wearing the forearm pronation's assistant tableware, MBI VAS both increased more than when the patients did not wear the auxiliary tableware (all p＜0.05). When the subjects wore forearm pronation tableware, the duration of lunch significantly decreased and the quality of eating activity significantly improved compared to the ADL universal cuff in eating activity (all p＜0.05). CONCLUSION: After wearing the forearm pronation's assistant tableware, the patients with severe burns completely or almost completely accomplished independent eating, the duration was decreased, and during eating activity the quality and the satisfaction were improved. CLINICAL TRIAL REGISTRATION: Chinese Clinical trial registry, ChiCTR1800019963.

Bilateral anatomical variations in the extensor compartment of forearm and hand.

An unusual variation of the extensor muscles was found during the routine dissection of the posterior compartment of the forearm. The left forearm presented an extensor medii proprius muscle, the tendon of which had an unusual trajectory. It passed through the second extensor compartment between the tendons of the extensor carpi radialis longus and extensor carpi radialis brevis muscles. The right forearm presented two muscles for the index finger: one, the extensor indicis et medius communis, the tendon of which was split into three tendons, one radial and one ulnar for the index finger and a rudimentary tendon for the middle finger; the second muscle for the index finger had an unusual origin, common with the extensor carpi radialis brevis, and its tendon ran superficially to the tendon of the extensor indicis et medius communis muscle. Knowledge goes tendon variations can be significant not only for clinicians to misdiagnose a debilitating wrist extensor pain syndrome but also for surgeons to avoid iatrogenic injuries in hand surgery.

Gradual ulnar lengthening in Masada type I/IIb deformity in patients with hereditary multiple osteochondromas: a retrospective study with a mean follow-up of 4.2 years.

BACKGROUND: Gradual ulnar lengthening is the most commonly used procedure in the treatment of Masada type I/II deformity in patients with hereditary multiple osteochondromas. However, the treatment remains controversial for the recurrence of deformity in growing children. This study aims to evaluate the clinical and radiological outcomes of ulnar gradual lengthening in our clinic. METHODS: We retrospectively reviewed patients who underwent ulnar lengthening by distraction osteogenesis from June 2008 to October 2017. The carrying angle (CA) and range of motion (ROM) of the forearm and elbow were clinically assessed, and the radial articular angle (RAA) and ulnar shortening (US) were radiologically assessed before lengthening, 2 months after external frame removal, and at the last follow-up. RESULTS: The current study included 15 patients (17 forearms) with a mean age of 9.4 ± 2.3 years at the index surgery. The mean follow-up period was 4.2 ± 2.4 years. There were 9 patients (10 forearms) with Masada type I deformity and 6 patients (7 forearms) with Masada type IIb deformity. The mean amount of ulnar lengthening was 4.2 ± 1.2 cm. The mean RAA improved from 37 ± 8 to 30 ± 7° initially (p = 0.005) and relapsed to 34 ± 8° at the last follow-up (p = 0.255). There was a minimal deterioration of US yet significant improvement at the last follow-up compared to pre-op (p < 0.001). At the last follow-up, the mean forearm pronation and elbow flexion increased significantly (p < 0.001 and p = 0.013, respectively), and the mean carrying angle also improved significantly (p < 0.001). No patient with type IIb deformity achieved a concentric radial head reduction. CONCLUSIONS: Gradual ulnar lengthening significantly reduces cosmetic deformity and improves function in patients with Masada type I/IIb deformity. Our results supported early ulnar lengthening for patients with a tendency of dislocation of the radial head.

Older age and multi-joint external fixator are two risk factors of complications in ulnar lengthening in children with hereditary multiple exostosis.

OBJECTIVES: Hereditary multiple exostosis (HME) often involves forearm deformities. The aim of this study was to present the clinical results of 37 children who underwent ulnar lengthening with two different types of unilateral external fixators and to investigate the risk factors of complications. METHODS: We evaluated 37 children with forearm deformities caused by HME treated in our hospital from January 2008 to July 2019. The surgical procedures included resection of exostosis, osteotomy of the ulna, and gradual lengthening of the ulna with a unilateral external fixator. According to the type of fixator they received, the children were divided into two groups: group A received monorail fixators and group B received multi-joint fixators. Radiographic and functional parameters were assessed. Complications were recorded. RESULTS: All patients were followed-up for an average of 4.6 years (3.0 to 6.5). In both group A and group B, the ulna shortening (US), radial articular angle (RAA), carpal slip (CS), elbow flexion, forearm pronation, supination, and Mayo Elbow Performance Score (MEPS) values improved significantly from preoperatively to postoperatively (p < 0.05). However, the ulnar deviation was observed in 4 cases in group B and no cases in group A. According to logistic regression, the difference was only related to age (p < 0.05) and the type of external fixator (p < 0.05). CONCLUSIONS: Ulnar lengthening with unilateral external fixation is a safe and effective procedure for the treatment of HME. Regarding complications, deviation of the ulna axis was more likely to occur in older children with multi-joint external fixators.

Unusual presentation of acute compartment syndrome of the forearm and hand.

A 49-year-old man was referred to orthopaedics with an acute onset of left forearm and hand swelling, widespread blisters and erythema after lying face down on the floor for an unknown period of time. He also presented with left wrist stiffness due to pain and clawing of the fingers and glove-type loss of sensation in the whole hand. Any attempt to straighten the fingers or extend the wrist exacerbated the pain. Symptoms deteriorated rapidly. Compartment syndrome was diagnosed and surgical fasciotomies of his left forearm and left hand were performed following multidisciplinary urgent discussions between plastic surgeons, microbiologists, anaesthetists and orthopaedic surgeons. The left forearm and left hand underwent extensive decompression and subsequent skin grafting and had good healing despite the initial skin presentation. The patient has made a satisfactory recovery and has required extensive hand physiotherapy and social care.

Discondrosteosis de Léri-Weill. Presentación de una familia afectada / Léri-Weill dyschondrosteosis. Presentation of an affected family

RESUMEN Fundamentación: La discondrosteosis de Léri-Weill, displasia ósea de origen genético que afecta la región mesomélica con acortamiento de las extremidades, provoca talla baja con extremidades cortas con deformidad de Madelung; esta enfermedad muestra un patrón de herencia autosómico dominante con alta penetrancia. Objetivo: Describir las deformidades de esta discondrosteosis de baja frecuencia con expresividad variable, que se presentó de la misma forma en todos los afectados de esta familia. Presentación de caso: Se reportó una familia con enfermos en tres generaciones con deformidad de Madelung de ambas muñecas y baja estatura de origen mesomélico, que se mantiene seguimiento en consultas de Genética Clínica y Ortopedia. Conclusiones: El examen físico y radiológico imprescindibles para llegar al diagnóstico clínico. El método clínico y la valoración multidisciplinaria resultaron de gran valor para definir esta enfermedad y poder brindar un adecuado asesoramiento genético a esta familia.

ABSTRACT Background: Léri-Weill dyschondrosteosis, bone dysplasia of genetic origin that affects the mesomelic region with shortening of the extremities, causes short stature with short extremities with Madelung deformity.This disease shows an autosomal dominant inheritance pattern with high penetrance. Objective: To describe the deformities of this low frequency dyschondrosteosis with variable expressivity which was presented in the same way in all those affected in this family. Case presentation: A family with sick members was reported in three generations with Madelung deformity of both wrists and short stature of mesomelic origin which is followed up in consultations of Clinical Genetics and Orthopedics. Conclusion: The essential physical and radiological examination to reach the clinical diagnosis. The clinical method and the multidisciplinary assessment were of great value to define this disease and to be able to provide adequate genetic counseling to this family.

Clinical application of individualized 3D-printed navigation template to children with cubitus varus deformity.

BACKGROUND: Cubitus varus deformity is a common sequela of elbow fractures in children. Cubitus varus deformity treatment is tending toward 3D correction, which is challenging for orthopedic surgeons. This study aims to explore whether individualized 3D-printed navigation templates can assist with accurate and effective corrective treatment of children with cubitus varus deformity. METHODS: Thirty-five patients were treated for cubitus varus deformity from June 2015 to April 2017, including 21 boys and 14 girls, aged 4.6-13.2 years (average, 7.5 years). Of these cases, 17 deformities were on the left side and 18 were on the right side. All were treated with wedge osteotomy of the lateral distal humerus. 3D-printed navigation templates were used in 16 cases, while traditional surgery was used in 19 cases. All patients underwent computed tomography scans before surgery. Computer software was used to analyze the measurements and design and print individualized navigation templates. The navigation templates were matched, and surgery was initially simulated. Intraoperative individualized navigation templates were used to assist with accurate osteotomy and Kirschner wire fixation. Operation times were recorded in all cases, the carrying angles before and after surgery were assessed by computer, and postoperative elbow joint function was evaluated using Bellemore criteria. All measurement data were presented as means ± SD, and Student's t test was used to examine differences between groups. All count data between both groups were compared using the chi-square test or Fisher's exact test analysis. RESULTS: All individualized navigation templates matched well with the corresponding anatomical markers and were consistent with preoperative planning, simulated surgery, and intraoperative procedures. Average operation times from clear exposure to fixed Kirschner wire were 11.69 min (9.6-13.5 min) for the individualized navigation template group and 22.89 min (17.7-26.8 min) for the traditional operation group (p < 0.001). Average differences in postoperation carrying angles between affected and healthy sides were 1.13° (0-2.0°) and 4.21° (0-7.5°), respectively (p < 0.001). Follow-up 6-12 months postoperation showed that elbow function did not differ significantly between groups using the Bellemore criteria (p > 0.05). CONCLUSIONS: Individualized navigation templates simplify procedures, reduce operation time, and improve accuracy when used in orthopedic surgery to treat children with cubitus varus deformity.

Absence of flexor digitorum profundus muscle and variation of flexor digitorum superficialis muscle in a little finger: two case reports.

PURPOSE: Knowledge of rare variants of the FDP is of high clinical importance for physicians examining patients for tendon lacerations and especially for hand surgeons operating tendon injuries. METHODS: During routine dissection at our Department of Anatomy both cases were observed. RESULTS: Variations of flexor digitorum superficialis and flexor digitorum profundus muscles of the little finger were observed in two cadavers. In both cases, the flexor digitorum profundus muscle for the little finger was absent. Moreover, in the first case, the flexor digitorum superficialis muscle for the little finger was hypoplastic and in the second case it featured variable insertion. CONCLUSION: There were found only four cases in previous literature describing absent flexor digitorum profundus tendon without any muscle attachment to the base of the distal phalanx. Furthermore, all previously described cases were observed in living patients. To our best knowledge, a case report in cadaver has yet not been reported and is of high importance for hand surgeons examining the hand for tendon injuries.

Bilateral reversed palmaris longus muscle: a case report and systematic literature review.

PURPOSE: We present a case of a bilateral reversed palmaris longus muscle and a systematic review of the literature on this anatomical variation. METHODS: Routine dissection of a 90-year-old male cadaver revealed a rare bilateral reversed palmaris longus. This was documented photographically, and length and relation to anatomical landmarks were recorded. This finding stimulated a systematic review of the literature on the reversed palmaris longus variation, from which measurements were collated and statistical analysis performed to determine the prevalence, average length, relationship to side and sex, and to discuss its clinical and evolutionary implications. RESULTS: The average length of the muscle belly and tendon of reversed palmaris longus was 135 mm and 126 mm, respectively. Statistical analysis revealed no disparity in presentation due to sex and side; however, bilateral reversed palmaris longus has only been reported in males. A high proportion (70.8%) of reversed palmaris longus were discovered in the right upper limb compared to the left. CONCLUSION: Variations in palmaris longus are purported to be as a result of phylogenetic regression. Clinically, patients with this variant may present with pain or swelling of the distal forearm, often as a result of intense physical exertion related to occupation or sport. Clinicians should be aware of this muscle variant as its presence could lead to confusion during tendon allograft harvesting procedures in reconstructive and tendon grafting surgery.

Gradual ulnar lengthening by an Ilizarov ring fixator for correction of Masada IIb forearm deformity without tumor excision in hereditary multiple exostosis: preliminary results.

Bony exostoses are benign osteocartilaginous growths that start close to growth plates. Approximately 30-60% of patients have forearm deformities. The commonly encountered forearm deformities in these patients are bowing of the radius, with or without ulnar drift of the carpus, radial head dislocation, shortening of the ulna, and radial head dislocation. The current study reported on the results of management of radial head dislocation for type IIb Masada and Oho classification of forearm deformities by Ilizarov ulnar lengthening and without tumor excision. A series of 12 patients with Masada type IIb deformity were treated by Ilizarov lengthening at AlHadra University Hospital, Alexandria, Egypt, during the period from January 2008 to June 2014. There were eight males and four females; the right forearm was affected in seven patients. The mean age of the patients was 8.7 years (range: 7.5-10 years). All cases showed ulnar shortening with distal ulnar exostosis and radial head dislocation (Masada type IIb). All patients were operated on under general anesthesia, with application of the Ilizarov frame to the forearm. The frame used was assembled of two complete rings; the proximal one was fixed to the proximal ulna and the distal ring was fixed to both radius and ulna. Ulnar osteotomy was performed between the two rings, followed by ulnar lengthening 10 days postoperatively to lengthen the ulna and pull down the radius. Over a follow-up period of 33.2 months (24-48 months), all patients showed spontaneous reduction of the radial head and correction of the forearm deformity. The range of motion improved: flexion increased from 117.5° (110-130°) to 145° (130-160°) and extension increased to 4.6° (0-10°), whereas it was 13.8° (10-20°) preoperatively and the supination increased from 46.3° (40-50°) preoperatively to 73.6° (65-80°) postoperatively. Pronation improved from a preoperative average of 37.9° (30-40°) to 70.8° (60-80°) at the end of follow-up. The average amount of ulnar length was 27.9 mm (25-35) and the duration of external fixation was 103.3 days on average, with a range of 90-130. Thus, the average external fixation index was 3.7 days/mm (range: 3.6-4.0). Gradual lengthening of the ulna and pulling down the radius with an Ilizarov frame is an excellent method for correction of forearm deformity in patients with multiple hereditary exostosis (Masada IIb). Early intervention is the key to achieving spontaneous reduction of the radial head in all patients without the need for corrective osteotomy or tumor excision. Level of evidence: level IV.

A Rare Presentation and Management of Forearm Deformity in a Patient with Hereditary Multiple Exostoses: A Case Report.

CASE: We report the case of a patient with a long-standing and progressive forearm deformity, secondary to underlying hereditary multiple exostoses (HME). A salvage surgery was performed with excision of the pathologic parts of the radius and the ulna, followed by the creation of a 1-bone forearm. CONCLUSION: One of the common manifestations of HME is forearm deformity due to abnormal ossification and osteochondromas that affect the radius and/or the ulna. Progressive deformity can lead to increasing pain, joint instability, limited motion, and functional decline. Neglected or recalcitrant deformities pose a treatment challenge. At 1.5 years after surgery, the patient had a satisfactory outcome with a fully functional, pain-free forearm in a fixed, neutral position.

Anatomic Variation of the Median Nerve Associated with an Anomalous Muscle of the Forearm.

Documented anatomical variations are important not only for the study of the subject of anatomy, but also in clinical situation. This knowledge would aid surgeons in planning a preoperative strategy for surgical procedures and reconstructive surgery. The right forearm of a 35-year-old embalmed male cadaver present a splitting of the median nerve in the proximal 1/3 of the forearm to form medial and lateral divisions that accommodate an anomalous muscle. The split median nerve reunites at the distal 1/3 and continues as a single nerve. The anomalous muscle arises by muscle fibers from flexor digitorum superficialis and inserted by tendon into flexor digitorum profundus. There was no such variation in the left forearm. The knowledge of such anatomical variations is important to clinicians and surgeons in interpreting atypical clinical presentations and avoiding unusual injury during surgery.

An Evaluation of Forearm Deformities in Hereditary Multiple Exostoses: Factors Associated With Radial Head Dislocation and Comprehensive Classification.

PURPOSE: This study attempted to evaluate a series of patients with hereditary multiple exostoses (HME) who could not be categorized according to the widely accepted Masada classification and to identify radiographic variables such as radial bowing, ulnar shortening, ulnar variance, radial articular angle, and carpal slip predictive of deformity. METHODS: We retrospectively reviewed data on 102 upper limbs of 53 pediatric patients with HME. Demographics, site of forearm involvement, and radiographic parameters were documented. Patients with exostoses of the forearms were categorized into 6 groups based on location of the exostoses and presence or absence of a dislocated radial head. Proportional ulnar shortening was calculated as the ratio of ulnar length to radial length. RESULTS: According to the Masada classification, 4 limbs were normal, 10 were type I, 2 were type II, and 24 were type III. Sixty-six limbs were unclassifiable. We classified those 66 limbs using a modification of the Masada classification. Of the 106 limbs, 11 (10.3%) had a dislocated radial head. Based on the radiographic analysis, patients with proportional ulnar shortening of less than 0.9 had a higher risk of radial head dislocation than did those with proportional ulnar shortening of 0.9 or greater. Patients with radial bowing greater than 8.1% showed a higher frequency of radial head dislocation than did those with radial bowing of 8.1% or less. Exostoses of both the distal radius and ulna tended to increase the rate of radial head dislocation. A greater amount of negative ulnar variance caused more radial bowing and a greater radioarticular angle. CONCLUSIONS: We propose a new comprehensive forearm classification for patients with HME. Proportional ulnar shortening less than 0.9 and radial bowing 8.1% or greater can be used to predict the risk of radial head dislocation. TYPE OF STUDY/LEVEL OF EVIDENCE: Prognostic IV.

Metacarpal Bone Plane Examination by Ultrasonography for the Diagnosis of Fetal Forearm and Hand Deformity.

We explored the value of the metacarpal bone plane in screening for serious fetal forearm and hand deformities, excluding simple polydactyly and dactylion deformity, by ultrasonographic examination. Observed the second to fifth metacarpal bone plane of fetuses in 20,139 pregnant women at a gestational age of 16 to 30 weeks in The International Peace Maternity &Child Health Hospital of China Welfare Institute (IPMCH). There was a total 138 cases of fetal forearm and/or hand deformity among the 20,139 pregnant women. Of these, 134 cases were diagnosed, 4 cases were not diagnosed, and 1 case was misdiagnosed. Among the 134 diagnosed cases, there were 19 cases of hand absence, 5 cases of cleft hand, 13 cases of ectrodactyly, 26 cases of radius absence, 9 cases of forearm and hand dysplasia, 55 cases of thanatophoric dysplasia, 6 cases of wrist joint dysplasia, and 1 case of forearm amputation deformity. The deformity rate was 0.76%, the diagnostic coincidence rate was 99.97%, the sensitivity was 97.10%, the specificity was 99.99%, and the false negative rate was 2.9%. As such, careful observation of the metacarpal bone plane can be used increase the diagnosis rate of fetal forearm and hand deformity.