Combined simple elbow dislocation and forearm joint injuries. A systematic review of the literature with injury patterns and current treatment rationale.

INTRODUCTION: Recent studies have allowed a great improvement in understanding elbow and forearm traumatic injuries. Simple elbow dislocations combined with forearm injuries have been occasionally reported in the literature. The aim of this study was to detect the possible patterns of simple elbow dislocations and forearm fracture-dislocations, providing a classification scheme to guide surgical treatment. MATERIALS AND METHODS: PubMed search was performed to find combination of simple elbow dislocation and forearm joint injury, between 2000 and 2020, including clinical studies and case report. All articles related to pediatric patient or with complex elbow dislocation were excluded. After identification, articles were analyzed for the description of injury patterns reported according to locker-based classification system of forearm joint injuries. RESULTS: Finally, 15 articles were included. Most of the patients sustained high-energy trauma. According to locker-based classification system, simple elbow dislocation was combined with: MRUJ and DRUJ Galeazzi injury (2IR.3), PRUJ and MRUJ injury (1.2I), PRUJ and MRUJ injury with radial shaft fracture (1.2IR), PRUJ and MRUJ injury with ulnar shaft fracture (1.2 IU), PRUJ and MRUJ injury with radial and ulnar shaft fracture (1.2IRU), PRUJ MRUJ DRUJ Essex-Lopresti injury (1.2I.3), and PRUJ MRUJ DRUJ injury with radial shaft fracture (1.2IR.3). Thirteen out of 15 patients undergo surgical treatment. Clinical results were overall favorable. CONCLUSIONS: Simple elbow dislocation combined with forearm joint injury is an uncommon traumatic pattern usually secondary to high-energy trauma. A thorough knowledge of elbow and forearm biomechanics, and classification of anatomical lesion is mandatory for a successful treatment.

Concurrent musculoskeletal complaints in elbows, shoulders, and necks after common hand and forearm injuries or conditions: A cross-sectional study among 600 patients.

STUDY DESIGN: This is a cross-sectional study among 600 patients. INTRODUCTION: Isolated hand and forearm injuries or conditions are common in the emergency and orthopedic departments. So far, little is known about whether these patients suffer from concurrent musculoskeletal complaints (MSCs) besides their hand and forearm complaints. Neglecting concurrent MSCs in the upper limbs and necks could hamper rehabilitation and prolong the time taken to return to daily and work-related activities. PURPOSE OF THE STUDY: The purpose of this study was to investigate the prevalence of concurrent MSCs in the elbow, shoulder, and neck after common hand and/or forearm injuries or conditions. METHODS: This study included 600 patients with any type of diagnosis referred to rehabilitation after hand and/or forearm injuries or conditions. Basic characteristics, diagnoses, and location of patients' symptoms were collected and analyzed. RESULTS: The overall prevalence of concurrent MSCs was 40%. Twenty-eight percent of the whole sample developed concurrent MSCs after the hand and forearm injury or condition. The gender distribution was 68% women and 32% men. The most common location for complaints was the shoulder (62%), followed by the elbow (49%), and the neck (32%). DISCUSSION: The present results suggest that MSCs from the elbows, shoulders, or necks are very common in patients with hand and/or forearm injuries or conditions. CONCLUSION: Clinicians treating patients with isolated hand and forearm injuries or conditions should be aware of the high prevalence of concurrent MSCs. Future research should investigate if specific rehabilitation, focusing on concurrent MSCs, may influence the outcome in this population.

Paraumbilical perforator flap for soft tissue reconstruction of the forearm.

Numerous flaps exist for coverage of injuries to the upper extremity, ranging from local, to regional, to free tissue transfer. The choice of flap is dependent on a variety of factors, including patient, functional needs, and depth of injury. The paraumbilical perforator (PUP) flap for upper extremity coverage can offer the benefits and versatility of pedicled and free flaps while avoiding some of the donor-site morbidity and risks of free tissue transfer. We report the indications and management of two clinical cases that exemplify PUP flap application. Technical points of flap harvest, inset, timing of pedicle division, and pertinent anatomy are discussed.

Pedicled abdominal flap using deep inferior epigastric artery perforators for forearm reconstruction: A case report.

BACKGROUND: Pedicled abdominal flaps are a widely used surgical technique for forearm reconstruction in patients with soft tissue defects. However, some drawbacks include restricted flap size, partial flap loss, and donor-site morbidity. To address these concerns, we present a case of a pedicled abdominal flap using the deep inferior epigastric artery perforators (DIEP) for forearm reconstruction in a patient with a large soft tissue defect. CASE SUMMARY: A 46-year-old male patient was admitted to our hospital with forearm injury caused by a pressing machine. A 15 cm × 10 cm soft tissue defect with complete rupture of the ulnar side structures of the forearm was found. One week after orthopedic management of the neurovascular injury and fractures using the first stage of Masquelet technique, the patient was referred to the plastic and reconstructive surgery department for wound coverage. Surgical debridement and negative-pressure wound therapy revealed a 20 cm × 15 cm soft tissue defect. A pedicle abdominal flap with the DIEP was used to cover the defect. Three weeks later, the flap was detached from the abdomen, and the abdominal defect was directly closed. Subsequently, the second stage of Masquelet technique was performed at the fracture site at week 10. Finally, all donor and recipient sites healed without complications, such as flap dehiscence, infection, hematoma, or necrosis. Fracture site osteosynthesis was achieved without complications. CONCLUSION: Pedicled abdominal flap using the DIEP provides a reliable option for forearm reconstruction in patients with large soft tissue defects.

The Outcomes of Extensor Tendon Repair Based on Timing of Repair.

Background: Little is known regarding the effect timing of repair has on extensor tendon repair results. The purpose of this study is to determine if a relationship exists between the time of extensor tendon injury to extensor tendon repair and patient outcomes. Methods: A retrospective chart review was conducted on all patients that underwent extensor tendon repair at our institution. The minimum time to final follow-up was 8 weeks. Patients were then divided into two cohorts for analysis; those that underwent repair less than 14 days after injury and those that underwent extensor tendon repair at or greater than 14 days after injury. These cohorts were further sub-grouped by zone of injury. Data analysis was then completed using a two-sample t-test assuming unequal variance and ANOVA for categorical data. Results: A total of 137 digits were included in final data analysis, with 110 digits repaired less than 14 days from injury and 27 digits in the greater than or equal to 14 days to surgery group. For zones 1-4 injuries, 38 digits were repaired in the acute surgery group and eight digits in the delayed surgery group. There was no significant difference in final total active motion (TAM) (142.3° vs. 137.4°). Final extension was also similar between the groups (2.37° vs. 2.13°). For zones 5-8 injuries, 73 digits were repaired acutely, and 13 digits were repaired in delayed fashion. There was no significant difference in final TAM (199.4° vs. 172.7°). Final extension was also similar between the groups (6.82° vs. 5.77°). Conclusions: We found time from extensor tendon injury to surgical repair did not affect final range of motion when comparing acute repair within 2 weeks from injury or delayed repair greater than 14 days from injury. Additionally, there was no difference in secondary outcomes, such as return to activity or surgical complications. Level of Evidence: Level IV (Therapeutic).

Medial three-finger drop in high-energy forearm trauma: An unrecognized peripheral nerve injury. A report of two cases.

CASE: Absent active extension at metacarpophalangeal (MCP) joints of medial three fingers with intact extension of index finger and thumb following high energy forearm trauma due to recurrent branch of posterior interosseous nerve (RBPIN) injury has not been reported yet. The aim is to highlight an unrecognized sequel of a commonly encountered forearm trauma in two patients who sustained fractures around the elbow and forearm. CONCLUSION: In the acute traumatic setting, medial three-finger drop due to RBPIN injury can be missed or misdiagnosed. This has medico-legal and prognostic implications.

[Effectiveness of open reduction and internal fixation for bipolar fracture-dislocation of forearm].

OBJECTIVE: To explore the effectiveness of open reduction and internal fixation for bipolar fracture-dislocation of the forearm. METHODS: Between June 2014 and March 2019, 14 patients with bipolar fracture-dislocation of the forearm were treated. There were 9 males and 5 females, aged from 19 to 52 years (mean, 34.9 years). There were 8 cases of falling injuries, 4 cases of traffic accident injuries, 1 case of sports injury, and 1 case of machine strangulation injury. The time from injury to admission was 2-48 hours, with an average of 16.6 hours. All patients were closed injuries. All patients were treated with open reduction and internal fixation; the upper radioulnar joints were treated with circumferential ligament repair or lateral collateral ligament repair according to the joint stability. And the patients with lower radioulnar joint instability were also treated with the TightRope plate with loop fixation. After 3 weeks of plaster fixation, the patients started functional exercises. The fracture healing time, stability and range of motion of wrist and elbow joints, and forearm rotation function were recorded. The effectiveness was evaluated by Anderson's forearm function score at last follow-up. RESULTS: The incisions healed by first intention. All 14 cases were followed up 12-36 months with an average of 24.8 months. All fractures healed, with an average healing time of 14.9 weeks (range, 12-18 weeks). The stabilities of the upper and lower radioulnar joints restored well. At last follow-up, the elbow flexion and extension range of motion was 65°-160°, with an average of 124.6°; the wrist flexion and extension range of motion was 115°-165°, with an average of 155.0°; the forearm rotation range of motion was 65°-165°, with an average of 154.6°. According to Anderson's forearm function score, 8 cases were excellent, 5 cases were good, and 1 case was unsatisfactory. CONCLUSION: The treatment of bipolar fracture-dislocation of the forearm needs comprehensive consideration and individualized treatment plan. The focus is to restore the anatomical structure of the radius and ulna and firm internal fixation, stabilize the upper and lower radioulnar joints, and perform functional exercises as soon as possible after operation to obtain satisfactory effectiveness.

Management of a Multi-Level Forearm Microsurgical Reconstruction and the Following Transfusion-Related Acute Lung Injury.

Transfusion-related acute lung injury (TRALI) is a clinical syndrome characterized by acute respiratory distress following blood transfusion. This case-based technical report documents a case on the management of a multi-level forearm microsurgical reconstruction and the following TRALI syndrome that developed shortly after blood transfusion in a 29-year-old male. Multilevel microsurgical revascularization was performed via saphenous vein autograft arterial reconstruction from the proximal 1/3 ulnar artery to the ulnar side of the deep superficial palmar arterial arch. TRALI was resolved with intensive care unit monitoring and treatment. There are several reports of TRALI in literature, as well as proposed mechanisms of pathogenesis, however, no case on the management of a multilevel forearm arterial reconstruction via a long saphenous vein autograft and associated TRALI syndrome have been reported.

Brachialis muscle transfer for reconstructing digital flexion after brachial plexus injury or forearm injury.

Restoration of digital flexion after brachial plexus injury or forearm injury has been a great challenge for hand surgeons. Nerve transfer and forearm donor muscle transfer surgeries are not always feasible. The present study aimed at evaluating the effectiveness of restoring digital flexion by brachialis muscle transfer. Ten lower brachial plexus- or forearm-injured patients were enrolled. After at least 12 months following surgery, the middle-finger-to-palm distance was less than 2.5 cm in six patients. In the other four patients with less satisfactory results, secondary tenolysis surgery was performed and the middle-finger-to-palm distances were reduced to 2.0-4.0 cm. The average grasp strength was 20 ± 4 kg. Elbow flexion was not adversely affected. In conclusion, brachialis muscle transfer is an effective method for reconstructing digital flexion, not only in lower brachial plexus injury, but also in forearm injury patients. LEVEL OF EVIDENCE: IV.

Analysis of emergency reconstruction of forearm Gustilo III B and III C fracture with complex tissue defect: outcomes and related factors / 中华显微外科杂志

Objective:To discuss outcomes of emergency repairing for Gustilo III B and III C fractures of forearm with complicated tissue defects and the related influence factors.Methods:From January 2014 to Feburary 2022, data of 98 cases of Gustilo III B and III C fractures with large compound defects of soft tissue, blood vessel, bone, tendon or muscle from elbow to wrist were collected. Primary debridement, bone fixation, wound coverage by free flap, bone transfer(or bone cement filling) or dynamic reconstruction of muscle were completed with emergency surgery in Department of Hand and Foot Microsurgery, Xi'an Fengcheng Hospital. Postoperative follow-ups were conducted through outpatient clinic visits, telephone and WeChat reviews. Video clips, questionnaires and the latest information of patients were also analysed. Rank sum test and Chi-square test were used to examine the relationship between independent variables such as general condition, disease condition and surgical procedures of chimeric tissue transfer group and simple flap transfer group, together with dependent variables such as limb salvage, number of surgery, wound healing, function scores, and complications. P<0.05 were further included in the regression equation to discover the relationship between multiple independent variables and dependent variables. Results:Follow-up lasted for 6-96 months, with an average of 71.1 months. In the chimeric group, the limb salvage rate was at 95.1%, with an infection rate of 8.50% and an average number of surgery was 2.13±0.89. In the simple flap transfer group, the limb salvage rate was at 87.5%, with an infection rate of 15.38% and an average number of surgery was 2.62±0.64. The good rate of Anderson score was 65.3% and the average score of Disability of the Arm, Shoulder and Hand(DASH) was 32.9(0-60) points for all the patients. There were significant differences in dependent variables of limb salvage and infection rate between the 2 groups ( P<0.05). Ischemia time and method of bone fixation led to significant differences in number of surgery ( P<0.05). Methods of bone fixation and the types of flap made significant differences in wound healing ( P<0.05). Underlying disease, bonedefect, Gustilo classification and method of bone fixation all contributed to the significant differences in function score ( P<0.05 or P<0.01) . Conclusion:Emergency surgery for repair of serious injury of forearm has a relatively high limb salvage rate and good functional effects. The limb salvage rate is not correlated with independent variables such as severity of injury, Mangledextremity Severity Score (MESS) and ischemia time, while transfer of a simple flap or a chimeric flap is significantly correlated with the limb salvage rate, infection and wound healing. The severity of injury, ischemia time and bone defect are correlated with functional assessment, number of surgery and bone healing.

Mini C-arm: faster, cheaper, safer?

BACKGROUND: Mini C-arm image intensifiers (IIs) are promoted to permit lower radiation dose than traditional IIs with a lower purchase price and without the need for a radiographer, saving time. In real-world usage, radiation dose is not always lower. METHODS: A retrospective review of prospectively collected data for 620 children undergoing forearm fracture reduction in theatre was undertaken. Imaging was performed with the Fluoroscan mini C-arm or a comparison traditional II. Radiation dose and theatre time were recorded. RESULTS: There was no significant difference in radiation dose as measured by dose-area product (0.013 versus 0.014 Gy.cm2 , P = 0.22). We noted an inverse association between operator experience and radiation dose. The mini C-arm allowed a shorter procedure time (26 versus 30 min, P < 0.001) and theatre time (13 versus 16 min, P < 0.001). Re-displacement rates were similar (1.3 versus 2.2%). The Fluoroscan is AU$120 000 cheaper to purchase and AU$35 283 cheaper to run per year than the comparison II. Consultants had a 14% lower dose-area product (0.012 versus 0.014 Gy.cm2 , P < 0.001) and 18% shorter screening time (8 versus 9.8 s, P < 0.001) than registrars. CONCLUSION: The Fluoroscan mini C-arm II does not demonstrate a radiation saving during closed reductions of paediatric forearm fractures but allows shorter procedures and theatre time with similar re-displacement rates. The purchase price is lower than a traditional II. We noted that operator experience reduces radiation dose.

Evaluation and treatment of the elbow and forearm injuries in the emergency department.

Elbow and forearm injuries result most commonly from direct blows to the area, or from fall on outstretched hand. The elbow may be injured if it is locked at the time of impact. Elbow or forearm bone dislocations may occur alone or in conjunction with fractures and generally require reduction to minimize future morbidity. The primary goal of management is to achieve anatomic reduction of any fracture or dislocation, while allowing for early range of motion to minimize future morbidity, including in particular elbow stiffness and consequently limited mobility of the joint.