A Case of Acute Plastic Deformation of the Forearm in a Medieval Hispano-Mudejar Skeleton (13-14th Centuries AD).

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.

Global and Spatial Compartmental Interrelationships of Bone Density, Microstructure, Geometry and Biomechanics in the Distal Radius in a Colles' Fracture Study Using HR-pQCT.

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.

BPBSAM: Body part-specific burn severity assessment model.

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.

Is the visibility of standardized inflicted bruises improved by using an alternate ('forensic') light source?

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.

Recurrent branch of anterior interosseous artery perforator-based propeller flap for distal forearm injuries: Report of 2 cases.

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.

Survival to amputation in pre-antibiotic era: a case study from a Longobard necropolis (6th-8th centuries AD).

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.

Ultrasound-Assisted Reduction of Displaced and Shortened Fractures by Pediatric Emergency Physicians.

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.

¿Qué hay nuevo sobre traumatismos en edad pediátrica? / What’s new in children orthopaedic trauma?

Cada vez son más frecuentes la aparición en la bibliografía de artículos relacionados con problemas en edad pediátrica. Con el objetivo de actualizar información hemos realizado una revisión de la bibliografía publicada en las principales revistas relacionadas con la ortopedia y traumatología infantil durante el año 2015 seleccionando aquellos que trataban sobre traumatismos en edad pediátrica. El artículo ha sido divido en bloques por región anatómica y se resume la información más destacada de las publicaciones

Increasingly frequent occurrence in the literature related problems in childhood items. In order to update information we have conducted a review of the literature published in leading journals related to orthopedics and traumatology child during 2015 selecting those that dealt with trauma age pediatric. The article has been divided into blocks by anatomical region and the most important information is summarized publications

Factors Associated With Orthopedic Aftercare in a Publicly Insured Pediatric Emergency Department Population.

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.

Adipofascial radial artery perforator flap interposition to treat post-traumatic radioulnar synostosis in a patient with head injury.

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.

Double jeopardy: two episodes of forearm compartment syndrome in the same patient.

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.

Home-made explosive found inside injured Afghan.

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.

Systematic review: functional outcomes and complications of intramedullary nailing versus plate fixation for both-bone diaphyseal forearm fractures in children.

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.

A new way to treat forearm post-traumatic non-union in young patients with intramedullary nailing and platelet-rich plasma.

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.

Forearm post-traumatic deformities: classification and treatment.

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.

Animal attack: an unusual case of multiple trauma in childhood.

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.