Sideswipes injuries of upper limbs: a case series report and review of literature

BACKGROUND

Sideswipe injuries are consequent to object striking an elbow on the window edge of a moving vehicle. It often results in severe soft tissue and bony injuries or partial amputation of the upper limb. Functional outcome in most patients is poor. The aim is to highlight the occurrence and functional outcome of these injuries.

METHOD

In our series we report three cases which presented to us in succession within four weeks.

RESULTS

Two of the patients were passengers of commercial buses while one patient is the driver of a private car. Two were males. All were protruding their arm from the open vehicle window at the time of impact. All presented within five hours of injury. All sustained open fracture-dislocations. All were managed with external fixation and soft tissue cover. They all had poor outcome as evidenced by joint stiffness.

CONCLUSION

The functional outcome of such injuries is usually poor especially if the dominant limb is involved. Therefore the need for prevention cannot be overemphasized. Simple measures like ensuring that no part of the limb is Sticking outside a moving vehicle, winding up glass up to mid window level etc will greatly reduce the occurrence of these injuries.

Arm and shoulder conditions, active component, U.S. Armed Forces, 2003-2012

This analysis estimated the incidence and health care burden of acute and chronic conditions of the arm and shoulder among active component service members of the Armed Forces from 1 January 2003 through 31 December 2012. There were 196,789 diagnosed incident cases of acute arm and shoulder conditions for a rate of 13.7 cases per 1,000 person-years. The annual incidence rates of sprains, the most common acute condition, nearly doubled during the period. Diagnoses of chronic conditions (overall rate of 28.8 per 1,000 person-years) increased 25 percent during the period, mainly associated with a doubling of the incidence of diagnoses of joint pain. Incidence rates of chronic disorders were progressively higher among successively older age groups of service members. The health care burden of all arm and shoulder conditions together steadily increased during the period, as indicated by numbers of health care encounters, individuals affected, and lost work time. The most commonly documented causes associated with acute and chronic conditions are described.

Comparative outcome of bomb explosion injuries versus high-powered gunshot injuries of the upper extremity in a civilian setting

BACKGROUND

Explosion injuries to the upper extremity have specific clinical characteristics that differ from injuries due to other mechanisms.

OBJECTIVES

To evaluate the upper extremity injury pattern of attacks on civilian targets, comparing bomb explosion injuries to gunshot injuries and their functional recovery using standard outcome measures.

METHODS

Of 157 patients admitted to the hospital between 2000 and 2004, 72 (46%) sustained explosion injuries and 85 (54%) gunshot injuries. The trauma registry files were reviewed and the patients completed the DASH Questionnaire (Disabilities of Arm, Shoulder and Hand) and SF-12 (Short Form-12) after a minimum period of 1 year.

RESULTS

Of the 157 patients, 72 (46%) had blast injuries and 85 (54%) had shooting injuries. The blast casualties had higher Injury Severity Scores (47% vs. 22% with a score of > 16, P = 0.02) and higher percent of patients treated in intensive care units (47% vs. 28%, P = 0.02). Although the Abbreviated Injury Scale score of the upper extremity injury was similar in the two groups, the blast casualties were found to have more bilateral and complex soft tissue injuries and were treated surgically more often. No difference was found in the SF-12 or DASH scores between the groups at follow up.

CONCLUSIONS

The casualties with upper extremity blast injuries were more severely injured and sustained more bilateral and complex soft tissue injuries to the upper extremity. However, the rating of the local injury to the isolated limb is similar, as was the subjective functional recovery.

Upper body musculoskeletal symptoms of Latino poultry processing workers and a comparison group of Latino manual workers

BACKGROUND

Upper body musculoskeletal injuries are often attributed to rapid work pace and repetitive motions. These job features are common in poultry processing, an industry that relies on Latino immigrants. Few studies document the symptom burden of immigrant Latinos employed in poultry processing or other manual jobs.

METHODS

Latino poultry processing workers (n = 403) and a comparison population of 339 Latino manual workers reported symptoms for six upper body sites during interviews. We tabulated symptoms and explored factors associated with symptom counts.

RESULTS

Back symptoms and wrist/hand symptoms lasting more than 1-day were reported by over 35% of workers. Poultry processing workers reported more symptoms than comparison workers, especially wrist and elbow symptoms. The number of sites at which workers reported symptoms was elevated for overtime workers and workers who spoke an indigenous language during childhood.

CONCLUSION

Workplace conditions facing poultry processing and indigenous language speaking workers deserve further exploration.

Pathomimie de l'enfant: à propos d'une observation

La pathomimie cutanée se définit comme une maladie factice, provoquée dans un etat de conscience claire par le patient lui-même, au niveau du revêtement cutanéo-muqueux et/ou des phanères. Rare chez l'enfant, il s'agit d'une manifestation psychopathologique potentiellement grave et souvent difficile à prendre en charge. Nous rapportons le cas d'une fillette de 10 ans présentant une pathomimie sous forme de lésions excoriées multiples du visage.

Extremity firearm trauma: the impact of injury pattern on clinical outcomes

As a group, the extremities are the most commonly injured anatomic region in nonfatal firearm trauma and are associated with high rates of vascular and bony injury. This study examines the epidemiology, incidence and distribution of firearm-related extremity trauma and the relationship between injury pattern and local or systemic complications. Review of the National Trauma Databank identified 6987 patients with isolated extremity firearm injury. Epidemiologic data, injury pattern incidence, and local and systemic complications were reviewed. Multivariate analysis identified the impact of extremity injury pattern on complications. Overall fracture incidence was 22 per cent. Fracture was associated with both vascular (odds ratio [OR], 1.9; 95% confidence interval [CI], 1.5 to 2.4; P < 0.001) and nerve injury (OR, 2.6; 95% CI, 1.9 to 3.5; P < 0.001). Isolated fracture increased risk of compartment syndrome (OR, 2.4; 95% CI, 1.1 to 5.3; P = 0.035). Vascular injury alone increased the risk of compartment syndrome (OR, 11.5; 95% CI, 5.0 to 26.2; P < 0.001) and deep venous thrombosis (OR, 7.9; 95% CI, 2.5 to 25.2; P < 0.001). Fracture and vascular injury together also increased risk of wound infection (OR, 9.7; 95% CI, 3.9 to 23.4; P < 0.001). In patients with extremity trauma, the injury pattern significantly impacts local but not systemic complication rates. Gunshot-related fracture, occurring in one-fifth of patients, increases the risk of vascular and nerve injury. Vascular injury, with or without fracture, is the biggest predictor of local complications.

Injuries among powered two-wheeler users in eight European countries: a descriptive analysis of hospital discharge data

Powered two-wheelers (PTWs--mopeds, motorcycles, and scooters) remain the most dangerous form of travel on today's roads. This study used hospital discharge data from eight European countries to examine the frequencies and patterns of injury among PTW users (age≥14 years), the predicted incidence of the loss of functional ability, and the mechanisms of the head injuries observed (all in light of increased helmet use). Of 977,557 injured patients discharged in 2004, 12,994 were identified as having been injured in PTW collisions. Lower extremity injuries accounted for 26% (25.6-26.7, 95% C.I.) of the total injuries, followed by upper extremity injuries (20.7%: 20.3-21.2), traumatic brain injuries (TBI) (18.5%: 18-19), and thoracic injuries (8.2%: 7.8-8.5). Approximately 80% of the lower extremity injury cases were expected to exhibit some functional disability one year following discharge (predicted Functional Capacity Index, pFCI-AIS98<100), compared to 47% of the upper extremity injury cases and 24% of the TBI cases. Although it occurred less frequently, patients that were expected to experience some functional limitation from TBI were predicted to fair worse on average (lose more functional ability) than patients expected to have functional limitations from extremity injuries. Cerebral concussion was the most common head injury observed (occurring in 56% of head injury cases), with most concussion cases (78%) exhibiting no other head injury. Among the AIS3+ head injuries that could be mapped to an injury mechanism, 48% of these were associated with a translational-impact mechanism, and 37% were associated with a rotational mechanism. The observation of high rates of expected long-term disability suggests that future efforts aim to mitigate lower and upper extremity injuries among PTW users. Likewise, the high rates of concussion and head injuries associated with a rotational mechanism provide goals for the next phase of PTW user head protection.

Paediatric injuries due to home treadmill use: an emerging problem

INTRODUCTION

The use of home exercise equipment is increasing and treadmills are becoming more popular. This has brought with it an emerging but preventable problem. We present our experience, highlight the importance and promote public awareness of this type of injury. To our knowledge this has not been reported previously in the UK.

METHODS

A retrospective review was conducted of the medical records at two regional burn units of children who sustained treadmill-related injuries between July 2003 and July 2009. Data on patient demographics, mechanism of injury, management, surgical intervention and outcome were recorded.

RESULTS

Twenty-nine children (15 boys, 14 girls) sustained treadmill-related injuries. The mean age was 3.8 years (range: 1-13 years). All injuries occurred at home and the majority of children trapped their hand under the running belt when an adult was using the machine. Most of the injuries were to the upper limb (97%) with less than 1% of the total body surface area burnt. More than two-thirds of patients had deep burns and 17 (58%) required surgical intervention. Five patients developed hypertrophic scars. All patients achieved a good functional outcome.

CONCLUSIONS

Treadmills can pose a significant danger to children. These injuries are preventable. Regulatory authorities, manufacturers and parents should take steps to prevent this emerging health problem.

Sonographic evaluation of peripheral nerve injuries following the Wenchuan earthquake

PURPOSE

To analyze retrospectively the sonographic characteristics of the peripheral nerve injuries (PNIs) resulted from Wunchuan earthquake.

METHODS

The sonographic images of 38 patients with surgically proved PNIs were reviewed and compared with the surgical findings.

RESULTS

A total of 78 nerves in 38 patients were found injured in surgery, which included 16 median nerves in the forearm (20.5%), 6 ulnar nerves in the forearm or arm (7.7%), 8 radial nerves in upper limb (10.0%), 8 sciatic nerves (10.3%) in gluteal region, 17 tibial nerves in the leg (21.8%), and 23 peroneal nerves (29.5%). The most common injured nerve in the lower extremity was the peroneal nerve (29.5%) and in upper extremity was the median nerve (20.5%). Sonography correctly diagnosed 72 earthquake-related nerve injuries (92.3%), which included 5 complete disruption (6.4%), 4 partial disruption (5.1%), 63 nerve entrapment (88.5%, included 1 entrapment by bone calus, 38 entrapments by the scar tissue, 13 entrapments by the thickened muscle or tendinous arch, and 11 entrapment in the narrowed osteofibrous tunnels).

CONCLUSIONS

Nerve entrapment injury was the common sonographic finding in earthquake-related PNI.

Determination of pre-impact occupant postures and analysis of consequences on injury outcome--part II: biomechanical study

This paper considers pre-impact vehicle maneuvers and analyzes the resulting driver motion from their comfort seating position. Part I of this work consisted of analyzing the driver behavior during a simulated crash in a car driving simulator. The configuration of the virtual accident led to an unavoidable frontal crash with a truck. The typical response to this type of emergency event was to brace rearward into the seat and to straighten the arms against the steering wheel, or, to swerve to attempt to avoid the impacting vehicle. In a turn crossover maneuvers, the forearm is directly positioned on the airbag module at time of crash. This position represents a potential injurious situation and is investigated in this Part II. Static airbag-deployment tests were realized in collaboration with Zodiac using conventional airbag (sewn cushion, pyrotechnical system and open event) and a Hybrid III 50th Male Dummy seated with the left arm positioned in the path of the deploying airbag. These experiments were numerically reproduced with Madymo and the ellipsoid Hybrid III dummy model. The dummy arm interaction with airbag was correlated with experiments. Then, a numerical simulation of a frontal collision at 56 km/h was realized. The results of the computational runs put forward injurious situations when the driver's arm was in front of the steering wheel. Indeed, in this case, the arm could hit the head under airbag deployment and induced serious neck bending and violent head launching. To mitigate head and neck trauma in this out-of-position situation, an airbag prototype (bonded cushion, two pure helium cold gas generators allowing mono- or multi-stage inflating, patented silicone membrane) was proposed by Zodiac. The results of static airbag-deployment tests with conventional and prototype airbags showed a significant reduction of the maximum linear head acceleration and neck bending with airbag prototype when a dual stage inflating was ignited, due to a reduced 'flinging' of the arm.

[Waveboard-related injuries. Greater protection is advised]

OBJECTIVE

Waveboarding, a type of skateboarding, is a new craze among children. The aim of this study is to describe how many children visit the emergency department as a consequence of waveboarding and the types of injury they have.

DESIGN

Retrospective, descriptive.

METHOD

All records of children aged 5 to 15 years who had visited the emergency department of the Medical Center Alkmaar in the period March to May 2010 were examined. If a case of waveboard-related injury was found then the type of injury was noted. For all of the injuries a phone call was made to try to find out if protective gear had been worn.

RESULTS

A total of 1418 records from 2010 were investigated. In 132 cases, a waveboard-related injury was found. Contusion was found in 31% of cases and a fracture in 64% of cases. The 2 most frequently occurring sites of injury were the forearm and wrist (53%) and the elbow (14%). In 3% of the waveboard-related injuries the child concerned had worn any protective gear.

CONCLUSION

Children who visited the emergency department due to waveboard-related injuries mainly had injuries to the wrists, forearm and elbow. Only 3% of the children wore protective gear when waveboarding. As effective protection against accident-related injuries exists for skaters, the wearing of protective gear during waveboarding can be expected to lead to a reduced number of injuries.

Treatment of post-burn upper extremity, neck and facial contractures: report of 77 cases

BACKGROUND

Post-burn contractures severely deteriorate life quality. We aimed to present our treatment protocols for post-burn sequelae and the contractures that cause functional limitations.

METHODS

Seventy-seven cases with post-burn contracture were treated in our clinic. Post-burn contractures occurring after a burn injury affected the upper extremity, face and neck in 60, 17 and 6 cases, respectively. Skin grafts, local flaps such as advancement flaps, Z-plasties, K-plasties, regional flaps such as posterior interosseous flap, tissue expanded flaps, and free flaps were used according to the severity of the contractures.

RESULTS

In one patient with type II axillary contraction, recurrence was seen. Full range of motion was achieved in the 3.6-year follow-up period in elbow contractures. Eight of 71 phalangeal joint contractures recurred. Two patients underwent reoperation for neck contracture recurrences.

CONCLUSION

Excellent results were seen with prefabricated flaps, which were used for the facial reconstruction.

Pain catastrophizing and lower physical fitness in a sample of computer screen workers with early non-specific upper limb disorders: a case-control study

In computer workers psychological factors and physical fitness may play an important role in the onset and course of non-specific work-related upper limb disorders (WRULD) beyond socio-demographic factors. Based on our experiences in daily practice we assumed that pain catastrophizing and other psychological variables such as perfectionism, anxiety state and trait, and low physical fitness, are possibly associated with the occurrence of WRULD. We aim to study the association between pain catastrophizing, perfectionism, anxiety (state and trait), physical fitness, sex and level of education and the occurrence of WRULD, controlling for age as a confounder. Eighty-eight computer workers with early non-specific WRULD, who had been recruited for an intervention study, were compared with 31 healthy computer workers (controls) recruited from different departments of a university. This cross-sectional case-control study examined the influence of aforementioned variables on WRULD by means of logistic regression analyses. Among the different predictor variables investigated, pain catastrophizing (OR=1.37; 95%CI 1.17-1.59) and lower physical fitness had a positive relationship with WRULD (OR=0.65; 95%CI 0.48-0.87). According to this study, pain catastrophizing and lower physical fitness seem to be associated with early non-specific WRULD in computer workers. Prospective studies are needed to unravel these relationships.

Acute trauma to the upper extremity: what to do and when to do it

The management of acute trauma to the upper extremity includes the urgent treatment of injuries and the timing and choice of surgical stabilization and reconstruction. To evaluate and treat severe upper extremity trauma, the orthopaedic surgeon should understand the principles of emergency department and operating theater management of commonly seen traumatic injuries to the distal humerus, elbow, forearm, wrist, and hand. A review of the principles for treating these complex injuries, including principles of soft-tissue coverage, will aid surgeons in achieving the goal of providing optimal treatment for their patients.

[Hand-arm vibration syndrome in a nurse carrying out gypsum cutting operations]

BACKGROUND

A professional nurse, employed mainly on gypsum cutting operations, developed a hand-arm vibration syndrome with Raynaud's phenomenon, neurosensitive disorders and impairment of the bone and joints apparatus of the hand and arm.

METHODS

The nurse underwent diagnostic investigations (cold test, X-ray of the upper limbs, blood tests); also the vibration levels transmitted from instrument were measured and the exposure times were established.

RESULTS AND CONCLUSIONS

Clinical investigations showed the presence of a hand-arm vibration syndrome with secondary Raynaud's phenomenon and environmental surveys revealed very high vibration levels, such as could be associated with the disease with a causal relationship. In the literature no reports exist of the vibration syndrome being associated with health care workers in orthopaedic departments. The case described in this study occurred because of peculiar organisational factors that most likely have never occurred in other hospitals or orthopaedic departments.

[Work-related musculoskeletal disorders: appropriateness of the requests of clinical consultation in occupational medicine departments]

BACKGROUND AND OBJECTIVES

The authors analyze the results of the clinical assessment of patients suffering from suspected work-related muscular-skeletal disorders (WMSDs), observed during the course of 2008 in the Department of Occupational Medicine of the Ospedali Riuniti hospital in Bergamo. The aim was to analyse the appropriateness of the requests of clinical consultation, comparing the cases sent by general practitioners and by occupational physicians.

METHODS

We assessed 149 patients (mean age 47 years, DS 9.4; mean work seniority 29.5 years, DS 10.2), investigating 218 disorders in different muscular-skeletal segments. The majority of patients (63.7%) for whom a clinical consultation was requested were sent by general practitioners, 32.9% by occupational physicians, 3.4% by the National Insurance Institute for Occupational Accidents and Diseases (INAIL). The assessment was made in two steps: first a clinical and instrumental definition of the disorders, prescribing the necessary medical investigations were the diagnosis was not already clear; secondly a definition of the aetiology, requesting documentation about working conditions when this was not clear from the medical history, experience and literature, or making an inspection.

RESULTS

A majority of the patients (40.2%) were employed in the construction industry. Regarding symptoms, 54.4% of the subjects reported low back pain, 74.5% upper limb disorders (some of the patients reported several problems in different segments). The clinical diagnosis was already clear at the first consultation for 62.8% of all cases; for the other 37.2% it was necessary to prescribe some instrumental examinations or specialistic (neurologic, physiatric, orthopaedic) medical examinations. We concluded for a diagnosis of WMSDs in 99 (45.4%) of the 218 cases (50% of the assessments requested by occupational physicians, 45.3% of the assessments requested by general practitioners). The most frequent reason for rejecting an occupational aetiology was the lack of correlation between type of disease and occupational exposure, both for patients referred by occupational physicians (58.1%) and by general practitioners (51.8%).

DISCUSSION

The results demonstrated that the appropriateness requests for clinical consultation was identical for general practitioners and occupational physicians. All physicians showed a high degree of attention for the upper limb disorders, which is a topical subject of great epidemiological interest. General practitioners and occupational physicians need to take more advantage of the diagnostic support and clinical evaluations offered by Occupational Medicine Departments and Universities for WMSDs.

Internal consistency, test-retest reliability and concurrent validity of a questionnaire on work-related exposure related to arm, shoulder and neck symptoms in computer workers

The aim of this study was to determine the internal consistency, test-retest reliability and concurrent validity of the RSI QuickScan, a newly developed questionnaire that aims to identify the presumed risk factors for neck, shoulder and arm symptoms in a population of computer workers. The internal consistency was calculated using item analysis. The test-retest reliability and concurrent validity were analysed by calculating the percentage of agreement, Cohen's Kappa and the Ppositive and Pnegative. The concurrent validity was also tested by comparing the results from the new questionnaire with those from the original questionnaires that the current questionnaire was based on, on-site expert observations and direct measurements. The results indicate that the RSI QuickScan is a measurement tool with acceptable internal consistency, reliability and concurrent validity. The questionnaire can be used as a means to rapidly collect data on a large population of office workers and at low cost.

Upper limb discomfort profile due to intermittent isometric pronation torque at different postural combinations of the shoulder-arm system

Twenty-seven right-handed male university students participated in this study, which comprised a full factorial model consisting of three forearm rotation angles (60% prone and supine and neutral range of motion), three elbow angles (45 degrees , 90 degrees and 135 degrees ), three upper arm angles (45 degrees flexion/extension and neutral), one exertion frequency (15 per min) and one level of pronation torque (20% maximum voluntary contraction (MVC) relative to MVC at each articulation). Discomfort rating after the end of each 5 min treatment was recorded on a visual analogue scale. Results of a repeated measures analysis of covariance on discomfort score, with torque endurance time as covariate, indicated that none of the factors was significant including torque endurance time (p = 0.153). An initial data collection phase preceded the main experiment in order to ensure that participants exerted exactly 20% MVC of the particular articulation. In this phase MVC pronation torque was measured at each articulation. The data revealed a significant forearm rotation angle effect (p = 0.001) and participant effect (p = 0.001). Of the two-way interactions, elbow*participant (p = 0.004), forearm*participant (p = 0.001) and upper arm*participant (p = 0.005) were the significant factors. Electromyographic activity of the pronator teres and biceps brachii muscles revealed no significant change in muscle activity in most of the articulations. Industrial jobs involving deviated upper arm postures are typical in industry but have a strong association with injury. Data from this study will enable better understanding of the effects of deviated upper arm postures on musculoskeletal disorders and can also be used to identify and control high-risk tasks in industry.

Free-fillet flap harvested in 'severe, high-energy landmine explosion' injuries of lower extremity: a case report

Fillet flaps harvested from the non-replantable or unsalvageable amputated segment can be used to cover tissue defects. We discuss the case of a patient who had suffered a severe high-energy landmine injury, including severe leg damage, resulting in a below-knee amputation and soft-tissue defect around the forearm region. We successfully harvested the fillet from the amputated part of the extremity to the forearm region. We conclude that harvesting of a fillet flap from severely injured lower extremity, resulting from a high-energy landmine explosion, is technically feasible.