Prevention of re-fractures of both bones of the forearm in children

PURPOSE

The aim of this study was to observe if the re-fracture rate after forearm both bones was decreased by protecting the forearm with a preventive brace for 6 months following the fracture and by ceasing all physical activities.

METHODS

We performed a retrospective study in 75 consecutive cases of diaphyseal fracture of both bone of forearms, in 52 boys and 23 girls aged from 6 months to 11 years. It concerned a first episode of fracture in 84% of cases and a re-fracture in 17%.

RESULTS

Re-fracture rate was 0% in the group where a protective brace was worn while it was 20% in the group without brace.

CONCLUSIONS

Both the wearing of a protective brace and absence of sport for 6 months may decrease the re-fracture rate to 0%, if the patient is compliant by wearing it and by ceasing all physical activities.

Free Vascularized Fibula for the Treatment of Traumatic Bone Defects and Nonunion of the Forearm Bones

Eighteen infected nonunions and segmental defects of both the radius and ulna which had failed to resolve with conventional treatment were treated with a free vascularized fibular graft to restore radial, but not ulnar, continuity. In three patients there was destruction of the wrist joint and in two destruction of the elbow. The time from injury to referral ranged from 4 weeks to 3 months. The ipsilateral fibula was used as an osseous or osseocutaneous free flap to reconstruct the radius. All fractures united with good soft-tissue healing and resolution of infection. One patient required additional cancellous bone grafting. The mean period required for radiographic bone union was 4 months. Reconstruction of only the radius provided a stable forearm with a reasonable range of forearm rotation.

Dupuytren’s Disease Secondary to Acute Injury, Infection or Operation Distal to the Elbow in the Ipsilateral Upper Limb – A Historical Review

The aggregated total of 385 cases of Dupuytren’s disease arising after acute or specific injury, operation or infection of the forearm, wrist or hand between 1614 and 2003 are documented, including a personal series of 52 cases. The history of this relationship is recorded and the medico legal implications of the association are discussed.

A Pronator Teres-sparing Volar Approach for Osteosynthesis of Midshaft Diaphyseal Radius Fractures

Henry's approach is widely considered the "workhorse" for exposing the volar radius and has not really changed since his original description in 1945. We describe a pronator teres-sparing volar approach to the forearm, for osteosynthesis of midshaft diaphyseal radius fractures. We believe this approach is safe, simple, and reproducible, and has several practical and theoretical advantages over Henry's original description.

[Stab wounds of the hand and forearm due to Kuluna in Kinshasa (Democratic Republic of Congo): types of injuries and treatment]

Democratic Republic of Congo (DRC), a particular form of juvenile delinquency and insecurity intensifies in the city of Kinshasa. This is the phenomenon Kuluna. It is organized gangs equipped with machetes and other weapons. The main objective of this study is to know the phenomenon Kuluna and describe the upper limb injuries caused by machetes, while insisting on the specifics of the management of these lesions in our communities. This retrospective descriptive study examines 14 cases of wounds of the hand and forearm due to stab phenomenon Kuluna, in Kinshasa. It covers the period from 1 November 2010 to 1 November 2013. Among the 14 patients with lesions in the hand and forearm admitted and treated at the Unit of Plastic Reconstructive and Aesthetic Surgery, Hand Surgery and Burns, University Clinics of Kinshasa to attacks due to the phenomenon Kuluna. We have 11 men and 3 women. The average age was 33, 5 years (extremes of 21 and 56 years). The right upper limb is reached that the left upper limb, respectively 12 patients and 2 patients. The lesions are localized to the wrist in the majority of cases (10 patients) in the palm of hand and in 3 patients in the fingers in 1 patient. The palmar surface is reached (10 cases) and the dorsal (4 cases). Zone 5 of the International Classification of flexor and Zone 8 topographic classification extensors at hand are the predilection sites of lesions respectively the palmar surface (6 out of 10) and the dorsal (2 case 4). The median nerve at the wrist is cut in half the cases. On bone lesions localized to the forearm, we observed a high incidence of fracture of the ulna (62.5%). The treatment begins with the stabilization of bone pieces, gestures revascularization and nerve sutures and suture tendon and finally skin coverage. Rehabilitation was mandatory, she supervises the actions of repair and it continues until the recovery of function.

Callus Formation and Mineralization after Fracture with Different Fixation Techniques: Minimally Invasive Plate Osteosynthesis versus Open Reduction Internal Fixation

Minimally invasive plate osteosynthesis(MIPO) has been considered as an alternative for fracture treatment. Previous study has demonstrated that MIPO technique has the advantage of less soft tissue injury compared with open reduction internal fixation (ORIF). However, the comparison of callus formation and mineralization between two plate osteosynthesis methods remains unknown. In this experiment, ulna fracture model was established in 42 beagle dogs. The fractures underwent reduction and internal fixation with MIPO or ORIF. Sequential fluorescent labeling and radiographs were applied to determine new callus formation and mineralization in two groups after operation. At 4, 8 and 12 weeks postoperatively, the animals were selected to be sacrificed and the ulna specimens were analyzed by Micro-CT. The sections were also treated with Masson staining for histological evaluation. More callus formation was observed in MIPO group in early stage of fracture healing. The fracture union rate has no significant difference between two groups. The results indicate that excessive soft tissue stripping may impact early callus formation. As MIPO technique can effectively reduce soft tissue injury with little incision, it is considered to be a promising alternative for fracture fixation.

[LONG-TERM RESULTS OF DELAYED REPAIR OF MEDIAN NERVE INJURY]

OBJECTIVE

To review and analyze the long-term results of delayed repair of median nerve injury.

METHODS

Between January 2004 and December 2008, 228 patients with median nerve injury undergoing delayed repair were followed up for more than 4 years, and the clinical data were retrospectively analyzed. There were 176 males (77.19%) and 52 females (22.81%), aged 2-71 years (median, 29 years). The main injury reason was cutting injury in 159 cases (69.74%); 203 cases had open injury (89.04%). According to the injury level, injury located at area I (upper arm) in 38 cases (16.67%), at area II (elbow and proximal forearm) in 53 cases (23.25%), at area III (anterior interosseous nerve) in 13 cases (5.70%), and at area IV (distal forearm to wrist) in 124 cases (54.39%). The delayed operations included delayed suture (50 cases, 21.93%), nerve release (149 cases, 65.35%), and nerve graft (29 cases, 12.72%).

RESULTS

For patients with injury at area I and area II, the results were good in 23 cases (25.27%), fair in 56 cases (61.54%), and poor in 12 cases (13.18%) according to modified Birch and Raji's median nerve grading system; there was significant difference in the results between 3 repair methods for injury at area II (χ2 = 6.228, P = 0.044), but no significant difference was found for injury at area I (χ2 = 2.241, P = 0.326). Twelve patients (13.18%) needed musculus flexor functional reconstruction. Recovery of thenar muscle was poor in all patients, but only 5 cases (5.49%) received reconstruction. Thirteen cases of nerve injury at area III had good results, regardless of the repair methods. For patients with injury at area IV, the results were excellent in 6 cases (4.84%), good in 22 cases (17.74%), fair in 72 cases (58.06%), and poor in 24 cases (19.35%) according to Birch and Raji's grading system; there was significant difference in the results between 3 repair methods (χ2 = 12.646, P = 0.002), and the result of delayed repair was better.

CONCLUSION

The results of delayed repair is poor for all median nerve injuries, especially for high level injury. The technique of repair methods vary with injury level. For some delayed median nerve injuries, early nerve transfer may be a better choice for indicative patients.

Deep burn of hand and forearm treated by abdominal wall flap. A case report

AIM

Post-traumatic hand and forearm defects always represent a challenge for reconstructive surgeons, especially when multiple structures are involved, because of a high rate of amputation.

MATERIAL OF STUDY

A 21 years old woman arrived to the E.R. with a complex crush-burn trauma of the upper limb caused by an accident with an industrial ironing machine, resulting in a ulnar bone fracture, ulnar artery laceration and a wide burn of the dorsum of the right forearm.

RESULT

We achieved toTAL limb salvage with coverage of the "nobles" structures of the forearm.

DISCUSSION AND CONCLUSIONS

Different reconstructive methods have been used over time to treat these defects focusing the attention on both functional and cosmetic aspects. The abdominal pedicle flap was one of the achiest reconstructive methods for hand and forearm defects. In an era in which microsurgery takes the lion's share, some basic procedure may be helpful, especially in certain cases. In this study the authors reported a case of a young woman with a complex trauma of the right arm resulting from an occupational accident.

[REPAIRING SKIN AND SOFT TISSUE DEFECT IN PALM OR DORSUM OF HAND AND FOREARM WITH EPIGASTRIC BILOBED FLAP]

OBJECTIVE

To introduce the surgical method and effectiveness of repairing skin and soft tissue defect in the palm or dorsum of the hand and forearm with epigastric bilobed flap.

METHODS

Between October 2010 and December 2013, 4 male patients with skin and soft tissue defect in the palm or dorsum of the hand and forearm were treated, aged from 36 to 62 years. Of them, 3 cases had degloving injury caused by machines and 1 case had necrosis of fingers and skin after surgery of crush injury. The time from injury to hospitalization was from 3 hours to 15 days. Among the 4 cases, the size of palmar defect was 7 cmx4 cm to 16 cmx6 cm, and the size of dorsal defect was 10 cmx7 cm to 20 cmx10 cm. The epigastric bilobed flap was designed based on the axial vessel which was formed by inferior epigastric artery, superior epigastric artery, and intercostals arteries. The size of flap ranged from 12 cmx4 cm to 18 cmx6 cm in the vertical direction, 15 cmx8 cm to 22 cmx11 cm in the oblique direction. The donor site was directly closed. The pedicles were cut at 22 to 24 days after repairing operation.

RESULTS

All the flaps survived well with the wound healing by first intention. Four patients were followed up 3 months to 1 year and 2 months. The other flaps had good appearance and texture except 1 bulky flap. The flap sensation basically restored to S2-S3. The function of the hands recovered well.

CONCLUSION

Skin and soft tissue defect in the palm or dorsum of the hand and forearm can be repaired with the epigastric bilobed flap, because it has such advantages as big dermatomic area and adequate blood supply. Besides, the operation is practical, safe, and simple.

[SURGICAL TECHNIQUE OF BLOCKING INTRAMEDULLARY OSTEOSYNTHESIS OF FOREARM FRACTURES]

An introduction of blocking osteosynthesis was recently included into practice of treatment of forearm fractures. The forearm has a very difficult biomechanics and extremely important functional value. There are really high requirements to accuracy of reposition and stability of forearm fracture fixation. The blocking osteosynthesis successfully combines fixation stability with functionality, although its performance technique isn't so simple, that forces experts to use other methods of fixation. It is possible successfully use advantages of the method by studying and keeping variety of operation nuances of blocking osteosynthesis on forearm in order to restore anatomy, biomechanics and obtain the stable fixation. The period of rehabilitation could be combined with period of union of bones in this case without postoperative complications such as nonunion of bones, construction fractures and instability of osteosynthesis. The method would be optimal provided that a surgeon masters the technique of construction implantation. There are maximum advantages in treatment of complicated fractures (nonunion of bones, false joint and defects) due to functionality of the method.

Epidemiology of forearm fractures in adults in Denmark: national age- and gender-specific incidence rates, ratio of forearm to hip fractures, and extent of surgical fracture repair in inpatients and outpatients

National epidemiological studies of forearm fractures are scarce. We examined in- and outpatient rates in Denmark, including anatomical location, surgery, hospitalization ratio, recurrent fractures, and ratio of forearm to hip fractures. This may be useful for triangulation in countries with less detailed information. Rates were higher than previously estimated.

INTRODUCTION

Despite a significant contribution to the overall burden of osteoporotic, nonvertebral fractures, relatively little information is available about age- and gender-specific incidence rates for many countries including Denmark.

METHODS

We used national individual patient data on inpatient and outpatient treatment to calculate rates of forearm fractures, taking readmissions into account, with subtables for distal and proximal fractures. We also calculated ratios of forearm to hip fractures that may be useful when imputing forearm fracture rates from other administrative sources. In addition, we report the rates of hospital admission and the rates of surgical treatment, allowing readers to extrapolate from the number of admissions or surgical procedures to incidence rates, should their data sources be less comprehensive.

RESULTS

Forearm fracture rates were 278 per 100,000 patient years in men aged 50+ and 1,110 per 100,000 in women aged 50+. The female to male incidence rate ratio was 4.0 for the age group 50+ but close to unity in persons aged 40 or under. Two thirds of patients were treated on an outpatient basis with little difference across age and gender strata. Four out of five fractures were treated conservatively. The rate of forearm fractures in Denmark was somewhat higher in both genders than recently imputed from hip fracture rates and were close to the rates previously reported in studies from Norway and Sweden.

CONCLUSION

The rates of forearm fracture in Denmark are higher than previously estimated and very similar to the high risk reported from studies in Norway and Sweden.

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.

[Manual reduction of children's Monteggia fractures associated with anterior interosseous nerve injury]

OBJECTIVE

To study clinical results of the manual reduction in treatment.

METHODS

From October 2010 to April 2013,39 children with Monteggia fracture associated with anterior interosseous nerve injury were treated by manual reduction and fixation on buckling rotation backward,including 17 females and 22 males with an average age of 6.3 years old ranging from 3.2 to 11 years old. Among them, 15 cases were on the right side and 24 cases on the left. The course of disease was 40 minutes to 8 days (averaged 1.5 days). There were 7 cases with skateboard injured, 13 cases with stumble injured, 11 cases with falling injured,8 cases with air bed injured. According to Bado classification, 13 cases were type II, 22 cases were type III, 4 cases were type IV.

RESULTS

The distal forefinger showed exercise normally in 34 cases at 3 weeks after treatment, and the patients restored normal activities at 6 weeks after treatment. All patients were follow-up from 54 days to 6 months (averaged 67 days. According to Mayo elbow functional evaluation standard,the scoring result was 19.62±1.35 in activity, 45.00 ± 0.00 in pain, 9.87 ± 0.80 in stability, 25.00±0.00 in strength, 99.49 ±1.92 in total. The outcome of all patients was excellent and good evaluation results.

CONCLUSION

If the anterior interosseous nerve injury could be identified early and treated timely, patients could gradually restore reasonable function and recover with satisfactory results. Raising understanding of anterior interosseous nerve injury can effectively reduce misdiagnosis.

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.

Timing of forearm arterial repair in the well-perfused limb

The purpose of this study was to evaluate the difference in the outcomes of patients with a well-perfused hand who were taken to the operating room (OR) within 6 hours of forearm arterial injury vs patients who were treated in a semiurgent fashion. A review of 201 consecutive patients who were taken to the OR with forearm-level radial or ulnar arterial injury identified 26 patients who had a well-perfused hand at presentation in whom hemostasis was achieved within 15 minutes with manual pressure and no signs of hemodynamic instability. Outcomes of interest included short-version Disabilities of the Arm, Shoulder and Hand (quickDASH) scores and patient-reported cold intolerance. Of the 26 patients, group 1 included 17 patients who were taken to the OR within 6 hours and group 2 included 9 patients who were taken to the OR in a delayed fashion. Minimum follow-up in both groups was 13 months. Average quickDASH score was 24.5 and 14.1 for groups 1 and 2, respectively. Average time spent in the OR was significantly less in group 2 compared with group 1 (1.7 vs 2.8 hours). In the setting of forearm arterial injury with a well-perfused distal limb, there was no difference in functional outcome in patients taken to the OR emergently compared with those who underwent surgery in a delayed manner. With careful evaluation and monitoring, semiurgent operative repair is feasible and may improve certain aspects of patient care and hospital resource use. Outcome measures in this study support semiurgent treatment of these injuries.

Flap reconstruction of the elbow and forearm: a case-based approach

Elbow and forearm wounds have distinct reconstructive requirements, but both require a durable and pliable solution. Pedicle, free fasciocutaneous and muscle, and distant (2-stage) flaps have a role in wound reconstruction in these unique areas. This article presents practical surgical cases as a guide to soft tissue reconstruction of the elbow and forearm.

The sensory restoration in radial nerve injury using the first branch of dorsal ulnar cutaneous nerve--a cadaveric study for the feasibility of procedure and case demonstration

OBJECTIVE

To demonstrate the new sensory restoration technique in radial nerve injury using the first branch of dorsal ulnar cutaneous nerve as the donor sensory nerve.

MATERIAL AND METHOD

Forty formalin-preserved cadavers (18 males and 22 females) were used as the subjects of the present study. The localization of the origin of first branch of dorsal ulnar cutaneous nerve was performed. The measurement was done to determine the origin of this nerve in relation to the tip of ulnar styloid. The simulated transfer was done. The length of the superficial radial nerve that had to be cut was determined. The measurement was done by two observers to determine the reliability of measurement.

RESULTS

The mean horizontal distance (X) to the origin of first branch of dorsal ulnar cutaneous nerve measured from the tip of ulnar styloid on the right and left side were 5.22 mm and 6.51 mm respectively. The mean vertical distance (Y) to the origin of first branch of dorsal ulnar cutaneous nerve measured from the tip of ulnar styloid on the right and left side were -7.72 mm and -4.37 mm respectively. The mean length of superficial radial nerve that had to be cut to allow tension free anastomosis, measured from the tip of radial styloid on the right and left side were 68.21 mm and 65.92 mm respectively. The estimated average size of the transferred branch of ulnar cutaneous nerve was about 70% of the size of superficial radial nerve.

CONCLUSION

The sensory restoration in radial nerve injury using sensory nerve transfer from the first branch of dorsal ulnar cutaneous nerve was technically feasible regarding to the comparable size between two nerves and anatomic consistency of the first branch of dorsal ulnar cutaneous nerve.

Outcomes of free adipofascial flaps combined with tenolysis in scarred beds

PURPOSE

To review our outcomes of transferring vascularized free adipofascial flaps used to change the local tissue conditions at the time of tenolysis in adhesion-prone beds.

METHODS

Eleven free adipofascial flaps were transplanted in 10 patients after tenolysis on the forearm (3 cases), the dorsum of the hand (5 cases), or the dorsum of the proximal phalanx (3 cases). All recipient areas had badly scarred beds, 7 of which had previously failed tenolyses. In addition to tenolysis (10) or the insertion of bridging tendon grafts (1), arthrolysis of several involved joints and bone fixation for nonunion (3 cases) were carried out simultaneously. The adipofascial flap was then wrapped around the tendons or interposed between the scarred tissue and the freed tendons. In 8 cases, the flap was the lateral arm adipofascial flap, whereas adipose flaps from the toes were used for the fingers.

RESULTS

All flaps survived without vascular crisis. In all cases, total active motion was similar to the passive motion obtained at surgery. Average Disabilities of the Arm, Shoulder, and Hand score improved from 69 to 10, and average Patient-Rated Wrist Hand Evaluation score improved from 65 to 9. Secondary surgery was needed to reduce the bulk of the flap in 3 patients. One patient required an additional procedure to obtain an optimum result.

CONCLUSIONS

Free adipofascial flaps provided satisfying results in this group of patients. The flaps should be considered when the bed is scarred or after a failed tenolysis.

TYPE OF STUDY/LEVEL OF EVIDENCE

Therapeutic IV.

Current options to surgical treatment in osteoporotic fractures

Treatment of osteoporotic fractures leads to significant challenges for the surgeon, including poor implant fixation related to low bone quality and compromised capacity of fracture healing. This article reviews the osteosynthesis and arthroplasty results in the surgical treatment of proximal femur, proximal humerus and wrist fractures to define the current options to decrease failure in fragility fracture management.

Comparative morphometry of the antebrachial and crural interosseous membranes: preliminary study for the use of the crural interosseous membrane in the surgical repair of the antebrachial interosseous membrane tears

INTRODUCTION

Traumatic tears of the antebrachial interosseous membrane (AIOM) on its whole length are difficult to treat, particularly in the Essex-Lopresti syndrome. The number of ligamentoplasty techniques described in the literature witnesses the difficulty of its reconstruction and the absence of reliable and satisfying procedure. The aim of this study was to explore a new way of treatment, which consists in replacing the AIOM by the crural interosseous membrane (CIOM), harvested from the same patient.

MATERIALS AND METHODS

A morphometric study of the AIOM and CIOM has been conducted on both sides of 15 formalin preserved corpses (i.e. 30 AIOM and 30 CIOM). Studied data were: length of forearms and legs, length and width (at different locations) of the membranes, in situ and after harvesting, and orientation of their fibers. The thickness of membrane was also measured but only after harvesting.

RESULTS

Concerning the AIOM, the mean length was 13.3 cm in situ and 12.8 cm after harvesting. Its width was maximal at the union of middle and distal thirds with an average value of 1.7 cm in situ and 1.45 cm after harvesting. Mean thickness was 1 mm. Anterior fibers were oblique distally and medially (20.5° ± 0.95°), and posterior fibers were oblique distally and laterally (40° ± 3.4°). Concerning the CIOM, the mean length was 24.75 cm in situ and 23.9 cm after harvesting. Its width was maximal at the union of proximal and middle thirds with an average value of 2.3 cm in situ and 1.85 cm after harvesting. Mean thickness was 0.5 mm. Obliquity of its fibers was reverse of that of the AIOM: the anterior fibers were quite oblique distally and laterally (13° ± 2.6°), and the posterior fibers oblique were oblique distally and medially (24.2° ± 2.48°).

DISCUSSION

From these results, one may conclude that the largest length and width of the CIOM allow its use as substitute for the injured AIOM. The orientation of its fibers should necessitate either its reversal while using the same side or the use of the CIOM of the opposite side; its relative sharpness could signify that its biomechanical properties could be worse. A biomechanical study is necessary to evaluate how this new way of replacing the AIOM could resist to the strains imposed on the forearm.

[Anterolateral thigh and groin conjoined flap for emergent repair of ultra-long complex tissue defects in forearm and hand]

OBJECTIVE

To evaluate the effectiveness of anterolateral thigh and groin conjoined flap in emergent repair of ultra-long complex tissue defects in forearm and hand.

METHODS

Between February 2009 and October 2011, 6 patients with complex tissue defect of dorsal forearm and hand were in adminsion. There were 5 male and 1 female with an average age of 38.5 years (range, 32-47 years). Injury reasons included machine injury in 5 cases and traffic accident injury in 1 case. Injury to admission time was from 3 to 16 hours (mean, 6 hours). All case were single limb injury, including right forearm and hand injury in 4 cases and left forearm and hand injury in 2 cases. The wound area was from 36 cm x 9 cm to 48 cm x 12 cm. The type of associated injury included elbow dislocation associated with open injury in 2 cases; fractures of the radial, ulnar, and metacarpal bone in 4 cases; defects of wrist dorsal skin and extensor tendons of fingers and wrist in 5 cases; and defects of ulnar artery and ulnar nerve in 1 case. The anterolateral thigh and groin conjoined free flaps were used to repair defects in the forearm and hand in emergency. The area of flap was from 36 cm x 9 cm to 48 cm x 12 cm. Meanwhile the partial functional reconstruction was performed. The donor site was repaired by skin grafts.

RESULTS

The anastomotic embolization of vascular pedicle and arteria interossea dorsalis occurred in 1 case, purulent secretion under the flap in 1 case, which were cured after symptomatic treatment; the skin flaps completely survived, and primary healing of the wounds were obtained in the other cases. The donor skin grafts survived in 2 cases, and partial necrosis of the skin graft of lower abdominal occurred in 4 cases, and healed after changing dressing. All of the 6 patients were followed up 3 to 18 months (mean, 10 months). The appearance and texture of the flaps were good. The protective sensation was recovered in 2 cases followed up for more than 14 months; no sensory recovery was observed in the other cases. At last follow-up, according to the upper extremity functional evaluation standard by Hand Surgery Branch of Chinese Medical Association, the results were excellent in 1 case, good in 4 cases, and poor in 1 case, and the excellent and good rate was 83.3%.

CONCLUSION

It could get a good short-term effectiveness to use the anterolateral thigh and groin conjoined flap for emergent repair of the ultra-long and complex tissue defects in forearm and hand.

Ultrasound-guided injection of steroid in multiple postamputation neuromas

After limb amputation, neuromas may be asymptomatic when not compressed, but can cause unexplained discomfort when a prosthesis is worn. The sonographic presentation of multiple postamputation neuromas has rarely been reported. A 40-year-old female with a left, below-elbow amputation suffered from late-onset stump pain and prosthesis intolerance. Physical examination revealed a painful nodule, whereas sonographic findings disclosed three hypoechoic masses derived from the median, ulnar, and radial nerves. Marked pain reduction was reported 2 weeks after sonography-guided steroid injection. Investigation of all damaged nerves in the residual limbs is important.