Plastic deformation of the forearm in an adult: treatment with multiple osteotomies

Plastic deformation of the forearm is a rare and frequently missed injury in adults that can result in significant loss of forearm rotation. We report on a skeletally mature 19-year-old man with traumatic plastic deformation of the radius and ulna resulting in complete loss of forearm pronation. The patient was treated with multiple-level osteotomies of the radius and ulna 7 months postinjury. The patient had full forearm pronation at 4 months followup.

Paediatric forearm refractures with retained plates managed with flexible intramedullary nails

During the past 18 months we have managed four paediatric patients who have sustained forearm refractures associated with retained plates that were used to treat their original fracture. Although this complication is not new, most literature regarding paediatric forearm refracture relates to refractures that occur after closed treatment or after removal of metalwork. We treated the patients in this small series with plate removal and intramedullary stabilisation using elastic stable intramedullary nails (Nancy, Depuy, UK) as opposed to revision plating. Treatment of this complication by this method has not previously been described.

[Elastic stable intramedullary nailing (ESIN) in pediatric forearm shaft fractures: intraoperative image intensifier times]

AIM

Elastic stable intramedullary nailing (ESIN)is the therapy of choice in pediatric forearm shaft fractures. It requires increased intraoperative image intensifier times and radiation load.

METHOD

We performed a retrospective analysis of 78 operative procedures from a five-year period. In 16 cases the image intensifier times of the distinct steps of the operation were investigated prospectively.

RESULTS

Average duration of the surgical procedure was 36.9 (18-144) minutes. Average radiation time was 59.5 (8-222) seconds. In educational operations, the duration of surgery was significantly longer than in procedures performed by experienced surgeons, but radiation times only were increased tendentially. In those procedures investigated prospectively, 53.1% of the image intensifier time was used for fracture passage.

CONCLUSION

In ESIN of forearm shaft fractures,intraoperative image intensifier times of less than 2 minutes can be expected. Low intraoperative radiation times are a mark of quality. They serve for radiation protection of the patients, surgeons and OT staff.

[Repair of soft-tissue defect of amputation stumps of the forearm with free flap from the traumatic amputated extremity]

OBJECTIVE

To report the clinical results of the repair of soft-tissue defect of amputation stumps of the forearm with free flap from the traumatic amputated extremity.

METHODS

Five patients, 4 males and 1 female, aged 32 (22 - 43), with soft-tissue defect of the remaining stump of the traumatic amputation of the forearm, 3 cases in the right forearm and 2 cases in the left forearm, underwent repair of the defect by free flap from the traumatic amputated extremity with the size of the flaps ranging from 8 cm x 9 cm to 9 cm x 12 cm. The patients were followed up for 2.6 years (1.5 - 3.5 years).

RESULTS

Superficial infection occurred in one patient postoperatively and the wound was gradually healed by daily wound dressings. All the flaps survived completely with satisfactory clinical results. The cosmetic appearance on the recipient area was good and the function of the elbow recovered satisfactorily.

CONCLUSION

The flap from the traumatic amputated extremity has a constant vascular anatomy and a long vascular pedicle, so that dissection of the flap can be accomplished easily. The surgery allows to preserve the functional length or the elbow function of the remaining stump of the traumatic amputation.

[Cross-bridge vascular anastomosis free tissue transplantation in repairing tissue defects of extremities]

OBJECTIVE

To investigate the application and effect of the cross-bridge vascular anastomosis free flap transplantation for tissue defects of extremities.

METHODS

From May 1982 to November 2005, 110 cases of tissue defects of extremities were treated with cross-bridge vascular anastomosis free tissue transplantation. Of 110 patitents, 80 were male and 30 were female with a median age of 30 years(5 to 54 years). Tissue defects were caused by traffic accidents (59 cases), machine injuries (32 cases) and mangled injuries (19 cases). The locations were the forearms in 2 cases and the legs in 108 cases. And 69 cases had simple soft tissue defects, 6 cases had simple bone defects, and 35 cases had complicated defects. The length of bone defect ranged from 5 cm to 19 cm and the area of soft tissue defect ranged from 6 cm x 10 cm to 15 cm x 35 cm. The graft tissue included latissimus dorsi musculocutaneous flap, vastus anterolateral flap,cutaneous fibula flap, osseous fibula flap, and cutaneous iliac flap. The cross-bridge of the two lower extremities was performed in 106 cases, the cross-bridge of the two upper extremities in 2 cases, and the cross-bridge of the upper-lower extremities in 2 cases. The composite tissue transplantation was used if the graft tissues were two or more. The wounds of donor site was directly sutured in 67 cases, and partly sutured with skingrafting in 43 cases.

RESULTS

Vascular crisis occurred in 9 cases. Vascular crisis was relieved in 5 cases and grafting tissues was survival after exploring the vessel; 4 cases failed. The graft tissue was survival in 101 cases, and the survival rate was 96.4%. The follow-up time was 4 months to 22 years with an average of 6.3 years. Graft bone healed and mean healing time was 4 months. The flap appearance was satisfactory and extremity function was restored to normal. One case became necrosis in the edge of the flap and cured by debridement, dressing and skingrafting, the other got primary healing at 2-3 weeks after operation.

CONCLUSION

The application of the cross-bridge vascular anastomosis free tissue transplantation for tissue defects of extremities is an effective method, when extremities have no vessel anastomosed.

Treatment of non-union of the forearm using distraction-compression osteogenesis

BACKGROUND

The goal of the study is presentation broad abilities like gives Ilizarov method in the treatment of posttraumatic nonunion the of forearm with concomitant shortening and axis deformity, in minimally invasive technique, with contemporary axis correction and lengthening .

MATERIAL AND METHODS

. Authors present 6 patient operated on with the use of Ilizarov method, in years 2001-2005 , suffer from vital nonunion of the forearm - 6 cases radius; 1 case ulna and radius. In all cases with nonunion concomitant shortening of the radius from 2 to 3 cm and valgosity of radius with deformity in sagittal plane in 4 patients (2antecurvation, 2 retrocurvation). All patients had restricted rotation ROM of forearm and restriction of wrist motion . Author's modification of Ilizarov apparatus (with mini-Schanz's half-pins, which permitted rotation of forearm) was used in most of patients. In 3 cases monofocal slow correction with lengthening within nonunion was performed. In 2 cases bifocal, one-step slow correction of deformity and compression within nonunion with lengthening was performed. In 1 remaining case compression of ulna nonunion and compression with deformity correction of radius nonunion were performed. Distraction and correction start in 7 postoperative day in rate from 0,25 to 1 mm/day and correspondingly from1 to 2o/day.

RESULTS

Time of correction and distraction was average 63,3 days (40 - 90 days) . Total time of stabilization was average 25,4 weeks (20 - 35 weeks). Bone union was obtained in all patients. In all cases considerable recovery of limb function was achieved. All patients had superficial pin-tract infection . One patient had staphylococcal pin-tract infection of soft tissues, which retreat after 3-weeks guided antibiotic therapy.

CONCLUSION

The Ilizarov method permit for contemporary axis correction and/or distraction or compression. There is the method of choice in the treatment of nonunion of forearm with concomitant shortening and axis deformity.

Actualities in big segments replantation surgery

Replantation of an amputation is no longer a difficult technical problem. Indeed, the experience gathered over the last few decades, right from the first concepts posed by the pioneers up to the present era and the improved technical aids, all go to suggest that the majority of amputated segments may now be reconstructed. However, what we really want from a replant is not just survival but function. Indications for replantations must follow careful and objective patient selection together with the evaluation of type and site of lesion and possible complications. Furthermore, the important role of emergency organization in this type of surgery is to be emphasized. Nowadays, clean cut injuries are rarer and are being substituted by high energy trauma which may produce extensive tissue lesions that increase complications and lead to poor functional results. Consequently, some authors were induced to describe evaluation systems for decision making which still present problems which are in part due to the large number of parameters to be taken into consideration as well as to the complex functionality of the upper limb. This led us to evaluate our case series of 52 major replantations of the upper limb over the last 10 years and to compare it with other published series. The best form of reconstruction following total amputation of a major limb segment is still its replantation. The highly significant increase in the quality of life is able to justify the higher social costs and the number of operations required.

Antibiotic-impregnated cement spacer for bone defects of the forearm and hand

Management of bone loss, particularly in the face of open or contaminated wounds, presents a reconstructive challenge. Polymethylmethacrylate impregnated with antibiotics has been used successfully in the treatment of infected total joint arthroplasty and open fractures. The cement delivers high-dose local concentrations of antibiotics while filling a space. This article presents our use of an antibiotic-impregnated cement spacer for bone loss in the forearm or hand in the face of open or infected wounds. The cement spacer fills a potential space, prevents the involution of the surrounding soft tissue, and delivers appropriate antibiotics. When the spacer is removed, the remaining sheath serves to hold and contain the cancellous bone graft.

Salvage of replanted upper extremities with major soft-tissue complications

Soft-tissue complications in the replantation wound, either septic or non-septic, are the main cause of failure in major extremity replantations. In the presence of necrosis or infection, vascular errosion or thrombosis readily develops and can lead to limb loss. Very aggressive surgical treatment has been recommended to salvage the replanted limb in these highly unstable clinical situations. Over a 10-year period, 423 amputated parts were replanted, 56 of which were replants proximal to the wrist. The experience of the author in treating 11 cases of critical soft-tissue necrosis (four septic and seven non-septic) after major replantation of the upper extremity with aggressive debridement and flap coverage, is reported. All flaps and limbs survived.

Management of posttraumatic metadiaphyseal radioulnar synostosis

Posttraumatic radioulnar synostosis results in functional loss of forearm rotation. Treatment preference is to excise the synostosis when associated fractures have healed or when the process is radiographically static. Interposition material is used in the region of the proximal radioulnar joint or when the medullary canal of the radius or ulna is breached. Irradiation is limited to lesions at or proximal to the radial tuberosity. Postoperative management includes resting splint that holds the extremity in the extremes of forearm rotation, and intermittent active and passive range of motion exercises. Anti-inflammatory medications are used only during hospitalization. Results have shown a good functional arc of pronosupination, and no recurrence, especially when the process is limited to the midforearm.

Initial assessment and management of complex forearm defects

Complex trauma to the forearm often involves significant damage to or loss of bone, muscle, skin, tendons, and neurovascular structures. Treatment focuses on regaining long-term hand function, which is best achieved by combining plastic and orthopedic surgical expertise in a team that includes experienced upper arm rehabilitation therapists. The reconstruction goal is to restore a level of hand function that allows the patient to incorporate the injured hand back into daily activities. We define complex defects as those involving significant segmental loss of one or more tissue types. This article provides a framework by which these often formidable and overwhelming injuries can be approached, and discusses some of the surgical options used to reconstruct complex defects of the forearm.

Intérêt de l'Intégra® dans la prise en charge d'un dégantage complet de l'avant-bras. À propos d'un cas

A 43-year-old man suffered complete skin degloving of the right forearm in a work accident with a farm machine. Initial treatment using a total skin flap graft after fat removal failed because of nearly complete necrosis after ten days. Artificial dermis (Intégra) was then used to ensure skin cover and reduce adherence phenomena. Postoperative complications were minor, and a split-thickness graft performed after three weeks led to healing five weeks later. At one year of follow-up, scar quality was considered very good, with normal and symmetric mobility. This case suggests that Intégra could be a valid surgical alternative in the management of skin degloving injuries.

[Clinical application of vasularisied anterolateral thigh fascial flap]

OBJECTIVE

To evaluate a modified anterolateral thigh fascial flap designed for the treatment of the soft tissue defects in the forearms and hands.

METHODS

From September 2000 to December 2003, a modified anterolateral thigh fascial flap combined with the intermediate split thickness skin graft was applied to the treatment of 13 patients with the soft tissue defects in the forearms or the hands. There were 8 males and 5 females, aged 19-43 years (average, 27. 6 years). Three patients had a mangled injury, 4 had a belt injury, and 6 had a crush injury; 6 patients had their tissue defects on the palm side of the forearm, 6 had their tissue defects on the dorsal side of the hand, and 1 had the defect in the index finger (dorsal side of the hand). The tissue defects ranged in size from 17. 5 cm x 7. 7 cm to 4. 6 cm x 3. 4 cm. In addition, 4 of the patients had an accompanying fracture in the forearm or the hand, and the remaining 9 had an extenor tendon injury. All the patients underwent emergency debridement and reposition with an internal fixation for the fracture; 3-5 days after the repair of the injured nerves, muscle tendons and blood vessels, the tissue defects were repaired with the anterolateral thigh fascial flap combined with the intermediate split thickness skin graft.

RESULTS

No vascular crisis developed after operation. All the flaps survived except one flap that developed a parial skin necrosis (2.0 cm x 1.0 cm) in the hand, but the skin survived after another skingrafting. The follow-up for 3-12 months revealed that all the flaps and skin grafts had a good appearance with no contracture of the skin. According to the evaluation criteria for the upper limbs recommended by the Hand Society of Chinese Medical Association, 9 patients had an excellent result, 2 had a good result, I had a fair result, and 1 had a poor result, with a good/excellence rate of 85%.

CONCLUSION

The modified anterolateral thigh fascial flap combined with the skin graft is one of the best methods for the treatment of the soft tissue defects in the forearms and the hands. This method has advantages of no requirement for a further flap reconstruction, no skin scar or contracture in the future, easy management for the donor site, and less wound formation.

Long-term functional results of primary reconstruction of severe forearm injuries

Severe forearm injuries caused by machinery such as a power saw represented about 0.2% of all upper limb injuries operated on in the plastic surgery section of our institute between 1993 and 1997. These are complex and contaminated injuries with severe damage to skin, muscles, tendons, nerves, vessels and bones. Primary repair or reconstruction of all the divided vital structures was carried out in our series of four patients, including one 4-cm cable nerve graft for a median nerve defect. After an average 22-month follow up, the functional results showed grade M4 motor recovery and better than grade S3+ sensory recovery of the hand in all four patients. We suggest that a definitive primary procedure is best when possible. This will achieve a better functional outcome from early neural regeneration, and will reduce the frequency of secondary procedures, cause less scarring, and shorten the duration of hospital stays and rehabilitation periods.

Paediatric forearm fractures: the increasing use of elastic stable intra-medullary nails

This paper entails a clinical review of outcomes and complications of 19 consecutive paediatric patients having undergone elastic stable intramedullary nailing for diaphyseal forearm fractures over a one year period. The mean age of patients was 9 years. The majority were male with a ratio of 17:2. In this group there were two patients with grade 1 open fractures. Four of the fractures required open reduction due to difficulty in reduction and soft tissue interposition. All fractures went on to osseous union with minimal deformity and full recovery. There were three complications which included one EPL rupture requiring delayed repair, one EPB partial rupture repaired at time of surgery, and one superficial radial nerve injury. Two patients also presented with nails penetrating the skin prior to removal. Elastic stable intramedullary nails offer good fixation to control deformity in midshaft forearm fractures for paediatric patients. However there is a high rate of possible complications around the radial insertion point.

Traumatic below-elbow amputations

Prehension, intelligence, and erect posture distinguish humans from lower animals. Hands are instrumental for our survival and welfare. We use our hands when we work, recreate, and communicate. A handshake, a touch, a sign, or signal has significant social and communicative meanings. Hands play a major role in defining the skill level of our activities and our level of social expression and integration. Indeed, refined psychomotor precision of hand function may distinguish some individuals among us, gifting society with its more skilled craftsmen, surgeons, artisans, musicians, athletes, and the like in a highly digital world. For others, their hands are critical in providing and caring for their families. Injury severity scores may identify the majority of patients that require amputation; however, injury severity scoring system predictions in individual patients may be problematic and should be used with caution. Amputees require comprehensive multidisciplinary treatment and compassion so that they can successfully overcome their losses. Ultimately, the patients must change, adjust, and adapt to successfully reintegrate themselves into their families, peer groups, job settings, and society as a whole. Early amputation may decrease the incidence and severity of phantom pain compared to amputation after the failure of reconstruction. Early prosthetic fitting, training, and physical rehabilitation; early psychological and sociological support; and early return to work facilitate successful functional recovery. Psychological recovery may be a more arduous and extended process than physical recovery. We must teach our amputees from the outset to use their losses as an incentive for success, assist them to regain their quality of life, and encourage them to act as role models for and to educate others.

Free functional muscle transfer failure and thrombophilic gene mutations as a potential risk factor: A case report

The evolution of microsurgery popularized the free functioning muscle transfers as secondary procedures to reanimate paralyzed extremities after severance of the brachial plexus, especially when the surgeon deals with late cases. Studies considering transplantation, describe thrombophilic factors as a cause of severe complications after transplantation, such as acute or early rejection episodes, delayed graft function, or chronic graft dysfunction. It is the first time that thrombophilia associated with free muscle-graft rejection is reported. A young man who had two free functional muscle transfers for brachial plexus reconstruction in the same forearm within an interval of 6 months. The free functional muscle transfer was failed in both cases because of vein thrombosis and subsequent arterial clot. The possibility of thrombophilia was investigated and during the genetic investigation it was discovered that he was heterozygous for the mutations of factor V, G1691A-Leiden, A4070G and homozygous for the MTHFR C677T mutation.

An anterolateral thigh flap based on the superior cutaneous perforator artery: An anatomic study and case reports

This study was performed to observe the patterns of the superior perforator artery as a pedicle for an anterolateral thigh flap and report the results of clinical application. The perforator arteries at the anterolateral part of the thigh were observed on 50 lower limbs from embalmed cadavers and the results of 65 clinical cases who received transfer of the anterolateral thigh flap, which adopted the superior perforator artery as the pedicle. This study found that 34 superior perforator arteries presented in 29 of the 50 cadaveric limbs (58%), which might arise from the ascending branch, the transverse branch, and the descending branch of the lateral circumflex femoral artery. All flaps of the 65 clinical cases survived postoperatively. Our results showed that the superior perforator artery has a high occurrence and a relative constant location. We thought that it could be adopted as a complement of the conventional perforator artery.

Burn scars treated by pinhole method using a carbon dioxide laser

Many patients with burn injuries have various complications and emotional problems due to scars. Although various modalities to improve burn scars have been attempted, such as excision of scars, skin grafts, laser abrasion and silicone product usage, the cosmetic outcomes have not been satisfactory for a large portion of patients. Herein, we describe two cases which showed satisfactory cosmetic results after treatment of burns scars with the pinhole method using a carbon dioxide (CO(2)) laser that allowed us to make deep, closely set holes reaching down to the upper dermis. A 20-year-old female patient with a scar on her neck and a 25-year-old female patient with a scar on her right forearm after burn injuries are presented. As early as only a few weeks after the treatment, the scars showed relaxation of contracture, reduction of wrinkles and improvement of texture and color compared to before the treatment. Treatment of burn scars with the pinhole method can be easily performed and results in dramatic improvement in scar quality with only a few side-effects.

Free Flap Choice for Soft Tissue Reconstruction of the Severely Damaged Upper Extremity

Reconstruction of complex wounds of the hand associated with severe bone, tendon, nerve and soft-tissue injuries has been a major problem in hand surgery. Early definitive soft-tissue coverage of this kind of extensive wound with well-vascularized tissue is one of the most important stages of reconstruction for salvage of the extremity and restoration of function. Although multiple free flap donor sites have been described for complex upper extremity wounds, the authors think that anterolateral thigh (ALT) and lateral arm (LA) flaps are good choices for soft-tissue reconstruction in the upper extremity because of their reconstructive characteristics. These flaps can be used as flow-through and also sensate flaps. There is no need for position change intraoperatively and two teams may work simultaneously. Donor sites can be hidden and there is no required sacrifice of major artery or muscle.

[Bipolar dislocation injury of the forearm]

Bipolar dislocation injury of the forearm is rarely documented. It is a combined forearm injury with trauma on the elbow side and on the side of the wrist joint. We describe two different cases of this complex dislocation. The first patient suffered from a Monteggia-like dislocation fracture with transscaphoid dislocation of the wrist. The second person had an acute longitudinal radioulnar membrane dissociation after elbow dislocation with an additional scapholunate tendon rupture. The difficult management of these injuries is illustrated by these cases.

Biomechanical comparison of flexible intramedullary nailing versus crossed Kirschner wire fixation in a canine model of pediatric forearm fractures

This study compares the biomechanical properties of crossed Kirschner wires with those of flexible intramedullary nails in a canine model. The Kirschner wire groups had greater anteroposterior, lateral, and torsional stiffness and force to failure rates in most of the bones tested. Bones fixated with flexible intramedullary nails could bend and recoil during failure testing. The bones fixated with Kirschner wires failed at smaller levels of displacement and frequently had hardware cut-out during failure testing. Flexible intramedullary nails have more recoil and do not induce new fracture lines, which may explain their clinical superiority to Kirschner wires despite providing less rigid fixation.