Cast index in predicting outcome of proximal pediatric forearm fractures

Background:Many pediatric forearm fractures can be treated in plaster following closed reduction. The cast index (CI, a ratio of anteroposterior to lateral internal diameters of the cast at the fracture site) is a simple, reliable marker of quality of molding and a CI of >0.8 correlates with increased risk of redisplacement. Previously, CI has been applied to all forearm fractures. We hypothesize that an acceptable CI is more difficult to achieve and does not predict outcome in fractures of the proximal forearm.Results:The mean CI was 0.77. Remanipulation was required in five cases (6%), all distal half fractures – mean CI 0.79. CI was higher in proximal half forearm fractures (0.83 vs. 0.76, P = 0.006), nonetheless these fractures did not re-displace more than distal fractures.Conclusion:Cast index is useful in predicting redisplacement of manipulated distal forearm fractures. We found that in proximal half forearm fractures it is difficult to achieve a CI of <0.8, but increased CI does not predict loss of position in these fractures. We therefore discourage the use of CI in proximal half forearm fractures.     

An Anatomical Study to Demonstrate the Proximity of Kirschner Wires to Structures at Risk in Percutaneous Pinning of Distal Radius Fractures

Distal radius fractures are often treated using percutaneous Kirschner wires (K-wires). The sensory nerves in this area, extensor tendons, radial artery and cephalic vein are at risk of injury in this procedure. We undertook a cadaveric investigation to identify probability of damage to these ‘at risk’ structures by measuring their distances in relation to standard K-wire sites. Nine upper limbs from six formalin-preserved cadavers were studied. Four K-wires were placed percutaneously simulating fixation of a distal radius fracture. Careful dissection was done preserving the original position of neurovascular and tendinous structures. Distances to relevant soft-tissue structures from each K-wire were measured using an electronic digital caliper. Distance of superficial nerves from radial styloid and Lister’s tubercle was measured to determine their ‘safe distance’ from these fixed landmarks. None of the superficial nerves were injured by a K-wire. Cephalic vein had been pierced on 4 occasions (4/18) and extensor tendons on 3 occasions (3/18). Wilcoxon signed-rank test was used to compare distance of the superficial nerves from radial styloid and Lister tubercle, and the latter was found to be the safer option. This study highlights the inherent danger in percutaneous K-wire fixation of wrist fractures. Limited size of the area, where K-wires can be positioned, and anatomic variations of neurovascular structures pose obstacles in developing guidelines for reducing risk of injury. We advocate use of mini-open approach and guiding devices to avert complications of inadvertent impalement and damage to these structures.     

Reconstruction of Lateral Skull Base Defects with Radial Forearm Free Flaps: The Double-Layer Technique

Introduction The radial forearm flap has fallen out of favor in lateral skull base reconstruction in recent literature. However, especially when used in a double layer, a radial forearm may be able to provide the thickness of a large flap while taking advantage of the pliability for which the flap is renowned. Objective To report the results of the double-layer technique of radial forearm free flap reconstruction of lateral temporal bone defects. Design A retrospective chart review. Setting A tertiary care institution. Participants All consecutive patients who underwent lateral temporal bone resections and were reconstructed with free flaps from 2006 to 2012. Major Outcome Measures Flap success rate, complications, and rate of revision surgery. Results A total of 17 patients were identified with free flap reconstruction of the lateral skull base. Seven received reconstruction with a double-layer radial forearm flap. Reconstruction-related complications in this group included one case of facial cellulitis. The flap success rate was 100%. These results were comparable with patients who had other flaps. Conclusions The radial forearm free flap may be an effective reconstruction option for lateral temporal bone defects especially when used in the double-layer technique.     

Non-anatomical reconstruction of lateral ulnar collateral ligament of the elbow after tumor resection

We present the case of an 80-year-old man with a tumor recurrence on his right arm 6 years after initial treatment. The lateral aspect of the elbow joint, involving overlaying skin, muscles, tendons, joint capsule, lateral collateral ligament complex, the lateral 1/3 of the capitellum, and lateral epicondyle of humerus were excised in the tumor resection. Intraoperative assessment revealed multidirectional instability of the elbow, and joint stabilization was needed. Because the lateral epicondyle was resected, graft placement in an anatomical position was impossible to carry out. Therefore, non-anatomical reconstruction of lateral ulnar collateral ligament with palmaris longus tendon graft was performed. The skin was reconstructed using an antegrade pedicled radial forearm flap. For wrist extension reconstruction, the pronator quadratus tendon was transferred to the extensor carpi radialis brevis tendon. One year after the operation, elbow range of motion was 5–130°. The patient remains symptom free. The Mayo elbow performance score is good. The Musculoskeletal Tumor Society rating score is excellent. To our knowledge, this is the first report of an elbow lateral ulnar collateral ligament reconstruction after tumor resection.     

Melanotic neuroectodermal tumor of infancy in the soft tissue of the forearm: report of a case

Melanotic neuroectodermal tumor of infancy is rare. Only 3 cases have been reported in the soft tissue of the extremities up to date. It has a typically biphasic feature in morphology. Epithelial and melanotic markers are positive in the epitheliod cells and neuron-specific enolase or synaptophysin is positive in the small blue round cells in immunohistochemistry. Radical resection and close follow-up is the treatment strategy in general situation. Here we report one case of MNTI in the upper extremity with review of the literature. This is the first case of MNTI in the forearm.     

Donor-site morbidity after harvesting of radial forearm free flaps—comparison of vacuum-assisted closure with conventional wound care: A randomized controlled trial

IntroductionRadial forearm free flaps (RFFF) are often used to replace tissue removed in head and neck surgery. In recent years, many attempts have been made to reduce donor-site morbidity and to prevent common complications such as infection, skin-graft necrosis, tendon exposure and subsequent impairment of hand function. One promising option is the use of vacuum-assisted-closure wound therapy (VAC). The objective of this study was to evaluate the effectiveness of VAC compared with a conventional bolster dressing (CBD).Material and methodsA randomized controlled trial was enrolled. Our study was prospective in design and included patients with a skin-grafted forearm defect after harvesting of RFFF. Patients who met the inclusion criteria were randomly assigned into two study arms. The predictor variable was the type of wound therapy (VAC therapy compared with CBD) and the outcome variables were (1) the size of the wound area, (2) wrist movement and (3) grip strength. Outcome variables were assessed 12 days, three weeks and eight weeks after surgery.ResultsFifty patients (33 males, mean age 61.7 years [SD 15.5]; 17 females, mean age 54.7 years [SD 10.5]) were included consecutively in the study. Patients in the VAC group experienced a faster postsurgical reduction of wound area and had better wrist movement; nonetheless, the differences between the VAC group and CBD group did not reach statistical significance. In contrast, the recovery of postsurgical grip strength was significantly faster in the VAC group.ConclusionsOur study failed to prove that VAC therapy is significantly superior to CBD for all the variable studied. Because VAC therapy has some positive effects, however, we recommend further development of this negative-pressure wound treatment, rather than the termination of its use.     

应用近红外光谱监测前臂皮瓣供区术后血运变化

目的：利用近红外光谱技术对前臂皮瓣供区术前及术后的血氧饱和度（SO2）进行监测,总结前臂桡侧皮瓣制备术后供区SO2的变化规律,探讨前臂桡侧皮瓣制备术对供区血运的影响。方法：临床上接受前臂皮瓣制备术的患者35例,选择前掌大鱼际、小鱼际作为前臂皮瓣供区监测部位。自术前1天至术后第7天,用近红外光谱血氧检测仪（TSAH-100）对供区和对侧相同监测部位的SO2进行监测,术后24 h内每4 h 1次,术后24 h后每天2次,持续至术后第7天。采用SPSS13.0软件包对大鱼际和小鱼际的SO2进行配对t检验,分析两者之间的差异。结果：前臂皮瓣供区大鱼际和小鱼际的SO2均呈现由低于对侧水平上升至高于对侧水平,然后逐渐下降至术前初始水平的变化特点。供区小鱼际SO2在术后20 h达到峰值,与对侧小鱼际相比有显著差异（P〈0.05）。供区大鱼际SO2在术后24 h达到峰值,术后12 h和术后48 h与对侧相差幅度较大,有显著差异（P〈0.05）。术后第7天,供区大鱼际和小鱼际SO2较对侧无显著差异（P〉0.05）。结论：前臂桡侧皮瓣制备术对其供区组织的血运产生了一定程度的影响。在无桡动脉和头静脉变异的情况下,桡动脉与尺动脉之间的交通支循环能保证前臂桡侧皮瓣术后供区的血流灌注量,其血运在术后6~7 d内基本恢复至术前状态。     

前臂纵向不稳定的生物力学研究

目的研究前臂纵向不稳定的生物力学机制,为临床诊断及治疗提供可靠的理论依据。方法12具新鲜冷冻尸体上肢标本制成生物力学模型,固定于MTS858型生物材料实验机上加载恒定100N的轴向负荷,测试不同解剖状态对桡骨纵向位移及前臂纵向稳定性的影响。结果单纯切断骨间膜对前臂的纵向稳定性影响甚微。切除桡骨头,前臂的纵向稳定性降低,桡骨向近端移位明显,再切断骨间膜,将使上述改变加重。结论桡骨是维持前臂纵向稳定的主要结构,前臂骨问膜是次要稳定结构。桡骨头切除后骨间膜损伤是前臂纵向不稳定产生并发症的主要原因。     

Acumed前臂髓内钉治疗尺桡骨骨折的临床研究

目的观察Acumed前臂髓内钉治疗尺桡骨骨折的临床疗效。方法采用Aeumed前臂髓内钉治疗尺桡骨骨折33例,其中男23例,女10例;年龄21～65岁,平均37．5岁。桡骨干单骨折13例,尺骨干单骨折18例,前臂双骨折2例。结果30例患者得到随访,随访8～16个月,平均13．4个月,29例顺利愈合,平均愈合时间为14周,1例桡骨干骨折出现不愈合,后给予更换内固定后愈合。根据Anderson评分,优21例,良7例,可1例,差1例,本组优良率,93．3％。结论．．Acumed前臂髓内钉具有手术简单、微创等优点,对骨折愈合及伤肢功能恢复有较好的临床疗效。