SMITH'S FRACTURE: A REVIEW

Although an uncommon injury, Smith's fracture is a fracture around a wrist joint which must be remembered in all injuries in this vicinity. Its diagnosis was missed in 75 per cent of cases in this series. Smith's fractures fall into 4 distinct types as determined by the patient's age and X-ray appearances. It is suggested that all Smith's fractures should be reduced with the hand in maximum supination, in an above-elbow plaster cast, for six weeks. Even when adequately treated, all patients are left with some disability, but this is very much less than in those where the diagnosis is missed or the fracture treated as a Colles' fracture, or treated by open reduction.     

Off-axis loads cause failure of the distal radius at lower magnitudes than axial loads: A side-to-side experimental study

Off-axis loading associated with a fall onto the outstretched hand has been hypothesized to induce distal radius failure at lower magnitudes than axially directed loading commonly used in biomechanical models for estimating fracture risk. However, this hypothesis has not been tested with side-to-side experimental testing. The objective of this study was to compare distal radius failure loads between forearm pairs experimentally tested in an axial or off-axis loading configuration. We acquired 18 pairs of cadaveric forearms from 18 female donors (mean age (standard deviation): 84.4 (7.9) years). Each forearm pair was tested to failure using either an axial compression test (vertical orientation with 0° dorsal inclination, 3°-6° radial inclination) or an off-axis test corresponding to the hand position during a fall (15° dorsal inclination, 3°-6° radial inclination). Failure testing was performed at 3 mm/s onto the palm of the hand until fracture occurred. Of the 18 pairs, 11 sustained a distal radius fracture. We compared failure loads between the two groups using a paired t test. Results indicated that failure load under off-axis loading was 29% lower than failure load under axial compressive loading (mean difference: −0.31 kN; 95% confidence interval: −0.47 to −0.16 kN, P = .001). In conclusion, off-axis loading associated with a fall onto the outstretched hand resulted in a 29% lower failure load. Integrating an off-axis loading configuration into current biomechanical models of distal radius bone strength may prevent overestimating of failure load and may offer a clinically relevant option to estimate distal radius fracture risk and monitor therapy efficacy.     

Smith's Fracture

Smith's fracture is not common below the age of 20 years. The left wrist is more commonly involved. The ratio between Types 1, 2 and 3 of the fracture is 4:2:1. Pronation injury is the commonest mechanism. A fall on the back of the hand and compression with shearing force are the other two mechanisms. Closed manipulation and immobilisation in plaster extending from the middle of the arm up to the knuckles with the forearm in full supination is an excellent method of treatment. We have obtained excellent, good or fair results in 86.4% of our cases.     

Type 2 Diabetes and Risk of Hip Fractures and Non‐Skeletal Fall Injuries in the Elderly: A Study From the Fractures and Fall Injuries in the Elderly Cohort (FRAILCO)

Questions remain about whether the increased risk of fractures in patients with type 2 diabetes (T2DM) is related mainly to increased risk of falling or to bone‐specific properties. The primary aim of this study was to investigate the risk of hip fractures and non‐skeletal fall injuries in older men and women with and without T2DM. We included 429,313 individuals (aged 80.8 ± 8.2 years [mean ± SD], 58% women) from the Swedish registry “Senior Alert” and linked the data to several nationwide registers. We identified 79,159 individuals with T2DM (45% with insulin [T2DM‐I], 41% with oral antidiabetics [T2DM‐O], and 14% with no antidiabetic treatment [T2DM‐none]) and 343,603 individuals without diabetes. During a follow‐up of approximately 670,000 person‐years, we identified in total 36,132 fractures (15,572 hip fractures) and 20,019 non‐skeletal fall injuries. In multivariable Cox regression models where the reference group was patients without diabetes and the outcome was hip fracture, T2DM‐I was associated with increased risk (adjusted hazard ratio (HR) [95% CI] 1.24 [1.16–1.32]), T2DM‐O with unaffected risk (1.03 [0.97–1.11]), and T2DM‐none with reduced risk (0.88 [0.79–0.98]). Both the diagnosis of T2DM‐I (1.22 [1.16–1.29]) and T2DM‐O (1.12 [1.06–1.18]) but not T2DM‐none (1.07 [0.98–1.16]) predicted non‐skeletal fall injury. The same pattern was found regarding other fractures (any, upper arm, ankle, and major osteoporotic fracture) but not for wrist fracture. Subset analyses revealed that in men, the risk of hip fracture was only increased in those with T2DM‐I, but in women, both the diagnosis of T2DM‐O and T2DM‐I were related to increased hip fracture risk. In conclusion, the risk of fractures differs substantially among patients with T2DM and an increased risk of hip fracture was primarily found in insulin‐treated patients, whereas the risk of non‐skeletal fall injury was consistently increased in T2DM with any diabetes medication. © 2016 American Society for Bone and Mineral Research.     

Coconut palm-related injuries in the Pacific Islands

Introduction : Coconut palms are an integral part of life in the Solomon Islands, given the widespread dependence of subsistence agriculture. Injuries related to the coconut palm are thus inevitable. Hospital records from the Central Referral Hospital were reviewed to identify (i) how commonly the coconut palm is implicated in injuries referred to the surgery department; (ii) which patients are being injured; and (iii) the type of injuries sustained. Methods : The present study reviews all patients referred to the Department of Surgery and Orthopaedics between January 1994 and December 1999 who had a coconut palm‐related injury. This was possible due to the trauma epidemiology form, which records the patient details, cause of injury, fracture details and other injury information. Results : A total of 3.4% of all injuries presenting to the surgical department was related to the coconut palm. Eighty‐five patients fell from the coconut palm, 16 patients had a coconut fruit fall on them, three patients had a coconut palm fall on them and one patient kicked a coconut palm. The majority of patients who were injured by falling from a coconut palm were young (aged 6–25 years). Eleven of the 16 patients struck by falling fruit were under 25 years of age. The majority of injuries sustained were fractures. Patients falling from coconut palms sustained mainly upper limb fractures (60.1% of all fractures) or spinal fractures (16.3%). Patients injured by falling fruit sustained skull or upper limb fractures. All skull fractures occurred in patients under the age of 10 years. Conclusion : This is the largest review of coconut palm‐related injuries. It highlights some epidemiological facts that raise considerations for preventative health measures in the Solomon Islands. Parents and young children must be warned of the dangers of playing beneath coconut trees. Boy and girls should be warned of the dangers of collecting fruit. With an increasing amount of schooling becoming available the Solomon Islands is an ideal place to direct an education programme about the dangers of coconut palms as well as many other primary health issues. Because subsistence farming plays a crucial role in the life of most Solomon Islanders, injuries that result in loss of function are crippling both to the patient and the village. Any preventative measure to reduce the rates of injury will be important.     

Evaluation of grip strength in hook of hamate fractures treated with osteosynthesis. Is this surgical treatment necessary?

ObjectiveThe aim of this study was to evaluate the outcomes of open reduction and internal fixation (ORIF) in hamate hook fractures and review the literature on this surgical procedure.MethodsWe report the outcomes of ORIF of hamate hook fractures in 13 consecutive patients (12 men and 1 woman; mean age: 32 years (range, 22–48 years)). In eight patients (61%) the fracture was associated with ulnar nerve neuritis in Guyon's canal. We assessed the following clinical data: age, sex, mechanism of injury, side of the injured hand and associated lesions, fracture classification, average time from injury to correct diagnosis, surgical technique, complications, and length of follow-up.All patients underwent radiological imaging, including standard radiographs in two planes (anteroposterior and lateral projections), and a CT study. Functional outcomes evaluated were pain, range of motion, grip strength, Disabilities of the arm, shoulder and hand (DASH) and Mayo wrist score.ResultsThe mean follow-up was 36 months (range, 12–144 months). All 13 cases were treated with ORIF of the hook of the hamate. Mean VAS pain score was 5 preoperatively (4–9) and 1 (0–2) postoperatively. All patients returned to pre-injury level and only one patient felt pain on activity. Preoperative modified Mayo wrist score was 51 and the postoperative value was 94. All outcomes scores improved significantly from preoperative values. The patients who participated in sports postoperatively were able to do so at or near pre-injury levels. Postoperative average range of wrist motion was 76° in extension, 71° in flexion, 14° in ulnar deviation, and 21° in radial deviation.Mean grip strength in the hand with the hook fracture was 58 kg compared with 53 Kg in the unaffected hand. All patients returned to their pre-injury level of functioning after 10–12 weeks and there were no complications. Analysis of grip strength revealed values comparable with the unaffected hand.ConclusionORIF of hamate hook fractures is a safe and effective technique to restore normal grip strength and return to pre-injury level. In cases of ulnar nerve neuritis, neurolysis of the deep palmar branch is mandatory.Level of evidenceLevel IV, Therapeutic study.     

Outcomes for late presenting lateral condyle fractures of the humerus in children: A case series

BackgroundFractures of lateral condyle of humerus are very common in children. While the management of acute displaced and rotated lateral condyle fracture of humerus with early open reduction and internal fixation yields good results, the results of late treatment are less clear. We conducted this study to analyse the results of operative treatment of late presenting fractures and see if it is dependent on the patient's age, fracture type, or the time until treatment.Materials & methodsA retrospective study of 40 patients with a symptomatic lateral condyle fracture beyond 3 weeks, who underwent open reduction and internal fixation between January 2002 and December 2011, was conducted. Fractures were described as per Jakob's classification. Patients radiographs were evaluated, and clinical evaluation was done with Mayo elbow scoring and Dhillon scoring system as well as range of motion.ResultsThirty-nine fractures united with average time of 7.8 weeks except one who had previous surgery done for the fracture and developed avascular necrosis. The average Mayo score was 93 and average Dhillon score was 7.6. The average improvement in the arc of motion was 40.32° (77.3–117.6°). Younger age and shorter time to operation had a statistically significant but weak effect on outcomes.ConclusionsFunctional outcomes of fractures managed surgically revealed good results, even in the fractures presenting more than 12 weeks after injury. Families with children presenting late should be offered ORIF to improve function and decrease symptoms.     

Predicting intertrochanteric extension of greater trochanter fractures of the hip on plain radiographs

IntroductionIt is important to distinct between isolated greater trochanter (GT) fractures and complete intertrochanteric (IT) extension to prevent unwanted morbidities. Aim of this study was to determine if there was any particular fracture pattern, of GT fractures on a plain radiograph of the hip which could predict IT extension.MethodRetrospective review of radiographs of 49 patients with a GT fracture who presented in the last 10 years (January 2005–December 2015). All images were reviewed by a consultant musculoskeletal radiologist and an orthopaedic surgeon. The AP plain radiographs were assessed to look for fracture angle and length of the fracture. The fracture length was taken as a percentage and was measured as the length of the fracture crossing the intertrochanteric line/the total length of the intertrochanteric line. The fracture angle was measured as the angle between a line drawn from the most superior point of the fracture on the lateral cortex of the GT, to a perpendicular line along the medial cortex of the femoral shaft. The subsequent MRI and CT scans were assessed to see if there was true intertrochanteric extension.Results32 patient were female and 17 male. 27 CT scans of which 8 showed complete IT extension. 22 had MRI scan of which 6 showed complete extension. The mean fracture length of patients with complete extension was 56% with a range of 50%–63%. The mean fracture length of patients with incomplete extension was 33% with a range of 12%–55%. The mean fracture angle for patients with complete extension was 39 ° with a range of 35–42°. The mean fracture angle for patients with incomplete extension was 58 ° with a range of 44–124°.ConclusionFor greater trochanter fractures that do not cross >50% of the IT line and do not have a fracture angle between 35 and 42° do not require further imaging as they will not have complete intertrochanteric extension.     

Avulsion Fracture of the Calcaneal Tuberosity: Classification and Its Characteristics

Background

Not much is known regarding avulsion fractures of the calcaneal tuberosity. We propose a modified classification scheme that presents the four types of calcaneal avulsion fracture as described by surgical and magnetic resonance imaging (MRI) findings, and evaluation of their specific features.

Methods

Out of 764 cases of calcaneal fractures, we examined 20 cases (2.6%) that involved the tuberosity of the calcaneus. Each case was classified depending on the avulsed fracture patterns as follows; type I is a ''simple extra-articular avulsion'' fracture, type II is the ''beak'' fracture, type III is an infrabursal avulsion fracture from the middle third of the posterior tuberosity, and finally in type IV there is the ''beak'', but a small triangular fragment is separated from the upper border of the tuberosity. We examined the features of each avulsed type according to several criteria including patient age, gender, anatomical variances of the Achilles tendon, the fibers involved and the mechanism of injury.

Results

The type I fracture (8/20 cases) was the most common and likely to occur in elderly women. However, in other types, they were more common in relatively younger male patients. Type I were usually caused due to an accidental trip causing a fall by the patient. However, the dominant cause of type II (5/20 cases) fractures a direct blow or hit directly to the bone. Type III (4/20 cases) and IV (3/20 cases) fractures were likely to occur due to falling. All fibers within the Achilles tendon are involved in both type I and II fractures. However, only the superficial fibers are involved in type III fractures, whereas the deep fibers are involved in type IV fractures.

Conclusions

The avulsion patterns of the calcaneal tuberosity fractures are the result of several factors including the bony density level, the mechanism of injury and the fibers of the Achilles tendon that transmit the force. Accurate diagnosis of type III and IV is dependant on MRI technology to confirm the specific location of the injury and provide proper patient treatment therapeutics.     

Surgical Outcomes for C2 Tear Drop Fractures: Clinical Relevance to Hangman's Fracture and C2‐3 Discoligamentous Injury

ObjectiveTo analyze characteristics of surgically managed tear drop (TD) fractures of the C₂ axis associated with other injuries such as hangman''s fracture and C_2‐3 discoligamentous injury as well as treatment outcomes.MethodsA total of 14 patients (eight men and six women) with TD fractures of the C₂, who were surgically treated at four national trauma centers of tertiary university hospitals from January 2000 to December 2017, were included in this retrospective study. The mean age of the patients was 45.5 years (ranging from 19 to 74 years). The characteristics, surgical treatment methods (anterior fusion vs posterior fusion), and results of 14 TD fractures of the C₂ were analyzed retrospectively. And the clinical relevance between C₂ TD fracture and hangman''s fracture and C_2‐3 discoligamentous injury was investigated through the co‐occurrence between injuries. The mean follow‐up time after surgery was 22.6 months (ranging from 12 to 60 months).ResultsAmong 14 patients with TD fracture of the C₂, four patients (28.6%) had anterior TD fracture and 10 patients (71.4%) had posterior TD fracture. All 10 posterior TD fracture patients had anterior C_2‐3 displacement. While two of four anterior TD fracture patients had posterior C_2‐3 displacement, the remaining two did not. All 14 patients of TD fracture had at least two or more other associated C₂ injuries as well as C_2‐3 discoligamentous injuries. About 92.9% (13/14) of the patients had typical or atypical hangman''s fracture; 100% (10/10) of the posterior TD fracture patients had hangman''s fracture, but 75% (3/4) of the anterior TD fracture had hangman''s fracture. At admission, 13 patients were neurologically intact. However, the remaining patient had spinal cord injury with American Spinal Injury Association (ASIA) impairment scale B with C_2‐3 bilateral facet dislocation. All four anterior TD fracture patients underwent posterior C_2‐3 fusion. While four of 10 posterior TD fracture patients underwent C_2‐3 anterior fusion, the remaining six underwent posterior fusion. At last follow‐up, 100% (14/14) of the patients achieved solid fusion, and visual analog scale for neck pain was significantly improved (5.9 vs 2.2, P < 0.001). One patient with ASIA impairment scale B had significantly improved to scale D. No major complications occurred.ConclusionOur study showed that surgically managed TD fractures of the C₂ showed a high incidence of other associated spine injuries including hangman''s fracture and C_2‐3 discoligamentous injury. Therefore, special attention and careful radiologic evaluation are needed to investigate the presence of other associated spine injuries including hangman''s fracture and C_2‐3 discoligamentous injury, which are likely to require surgery.     

Clinical Characteristics,Mechanism, and Outcome of Humeral Shaft Fractures Sustained during Arm Wrestling in Young Men: A Retrospective Study

Objective

Humeral fractures are common in arm wrestling and other sports and military activities requiring similar movements; however, the precise mechanism is poorly understood. Here, we present an overview of the characteristics, possible mechanisms, and treatment of humeral shaft fractures sustained during arm wrestling.

Methods

We reviewed 8 years (January 2013 to January 2021) of medical records and retrospectively analyzed data from 27 patients with humeral shaft fractures sustained during arm wrestling. The clinical data included sex, age, affected arm, alcohol consumption, muscle warm-up, history of competitive participation, opponents' characteristics, wrist position, and post-fracture radial nerve injuries. The fracture configurations were radiographically assessed and analyzed. Surgical management included single or dual plating. Scores on the Disability of the Arm, Shoulder, and Hand questionnaire (DASH) were evaluated preoperatively and postoperatively at the last follow-up visit.

Results

All fractures sustained during arm wrestling were spiral fractures of the distal third of the humerus. Of these, 11 were 12-A1 type and 16 were 12-B2 type with a wedge fragment. The two subtypes differed in the total fracture line length (12-A1: 0.18 ± 0.04; 12-B2: 0.23 ± 0.04; P < 0.001). The radial nerve injury rate was 0/11 (0%) in patients with 12-A1 type fractures and 7/16 (43.8%) in patients with 12-B2 type fractures (P = 0.011). Most patients were young men (mean age, ~25 years) with a history of competitively participating in arm wrestling for >2 years. Cold seasonal temperatures and a lack of warm-ups increased the risk of injury. All patients showed improved DASH scores at the last follow-up (12-A1:77.82 ± 5.14 to 10.25 [5.38]; 12-B2:78.91 ± 7.46 to 8.95 [3.17]; P < 0.001). No significant differences were observed among the different surgical treatments.

Conclusions

Individuals who participated in arm wrestling were at risk of humeral shaft fractures (type 12-A1 or 12-B2). The 12-B2 type occurs with a wedge fragment and is frequently accompanied by radial nerve injuries. The characteristics of arm-wrestling fractures and the mechanism(s) underlying these fractures can help orthopedic surgeons understand the causes of these fractures and similar fractures sustained in traditional sports. This understanding will help surgeons choose more effective surgical treatments that will result in more desirable functional outcomes and a faster return to work.     

A Completely Displaced Salter-Harris I Fracture of the Distal Radial Epiphysis with Intact Ulna: a Case Report and Review of the Literature

We present a 12-year-old boy with a displaced fracture of the distal radial epiphysis type I according to the Salter-Harris classification. The distal radial epiphysis was completely dorsally displaced, while the distal ulna remained intact. The injury was result of a fall on the patient’s outstretched hand. Closed reduction was applied and the forearm was immobilized with a long arm cast.

In the radiological re-examination a week later, a complete re-displacement of the fracture was detected. Open reduction followed and interposed flexor tendons (flexor pollicis longus and flexor carpi radialis) were found in the anatomical position of the distal radial epiphysis. The displaced epiphysis was reduced and fixed with two Kirschner wires and a long arm cast for a period of 6 weeks.

The follow-up examination 2 years later showed that the movement range of the wrist joint was not limited and skeletal growth of the radius was not disturbed.

The failure of closed reduction in these fractures is due to anatomical obstacles such as periosteum, flexor tendons and pronator quadratus interposition. Repeated forceful manipulations to achieve closed reduction must be avoided because of the potential for a number of complications, such as growth arrest, compartment syndrome, and avascular necrosis of the epiphysis.     

克氏针预制弯度内固定治疗儿童前臂骨折

目的 ：探讨克氏针预制弯度内固定治疗儿童前臂骨折的临床疗效。方法 ：自2019年10月至2022年12月采用克氏针预制弯度内固定治疗儿童前臂骨折32例,男25例,女7例;年龄3～15(8.0±0.5)岁;左侧18例,右侧14例;桡、尺骨双骨折24例,Monteggia骨折3例,Galeazzi骨折4例,桡骨颈“歪戴帽”骨折1例。记录患者手术时间、术中出血量、X线透视次数、骨折愈合时间和并发症,并采用上肢功能评定表（disabilities of arm,shoulder and hand,DASH）和Grace-Eversman前臂双骨折评价系统评估克氏针预制弯度内固定治疗儿童前臂骨折的临床疗效。结果 ：32例患者获得随访,时间2～12(7.16±2.51)个月。术中出血量（20.68±5.50） ml,X线透视次数（5.80±2.50）次,手术时间（24.34±5.10） min。32例均骨折顺利愈合,愈合时间（8.82±1.62）周。2例出现并发症,其中1例术后拇长伸肌腱断裂,1例术后预制弯度克氏针在骨髓腔旋转导致骨折明显移位。DASH评分0～16(8.32±1.50)分;依据Gr...     

Mid‐term outcomes of contoured plating for comminuted fractures of the olecranon

Objective: To evaluate the mid‐term outcomes of contoured plating for comminuted fractures of the olecranon. Methods: Twenty eight patients were available for analysis. Their mean age was 41 years (range, 25 to 61 years). Associated fractures were of the coronoid process in three, radial head in four, and both in three patients. A plate and screw system was used to stabilize comminuted fractures of the olecranon in all cases. Coronoid fractures were stabilized according to the fracture patterns. Displaced radial head fractures were treated with either mini‐screw fixation or radial head replacement. Because of the severity of their fractures, 12 patients underwent primary bone grafting. Results: Primary stability was achieved in 25 of 28 cases. There were no cases of non‐union. The mean time to union was 15 weeks (range, 12–22 weeks). The mean range of flexion of the elbow was from 14° to 125°, with 65° of pronation and 74° of supination. The end results were 6 excellent, 16 good, 4 fair and 2 poor, based on the Broberg and Morrey scale. The excellent plus good rate was 78.6%. Conclusion: Favorable mid‐term outcomes can be achieved by contoured plating of complex, comminuted fractures of the olecranon.     

Posterior shoulder fracture–dislocation: an update with treatment algorithm

Posterior shoulder fracture–dislocation is a rare injury accounting for approximately 0.9 % of shoulder fracture–dislocations. Impression fractures of the articular surface of the humeral head, followed by humeral neck fractures and fractures of the lesser and grater tuberosity, are the more common associated fractures. Multiple mechanisms have been implicated in the etiology of this traumatic entity most commonly resulting from forced muscle contraction as in epileptic seizures, electric shock or electroconvulsive therapy, major trauma such as motor vehicle accidents or other injuries involving axial loading of the arm, in an adducted, flexed and internally rotated position. Despite its’ scarce appearance in daily clinical practice, posterior shoulder dislocation is of significant diagnostic and therapeutic interest because of its predilection for age groups of high functional demands (35–55 years old), in addition to high incidence of missed initial diagnosis ranging up to 79 % in some studies. Several treatment options have also been proposed to address this type of injury, ranging from non-surgical methods to humeral head reconstruction procedures or arthroplasty with no clear consensus over definitive treatment guidelines, reflecting the complexity of this injury in addition to the limited evidence provided by the literature. To enhance the literature, this article aims to present the current concepts for the diagnosis, evaluation and treatment of the patients with posterior fracture–dislocation shoulder, and to present a treatment algorithm based on the literature review and our own experience.     

Percutaneous pinning for non-comminuted extra-articular fractures of distal radius

Background:

Various treatment modalities have been described for the treatment of extra-articular distal radius fractures each with its own merits and demerits. Most of the work done with percutaneous pinning has shown a significant residual stiffness of the hand and wrist. Our technique involves percutaneous pinning of the fracture and immobilization in neutral position of the wrist for three weeks. This study''s aim was to examine the functional outcome of percutaneous K-wiring of these extra-articular distal radius fractures with immobilization in neutral position of the wrist.

Materials and Methods:

This is a prospective study of 32 patients aged between 18 and 70 years with extra-articular distal radius fracture. Patients were treated with closed reduction and percutaneous pinning using two or three K-wires. A below- elbow plaster of paris dorsoradial slab was applied in neutral position of the wrist for 3 weeks. At the end of 3 weeks, the slab was removed and wrist physiotherapy started. The radiographs were taken postoperatively, at 3 weeks, 6 weeks and 6 months. The functional evaluation of the patients was done at 6 months follow-up. We used Sarmiento''s modification of Lindstrom criteria and Gartland and Werley''s criteria for evaluation of results.

Results:

Excellent to good results were seen in 93.75% of the cases while 6.25% had fair results. The complications observed were pin loosening (n=13), pin tract infection (n=2), malunion (n=2), wrist joint stiffness (n=2), reduced grip strength (n=2) and injury to the superficial radial nerve (n=1).

Conclusion:

Percutaneous pinning followed by immobilization of the wrist in neutral position is a simple and effective method to maintain reduction and prevent stiffness of wrist and hand.     

The free triple chimeric dorsalis pedis flaps for repair of multifinger soft tissue defects: A report of two cases

The reconstruction of complex hand injury such as multifinger soft tissue defect remains a challenging problem. Two cases of repair of multifinger injury with exposed bones using the free chimeric flaps based on the dorsalis pedis vessels are presented. Two male patients, 46 years old and 36 years old, suffered from a thermocompression injury to the dorsum of fingers resulting in soft tissue defects of multiple fingers. The chimeric free flap was designed and applied to cover the defects. The donor sites were covered by skin grafts. The postoperative courses were uneventful. Both patients were followed up for 10–12 months. The maximal flexion angle of the distal interphalangeal, proximal interphalangeal, and metacarpophalangeal joints were 40°–85° at the end of the follow‐up. The protective sensation was achieved on the dorsal fingers. The report suggests that the free chimeric flaps based on the dorsalis pedis artery may be an alternative for the reconstruction of the multifinger dorsal soft tissue defects. © 2013 Wiley Periodicals, Inc. Microsurgery 33:660–666, 2013.     

A safe and cost-effective method for treatment of angulated fifth metacarpal shaft fractures in the out-patient clinic

Introduction

Surgical treatment is justified in patients with fifth metacarpal shaft fractures with angulation exceeding 30°, as these patients are prone to have shortening, restriction of movements, decreased efficiency of the flexor tendons and poor cosmetic results. The authors describe a new technique where these patients can be treated in the clinic non-surgically.

Material and methods

Twenty-three patients with angulated fractures were prospectively enrolled for the study from Jan 2009 to Dec 2009. After appropriately instructing the patient, an ulnar nerve block was performed at the wrist. Once the nerve block had taken effect, the fracture was manipulated and an ulna gutter 3-point moulded splint was applied in the plaster room. The reduction was then confirmed with an x-ray. The patients were assessed using disability of arm, shoulder and hand (DASH) score and radiographs at follow-up.

Results

At the average follow-up of 12.38 months (range, 9–17), the DASH score was 2.03 (range, 0–6.7). The return to sports/work was at 3.2 weeks (range, 1–6) following the injury. The DASH work and sports score was 3.55 (range, 0–12.5) and 0.89 (range, 0–12.5) respectively. The mean initial fracture angulation of 40.05°, reduced to 15.76°. All the patients had a completely pain-free manipulation with no complications related to the technique and reduction.

Conclusions

In the current economic climate with pressure on time and resources, the authors suggest the treatment described above of these fractures in the clinic. It is a safe, cost-effective and easily learnt technique.     

Fracture of the hook of the hamate

We removed the fracture fragment from fifty-nine patients who had an isolated fracture of the hook of the hamate. Preoperatively, all had complained of pain and tenderness on the ulnar side of the palm or on the dorsal ulnar aspect of the wrist. Most fractures were thought to have occurred while the patient was swinging a racquet, golf club, or baseball bat. Some fractures were caused by striking the palm on a solid object, by falling on the palm, or by a crush injury to the hand. Most of the fractures were diagnosed conclusively on a carpal tunnel roentgenogram or on a special oblique roentgenogram of the wrist supinated. We now believe that computed axial tomography is the best imaging technique for demonstrating this fracture. Except for two patients who had a crush injury, all of the patients returned to their regular occupational and athletic pursuits. There were no surgical complications.     

Investigation of the Association Between the Acute Ankle Injury Caused by Fall From Own Height and Body Mass Index

In the emergency settings, increased body mass index (BMI) is a risk factor for traumatic orthopedic injuries. The aim of this study was to assess the association between the acute ankle injuries (sprain or fracture) and BMI. This prospective cohort study included patients ≥18 years of age with acute traumatic ankle injuries (either sprain or fracture) caused by fall from own height when walking at ground level and who received primary treatment at the emergency room of a university hospital between May and October 2017. Of the 107 patients who met the inclusion criteria, 58 (54%) patients experienced acute ankle sprains and 49 (46%) experienced acute ankle fractures. No significant association was detected between fracture severity (as assessed by the Danis–Weber classification) and BMI (p?=?.860). The most frequent ankle injury in patients with normal BMI was ankle sprain. In our cohort, obesity was not the primary determinant of the severity of ankle injury. However, age was a key determinant of the type of injury; patients >30 years of age were 20% more likely to suffer an ankle fracture.