Congenital Volkmann-Lesser ischemic contracture of the upper limb

Neonatal vascular compromise to limbs has been associated traditionally with perinatal injury of the brachial plexus, fracture of the clavicle or humerus, or iatrogenic causes. Congenital Volkmann's ischemic contracture is an exceptional etiology of ischemic limb in the newborn. Fewer than 10 cases had been described in the literature. The authors report a newborn presenting at birth with partial bluish discoloration of the right forearm. The clinical picture and laboratory studies lead to the diagnosis of congenital Volkmann-Lesser ischemic contracture.     

Forearm compartment syndrome in the newborn: report of 24 cases

PURPOSE: Isolated cases of ischemia, compartment syndrome, or Volkmann's ischemic contracture in the forearm of the newborn infant have been reported in the past. The purpose of this study is to review a large series of patients with neonatal forearm compartment syndrome and to report the important clinical features. METHODS: A search of medical records from 1980 to 2000 identified 24 children with evidence of ischemia of the forearm at the time of birth. Records and images were reviewed for prenatal and birth history, maternal factors, medical conditions, pattern of involvement, treatment, and outcomes. Patients were grouped according to the extent of initial soft-tissue involvement. RESULTS: All patients presented with a sentinel forearm skin lesion. Patterns of involvement ranged from mild skin and subcutaneous lesions to dorsal and volar compartment syndrome with or without distal tissue loss. Early treatment intervention was limited to a single case in which the diagnosis of compartment syndrome was made and an emergency fasciotomy was performed with a good outcome. In other cases tissue loss, compressive neuropathy, muscle loss, and late skeletal changes were responsible for impaired function. Distal bone growth abnormality was common. CONCLUSIONS: Forearm compartment syndrome in the newborn is not as uncommon as previously thought. The skin lesion was the common, salient, initial diagnostic finding. Early diagnosis and appropriate referral led to the salvage of a functional limb in 1 of the patients in this series. The severity of the initial insult correlated with the degree of impairment in growth and function. The delayed diagnosis and treatment of an evolving compartment syndrome may compromise further final function.     

Neonatal gangrene in the newborn infant of a diabetic mother

The newborn daughter of a diabetic mother developed neonatal gangrene of an upper extremity with massive muscle necrosis of the forearm, and required early dorsal and volar fasciotomies with subsequent debridements to salvage the limb. Decreased perfusion and local ischemia resulting in neonatal gangrene may result from the greater propensity for intravascular thrombosis in infants whose mothers have diabetes mellitus. While previous investigators have suggested that surgical intervention should be avoided in neonatal gangrene, in more severe cases early fasciotomy may be required to salvage a limb and avoid life-threatening complications.     

Congenital pressure necrosis of the forearm in a newborn infant

The authors report a case of congenital pressure necrosis of the forearm presenting in a newborn infant. The patient presented with an edematous and purpuric upper extremity with no underlying vascular compromise. After demarcation of the nonviable tissue during the first month of life, the extremity was debrided, and a thin split-thickness skin graft was applied. Graft contracture over the subsequent year was released and reconstructed with a full-thickness skin graft. Patient follow-up at age 22 months demonstrated progressive return of strength and function of the extremity with restoration of soft-tissue bulk and contour. When presented with this unusual circumstance, the plastic surgeon should be familiar with its differential diagnosis and management. Conservative debridement and age-appropriate resurfacing of the remaining wound were the essential treatment principles followed in this patient.     

Supracondylar fractures of the humerus associated with ipsilateral forearm fractures in children: a report of forty-seven cases

Supracondylar fractures of the humerus associated with ipsilateral forearm fractures are uncommon and treatment recommendations are controversial. The purpose of this study was to determine whether pin fixation of both fracture components, humerus and forearm, would improve the outcome. In a two-center trial, 884 children sustaining supracondylar fractures of the humerus were retrospectively reviewed, and 47 (5.3%) showed associated ipsilateral forearm fractures. Of those, 29 underwent Kirschner-wire fixation of the forearm fracture, and 18 of the forearm fractures were treated with casting alone. Three of the 18 forearm fractures with casting alone reangulated. There were no reangulations in the patients who had pin fixation of their fractures. There were no complications due to pin fixation in the humerus or the forearm. In unstable supracondylar humerus and forearm fractures, stabilization with pin fixation to prevent reangulation should be considered.     

经双皮质克氏针张力带治疗尺骨鹰嘴骨折术后前臂旋后功能障碍

目的分析双皮质克氏针张力带法治疗尺骨鹰嘴骨折导致前臂旋后功能障碍的原因。方法2000年7月至今采用该方法治疗的尺骨鹰嘴骨折病人43例。通过对术中穿入克氏针时前臂的旋转位置、克氏针的穿入方式、克氏针穿出尺骨前方皮质的长度与前臂旋后范围的相关性加以分析,以确定该方法导致前臂旋后障碍的可能原因,并提出解决办法。结果该组病人前臂旋后功能的恢复明显较旋前功能恢复差,前臂处于旋前位和交叉穿针是导致该现象的主要原因。结论经双皮质克氏针张力带治疗尺骨鹰嘴骨折时,前臂旋后功能障碍的发生率较高。严格遵循手术操作规范可降低该并发症的发生率。     

Quantitative Assessment of Forearm Muscle Size, Forelimb Grip Strength, Forearm Bone Mineral Density, and Forearm Bone Size in Determining Humerus Breaking Strength in 10 Inbred Strains of Mice

Bone strength is an important clinical endpoint of osteoporosis research. The evaluation of the relative importance of bone and muscle components to bone strength has widespread implications for the understanding and preventing of osteoporosis. The objectives of this study were to understand the interrelationship between the different components of the muscular skeletal system and to determine the effect of forearm muscle size, forelimb grip strength, forearm bone mineral density (BMD), and forearm bone size on the humerus breaking strength among 10 inbred strains of mice. The forearm muscle size was measured using a peripheral quantitative computed tomography (pQCT). The forearm BMD and forearm bone size were measured using a PIXIMUS Densitometer. The forelimb grip strength and humerus breaking strength were measured using an Instron Mechanical Tester. Significant correlations were found among the five regional phenotypes. All variables have a moderately high genetic component with heritability estimates of 0.83 for forelimb grip strength, 0.76 for forearm muscle size, 0.6 for forearm BMD, 0.63 for forearm bone size, and 0.68 for humerus breaking strength. Forward stepwise multiregression analysis showed that the forearm BMD, forelimb grip strength, and forearm bone size were three major determinants of bone strength and explained 61% of the variation in bone breaking strength. These data suggest that evaluation of these three parameters together, rather than BMD alone, is a more effective, noninvasive approach for predicting fracture risk.     

A new technique of catheter placement for measurement of forearm compartment pressures

Hitherto described techniques of catheter placement in the forearm for compartment pressure measurement in the evaluation of forearm compartment syndrome place the underlying neurovascular structures at risk for injury. Based on the cross-sectional anatomy of the forearm, two previously undescribed routes are detailed that provide safer access to the deep volar forearm compartment. Via the ulnar approach, the catheter is inserted medial to the subcutaneous border of the ulna and advanced radially, transversely, skimming over the volar aspect of the ulna into the belly of flexor digitorum profundus. Via the dorsal approach the catheter is inserted radial to the subcutaneous border of the ulna in the supinated forearm. Using the ulna as a guide the catheter is advanced through the dorsal forearm compartment and interosseous membrane into the deep volar compartment. By this route, pressures of both dorsal and volar compartments of the forearm can be measured with a single catheter insertion.     

Forearm rotation alters interosseous ligament strain distribution

Recent interest in reconstruction of the interosseous ligament (IOL) of the forearm has led to questions concerning optimal placement of the reconstructive graft as well as the ideal rotational position of the forearm during graft tensioning. We therefore studied the strain distribution in the IOL to determine which fibers are strained in different positions of forearm rotation. Five cadaveric human forearms were subjected to compressive axial load (simulating power grip) and the strain values across the entire IOL were measured with the forearm in neutral, supination, and pronation. The strain distribution in the IOL changed with forearm rotation. The highest overall strain was found in neutral. In neutral and pronation, higher strain was observed in the proximal region of the IOL. In supination, however, higher average strain was seen in the distal region of the IOL. These results suggest that a reconstructive graft placed in the proximal region of the IOL and tensioned in neutral rotation would provide balanced constraint in different positions of forearm rotation. A graft placed in the distal region and tensioned in forearm neutral, however, may limit forearm rotation.     

前臂骨间背侧动脉逆行岛状皮瓣修复手部创面

目的探讨应用前臂骨间背侧动脉逆行岛状皮瓣修复手部皮肤缺损的临床效果。方法应用前臂骨间背侧岛状皮瓣逆行修复16例手部皮肤缺损。结果16例皮瓣全部存活。随访6-15个月,皮瓣弹性良好,耐摩擦。无皮瓣边缘坏死发生,无前臂骨间背侧神经损伤,患肢功能恢复较满意。结论前臂骨间背侧动脉逆行岛状皮瓣是修复手部皮肤软组织缺损的可靠方法。     

Ultrasonic evaluation of biomechanical properties of the interosseus membranes of the forearm. I. Selection of a quality index

In the article is presented the echographic semiotics of the forearm interosseous membrane, based on the results of 10 forearm examinations. Qualitative echographic parameters, describing the forearm interosseous membrane geometry in different biomechanical situations, have been analysed. It has been determined that the ultrasound echography permits to visualize for certain the forearm interosseous membrane. As the criteria of the membrane geometry can be used such indicators as its area and profile height. Ultrasound echography permits to detect interosseous membrane tissue strain in case of forearm rotation and external compression in interosseous space, due to which its elasticity is evaluated.     

One-bone forearm operation for defective ulna osteomyelitis: a case report

A four-year-old boy with forearm instability secondary to defective ulna osteomyelitis underwent one-bone forearm operation in neutral supination-pronation position. A year after the operation, shortening (3 cm) of the forearm was detected. Radiographs showed delayed union; however, a stable and functional forearm was obtained. The patient was able to use his fingers.     

The reverse posterior interosseous flap: A solution for flap necrosis based on a review of 87 cases.

PURPOSE: The relationship of the flap necrosis to the placement of the flaps on the forearm was outlined and a solution in avoiding flap necrosis is discussed. METHODS: The relationship of the flap necrosis to the placement of the flaps on the forearm was investigated in 87 consecutive posterior interosseous island flaps used for the reconstruction of the hand and wrist. Fifty-eight flaps were taken from the middle and proximal thirds of the forearm, the distal edges being within the middle third of the forearm in 24 and the distal edges being within the distal third of the forearm in 34. Twenty-nine flaps were harvested within the boundaries of the distal two-thirds of the forearm, the distal edge being proximal to the distal third of the forearm in 23 and the distal edge being distal to the third of the forearm in six. The Length of the flaps varied from 6.5 cm to 12 cm. The pedicle length measure 4-13 cm. The number of perforators for each flap was recorded also. RESULTS: Flaps survived complete in 78 (89.6%) patients. Six patients had superficial necrosis of the distal part of the flap (6.8%). Three flaps were totally lost and alternative coverage was used (3.8%). The flaps that ended up with partial necrosis appeared to be in related to the site it was taken from. One flap with total necrosis and one with partial ncrosis were taken within the boundaries of the proximal third of the forearm while the distal edge was proximal to the level of distal third. One flap with total necrosis and one with partial necrosis were taken from the proximal third of the forearm while their distal edge were at the limits of the distal third of the forearm. The remaining flap ending up with total necrosis was taken from the distal third of the forearm with a short pedicle. CONCLUSIONS: For the reverse posterior interosseous flap to be reliable the flap should include the septocutaneous perforators in the distal third of the forearm. To cover distant defects reliably by a flap with a long pedicle, the flap should extend up to the distal third of the forearm to include a piece of skin with numerous perforators.     

Compartment syndrome in ipsilateral humerus and forearm fractures in children

Ipsilateral fractures of the humerus and forearm are uncommon injuries in children. The incidence of compartment syndrome in association with these fractures is controversial. The authors reviewed 978 consecutive children admitted to the hospital with upper extremity long bone fractures during a 13-year period. Forty-three children with ipsilateral fractures of the humerus and forearm were identified. Of 33 children with a supracondylar humerus fracture and ipsilateral forearm fracture, three children (7%) had compartment syndrome develop and required forearm fasciotomies. All three cases of compartment syndrome occurred among nine children with ipsilateral displaced extension supracondylar humerus and displaced forearm fractures; the incidence of compartment syndrome was 33% in this group. These findings suggest that children who sustain a displaced extension supracondylar humerus fracture and displaced forearm fracture are at significant risk for compartment syndrome. These children should be monitored closely during the perioperative period for signs and symptoms of increasing intracompartmental pressures in the forearm.     

Decreasing the toxic potential of intravenous regional anaesthesia

In an attempt to reduce the dose of local anaesthetic agent during intravenous regional anaesthesia (IVRA) of the upper limb, we have used a forearm tourniquet in 12 adult volunteers. The volume of the forearm venous system was predetermined angiographically. We performed IVRA with three solutions of lidocaine (0.25, 0.375, 0.5 per cent) administered in a volume equal to the forearm venous system. Angiographic results indicate that: a forearm tourniquet provides adequate vascular isolation; the volume of the forearm venous system can be correlated with body weight; the progression of the fluid in the venous system follows a pattern that is similar for all patients with the small veins of the distal forearm and proximal hand being filled last. With this technique, lidocaine 0.5 per cent resulted in a dose of 1.5 mg.kg-1 and provided excellent analgesia. Lower concentrations were unsatisfactory. We conclude that the use of a forearm tourniquet allows reduction of the local anaesthetic dose to a non-toxic level and thus increases the safety of IVRA.     

Forearm Bone Mineral Density in Familial Hypocalciuric Hypercalcemia and Primary Hyperparathyroidism: A Comparative Study

Studies have shown that cancellous bone is relatively preserved in primary hyperparathyroidism (PHPT), whereas bone loss is seen in cortical bone. Familial hypocalciuric hypercalcemia (FHH) patients seem to preserve bone mineral in spite of hypercalcemia and often elevated plasma parathyroid hormone (PTH). The objective of this study was to compare total and regional forearm bone mineral density (BMD) in patients with PHPT and FHH and to examine if differences can be used to separate the two disorders. We included 63 FHH, and 121 PHPT patients in a cross-sectional study. We performed dual-energy X-ray absorptiometry scans of the forearm, hip and lumbar spine and measured a number of biochemical variables. PTH patients had significantly lower Z-scores in all parts of the forearm compared to FHH. This was also the case after adjustment for body mass index. When stratifying for age, gender and PTH, T-scores were still significantly lower in PHPT patients than in FHH patients at the total, the mid and the ultradistal forearm, but not at the proximal 1/3 forearm. In a multiple regression analysis BMD Z-score was lower in PHPT compared to FHH at the total forearm, the mid forearm and the ultradistal forearm but not the proximal forearm when adjusting for biochemical variables including PTH, 1,25(OH)₂D and Ca²⁺. These observations support that inactivating mutations in the CASR gene in bone cells in FHH may protect against forearm bone loss. Differences between the two groups in total or regional forearm BMD were inferior to the calcium/creatinine clearance ratio as a diagnostic tool to separate FHH from PHPT.     

Management of injuries to the interosseous membrane

Injury to the interosseous membrane of the forearm typically occurs in conjunction with disruption of the radial head and the distal radioulnar joint. Frequently, the true extent of injury is not initially appreciated, and patients may develop longitudinal instability of the forearm, with wrist pain, forearm discomfort, and instability. This article outlines various treatment strategies, which include considerations at the wrist, forearm, and elbow.     

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。     

Dynamic splinting of forearm rotational contracture after distal radius fracture

The results of dynamic forearm rotational splinting for the treatment of forearm rotational contractures in patients with acceptably aligned, healed distal radius fractures are documented. Fifteen patients with distal radius fractures that healed with < or =+5 mm ulnar variance and < or =20 degrees dorsal tilt had dynamic forearm rotational splinting for contractures that had failed conventional hand therapy. Average pronosupination arc before splinting was 83 degrees. Dynamic forearm rotational splinting increased forearm rotation by 52% to an average of 126 degrees. Only one patient with development of ectopic bone in the interosseous space during splinting failed to obtain at least 30 degrees pronation and supination after splinting. Dynamic forearm rotational splinting effectively treats rotational contractures in patients who have healed distal radius fractures that are in acceptable alignment.     

One-bone forearm fusion for pediatric supination contracture due to neurologic deficit.

The purpose of this study was to review the construction of a one-bone forearm performed to change the position of the forearm in children with fixed supination deformity due to upper extremity neurologic deficit. The one-bone forearm arthrodesis has been previously described in treating trauma, tumors, infection, and congenital deformities. It has not been described to improve forearm position in neurologically impaired upper extremities. We retrospectively evaluated 6 pediatric patients with upper extremity weakness and severe supination contracture who underwent forearm arthrodesis in neutral or slight pronation. Five patients achieved fusion, and 1 patient had an atrophic nonunion (17% nonunion rate). Average follow-up was 6 years 6 months (range 1 year 9 months to 11 years 2 months), and all patients were satisfied with their new forearm position.