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    References.doc.doc References.doc.doc Document Transcript

    • References Skokan, E.G., Olson, L.M., Cook, L.J. and Cornell, H.M. (2001), Snowmobile injuries in Utah. Academic Emergency Medicine, 8 (12), 1173-1177. Abstract: mObjective: To describe the epidemiology of snowmobile injuries in Utah. Methods: Analysis of probabilistically linked statewide emergency department (ED), hospital admission, and death certificate data for 1996 and 1997. Results: There were 625 cases of snowmobile-related injuries. The majority (83%) were evaluated in the ED only. Median ED patient age was 29 years (range 3-74 years), and 66% were male. The leading diagnoses were open wounds to the head (7.8%), back strains (5.4%), and contusions of the trunk and lower extremities 5.2% and 5.0%, respectively). An Injury Severity Score (ISS) of greater than or equal to4 (range 1-75) was found in 37% of the ED patients. The median charge was $373 per patient, with two- year cumulative charges of $266,283. One hundred seven patients required inpatient hospital care, Median inpatient age was 32 years (range 4-92 years), and 60% were male. Leading inpatient diagnoses were fracture of the vertebral column (9.3%), lower extremity fracture (9.3%), upper extremity fracture (6.5%), and pelvis fracture (3.7%). An ISS of greater than or equal to4 (range 1-38) was found in 70% of the hospitalized patients. Average length of stay was 3 days, with a range of 1 to 68 days. Median inpatient charge was $6,003 per patient, with two- year cumulative charges of $1,333,218. Ten inpatients required transfer for rehabilitation or skilled nursing care. There were a total of six fatalities, three of which occurred in the ED, one in the inpatient population, and two identified from the death certificate database. Conclusions: By combining ED, inpatient, and death certificate data sets, probabilistic linkage provides a comprehensive description of snowmobile- related injuries and a baseline evaluation of morbidity, mortality, and financial burden Keywords: extremity/fracture/injury control/probabilistic linkage/rehabilitation/snowmobile/sports and recreational injuries/trauma Voaklander, D.C., Kelly, K.D., Sukrani, N., Sher, A. and Rowe, B.H. (2001), Sledding injuries in patients presenting to the emergency department in a northern city. Academic Emergency Medicine, 8 (6), 629-635. Abstract: Objectives: Sledding is a common recreational activity in northern communities. The objective of this study was to examine the frequency and nature of sledding injuries (SIs) in patients presenting to emergency departments (EDs). Methods: The data were derived from a cohort of patients treated at all five EDs in an urban Canadian health region over a two-year period. Following chart review, consenting patients were interviewed by telephone about their sledding activities and the circumstances surrounding the injury. Results: Three hundred twenty-eight patients were correctly coded as having SIs, with 212 patients (65%) reached during the follow-up survey. The median age of those with SIs was 12 years (IQR = 8, 21), and 206 (59%) were male. Injury rates peaked in the l0-14- year age group (87/100,000) for boys and in the 5-9-year age group (75/100,000) for girls. Most patients stated they were drivers (75%), fewer than half were thrown from the sled (42%), and fewer than half (44%) were sledding on community-designated sledding hills at the time of injury. Injuries to the lower extremity (32%), upper extremity (31%), and head (13%) were most common. Thirty-seven (11%) patients with SIs were admitted to hospital vs 4% of patients with other sports/recreation injuries (p < 0.05). Conclusions: Sledding injuries are common and potentially serious wintertime injuries in northern communities, involving primarily younger patients, with a large pre-adolescent group. However, older sledders (>20 years) have poorer outcomes
    • (hospitalization, lost time from work/school) than their younger counterparts. The SIs treated in the ED appear to lead to hospitalization more frequently than other types of sport/recreation injury, and injury prevention strategies appear warranted Keywords: emergency department/EPIDEMIOLOGY/epidemiology/extremity/fracture/ ICE HOCKEY INJURIES/injury/ONTARIO/outcomes/sledding/upper extremity Duma, S.M., Boggess, B.M., Crandall, J.R., Hurwitz, S.R., Seki, K. and Aoki, T. (2003), Upper extremity interaction with a deploying side airbag: a characterization of elbow joint loading. Accident Analysis and Prevention, 35 (3), 417-425. Abstract: Computer simulations, dummy experiments with a new enhanced upper extremity and small female cadaver experiments were used to analyze the small female upper extremity response under side airbag loading. After establishing a worst case initial position, three tests were performed with the fifth percentile female hybrid III anthropometric test dummy and six experiments with small female cadaver subjects. A new fifth percentile female enhanced upper extremity was developed for the dummy experiments that included a two-axis wrist load cell in addition to the existing six-axis load cells in both the forearm and humerus. Forearm pronation was also included in the new dummy upper extremity to increase the biofidelity of the interaction with the handgrip. Instrumentation for both the cadaver and dummy tests included accelerometers and MHD angular rate sensors on the forearm, humerus, upper and lower spine. In order to quantify the applied loads to the cadaver hand and wrist from the door mounted handgrip, the handgrip was mounted to the door through a five-axis load cell and instrumented with accelerometers for inertial compensation. All six of the cadaver tests resulted in upper extremity injuries including comminuted mid-shaft humerus fractures, osteochondral fractures of the elbow joint surfaces, a transverse fracture of the distal radius and an osteochondral fracture of the lunate carpal bone. The results from the 6 cadaver tests presented in this study were combined with the results from 12 previous cadaver tests. A multivariate logistic regression analysis was performed to investigate the correlation between observed injuries and measured occupant response. Using inertially compensated force measurements from the dummy mid-shaft forearm load cell, the linear combination of elbow axial force and shear force was significantly (P = 0.05) correlated to the observed elbow injuries. (C) 2002 Elsevier Science Ltd. All rights reserved Keywords: airbag/bone/elbow/elbow joint/extremity/forearm/fracture/fractures/hand/handgrip/humerus/hybrid/injuries/inj ury/pronation/side airbag/upper extremity/upper-extremity/wrist Mortensson, W. and Thonell, S. (1991), Left-Side Dominance of Upper Extremity Fracture in Children. Acta Orthopaedica Scandinavica, 62 (2), 154-155. Abstract: In 148 children who had sustained trauma to the upper extremities from falls, fractures were twice as common on the left as on the right side. This seemed to be due to the childrens' preferential use of the left hand to parry the fall even when both hands were free and because the left arm seemed to be more easily broken than the right arm during trauma Keywords: children/extremities/fall/falls/fractures/hand/trauma Shearman, C.M. and El Khoury, G.Y. (1998), Pitfalls in the radiologic evaluation of extremity trauma: Part I. The upper extremity. American Family Physician, 57 (5), 995-1002. Abstract: Family physicians often are required to evaluate patients who present with acute skeletal trauma. The first of this two-part series discusses the features and evaluation of some commonly missed fractures and dislocations 4 the upper limb,
    • excluding the hand. Dislocations of the sternoclavicular joint are infrequent and often missed. Clavicular fractures in adults usually are not hard to diagnose. Acromioclavicular joint dislocations represent about 10 percent of all dislocation injuries to the shoulder girdle. Forty percent of all dislocations occur at the glenohumeral joint, Scapular fractures are often a result of significant force. Multiple views should be obtained in adults with a suspected fracture of the elbow. Complications in fractures of the wrist are strongly related to the location of the fracture Keywords: acute/dislocation/extremity/fracture/fractures/hand/injuries/trauma/upper extremity/upper-extremity/wrist Kocher, M.S. and Feagin, J.A. (1996), Shoulder injuries during alpine skiing. American Journal of Sports Medicine, 24 (5), 665-669. Abstract: We retrospectively reviewed alpine skiing injuries at a destination ski resort during three seasons to characterize the incidence and types of shoulder injuries. A total of 3451 injuries in 3247 patients were reviewed. The overall injury rate was 4.44 injuries per 1000 skier-days. Injuries to the upper extremity represented 29.1% (N = 1004) of all alpine ski injuries. Injuries involving the shoulder complex (393 injuries in 350 patients) accounted for 39.1% of upper extremity injuries and 11.4% of all alpine skiing injuries. The rate of shoulder injury was 0.51 injuries per 1000 skier-days. Patients with shoulder injuries had a mean age of 35.4 years, and the male-to-female ratio of these patients was 3:1. Falls represented the most common mechanism of shoulder injury (93.9%) in addition to collisions with skiers (2.8%), pole planting (2.3%), and collisions with trees (1%). The most common shoulder injuries were rotator cuff strains (24.2%), anterior glenohumeral dislocations or subluxations (21.6%), acromioclavicular separations (19.6%), and clavicle fractures (10.9%). Less common shoulder injuries included greater tuberosity fractures (6.9%), trapezius muscle strains (6.4%), proximal humeral fractures (3.3%), biceps tendon strains (2.3%), glenoid fractures (1.5%), scapular fractures (1%), humeral head fractures (1%), sternoclavicular separations (0.5%), an acromial fracture (0.3%), a posterior glenohumeral dislocation (0.3%), and a biceps tendon dislocation (0.3%) Keywords: AUSTRALIA/clavicle/dislocation/extremity/fracture/fractures/injuries/injury/PREV ENTION/ski/SKIERS THUMB/SNOWBOARDING INJURIES/TRENDS/upper extremity/UPPER EXTREMITY INJURIES/upper-extremity Morrison, A.L., Chute, D., Radentz, S., Golle, M., Troncoso, J.C. and Smialek, J.E. (1998), Air bag-associated injury to a child in the front passenger seat. American Journal of Forensic Medicine and Pathology, 19 (3), 218-222. Abstract: We report the case of a 3.5-year-old front seat passenger who suffered significant head and neck injuries as a result of air bag deployment in a collision of <30 mph. These lesions included multiple abrasions of the lower half of the face, nose, forehead, and right ear, torn frenula, conjunctival petechiae, comminuted fractures of the left and right lateral frontal regions and right parietal bone, diastatic fracture of the coronal suture, subgaleal and subarachnoid hemorrhages, cortical contusions, subluxation of the atlantooccipital joint, and fracture of the C4 vertebral body. These lesions are consistent with trauma secondary to the deploying air bag and the head striking the interior of the car. The findings in this case further support the Centers for Disease Control and Prevention (CDC) guidelines of keeping children properly restrained, preferably In the back seat, or as far as possible from air bags Keywords: air bag/air bags/bone/child/children/DEPLOYMENT/DRIVER FATALITIES/fracture/fractures/frontal crash/injuries/injury/OCULAR
    • TRAUMA/passenger/trauma/UPPER EXTREMITY INJURIES Marshall, K.W., Koch, B.L. and Egelhoff, J.C. (1998), Air bag-related deaths and serious injuries in children: Injury patterns and imaging findings. American Journal of Neuroradiology, 19 (9), 1599-1607. Abstract: Background and purpose: As of november 1, 1997, automotive air- bag deployments occurring in low-speed collisions had resulted in the deaths of 49 children and in the serious injuries of 19 children in the united states. The purpose of this study was to investigate the patterns of injury occurring in this new mechanism of pediatric trauma. Methods: In search of common patterns of injury, three pediatric radiologists retrospectively evaluated the available autopsy and imaging studies in 11 such cases not previously reported in the medical literature, in addition to three published case studies. Results: The cause of death or serious injury in every case was the direct result of neurologic injury. Injury patterns differed according to the child's age and type of restraint used at the time of collision. Crush injury to the skull predominated in infant victims traveling in rear-facing child safety seats, and both cranial and cervical spine trauma occurred in older children traveling restrained, improperly restrained, or unrestrained in the vehicle's front passenger seat. Conclusion: Air-bag systems pose a potentially fatal threat to the front-seat child passenger. This is directly related to the biomechanics at impact placing the child closer to the deploying air bag, an understanding of the biomechanics provides the radiologist insight into the two types of injury patterns observed Keywords: air bag/biomechanics/cervical spine/children/DEPLOYMENT/DRIVER/FATALITY/FRACTURE/impact/injuries/i njury/pediatric/TRAUMA/UPPER EXTREMITY INJURIES Shorter, N.A., Mooney, D.P. and Harmon, B.J. (1999), Snowboarding injuries in children and adolescents. American Journal of Emergency Medicine, 17 (3), 261-263. Abstract: To study snowboarding injuries in children and adolescents, a 6-year retrospective study was conducted of patients 18 years old and younger admitted to a pediatric trauma center after snowboarding accidents. The study was designed to identify the most severely injured patients. Comparison was made to data from a recent comparable study of skiing injuries. Twenty seven patients were identified, all but one male and none under 10 years old. Nineteen were injured in a fall, 6 collided with a stationary object, one collided with a skier, and in one case the mechanism of injury was unclear. The average pediatric trauma score was 10.5, and the average injury severity score 10.2. Most of the 12 head injuries were minor. Most extremity fractures were to the upper extremity. There were two lumbar vertebral burst fractures, suggesting that the sport may predispose to this injury. There were no deaths. When compared with skiing, in snowboarding the overall severity of injury is lower, collision is a less common mechanism of injury and results in less serious injury, head injuries are less severe, the relative frequency of upper extremity fracture is higher, abdominal injuries are caused by falls rather than collisions, and facial injuries are less common. These differences are predictable on the basis of differences in the equipment. However, it is too early to say that snowboarding has less potential for life threatening injury than skiing. Expected changes in the mix of participants, with an increase in the average skill level over time, may well result in different patterns, mechanisms, and severity of injury. Copyright (C) 1999 by W.B. Saunders Company Keywords: childhood/children/extremity/fall/falls/fracture/fractures/injuries/injury/pediatric/SC
    • ORE/SEVERITY/SKIING INJURIES/snowboarding/sport/trauma/TRAUMA/upper extremity/upper-extremity O'Neill, D.F. and McGlone, M.R. (1999), Injury risk in first-time snowboarders versus first-time skiers. American Journal of Sports Medicine, 27 (1), 94-97. Abstract: Between 1994 and 1996 we studied injury patterns in more than 22,000 first- time snowboarders and first-time skiers to determine the comparative injury risk of these two popular sports coexisting in winter resort areas. The first-time participants included in this study had no previous experience in their activity of choice and enrolled in Learn to Snowboard and Learn to Ski programs in two major northeastern ski resorts. Data were gathered from physician evaluations at the medical clinics at each mountain. Two hundred seventy-three (4%) of the first-time snowboarders (N = 6585), and 641 (4%) of the first-time skiers (N = 15,795) sustained an injury. Injuries were further evaluated by location (upper extremity, lower extremity, head, and trunk area) and severity (emergent versus nonemergent). Snowboarders had a higher percentage of upper extremity injuries (53%), while skiers had a higher percentage of lower extremity injuries (63%). Snowboarders, however, sustained a significantly higher incidence of emergent injuries (such as fracture, concussion, dislocation, lost teeth) necessitating immediate intervention. While there have been other reports describing injuries in these activities, no previous study attempted to look at the first- time participants with similar age, experience, and equipment to determine comparative risk. We conclude that for the first-time participant, snowboarding does show a higher incidence of emergent injuries Keywords: dislocation/extremity/fracture/injuries/injury/severity/ski/snowboarding/upper extremity/upper-extremity Sorock, G.S., Lombardi, D.A., Hauser, R.B., Eisen, E.A., Herrick, R.F. and Mittleman, M.A. (2001), A case-crossover study of occupational traumatic hand injury: Methods and initial findings. American Journal of Industrial Medicine, 39 (2), 171-179. Abstract: Background Acute hand injury is the beading cause of occupational injury created in United States' hospital emergency departments (e.g., laceration, crush or fracture). To identify risk factors for traumatic hand injuries, we conducted a case- crossover study of transient exposures (e.g., being rushed) for acute occupational traumatic hand injury. Methods The case-crossover method, which uses subjects as their own controls, was used to identify risk factors for occupational hand injury. Two hundred and thirty-two subjects were recruited from 17 occupational health clinics in New England and interviewed by telephone a median of 1.2 days after their injury. The a priori hazard period was defined as 10 min before the injury. Two control periods were used: one was 60-70 min prior to the injury (matched-pair interval analysis); the other was the total work-time exposed, on average, in the previous month (usual frequency analysis). Results In the usual frequency analysis, the relative risk for using malfunctioning dr different-from-usual equipment or tools in the hazard period was 25.5 (95% confidence interval = 18.4-35.2). Relative risks were also significantly elevated for performing a task using an unusual work method, doing an unusual task, being distracted, or being rushed. Wearing gloves appeared to be protective (relative risk = 0.8, 95% CI = 0.5-1.2). Matched-pair interval analysis, where appropriate, provided similar findings but herd much wider confidence intervals. Conclusions This study demonstrates that the case-crossover design is a feasible and efficient method for studying transient risk factors for sudden-onset traumatic occupational hand injury. The usual frequency analysis proved more useful than the match-pair approach to control period selection. Am. J. Ind. Med. 39:171-
    • 179, 2001. (C) 2001 Wiley-Liss, Inc Keywords: acute/case- crossover/epidemiology/fracture/hand/injuries/injury/occupational/occupational injury/RISK/trauma/upper extremity Ponder, B.L., Gleason, T.F. and Mardjetko, S.M. (2002), Neurophysiologic Intraoperative monitoring during percutaneous thoracolumbar kyphoplasty: A multimodality approach. American Journal of Electroneurodiagnostic Technology, 42 (2), 103-118. Abstract: We report techniques to monitor the functional integrity of the spinal cord and physiologic status of the spinal nerve roots during percutaneous throracolumbar kyphoplasty for treatment of vertebral compression fractures. Monitoring of the functional integrity of the anterior and posterior spinal cord can be accomplished with the use of electric transcranial motor evoked potentials (tceMEPs) and somatosensory evoked potentials (SSEPs), respectively. The physiologic status of the spinal nerve roots can be monitored continuously with spontaneous electromyography (EMG) monitoring. Lower extremity SSEPs are obtained using stimulation of the posterior tibial nerve (PTN) at the ankle; upper extremity SSEPs are obtained using stimulation of the median nerve or ulnar nerve. TceMEPs are obtained with stimulation of the motor cortex (precentral gyrus) at the scalp and recording compound muscle action potentials (CMAPs) in the hands and legs. Intramuscular electromyographic activity is referentially recorded in all extremities and specific muscle groups innervated by spinal nerves at the level of the procedure. SSEPs, tc(e)MEPs, and EMG can be effectively obtained and monitored during percutaneous thoracolumbar kyphoplasty. This technique of multimodality neurophysiologic monitoring provides invaluable intraoperative data for the surgeon regarding the functional integrity of the patient's spinal cord and physiologic status of the spinal nerve roots, thereby decreasing the likelihood iatrogenic neurologic injury and post-operative neurologic deficits Keywords: extremities/extremity/FRACTURES/injury/kyphoplasty/neurophysiologic monitoring/somatosensory evoked potentials/spontaneous EMG/transcranial motor evoked potentials/upper extremity/upper-extremity/vertebral compression fracture Jernigan, M.V. and Duma, S.M. (2003), The effects of airbag deployment on severe upper extremity injuries in frontal automobile crashes. American Journal of Emergency Medicine, 21 (2), 100-105. Abstract: The purpose of this study was to investigate severe upper extremity injuries resulting from frontal automobile crashes and to determine the effects of frontal airbags. The National Automotive Sampling System database files from 1993 to 2000 were examined in a study that included 25,464 individual cases that occurred in the United States. An analysis of the cases indicated that occupants exposed to an airbag deployment were statistically more likely to sustain a severe upper extremity injury (2.7%) than those occupants not exposed to an airbag deployment (1.6%) (P = .01), In particular, 0.7% of occupants exposed to an airbag deployment sustained a severe upper extremity injury specifically from the airbag. In addition, when in crashes with an airbag deployment, older occupants were at a higher risk for severe upper extremity injury, as well as occupants in crashes with higher changes in velocity. Copyright 2003, Elsevier Science (USA). All rights reserved Keywords: airbag/ANGLE-RECESSION/automobile/BAG INFLATION/extremity/FRACTURE/fracture/HYPHEMA/injuries/injury/MOTOR- VEHICLE COLLISIONS/OCULAR TRAUMA/SIDE IMPACT CRASHES/upper extremity/upper-extremity
    • Schutzman, S.A. and Teach, S. (1995), Upper-Extremity Impairment in Young- Children. Annals of Emergency Medicine, 26 (4), 474-479. Abstract: Study objective: To determine the spectrum of disorders in children younger than 6 years with upper-extremity injury or immobility and to identify clinical findings associated with specific disorders. Design: Prospective patient series. Setting: Urban pediatric emergency department. Participants: Children younger than 6 years seen during a 6-month period with injury or immobility of an upper extremity. Results: We identified 178 episodes of immobility or injury of an upper extremity. Radial head subluxation (RHS) was the most frequent diagnosis (63%; 99 definite and 13 probable), followed by fracture (22%) and soft-tissue injury (STI; 13%). One patient each had humeral osteomyelitis and neurologic impairment. The mean age of children with RHS was significantly less than that of children with fractures 127+/-12 months versus 39+/-19 months, P<.01); the only diagnoses in children younger than 4 months old were infection and neurologic impairment. Multivariate regression analysis showed point tenderness and swelling correlated with fractures (P<.05). Decreased arm movement, absence of swelling, and a pull as the mechanism of injury correlated with RHS (P<.05). However, arm traction occurred in only 55% of the children with RHS (95% confidence interval=.46 to .64). By 1 week after the evaluation, all children without fractures had recovered, except one each with a sprain, osteomyelitis, and neurologic impairment. Conclusion: Most children with arm injury or immobility have bony or soft- tissue trauma, the majority being RHS. Clinical findings varied between diagnoses and may aid the clinician in deciding whether attempted reduction of RHS is indicated or whether radiographs are warranted first. Nontrauma diagnoses are unusual but should be considered, particularly in the child younger than 6 months old. Appropriate immobilization and follow-up are important for the management of children without a dear diagnosis at the initial evaluation Keywords: child/children/emergency department/extremity/fracture/fractures/injury/pediatric/radiographs/trauma/upper extremity/upper-extremity Chang, L.D., Goldberg, N.H., Chang, B. and Spence, R. (1994), Elbow Defect Coverage with A One-Staged, Tunneled Latissimus- Dorsi Transposition Flap. Annals of Plastic Surgery, 32 (5), 496-502. Abstract: Upper extremity reconstruction is very challenging due to the unavailability of expendable local muscles. A review of the literature reveals that the latissimus dorsi muscle has been used for functional restoration of elbow extension and flexion as well as soft-tissue coverage of upper arm and shoulder defects. In addition, the latissimus dorsi muscle has been used for forearm reconstruction. Although we have been unable to find any reports of the use of the latissimus dorsi muscle for pure coverage of complex elbow wounds, we have successfully used the latissimus dorsi transposition flap to cover complex elbow defects in a one-staged procedure for patients. In 3 of 4 patients, the latissimus dorsi transposition flap was the first choice. In the other patient, the latissimus dorsi flap was successfully used as an alternative choice for coverage of an open, comminuted elbow fracture after a failed rectus abdominis free tissue transfer. A technique is described for coverage of complex elbow defects by transferring a latissimus dorsi muscle on its vascular pedicle with or without an overlying skin island. This procedure is safe, one-staged, and results in minimal donor morbidity. The latissimus dorsi transposition flap provides reliable coverage of complex elbow defects and should be considered the flap of choice for coverage of the elbow
    • Keywords: elbow/extremity/FLEXION/forearm/fracture/MUSCLE/MUSCULOCUTANEOUS FLAP/MYOCUTANEOUS FLAP/RECONSTRUCTION/RESTORATION/UPPER ARM Rosenthal, A.H. and Chung, K.C. (2002), Intrafocal pinning of distal radius fractures: A simplified approach. Annals of Plastic Surgery, 48 (6), 593-599. Abstract: Distal radius fractures are not often treated by plastic surgeons. At the authors' institution, plastic surgery manages half of all traumas below the elbow, including distal radius and forearm fractures. This opportunity gives the residents a unique perspective for comprehensive training in treating upper extremity injuries. Because a distal radius fracture is the most common fracture of the upper extremity, the authors describe the use of intrafocal pinning as a simple and effective approach in the treatment of extra-articular distal radius fractures (Colles' fractures). They conducted a prospective study of 18 patients with Colles' fractures treated sequentially at their institution from 1998 to 2001 using this technique. They measured ulnar variance and palmar tilt of the distal radius at the time of injury, after closed reduction, immediately postoperatively, and 11 weeks postoperatively. Acceptable distal radius reduction aims to achieve at least neutral ulnar variance and 0-deg palmar tilt. Compared with closed reduction, they achieved superior anatomic reduction with intrafocal pinning: ulnar variance, (+)2.6 mm vs. -1.4 mm; palmar tilt, -13.3 deg vs. (+)2.1 deg). These results were stable at the 11-week follow-up. Intrafocal pinning is a valuable tool in the management of Colles' fractures. It is simple to perform and to teach, and it produces results that are superior to closed reduction alone Keywords: extremity/forearm/fracture/fractures/injuries/injury/upper extremity/upper- extremity Alektiar, K.M., Leung, D., Zelefsky, M.J., Healey, J.H. and Brennan, M.F. (2002), Adjuvant brachytherapy for primary high-grade soft tissue sarcoma of the extremity. Annals of Surgical Oncology, 9 (1), 48-56. Abstract: Background: We reviewed single-institution experience using brachytherapy alone for primary high-grade soft tissue sarcoma of the extremity. Methods: Between July 1982 and September 1997, 202 adult patients with primary high-grade soft tissue sarcoma of the extremity were treated with limb-sparing surgery and adjuvant brachytherapy. All patients underwent complete gross resection, but the margin of resection was microscopically positive in 18% of patients. The median dose of brachytherapy was 45 Gy delivered over 5 days. Tumors located in the shoulder or groin were defined as central location. Complications were assessed in terms of wound complications, bone fracture, and peripheral nerve damage. Results: With a median follow-up of 61 months, the 5-year local control, distant relapse-free survival, and overall survival rates were 84%, 63%, and 70%, respectively. On multivariate analysis, poor local control correlated with shoulder location, positive microscopic margins of resection, and nonshoulder upper extremity site. The 5-year actuarial rates of wound complications requiring reoperation, bone fracture, and grade greater than or equal to3 nerve damage were 12%, 3%, and 5%, respectively. Conclusions: Adjuvant brachytherapy provides adequate local control and acceptable morbidity that compares favorably with data reported for external beam radiation. Shoulder tumor location was identified as an independent prognostic factor for poor local control. mandating further improvement in the local management of these tumors Keywords: bone/brachytherapy/EXTERNAL-BEAM
    • IRRADIATION/extremity/fracture/high grade/LOCAL- CONTROL/POSTOPERATIVE RADIOTHERAPY/PREOPERATIVE RADIATION/PROSPECTIVE RANDOMIZED TRIAL/RADIATION- THERAPY/soft tissue sarcoma/SUPERFICIAL TRUNK/SURGERY/SURGICAL MARGINS/upper extremity/upper-extremity/WOUND COMPLICATIONS Song, H.K., Guy, T.S., Kaiser, L.R. and Shrager, J.B. (2002), Current presentation and optimal surgical management of sternoclavicular joint infections. Annals of Thoracic Surgery, 73 (2), 427-431. Abstract: Background. Infection of the sternoclavicular joint is unusual, and treatment of this entity has not been standardized. We sought to characterize the current presentation and optimal management of this disease. Methods. We retrospectively reviewed the records of the last 7 patients undergoing operation for suppurative infections of the sternoclavicular joint at this institution. Patients were interviewed regarding upper extremity function after formal joint resection. Results. Predisposing factors were common and included diabetes mellitus (n = 2), clavicular fracture (n = 1), human immunodeficiency virus infection (n = 1), immunosuppression (n = 1), and pustular skin disease (n = 1). All patients presented with local symptoms including clavicular mass and tenderness. Diagnosis and evaluation were facilitated by cross-sectional imaging. Organisms isolated included Staphylococcus aureus, group G streptococcus, and Proteus and Propionibacterium species. Antibiotic therapy and simple drainage and debridement were generally ineffective, leading to recurrence of infection in 5 of 6 patients treated initially in this manner. Six patients were treated with resection of the sternoclavicular joint and involved portions of first or second ribs with soft tissue coverage by advancement flap from the ipsilateral pectoralis major muscle. Response to this therapy was excellent, with cure in all patients, no wound complications, and excellent upper extremity function at long- term follow-up. Conclusions. Aggressive surgical management including resection of the sternoclavicular joint and involved ribs with pectoralis flap closure would appear to be the preferred treatment for all but the most minor infections of the sternoclavicular joint. This approach has minimal impact on upper extremity function. (C) 2002 by The Society of Thoracic Surgeons Keywords: CT/extremity/fracture/HEROIN- ADDICTS/impact/RECONSTRUCTION/SEPTIC ARTHRITIS/upper extremity/upper-extremity Franck, W.M., Olivieri, M., Jannasch, O. and Hennig, F.F. (2002), An expandable nailing system for the management of pathological humerus fractures. Archives of Orthopaedic and Trauma Surgery, 122 (7), 400-405. Abstract: Background: People with metastatic fracture of the humerus are of poor general health. Often they are not able to compensate the handicap of an impaired extremity. Standard osteosynthetic techniques are not always applicable. To reduce the trauma of the operation, we used the Fixion(R) expandable nail system. Methods: At two centers, 23 metastatic fractures of the humerus (in 22 patients) were stabilized with a new nailing system. The nail expands under hydraulic pressure up to 150% of its uninflated diameter, gaining long frictional contact to the bone. All patients were followed up until osseous healing occurred or until they died. Results and conclusions: The operative time was approximately 32 min, including 1.4 min fluoroscopy time. Nail insertion is brief and therefore not very stressful to the group of debilitated patients who require this intervention. Immediately postoperatively, the upper extremity is stable to permit physiotherapy. In these few patients, we saw no complications. The advantages of the surgical approach appear to outweigh those of
    • conservative management options if a simple and safe surgical technique makes the humerus stable enough to resist normal daily loads Keywords: bone/bone metastases/extremity/fracture/fractures/humerus/nailing system/osteoporosis/pathological fracture/SHAFT/trauma/upper extremity/upper- extremity Smith, G.A. and Shields, B.J. (1998), Trampoline-related injuries to children. Archives of Pediatrics & Adolescent Medicine, 152 (7), 694-699. Abstract: Objective: To describe the epidemiological features of trampoline-related injuries among children treated in an urban pediatric emergency department. Design: A descriptive study of a consecutive series of patients. Setting: The emergency department of a large, urban, academic children's hospital. Participants: Children treated for trampoline-related injuries from May 1, 1995, through April 30, 1997. Results: Two hundred fourteen children were treated for trampoline-related injuries during the study period, representing, on average, 1 child treated approximately every 3 days. Children ranged in age from 1 to 16 years (mean [SD], 9.4 [3.6] years). The area of the body most commonly injured was a lower extremity (36.0%), followed by an upper extremity (31.8%), the head (14.5%), the trunk (9.8%), and the neck (7.9%). The most common type of injury was a soft tissue injury (51.9%), followed by fracture (34.6%) and laceration (11.7%). Several patterns of trampoline- related injury were identified. Extremity fractures were more common in the upper extremities (P = .006; relative risk [RR] = 1.64; 95% confidence interval [CI], 1.16-2.31); however, soft tissue injuries were more common in the lower extremities (P = .006; RR = 1.66; 95% CI, 1.16-2.38). Lacerations were associated with injury to the head region (P < .001; RR = 67.9; 95% CI, 16.8-273.6) and were more common among children younger than 6 years (P = .02; RR = 2.58; 95% CI, 1.24-5.34). Soft tissue injuries were more common among children 6 years of age and older (P = .01; RR = 1.66; 95% CI, 1.08-2.55). Four patients (1.9%) with fractures were admitted to the hospital. The trampoline was located in the backyard in 96% (119/124) of cases. Adult supervision was present at the time of injury for 55.6% (65/117) of children, including 73.3% (22/30) of children younger than 6 years. Parents reported that they had been aware of the potential dangers of trampolines before the injury event (73% [81/111]), that their child had previously attempted a flip on a trampoline (56.9% [66/116]), that this was not the child's first injury on a trampoline (10% [12/120]), and that their child continued to use a trampoline after the current injury event (54.8% [63/115]). Conclusions: Trampoline-related injuries to children treated in the emergency department are almost exclusively associated with the use of backyard trampolines. The prevention strategies of warning labels, public education, and adult supervision are inadequate to prevent these injuries. Children should not use backyard trampolines, and the sale of trampolines for private recreational use should be halted Keywords: child/children/emergency department/extremities/extremity/fracture/fractures/injuries/injury/pediatric/preventi on/QUADRIPLEGIA/SPINE/upper extremity/upper-extremity Tinetti, M.E., Baker, D.I., Gottschalk, M., Williams, C.S., Pollack, D., Garrett, P., Gill, T.M., Marottoli, R.A. and Acampora, D. (1999), Home-based multicomponent rehabilitation program for older persons after hip fracture: A randomized trial. Archives of Physical Medicine and Rehabilitation, 80 (8), 916-922. Abstract: Objective: To determine whether a home-based systematic multicomponent rehabilitation strategy leads to improved outcomes relative to usual care. Design: A randomized controlled trial with 12 months of follow-up. Setting: General
    • community; 27 home care agencies. Participants: Three hundred four nondemented persons at least 65 years of age who underwent surgical repair of a hip fracture at two hospitals in New Haven, CT, and returned home within 100 days. Intervention: Systematic multicomponent rehabilitation strategy addressing both modifiable physical impairments (physical therapy) and activities of daily living (ADL) disabilities (functional therapy) versus usual care. Main Outcome Measures: A battery of self-report and performance-based measures of physical and social function. Results: There was no significant difference in the proportion of participants in the two groups who recovered to prefracture levels in self-care ADL at 6 months (71% vs 75%) or 12 months (74% in both groups) or in home management ADL at 6 months (35% vs 44%) or 12 months (44% vs 48%). There also was no difference between the two groups in social activity levels, two timed mobility tasks, balance, or lower extremity strength at either 6 or 12 months. Compared with participants who received usual care, those in the multicomponent rehabilitation program showed slightly greater upper extremity strength at 6 months (p = .04) and a marginally better gait performance (p = .08). Conclusions: The systematic multicomponent rehabilitation program was no more effective in promoting recovery than usual home-based rehabilitation. Compared with previous cohorts, however, participants randomized to usual care in our study received more rehabilitative and home care services and experienced a higher rate of recovery. This finding is important given the current pressures to reduce home services. The challenge is to determine the composition and duration of rehabilitation and home services that will ensure optimal functional recovery most efficiently in older persons after hip fracture. (C) 1999 by the American Congress of Rehabilitation Medicine and the American Academy of Physical Medicine and Rehabilitation Keywords: activities of daily living/CARE/CLINICAL- TRIAL/CT/DISABILITY/ELDERLY PATIENTS/extremity/fracture/INDEPENDENCE/OUTCOMES/PERFORMANCE/ PROXIMAL FEMUR/RECOVERY/rehabilitation/THERAPY/upper extremity/upper-extremity Nehler, M.R., Taylor, L.M., Moneta, G.L. and Porter, J.M. (1997), Upper extremity ischemia from subclavian artery aneurysm caused by bony abnormalities of the thoracic outlet. Archives of Surgery, 132 (5), 527-532. Abstract: Objective: To describe our experience with surgical therapy for upper extremity ischemia incident to emboli from aneurysms of the subclavian artery. Design: Retrospective review case series. betting: Vascular surgery practice at a university hospital-based tertiary referral center. Patients: All patients treated for upper extremity ischemia caused by embolism from a subclavian artery aneurysm from January 1, 1990, to July 31, 1996. Intervention: All patients underwent detailed history and physical examination, screening for immunologic and hypercoaguable disorders, noninvasive vascular laboratory evaluation, and arteriography of the aortic arch in both arms and hands. Surgical treatment consisted of rib excision or fracture plating, aneurysm excision, and interposition vein grafting, with additional saphenous vein bypasses to brachial or forearm arteries as needed to provide uninterrupted circulation to the wrist. Results: Twelve patients (6 males; mean age, 37 years) were treated. All had episodic upper extremity ischemia with an initial misdiagnosis of primary vasospastic disorder. Rest pain and/or ischemic ulceration developed in 3. Duration of symptoms before correct diagnosis averaged 7 months (range, 1-36 months). All patients had bony abnormalities of the thoracic outlet (8 cervical ribs, 3 abnormal first ribs, and 1 unstable clavicular fracture). All aneurysms
    • contained intraluminal thrombus, and all patients had multiple ipsilateral distal arm, forearm, and/or hand arterial occlusions indicating chronic and repeated embolization. All patients underwent aneurysm excision and interposition vein grafting, with additional vein bypass to the brachial (3 patients) and/or forearm arteries (5 patients). Mean follow-up was 18 months (range, 2 weeks to 63 months). Eleven patients had complete symptomatic relief, and 1 patient improved. All subclavian interposition grafts remained patent. Two distal bypass grafts occluded in patients with preoperative arteriograms demonstrating no patent forearm arteries. There has been no limb loss. Conclusions: Hand ischemia caused by embolization from a subclavian artery aneurysm occurs in young patients without atherosclerosis and is frequently misdiagnosed as vasospasm. Despite advanced disease and multiple chronic distal arterial occlusions, surgical treatment by resection of bony abnormalities, aneurysm excision and grafting, and distal bypass grafting produces excellent results Keywords: DIAGNOSIS/embolism/extremity/forearm/fracture/hand/INJURIES/MANAGEME NT/RAYNAUDS SYNDROME/RIB/treatment/upper extremity/upper- extremity/VASCULAR COMPLICATIONS/wrist Baron, J.A., Barrett, J.A. and Karagas, M.R. (1996), The epidemiology of peripheral fractures. Bone, 18 (3), S209-S213. Abstract: Although much is known about hip fracture epidemiology, there are relatively little data regarding fractures at other peripheral sites. Epidemiological differences between fractures are important, since they imply that an understanding of the consequences and clinical expression of osteoporosis requires the study of many different fracture types. Recent data regarding the basic epidemiology of limb fractures among the elderly in industrialized countries have made some patterns clear. Fractures outside the hip are relatively common events, and before age 70 to 75, ankle and distal forearm fractures occur more commonly than fractures of the hip. Among the elderly, fractures at the most proximal and most distal ends of the limbs have the highest incidence. Thus, in the upper extremity, fractures of the proximal humerus and distal forearm are the most common, while in the lower extremity, those at the hip and ankle predominate. Outside the axial skeleton, females have higher rates for most fracture types, and at most fracture sites whites have higher rates than blacks. In each limb, the most proximal fractures tend to have the most pronounced age- related increases in risk Keywords: BONE/elderly/ELDERLY WOMEN/epidemiology/extremity/FOREARM/fracture/fractures/hip fracture/humerus/INCREASING INCIDENCE/osteoporosis/OSTEOPOROSIS/POPULATION/race/RISK/upper extremity/upper-extremity Masmejean, E.H., Chavane, H., Chantegret, A., Issermann, J.J. and Alnot, J.Y. (1999), The wrist of the formula 1 driver. British Journal of Sports Medicine, 33 (4), 270-273. Abstract: Objectives-During formula 1 driving, repetitive cumulative trauma may provoke nerve disorders such as nerve compression syndrome as well as osteoligament injuries. A study based on interrogatory and clinical examination of 22 drivers was carried out during the 1998 formula 1 World Championship in order to better define the type and frequency of these lesions. Methods-The questions investigated nervous symptoms, such as paraesthesia and diminishment of sensitivity, and osteoligamentous symptoms, such as pain, specifying the localisation
    • (ulnar side, dorsal aspect of the wrist, snuff box) and the effect of the wrist position on the intensity of the pain. Clinical examination was carried out bilaterally and symmetrically. Results-Fourteen of the 22 drivers reported symptoms. One suffered cramp in his hands at the end of each race and one described a typical forearm effort compartment syndrome. Six drivers had effort "osteoligamentous" symptoms: three scapholunate pain; one medial hyperpcomression of the wrist; two sequellae of a distal radius fracture. Seven reported nerve disorders: two effort carpal tunnel syndromes; one typical carpal tunnel syndrome; one effort cubital tunnel syndrome; three paraesthesia in all fingers at the end of a race, without any objective signs. Conclusions-This appears to be the first report of upper extremity disorders in competition drivers. The use of a wrist pad to reduce the effects of vibration may help to prevent trauma to the wrist in formula 1 drivers Keywords: cumulative trauma/extremity/FOREARM/fracture/HAND/INJURIES/ligamentous distension/nerve compression/race/racing drivers/trauma/upper extremity/upper- extremity/wrist Black, G.B. and Amadeo, R. (2003), Orthopedic injuries associated with backyard trampoline use in children. Canadian Journal of Surgery, 46 (3), 199-201. Abstract: Introduction: Trampolining on an outdoor oval or circular trampoline is a popular activity for children but is associated with a number of orthopedic injuries, especially in children between the ages of 5 and 15 years. In this paper we review the orthopedic injuries in children associated with backyard trampoline use, through our experience with a series of children admitted to the Winnipeg Children's Hospital, the only tertiary care pediatric centre in Manitoba. Methods: We reviewed the charts, x-ray films and operative reports for 80 children under 16 years old (mean 9 yr, with 14 [18%] children between 2 and 4 yr) with an orthopedic injury sustained when using a trampoline in the backyard. We noted the mechanism of injury and type and severity of orthopedic injury sustained. Results: Fifty-two (65%) children were injured on the trampoline mat, and 24 (30%) were injured when they were ejected from the trampoline. Sixty (75%) children sustained a fracture or fracture- dislocation. Forty-eight (80%) orthopedic injuries occurred in the upper extremity. No child died as a result of a trampoline injury. Conclusion: The use of the "backyard" trampoline by young children can cause significant orthopedic injury Keywords: child/children/extremity/fracture/fracture dislocation/injuries/injury/pediatric/QUADRIPLEGIA/severity/trampoline/upper extremity/upper-extremity Harrington, K.D. (1997), Orthopedic surgical management of skeletal complications of malignancy. Cancer, 80 (8), 1614-1627. Abstract: Coincident with improved overall cancer palliation during the past 2 decades has been an increasing incidence of clinically apparent bone metastases, and from these metastases subsequent pathologic fractures of the long bones, spine, and pelvis. Current techniques for surgical management of these fractures are extremely effective in alleviating pain and allowing patients to resume an ambulatory status, often without the need of external support. This, in turn, has significantly improved the quality of the remaining months or years of these individuals' lives. In fact, the long term survival of patients after their first long bone pathologic fracture from malignancy has more than tripled for the most common cancers (breast carcinoma, prostate carcinoma, lymphomas, and myelomas) during the past 25 years. Surgical techniques for stabilizing pathologic or impending fractures must be individualized for the area of involvement, the particular qualities of the bone involved, and the
    • potential for involvement of adjacent soft tissue structures. Long bone fractures most commonly occur in the femur and humerus and are typically internally fixed by intramedullary devices that control impaction, distraction, and torquing stresses by the use of proximal and distal interlocking fixation. Such fixation must be able to withstand weight-bearing stresses on lower extremity long bones. Upper extremity pathologic fractures are often subjected to distractive forces inherent in lifting and pulling, but they are also subjected to heavy compressive forces, particularly in patients who require crutches or other devices to assist them in walking. Fixation of upper or lower extremity long bone fractures ordinarily may be accomplished with minimal blood loss or morbidity. in contrast, fractures or impending fractures involving the acetabulum necessitate extensive joint reconstruction, with inherent increased potential for morbidity and complications. For this reason, the anticipated prognosis for survival and mobility should be greater preoperatively for patients with acetabular fractures than for patients with fractures of either upper or lower extremity long bones. Most spinal metastases can be managed conservatively. Those requiring surgical intervention present with progressive neurologic compromise, which requires decompression, or spinal instability, which requires stabilization. Constructs for internal stabilization of the spine must not be adversely affected by local postoperative irradiation. Ninety-six percent of patients experience good or excellent relief of pain after internal fixation of pathologic malignant long bone fractures. Eighty-four percent of patients with acetabular fractures experience good or excellent relief of pain after joint reconstruction. Eighty-two percent of patients with neurologic compromise secondary to vertebral malignancy improve at least one functional grade after decompression and stabilization, and 88% experience good or excellent relief of spinal pain with restoration of walking ability. Thirty-two percent survived for more than 2 years after spinal decompression and stabilization. Patients with pathologic fractures from metastatic carcinoma of the breast had a mean survival of 24.6 months after surgical management of their fractures. There was a similarly encouraging improvement in the survival statistics for patients with other primary tumor types. Most malignant pathologic fractures of the pelvis, long bones, or spine are amenable to effective stabilization by the techniques described in this article. These techniques allow resumption of weight-bearing ambulation in all but a few patients, good or excellent relief of pain in the vast majority, and an enhanced anticipation of survival and improvement in quality of life. (C) 1997 American Cancer Society Keywords: bone/bone fractures/bone metastases/extremity/fracture/fractures/humerus/metastases/orthopedic surgical stabilization/paraplegia/pathologic fractures/surgical management/weightbearing Demirkilic, U., Kuralay, E., Yilmaz, A.T., Ozal, E., Tatar, H. and Ozturk, O.Y. (1998), Surgical approach to military vascular injuries. Cardiovascular Surgery, 6 (4), 342-346. Abstract: Purpose of study: Vascular injuries caused by high-velocity military missiles are associated with bone fracture. soft- tissue. nerve and tendon injuries. In this study we will discuss the surgical strategy and results of vascular injuries, which require a different approach from primary and elective surgical procedure. Basic methods: Surgical interventions were performed in 116 patients. Vascular lesions were localized on the lower extremity in 53, upper extremity in SS, and nine were in other regions. Vascular injuries were concomitant with bone fracture in 46 and nerve injuries in 36 patients. Vascular repair was performed after orthopedic stabilization in vessels with an ischemic period of less than 4 hours. Principal findings:
    • Fasciotomy was performed after vascular repair in the 22 cases that had arrived after 8 hours. Amputation was required in two cases. There was one mortality. Conclusions: The best results are obtained when a multidisciplinary and emergency approach are used by the team of vascular, orthopedic. plastic and neurosurgeons who are experienced in military injuries. (C) 1998 The International Society for Cardiovascular Surgery. Published by Elsevier Science Ltd. All rights reserved Keywords: ARTERIAL INJURIES/blast effects/bone/bone fracture/extremity/fracture/high velocity missiles/injuries/MANAGEMENT/POPLITEAL/TEMPORARY INTRALUMINAL SHUNTS/TRAUMA/upper extremity/upper-extremity/vascular injury Chou, P.H., Chou, Y.L., Lin, C.J., Su, F.C., Lou, S.Z., Lin, C.F. and Huang, G.F. (2001), Effect of elbow flexion on upper extremity impact forces during a fall. Clinical Biomechanics, 16 (10), 888-894. Abstract: Objective. The overall objectives are to develop a biomechanical model for a simulated fall with outstretched hand. Design. Cross-sectional study involving young healthy volunteers in a university research laboratory setting. Background. Little is known about the factors which influence fracture risk during a fall on outstretched hand. Methods. A group of 11 male subjects volunteered for this investigation. A set of eight reflective markers was placed bilaterally on selected anatomic landmarks. Subjects were suspended with both elbows extended and wrists dorsiflexed, preparing to impact the ground and force plates from two different fall heights: 3 and 6 cm. Two different postures for the elbows were employed. In the elbow extension experiment, the elbows were extended at all times. In the elbow flexion experiment, the elbows were extended at impact, but then flexed immediately, as though in the initial downward phase of a push-up exercise. Result. Increasing the fall height significantly increased the upper extremity axial forces by 10% and 5%. No significantly different differences were found in the axial forces applied to the wrist, elbow or shoulder between the elbow flexion and elbow extension trials, but the elbow mediolateral shear force was 68% larger (P=0.002) in the extension trials. Conclusions. Performing an elbow flexion movement at impact reduces the first peak impact force value and postpones the maximum peak value. Although changing the fall arrest strategy from elbow extension to elbow flexion did not affect the peak impact force oil the hand, it did require substantially greater elbow and shoulder muscle strengths Keywords: biomechanics/bone fracture/elbow/extremity/fall/forward falls/fracture/FRACTURES/hand/impact/OUTSTRETCHED HAND/upper extremity/upper-extremity/wrist Sinha, A.K., Kaeding, C.C. and Wadley, G.M. (1999), Upper extremity stress fractures in athletes: Clinical features of 44 cases. Clinical Journal of Sport Medicine, 9 (4), 199-202. Abstract: Purpose: To review the clinical features of a large series of active patients with a stress fracture in a non-weight-bearing location of the upper extremity or ribs. Design: Multicenter cross-sectional study. Setting: Multiple academic medical centers. Participants: 44 patients with a diagnosis of upper extremity or rib stress fracture. Main Outcome Measures: Clinical features according to anatomic location, primary sport, and subdivided according to the nature of the sport- specific skills involved. Results: A diagnosis of stress fracture was made in 44 patients based on history and physical examination, and confirmed by radiography, scintigraphy, magnetic resonance imaging (MRI), computed tomography (CT), or a combination of imaging techniques. Patients were subjectively divided into four categories based
    • on the predominant type of upper extrem- ity activity required for participation in their sport: 1) weight lifter (e.g., football, weight lifting, wrestling); 2) upper extremity weight bearer (e.g., gymnastics, diving, cheerleading); 3) thrower (e.g., pitcher, soccer goalie, javelin); or 4) swinger (e.g., golf, tennis). We noted that all fractures in the weight bearers occurred distal to the elbow, whereas in the throwers most fractures affected the shoulder girdle. Lower rib stress fractures predominated in the swingers group, whereas weight lifters had fractures located throughout the upper extremity. Conclusion: Stress fracture should be considered in the differential diagnosis of athletes presenting with upper extremity or rib pain of bony origin that is of insidious onset. Further study of the sport-specific patterns of injury described here may improve our ability to treat and prevent these injuries Keywords: BONE/CT/elbow/extremity/FATIGUE/fatigue fracture/fracture/fractures/injuries/injury/PLAYER/rib/RIBS/sport/stress fracture/ULNA/upper extremity/upper-extremity Ahluwalia, R., Datz, F.L., Morton, K.A., Anderson, C.M. and Whiting, J.H. (1994), Bilateral Fatigue Fractures of the Radial Shaft in A Gymnast. Clinical Nuclear Medicine, 19 (8), 665-667. Abstract: A 24-year-old female gymnast had a 3-month history of bilateral forearm pain. A Tc-99m MDP bone scan demonstrated focally increased activity in the radial shafts on blood pool and delayed images, characteristic of fatigue fractures. Fatigue fractures commonly occur in the lower extremities. Upper extremity fatigue fractures, in contrast, are uncommon and usually involve the humerus or ulna. Fatigue fracture of the radial shaft from gymnastic exercise has not been previously reported Keywords: bone/extremities/extremity/forearm/fracture/fractures/humerus/INJURIES/STRESS- FRACTURES/ulna Simpson, N.S. and Jupiter, J.B. (1995), Complex Fracture Patterns of the Upper Extremity. Clinical Orthopaedics and Related Research, (318), 43-53. Abstract: Combined skeletal injuries to the upper limb present complex management problems because they may result in dysfunction of the terminal unit of the upper limb-the hand. This article explores complex patterns of skeletal and soft tissue injuries, including complex soft tissue trauma with closed and open fractures; the floating shoulder, elbow, and forearm; and the role of skeletal fixation in conjunction with the complex fracture patterns. As the functional capacity of the upper limb reflects an integration of all its component parts, a combined approach to skeletal and soft tissue trauma is of fundamental importance in upper limb trauma Keywords: elbow/EXPERIENCE/EXTERNAL FIXATION/forearm/fracture/fractures/hand/HUMERAL SHAFT FRACTURES/INJURIES/LOCKING NAIL/trauma Tscherne, H., Regel, G., Pape, H.C., Pohlemann, T. and Krettek, C. (1998), Internal fixation of multiple fractures in patients with polytrauma. Clinical Orthopaedics and Related Research, (347), 62-78. Abstract: Within the last decade understanding of the pathogenetic consequences of trauma has been improved significantly An additional reduction of lethality has been achieved that in part is related to increasing discrimination of complex injury patterns, Accordingly, additional staging in fracture management of these injuries has been developed, An overview of the current status of fracture management in polytrauma is given and certain regimens that are still controversially are discussed, The principles determined are based on the treatment experience of 4003 multiply
    • injured patients within the past 23 years, The most important principles within the first hours after trauma represent adequate hemorrhage control, In fracture treatment the primary goal remains to perform primary stable osteosynthesis, In severe polytrauma with severe injuries to the extremities, the first decision is whether limb salvage can be achieved without risk of deterioration of the patient's condition, If this is the case, open fractures Grades III b and c usually can be stabilized primarily by unreamed intramedullary nailing or percutaneous plating, The priority pattern in multiple closed fractures is as follows: (1) tibia; (2) femur; (3) pelvis; (4) spine; and (5) upper extremity, Exceptions may ensue if severe head or thoracic trauma is present, Delayed treatment is performed for complex joint reconstruction, definitive treatment of maxillofacial injuries, and soft tissue reconstruction Keywords: CLASSIFICATION/extremities/extremity/EXTREMITY SEVERITY SCORE/fracture/fractures/HEMORRHAGE/INJURIES/injury/intramedullary nailing/limb salvage/OSTEOSYNTHESIS/PELVIC FRACTURES/SALVAGE/STATE/TRAUMA/treatment/upper extremity/upper- extremity Blakemore, L.C., Cooperman, D.R., Thompson, G.H., Wathey, C. and Ballock, R.T.A. (2000), Compartment syndrome in ipsilateral humerus and forearm fractures in children. Clinical Orthopaedics and Related Research, (376), 32-38. Abstract: 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 Keywords: bone/bone fractures/children/extremity/forearm/fracture/fractures/humerus/injuries/SUPRACO NDYLAR/upper extremity/upper-extremity Newport, M.L. (2000), Upper extremity disorders in women. Clinical Orthopaedics and Related Research, (372), 85-94. Abstract: Carpal tunnel syndrome, Colles' fracture, and osteoarthritis of the basilar joint of the thumb are only three of the many upper extremity conditions that preferentially affect women. With more and more women entering the workplace, these conditions become more disruptive of patients' lifestyles and even may be increasing in incidence. Orthopaedic surgeons traditionally have focused on the surgical treatment of patients with these conditions, but it is becoming increasingly clear that surgeons also must focus on delineating pathophysiology to better identify those individuals at risk and help prevent these potentially disabling disorders Keywords: CARPAL-TUNNEL SYNDROME/extremity/fracture/FRACTURES/HIP/INDUSTRY/TRAPEZIUM/trea tment/upper extremity/upper-extremity
    • Jazrawi, L.M., Bai, B., Simon, J.A., Kummer, F.J., Birdzell, L.T. and Koval, K.J. (2000), A biomechanical comparison of Schuhli nuts or cement augmented screws for plating of humeral fractures. Clinical Orthopaedics and Related Research, (377), 235-240. Abstract: Schuhli locking nuts can be used in poor quality cortical bone to enhance fixation stability as an alternative to cement augmented screws. This study compared the fixation strength and stability of plate constructs using Schuhli locking nuts with standard screws and cement augmented screws for fixation of simulated humeral shaft fractures in a test model with osteoporosis, The constructs were tested in axial compression, 4-point bending, and torsion to determine fixation stability. The humeri were cycled in torsion (4.5 Nm) for 1000 cycles to simulate upper extremity use during the early postoperative period and retested for stability. The Schuhli locking nuts and cement augmented screws had significantly greater fixation stability than the standard screws before (range, 6-14 times greater) and after cycling in torsional loading (range, 3-3.6 times greater). Although cement augmented screws and Schuhli augmentation showed increased fixation stability compared with the standard screws in axial and 4-point bending before cycling (range, 1.3-1.4 times greater), this was not significant. Compared with Schuhli fixation, cement augmented screws showed no significant difference in fixation stability in all loading modes before and after cycling. Schuhli locking nuts offer the stability of cement augmentation while avoiding its potential adverse effects on fracture healing with extravasation and thermal necrosis Keywords: bone/extremity/FIXATION/fracture/fractures/osteoporosis/shaft fractures/SYSTEMS/upper extremity/upper-extremity Johnson, E.C. and Strauss, E. (2003), Recent advances in the treatment of gunshot fractures of the humeral shaft. Clinical Orthopaedics and Related Research, (408), 126-132. Abstract: The increase in violent crime has lead to an increase in gunshot-induced fractures in the United States. Injuries to the upper extremity are common. The treatment of gunshot injuries depends on the extent of soft tissue disruption and the type and location of fracture. Most of these injuries are a result of low-energy gunshot wounds that may be treated conservatively under the appropriate conditions. Low-energy fractures that require operative stabilization may be done with predictable results for achieving union with intramedullary fixation or compression plating. Complex open fractures from gunshot wounds associated with neurovascular injuries present a therapeutic challenge to the orthopaedic surgeon. The fractures associated with these injuries often are comminuted and unstable. Bone loss is common. Soft tissue disruption plays a more important role in high-energy gunshot- induced fractures. In these cases, external fixation is the treatment of choice for stabilization. Recent advances in the use of external fixation have led to quick fracture stabilization, stability for vascular repair, and access to the wound for debridement and subsequent soft tissue surgery Keywords: COST/EXPERIENCE/EXTERNAL FIXATION/extremity/fracture/fractures/INJURIES/intramedullary fixation/NAILS/ NONUNIONS/SYSTEMS/TRAUMA/treatment/upper extremity/upper- extremity/WOUNDS Capo, J.T. and Hastings, H. (1998), Metacarpal and phalangeal fractures in athletes. Clinics in Sports Medicine, 17 (3), 491-+. Abstract: The high demands plated on the upper extremity in sporting activities subject the competitive athlete to common injuries of the hand. Treatment options are based
    • on the fracture configuration, associated extremity injuries, and status of the surrounding soft tissue. Metacarpal and phalangeal fractures may usually be treated by closed, nonoperative methods, and most athletes may quickly return to play with a protective orthosis. Supplemental methods of fixation, such as percutaneous pins and tension-band wires, may be used for unstable fractures. When required, open reduction and internal fixation can provide optimum stability to the fracture, which allows immediate range-of-motion and early return to play Keywords: extremity/fracture/fractures/HAND/INJURIES/upper extremity/upper- extremity/WRIST Haupt, H.A. (2001), Upper extremity injuries associated with strength training. Clinics in Sports Medicine, 20 (3), 481-+. Abstract: Strength training has become an integral part of the training program for competitive athletes; however, with the increasing interest in health and fitness by the general population, combined with the burgeoning number of personal trainers, strength training is becoming an integral part of the general fitness programs of all age groups of both sexes. As a result, strength training injuries will likely become more common in the future. Understanding the injury patterns associated with strength training will not only be of benefit to team physicians and those caring for competitive athletes, but also for general practitioners and sports medicine specialists caring for the general population. In this article, the author presents a review of the reported injuries associated with strength training, discussing not only their treatment but also preventive strategies that emphasize proper strength training techniques. The injury patterns are organized and presented on an anatomic basis Keywords: ANABOLIC-STEROIDS/ATRAUMATIC OSTEOLYSIS/AVULSION/BODY BUILDER/DISTAL CLAVICLE/extremity/injuries/injury/NEUROPATHY/PECTORALIS MAJOR MUSCLE/STRESS-FRACTURE/TENDON-RUPTURE/treatment/WEIGHT LIFTER Izzi, J., Dennison, D., Noerdlinger, M., Dasilva, M. and Akelman, E. (2001), Nerve injuries of the elbow, wrist, and hand in athletes. Clinics in Sports Medicine, 20 (1), 203-+. Abstract: Upper extremity compression neuropathies are fairly rare in athletes. Initially, most can be managed conservatively. These conditions can follow direct contusion of the tissues that overlay these peripheral nerves or can result from vigorous, repetitive athletic activity leading to tissue swelling and ischemia with nerve compression symptoms. A complete history and physical examination, including a neurologic examination, should be paramount when treating athletes with upper extremity injuries Keywords: CARPAL-TUNNEL SYNDROME/COMPRESSIVE NEUROPATHIES/elbow/ENTRAPMENT NEUROPATHIES/extremity/FOREARM/FRACTURE/HAMATE/hand/HOOK/inju ries/nerve compression/NEUROVASCULAR INJURIES/ULNAR NERVE/UPPER EXTREMITY/upper-extremity/wrist Hanker, G.J. (2001), Radius fractures in the athlete. Clinics in Sports Medicine, 20 (1), 189-+. Abstract: Distal radius fractures are frequent injuries in competitive and recreational athletes, and are the most common fracture seen in the upper extremity. The distal radius fracture can occur in virtually any sport and in all age groups. Treatment requires a stable, anatomic fracture reduction, with complete restoration of normal anatomical wrist joint parameters. Wrist arthroscopy can assist with fracture
    • reduction and fixation and the discovery of associated injuries such as triangular fibrocartilage complex tears, intrinsic and extrinsic Ligamentous tears, or cartilage injuries. A comprehensive rehabilitation program accompanies the athlete's distal radius fracture care, leading to a favorable outcome and early return to athletic competition Keywords: extremity/fracture/fractures/injuries/outcome/rehabilitation/sport/upper extremity/upper-extremity/wrist Mayr, J., Gaisl, M., Purtscher, K., Noeres, H., Schimpl, G. and Fasching, G. (1994), Baby Walkers An Underestimated Hazard for Our Children. European Journal of Pediatrics, 153 (7), 531-534. Abstract: Baby walkers (BWs) continue to be a frequent cause of head injuries in young children. A random sample survey of 240 families with children aged 2-6 years revealed a use rate of baby walkers of 55%. Of the children using baby walkers 20% were found to have suffered a BW-related accident. In a retrospective study we reviewed 172 case reports of infants who suffered a BW-related injury between January 1990 and June 1993. We observed 19 skull fractures, 23 concussions of the brain and 125 contusions and lacerations of the head including 4 teeth luxations and 3 fractures or distorsions of the upper extremity. BW-related injuries represent the third most common mode of injury in children aged 7-14 months. We conclude that despite previous warnings BW still represent a frequent cause of severe head injuries in young children. We recommend a general ban on the sale and manufacture of BWs Keywords: BABY WALKER/children/COMPLICATIONS/extremity/fractures/HEAD INJURY/injuries/INJURY/INJURY PREVENTION/SKULL FRACTURE/survey/upper extremity/upper-extremity Till, H., Huttl, B., Knorr, P. and Dietz, H.G. (2000), Elastic stable intramedullary nailing (ESIN) provides good long-term results in pediatric long-bone fractures. European Journal of Pediatric Surgery, 10 (5), 319-322. Abstract: The present study evaluates the long-term outcome of elastic stable intramedullary nailing (ESIN) in children with long-bone shaft fractures. 70 patients were examined, the present mean age of patients was 12.7 (+/-3.26) years, mean time interval since surgery was 3.1 (+/-1.49) years. Following ESIN at the lower extremity (23 femur fractures, 14 tibia fractures), keloid formation was remarkable in one patient, range of motion (ROM) was adequate in all but one boy (extension deficit of the hip of 10 degrees). Overall leg length discrepancy was +4.1 mm (+/-5.2 mm) following ESIN for femur fracture and +3.2 mm (+/- 6.4 mm) following tibia fracture. Radiologically, all fractures had healed and no signs of avascular necrosis (AVN) could be detected. Malalignment was documented in one girl following tibia fracture (valgus of 12 degrees). Assessment of the upper extremity (28 forearm fractures, 5 humerus fractures) revealed keloid formation in 5 children. Impaired ROM was found in three children following ESIN for a forearm fracture (limited pro- /supination). Radiological controls detected one case of retrocurvation of the humerus (12 degrees, polytrauma patient) and one varus deviation of the radius in a 10-year old boy. Questioning the children about their opinion of the treatment, 93% considered the cosmetic results as good (6% fair), they judged the functional ability as perfect in 91%(9% fair) and 93% expressed great overall content (6% fair, 1% poor). In conclusion, ESIN provides good long-term results and can be a beneficial method for children with long-bone fractures Keywords: CHILDREN/children/extremity/FEMORAL-SHAFT FRACTURES/FIXATION/FOREARM/fracture/fractures/humerus/intramedullary
    • nailing/long-term results/outcome/pediatric/shaft fractures/treatment/upper extremity/upper-extremity Sato, Y., Ohshima, T. and Kondo, T. (2002), Air bag injuries - a literature review in consideration of demands in forensic autopsies. Forensic Science International, 128 (3), 162-167. Abstract: Air bags have been implicated in saving lives and reducing morbidity associated with motor vehicle crashes since their introduction in the mid-1970s. However, there is increasing evidence showing that air bags can be a source of injury and even death in certain circumstances. As the number of air bag- equipped vehicles increases, air bag-related injuries have occurred more frequently. Thus, a greater awareness of air bag- related injuries is required in forensic autopsies. Here, we review thoroughly the literature concerning air bag-related injuries with special regard to their nature and causative mechanisms, and summarize air bag-related injuries observed in adults, children and infants. (C) 2002 Elsevier Science Ireland Ltd. All rights reserved Keywords: air bag/air bags/AUTOMOBILE AIRBAG/CHILDREN/DEPLOYMENT/forensic autopsy/FRACTURE/HEAD- INJURY/injuries/injury/motor vehicle/OCULAR TRAUMA/PATTERNS/SECONDARY/UPPER EXTREMITY INJURIES/VALVE INJURY Botte, M.J., Fronek, J., Pedowitz, R.A., Hoenecke, H.R., Abrams, R.A. and Hamer, M.L. (1998), Exertional compartment syndrome of the upper extremity. Hand Clinics, 14 (3), 477-+. Abstract: Exertional compartment syndrome is characterized by intracompartmental pressures that rise transiently following repetitive motion or exercise, thereby producing temporary, reversible ischemia, pain, weakness, and, occasionally, neurologic deficits. The exact cause or pathogenesis remains unclear; a disturbance of microvascular flow caused by elevated intramuscular pressure leads to tissue ischemia, depletion of high-energy phosphate stores, and cellular acidosis. Anatomic contributing factors may include a limited compartment size, increased intracompartmental volume, constricted fascia, loss of compartment elasticity, poor venous return, or increased muscle bulk. The diagnosis is suspected based on history and confirmed with physical examination and intramuscular pressure evaluation before and after exercise (stress test). Differential diagnosis includes claudication or other vascular abnormalities, myositis, tendinitis, periostitis, chronic strains or sprains, stress fracture, other compression or systemic neuropathies, and cardiac abnormalities with angina or referred extremity pain. Initial treatment includes activity modification; refractory symptoms can be managed with elective fasciotomy Keywords: ANTEROLATERAL- COMPARTMENT/DIAGNOSIS/extremity/fasciotomy/fracture/HAND/LOWER LEG/MUSCLE/PRESSURE/stress fracture/treatment/upper extremity/upper- extremity Ouellette, E.A. (1998), Compartment syndromes in obtunded patients. Hand Clinics, 14 (3), 431-+. Abstract: A high index for compartment syndrome should be maintained in all patients with an injured upper extremity. This is particularly important in obtunded patients and any other patients whose ability to communicate is impeded. Such patients include victims of severe or multiple trauma, particularly to the head, spinal cord, or upper extremity nerves; burn victims; patients who are under anesthesia or sedated; critically ill patients; substance abusers or drug-overdosed patients; mentally ill or
    • disabled patients; and infants and young children. Common causes of upper extremity compartment syndromes in these patients are prolonged limb compression due to drug overdose, extravasation of intravenous or arterial fluid administration, thrombolytic therapy for myocardial infarction, and trauma. If a compartment syndrome of the forearm, hand, or upper arm is suspected, the patient should be examined closely and frequently, and changes over time should be documented carefully. Adjunctive diagnostic techniques, particularly intracompartmental pressure measurement, play an essential role in these patients, in whom it may be difficult or impossible to assess symptoms and signs or make an accurate differential diagnosis by physical examination alone. Once a compartment syndrome is diagnosed, emergent fasciotomy is needed to prevent devastating loss of function Keywords: ARM/BICEPS/CHILDREN/extremity/fasciotomy/FOREARM/FRACTURE/HAND/ PRESSURES/trauma/upper extremity/upper-extremity/WICK CATHETER Goodwin, R.C. and Kuivila, T.E. (2002), Pediatric elbow and forearm fractures requiring surgical treatment. Hand Clinics, 18 (1), 135-+. Abstract: Many fractures of the upper extremity in the skeletally immature heal quickly and with remarkable remodeling ability. Others are difficult for even the most experienced pediatric trauma maven. Concerning these more difficult injuries, however, modern techniques and technology (both orthopedic and radiographic) have drastically improved the results for patients and surgeons alike. A thorough understanding of trauma pathology, adeptness with technique and equipment, and high- quality intraoperative imaging have truly revolutionized pediatric operative fracture care to the point at which outcomes can be optimized and complications potentially eliminated Keywords: CHILDHOOD/CHILDREN/DISPLACED SUPRACONDYLAR FRACTURES/elbow/extremity/FIXATION/forearm/fracture/fractures/HAND/HUM ERUS/injuries/MANAGEMENT/MONTEGGIA/NERVE PALSY/outcomes/pediatric/trauma/treatment/upper extremity/upper-extremity Nielsen, D., Nowinski, R.J. and Bamberger, H.B. (2002), Indications, alternatives, and complications of external fixation about the elbow. Hand Clinics, 18 (1), 87-+. Abstract: This article reviews the varied indications for external fixation about the elbow including fracture stabilization, instability, contracture, coronoid fractures, and articular surface injuries. Options for each specific topic will also be considered. Potential complications of fixator applications and their suggested management are discussed Keywords: DISTRACTION ARTHROPLASTY/elbow/fracture/FRACTURES/HAND/ HINGE-DISTRACTOR/injuries/UPPER EXTREMITY Mckee, M.D., Seiler, J.G. and Jupiter, J.B. (1995), The application of the limited contact dynamic compression plate in the upper extremity: An analysis of 114 consecutive cases. Injury-International Journal of the Care of the Injured, 26 (10), 661-666. Abstract: We sought to assess the clinical effectiveness of a new plate design which offers improved biological and biomechanical features, the limited contact dynamic compression (LCDC) plate. We analysed 114 LCDC plates applied consecutively for upper extremity fractures or reconstruction in 94 patients. Three patients were lost to follow-up, leaving 111 plates in 91 patients followed to definitive fracture/ osteotomy outcome, Thirty-seven plates were applied for reconstruction in 35 patients, including II where standard implants had failed. Fifty-six patients had 74 plates applied for acute fractures including 12 open fractures, 23 multiply injured
    • patients, 26 patients with concomitant fractures and seven associated neurovascular injuries. All patients were followed to definitive outcome. Union was achieved at an average of 10.7 weeks in 105 platings, while three delayed unions eventually united without further intervention, an overall union rate of 108/111, or 97.3 per cent. There were no mechanical failures of the plates or screws. In this large series a union rate of 97.3 per cent with no implant failures confirms its clinical application for traumatic and reconstructive problems in this area. Improved contouring, easier screw placement, decreased interference with cortical bone blood flow and excellent union rates are definite short-term advantages. Theoretical long-term benefits of decreased stress-shielding and lower refracture rates will require longer follow up Keywords: acute/bone/CARE/extremity/fractures/injuries/outcome/upper extremity/upper extremity fractures/upper-extremity Pennig, D., Gausepohl, T. and Mader, K. (2000), Transarticular fixation with the capacity for motion in fracture dislocations of the elbow. Injury-International Journal of the Care of the Injured, 31 35-44. Abstract: Post-traumatic stiffness of the elbow joint is a frequent result of immobilisation leading to severe disability in the use of the upper extremity. Recognition of the tendency to stiffness leads to the assumption that the strong self- healing forces of the capsule and ligament apparatus converts the initial instability of the joint after ligament disrupture, into a high-grade undirected stability following immobilisation. Directed stability as it is produced by the natural ligament apparatus of the joint on the other hand produces a guided movement of the joint in one direction. These theoretical considerations lead to the idea that the self- healing forces of the ligament apparatus under continous guided movement of the joint will result in a stable and movable joint to allow healing of the compromised soft tissue envelope and moreover to maintain Free soft tissue access without compromising the stability. For this a unilateral fixator with motion capacity was developed. The joint bridging application approaches the humerus and ulna from the lateral side. The proximal pin group is inserted into the proximal region of the humerus respecting the radial nerve. The distal pin group is implanted from the dorsal side into the middle third of the ulna. The fixator has a hinge joint. The design of the fixator clamps, bars and the hinge joint allows simple alignment with the rotational axis of the elbow. Pro- and supination of the forearm is unhindered. Flexion and extension can be permitted according to the soft tissue situation. (C) 2000 Elsevier Science Ltd. All rights reserved Keywords: CARE/dislocation/elbow/elbow joint/extremity/fixator with motion capacity/forearm/fracture/fracture dislocation/hand/high grade/humerus/supination/ulna/upper extremity/upper-extremity Brudvik, C. (2000), Child injuries in Bergen, Norway. Injury-International Journal of the Care of the Injured, 31 (10), 761-767. Abstract: We, undertook a prospective collection of data on all children below the age of 16 presenting with a history of trauma to the Accident and Emergency Department and at Haukeland University Hospital in the city of Bergen, Norway during 1998. Our study included 7.041 new injuries, giving an annual injury incidence of 9% for preschool children, and 13% for children aged 6 to 15. Boys were injured more often than girls, and they hurt themselves equally at all age groups. Girls, however, had the lowest incidence of injury at 4-6 years of age, and two peaks at 2 and at 10-12 years of age. In the youngest children there was a predominance of head injury (51%) while in school children upper extremity injury was the commonest (46%). Most of the younger children sustained their injuries at home, while older children were
    • injured both at home and school. Sixty percent of all medically treated patients with injuries associated with roller blade, skateboard or snowboard activities sustained a fracture. These newer sports create a new injury pattern, but soccer and bicycle injuries still predominate. On comparing our data with previous studies performed a decade ago, we found a significant decline in bicycle injuries (p = 0.019), but burns are still as common (p = 0.35), which suggests a need to focus more on burns prevention. (C) 2000 Elsevier Science Ltd. All rights reserved Keywords: BURNS/CARE/children/EPIDEMIOLOGY/extremity/fracture/head injury/injuries/injury/prevention/trauma/upper extremity/upper-extremity Soffe, K.E., Quinlan, J.F., Niall, D., MacManus, W.F. and Hynes, D. (2003), An open forearm fracture with intermedullary foreign body plug - a complication of airbag deployment. Injury-International Journal of the Care of the Injured, 34 (4), 312-315 Keywords: airbag/BAGS/CARE/forearm/fracture/UPPER EXTREMITY INJURIES Bialocerkowski, A.E., Grimmer, K.A. and Bain, G.I. (2000), A systematic review of the content and quality of wrist outcome instruments. International Journal for Quality in Health Care, 12 (2), 149-157. Abstract: Objective. To assess the content and quality of published wrist outcome instruments using standardized criteria. Design. An analytical study that examined 32 wrist outcome instruments sourced from textbooks, Medline (1951 to present) and Current Contents. Main measures. The content of each instrument was classified into four categories: traditional measures (such as range of movement and strength), measures of the ability to perform daily activities, compensatory mechanisms used, and 'other'. Analysis included the frequency of assessment per category and the method of assessment. In addition, each instrument was graded using 13 quality criteria. Three criteria (scientific justification of the content and scoring system used, demographic utility) were considered to be essential. Results. Eighty-two per cent of instruments reviewed for this paper contained traditional measures, of which most were assessed objectively. The ability to perform specific daily activities was assessed in 31% of the instruments whereas compensatory mechanisms were evaluated in only one instrument. These variables were not assessed in a consistent manner. Using the quality scoring system derived for this study, the quality of the instruments was generally poor. Only one instrument fulfilled all of the essential criteria. Only four instruments completely satisfied more than 50% of the criteria. Conclusions. Most wrist outcome instruments neglected to assess the impact of the disorder on the individual. Outcome was generally not expressed in functional terms or in terms that were relevant to each individual. The majority of the reviewed articles had poor quality. Thus use of these instruments may preclude sensitive evaluation of the efficacy of any intervention Keywords: CARE/COLLES FRACTURE/DISTAL RADIUS/EPIDEMIOLOGY/EXTERNAL FIXATION/GENERAL-POPULATION/ HEALTH/health care/impact/INJURIES/outcome/outcome and process assessment/PREVALENCE/quality assurance/research design/review literature/UPPER EXTREMITY/VALIDITY/wrist Duma, S.M., Schreiber, P.H., McMaster, J.D., Crandall, J.R., Bass, C.R. and Pilkey, W.D. (1999), Dynamic injury tolerances for long bones of the female upper extremity. Journal of Anatomy, 194 463-471. Abstract: This paper presents the dynamic injury tolerances for the female humerus and forearm derived from dynamic 3-point bending tests using 22 female cadaver upper extremities. Twelve female humeri were tested at an average strain rate of 3.7, 1.3 %/ s. The strain rates were chosen to be representative of those observed during upper
    • extremity interaction with frontal and side airbags. The average moment to failure when mass scaled for the 5th centile female was 128 +/- 19 Nm. Using data from the in situ strain gauges during the drop tests and geometric properties obtained from pretest CT scans, an average dynamic elastic modulus for the female humerus was found to be 24.4 +/- 3.9 GPa. The injury tolerance for the forearm was determined from 10 female forearms tested at an average strain rate of 3.94 +/- 2.0 %/s. Using 3 matched forearm pairs, it was determined that the forearm is 21% stronger in the supinated position (92 +/- 5 Nm) versus the pronated position (75 +/- 7 Nm). Two distinct fracture patterns were seen for the pronated and supinated groups. In the supinated position the average difference in fracture time between the radius and ulna was a negligible 0.4 +/- 0.3 ms. However, the pronated tests yielded an average difference in fracture time of 3.6 +/- 1.2 ms, with the ulna breaking before the radius in every test. This trend implies that in the pronated position, the ulna and radius are loaded independently, while in the supinated position the ulna and radius are loaded together as a combined structure. To produce a conservative injury criterion, a total of 7 female forearms were tested in the pronated position, which resulted in the forearm injury criterion of 58 +/- 12 Nm when scaled for the 5th centile female. It is anticipated that these data will provide injury reference values for the female forearm during driver air bag loading, and the female humerus during side air bag loading Keywords: air bag/air bags/automobile safety/bone fractures/CT/extremities/extremity/forearm/fracture/humerus/injury/skeletal injury/ulna/upper extremity/upper-extremity Hsiao, E.T. and Robinovitch, S.N. (1998), Common protective movements govern unexpected falls from standing height. Journal of Biomechanics, 31 (1), 1-9. Abstract: Simple energy considerations suggest that any fall from standing height has the potential to cause hip fracture. However, only 1-2% of falls among the elderly actually result in hip fracture, and less than 10% cause serious injury. This suggests that highly effective movement strategies exist for preventing injury during a fall. To determine the nature of these, we measured body segment movements as subjects (aged 22- 35 yr) stood upon a gymnasium mattress and attempted to prevent themselves from falling after the mattress was made to translate abruptly. Subjects were more than twice as likely to fall after anterior translations of the feet, when compared to posterior or lateral translations. In falls which resulted in impact to the pelvis, a complex sequence of upper extremity movements allowed subjects to impact their wrist at nearly the same instant as the pelvis (average time interval between contacts = 38 ms), suggesting a sharing of contact energy between the two body parts. Finally, marked trunk rotation was exhibited in falls due to lateral (but not anterior or posterior) perturbations, resulting in the avoidance of impact to the lateral aspect of the hip. These results suggest that body segment movements during falls, rather than being random and unpredictable, involve a repeatable series of responses which facilitate safe landing. (C) 1998 Elsevier Science Ltd. All rights reserved Keywords: balance/COMMUNITY/elderly/extremity/fall/falls/fracture/hip fracture/HIP-FRACTURES/IMPACT/injury/protective responses/RISK-FACTORS/ upper extremity/upper-extremity/wrist/wrist fracture Chiu, J. and Robinovitch, S.N. (1998), Prediction of upper extremity impact forces during falls on the outstretched hand. Journal of Biomechanics, 31 (12), 1169-1176. Abstract: Among the most common causes of upper extremity fracture is a fall on the outstretched hand. Yet few data exist on the biomechanical factors which affect injury risk during this event. In this study, we measured impact forces during low-
    • height (0-5 cm), forward falls onto the outstretched hand, and found that these are governed by an initial high-frequency peak and a subsequent, lower-frequency oscillation. This behavior was well-simulated by a two-degree-of-freedom, lumped- parameter mathematical model. Increases in body mass caused greater increases in the peak magnitude of the low-frequency component (F-max2) than the high- frequency component (F-max1). However, increases in Fall height more strongly influenced F-max1, which exceeded F-max2 for all but very low fall heights. Model predictions suggest that fall heights greater than 0.6 m carry significant risk for wrist fracture, since above this height, peak fords surpass the average fracture force of the distal radius. Finally, while the shoulder experiences lower peak force than the wrist (since F-max1 is not transmitted proximally), it undergoes considerably greater deflection, and thereby absorbs the majority of impact energy during a fall. (C) 1998 Elsevier Science Ltd. All rights reserved Keywords: DISTAL RADIUS/distal radius fracture/extremity/fall/falls/forward falls/fracture/FRACTURES/hand/HIP/impact/impact force/IN- LINE/injury/mathematical model/RISK/SKATING INJURIES/STRENGTH/trauma/ upper extremity/upper-extremity/WOMEN/wrist DeGoede, K.M. and Ashton-Miller, J.A. (2003), Biomechanical simulations of forward fall arrests: effects of upper extremity arrest strategy, gender and aging-related declines in muscle strength. Journal of Biomechanics, 36 (3), 413-420. Abstract: Computer simulation was used to predict the extent to which age-related muscle atrophy may adversely affect the safe arrest of a forward fall onto the arms. The biomechanical factors affecting the separate risks for wrist fracture or head impact were examined using a two-dimensional, 5-link, forward dynamic model. The hypothesis was tested in older females that age- related loss in muscular strength renders the use of the arms ineffective in arresting a forward fall without either a torso impact exceeding 0.5 m/s or distal forearm loads sufficient to fracture the wrist. The results demonstrate that typical age- related decline in arm muscle strength substantially reduces the ability to arrest a forward fall without the elbows buckling and, therefore, a risk of torso and/or head impact. The model predicted that older women with below-average bone strength risk a Colles fracture when arresting typical falls, particularly with an extended arm. (C) 2003 Elsevier Science Ltd. All rights reserved Keywords: AGE/bone/DISTAL RADIUS/extremity/fall/falls/forearm/fracture/impact/IMPACT FORCE/injury/LOAD/OSTEOPOROTIC FRACTURES/OUTSTRETCHED HAND/PREDICTION/simulation/STIFFNESS/UNEXPECTED FALLS/upper extremity/upper-extremity/wrist/wrist fracture/WRIST FRACTURES Alman, B.A., Debari, A. and Krajbich, J.I. (1995), Massive Allografts in the Treatment of Osteosarcoma and Ewing Sarcoma in Children and Adolescents. Journal of Bone and Joint Surgery-American Volume, 77A (1), 54-64. Abstract: A retrospective review was performed of the results of all allograft reconstructions that had been done after the resection of an osteosarcoma or an Ewing sarcoma in a skeletally immature patient between 1982 and 1989 at The Hospital for Sick Children in Toronto. There were twenty-six patients. Six reconstructions were intercalary, sixteen were resection arthrodeses, three followed resection of a bone segment including the epiphysis (osteoarticular reconstruction), and one was a replacement of the entire humerus. Resection arthrodesis about the knee was performed with a smooth intramedullary rod and with one growth plate left intact, Six procedures were performed in the upper extremity. Excluding the patients
    • who died, the average duration of follow-up was five years and three months, Twenty-one of the twenty-six patients had reached skeletal maturity at the time of follow-up. Eighteen (69 per cent) of the patients had a good or excellent result, four (15 per cent) had a fair result, and four had a failure. Twenty patients (77 per cent) had at least one complication (other than a limb-length discrepancy), and fourteen (54 per cent) sustained at least one fracture of the allograft. Fifteen patients who had had a reconstruction in the lower extremity had survived with survival of the allograft at the time of the latest follow-up. A limb-length discrepancy of at least two centimeters developed in nine of the fifteen patients. Five were managed with a contralateral epiphyseodesis, and one of them had an unsuccessful attempt at limb- lengthening as well. The patients who had a limb-length discrepancy of more than three centimeters at the time of follow-up had been significantly younger (p < 0.05) at the time of the reconstruction than those who had a smaller discrepancy. Three allografts (12 per cent), two of which were implanted early in the series, became infected. Soft-tissue coverage is of paramount importance for the prevention of infection, and we now routinely perform primary muscle (gastrocnemius or latissimus dorsi) transfers when dealing with an inadequate muscle envelope. Twelve patients were followed for more than four years (average, six Sears and seven months); they had no complications other than increased limb-length discrepancy and one subluxation of the shoulder after the first four years following the reconstruction. Although the rate of complications is higher than in adults, allograft reconstruction remains a useful option for the management of skeletally immature individuals. Its use in the lower extremity should be reserved for patients in whom limb-length inequality can be treated easily Keywords: allograft/BONE/BONE SARCOMAS/extremity/fracture/humerus/JOINT/MANAGEMENT/prevention/TRA NSPLANTATION/TUMORS/upper extremity/upper-extremity Eskola, A., Santavirta, S., Viliakka, T., Wirta, J., Partio, E. and Hoikka, V. (1996), The results of operative resection of the lateral end of the clavicle. Journal of Bone and Joint Surgery-American Volume, 78A (4), 584-587. Abstract: Seventy-three patients had operative resection of the lateral end of the clavicle for the treatment of a painful condition of the acromioclavicular joint. Thirty-two of the patients had had a traumatic separation of the acromioclavicular joint, eight had had a fracture of the lateral end of the clavicle, and thirty-three had primary acromioclavicular osteoarthrosis. An average of sixteen millimeters (range, five to thirty-seven millimeters) was resected; the amount was similar in each of the three groups. The patients were evaluated an average of nine years (range, four to sixteen years) after the operation. The result was considered good in twenty-one patients, satisfactory in twenty-nine, and poor in twenty-three. A poor result was more common in the patients who had had a fracture of the lateral end of the clavicle (p < 0.01), Forty-six patients reported pain with exertion, and thirteen noted pain at rest. Eighteen patients had a decrease in the strength of the involved upper extremity and sixteen had some limitation of the mobility of the shoulder. Elevation of the lateral end of the remaining part of the clavicle as compared with the scapula was noted in eighteen patients and was more likely to be associated with pain (p < 0.05). The extent of the resection was significantly associated with pain; patients who had had a smaller amount of resection (ten millimeters or less) had less pain than those who had had a larger amount (p < 0.03). A good result was more common in the patients in whom less than ten millimeters had been resected and who had had a previous traumatic separation of the acromioclavicular joint or had primary acromioclavicular
    • osteoarthrosis. We recommend that resection of the lateral end of the clavicle be considered with caution for patients who have severe post-traumatic or degenerative osteoarthrosis of the acromioclavicular joint. If resection is performed, it should not exceed ten millimeters Keywords: BONE/clavicle/extremity/fracture/JOINT/scapula/treatment/upper extremity/upper-extremity Jupiter, J.B., Fernandez, D.L., Toh, C.L., Fellman, T. and Ring, D. (1996), Operative treatment of volar intra-articular fractures of the distal end of the radius. Journal of Bone and Joint Surgery-American Volume, 78A (12), 1817-1828. Abstract: We retrospectively reviewed the results of operative treatment of forty-nine volar marginal intra-articular fractures of the distal end of the radius. According to the Comprehensive Classification of Fractures, there were two B3.1 fractures (characterized by a small volar fragment, with the sigmoid notch intact), three B3.2 fractures (characterized by a large volar fragment that included the sigmoid notch), and forty-four B3.3 fractures (characterized by comminution of the volar fragment). Although all fractures healed and only nine patients had evidence of osteoarthrosis on follow-up radiographs, there were six early and fourteen late complications, some of which adversely influenced the over-all outcome, After an average of fifty-one months (range, twenty-four to 117 months), there were thirty-one excellent, ten good, and eight fair results according to the system described by Gartland and Werley, and thirty-two excellent, nine good, five fair, and three poor results according to the modified system of Green and O'Brien. Two factors were found to have a significant association with a fair or poor outcome: evidence of osteoarthrosis on the most recent follow-up radiographs and reversal of the normal volar tilt of the distal end of the radius. The age of the patient, the interval from the injury to the operation, a concomitant injury of the ipsilateral upper extremity, an associated fracture of the ulnar styloid process, the radio-ulnar index, ulnar angulation, the classification of the fracture, comminution of the volar fragment, and articular incongruity were not significantly associated with the outcome Keywords: BONE/CLASSIFICATION/extremity/fracture/fractures/injury/JOINT/outcome/radio graphs/treatment/upper extremity/upper-extremity Deibert, M.C., Aronsson, D.D., Johnson, R.J., Ettlinger, C.F. and Shealy, J.E. (1998), Skiing injuries in children, adolescents, and adults. Journal of Bone and Joint Surgery-American Volume, 80A (1), 25-32. Abstract: We prospectively gathered data on skiing injuries that had been sustained at the Sugarbush North ski area since 1972 and at the Sugarbush South ski area since 1981. The purpose of the current study was to document the overall rates of injury in children, adolescents, and adults participating in alpine skiing. We also sought to determine the ten most common injuries in each age- group. Finally, we analyzed short-term and long-term trends to determine if changes in equipment had had an effect on the frequency or pattern of injury. From the 1981-1982 to the 1993- 1994 season, there were 2.79 injuries per 1000 skier days: 4.27 injuries in children, 2.93 in adolescents, and 2.69 in adults. During the last eight years of the study, the most common injuries were a contusion of the knee in children, a sprain of the ulnar collateral ligament of the thumb in adolescents, and a grade-III sprain of the anterior cruciate ligament in adults. The short-term trends revealed that, in children, the frequency of tibial fractures decreased 10 per cent while that of fractures of the upper extremity increased 8 per cent. The long-term trends showed that, in adults, the rate of tibial fractures decreased 89 per cent while that of injuries of the anterior cruciate
    • ligament increased 280 per cent. The overall rate of injury decreased 43 per cent from the beginning of the study in 1972 to the end of the study in 1994; the decrease was 58 per cent in children, 45 per cent in adolescents, and 42 per cent in adults. Data on the types of equipment and the binding- release values were collected prospectively from injured skiers and from 2083 non-injured skiers. Of the fifty-nine skiers who sustained a spiral fracture of the tibia, forty-two (71 per cent) had binding-release values that were higher than the average for the uninjured group. We believe that the use of properly functioning modern equipment will decrease the rate of injury, particularly in children Keywords: BONE/children/EQUIPMENT/extremity/fracture/fractures/injuries/injury/JOINT/ski /upper extremity/upper-extremity Gill, D.R.J., Cofield, R.H. and Morrey, B.F. (1999), Ipsilateral total shoulder and elbow arthroplasties in patients who have rheumatoid arthritis. Journal of Bone and Joint Surgery-American Volume, 81A (8), 1128-1137. Abstract: Background: The data on seventeen patients with rheumatoid arthritis who had been managed with ipsilateral total shoulder and elbow arthroplasties were analyzed to determine whether the operative technique, the presence of total shoulder and total elbow prostheses in the same upper extremity, or complications of the arthroplasties affected the result in each joint or the overall functional outcome of the upper extremity. Methods: Seventeen patients with rheumatoid arthritis who were managed with a total of eighteen ipsilateral total shoulder and elbow arthroplasties were evaluated. The most recent physical examination was at an average of six years and six months (range, two years and one month to fourteen years) postoperatively. Radiographs, including 40-degree oblique and axillary radiographs of the shoulder as well as anteroposterior and lateral radiographs of the elbow, were made at an average of six years and eleven months (range, two years and two months to twenty-two years and eleven months) postoperatively. The radiographs of the shoulder were examined for loosening of the glenoid component, glenohumeral subluxation, and radiolucency at the bone-cement or bone-implant interface. The functional results of the total shoulder arthroplastics were evaluated with use of the rating systems of Neer ct al. and Cofield. The Mayo elbow-performance score was used to evaluate elbow function. A rating system was also developed to assess the overall function of the upper extremity, including pain and motion of both the elbow and the shoulder. With this system, the overall function of the upper extremity was rated as excellent, good, fair, or poor. Results: Evaluation of the shoulders revealed substantial relief of pain and an increase in active elevation. On radiographic evaluation, eight glenoid and five humeral components were considered to be loose. There were no reoperations. According to the rating system of Neer et al., eight shoulders had a satisfactory result and eight had an unsatisfactory result with limited active abduction. Limited- goals rehabilitation was successful after one shoulder arthroplasty and unsuccessful after another There were two type-B periprosthetic humeral fractures. There was also substantial relief of pain in the elbows as well as an increase in the extension-flexion are; the. pronation-supination are was sufficient for tasks of daily living. There was no radiographic loosening. Two elbows had an avulsion of the triceps, and two had aseptic loosening (one of which also had a worn bushing); all four needed a reoperation. One other elbow had persistent ulnar neuritis. The average interval between the arthroplasties was two years and eight months when the shoulder was replaced first and three years and five months when the elbow was replaced first. The interval between the joint replacements and the
    • sequence of the joint replacements were not found to influence the outcome. Function of the extremity was improved by replacement of either the shoulder or the elbow alone; however, it improved significantly only when both joints were replaced (p = 0.03). According to combined clinical outcomes scores, there were nine excellent outcomes, four good outcomes, four fair outcomes, and one poor outcome after ipsilateral total shoulder and elbow arthroplasties. Conclusions: When there is severe arthritis of both the shoulder and the elbow, consideration should be given to replacing both joints in order to obtain optimum functional and clinical outcomes. The possibility of fracture of the humeral shaft necessitates an alteration of the technique for ipsilateral total shoulder and elbow arthroplasties Keywords: BONE/elbow/EXPERIENCE/extremity/fracture/fractures/outcome/outcomes/PROS THESIS/radiographs/rehabilitation/REPLACEMENT/upper extremity/upper- extremity Mehlman, C.T., Scott, K.A., Koch, B.L. and Garcia, C.F. (2000), Orthopaedic injuries in children secondary to airbag deployment. Journal of Bone and Joint Surgery- American Volume, 82A (6), 895-898 Keywords: BAGS/BONE/children/DEATHS/FATAL INJURIES/FRACTURE/injuries/ PATTERNS/UPPER EXTREMITY INJURIES Moro, J.K., Werier, J., MacDermid, J.C., Patterson, S.D. and King, G.J.W. (2001), Arthroplasty with a metal radial head for unreconstructible fractures of the radial head. Journal of Bone and Joint Surgery-American Volume, 83A (8), 1201-1211. Abstract: Background: Treatment of unreconstructible comminuted fractures of the radial head remains controversial. There is limited information on the outcome of management of these injuries with arthroplasty with a metal radial head implant. Methods: The functional outcomes of arthroplasties with a metal radial head implant for the treatment of twenty-five displaced, unreconstructible fractures of the radial head in twenty-four consecutive patients (mean age, fifty-four years) were evaluated at a mean of thirty-nine months (minimum, two years). There were ten Mason type- III and fifteen Mason-Johnston type- IV injuries. Two of these injuries were isolated, and twenty- three were associated with other elbow fractures and/or ligamentous injuries. Results: At the time of follow-up, Short Form-36 (SF-36) summary scores suggested that overall health- related quality of life was within the normal range (physical component = 47 +/- 10, and mental component = 49 +/- 13). Other outcome scales indicated mild disability of the upper extremity (Disabilities of the Arm, Shoulder and Hand score = 17 +/- 19), wrist (Patient-Rated Wrist Evaluation score = 17 +/- 21 and Wrist Outcome Score = 60 +/- 10), and elbow (Mayo Elbow Performance Index = 80 +/- 16). According to the Mayo Elbow Performance Index, three results were graded as poor; five, as fair; and seventeen, as good or excellent. The poor and fair outcomes were associated with concomitant injury in two patients, a history of a psychiatric disorder in three, comorbidity in two, a Workers' Compensation claim in two, and litigation in one. Subjective patient satisfaction averaged 9.2 on a scale of 1 to 10. Elbow flexion of the injured extremity averaged 140 degrees +/- 9 degrees; extension, -8 degrees +/- 7 degrees; pronation, 78 degrees +/- 9 degrees; and supination, 68 degrees +/- 10 degrees. A significant loss of elbow flexion and extension and of forearm supination occurred in the affected extremity, which also had significantly less strength of isometric forearm pronation (17%) and supination (18%) as well as significantly less grip strength (p < 0.05). Asymptomatic bone lucencies surrounded the stem of the implant in seventeen of the twenty-five elbows. Valgus stability was restored, and proximal radial migration did not occur.
    • Complications, all of which resolved, included one complex regional pain syndrome, one ulnar neuropathy, one posterior interosseous nerve palsy, one episode of elbow stiffness, and one wound infection. Conclusions: Patients treated with a metal radial head implant for a severely comminuted radial head fracture will have mild-to- moderate impairment of the physical capability of the elbow and wrist. At the time of short-term followup, arthroplasty with a metal radial head implant was found to have been a safe and effective treatment option for patients with an unreconstructible radial head fracture; however, long-term follow-up is still needed Keywords: BONE/ELBOW/extremity/forearm/fracture/fractures/injuries/injury/outcome/outcom es/pronation/REPLACEMENT/STABILITY/supination/treatment/upper extremity/upper-extremity/wrist Heitmann, C., Erdmann, D. and Levin, L.S. (2002), Treatment of segmental defects of the humerus with an osteoseptocutaneous fibular transplant. Journal of Bone and Joint Surgery-American Volume, 84A (12), 2216-2223. Abstract: Background: There are limited reconstructive options for the treatment of segmental bone defects of the upper extremity that are >6 cm in length, especially those that are associated with soft-tissue defects. The purpose of the present review was to report on our experience with fifteen patients who received an osteoseptocutaneous fibular transplant for reconstruction of a humeral defect. Methods: The study cohort included eight male patients and seven female patients with an average age of forty-one years. The indications for the procedure included segmental nonunion (nine patients), a gunshot wound (three), a defect at the site of a tumor resection (two), and failure of an allograft-prosthesis reconstruction (one). The fibular graft was fixed by means of intramedullary impaction in eleven patients, was used as an onlay graft in three, and was used as a strut between the intact diaphysis and the humeral head in one. Results: The average length of the segmental humeral defect was 9.3 cm. The average length of the fibular graft was 16.1 cm, and the average length and width of the skin paddle were 8.1 and 4.5 cm. The average duration of follow-up was twenty-four months. Three patients had venous thrombosis and underwent a successful revision of the anastomosis. Four patients had early failure of graft fixation. Three patients had a fracture of the fibular graft within the first year postoperatively. All but one of these latter seven patients were successfully treated with open reduction, internal fixation, and additional bone-grafting. One patient with an infection at the site of a nonunion and signs of graft resorption required a second fibular transplant. Conclusions: The osteoseptocutaneous fibular transplant is an effective treatment for combined segmental osseous and soft-tissue defects of the arm. However, the application of this technique to the arm is more complex than application to the forearm and is associated with a higher rate of complications Keywords: BONE/DONOR-SITE MORBIDITY/extremity/FLAP/forearm/fracture/humerus/RECONSTRUCTION/TR ANSFERS/treatment/UPPER EXTREMITY/upper-extremity/VASCULARIZED BONE-GRAFTS Mckee, M.D., Wild, L.M. and Schemitsch, E.H. (2003), Midshaft malunions of the clavicle. Journal of Bone and Joint Surgery-American Volume, 85A (5), 790-797. Abstract: Background: The purpose of this study was to analyze the functional results of corrective osteotomy of a malunited clavicular fracture in patients with chronic pain, weakness, neurologic symptoms, and dissatisfaction with the appearance of the shoulder. Methods: We identified fifteen patients (nine men and six women with a
    • mean age of thirty-seven years) who had a malunion following nonoperative treatment of a displaced midshaft fracture of the clavicle. The mean time from the injury to presentation was three years (range, one to fifteen years). Outcome scores revealed major residual deficits. The mean amount, of clavicular shortening was 2.9 cm (range, 1.6 to 4.0 cm). All patients underwent corrective osteotomy of the malunion through the original fracture line and internal fixation. Results: At the time of follow-up, at a mean of twenty months (range, twelve to forty-two months) postoperatively, the osteotomy site had united in fourteen of the fifteen patients. All fourteen patients expressed satisfaction with the result. The mean DASH (Disabilities of the Arm, Shoulder and Hand) score for all fifteen patients improved from 32 points preoperatively to 12 points at the time of follow-up (p = 0.001). The mean shortening of the clavicle improved from 2.9 to 0.4 cm (p = 0.01). There was one nonunion, and two patients had elective removal of the plate. Conclusions: Malunion following clavicular fracture may be associated with orthopaedic, neurologic, and cosmetic complications. In selected cases, corrective osteotomy results in a high degree of patient satisfaction and improves patient- based upper-extremity scores. Level of Evidence: Therapeutic study, Level I (case series [no, or historical, control group]). See Instructions to Authors for a complete description of levels of evidence Keywords: BONE/clavicle/fracture/FRACTURED CLAVICLE/injury/JOINT/OUTLET SYNDROME SECONDARY/treatment/upper extremity/upper-extremity Nakamizo, A., Inamura, T., Amano, T., Inoha, S., Tokuda, K., Yasuda, O., Ikezaki, K. and Fukui, M. (2002), Decreased thalamic metabolism without thalamic magnetic resonance imaging abnormalities following shearing injury to the substantia nigra. Journal of Clinical Neuroscience, 9 (6), 685-688. Abstract: A 36-year-old man had fallen about 8 metres. Radiographs showed a mandibular fracture, indicating rotatory force applied to the head. Fluid-attenuated inversion recovery (FLAIR) imaging showed hyperintensity in both medial temporal lobes, left medial midbrain, right midbrain including cerebral peduncle, left pulvinar, left external capsule, fornix, splenium of corpus callosum, and deep white matter of both frontal lobes. Quantitative [F-18]fluoro-deoxyglucose (FDG)-positron emission tomography (PET) indicated markedly suppressed glucose metabolism in the left thalamus but not markedly in the striatum. At that time the neurologic examination demonstrated complete left hemiparesis, severe rigidity of the right upper extremity, and inability to move the right hand and fingers. Levodopa at 300-600mg/day improved movement of the fingers, decreased the rigidity in the extremity, and lessened the metabolic abnormality. Diminished metabolism in the left thalamus may have contributed to symptoms. The case illustrates the usefulness of PET in disclosing symptom causing abnormalities not detected by magnetic resonance imaging. (C) 2002 Elsevier Science Ltd. All rights reserved Keywords: BRAIN-STEM HEMORRHAGE/COMPUTERIZED- TOMOGRAPHY/CROSSED CEREBELLAR DIASCHISIS/DAMAGE/DIFFUSE AXONAL INJURY/diffuse axonal injury/extremity/fracture/hand/HEMIPLEGIA/injury/LESIONS/levodopa/PARASA GITTAL WHITE-MATTER/positron emission tomography (PET)/rigidity/SEVERE HEAD- INJURY/shearing injury/substantia nigra/upper extremity/upper-extremity Seitz, W.H. and Froimson, A.I. (1991), Callotasis Lengthening in the Upper Extremity - Indications, Techniques, and Pitfalls. Journal of Hand Surgery-American Volume, 16A (5), 932-939. Abstract: Bone lengthening through callotasis has been performed in 12 bones of the
    • upper extremity in eight patients. Diagnoses included congenital amputations, phocomelia, radial agenesis, traumatic amputations, and infected fracture with bone loss. Nine of the 12 procedures resulted in complete consolidation of the transport gap with new bone without need for bone graft. One patient died of unrelated illness before completion of treatment but demonstrated early consolidation of the gap. In two cases bone graft was required. Complications included one superficial pin tract infection and one case of premature cessation of lengthening because of hand deviation. Early experience with this technique indicates that it is effective in the management of bone defects in the upper extremity. It appears that in most cases a half-frame lengthening device, rather than a more complex circular frame, can be used in the non-weight-bearing upper extremity. Adequate control of the distal segment, appropriate choice of location for corticotomy, and gentle handling of the bone and periosteum can improve results and minimize complications Keywords: bone/extremity/fracture/HAND/treatment/upper extremity/upper-extremity Ishizuki, M. and Furuya, K. (1991), Clinical-Application of Sapphire Pins As An Internal-Fixation Device for the Upper Extremity. Journal of Hand Surgery- American Volume, 16A (5), 922-928. Abstract: Since June 1980, sapphire pins (monocrystalline alumina ceramic pins) have been used in 22 patients as an internal fixation device for hand and elbow problems. In our follow-up studies, good bone healing was observed in all cases except for one delayed union in a fracture of the diaphysis of the proximal phalanx. Radiographs showed no pin migration or osteolytic reaction around the pins. We therefore conclude that our device and its insertion technique can be successfully applied to intraarticular fractures and fractures in the vicinity of the joint Keywords: bone/elbow/fracture/fractures/HAND Wright, T.W. and Glowczewskie, F. (1998), Vascular anatomy of the ulna. Journal of Hand Surgery-American Volume, 23A (5), 800-804. Abstract: The vascular anatomy of the ulna was studied. Ten fresh-frozen upper extremity specimens were injected with India ink and latex solution. The extraosseous anatomy was dissected. The intraosseous anatomy was evaluated after treatment with the modified Spalteholtz technique. The proximal periarticular portion of the ulna was supplied by numerous, very small periarticular branches running in the capsule. A major intramedullary nutrient vessel arose from the ulnar artery or ulnar recurrent artery in all specimens and entered at the base of the coronoid. The ulnar artery gave off a common interosseous artery that branches into posterior and anterior interosseous vessels that course distally on the interosseous membrane. The interosseous vessels were critical for they supply the only observed vascular branches to the ulna diaphysis. The anterior interosseous vessel supplied on average 7 branches (range, 3-11 branches) to the ulna diaphysis spaced at generally regular 2- cm intervals, with the number of branches decreasing in the distal third. The posterior interosseous artery supplied an average of 11 branches (range, 9-14 branches) to the ulna diaphysis spaced at l-cm intervals. The distal ulna metaphysis was supplied by terminal branches of the anterior interosseous artery. The ulnar head was supplied by small branches off the ulnar artery proper. In summary, the blood supply to the ulna diaphysis was dependent on segmental vessels provided by the anterior and posterior interosseous vessels. No dominant intramedullary vessel was observed in the diaphysis. The interosseous vessels should be protected when treating a ulna Fracture or a nonunion, or when performing an osteotomy. Copyright (C) 1998 by the American Society For Surgery oi the Hand Keywords: extremity/HAND/treatment/ulna/upper extremity/upper-extremity
    • Bickley, M.B.T. and Hanel, D.P. (1998), Self-tapping versus standard tapped titanium screw fixation in the upper extremity. Journal of Hand Surgery-American Volume, 23A (2), 308-311. Abstract: Most screws used in fracture fixation necessitate a separate step for tapping of the screw hole. Titanium screw systems have been developed in which the screws can be inserted directly after a drill hole is made. These self-tapping screws thereby eliminate an operative step. A retrospective study was conducted that evaluated all wrist and hand procedures performed between January 1992 and December 1994 by 1 surgeon using screw fixation. The results of 39 cases treated with standard tapped titanium screws were compared with 28 cases treated with self-tapping titanium screws. Nearly identical union and complication rates were obtained in each group. Comparable results can be obtained with self-tapping screw fixation, which limits the number of instruments needed, eliminates an operative step, and thereby may diminish operative risk and shorten operative time. Copyright (C) 1998 by the American Society for Surgery of the Hand Keywords: extremity/fracture/FRACTURES/HAND/SYSTEMS/upper extremity/upper- extremity/wrist Kay, R.M. and Kuschner, S.H. (1999), Bilateral proximal radial and scaphoid fractures in a child. Journal of Hand Surgery-British and European Volume, 24B (2), 255-257. Abstract: A 13-year-old boy fell and suffered concomitant bilateral fractures of the proximal radius and scaphoid. Ipsilateral fractures of the proximal radius and scaphoid have been reported only once previously in a child, and never bilaterally. This article reviews paediatric proximal radial fractures and scaphoid fractures and their associated injuries. This report underlines the importance of examining for other injuries when a child presents with an apparently isolated upper extremity fracture Keywords: child/extremity/fracture/fractures/HAND/injuries/NECK FRACTURES/upper extremity/upper-extremity Chung, K.C. and Spilson, S.V. (2001), The frequency and epidemiology of hand and forearm fractures in the United States. Journal of Hand Surgery-American Volume, 26A (5), 908-915. Abstract: The purpose of this study was to estimate the frequency and describe the epidemiology of hand and forearm fractures in the United States. We extracted cases with ICD-9-CM diagnostic codes of 813.0 to 817.1 from the 1998 National Hospital Ambulatory Medical Care Survey. In 1998 there were 1,465,874 estimated cases of hand/forearm fractures, accounting for 1.5% of all emergency department cases. Radius and/or ulna fractures comprised the largest proportion of fractures (44%). The most affected age group was 5 to 14 years of age (26%). Private insurance paid for 49% of the cases. Most of the fractures occurred at home (30%); the street/highway was the second most likely fracture location (14%). Accidental falls caused the majority (47%) of fractures. Large database analysis provides important information that can be used to target interventions toward vulnerable populations and to allocate adequate resources for treating upper extremity fractures. Copyright (C) 2001 by the American Society for Surgery of the Hand Keywords: EMERGENCY/emergency department/epidemiology/extremity/falls/forearm/fracture/fractures/hand/hand fractures/INJURIES/large database analysis/ulna/upper extremity/upper extremity fractures/upper-extremity/VISITS Bruyns, C.N.P., Jaquet, J.B., Schreuders, T.A.R., Kalmijn, S., Kuypers, P.D.L. and Hovius, S.E.R. (2003), Predictors for return to work in patients with median and
    • ulnar nerve injuries. Journal of Hand Surgery-American Volume, 28A (1), 28-34. Abstract: Purpose: One of the consequences of median and ulnar nerve trauma is delayed return to work. The aim of this study was to determine return to work (RTW) and risk factors for delayed RTW in addition to time off work (TOW). Differences among median, ulnar, and combined median-ulnar nerve injuries were examined. Methods: In this study 96 patients who were employed at the time of injury and who had undergone surgery for median, ulnar, or combined nerve injuries between 1990 and 1998 were evaluated. The response rate was 84% (n = 81). Results: Within 1 year after injury, 59% (n = 48) returned to work. Mean TOW was 31.3 weeks. Return to work after combined nerve injuries was 24% versus after isolated median (80%) and ulnar (59%) nerve injuries. Level of education, type of job, and compliance to hand therapy were predictors for RTW. Furthermore, grip- strength loss, tip pinch strength loss, and sensory recovery differed strongly between the RTW and no-RTW population. Conclusions: The predictors found in this study increase our understanding of delayed RTW after median and ulnar nerve injury and may be used to optimize postinjury rehabilitation. Copyright (C) 2003 by the American Society for Surgery of the Hand Keywords: DISABILITY/DISORDERS/FRACTURE/HAND/injuries/injury/median/nerve injury/OUTCOMES/predictors/PRODUCTIVITY/rehabilitation/RTW/TRAUMA/ul nar/UPPER EXTREMITY Sim, E. (1995), Vertical Facet Splitting - A Special Variant of Rotary Dislocations of the Cervical-Spine. Journal of Neurosurgery, 82 (2), 239-243. Abstract: A special variant of rotary displacement of the cervical spine with vertical splitting of an inferior articular process by its articulating partner is reviewed. Eighteen patients with unilaterally locked facet joints confirmed by computerized tomography were seen between 1986 and 1991. Five patients presented with vertical split fractures of an inferior articular process by impaction of the superior process of the subjacent vertebra. This specific fracture pattern is not accounted for in current classifications. Four males and one female with a mean age of 31 years (range 16 to 49 years) were affected. Three of the patients showed no neurological deficits. One patient presented with cerebral contusion and paresis of the right upper extremity, and in one patient the posterior funiculus was involved. Three of the injuries had been sustained recently; the other two were of longer duration. Surgical treatment was chosen in the three cases of recent injury. In two cases surgery was prompted by neurological deficits; in the third case impaction was felt to be of inadequate depth. Surgery consisted in fracture reduction and interbody fusion using plates. The two cases of longterm fractures were treated conservatively, and ankylosis of the facet joints eventually provided adequate stability. If radicular or spinal symptoms are absent, this special variant of locked facet joints can successfully be treated conservatively leaving the rotary displacement uncorrected, provided impaction is adequately deep. The author's experience has shown that indications for surgical management are relative rather than absolute in this fracture variant and that use of computerized tomography is essential to establish the fracture pattern Keywords: CERVICAL SPINE/CLASSIFICATION/DIAGNOSIS/extremity/FACET SPLITTING/fracture/FRACTURES/INJURIES/injury/INSTABILITY/surgical management/treatment/TREATMENT EVALUATION/upper extremity/upper- extremity/VARIANT OF DISLOCATION Guiot, B. and Fessler, R.G. (1999), Complex atlantoaxial fractures. Journal of Neurosurgery, 91 (2), 139-143.
    • Abstract: Object. The authors conducted a retrospective study to evaluate the treatment of complex C1-2 fractures. Methods. There were 10 cases of complex C1-2 fractures. Six patients were men (median age 58 years) and four patients were women (median age 55.5 years). Injuries resulted from seven falls, two motor vehicle accidents, and one diving incident. Three patients suffered from upper-extremity weakness. Neurological function in seven patients was intact preoperatively. Fracture combinations included six Jefferson/Type II odontoid, two anterior ring/Type II odontoid, one posterior ring/Type II odontoid, and one posterior ring/Type III odontoid/Type III hangman's fracture. All patients underwent surgery, five after halo immobilization for an average of 4 months failed to provide stability. Treatment included placement of six odontoid screws, one posterior C1-2 transarticular screw, one odontoid screw with anterior C1-2 transarticular screw fixation, one C1-2 transarticular screw with C1-2 Songer cable fusion, and one odontoid screw with bilateral C-2 pedicle screw fixation. Specific treatment was determined by the combination of fractures. Postoperatively, all patients were immobilized in a hard collar for 3 months. There were no intraoperative surgery- related complications. The mean follow-up period was 28.5 months. Neurological recovery was observed in one of three patients who presented with neurological deficits. Fusion occurred in all cases. Conclusions. The goals in treating these complex fractures are to achieve early maximum stability and minimum reduction in range of motion. These are often competing phenomena. Frequently in cases of atlas-axis fracture, odontoid screw fixation combined with hard collar immobilization is the best therapy, provided the transverse atlantal ligament is competent. If not, C1-2 stabilization with placement of transarticular screws is required for best results Keywords: atlas/axis/cervical spine injury/CERVICAL- SPINE/falls/FIXATION/fracture/fractures/INJURIES/LIGAMENT/MANAGEMEN T/motor vehicle/treatment/upper extremity/upper-extremity Mayr, M.T., Subach, B.R., Comey, C.R.H., Rodts, G.E. and Haid, R.W. (2002), Cervical spinal stenosis: outcome after anterior corpectomy, allograft reconstruction, and instrumentation. Journal of Neurosurgery, 96 (1), 10-16. Abstract: Object. The authors undertook a retrospective single- institution review of 261 patients who underwent anterior cervical corpectomy, reconstruction with allograft fibula, and placement of an anterior plating system for the treatment of cervical spinal stenosis to assess fusion rates and procedure- related complications. Methods. Between October 1989 and June 1995, 261 patients with cervical stenosis underwent cervical corpectomy, allograft fibular bone fusion, and placement of instrumentation for spondylosis (197 patients), postlaminectomy kyphosis (27 patients), acute fracture (25 patients), or ossification of the posterior longitudinal ligament ( 12 patients). All patients suffered neck pain and cervical myelopathy or radiculopathy refractory to medical management. Of the procedures, 133 involved a single vertebral level (two disc levels and one vertebral body). 96 involved two levels. 31 involved three levels, and a single patient underwent a four- level procedure. Clinical and radiographic outcomes were assessed postoperatively and at 6-month intervals. The mean follow-up period was 25.7 months (range 24-47 months). Successful fusion was documented in 226 patients (86.6%). A stable. fibrous union developed in 33 asymptomatic patients (12.6%), whereas an unstable pseudarthrosis in two patients (0.8%) required reoperation. There were no cases of infection, spinal fluid leakage, or postoperative hematoma. Complications included transient unilateral upper-extremity weakness (two patients), dysphagia (35 transient and seven permanent), and hoarseness (35 transient and two permanent). In 14 patients (5.4%)
    • radiological studies demonstrated evidence of hardware failure, Conclusions. Cervical corpectomy with fibular allograft reconstruction and anterior plating is an effective means of achieving spinal decompression and stabilization in cases of anterior cervical disease, Symptomatic improvement was achieved in 99.2% of patients. In their series the authors found a fusion rate of 86.6% and rates of permanent hoarseness of 3.4%, dysphagia of 0.7%, and an instrumentation failure rate of 5.4% Keywords: acute/allograft/BONE/CASPAR/cervical spine/cervical spondylosis/COMPLICATIONS/corpectomy/FIBULAR ALLOGRAFT/FIXATION/ fracture/INTERBODY FUSION/OSTEOSYNTHESIS/outcome/outcomes/PLATE/spinal fusion/SPONDYLOTIC MYELOPATHY/STABILIZATION/treatment/upper extremity/upper-extremity Ostermann, P.A.W., Ekkernkamp, A., Henry, S.L. and Muhr, G. (1994), Bracing of Stable Shaft Fractures of the Ulna. Journal of Orthopaedic Trauma, 8 (3), 245-248. Abstract: In the laboratory an ulnar osteotomy was performed in 10 cadaveric specimens, which included 5 distal-third junctions and 5 middle-third junctions. The interosseous membrane was left intact. Each specimen was rotated through full pronation and full supination. Displacement less than half shaft width was considered stable. The interosseous membrane was subsequently released 2 cm proximal and 2 cm distal to the osteotomy. Repeated pronation and supination range of motion documented gross displacement greater than half of the width of the shaft and was diagnosed as unstable. To evaluate this hypothesis, a clinical trial of 30 stable ulnar shaft fractures of the middle and distal thirds were treated with functional bracing between 1984 and 1990. A simple protocol was followed: A long arm cast was applied for approximately 5-7 days until the patient experienced only mild pain. At 5-7 days, a prefabricated forearm brace was fitted and the patient began physical therapy, advancing the upper extremity to full functional use. The bracing was continued until radiographic union had occurred. Twenty-nine clinical cases were evaluated to fracture union. The mean time to union was 7.3 weeks (range: 6-9 weeks). One delayed union was reported in the series. At 16 weeks surgical intervention was recommended and an open reduction and internal fixation with cancellous bone grafting was performed. Twenty-nine patients regained full range of motion, and one had limited supination/pronation due to a previous injury of the radial head. In conclusion, functional bracing of stable ulnar shaft fractures leads to a high incidence of fracture union and achieves good to excellent functional results. The success of this technique is dependent on the proper selection of a stable ulnar fracture as related to the integrity of the interosseous membrane Keywords: bone/BRACING/extremity/forearm/fracture/fractures/injury/pronation/shaft fractures/STABLE UNSTABLE FRACTURES/supination/TRAUMA/ULNAR SHAFT FRACTURES/upper extremity/upper-extremity MacDermid, J.C., Turgeon, T., Richards, R.S., Beadle, M. and Roth, J.H. (1998), Patient rating of wrist pain and disability: A reliable and valid measurement tool. Journal of Orthopaedic Trauma, 12 (8), 577-586. Abstract: Objective: The goal of this study was to develop a reliable and valid tool for quantifying patient-rated wrist pain and disability. Design: Survey, tool development, reliability, and validity study. Setting: Upper extremity unit. Participants: One hundred members of the International Wrist Investigators were surveyed by mail to assist in development of the scale. Patients with distal radius (ra = 64) or scaphoid (n = 35) fractures were enrolled in a reliability study, and 101 patients with distal radius
    • fractures were enrolled in a validity study. Intervention: Information from the expert survey, biomechanical literature, and patient interviews was used as a basis for item generation and definition of structural limitations for a scale that would be practical in the clinic. Patients with distal radius or scaphoid fractures completed the Patient- Rated Wrist Evaluation (PRWE) on two occasions to determine test-retest reliability. Patients with distal radius fractures (n = 101) completed the PRWE and the SF-36 and were tested with traditional impairment measures at baseline and at two, three, and six months after fracture to determine construct and criterion validity. Main Outcome Measures: Reliability coefficients (ICCs) and validity correlations (Pearson product moment correlations). Results: Patient opinions on pain and on ability to do activities of daily living and work were thought to be the most important dimensions to include in subjective outcome tools. Brevity and simplicity were seen as essential in the clinic environment. A fifteen-item questionnaire (the PRWE) was designed to measure wrist pain and disability. Test-retest reliability was excellent (ICCs > 0.90). Validity assessment demonstrated that the instrument detected significant differences over time (p < 0.01) and was appropriately correlated with alternate forms of assessing parameters of pain and disability. Conclusions: The PRWE provides a brief, reliable, and valid measure of patient- rated pain and disability Keywords: activities of daily living/disability/extremity/fracture/fractures/outcome/RELIABILITY/reliability/surv ey/TRAUMA/wrist Skaggs, D.L., Hale, J.M., Buggay, S. and Kay, R.M. (1998), Use of a hybrid external fixator for a severely comminuted juxta-articular fracture of the distal humerus. Journal of Orthopaedic Trauma, 12 (6), 439-442. Abstract: Severely comminuted, juxta-articular fractures present a difficult management dilemma for orthopaedic surgeons. Recently, hybrid external fixators have been used for treatment of such fractures in the lower extremity, particularly in the tibial plateau and the tibial plafond. The same technique may be applied to the upper extremity with gratifying results. This technique has the advantage of minimal dissection while restoring limb alignment and permitting immediate joint motion. The proximity of neurovascular structures to the humerus requires careful attention to anatomic detail when placing such a fixator Keywords: COMBINATION/external fixator/extremity/fracture/fractures/humerus/hybrid/juxta- articular/TRAUMA/treatment/upper extremity/upper-extremity Robinovitch, S.N. and Chin, J. (1998), Surface stiffness affects impact force during a fall on the outstretched hand. Journal of Orthopaedic Research, 16 (3), 309-313. Abstract: Falls on the outstretched hand are among the most common causes of traumatic bone fracture. However, little is known regarding the biomechanical factors that affect the risk for injury during these events. In the present study, we explored how upper-extremity impact forces during forward falls are affected by modification of surface stiffness, an intervention applicable to high-risk environments such as nursing homes, playgrounds, and gymnasiums. Results from both experimental and linear biomechanical models suggest that during a fall onto an infinitely stiff surface, hand contact force is governed by a high-frequency transient (having an associated peak force F- max1), followed by a low-frequency oscillation (having an associated lower magnitude peak force F-max2). Practical decreases in surface stiffness attenuate F-max1 but not F-max2 or the magnitude of force transmitted to the shoulder. Model simulations reveal that this arises from the compliant surface's ability to decrease the velocity across the wrist damping elements
    • at the moment of impact (which governs F-max1) but inability to substantially reduce the peak deflection of the shoulder spring (which governs F-max2). Comparison between model predictions and previous data on fracture force suggests that feasible compliant surface designs may prevent wrist injuries during falls from standing height or lower, because F- max1 will be attenuated and F-max2 will remain below injurious levels. However, such surfaces cannot prevent F-max2 from exceeding injurious levels during falls from greater heights and therefore likely provide little protection against upper- extremity injuries in these cases Keywords: bone/bone fracture/extremity/fall/falls/forward falls/fracture/hand/impact/impact force/injuries/injury/PLAYGROUND INJURIES/ RADIUS/upper extremity/upper-extremity/wrist Brindle, T.J. and Coen, M. (1998), Scapular avulsion fracture of a high school wrestler. Journal of Orthopaedic & Sports Physical Therapy, 27 (6), 444-447. Abstract: This case study details a rare injury managed conservatively with aggressive therapy with early return to competition. A 17- year-old high school wrestler suffered indirect trauma to the right upper extremity. The patient was forced to the mat where he felt pain in the posterior aspect of his shoulder and was point tender over the inferior pole of his right scapula. Radiographs reveal an avulsion fracture at the inferior angle oi the scapula. Aggressive therapy included modalities to control inflammation and muscle guarding in addition to early scapular mobility. Maintenance oi glenohumeral motion and upper extremity strengthening was started within a week. The patient was able to wrestle in the state tournament 3 weeks after initial injury. At the 6-month follow-up, the patient had no clinical tenderness, full range oi motion, and no motor deficits. The outcome resulted in clinical and radiological healing of the fracture and no functional deficits Keywords: avulsion/extremity/fracture/injury/outcome/scapula/THERAPY/trauma/upper extremity/upper-extremity Bailey, C.S., MacDermid, J., Patterson, S.D. and King, G.J.W. (2001), Outcome of plate fixation of olecranon fractures. Journal of Orthopaedic Trauma, 15 (8), 542-548. Abstract: Objectives: To evaluate the functional outcome of plate fixation for displaced olecranon fractures, both simple and comminuted. Design: Retrospective patient, chart, and radiographic review. Setting: Academic teaching hospital. Patients: Twenty-five patients who underwent plate fixation of displaced olecranon fractures by two surgeons were independently reviewed at an average follow-up of thirty-four months (range, 15-69 months). Main Outcome Measurements: Physical capability was assessed by measuring range of motion and isometric elbow strength. Patient- rated outcomes were evaluated using the SF-36, DASH, Mayo Elbow Performance Index (MEPI), and visual analogue scales for patient satisfaction and pain. Radiographs were evaluated preoperatively, postoperatively, and at the time of final review. Results: The average patient age was fifty-four years (range, 14-81 years). The Mayo classification of fractures was fourteen Type II and eleven Type III. An adequate reduction was maintained in all elbows until union. Physical capability measures indicated nonsignificant side-to-side differences in motion or strength, except for supination motion, which was reduced in the injured arm (p = 0.003). The MEPI-rated outcome was twenty-two excellent or good. Patient satisfaction was high (9.7/10), with a low pain rating (1/10). The mean DASH score was consistent with almost normal upper extremity function. The SF-36 showed no difference in physical health as compared with the average American population. Twenty percent of patients required plate removal because of prominence of the internal fixation. The
    • outcome was not influenced by fracture pattern. Conclusion: Plate fixation is an effective treatment option for displaced olecranon fractures with a good functional outcome and a low incidence of complications Keywords: ELBOW/extremity/fracture/fractures/olecranon/outcome/outcomes/plate fixation/supination/TRAUMA/treatment/upper extremity/upper-extremity Beredjiklian, P.K., Bozentka, D.J. and Ramsey, F.L. (2002), Ipsilateral intercondylar distal humerus fracture and Monteggia fracture-dislocation in adults. Journal of Orthopaedic Trauma, 16 (6), 438-440. Abstract: We present two cases of ipsilateral Monteggia fracture- dislocations and intercondylar distal humerus fractures in juries has not adults. To our knowledge, this combination of in been described in skeletally mature individuals. Both patients were treated with rigid internal fixation of the bony injuries as well as early rehabilitation protocols. Despite the severity of the injuries, both patients had satisfactory results. Adherence to established internal fixation protocols is critical in the treatment of complex upper extremity injuries Keywords: extremity/fracture/fracture dislocation/fractures/humerus/injuries/rehabilitation/severity/TRAUMA/treatment/up per extremity/upper-extremity Kerkhoffs, G.M.M.J., Kuipers, M.M., Marti, R.K. and Van der Werken, C. (2003), External fixation with standard AO-plates: Technique, indications, and results in 31 cases. Journal of Orthopaedic Trauma, 17 (1), 61-64. Abstract: The standard AO-plate was used as an external fixator in 31 patients with an infected nonunion or open fracture mainly of the upper extremity. With the use of this technique, good stability can be achieved with an inexpensive and relatively simple construction. The low profile of the frame is an advantage for the patient Keywords: AO-plate/bone/external fixation/external fixator/extremity/fracture/nonunion/open fracture/TRAUMA/upper extremity/upper- extremity Barnes, C.L., Blasier, R.D. and Dodge, B.M. (1991), Intravenous Regional Anesthesia - A Safe and Cost-Effective Outpatient Anesthetic for Upper Extremity Fracture Treatment in Children. Journal of Pediatric Orthopaedics, 11 (6), 717-720. Abstract: We reviewed our most recent 100 consecutive cases with respect to efficacy and safety of anesthesia in which Bier block anesthesia was used to reduce upper extremity fractures. Records were reviewed to document diagnosis, number of reduction attempts, efficacy of anesthesia, and incidence of complications and untoward effects. No adverse effects were noted from lidocaine injection or tourniquet release. The cost of Bier block anesthesia administered in the emergency room (ER) was significantly less than that of a general anesthetic in the operating room. We have found the Bier block to be a safe, reliable, and cost-effective anesthetic in treatment of children's upper extremity fractures in the ER Keywords: ANESTHESIA/CHILDRENS FRACTURES/extremity/fractures/treatment/ upper extremity/upper extremity fractures/upper-extremity Buckley, S.L., Sturm, P.F., Buck, B.D. and Robertson, W.W. (1993), Upper Extremity Restraint During Hip Spica Cast Application. Journal of Pediatric Orthopaedics, 13 (4), 529-530. Abstract: Control of the upper extremities of a sedated or anesthetized patient can be a cumbersome and difficult problem during hip spica cast application. To overcome this, we developed a simple technique to control the upper extremities without placing the neurovascular structures under tension while allowing easy venous access for the anesthesia personnel. Use of a simple armboard made of supplies commonly
    • available in the cast room has made this possible. The construction and clinical use of this armboard is described. It has been used successfully for > 12 months at the authors' institution with no untoward effects Keywords: extremities/FEMUR FRACTURE/HIP SPICA CAST Camp, J., Ishizue, K., Gomez, M., Gelberman, R. and Akeson, W. (1993), Alteration of Baumann Angle by Humeral Position - Implications for Treatment of Supracondylar Humerus Fractures. Journal of Pediatric Orthopaedics, 13 (4), 521-525. Abstract: To determine the effects of limb positioning on Baumann's angle, we made a controlled radiographic study of a 6-year-old cadaver upper extremity specimen. Radiographic measurement of Baumann's angle was obtained at 10-degrees increments of humeral rotation from 40-degrees of internal rotation to 40- degrees of external rotation. These measurements were obtained with the humerus parallel to the x-ray cassette and with the humerus flexed 30-degrees from the cassette. Measurement of Baumann's angle with radiographs obtained with the humerus parallel to the x-ray cassette was associated with less variation in the measured angle (6-degrees of change for every 10-degrees of rotation). The relevance of these findings in management of supracondylar fractures is discussed Keywords: BAUMANN ANGLE/extremity/fractures/humerus/POSITION/radiographs/ ROTATION/SUPRACONDYLAR FRACTURE/upper extremity/upper-extremity Nork, S.E., Hennrikus, W.L., Loncarich, D.P., Gillingham, B.L. and Lapinsky, A.S. (1999), Relationship between ligamentous laxity and the site of upper extremity fractures in children: Extension supracondylar fracture versus distal forearm fracture. Journal of Pediatric Orthopaedics-Part B, 8 (2), 90-92. Abstract: Eighty children who had fallen on an outstretched hand and sustained either a displaced supracondylar fracture (group 1) or a displaced distal forearm fracture (group 2) were prospectively studied. Ligamentous laxity in these 80 patients was determined by four methods: (a) contralateral elbow hyperextension, (b) knee hyperextension, (c) the ability to touch the thumb to the ipsilateral forearm, and (d) the ability to extend the thumb past the ulnar border of the clenched fist. Elbow hyperextension averaged 10.5 degrees in group 1 and 4.4 degrees in group 2 (P < 0.0001). Knee hyperextension averaged 7.2 degrees in group 1 and 2.4 degrees in group 2 (P < 0.001). Twenty-one of 38 patients in group 1 (55%) compared with 8 of 42 patients in group 2 (19%) could touch the thumb to the ipsilateral forearm (P < 0.001). Twenty-seven of 38 patients in group 1 (71%) compared with 5 of 42 patients in group 2 (12%) could extend the thumb past the ulnar border of the clenched fist (P < 0.001). The authors conclude that a child who demonstrates ligamentous laxity is more likely to sustain an extension supracondylar humerus fracture than a distal forearm fracture when he or she falls on the outstretched hand to break the force of the fall Keywords: child/children/elbow/extremity/fall/falls/forearm/fracture/fractures/hand/humerus/lig amentous laxity/pediatric/upper extremity/upper extremity fractures/upper-extremity Armstrong, D.G., Newfield, J.T. and Gillespie, R. (1999), Orthopedic management of osteopetrosis: Results of a survey and review of the literature. Journal of Pediatric Orthopaedics, 19 (1), 122-132. Abstract: Osteopetrosis or Albers-Schonberg disease is a rare hereditary disorder of osteoclast function in which resorption of bone is diminished, resulting in abnormally dense bones. The condition is known to occur in at least four recognizable clinical patterns, each of which is variable. The optimal treatment of fractures and of bone deformity in these patients has not previously been made clear.
    • To determine appropriate orthopedic management of the condition, we conducted a survey of the membership of the Pediatric Orthopedic Society of North America. The combined experience of 57 surgeons who treated 79 patients with osteopetrosis was compiled. Four femoral neck fractures treated by closed reduction and internal fixation had a satisfactory result, but three treated nonoperatively developed varus and required osteotomy. A total of 20 hips was treated for coxa vara by various means, none of which was free of complications. Valgus osteotomy, when used as the primary treatment for coxa vara, was the most consistently satisfactory procedure, whereas in situ pinning failed in two of three hips. Fourteen subtrochanteric fractures and 31 other fractures of the femur were treated. Good results were reported with traction or casting or both in the majority of those fractures. Twenty-nine tibia fractures were treated successfully, the majority by nonoperative means. Upper extremity fractures healed well with closed reduction and casting. Vertebral fractures, spondylolysis, and back pain were most frequently treated without surgery Keywords: AUTOSOMAL-DOMINANT OSTEOPETROSIS/BONE/CHILD/coxa vara/extremity/FEMORAL-NECK FRACTURE/fractures/HETEROGENEITY/MALIGNANT OSTEOPETROSIS/osteopetrosis/PATTERNS/survey/treatment Wang, M.Y., Kim, K.A., Griffith, P.M., Summers, S., Mccomb, J.G., Levy, M.L. and Mahour, G.H. (2001), Injuries from falls in the pediatric population: An analysis of 729 cases. Journal of Pediatric Surgery, 36 (10), 1528-1534. Abstract: Background/Purpose: Falls are classified as low or high level for triage purposes. Because triage criteria dictate less urgency for low-level falls, this classification scheme has important implications for pediatric emergency care. Methods: Retrospective analysis was conducted of 729 (393 low-level and 336 high- level) pediatric patients treated for fall-related trauma (1992 through 1998). Falls were classified as low (< 15 feet) or high-level (greater than or equal to 15 feet). All falls were reported as accidental or unintentional. Results: The overall mortality rate was 1.6% (2.4% for high-level falls compared with 1.0% for low-level falls). All 4 patients who died of a low-level fall had an abnormal head computed tomography (CT) scan and intracranial hypertension. Half of deaths from high-level falls were attributable to intracranial injuries, and half were caused by severe extracranial injuries. Common extracranial injuries were upper extremity fracture (6.2%), lower extremity fracture (5.6%), pulmonary contusion (1.8%), pneumothorax (1.1%), liver laceration (1.1%), bowel injury (1.0%), and splenic injury (2.1%). Orthopedic and thoracic injuries resulted more commonly from high-level fails, whereas abdominal injuries were as likely to occur after a low- level fall. Conclusions: Intracranial injury accounts for the majority of deaths from falls. Children suffering low-level falls were at similar risk for intracranial and abdominal injuries compared with those who fell from greater heights. Pediatric trauma triage criteria should account for these findings. Copyright (C) 2001 by W B. Saunders Company Keywords: abdominal injury/BLUNT TRAUMA/CARE/CHILDREN/CT/DEATHS/EPIDEMIOLOGY/extremity/fall/falls/ fracture/Glasgow Coma Scale/head injury/INFANTS/injuries/injury/OUTCOMES/pediatric/PREVENTION/SEVERITY /THORACIC TRAUMA/trauma/upper extremity/upper-extremity Carsi, B., Abril, J.C. and Epeldegui, T. (2003), Longitudinal growth after nonphyseal forearm fractures. Journal of Pediatric Orthopaedics, 23 (2), 203-207. Abstract: The overgrowth phenomenon after fracture has been considered rare in the
    • upper extremity. This study analyzes 119 patients with forearm fractures treated conservatively. All patients had scanograms of both forearms 5 years later. A difference in length more than 2 mm was considered a discrepancy. Positive values of discrepancy were called overgrowth. A radial length discrepancy was observed in 80 patients (67.2%) and overgrowth in 38 (26.8%); ulnar values were 65 (54.6%) and 29 (24.3%), respectively. Radial overgrowth and ulnar overgrowth were related to the location of the radial fracture and handedness but not to the type of fracture, age or sex of the patient, or the presence or absence of an associated ulnar fracture. Discrepancy did not show a significant relationship to any of these variables. Surprisingly, fractures in the proximal and middle thirds often presented with overgrowth, whereas those closer to the distal physis did not Keywords: discrepancy/extremity/forearm/forearm fractures/fracture/fractures/nonphyseal/overgrowth/upper extremity/upper-extremity Gupta, G.G., Lucas, G. and Hahn, D.L. (1997), Biomechanical and computer analysis of radial head prostheses. Journal of Shoulder and Elbow Surgery, 6 (1), 37-48. Abstract: Radial head fractures can lead to significant upper extremity disability. A comminuted radial head fracture with a medial collateral ligament tear presents a clinical conundrum. The radiocapitellar (RC) joint should be maintained, yet the head Frequently cannot be reduced and stabilized. The silicone rubber implant currently available is not biomechanically or clinically satisfactory, and thus there is a need For a more suitable prosthetic replacement for the radial head. We have attempted to design such a prosthesis and have examined prosthetic design with various materials that would best transmit force at the RC joint. Design configurations based on our cadaveric and radiographic measurements were tested with structural finite element method computer analyses. Materials examined included titanium alloy, cobalt-chrome alloy, alumina ceramic, and ultrahigh molecular weight polyethylene (UHMWPE). Metals and ceramic transmitted force at the distal bone and implant interface and strain shielded the proximal radial cortex while UHMWPE distributed load uniformly through the cortex and along the entire bone and implant interface. In addition, load transmission comparisons were made with the intact radial head, with a silicone prosthesis, and with 6 and 10 mm thick UHMWPE prostheses in cadaveric specimens. UHMWPE prostheses transmit more force to the RC joint than the silicone prosthesis and with loads closer to physiologic levels at all flexion angles. UHMWPE prostheses not only transmit much more force than silicone, but because of substantially less deformation under load also provide more stability to the joint Keywords: bone/disability/ELBOW/ELBOW JOINT/extremity/fracture/fractures/REPLACEMENT/SHOULDER/STABILITY/up per extremity/upper-extremity McLaughlin, J.A., Light, R. and Lustrin, I. (1998), Axillary artery injury as a complication of proximal humerus fractures. Journal of Shoulder and Elbow Surgery, 7 (3), 292-294. Abstract: Proximal humerus fractures are common injuries and represent approximately 5% of all fractures.(10, 14, 21) These fractures are infrequently associated with neurovascular injuries. Brachial plexus injuries are uncommon,(18) whereas axillary artery injuries are rare.(5-9, 11, 12, 16-20, 22-24) A review of 19 previously reported cases of axillary artery injury after proximal humerus fracture revealed that 84% occurred in patients older than 50 years, 53% were associated with brachial plexus injury, and 21% resulted in upper extremity amputation. This study describes a case of axillary artery injury after proximal humerus fracture and, on the basis of a
    • literature review, offers suggestions for the early diagnosis and effective treatment of this uncommon injury Keywords: ANTERIOR DISLOCATION/ELBOW/extremity/fracture/fractures/humerus/injuries/injury/MAN AGEMENT/NECK/SHOULDER/treatment/upper extremity/upper-extremity Koch, P.P., Gross, D.F.L. and Gerber, C. (2002), The results of functional (Sarmiento) bracing of humeral shaft fractures. Journal of Shoulder and Elbow Surgery, 11 (2), 143-150. Abstract: At the Department of Orthopaedics of the Kantonsspital Fribourg, 67 humeral shaft fractures were treated by Sarmiento bracing in a 15-year period. There were 54 isolated fractures and 73 fractures sustained as a component of polytrauma. Fifty- eight cases (87%) hod healed clinically at a mean of 7 0 weeks; 9 cases failed to heal, so further treatment was carried out operatively. Of the conservatively managed fractures, 95% (55 cases) heated with an excellent or good result. Three patients noted a slight limitation of active range of motion, but all 58 patients returned to full duty at their jobs. Among 9 patients with delayed or nonunion leading to operative intervention, there were 6 cases with transverse fractures. Major reasons for failed conservative management were an incorrect indication, a significant axial deformity or a hyperextended position of the fracture fragments. In our experience, active repositioning of humeral shaft fractures is not effective in avoiding a delay in fracture healing. The decision to use functional bracing in polytrauma patients should depend on the time of expected bedridden immobilization, on the presence of additional fractures of the ipsilateral upper extremity and on the patient's need for crutches. The conservative treatment of humeral shaft fractures with the Sarmiento brace remains the treatment of choice, in spite of newer intramedullary operations that are allegedly minimally invasive and technically less complicated Keywords: ELBOW/extremity/fracture/fractures/RADIAL NERVE/shaft fractures/treatment/upper extremity/upper-extremity Nicholas, J.J., Reidy, M. and Oleske, D.M. (1998), An epidemiologic survey of injury in golfers. Journal of Sport Rehabilitation, 7 (2), 112-121. Abstract: In order to supplement the literature that describes individual injuries of the shoulder, carpal tunnel, and back in golfers, we administered a sun ey to demonstrate the incidence of golfers' injuries and describe the most frequent types. A questionnaire was administered to 1,790 members of the New York State Golf Association (amateur) under age 21. Three hundred sixty-eight players responded. Half of those responding had been struck by a golf ball at least on one occasion (47.6%), and 23% of the injuries were to the head or neck. Male golfers were 2.66 times more likely to be struck by a golf ball than females. Women and golfers with a higher handicap were at an increased risk for upper extremity problems, whereas younger and overweight golfers were more likely to have golf-related back problems. We concluded that golf is associated with a significant morbidity. Repetitious trunk and upper limb motions probably contribute to musculoskeletal disorders. However, an unexpectedly high incidence of trauma from projectile golf bails leads to the conclusion that no amount of stretching or muscular exercise is as important as increased alertness by golfers to decrease this hazard Keywords: CHILDREN/extremity/FRACTURE/HEAD- INJURIES/injuries/injury/survey/trauma/upper extremity/upper-extremity Malanga, G.A. and Smith, J.M. (1996), Lower extremity injuries in in-line skaters: A report of two cases. Journal of Sports Medicine and Physical Fitness, 36 (2), 139-142.
    • Abstract: In-line skating has become a very popular sport over the past several years. Previous studies examining the injuries associated with this sport have emphasized the incidence upper extremity injuries, Two cases are described in which patients suffered severe lower extremity injuries while inline skating: one had a femoral shaft spiral fracture and the other bilateral anterior cruciate ligament and medial collateral ligament injuries, Although a predominance of upper extremity injuries associated with this sport has been widely noted, increased numbers of participants, higher speeds and changing skate designs may further predispose skaters to leg, knee and ankle injuries Keywords: extremity/fracture/fractures/injuries/knee ligaments/leg/skating in- line/SKATING INJURIES/sport/upper extremity/upper-extremity Yang, C.B. and Huang, S.C. (1997), Humeral lengthening using the Ilizarov technique. Journal of the Formosan Medical Association, 96 (4), 291-294. Abstract: Significant shortening of the humerus may cause cosmetic, psychologic and functional problems. From 1989 to 1993, we performed humeral lengthening using the Ilizarov technique on six patients. The indications were: 1) significant inequality (> 4-14 cm); 2) significant functional impairment; and 3) poor aesthetic appearance or related psychologic problems. There were three females and three males, with a mean age of 17.7 years. The right humerus was affected in two patients, the left in four. Etiologies included sequelae of neonatal septic shoulder in three patients, sequelae of childhood trauma in one, malunion in one and congenital bone anomaly in one. Mean shortening of the humerus was 9.2 cm. Total average treatment time was 250 days. Mean lengthening was 8.7 cm. Complications included transient radial nerve palsy in one patient and delayed union in another. Bone grafting was performed on the patient who sustained delayed union. Fracture of the distraction site occurred after removing the Ilizarov device, and open reduction and internal fixation was performed. Functional and aesthetic status was improved in all six patients, over a minimum of 2 years follow-up. Lengthening of the humerus can be performed satisfactorily using the Ilizarov technique Keywords: bone/bone lengthening/childhood/CHILDREN/humerus/Ilizarov technique/ NONUNIONS/trauma/treatment/UPPER EXTREMITY Burns, G.A., Cohn, S.M., Frumento, R.J., Degutis, L.C. and Hammers, L. (1993), Prospective Ultrasound Evaluation of Venous Thrombosis in High- Risk Trauma Patients. Journal of Trauma-Injury Infection and Critical Care, 35 (3), 405-408. Abstract: To determine the incidence of venous thrombosis (VT), high-risk trauma patients were evaluated prospectively biweekly with Doppler ultrasound (US). Fifty- seven patients during an 8-month period met high-risk criteria for VT including age >45 years, >2 days bed rest, previous history of thromboembolism, spine fracture, coma, spinal cord injury, pelvic fracture, lower extremity injury, or femoral vein catheter. Doppler ultrasound showed 16 VTs in 12 patients. Venous thrombosis occurred despite prophylaxis (heparin or compression devices) in 9 of 12 patients. Iliac VT was noted in four patients, two of whom had no lower extremity VT. Upper extremity VT occurred in two patients who had received central venous catheters. Conclusions: (1) US surveillance may be valuable in high-risk trauma patients because VT is a common finding (21%), despite prophylactic measures. (2) Examination of the upper extremity and pelvic venous system appears to be important, since 33% (4 of 12) of our patients with VT developed thrombi isolated to these regions. These would not have been identified during routine lower extremity duplex studies Keywords: DEEP-VEIN
    • THROMBOSIS/extremity/fracture/HIP/injury/PULMONARY-EMBOLISM/spinal cord injury/THROMBOEMBOLISM/thrombosis/TRAUMA/ultrasound/upper extremity/upper-extremity Calle, S.C. and Eaton, R.G. (1993), Wheels-In-Line Roller Skating Injuries. Journal of Trauma-Injury Infection and Critical Care, 35 (6), 946-951. Abstract: Injuries sustained by patients using wheels-in-line roller skates were reviewed in a survey of 57 cases collected by the Roosevelt Hospital Hand Service and 444 cases compiled by the Consumer Product Safety Commission. Most patients were novice skaters in the second and third decades of life. Severe distal radius fractures and upper extremity soft-tissue trauma were the most common injuries in both groups. The distal radius (44.9%), scaphoid (13.9%), and radial head (10.4%) were the three most common fracture sites in the Roosevelt survey. Most (80%) skaters in this group did not wear protective equipment. In-line roller skating can and does produce disabling injuries. Also, several deaths were reported among skaters traveling in heavy traffic. To reduce the number of injuries, all skaters should wear protective gear, especially wrist and elbow pads. Splints reduce but do not eliminate the potential for trauma. In our study most injured skaters had not mastered controlled skating and stopping techniques. This new recreational sport is increasing in popularity and more injuries are expected if skaters fail to protect themselves properly Keywords: elbow/extremity/fracture/fractures/injuries/sport/survey/traffic/TRAUMA/upper extremity/upper-extremity/wrist Cheng, S.L., Rajaratnam, K., Raskin, K.B., Hu, R.W. and Axelrod, T.S. (1995), ''Splint- top'' fracture of the forearm: A description of an in- line skating injury associated with the use of protective wrist splints. Journal of Trauma-Injury Infection and Critical Care, 39 (6), 1194-1197. Abstract: Upper extremity injuries are commonly seen in the sport of in- line skating. The use of protective equipment, including wrist splints, has been advocated as a means to decrease both the incidence and severity of upper extremity injuries in this sport. We report on four cases of open forearm fractures in the in-line skaters that occurred adjacent to the proximal border of the wrist splints. The unusual nature of these injuries and the location of the fractures in relation to the location of the splints suggest that the two may be mechanistically related, The splint and distal forearm may act as a single unit to convert the impact from the level of the wrist to a torque moment, with the fulcrum located at the proximal border of the splint, The energy from the fall is then dissipated by the fracturing of the forearm bones at this level These cases suggest that the use of wrist splints may be associated with their own specific set of injury patterns Keywords: extremity/fall/forearm/fracture/fractures/impact/injuries/injury/injury patterns/severity/sport/TRAUMA/upper extremity/upper-extremity/wrist Huebner, C.J. and Reed, M.P. (1998), Airbag-induced fracture in a patient with osteoporosis. Journal of Trauma-Injury Infection and Critical Care, 45 (2), 416-418. Abstract: Since the introduction of automotive airbag technology, patterns of airbag- induced injuries have emerged. Various types of upper-extremity trauma including fractures have been described. Previous reports have focused on the location of the forearm before deployment as the major determinant of fracture. We describe a case of forearm fracture resulting from an airbag deployment in a lupus patient with documented osteoporosis, Bone strength has recently been determined in laboratory testing to be an important factor determining airbag-induced fracture risk. An airbag-
    • induced forearm fracture in an otherwise healthy individual may be an indicator of reduced bone strength Keywords: airbag/bone/bone mineral density/forearm/fracture/fracture risks/fractures/injuries/osteoporosis/TRAUMA/upper extremity/upper-extremity Sasaki, K., Takagi, M., Kiyoshige, Y. and Ogino, T. (1999), Snowboarder's wrist: Its severity compared with alpine skiing. Journal of Trauma-Injury Infection and Critical Care, 46 (6), 1059-1061. Abstract: Background: Although the upper extremity, especially the wrist, has been reported to be the most commonly injured site in snowboarding, the severity of these injuries is still unknown, The purpose of this study is to compare the severity of wrist injuries in snowboarding with those in alpine skiing for insight into the treatment of snowboarder's wrist, Materials and Methods: The cases of 11,598 patients injured while snowboarding and skiing who presented to the Zao clinic during the past 7 seasons were reviewed and compared. Demographics mere studied, focusing on fractures around the wrist joint. Roentgenographically precise assessment of the distal radial fracture was performed according to AO classification. Results: Snowboarders were more likely to injure the wrist than were skiers (18.7% vs. 2.5%, p < 0.01), In these wrist injuries, distal radial fractures occurred at a rate of 0.28 per 1000 snowboarders and 0.008 per 1000 skiers, Comminuted and articular fractures classified as AO type A3, B and C, which required surgical treatment, were 49.4% of distal radial fractures in snowboarders and 23.8% in skiers. Conclusion: Wrist injury sustained while snowboarding is characterized as a severe and complex injury, Thus, we call attention to its severity in the treatment of snowboarder's wrist Keywords: 4-YEAR/classification/COLLES FRACTURES/distal radial fracture/EXTERNAL FIXATION/extremity/fracture/fractures/INJURIES/injury/PLASTER/severity/ski/sn owboard/snowboarding/TRAUMA/treatment/upper extremity/upper-extremity/wrist Richter, M., Otte, D., Jahanyar, K. and Blauth, M. (2000), Upper extremity fractures in restrained front-seat occupants. Journal of Trauma-Injury Infection and Critical Care, 48 (5), 907-912. Abstract: Background: The aim of our study was to analyze the injury mechanism of upper extremity fractures in car crashes, to create a basis for developing prophylactic devices. Methods and Results: During 1985-1995, 3,260 restrained car drivers (1,228 front-seat passengers) were injured in 9,380 crashes involving cars. A total of 179 drivers (5.5%) (front-seat passengers: n = 53, 4.3%) sustained fractures of the arm. The hand (25%), wrist (23%), and forearm (23%) were affected most often, and the elbow (9%), upper arm (10%), and shoulder (10%) were seldom affected. No considerable differences of the injury mechanism were found comparing drivers with front-seat passengers. Fractures were mainly caused by head-on collisions (n = 119, 51%) or multiple collisions (n = 78, 34%), In 73% of the crashes (n = 166), delta-v exceeded 30 km/h (18.6 mph). A lower Delta-v resulted mainly in fractures affecting the shoulder and wrist. Conclusion: Because more than half of the upper extremity fractures resulted from a direct impact to the hand, arm, or both, modifications to improve the energy absorption by padding dashboard and inner door or by additional airbags are promising Keywords: BELTS/car crash/classification/elbow/extremity/FATALITIES/forearm/fracture of the arm/fractures/hand/impact/INJURIES/injury/injury mechanism/prevention/RISK/TRAUMA/upper extremity/upper extremity fractures/upper-extremity/wrist
    • Stalp, M., Koch, C., Ruchholtz, S., Regel, G., Panzica, M., Krettek, C. and Pape, H.C. (2002), Standardized outcome evaluation after blunt multiple injuries by scoring systems: A clinical follow-up investigation 2 years after injury. Journal of Trauma- Injury Infection and Critical Care, 52 (6), 1160-1168. Abstract: Objective: The objective of this study was to evaluate the state of rehabilitation in patients with blunt multiple injuries 2 years after their initial injuries, using several standardized scales and a recently described comprehensive scoring system, by means of a prospective clinical multi-center study. Methods: Two years after the initial injury, patients with blunt multiple injuries (Injury Severity Score greater than or equal to 16) underwent a clinical follow-up in 5 German Level I trauma centers. The reassessment included a complete head-to-toe examination of the musculoskeletal system and a neurologic examination. The following patient- assessed health status scores were used to determine the quality of life: Short-Form 12, Functional Independence Measurement, and Musculoskeletal Function Assessment. Moreover, a comprehensive scoring system developed in our department (Hannover Score for Polytrauma Outcome [HASPOC]) was used that includes provider- report (physician's examination) and self-report (score systems) criteria. Results: Two hundred fifty-four of 312 patients who had been injured between January 1995 and July 1996 were reexamined between January 1, 1997, and July 1, 1998. Among the remaining 58 patients, 9 had died by the time of follow-up, and 49 patients had not accepted the invitation. The mean age of those patients who underwent reexamination was 36 +/- 13 years, the mean Injury Severity Score was 24 +/- 6, and the mean initial Glasgow Coma Scale score was 11 +/- 4 (Abbreviated Injury Scale (AIS) head score of 3.3 +/- 1.1; AIS face, 1.4 +/- 0.1; AIS chest, 3.0 +/- 0.8; AIS abdomen, 1.7 +/- 0.6; and AIS extremities, 3.4 +/- 0.8). The general outcome (Short-Form 12) was as follows: grade I, 9%; grade II, 25%; grade III, 29%; grade IV, 25%; grade V, 6%; and grade VI, 6%. The outcome of the injured extremity demonstrated moderate or severe restrictions according to the Musculoskeletal Function Assessment in 41% of injuries of the lower extremity and in 16% of injuries of the upper extremity. Among patients with injuries to the lower extremity, 52% experienced pain or impaired ability to walk related to an injury of the foot or ankle, 31% indicated pain after a knee or thigh injury, and 27% indicated pain after a femoral or hip injury. The most severe deficits in the range of motion occurred in the foot and the ankle region (13.4% deficit of range of motion < 20% of normal range, p < 0.05 to other injuries). The results of the outcome obtained by self- report correlated with the clinical examination when a scoring system was used that was described recently, the HASPOC. Conclusion: In a standardized multicenter reexamination of patients with blunt multiple injuries, the general outcome was usually fair or good. Both the complaints and the objective results of specific extremity areas demonstrated that most limitations were because of injuries below the knee. These results were adequately reflected by a comprehensive scoring system, combining self-report and provider report (HASPOC) Keywords: CLASSIFICATION/DISABILITY/extremities/extremity/follow- up/FUNCTIONAL INDEPENDENCE MEASURE/German Trauma Registry/Glasgow Coma Scale/HEALTH SURVEY/injuries/injury/LOWER- EXTREMITY FRACTURE/MAJOR TRAUMA/multiple injuries/outcome/QUALITY/rehabilitation/REHABILITATION/scoring systems/SEVERE HEAD-INJURY/TRAUMA/TRAUMA RECOVERY PROJECT/ upper extremity/upper-extremity Chen, A.L., Joseph, T.N., Wolinksy, P.R., Tejwani, N.C., Kummer, F.J., Egol, K.A. and
    • Koval, K.J. (2002), Fixation stability of comminuted humeral shaft fractures: Locked intramedullary nailing versus plate fixation. Journal of Trauma-Injury Infection and Critical Care, 53 (4), 733-737. Abstract: Background. This study compared the fixation stability of two treatments for humeral shaft fractures with segmental bone loss during cyclic, physiologic loading. Methods. Six matched pairs of human humeri received either a 10-hole broad dynamic compression plate or a locked ante-grade inserted humeral nail applied to a humeral diaphyseal osteotomy with a 1.5-cm gap defect. The bone-implant humeral constructs were axially loaded for 10,000 cycles at 250 N and 500 N, with measurements of gap displacement and calculation of construct stiffness. The specimens were then loaded to failure. Results. Cyclic loading showed no difference between the two groups for average gap displacement or construct stiffness. The intramedullary nail constructs failed by humeral shaft splitting (n = 4) or head cut- out (n = 2) at an average of 958.3 N, whereas the plate constructs failed by humeral shaft splitting and screw pull-out (n = 3) or plate bending (n = 3) at an average of 641.7 N (p < 0.001). Conclusion. Although both methods offer similar fixation stability under physiologic loads, the higher load to failure demonstrated by intramedullary nail fixation may have implications for the patient with multiple injuries for whom partial weightbearing on the injured upper extremity may be necessary Keywords: BIOMECHANICS/bone/EXPERIENCE/extremity/fracture/fractures/humerus/injurie s/intramedullary fixation/intramedullary nailing/plate fixation/plate osteosynthesis/shaft fractures/SYSTEMS/TRAUMA/upper extremity/upper- extremity/weightbearing McHenry, T.P., Holcomb, J.B., Aoki, N. and Lindsey, R.W. (2002), Fractures with major vascular injuries from gunshot wounds: Implications of surgical sequence. Journal of Trauma-Injury Infection and Critical Care, 53 (4), 717-721. Abstract: Background: The sequence of surgical repair for penetrating extremity injuries requiring both vascular repair and fracture fixation is controversial. The optimal determination of repair order and its consequences is the purpose of this study. Methods: A retrospective review was performed of 27 patients over a 10-year period requiring acute revascularization and fracture fixation for isolated gunshot wound injuries. Injuries to the brachial artery and the femoral and popliteal vessels with accompanying fractures requiring operative stabilization were considered. The Mangled Extremity Severity Score, surgical sequence, limb viability, fasciotomy, incidence of iatrogenic vascular repair disruption, and length of hospitalization were analyzed. Results: There were 17 lower and 10 upper extremity injuries, with a mean Mangled Extremity Severity Score of 4.1. Fracture fixation preceded vascular repair in five cases, whereas revascularization preceded bone fixation in 22 cases. A temporary vascular shunt was used in 13 and definitive vascular repair with used in 9 patients. There were no cases of vascular repair, shunt disruption, or amputation after fracture fixation. Four of five (80%) patients with orthopedic fixation before revascularization required fasciotomies, whereas 8 of 22 (36%) patients with revascularization before fixation required fasciotomies, and this difference approached significance (p = 0.10). Patients with fasciotomies had a significantly longer mean length of hospitalization, 18.3 +/- 8.6 days compared with 10.8 +/- 8.1 days (p = 0.03). Conclusion: For patients with combined injuries, priority should be given to revascularization before orthopedic fixation because of shorter hospitalization and a trend toward lower fasciotomy rates. Revascularization before
    • fracture fixation did not result in iatrogenic disruption of the vascular repair Keywords: acute/BLUNT/bone/EXTERNAL FIXATION/extremity/FASCIOTOMY/fasciotomy/fracture/fractures/gunshot wound/ injuries/limb salvage/LOWER-EXTREMITY/MANAGEMENT/TRAUMA/upper extremity/upper-extremity/vascular injury Iserson, K.V. (1991), Relocating Dislocations in A Wilderness Setting - Use of Hypnosis. Journal of Wilderness Medicine, 2 (1), 22-26. Abstract: Joint dislocations or fracture/dislocations of extremities are disabling injuries in wilderness areas, both to the individual patient and to the patient's wilderness group. Recognizing the beneficial effect of early relocation of dislocations, wilderness practitioners are now encouraged to attempt joint relocations in the backcountry setting. To be successful, adequate sedation/relaxation must be achieved. Hypnosis was applied in six patients with shoulder or ankle dislocations. Successful relocations were accomplished in five of the patients. Those with upper extremity dislocations were immediately able to walk out with minimal assistance after relocation Keywords: ANESTHESIA/backcountry/DISLOCATION/extremities/extremity/HYPNOSIS/inju ries/RELOCATION/SEARCH AND RESCUE/upper extremity/upper-extremity Magaziner, J., Hawkes, W., Hebel, J.R., Zimmerman, S.I., Fox, K.M., Dolan, M., Felsenthal, G. and Kenzora, J. (2000), Recovery from hip fracture in eight areas of function. Journals of Gerontology Series A-Biological Sciences and Medical Sciences, 55 (9), M498-M507. Abstract: Background. This report describes changes in eight areas of functioning after a hip fracture, identifies the point at which maximal levels of recovery are reached in each area, and evaluates the sequence of recuperation across multiple functional domains. Methods. Community-residing hip fracture patients (n = 674) admitted to eight hospitals in Baltimore, Maryland, 1990-1991, were followed prospectively for 2 years from the time of hospitalization. Eight areas of function (i.e., upper and lower extremity physical and instrumental activities of daily living; gait and balance; social, cognitive, and affective function) were measured by personal interview and direct observation during hospitalization at 2, 6, 12, 18, and 24 months. Levels of recovery are described in each area, and time to reach maximal recovery was estimated using Generalized Estimating Equations and longitudinal data. Results. Most areas of functioning showed progressive lessening of dependence over the first postfracture year, with different levels of recovery and time to maximum levels observed fur each area. New dependency in physical and instrumental tasks fur those not requiring equipment or human assistance prefracture ranged from as low as 20.3% for putting on pants to as high as 89.9% for climbing five stairs. Recuperation times were specific to area of function, ranging from approximately 4 months fur depressive symptoms (3.9 months), upper extremity function (4.3 months), and cognition (4.4 months) to almost a year for lower extremity function (11.2 months). Conclusions. Functional disability following hip fracture is significant, patterns of recovery differ by area of function, and there appears to be an orderly sequence by which areas of function reach their maximal levels Keywords: activities of daily living/balance/DEPRESSION/DETERMINANTS/disability/DISABLEMENT/extre mity/fracture/HEALTH/hip fracture/MOBILITY/MORTALITY/OLDER/PERFORMANCE/SOCIAL SUPPORT/SURVIVAL/upper extremity/upper-extremity
    • Mcconnochie, K.M., Roghmann, K.J. and Pasternack, J. (1993), Developing Prediction Rules and Evaluating Observation Patterns Using Categorical Clinical Markers - 2 Complementary Procedures. Medical Decision Making, 13 (1), 30-42. Abstract: Substantial uncertainty often remains at the time that important diagnostic or therapeutic decisions must be made, despite the availability of multiple clinical indicators. Multiple indicators may be used to define observation patterns that are associated with the presence or absence of disease. Clinical prediction rules based on groups of observation patterns have been used to quantify probabilities and reduce error rates for some medical problems, but efficient use of multiple indicators remains a major challenge in medical practice. Medical outcomes and clinical observations are frequently categorical. Two statistical techniques appropriate for generating prediction rules from categorical data are logit analysis (LA) and recursive partitioning analysis (RPA). LA and RPA were compared in evaluating observation patterns for fractures among 666 upper-extremity injuries in children, and in developing prediction rules for selective radiographic assessment. Fracture estimates and error reductions provided by RPA and LA were very similar. Each technique generated a set of prediction rules with a range of misclassification probabilities, and evaluated the probabilities of fracture for all observation patterns. LA used more information than RPA in observation pattern evaluations, however, and provided fracture estimates specific to each pattern. With currently available statistical software, RPA output provides better statistical guidance in generating prediction rules, whereas LA provides more statistical information of use in evaluating observation patterns. LA warrants attention similar to that conferred on RPA. It appears that complementary use of LA and RPA would be valuable in developing clinical guidelines Keywords: children/fracture/fractures/injuries/LOGIT ANALYSIS/OBSERVATION PATTERNS/outcomes/PREDICTION RULES/PREDICTIVE MODELS/RECURSIVE PARTITIONING ANALYSIS/REGRESSION/ROC CURVE/upper extremity/upper-extremity Carretta, A. (2002), The chronic painful shoulder in overhead athletes. Medicina Dello Sport, 55 (4), 287-297. Abstract: Shoulder pain pathology, especially in overhead athletes, has in recent decades been the subject of steadily growing interest. This has led to a radical change in the clinico- diagnostic, therapeutic and rehabilitative criteria employed in this pathology By the general term "thrower's shoulder" is meant a chronic pain syndrome of the shoulder which affects certain categories of athletes and which presents the array of symptoms typical of scapulohumeral periarthritis. The pathology derives from functional overloading and the pathogenetic factor is reiterated microtrauma of the muscular insertions, particularly those of the rotator cuff (above all the supraspinatus) that often also involves the long head of the brachial biceps. Athletes who engage in so-called overhead sports (tennis, volleyball, basketball, hand-ball, swimming, water-polo, gymnastics, baseball, throwing) put their shoulders through considerable stress every time the upper extremity is stretched to the full in whatever particular movement is involved, namely when the extremity exceeds 900 elevation in the scapular plane. This is the main reason why this category of sportsmen and women is especially vulnerable to accidents such as bursitis, tendinitis, scapulohumeral conflict, shoulder instability and, in rare cases, peripheral neurological damage such as acute traction of the brachial plexus, lesion of the long thoracic nerve and suprascapular nerve entrapment. On the other hand, in "contact" sports (football, rugby, hockey, karate), other types of lesions, such as
    • scapulohumeral and acromioclavicular luxation and clavicular fracture, are more common. Arthroscopy has made it possible to introduce new diagnostic and therapeutic criteria for the most frequent conditions causing throwers shoulder, namely scapulohumeral instability and rotator cuff pathology In particular, study of specific lesions to the stabilisation system and the tendons has made it possible to make a sharp distinction between pain syndromes of so-called normal subjects who engage only occasionally in sporting activity, and syndromes which affect throwers who use their shoulders in a specific, repetitive manner for years. Arthroscopic investigation has had the effective merit of evidencing a clinical and anatomopathological situation that has thus far been misinterpreted and undervalued, namely that postero-superior glenoid conflict which is today unanimously recognised as the principal cause of chronic painful shoulder in throwers. Knowledge of this "new" pathology and its accurate diagnostic classification are essential for adequate treatment which is fundamentally of rehabilitative type and which aims to return the athlete to competitive activity as quickly as possible Keywords: acute/athletic injuries/classification/extremity/fracture/hand/IMPINGEMENT/injuries/INJURY/M ULTIDIRECTIONAL INSTABILITY/REPAIR/rotator cuff/ROTATOR CUFF TEARS/shoulder/SLAP LESIONS/traumatology/treatment/upper extremity/upper- extremity Sterling, J.C., Calvo, R.D. and Holden, S.C. (1991), An Unusual Stress-Fracture in A Multiple Sport Athlete. Medicine and Science in Sports and Exercise, 23 (3), 298-303. Abstract: Most overuse injuries are a direct result of repetitive stresses which may create a condition of maltraining. Young athletes are no exception to this rule. Swimming and baseball both create stresses to the humerus which may result in injuries to the shoulder and upper extremity. Stress fractures (fatigue fractures) are usually limited to the lower extremity (i.e., tibia or metatarsal). Upper extremity stress fractures, especially of the humerus, are very uncommon. Precipitating factors include repetitive stresses, low grade external forces, rapid application of muscular force to the bone, or an underlying disease or pathologic weakness of the bone. The majority of these fractures are primarily due to abnormal and repetitive stresses to bones. This case study examines the mechanism of injury, clinical presentation, and treatment of a clinically apparent stress fracture which ultimately converted to an overt humerus fracture in a 14-yr-old cross-trained athlete Keywords: BASEBALL THROWING/bone/EXERCISE/extremity/fracture/fractures/humerus/injuries/injury/ OVERUSE INJURIES/OVERUSE INJURY/stress fracture/SWIMMING/treatment/ UPPER EXTREMITY/upper-extremity Meyers, M.C., Sterling, J.C. and Souryal, T.O. (2003), Radiographic findings of the upper extremity in collegiate rodeo athletes. Medicine and Science in Sports and Exercise, 35 (4), 543-547. Abstract: Introduction & Purpose: Upper-extremity trauma has been extensively studied in traditional sports to reduce predisposition to injury. Limited attention has been directed toward nontraditional, high-collision sports such as rodeo. Therefore, the purpose of this study was to quantify radiographic changes of the upper extremity in collegiate rodeo athletes after seasonal competition. Methods: After written informed consent, 25 male roughstock athletes (age=21.0+/-1.4 yr; height=174.5+/-5.7 cm; weight=73.0+/-5.9 kg) competing in the College National Finals Rodeo reported for standard anteroposterior and lateral x-rays of both arms (hand/wrist, forearm, and
    • elbow). Results: Radiographs revealed 82 total abnormalities involving both left and right extremities of all athletes. Hand/wrist findings included 24 fractures (19 healed, 5 nonunion) involving scaphoid, styloid, interphalangeal, phalanx, and various metacarpals. Fourteen cases of degenerative joint disease (scaphoid/radius, scapholunate, triangulofibrocartilage, and carpometacarpal), joint calcification, dorsal instability, and scapholunate dissociation were observed. Forearm findings included ulnar cortical thickening, healed stress fractures, and plates/screws. Elbow findings revealed ulnar/humeral degeneration, calcification, posterior olecranon tip fracture, traction spurs, and joint space narrowing with loose bodies. Conclusion: Findings indicate a significant amount of radiographic evidence of repetitive trauma to the upper extremity in this sport. Development and mandatory use of effective external bracing beyond existing techniques at the collegiate level of competition should be encouraged Keywords: elbow/EXERCISE/extremities/extremity/forearm/fracture/fractures/hand/wrist/injury /INJURY/olecranon/sport/sports medicine/THUMB/trauma/upper extremity/upper- extremity/x-ray Doi, K. and Sakai, K. (1994), Vascularized Periosteal Bone-Graft from the Supracondylar Region of the Femur. Microsurgery, 15 (5), 305-315. Abstract: Free, vascularized thin corticoperiosteal grafts and small periosteal bone grafts harvested from the supracondylar region of the femur are described. These grafts are nourished from the articular branch of the descending genicular artery and vein. Thin corticoperiosteal grafts consist of periosteum with a thin layer of outer cortical bone and include the cambium layer, which has a better osteogenic capacity. This graft is elastic and readily conforms to the recipient bed configuration. Thin corticoperiosteal grafts were used to treat 11 patients with fracture non-union of an upper extremity that had no massive bone defects. Early, rapid union occurred in all patients except three: one in which the anastomosed vessel became obstructed and two in which the internal fixation of the fracture was unsecured. The small bone grafts consist of periosteum, full thickness cortex, and the underlying cancellous bone. This graft can be successfully harvested without disturbing the vascularity, unlike the currently used vascularized bone grafts. This graft was used to treat three patients with avascular necrosis of the body of the talus and could prevent the necrotic talus body from progressive collapse in patients in early stages of the disease. One patient with an infectious bone defect of the first metatarsal bone was successfully treated by vascularized bone graft with an accompanying skin flap. (C) 1994 Wiley-Liss, Inc Keywords: bone/extremity/fracture/upper extremity/upper-extremity Paradiso, G. (1997), Monomelic amyotrophy following trauma and immobilization in children. Muscle & Nerve, 20 (4), 425-430. Abstract: Two children aged 9 and 11 years suffered from left elbow sprain and right anterior tibial tuberosity cortical fracture respectively and were treated with plaster cast immobilization for about 30 days. They regained normal strength afterwards, but 9 and 2 months later developed insidious progressive weakness and wasting in the affected limb, mainly evident in the musculature surrounding the site of injury and sparing hand and foot muscles. Two to three years later the condition stabilized. Sensory abnormalities were not found. Electromyographic examination showed neurogenic pattern confined to the impaired extremity. The focal quality and the unusual disposition of muscle involvement suggest a correlation between trauma and/or immobilization and monomelic amyotrophy. (C) 1997 John Wiley & Sons, Inc
    • Keywords: children/DISTAL UPPER EXTREMITY/elbow/extremity/fracture/hand/injury/juvenile amyotrophy/LATERAL-SCLEROSIS/LOWER-LIMB/monomelic amyotrophy/motor neuron disease/MOTOR-NEURON- DISEASE/MUSCLE/SPINAL MUSCULAR-ATROPHY/trauma/trauma immobilization Eoh, W., Eleraky, M. and Sonntag, V.K.H. (1999), Surgical management of cervical spine metastases: A retrospective study. Neuro-Orthopedics, 25 (1-2), 27-37. Abstract: The medical records of eight patients (four men, four women; mean age, 62 years; age range, 46 to 82 years) with metastatic tumor growth along the cervical spine were reviewed retrospectively. Six patients suffered from severe neck pain, and three patients had severe pain and weakness of upper extremity. Two patients had incomplete quadriparesis and were unable to walk. The diagnostic workup consisted of plain radiography of the cervical spine, computed tomography (CT), CT myelography, and magnetic resonance imaging. Three patients had a pathologic fracture of the cervical spine. The most common primary tumor was prostatic carcinoma (n = 3). The cervical lesion was the first manifestation of malignancy in three patients. The tumor involved a single segment of the cervical spine in four patients, two segments in two patients, and three segments in two patients. The vertebral body had collapsed in three cases. Seven patients were treated surgically. The surgical technique was individualized according to the patient's general condition, the site of metastasis on the vertebra, the level involved, and the number of levels. The goals of surgical treatment were early mobilization, pain reduction, and improved quality of life. Depending on the site of pathology, either an occipitocervical decompression with fusion or an anterior-posterior decompression with reconstruction was performed. Typically, the operation was well tolerated by the patients. One patient had a transient cerebrospinal fluid leak. Postoperatively, all patients experienced pain relief. Of the patients with preoperative radiculopathy, three had complete and one had partial relief after surgery. One tetraparetic patient did not undergo surgery because of his poor general condition. The findings suggest that stabilization of the cervical spine is important when metastatic lesions jeopardize stability. Stabilization is effective in relieving pain and preventing quadriplegia Keywords: ANTERIOR/cervical spine/CORD COMPRESSION/CT/DECOMPRESSION/DISEASE/extremity/fracture/LESIONS/ metastases/SURGERY/surgical management/treatment/TUMOR/upper extremity/upper-extremity Tanabe, M., Watanabe, T., Matsumoto, S., Okamoto, H. and Shirakashi, K. (1999), Avulsion fracture of the anterior half of the foramen magnum involving the bilateral occipital condyles and the inferior clivus - Case report. Neurologia Medico- Chirurgica, 39 (5), 358-361. Abstract: A 38-year-old male presented with an avulsion fracture of the anterior half of the foramen magnum due to a traffic accident. He had palsy of the bilateral VI, left IX, and left X cranial nerves, weakness of his left upper extremity, and crossed sensory loss. He was treated conservatively and placed in a halo brace for 16 weeks. After immobilization, swallowing, hoarseness, and left upper extremity weakness improved. Hyperextension with a rotatory component probably resulted in strain in the tectorial membrane and alar ligaments, resulting in avulsion fracture at the sites of attachment, the bilateral occipital condyles and the inferior portion of the clivus. Conservative treatment is probably optimum even for this unusual and severe type of occipital condyle fracture
    • Keywords: avulsion/clivus/CT/extremity/foramen magnum/fracture/INJURY/NERVE PALSY/occipital condyle/traffic/TRAUMA/trauma/treatment/upper extremity/upper-extremity Carlson, N. and Logigian, E.L. (1999), Radial neuropathy. Neurologic Clinics, 17 (3), 499-+. Abstract: The radial nerve is the largest branch of the brachial plexus, and is commonly involved in upper extremity mononeuropathies. The radial nerve is primarily responsible for motor innervation of the upper extremity extensors, as well as receiving cutaneous innervation from most of the posterior arm, forearm, and hand. There are a variety of sites at which the radial nerve is susceptible to trauma and entrapment. Localizing radial nerve lesions is dependent on clinical knowledge of radial nerve anatomy, and sensory and motor examination Keywords: COMPRESSIVE NEUROPATHIES/CONDUCTION/DIGITAL NERVE/ENTRAPMENT/extremity/forearm/FRACTURE/hand/MUSCLE/NERVE PALSY/RELEASE/THUMB/trauma/TUNNEL-SYNDROME/upper extremity/upper-extremity Hefti, F., Vonlaer, L. and Morscher, E. (1991), Principles of the Pathogenesis of Posttraumatic Axis Deviations During the Growth Years. Orthopade, 20 (6), 324-330. Abstract: Deviations of the axis or leg-length discrepancies after fractures in children and adolescents can be due to growth disturbances or can be the result of incomplete reduction of the fracture. We distinguish between four types of growth disturbances. In type I, the overall growth activity of the cartilage is increased; growth is then enhanced, which results in the affected bone being too long without deviation; this usually occurs after fractures of the metaphysis or diaphysis. In type II, activity, the epiphyseal cartilage is severely impaired or completely arrested. The direction of growth is unchanged. This results in shortening of the bone, usually due to severe damage to the germination zone of the growth cartilage after destruction of the vessels or infection. In type III, growth of the epiphyseal plate is partially stimulated. The consequence of this disturbance is deviation of the axis with overgrowth (this is in fractures of the proximal tibia). Type IV is characterized by an asymmetric arrest of growth. This results in deviation of the axis and shortening. The cause of such growth arrest can be epiphyseolysis or epiphyseal fracture. The defect in growth cartilage heals with a bone bridge. This is a very serious kind of growth disturbance, and it occurs in only 1% of all fractures before skeletal maturity. Correction after incomplete reduction of fractures during growth can be direct or indirect and specific or nonspecific. Direct corrections occur in combination with fracture healing; indirect corrections occur with physiological changes of the growing skeleton without association with the healing process. We have observed a direct correction after side-to-side translation or after axis deviations in the frontal or sagittal plane. These are specific corrections. Rotational deformities must be corrected indirectly. This kind of repair is non-specific, such as after shortening or lengthening. We can easily tolerate deviations at the upper extremity except at the diaphysis of the forearm. The potential for spontaneous correction should be exploited. At the lower extremity no deviations should be tolerated except for moderate rotational deformities of the femur. Prolonged remodelling stimulates the growth cartilage. This results in leg lengthening. This can best be avoided by perfect reduction of the fracture Keywords: ADOLESCENT/axis/bone/CHILD/children/CORRECTION/DEVIATION/ EPIPHYSEAL PLATE/extremity/forearm/FRACTURE/FRACTURE
    • HEALING/fractures/GROWTH/GROWTH AGE/GROWTH CARTILAGE/GROWTH DISTURBANCE/leg/LEG- LENGTH DISCREPANCY/upper extremity/upper-extremity Regel, G., Weinberg, A.M., Seekamp, A., Blauth, M. and Tscherne, H. (1997), The complex injury of the elbow. Orthopade, 26 (12), 1020-1029. Abstract: The complex injury is characterized by a fracture and/or dislocation of the elbow in association with a serial injury of the upper extremity, or a severe soft tissue trauma, or a prolonged ischemia caused by vascular injury or compartment syndrom. They are defined as complex injuries because their treatment differs from that of a simple fracture implying that standardized concepts usually cannot be employed. The results of primary treatement show a high rate of complications. They are accompanied by functional deficits including pseudarthrosis and ankylosis. As a consequence, ulnar neuropathy may occur. Inadequate treatment leads to delayed rehabilitation and several secondary operations. The main goal points at the reconstruction of the elbow joint to restore function. Therefore, the logistical pathway of individual therapy is the key for success. The operation has to include fracture stabilisation of all injuries of the upper extremity. Only stable osteosynthesis makes early mobilisation possible. Transfixation of the elbow joint should be reserved for exceptional cases. The principals of AO have proven to be practical both for the distal humerus and the proximal forearm. Successful reconstruction of the elbow joint often demands extended approaches. ORIF of the proximal ulna can be achieved by indirect reposition techniques. Dynamic stabilisation should be established by conservation of the radial head and coronoid process. For treatment of soft tissue injury it is necessary to undertake local reconstructive measures. Operative treatment is widely indicated for forearm compartment syndrom. Diagnosis and therapy of possible accompanying vascular injury should be made early to avoid prolonged ischemia. Operative treatement of nerve injury is only indicated in case of sharp dissection of the nerve. Otherwise the reconstruction should be performed, but not earlier than three months. Rehabilitation outcome depends on primary therapy. Sufficient functional results are only achieved after early mobilisation and intensive physiotherapy. If necessary, arthrolysis is planned early and combined with removal of implants at 6 months post injury Keywords: complex trauma/dislocation/elbow/elbow joint/extremity/forearm/fracture/FRACTURES/humerus/injuries/injury/operative management/osteosynthesis/outcome/rehabilitation/therapeutical principals/trauma/treatment/ulna/upper extremity/upper-extremity/vascular injury Stein, J.S. and Strauss, E. (1995), Gunshot Wounds to the Upper Extremity - Evaluation and Management of Vascular Injuries. Orthopedic Clinics of North America, 26 (1), 29-35. Abstract: Upper extremity gunshot wounds often pose many clinically challenging problems. Vascular trauma is frequently associated with injuries to nearby nerves, veins, and bones. Early recognition of vascular injury is dependent on careful examination and liberal use of arteriography. Normal distal pulses may be present despite significant arterial trauma. Vascular reconstruction should follow accepted principles of repair. When unstable fractures coincide with vascular injuries, arterial perfusion may be reestablished initially using an intraluminal shunt. Definitive arterial reconstruction can then follow stabilization of the fracture. Vascular repair is successful in more than 90% of cases, but severe long-term functional limitations result from associated nerve injury Keywords:
    • ARTERIOGRAPHY/EXPERIENCE/extremity/fracture/fractures/injuries/injury/TR AUMA/vascular injury/veins Steinberg, B. (2002), Acute wrist injuries in the athlete. Orthopedic Clinics of North America, 33 (3), 535-+. Abstract: The athlete represents a special population in which injuries can occur either from a single acute traumatic event or as part of a continuum of overuse that leads to osseous or soft tissue failure. The spectrum of overuse with superimposed acute trauma makes the evaluation of the upper extremity in the competitive athlete more challenging. The expectation of this population for quick, full, painless recovery, coupled with the desire to return to the sport that caused the injury, makes the treatment difficult as well. This article will discuss athletic injuries of the forearm and wrist with an emphasis on evaluation, treatment, and criteria for return to play. Following a high- energy collision where there is immediate swelling and obvious deformity, the appropriate treatment is splinting and radiography of the forearm, wrist, and hand after initial complete neurovascular evaluation. This evaluation should also include assessment for compartment syndrome. Clinical evaluation with palpation comparing the compliance of the forearm and hand compartments to the uninjured contralateral limb can give an early assessment of compartment pressure [1]. If elevated compartment pressures are suspected, intercompartmental monitoring and possible surgical decompression is planned [2,3]. In our experience, as well as the literature [4], even blunt trauma without fracture (especially in football) can lead to compartment syndrome. In the acute high-energy athletic injury, surgical intervention follows the rules for general orthopaedic trauma [5]. Open fractures, markedly displaced fractures, compartment syndrome, and dislocations all require immediate intervention. Fortunately, most athletic injuries fall outside this category and can be treated on a less emergent basis. The rest of this article will focus on the more commonly seen athletic injuries of the wrist and forearm Keywords: acute/ANATOMY/DISTAL RADIUS/ELBOW/extremity/fall/forearm/fracture/fractures/hand/injuries/injury/MA NAGEMENT/SCAPHOID FRACTURES/sport/trauma/treatment/upper extremity/upper-extremity/wrist Lauritzen, J.B., Schwarz, P., Mcnair, P., Lund, B. and Transbol, I. (1993), Radial and Humeral Fractures As Predictors of Subsequent Hip, Radial Or Humeral Fractures in Women, and Their Seasonal- Variation. Osteoporosis International, 3 (3), 133-137. Abstract: Hip fractures are common in elderly women, and early risk assessment of future hip fractures is relevant in relation to prevention. We studied the predictive value of radial and humeral fractures in women. The influence of weather conditions on the risk was also studied. Women aged 20-99 years with a fracture of the distal radius (n = 1162) or proximal humerus (n = 406) were followed for 0 to 9 years. The relative risk (RR) and 95% confidence limits (CL) of subsequent fracture among women suffering radial or humeral fractures compared with the background population were calculated. Women 60-79 years of age who had suffered a fracture of the distal radius or proximal humerus had relative risks of sustaining a hip fracture of 1.9 (1.3-2.6, 95% CL) and 2.5 (1.3-3.6, 95% CL) respectively. The relative risk of hip fracture was highest within the first years following a fracture of the radius or the humerus. Women suffering an upper extremity fracture (radius or humerus) in snowy or icy weather had a marginally increased risk (RR = 1.3, 0.4-2.3, 95% CL and RR = 1.8, 0.3-3.4, 95% CL) for a later hip fracture. A woman 50 years old with a radial or a humeral fracture had an estimated residual lifetime risk of sustaining a subsequent hip fracture of 17% and 16% respectively compared with 11% for the background
    • population. The moderately increased risk of hip fractures in peri- and postmenopausal women suffering upper extremity fractures may be caused by a greater propensity to fall and/or be related to a higher degree of osteoporosis compared with the background population. For individuals other indicators of hip fracture should also be considered to improve the risk estimation of a later hip fracture Keywords: ACCIDENT DISPOSITION/COLLES FRACTURE/DISTAL FOREARM/elderly/EPIDEMIOLOGY/extremity/fall/fracture/fractures/hip fracture/ HUMERUS/OSTEOPOROSIS/prevention/PROXIMAL FEMUR/RADIUS/RISK/RISK OF HIP FRACTURE/SEASONAL VARIATION/upper extremity/upper extremity fractures/upper-extremity Parfitt, A.M. (1994), The 2 Faces of Growth - Benefits and Risks to Bone Integrity. Osteoporosis International, 4 (6), 382-398. Abstract: Bones grow by two processes: cortical bone is made by periosteal apposition (growth in width), and cancellous bone is made by endochondral ossification (growth in length). In both the axial and appendicular skeleton, about half of peak adult bone mass is accumulated during the adolescent growth spurt, which occurs two years earlier in girls than in boys, and is under pituitary control via interactions between growth hormone and sex hormones. Throughout growth, but particularly during adolescence, the ability of bone to adapt to mechanical loading is much greater than after maturity. This is the main reason why the effects of physical activity on bone are greater in cross-sectional studies in young athletes than in longitudinal studies in previously sedentary adults. In wild animals, by the time growth has ceased, the bones must be as strong as they will ever need to be, and attainment of further strength after cessation of growth would serve no biologic purpose. Adaptation of growing bone to mechanical loading is the purpose of the mechanostat, which enables physiologic adaptation in individuals to establish and maintain a species- specific property of the bones that is determined by evolutionary adaptation in populations. But growth confers risks as well as benefits to the skeleton. The large increase in incidence of upper extremity (particularly lower forearm) fractures, coincident with the adolescent growth spurt in both sexes, is due to an increase in cortical porosity as a consequence of an increase in intracortical bone turnover, which supplies some of the calcium needed by the growing ends of the long bones. This enables an increased demand for calcium to be spread over a longer time, analogous to the cyclic physiologic osteoporosis which occurs during the antler growth cycle in deer. The subsequent decline in cortical porosity is responsible for the continued increase in radial bone density after cessation of growth, referred to as consolidation. In the present state of knowledge, an increased incidence of fracture during the adolescent growth spurt is the inescapable consequence of an appropriate level of physical activity, and is the price that has to be paid in order to maximize bone accumulation during growth and minimize fracture risk in old age Keywords: ADOLESCENT FRACTURES/ALKALINE-PHOSPHATASE/bone/BONE ACCUMULATION/BONE TURNOVER/CALCIUM- METABOLISM/CORTICAL POROSITY/extremity/FACTOR-I/forearm/fracture/fractures/FUNCTIONAL LOAD-BEARING/MECHANISM AND METABOLIC SIGNIFICANCE/MECHANOSTAT/MINERAL-CONTENT/old age/OSTEOPOROSIS/PHOTON-ABSORPTIOMETRY/PHYSICAL ACTIVITY/PHYSICAL-ACTIVITY/POSTMENOPAUSAL WOMEN/PREMENOPAUSAL WOMEN/PUBERTY/SPINAL OSTEOPOROSIS/upper extremity/upper-extremity
    • Graafmans, W.C., Bouter, L.M. and Lips, P. (1998), The influence of physical activity and fractures on ultrasound parameters in elderly people. Osteoporosis International, 8 (5), 449-454. Abstract: In this cross-sectional study we investigated the relationship between ultrasound measurements in the calcaneus versus daily physical activity and fractures sustained in the past in elderly subjects. Ultrasound measurements were performed at both heels, which enabled us to examine determinants of differences between contralateral heels. Participants were 132 men and 578 women, aged 70 years and over (mean age and standard deviation (SD): 83 +/- 6 years), living in homes for the elderly (n = 343) or apartment houses for the elderly (n = 367). Broadband ultrasound attenuation (BUA) and speed of sound (SOS) were measured in the right and left calcaneus. The median difference (and interquartile range) between the two heels for BUA and SOS, expressed as a percentage of the mean value for each individual, was 9.6% (4.2-15.7%) and 1.0% (0.4-1.7%), corresponding to 25% and 40% of the study population SD, respectively. Greater differences in BUA between the two heels were associated with variables indicating poorer functional status, such as past fractures at the lower extremities. The level of daily physical activity was obtained by means of a questionnaire regarding household and leisure activities. Subsequently sumscores were calculated for daily physical activity and a subscore indicating weight-bearing physical activity. After adjustment for age, gender, residence, and body weight, physical activity scores were positively linearly related to both BUA and SOS. Each 5 point increase on the weight-bearing physical activity score, corresponding to, for example, walking for 2.5 h per week, was associated with a difference in BUA of 4.7 dB/MHz and in SOS of 5.1 m/s, which is similar to the differences associated with 10 kg higher body weight, or 10 years younger age. After the age of 50 years, 47 subjects had fractured a hip, 61 subjects had sustained another lower extremity fracture, 104 subjects a wrist fracture, and 62 subjects another upper extremity fracture. After adjusting for age, gender and residence, odds ratios for all fracture types in the lowest terciles of BUA and SOS versus the highest terciles ranged from 1.9 to 3.8. This study showed significant differences in ultrasound measurements between the left and the right heel, indicating that measurements at both sides are necessary for optimal evaluation of bone strength. Furthermore, after careful adjustments, ultrasound parameters had higher values with higher daily physical activity in elderly subjects and discriminated subjects with a history of fracture from those without Keywords: ATTENUATION/bone/BONE-MINERAL DENSITY/CALCANEUS/elderly/EXERCISE/extremities/extremity/fracture/fractur es/HIP-FRACTURES/MASS/OSTEOPOROSIS/physical activity/POPULATION/POSTMENOPAUSAL WOMEN/RISK/ultrasound/upper extremity/upper-extremity/weightbearing/wrist/wrist fracture Palvanen, M., Kannus, P., Parkkari, J., Pitkajarvi, T., Pasanen, M., Vuori, I. and Jarvinen, M. (2000), The injury mechanisms of osteoporotic upper extremity fractures among older adults: A controlled study of 287 consecutive patients and their 108 controls. Osteoporosis International, 11 (10), 822-831. Abstract: The risk factors for falls in older adults are well known but knowledge on the direct injury mechanisms that result in various osteoporotic fractures has been very sparse. The purpose of this study was therefore to clarify the injury mechanisms of osteoporotic upper extremity fractures of older adults and to compare these mechanisms with those of the control fallers, and in this way to obtain reliable insight into the etiology and pathogenesis of upper extremity fractures and thus to
    • enable fracture prevention. One hundred and twelve patients with a fresh fracture of the proximal humerus, 65 patients with an elbow fracture, 110 patients with a wrist fracture and 108 controls (no fracture, or a fracture other than the case fracture) were interviewed and examined between September 1995 and December 1997. The inclusion criteria of the subjects were that the patient was 50 years of age or older at the time of the accident, and that the fracture/injury had occurred as a result of low- energy trauma (typically a fall from standing height or less) within a week before the interview and examination. In 97% of patients with a proximal humerus or elbow fracture, and in all patients (100%) with a wrist fracture, the fracture was a result of a fall. In the control group this figure was 93%. In a polychotomous logistic regression analysis the intergroup differences in the fall directions (adjusted by gender, age and functional capacity) were statistically highly significant (chi (2) = 43.6, d.f. = 15, p<0.001). Most of the patients with a proximal humerus fracture or elbow fracture reported that they had fallen 'obliquely forward' (43% and 38%) or 'to the side' (29% and 26%), whereas in the wrist fracture group the main fall direction was also 'obliquely forward' (34%) but the other fall directions (i.e., 'forward', 'to the side', 'obliquely backward' and 'backward') were quite equally represented (13- 19%). The odds ratio (OR) for an obliquely forward fall resulting in a proximal humerus fracture was 3.5 [95% confidence interval (CI) 1.4-9.2), as compared with the fall directions of the controls and the 'obliquely backward' fall direction. In a logistic regression analysis the patients with a wrist fracture managed to break their fall (e.g., with an outstretched arm) more frequently than the patients in the other groups (OR 3.9; 95% CI 2.0-7.3). The patients with a proximal humerus fracture, in turn, managed to break their fall less frequently than the controls (OR 0.33; 95% CI 0.14-0.80). The same was true of the patients with an elbow fracture, although the difference was not significant (OR 0.49%; 95% CI 0.19-1.3). As objective evidence for a direct fall-induced impact on the fracture site, 68% of patients with a proximal humerus fracture revealed a fresh subcutaneous hematoma on the shoulder/upper arm, while such a hematoma was rare in the controls (2%) (p<0.001). Correspondingly, 62% of patients with an elbow fracture showed a similar hematoma on the elbow area, while this was seen in none of the controls (p<0.001). In patients with a wrist fracture a hand/wrist hematoma was seen in 58% of the victims, as compared with 18% of the controls (p<0.001). The study shows that the most typical osteoporotic upper extremity fractures of older adults have their specific injury mechanisms. A great majority of these fractures occur as a result of a fall and a subsequent direct impact of the fractured site. Effective fracture prevention could be achieved by minimizing the obvious risk factors of falling and reducing the fall- induced impact force with injury site protection Keywords: accidental falls/BONE-MINERAL DENSITY/DISTAL FOREARM/elbow/ elderly/ELDERLY PEOPLE/EPIDEMIOLOGY/extremity/FALL/falls/fracture/fractures/HIP FRACTURE/humerus/IMPACT/impact force/injury/injury mechanisms/NURSING- HOME/osteoporosis/prevention/PROXIMAL HUMERUS/RISK-FACTORS/trauma/ upper extremity/upper extremity fractures/upper-extremity/wrist/wrist fracture Wildner, M., Sangha, O., Clark, D.E., Doring, A. and Manstetten, A. (2002), Independent living after fractures in the elderly. Osteoporosis International, 13 (7), 579-585. Abstract: Although fractures are an important source of disability among the growing elderly populations of industrialized societies, patient-centered multidimensional outcome information is scarce. The purpose of this study was to quantify the natural
    • history of recovery from fractures of the upper and lower extremities, From the 1994/95 WHO MONICA survey in Augsburg, Germany, we selected all persons aged 58-78 years who had experienced a fracture during the preceeding 10 years, along with a control population twice as large. The Health Assessment Questionnaire (HAQ) and the Medical Outcomes Study Short Form 36 (SF-36) were administered to these subjects in 1998. Patients' recollection of fracture type and location were validated against medical records. The most recent fracture was in the upper extremity in 45 cases, lower extremity in 55 cases and elsewhere in 46 cases. Extremity fractures resulted in persistent and measurable impairment of the activities of daily living or general quality of life in patients 65 years or older, especially if the femur was involved. More than 40% of the interindividual variation of functional disability in the study group could be explained by age, sex, history of a fracture within 12 years and perceived difficulties walking. Existing generic and specific musculoskeletal outcome measurement instruments thus allow the assessment of functional recovery and health status after fractures in an elderly population. Geriatric assessment following fractures at higher age may improve ability to live independently. Difficulty walking deserves special attention, as it is associated with more general functional disability among the elderly Keywords: activities of daily living/disability/elderly/extremities/extremity/fracture/fractures/independence/osteop orosis/outcome/outcomes/OUTCOMES/QUESTIONNAIRE/survey/upper extremity/ upper-extremity/VALIDITY/WOMEN Magney, J.E., Staplin, D.H., Flynn, D.M. and Hunter, D.W. (1993), A New Approach to Percutaneous Subclavian Venipuncture to Avoid Lead Fracture Or Central Venous Catheter Occlusion. Pace-Pacing and Clinical Electrophysiology, 16 (11), 2133-2143. Abstract: Pacemaker and defibrillator leads and central venous catheters placed by commonly recommended techniques have been found to pass through the subclavius muscle, the costocoracoid ligament, or the costoclavicular ligament before entering veins medial to the first rib. Entrapment by these soft tissues subjects leads and catheters to stresses imposed by movements of the ipsilateral upper extremity. Accordingly, a new approach has been developed that introduces the lead or catheter into the subclavian vein near the lateral border of the first rib. This placement avoids soft tissue entrapment and may extend the longevity of leads and catheters Keywords: CENTRAL VENOUS CATHETERS/extremity/PACEMAKER LEAD/PACEMAKER LEADS/rib/SUBCLAVIAN VENIPUNCTURE/upper extremity/upper-extremity/veins Smith, G.A. (1998), Injuries to children in the United States related to trampolines, 1990-1995: A national epidemic. Pediatrics, 101 (3), 406-412. Abstract: Study Objective. To describe the epidemiology of trampoline- related injuries among children in the United States. Design. A retrospective analysis of data for children 18 years old and younger from the National Electronic Injury Surveillance System of the United States Consumer Product Safety Commission for 1990 through 1995. Results. There were an estimated 249 400 trampoline-related injuries [95% confidence interval (CI), 166 300-332 500] to children 18 years old and younger treated in hospital emergency departments in the United States during the 6-year study period. The number of injuries increased by 98% from 29 600 in 1990 to 58 400 in 1995, with an average of 41 600 (95% CI, 27 700-55 500) injuries per year, or 59.4 injuries per 100 000 United States children per year (95% CI, 39.6- 79.3). The median age of injured children was 10 years, and 50% were males. Ninety-three
    • percent of injuries occurred at home. Injuries to the extremities predominated among children of all ages and accounted for more than 70% of all injuries. This study identified several age-specific injury patterns. There was an inverse relationship between age versus the relative frequency of upper extremity injuries, and fractures and dislocations; and there was a direct relationship between age versus lower extremity injuries and soft tissue injury. There was also an inverse relationship between age versus facial injuries, head and neck injuries, and lacerations. Annually, an estimated 1400 children (95% CI, 800-2000), or 2.0 per 100 000 United States children (95% CI, 1.1-2.9), required hospital admission or interhospital transfer because of a trampoline- related injury. This represented 3.3% of all children with a trampoline-associated injury. Fractures or dislocations accounted for 83% of injuries among admitted or transferred children, and children with a fracture or dislocation were more likely to be admitted or transferred to another hospital (8.4%) than children with other types of injury (relative risk, 10.80; 95% CI, 9.40 < relative risk < 12.29). Among children released home from the emergency department, soft tissue injuries (53%), fractures or dislocations (30%), and lacerations (14%) were the most common injuries treated. Conclusion. Injuries related to trampolines, especially backyard trampolines, are an important cause of pediatric morbidity. These injuries have also resulted in death. The rapid increase in the number of trampoline- related injuries to children during recent years is evidence that current prevention strategies are inadequate. Children should not use trampolines at home, and the sale of trampolines for private recreational use should be stopped Keywords: children/dislocation/emergency department/epidemiology/extremities/extremity/fracture/fractures/injuries/injury/inju ry epidemiology/injury patterns/pediatric/pediatrics/prevention/QUADRIPLEGIA/SPINE/SURVEILLANC E/trampoline/trauma/upper extremity/upper-extremity Waltzman, M.L., Shannon, M., Bowen, A.P. and Bailey, M.C. (1999), Monkeybar injuries: Complications of play. Pediatrics, 103 (5), art-e58. Abstract: Background. Playground equipment resulted in >200 000 injuries from 1990 to 1994, according to the Consumer Product Safety Commission; 88% were attributable to climbers (monkeybars/jungle gyms [MB/JGs]), swings, and slides. Equipment-specific injury requiring emergency department (ED) evaluation has not been reported previously. Objective. To describe the spectrum of significant MB/JG- related injuries. Methods. A 2-year retrospective chart review was performed using the computerized charting system at a large urban Children's Hospital/Regional Pediatric Trauma Center with 50 000 ED visits per year. A telephone survey also was conducted after the chart review to obtain additional information concerning the injury location, the surface type below the equipment, and the presence of adult supervision. Results. A total of 204 patients were identified. Mean age was 6.2 years (range, 20 months to 12 years): 114 (56%) were male. A seasonal variation was noted with June to August accounting for 43% of visits. Injuries included fractures in 124 (61%), contusions in 20 (10%), neck and back strains in 17 (8%), lacerations in 16 (8%), closed held injuries in 10 (5%), abdominal trauma in 5 (3%), genitourinary injuries in 5 (3%), and miscellaneous injuries in the remainder. Among fractures, 90% were fractures of the upper extremity; 48 (40%) were supracondylar fractures. One child sustained a C7 compression fracture. Abdominal injuries included 1 child who sustained a splenic laceration. All genitourinary injuries (2 vaginal hematomas, 1 vaginal contusion, 1 penile laceration, and 1 urethral injury) were from straddle- type injuries. Fifty-one (25%) patients were admitted to the hospital. Of these, 47
    • (92%) required an operative procedure (orthopedic reduction or vaginal examination under anesthesia). Analysis of the telephone data revealed that the surface did not influence the injury type. Of the 79 fractures, 30 occurred on "soft surfaces." injury type was associated significantly with chronologic age. Younger children (1 to 4 years of age) sustained more long-bone fractures than did older children. The presence of adult (at least 18 years of age) supervision, did not influence the occurrence of fractures. Conclusions. These data suggest that 1) a significant proportion (25%) of MB/JG-related injuries that are evaluated in the ED require hospitalization; 2) most of the injuries resulting in admission will require operative intervention (92%); 3) the surface below the equipment has no influence on the type or severity of the injury; 4) younger children are more likely to sustain long-bone fractures than are older children; and 5) adult supervision does not influence the injury pattern. These data identify the need for additional investigation of means of making MB/JGs safer for child use Keywords: child/CHILDREN/emergency department/extremity/fracture/fractures/injuries/injury/jungle gym/monkeybar/PLAYGROUND EQUIPMENT/playground equipment/severity/SURFACES/survey/trauma/upper extremity/upper-extremity Mcclure, P.W. and Flowers, K.R. (1992), Treatment of Limited Shoulder Motion - A Case-Study Based on Biomechanical Considerations. Physical Therapy, 72 (12), 929-936. Abstract: This article describes the management of a 57-year-old female patient following a fracture and dislocation of the right humeral head. The treatment of the patient involved the use of thermal agents; manual therapy continuous passive motion, and splinting of the arm in an elevated position. We describe an approach to treatment of limited shoulder motion that is focused on identifying and applying tension to restricting structures rather than restoration of translatory gliding movements of the humeral head. Our treatment approach is based on recent data from biomechanical studies that challenge the concave-convex theory of arthrokinematic motion first described by MacConaill. We believe that tension in capsular tissues, rather than joint surface geometry, may control the translatory movements of the humeral head. The rationale for treatment involving low-load prolonged stress to tissues in the form of continuous passive motion and splinting is discussed as well as potential limitations of more brief forms of stress such as joint mobilization and manual stretching Keywords: dislocation/fracture/JOINT INSTABILITY/KINESIOLOGY BIOMECHANICS/MANUAL THERAPY/SHOULDER/SHOULDER JOINT/treatment/UPPER EXTREMITY Boon, A.J., Smith, J. and Laskowski, E.R. (1999), Snowboarding injuries - General patterns, with a focus on talus fractures. Physician and Sportsmedicine, 27 (4), 94-+. Abstract: Injury patterns in snowboarding differ from those in Alpine skiing. Snowboarders tend to have fewer knee and thumb injuries than skiers but more upper-extremity trauma, fractures in general, and ankle injuries. Of particular concern in snowboarding Is fracture of the lateral process of the talus (LPT), which masquerades as an inversion ankle sprain, is often missed, and can lead to significant disability. Signs are typically similar to those of inversion sprains, but pain on palpation of the lateral process can be helpful in diagnosis. Standard radiographs often do not show the fracture, so CT or lateral tomography may be required. The most minor, nondisplaced LPT injuries may heal with casting and rehab, but more severe fractures typically require surgery
    • Keywords: ANKLE/CT/disability/fracture/fractures/injuries/LATERAL PROCESS/radiographs/snowboarding/TOMOGRAPHY/trauma/upper extremity/upper-extremity Sakai, K., Doi, K. and Kawai, S. (1991), Free Vascularized Thin Corticoperiosteal Graft. Plastic and Reconstructive Surgery, 87 (2), 290-298. Abstract: This paper describes a new thin corticoperiosteal graft harvested from the medial condylar and supracondylar areas of the femur. It is based on the articular branch of the descending genicular artery and vein and consists of periosteum with a thin (0.5 to 1.0 mm) layer of outer cortical bone. By retaining the cortex, the cambium layer is preserved, and this is thought to have a better osteogenic capacity than vascularized periosteal grafts. This graft was used to treat six patients with fracture nonunion of the upper extremity in which conventional treatment had failed. Uneventful bony union was achieved in all patients within 10 weeks Keywords: bone/BONE-GRAFTS/CIRCULATION/CLEFT/extremity/FLAP/fracture/ MICROVASCULAR ANASTOMOSES/PALATE/PEDICLES/PERIOSTEAL GRAFTS/RABBITS/REPAIR/treatment/upper extremity/upper-extremity Duma, S.M., Schreiber, P.H., McMaster, J.D., Crandall, J.R. and Bass, C.R. (2002), Fracture tolerance of the male forearm: the effect of pronation versus supination. Proceedings of the Institution of Mechanical Engineers Part D- Journal of Automobile Engineering, 216 (D8), 649-654. Abstract: This paper presents the dynamic injury tolerance of the male forearm, derived from dynamic three-point bending tests using ten male cadaver upper extremities. The impact loading conditions were chosen to be representative of those observed during upper extremity interaction with frontal air bags. Using matched forearm pairs, it was determined that the forearm is significantly (p = 0.01) stronger in the supinated position, 126 +/- 13 N in, than in the pronated position, 108 +/- 8 N in. Two distinct fracture patterns were seen for the pronated and supinated groups. In the supinated position the average difference in fracture time between the radius and ulna was not significantly different (p = 0.24); however, the pronated tests yielded an average difference in fracture time that was significantly different (p = 0.05), with the ulna breaking before the radius in every test. This trend implies that in the pronated position the ulna and radius are loaded independently, while in the supinated position the ulna and radius are loaded together as a combined structure. To produce a conservative injury criterion, only the data from the pronated tests were included for an average failure tolerance of 108 N in. It is anticipated that these data will provide injury reference values for the male forearm during driver air bag loading Keywords: air bag/air bags/automobile/extremities/extremity/forearm/fracture/impact/injury/pronation/supi nation/ulna/upper extremity/upper-extremity Bass, C.R., Duma, S.M., Crandall, J.R., George, S., Kuppa, S., Khaewpong, N., Sun, E. and Eppinger, R. (2002), Comparison of upper extremity test devices for the evaluation of frontal air bags. Proceedings of the Institution of Mechanical Engineers Part D- Journal of Automobile Engineering, 216 (D10), 795-803. Abstract: This study examines the response of two upper extremity test devices under driver-side air bag deployment to contribute to the development of dummy surrogates for the investigation of primary contact forearm injuries during air bag deployments. The first of these test devices, the SAE 5th Percentile Female Arm (SAE arm), is an anthropomorphic representation of a small female forearm and upper arm that is instrumented with load cells, accelerometers and potentiometers to
    • enable the determination of upper extremity kinematics and dynamics. The second, the Research Arm Injury Device (RAID), is a simple beam test device designed for detailed investigation of moments and accelerations resulting from close contact in the initial stages of air bag deployment. It includes strain gauges distributed along its length to measure the distribution of moment applied by the air bag deployment. The study used four air bags representing a wide range of aggressivities in the current automobile fleet. Logistic risk functions for forearm fracture were developed using existing cadaver studies and the moment response of each test device. These risk functions indicate that, for 50 per cent risk of ulna or ulna/radius fractures, the SAE arm peak forearm moment is 67 N in while the RAID peak forearm moment is 373 N m Keywords: air bag/air bags/automobile/extremity/forearm/fracture/FRACTURE/fractures/INJURIES/RAID /ulna/upper extremity/upper-extremity Spence, L.D., Gironta, M.G., Malde, H.M., Mickolick, C.T., Geisinger, M.A. and Dolmatch, B.L. (1999), Acute upper extremity deep venous thrombosis: Safety and effectiveness of superior vena caval filters. Radiology, 210 (1), 53-58. Abstract: PURPOSE: To evaluate the safety and effectiveness of percutaneous filter placement in the superior vena cava for prevention of pulmonary embolism (PE) due to acute upper extremity deep venous thrombosis (DVT) in patients with contraindications to or unsuccessful anticoagulation. MATERIALS AND METHODS: Forty-one patients with acute upper extremity DVT and contraindications to or unsuccessful anticoagulation underwent percutaneous placement of a superior vena caval filter for prevention of PE. Four types of filters were used. Follow-up chest radiographs were used to detect filter migration, dislodgment, and fracture. Placements of central venous and Swan-Ganz catheters after filter insertion were recorded. Patients were followed up clinically for evidence of superior vena cava syndrome and PE. Kaplan-Meier survival rates were determined. Follow-up was 1 day to 221 weeks. RESULTS: No complications such as filter migration, dislodgment, or fracture occurred (median follow-up, 12 weeks). No patients developed clinical evidence of PE due to upper extremity thrombosis or superior vena cava syndrome (median follow-up, 15 weeks). Catheters were placed subsequent to filter placement in 23 patients (56%) without complication. CONCLUSION: Percutaneous filter placement in the superior vena cava is a safe and effective method for preventing symptomatic PE due to acute upper extremity DVT in patients in whom therapeutic anticoagulation has failed or is contraindicated Keywords: acute/AXILLARY/CLINICAL- EXPERIENCE/embolism/extremities/extremity/filters/fracture/GREENFIELD FILTER/interventional procedure/PLACEMENT/prevention/PROGRESS/pulmonary/PULMONARY- EMBOLISM/radiographs/thrombosis/upper extremity/upper-extremity/VEIN- THROMBOSIS/veins/venae cavae Bouaziz, H., Mercier, F.J., Narchi, P., Poupard, N., Auroy, Y. and Benhamou, D. (1997), Survey of regional anesthetic practice among French residents at time of certification. Regional Anesthesia, 22 (3), 218-222. Abstract: Background and Objectives. A survey of anesthesia practice was conducted among French residents in anesthesia at the end of their training. This study was performed mainly to evaluate the residents' experience in peripheral nerve blocks. Methods. Two short clinical cases were proposed to all French residents during a telephone interview immediately before their certification The first described the
    • case of a young asthmatic patient admitted for an elbow fracture. The second described an elderly woman with severe aortic stenosis admitted for a supracondylar fracture of the femur. A questionnaire had been prepared and was filled in during the interview. Each resident was asked to answer according to the actual choice he or she would have made. For both cases, when general anesthesia was chosen first, the next question was to discuss which regional anesthesia would be used if general anesthesia had to be discarded. In that way, the practical knowledge about most common peripheral nerve blocks learned during residency was investigated. Results. Of 77 residents registered as being at the end of their residency, 8 were on either sabbatical or maternity leave. Regional anesthesia was the first choice in 78% and 57% of cases for the first and second clinical cases, respectively. The regional anesthetic techniques chosen were axillary block (66%), interscalene block (31%), and intravenous regional anesthesia (3%) for case 1 and combined lumbar plexus and sciatic block (36%), epidural anesthesia (30%), single-shot spinal anesthesia (18%), and continuous spinal anesthesia (16%) for case 2. Throughout the residency of the group, 32 +/- 2 axillary blocks, 12 +/- 2 interscalene blocks (axillary vs interscalene, P < .0001), 21 +/- 3 femoral blocks, and 10 +/- 2 sciatic blocks (femoral vs sciatic, P < .0001) had been performed (mean rt SEM). They had also performed 2.5 +/- 0.5 continuous spinal anesthesias and 17 +/- 3 intravenous regional anesthesias respectively. Upper extremity blocks were more often used during residency than lower extremity blocks (44 +/- 3 vs 31 +/- 4, P < .01). A peripheral nerve stimulator was routinely used by 83% of residents. Conclusion. French residents in anesthesiology at time of certification are better trained for peripheral nerve blocks of the upper extremity than for those of the lower extremity. Axillary plexus and femoral nerve block are the most widely used blocks, probably reflecting the techniques the most mastered among teachers. Finally, the extensive use of a peripheral nerve stimulator by residents is probably the result of the widespread use of this device by teachers in France Keywords: axillary block/elbow/elderly/extremity/femoral nerve block/fracture/French residency training/interscalene block/peripheral nerve block/sciatic nerve block/survey/upper extremity/upper-extremity Vichard, P. and Gagneux, E. (1995), A rare fracture of the distal end of the femur - Mechanism and therapeutic implications. Revue de Chirurgie Orthopedique et Reparatrice de l Appareil Moteur, 81 (8), 736-740. Abstract: The authors present a curious type of fracture of the distal end of the femur. They discuss the mechanism and the factors responsible for that lesion. The treatment and result are finally presented. Material A 65 years old female, submitted to a crash accident while driving a car, with a seat in maximaly low position. She presented a bilateral open transverse fracture of the patella associated in the right limb to a fracture line between condyles and the patellar surface of the femur. Method Bilateral osteosynthesis of both patella had been realised in emergency through a transverse approach. Through the fractured right patella two anteroposterior screws had been used to fix the fractured femur. Result A plaster cast had been used for three weeks. Full weight bearing was permited after three months. Full range of motion of both knees was noticed after six months follow-up. Discussion The femoral fracture could have been fixed by another device like D.C.S. platescreen but it would be weaker. That type of fracture was produced because of flexed low position of the knee at the moment of the accident. Usually, supra- condylar femoral fractures are due to a force vector applied on the upper extremity of the tibia without any patellar fracture. In our case, the patella involved associated to a
    • fracture line between the condyles and the patellar surface. The structural anatomy (noeud sutural de Chevrier) explains the solidarity of the two femoral condyles Keywords: extremity/fracture/fractures/osteosynthesis/treatment/upper extremity/upper- extremity Sorock, G.S., Lombardi, D.A., Courtney, T.K., Cotnam, J.P. and Mittleman, M.A. (2001), Epidemiology of occupational acute traumatic hand injuries: a literature review. Safety Science, 38 (3), 241-256. Abstract: The purpose of this review was to summarize the literature on occupational, acute, traumatic hand injury and suggest directions for future research. In 1996, the leading occupational injury treated in United States' hospital emergency departments was an acute hand injury (e.g. laceration, crush or fracture). These injuries affected 30% of an estimated 3.3 million injured workers (990,000). Cuts and lacerations of the fingers ranked third after back and leg strains in the number of lost workday cases in the USA in 1994. The incidence rate of hand injuries studied in seven manufacturing environments around the world ranged from 4 to 11 per 100 workers per year. Workers aged 24 years or less had the highest risk of hand injury. Men had higher rates of severe hand injury than women. Despite the high frequency and significant amount of lost work time associated with these injuries, they are poorly understood from an etiological perspective. There is only one case-control study of occupational hand injury in the literature. That study suggested an important role for both fixed (age) and transient risk factors (doing an unusual task) at the time of the injury. More analytic epidemiological research is needed to identify potentially modifiable risk or protective factors (e.g. glove use) for acute hand injuries. In this regard, the case- crossover design, a relatively new epidemiological approach using cases as their own controls, could prove an efficient method for determining transient, modifiable risk factors for acute, occupational hand injury. (C) 2001 Elsevier Science Ltd. All rights reserved Keywords: ACCIDENTS/acute/epidemiology/fracture/hand/INDUSTRY/injuries/injury/IRON/l eg/MINNESOTA/occupational/occupational injury/POPULATION/RISK/trauma/UNITED-STATES/upper extremity/WORK- RELATED AMPUTATIONS Larsson, T.J. and Bjornstig, U. (1995), Persistent Medical Problems and Permanent Impairment 5 Years After Occupational Injury. Scandinavian Journal of Social Medicine, 23 (2), 121-128. Abstract: In a comprehensive, one year material of 1785 occupational injuries in the township of Umea, Sweden, 1985-04-01/ 1986-03- 31,the proportion of persons with persistent medical problems, two years after the event, was 39%. These were investigated again in 1990, five years after the event, and the proportion of persons with persistent medical problems had dropped to 23%. Around 4% of the injured had a definable permanent medical impairment, most often caused by a fracture, luxation or amputation of an upper extremity. Back injuries, however, were the most frequent cause for persistent medical problems, mostly in the form of ache and pain. Persons in health care, social and nursing occupations had a twice as high proportion of persistent problems as the average in the material. Of the persons that reported persistent medical problems when interviewed in 1990, one in three had changed his leisure time activities, one in five had changed jobs, and one in ten had retired early or was on long term sick leave. The group of early retired and persons on long term sick leave had a large proportion of young females and old males. The reader is reminded that conclusions and comparisons must be made with reference to the
    • assessment and benefit structure in the particular systems of social insurance and workers' compensation Keywords: BACK/extremity/fracture/health care/IMPAIRMENT/injuries/occupational/ OCCUPATIONAL INJURY/upper extremity/upper-extremity Moon, B.S., Price, C.T. and Campbell, J.B. (1998), Case report - Upper extremity and rib stress fractures in a child. Skeletal Radiology, 27 (7), 403-405. Abstract: Stress fractures in children are rare compared with the incidence in adults. This report describes an 11-year-old girl with stress fractures of the acromion, clavicle, and first rib on the left and contralateral fractures of the first and second ribs. It was eventually discovered that these fractures were caused by a nervous tic consisting of repetitive, vigorous shrugging and translation of the shoulders Keywords: 1ST RIB/acromion/child/children/clavicle/extremity/fractures/nervous disorder/rib/stress fracture/tic Fines, B.P. and Stacy, G.S. (2002), Stress fracture of the ulna in an adolescent baton twirler. Skeletal Radiology, 31 (2), 116-118. Abstract: Upper extremity stress fractures are rare, with the majority of those reported occurring in the ulna. The location of the fracture is influenced by the type of activity and mechanism of injury with which it is associated. We report the first case of a mid-ulnar stress fracture in a baton twirler due to chronic torsional stress. This patient was referred to our Orthopedic Oncology clinic with a preliminary diagnosis of osteoid osteoma Keywords: baton twirler/DIAPHYSIS/extremity/fracture/fractures/injury/PLAYER/radiographs/stress fracture/ulna Waters, R.L., Adkins, R.H., Sie, I.H. and Yakura, J.S. (1996), Motor recovery following spinal cord injury associated with cervical spondylosis: A collaborative study. Spinal Cord, 34 (12), 711-715. Abstract: A prospective multicenter study was conducted within the National Model Spinal Cord Injury System program to examine neurological deficits and recovery patterns following spinal cord injury (SCI) in individuals with cervical spondylosis and without a spinal fracture. Nineteen patients were evaluated. Sixty-eight percent presented intially with motor incomplete lesions. Of those who presented with motor incomplete injuries at their initial examination, 69 percent had less deficit in the lower than in the upper extremities, indicative of a central cord syndrome. At follow- up, 12 subjects were unable to ambulate, four required assistance and three were able to ambulate independently. On the average, subjects doubled their initial Asia Motor Score (AMS) scores by one year following injury. Residual upper extremity weakness, however, limited the ability to ambulate. Recovery of motor strength in this group is comparable to that of individuals with incomplete tetraplegia in general but the proportion who regain ambulatory function is less Keywords: cervical spondylosis/extremities/extremity/fracture/injuries/injury/motor recovery/OLDER/spinal cord injury/TETRAPLEGIA/tetraplegia/upper extremity/upper-extremity Wang, C.M., Chen, Y., Devivo, M.J. and Huang, C.T. (2001), Epidemiology of extraspinal fractures associated with acute spinal cord injury. Spinal Cord, 39 (11), 589-594. Abstract: Study design: A descriptive study of concurrent extraspinal fractures collected prospectively during initial hospital care. Objectives: To examine the frequency and related characteristics of concurrent extraspinal fractures among patients with a new onset of spinal cord injury (SCI). Setting: Model SCI care systems throughout the
    • United States. Methods: A consecutive sample of 5711 subjects admitted to the National SCI Database between 1986 - 1995 was recruited to estimate the incidence of extraspinal fractures associated with acute SCI, stratified by anatomic sites, demographics, and injury related characteristics. Results: Of 5711 subjects, 1585 (28%) patients had extraspinal fractures, 580 (37%) patients had more than one fracture site. The most common region of fractures was chest, followed by lower extremity, upper extremity, head, others. and pelvis. The overall incidence rate was higher for women than men, for whites than non-whites, for paraplegics than tetraplegics, and for those injured in motor vehicle crashes than others. Compared with patients having single fracture, those who had multiple fractures were likely to be white, paraplegic, and injured in motor vehicle crashes. There was no age difference in the incidence of concurrent fractures, single or multiple. Conclusions: Extraspinal fractures are not uncommon at the same time as SCI The fracture occurrence varies by gender, race, injury level, and etiology of injury. The knowledge of these associated factors will aid in early recognition of fractures, preventing complications, and facilitating rapid mobilization and rehabilitation outcomes among persons with SCI Keywords: acute/epidemiology/extraspinal fractures/extremity/fracture/fractures/injury/ LIMB FRACTURES/motor vehicle/outcomes/PATIENT/race/rehabilitation/spinal cord injury/upper extremity/upper-extremity Reindl, R., Sen, M. and Aebi, M. (2003), Anterior instrumentation for traumatic C1-C2 instability. Spine, 28 (17), E329-E333. Abstract: Study Design. Technical note, case report. and review of literature. Objective. Description of anterior transarticular internal fixation for traumatic C1-C2 instability. Summary of Background Data. The currently effective posterior approaches for instrumentation of the C1-C2 junction require considerable soft tissue dissection and prone patient positioning. Some medical and anatomic conditions restrict the posterior approach. Materials and Methods. An odontoid screw and anterior transarticular C1-C2 screws were used to instrument an unstable injury at this junction. The lesion consisted of a type II dens fracture and C1 ring disruption. Two high-quality fluoroscopy machines, a radiolucent OSI fracture table, and the Synframe (Synthes, Paoli, PA) retraction system are used for this procedure. The implant of choice is the 4.0-mm cannulated titanium screw. Results. At 4-month follow-up, successful stabilization without failure of hardware is documented. The patient's neurologic status is stable, with a minor residual left upper extremity motor deficit. The patient has restricted C-spine rotation but no neck pain with movement. Conclusion. Anterior stabilization through a standard Smith-Robinson approach of the C1-C2 junction with screws into the odontoid and the lateral masses of C1 is effective. Supine positioning and minimal soft tissue dissection are advantages of this method over standard posterior transarticular instrumentation. Knowledge of the local anatomy, strict adherence to the operative protocol, and high-quality fluoroscopy avoid potential surgical complications Keywords: atlanto-axial fusion/C1-C2 fusion/C1-C2 instability/cervical spine instrumentation/dens fracture/extremity/fracture/FUSION/GALLIE/injury/odontoid fracture/ODONTOID FRACTURES/PLATE/SPINE/STABILIZATION/TRANSARTICULAR SCREW FIXATION/upper extremity/upper-extremity Kocher, M.S., Dupre, M.M. and Feagin, J.A. (1998), Shoulder injuries from alpine skiing and snowboarding - Aetiology, treatment and prevention. Sports Medicine, 25 (3), 201-211.
    • Abstract: There has been a decrease in the overall injury rate and the rate of lower extremity injuries for alpine skiing, with a resultant increase in the ratio of upper extremity to lower extremity injuries. Upper extremity injuries account for 20 to 35% of all injuries during alpine skiing and nearly 50% of all injuries during snowboarding. The most common upper extremity injuries during skiing are, sprain of the thumb metacarpal- phalangeal joint ulnar collateral ligament, and the most common in snowboarding is wrist fracture. Shoulder injuries from skiing and snowboarding have been less well characterised. With the increased ratio of upper to lower extremity injuries during alpine skiing and the boom in popularity of snowboarding, shoulder injuries will be seen with increasing frequency by those who care for alpine sport injuries. Shoulder injuries account for 4 to 11% of all alpine skiing injuries and 22 to 41% of upper extremity injuries. The rate of shoulder injuries during alpine skiing is 0.2 to 0.5 injuries per thousand skier- days. During snowboarding, shoulder injuries account for 8 to 16% of all injuries and 20 to 34% of upper extremity injuries. Falls are the most common mechanism of shoulder injury, in addition to pole planting during skiing and aerial manoeuvres during snowboarding. Common shoulder injuries during skiing and snowboarding are glenohumeral instability, rotator cuff strains, acromioclavicular separations and clavicle fractures. Less common shoulder injuries include greater tuberosity fractures, trapezius strains, proximal humerus fractures, biceps strains, glenoid fractures, scapula fractures, humeral head fractures, sterno-clavicular separations, acromion fractures and biceps tendon dislocation. Prevention of shoulder injuries during skiing and snowboarding may be possible through interventions in education and technique, conditioning and equipment and environment Keywords: acromion/AUSTRALIA/clavicle/dislocation/EPIDEMIOLOGY/extremity/fracture/fr actures/humerus/injuries/injury/prevention/RISK/scapula/SKIERS THUMB/snowboarding/sport/treatment/TRENDS/upper extremity/UPPER EXTREMITY INJURIES/upper-extremity/wrist/wrist fracture Rettig, A.C. (1998), Elbow, forearm and wrist injuries in the athlete. Sports Medicine, 25 (2), 115-130. Abstract: Competitive and recreational athletes sustain a wide variety of soft tissue, bone, ligament, tendon and nerve damage to their upper extremities. Most such injuries are related to direct trauma or repetitive stress, and account for a significant amount of 'down time' for athletes participating in a wide range of sports, particularly those in which the arm is utilised for throwing, catching or swinging. Overuse injuries to the elbow include musculotendinous injuries, ulnar nerve injuries and ligamentous injuries. Osteochondrol lesions of the capitellum and posterior impingement injuries in the joint are frequently seen in athletes as well. Acute traumatic injuries to the elbow include tendon ruptures, elbow dislocations and intra- articular fractures. Forearm overuse injuries in athletes include fracture of the carpal scaphold, fracture of the hook of the hamate, Kienbock's syndrome and pisoquetral syndromes. ligamentous injuries include scapholunate, lunotriquetral and midcarpal instability injuries. Injuries to the distal radio- ulnar joint and triangular fibrocartilage are also quite common in athletes, and require careful evaluation and treatment Keywords: bone/elbow/extremities/forearm/FRACTURE/fractures/injuries/JOINT/LIGAMENT OUS INJURIES/MANAGEMENT/trauma/treatment/UPPER EXTREMITY/wrist Dufek, P., Thormahlen, F. and Ostendorf, U. (1999), Fracture of the Os pisiforme in in- line-skating. Sportverletzung-Sportschaden, 13 (2), 59-61.
    • Abstract: During the last years inline-skating became one of the most familiar kind of sports with more than 12 million inline- skaters. The danger of injuring is often underestemitated. Protectors and technique are important for an effective prophylaxis of injury. The upper extremity is mainly endangered. But despite effective protectors there is still the danger of injury. In particular protectors of the hand can shift the force when falling and result in a fracture of the Os pisiforme. This fracture can be missed in standard x-rays and only be diagnosed with special x-rays Keywords: extremity/fracture/hand/INJURIES/injury/inline-skating/Os pisiforme/PHYSIOLOGICAL-RESPONSES/protectors/upper extremity/upper- extremity Ostermann, P.A.W., Henry, S.L. and Seligson, D. (1992), Injury Severity Score Compared to Other Risk-Factors for Infection After Compound Fracture. Theoretical Surgery, 7 (4), 177-179. Abstract: In a consecutive series of 590 patients with 704 open fractures treated at the University of Louisville - Level I Trauma Center - from May 1983 to May 1989, grade of compounding, fracture location, Injury Severity Score and infection rates were determined. Included were 198 (28%) grade-I, 259 (37%) grade-II and 247 (35%) grade-III (86 IIIA, 119 IIIB, 42 IIIC) open fractures. All fractures underwent timely irrigation, debridement and skeletal stabilization. 157 open fractures received systemic antibiotic prophylaxis, and 547 compound fractures were managed with the supplemental use of tobramycin- PMMA beads. The infection rate was 1.5% (3/198) in the grade-I open fractures, 5% (13/259) in the grade-II compound fractures and 13.4% (33/247) in the grade-III open fractures. These differences between the fracture grades were statistically significant (P < 0.05). The infection rate in the lower extremity (8%, 45/579) was not significantly higher than in the upper extremity (3%, 4/125) (P < 0. 1). The Injury Severity Score was not a prognostic factor for the development of infection. Patients without an infected fracture had a mean ISS of 16 (range 9-59) and patients with infected fractures had a mean ISS of 14 (range 9-50) (P < 0.8). The most significant risk factor was the grade of the bony injury and the soft tissue compromise. Infection was significantly (P < 0.01) increased in patients with grade-IIIB and -IIIC fractures (18%, 29/161) Keywords: extremity/fracture/fractures/GRADE OF COMPOUNDING/INFECTION/injury/INJURY SEVERITY SCORE/OPEN FRACTURE/upper extremity/upper-extremity Wippermann, B., Schmidt, U. and Nerlich, M. (1991), Treatment Results in Compartment Syndrome of the Upper Arm. Unfallchirurg, 94 (5), 231-235. Abstract: Only a small number of cases of compartment syndrome in the upper arm has been reported in the literature. The authors have reviewed 14 patients with 14 cases of compartment syndrome treated at their institution from 1980 to 1988. In the majority of cases in this series, compartment syndrome was caused by blunt, high- energy trauma. There were 9 patients with multiple trauma, 7 of whom were motor cyclists, and fracture of the upper arm was present in most of these. In 5 patients scapulothoracic dissociation with disruption of the neurovascular bundle of the upper extremity concerned was present. In this series, 2 patients died of their injuries and three arms had to be amputated. At final follow-up after an average of 45 months (range 11-91 months) the functional result was dependent mainly on the severity of the associated injuries. Patients with isolated compartment syndrome had full recovery of upper limb function Keywords: extremity/fracture/injuries/severity/trauma/upper extremity/upper-extremity Schmid, A. and Rotzscher, V. (1993), Type and Severity of Skateboard Injuries.
    • Unfallchirurg, 96 (12), 641-644. Abstract: In this study 101 patients who had sustained a total of 123 skateboard injuries and had been treated in the Department of Surgery at the Elisabeth-Krankenhaus in Essen between December 1989 and July 1991 were reviewed. The ages of the patients ranged between 6 and 22 years; most injuries were sustained between the ages of 12 and 17 years (67.3%). The upper extremity was injured in 50.4%. Lower extremity injuries occured in 23.5%, head and face injuries in 22.7%, and chest injuries in 3.4%. The most common type ofinjury was a fracture (37.3%), most frequently to the wrist and forearm (56.5% of the fractures), followed by contusions (18.7%), lacerations (13.8%) and abrasions (10.6%). Of the 101 patients, 20 had to be hospitalized altogether 25 times, for an average duration of 7.3 days per person. The reasons for hospitalization were fractures in 18 patients, which had to be treated by open reduction and internal fixation in 7 cases and closed reduction in 14 cases. Concussion of the brain made hospitalization necessary for 2 cases Keywords: extremity/forearm/fracture/fractures/injuries/upper extremity/upper- extremity/wrist Regel, G., Seekamp, A., Blauth, M., Klemme, R., Kuhn, K. and Tscherne, H. (1996), Complex injury to the elbow joint. Unfallchirurg, 99 (2), 92-99. Abstract: High-velocity trauma now often results in complex injuries to the upper extremity, and especially the elbow joint. These can lead to both an enormous reduction in the range of motion of the shoulder, elbow and wrist joints, in severe cases with complete loss of upper extremity function. A complex injury is defined as a fracture and/or dislocation of the elbow in association with(1) a serial injury of the upper extremity, (2) a severe soft tissue trauma, or (3) concomitant injury to vessels or nerves. Serial fractures, in particular, can lead to enormous problems with treatment and are often associated with special complications. A standardized operative approach therefore seems essential. An analysis of our patient population was made to compare the frequency of different injury types, develop specific treatment regimens, and document the clinical course. We made a retrospective analysis of patients admitted to our facility between 1981 and 1992, with particular reference to cause of accident, severity of injury (ISS), type of fracture of the upper extremity (according to the AO classification), extent of soft tissue trauma and whether closed or open, and the concomitant injuries (vascular, compartment and nerve lesions). Type and sequence of therapy and any complications were noted, and the clinical course up to consolidation was recorded. The functional result (i.e., ROM, neurology) was observed at primary discharge and 12 weeks, 6 months and 2 years later. In the time period mentioned 224 complex injuries of the elbow region were noted. Often MVAs were the cause of the complex trauma (39% car/30% motorcycle). The average injury severity was scored as 32(ISS) in these, mostly polytraumatized, patients (68%). The most frequent fracture combination at the elbow region was combined with C2/C3 fractures of the distal humerus (57%) and proximal ulna (43%). A very commonly seen complex injury was the Monteggia equivalent, with fracture dislocation of the proximal ulna. Most (82%) of the injuries at the elbow region were open, and open lesions were similarly frequently seen at the forearm shaft. The most frequent concomitant injuries was were to the nerves (63.5%) and the plexus. A compartment syndrome developed in 23.8%. This complication was frequently seen in multiple trauma patients after primary resuscitation (extensive volume therapy) and in serial fractures with more than three associated lesions. In 67% of these complex injuries a definitive operation was performed as primary treatment (in the first 24 h after injury). Debridement of open
    • fractures and fasciotomy in compartment syndrome of the forearm are standard techniques in the initial care. In serial fractures all concomitant (humerus, forearm, wrist, etc.) fractures were operated on primarily. This primary treatment included ORIF of humeral and forearm fractures in 76%. In patients with multiple injuries (ISS > 30) primary treatment was not possible in 37%, and in these cases transfixation of the elbow joint was performed. Other indications for transfixation were severe comminution of the elbow joint, impossibility of achieving complete stability after ORIF, extensive soft tissue injuries with healing dependent on short- term immobilization, and finally status following extensive ligamentous reconstruction. The most frequent permanent disturbance was a persisting nerve lesion in our patients. A significantly reduced range of motion (30% deficit flexion/extension) was mostly seen at the elbow (17%); most frequently associated with serial fractures (> 3 associated injuries) and with severe semicircular soft tissue trauma. The most severe injury in combined trauma of the upper extremity is a serial fracture in the elbow region. Such fractures are often associated with vascular and nerve lesions. Even with primary fracture stabilization and early soft tissue management these often end with significant functional deficits. Planned arthrolysis (6 months posttrauma) and enforced rehabilitation can significantly improve the outcome of these complex injuries Keywords: classification/complex injury/complex trauma/dislocation/elbow/elbow joint/extremity/fasciotomy/forearm/fracture/fracture dislocation/fractures/humerus/injuries/injury/multiple injuries/operative management of the elbow/outcome/rehabilitation/serial fractures/severity/trauma/treatment/ulna/upper extremity/upper-extremity/wrist Wick, M., Ekkernkamp, A. and Muhr, G. (1997), Motorcycle accidents: An analysis of 86 cases. Unfallchirurg, 100 (2), 140-145. Abstract: A retrospective study of 86 motorcycle accidents that occurred in the year 1992 is reported. Examination of the case histories supplemented by telephone conversations yielded the following results: 90.7% of our patients were male and their average age was 28.8 years; the age group between 25 and 30 years was the most frequently involved (27.9%). Most motorcycle accidents happened during weekend trips out in the summertime. Special injury patterns were found for injuries of the upper and the lower extremity. Lower extremity injuries (46%), and especially open tibia fractures (19.7%), were among the most common injuries sustained by motorcyclists in crashes. Injuries of the upper extremity most frequently took the form of fracture of the distal radius (18.8%). The average stay in our hospital was 35.4 days. In 23.4% of cases the patients had to change their job after the accident. More than half the crashes happened with motorcycles with between 500 and 750 cc stroke volume. Over a third (34.5%) of the patients had held their driving licences for more than 8 years. A plea is made for more preventive measures, such as better driving instruction, better road conditions and legislative changes, against motorcycle crashes. From the aspects of cost and the rate of complications it is reasonable to strive for a surgical treatment as soon as possible after the crash Keywords: ALCOHOL/expenses/extremity/fracture/fractures/injuries/injury/injury patterns/LEG INJURIES/motorcycle accidents/RIDERS/traffic/treatment/upper extremity/upper-extremity Richter, M., Blauth, M., Otte, D. and Tscherne, H. (2000), Fractures of the upper extremity in restrained front seat occupants - Injury type and frequency in dependence on the accident mechanism. Unfallchirurg, 103 (5), 364-370. Abstract: During 1985 and 1995, 3,260 restrained car drivers (1,228 front seat
    • passengers) were injured in 9,380 crashes involving cars. 179 (5,5%) (front seat passengers: 53, 4.3%) of those sustained fractures, of the arm. Among the 384 single fractures the hand (25%), wrist (23%) and forearm (23%) were affected most often, elbow (9%), upper arm (10%) and shoulder (10%) rather seldom. Half of the evaluated fractures of the long tubular bones were type A-fractures due to the AO classification and the other two quarters, respectively type B- and C-injuries in each case. 16% were open fractures. No considerable differences of the injury mechanism were found comparing drivers and front seat passengers. Since over half of all fractures resulted from a direct impact to the hand and/or arm, modifications are necessary in order to improve the energy absorption by means of padding the dashboard and the inner door. The use of side- and front-airbags could serve as an additional auxiliary equipment, as long as it doesn't induce a supplemental stress, through unfolding of the airbag Keywords: airbag/BELTS/car accident/classification/elbow/extremity/FATALITIES/forearm/fracture of the arm/fractures/hand/impact/injury/injury mechanism/prevention/RISK/upper extremity/upper-extremity/wrist Enzler, M., Jaeck, W., Berger, M. and Leu, A. (1998), Bypass to the anterior interosseous artery in the forearm: Follow-up at 3 years. Vasa-Journal of Vascular Diseases, 27 (4), 250-252. Abstract: Bypass to the anterior interosseous artery in the forearm: Follow-up at 3 years A 56 year-old, otherwise healthy woman suffered from acute ischaemia of her left arm one year after a fracture of the radius which had been treated with plaster fixation. Angiography demonstrated occlusions of the brachial, radial and ulnar arteries. Three surgical thrombectomies, local fibrinolysis and throacoscopic sympathectomy all failed to restore adequate blood supply to the forearm and hand. The patient continued to have pain on exercise and even at rest. After three months, an autologous vein bypass graft was implanted from the proximal brachial artery to the anterior interosseous artery. Thereafter the patient became free of symptoms. At over three years, angiography was repeated and demonstrated a patent bypass. Furthermore, the lumen of the previously heavily diseased brachial artery had considerably improved in terms of diameter and regularity. These changes and possible mechanisms are discussed Keywords: acute/forearm/fracture/hand/ischaemia/UPPER EXTREMITY/upper- extremity Van Tilburg, C. (2000), In-area and backcountry snowboarding: medical and safety aspects. Wilderness & Environmental Medicine, 11 (2), 102-108. Abstract: Snowboarding is now a well-established winter sport and a popular mode of mountaineering. In-area and backcountry snowboarding are defined, as well as a new term, glisse, that refers to all types of skis and snowboards. New developments in equipment focus on boot and binding systems. Backcountry travel is highlighted, including ascent with snowshoes, skis, a splitboard, and crampons. Injuries are about 4-6 per 1000 snowboarding days. Upper extremity injuries are most often wrist sprains or fractures. Lower extremity injuries are primarily ankle sprains and are generally less severe than knee injuries in skiers. Fracture to the lateral process of the talus has been called snowboarder's fracture. Backcountry injuries include avalanche suffocation and trauma, deep snow immersion asphyxiation, hypothermia, frostbite, dehydration, fatigue, acute mountain sickness, and sunburn. Specific recommendations for prevention and safety are discussed Keywords: acute/ANKLE/avalanche/backcountry/deep snow immersion
    • asphyxiation/extremity/firn gliders/fracture/FRACTURES/glisse/INJURIES/PATTERNS/prevention/SKI/snowb oard/snowboarder's ankle/snowboarding/snowshoes/splitboard/sport/TALUS/trauma/ wrist Sarkar, M.R., Hoellen, I.P. and Kinzl, L. (1999), Fractures of the upper extremity in the elderly. Zeitschrift fur Orthopadie und Ihre Grenzgebiete, 137 (6), 486-491. Abstract: Problem: The primary goal in treating fractures in elderly persons is safe and rapid restoration of their functional capabilities to secure independence ih everyday activities. The intention of this paper is to present an overview of treatment principles useful in this age group. Methods: We analysed a series of 404 patients above the age of 70 years who underwent surgery for fractures of the arm between 1981 and 1997. Results: Diaphyseal fractures are less frequent in this age group and their treatment does not differ significantly from principles established for younger patients. The majority of fractures of the proximal humerus and the distal radius can be treated by conservative means. Unstable fractures are frequent in the distal humerus and the olecranon requiring operative reduction and osteosynthesis. Conclusions: Preferred operative techniques in aged persons inflict minimal surgical trauma and have a low rate of complications and secondary interventions. ln contrast, anatomical reconstruction has he highest priority in younger individuals Keywords: elderly/extremity/forearm/fracture/fractures/humerus/independence/old age/ olecranon/osteosynthesis/PROXIMAL HUMERUS/trauma/treatment/upper extremity/upper-extremity