Aims. The aim of this study was to assess the quality and scope of the current cost-effectiveness analysis (CEA) literature in the field of hand and upper limb orthopaedic surgery. Materials and Methods. We conducted a systematic review of MEDLINE and the CEA Registry to identify CEAs that were conducted on or after 1 January 1997, that studied a procedure pertaining to the field of hand and upper extremity surgery, that were clinical studies, and that reported outcomes in terms of quality-adjusted life-years. We identified a total of 33 studies that met our inclusion criteria. The quality of these studies was assessed using the Quality of Health Economic Analysis (QHES) scale. Results. The mean total QHES score was 82 (high-quality). Over time, a greater proportion of these studies have demonstrated poorer QHES quality (scores < 75). Lower-scoring studies demonstrated several deficits, including failures in identifying reference perspectives, incorporating comparators and sensitivity analyses, discounting costs and utilities, and disclosing funding. Conclusion. It will be important to monitor the ongoing quality of CEA studies in orthopaedics and ensure standards of reporting and comparability in accordance with Second Panel recommendations. Cite this article: Bone Joint J 2018;100-B:1416–23

The aim of this study was to investigate upper limb botulinum toxin A (BTX-A) injections in children with spastic hemiplegia. Ten children with hemiplegia, aged 10–17 years, received upper limb BTX-A injections and 6 weeks therapy. BTX-A was injected using EMG guidance into elbow and wrist flexors, and forearm pronators (dose 1–2 units/kg body wt (Botox®) per muscle). Follow-up assessments continued to 24 weeks post BTX-A. Outcome measures included three-dimensional (3-D) upper limb analysis of functional tasks, Melbourne Assessment; passive range of motion (PROM), and muscle tone. There were no serious adverse effects. Elbow flexor muscle tone was reduced to 12 weeks post BTX-A (p < 0.05). Mean passive elbow supination increased by 19 degrees (not significant, p= 0.3). Pre-injection 3-D analysis showed that, compared to controls, children with hemiplegia were slower at performing upper limb reaching tasks, using less elbow extension and supination, and utilising increased compensatory trunk forward flexion. Post BTX-A, the time to complete upper limb tasks did not change (p> 0.15). However, at least six subjects had increased elbow extension (average 17 degrees) and decreased trunk forward flexion (average 16 degrees) during upper limb reaching tasks. Five subjects improved their Melbourne Assessment score by 5% or greater. Decreased tone and individual improvements in upper limb functional tasks were seen post BTX-A and therapy. However deficits in timing of upper limb movements did not change post BTX-A

Abstract. Background. Reconstruction following resection of sarcomas of the upper extremity with methods described in the prevalent literature may not be possible in few selected cases. We describe Surgical Phocomelia or Phoco-reduction as a method of limb salvage in such cases of extensive sarcomas of the upper limb with its functional and oncological outcomes. Methods. Evaluation of functional and oncological outcomes was performed for 11 patients who underwent surgical phocomelia or phocoreduction for extensive sarcomas of the upper limb between 2010 and 2019. Results. Mean follow-up period in the study was27.8 months. Five patients required a segmental resection including the entire humerus while 6 patients underwent segmental resection around the elbow with a mean resection length of 21.5 cm. Mean MSTS 93 score was 22 depicting a good functional outcome. Mean hand grip strength on the operated side was 62% of the contralateral side with preservation of useful hand function. Mean time to humero-ulnar union was 6.7 months. Radial nerve palsy and implant failure occurred in 1 patient each. No patient developed local recurrence while 3 patients died of metastasis. Conclusion. Surgical phocomelia is a prudent alternative to severely incapacitating amputations in situations where other reconstruction methods are not feasible

Aims. The increase in prescription opioid misuse and dependence is now a public health crisis in the UK. It is recognized as a whole-person problem that involves both the medical and the psychosocial needs of patients. Analyzing aspects of pathophysiology, emotional health, and social wellbeing associated with persistent opioid use after injury may inform safe and effective alleviation of pain while minimizing risk of misuse or dependence. Our objectives were to investigate patient factors associated with opioid use two to four weeks and six to nine months after an upper limb fracture. Methods. A total of 734 patients recovering from an isolated upper limb fracture were recruited in this study. Opioid prescription was documented retrospectively for the period preceding the injury, and prospectively at the two- to four-week post-injury visit and six- to nine-month post-injury visit. Bivariate and multivariate analysis sought factors associated with opioid prescription from demographics, injury-specific data, Patient Reported Outcome Measurement Instrumentation System (PROMIS), Depression computer adaptive test (CAT), PROMIS Anxiety CAT, PROMIS Instrumental Support CAT, the Pain Catastrophizing Scale (PCS), the Pain Self-efficacy Questionnaire (PSEQ-2), Tampa Scale for Kinesiophobia (TSK-11), and measures that investigate levels of social support. Results. A new prescription of opioids two to four weeks after injury was independently associated with less social support (odds ratio (OR) 0.26, p < 0.001), less instrumental support (OR 0.91, p < 0.001), and greater symptoms of anxiety (OR 1.1, p < 0.001). A new prescription of opioids six to nine months after injury was independently associated with less instrumental support (OR 0.9, p < 0.001) and greater symptoms of anxiety (OR 1.1, p < 0.001). Conclusion. This study demonstrates that potentially modifiable psychosocial factors are associated with increased acute and chronic opioid prescriptions following upper limb fracture. Surgeons prescribing opioids for upper limb fractures should be made aware of the screening and management of emotional and social health. Cite this article: Bone Jt Open 2021;2(2):119–124

Upper limb amputations, ranging from transhumeral to partial hand, can be devastating for patients, their families, and society. Modern paradigm shifts have focused on reconstructive options after upper extremity limb loss, rather than considering the amputation an ablative procedure. Surgical advancements such as targeted muscle reinnervation and regenerative peripheral nerve interface, in combination with technological development of modern prosthetics, have expanded options for patients after amputation. In the near future, advances such as osseointegration, implantable myoelectric sensors, and implantable nerve cuffs may become more widely used and may expand the options for prosthetic integration, myoelectric signal detection, and restoration of sensation. This review summarizes the current advancements in surgical techniques and prosthetics for upper limb amputees. Cite this article: Bone Joint J 2021;103-B(3):430–439

Mirels’ score predicts the likelihood of sustaining pathological fractures using pain, lesion site, size and morphology. The aim is to investigate its reproducibility, reliability and accuracy in upper limb bony metastases and validate its use in pathological fracture prediction. A retrospective cohort study of patients with upper limb metastases, referred to an Orthopaedic Trauma Centre (2013–18). Mirels’ was calculated in 32 patients; plain radiographs at presentation scored by 6 raters. Radiological aspects were scored twice by each rater, 2-weeks apart. Inter- and intra-observer reliability were calculated (Fleiss’ kappa test). Bland-Altman plots compared variances of individual score components &total Mirels’ score. Mirels’ score of ≥9 did not accurately predict lesions that would fracture (11% 5/46 vs 65.2% Mirels’ score ≤8, p<0.0001). Sensitivity was 14.3% &specificity was 72.7%. When Mirels’ cut-off was lowered to ≥7, patients were more likely to fracture (48% 22/46 versus 28% 13/46, p=0.045). Sensitivity rose to 62.9%, specificity fell to 54.6%. Kappa values for interobserver variability were 0.358 (fair, 0.288–0.429) for lesion size, 0.107 (poor, 0.02–0.193) for radiological appearance and 0.274 (fair, 0.229–0.318) for total Mirels’ score. Values for intraobserver variability were 0.716 (good, 95% CI 0.432–0.999) for lesion size, 0.427 (moderate, 95% CI 0.195–0.768) for radiological appearance and 0.580 (moderate, 0.395–0.765) for total Mirels’ score. We showed moderate to substantial agreement between &within raters using Mirels’ score on upper limb radiographs. Mirels’ has poor sensitivity &specificity predicting upper limb fractures - we recommend the cut-off score for prophylactic surgery should be lower than for lower limb lesions

Nerve transfer is an emerging treatment to restore upper limb function in people with tetraplegia. The objective of this study is to examine if a flexible collage sheet (FCS) can act as epineurial-like substitute to promote nerve repair in nerve transfer. A preclinical study using FCS was conducted in a rat model of sciatic nerve transection. A prospective case series study of nerve transfer was conducted in patients with C5-C8 tetraplegia who received nerve transfer to restore upper limb function. Motor function in the upper limb was assessed pre-treatment, and at 6-,12-, and 24-months post-treatment. Macroscopic assessment in preclinical model showed nerve healing by FCS without encapsulation or adhesions. Microscopic examination revealed that a new, vascularised epineurium-like layer was observed at the FCS treatment sites, with no evidence of inflammatory reaction or nerve compression. Treatment with FCS resulted in well-organised nerve fibres with dense neurofilaments distal to the coaptation site. Axon counts performed proximal and distal to the coaptation site showed that 97% of proximal axon count of myelinated axons regenerated across the coaptation site after treatment with CND. In the proof of concept clinical study 17 nerve transfers were performed in five patients. Nerve transfers included procedures to restore triceps function (N=4), wrist/finger/thumb extension (N=6) and finger flexion (N=7). Functional motor recovery (MRC ≥3) was achieved in 76% and 88% of transfers at 12 and 24 months, respectively. The preclinical study showed that FCS mimics epineurium and enable to repair nerve resembled to normal nerve tissue. Clinical study showed that patients received nerve transfer with FCS experienced consistent and early return of motor function in target muscles. These results provide proof of concept evidence that CND functions as an epineurial substitute and is promising for use in nerve transfer surgery

Introduction. Purpose: Injuries to the long bones of the upper limb resulting in bone defects are rare but potentially devastating. Literature on the management of these injuries is limited to case reports and small case series. The aim of this study was to collate the most recent published work on the management of upper limb bone defects to assist with evidence based management when confronted with these cases. Materials and Methods. Methods: Following a preliminary search that confirmed the paucity of literature and lack of comparative trials, a scoping review using the Preferred Reporting Items for Systematic Reviews and Meta-Analysis extension for Scoping Reviews (PRISMA-ScR) was conducted. A literature search of major electronic databases was conducted to identify journal articles relating to the management of upper limb long bone defects published between 2010 and 2020. Results. Results: A total of 46 publications reporting on the management of 341 patients were reviewed. Structural autograft, bone transport, one-bone forearm and the induced membrane technique were employed in an almost equal number of cases. The implemented strategies showed similar outcomes but different indications and complication profiles were observed. Conclusions. Conclusion: Contemporary techniques for the management of post-traumatic upper limb bone defects all produce good results. Specific advantages, disadvantages and complications for each modality should be considered when deciding on which management strategy to employ for each specific patient, anatomical location, and defect size

Abstract. Objectives. Falling studies have been conducted in controlled environments but not in field studies for ethical reasons; this limits the validity and applicability of previous studies. We performed field studies on existing YouTube © videos of skateboarders falling. The aims were to measure the wrist angle at impact on videos of real unprotected falls and to study the dynamics of the upper limbs when falling. Methods. Youtube © videos of skateboarders falling were studied assessing the direction of the fall, the positions of both upper limbs and especially the wrists on impact. This study would not be ethical by other means. Results. In study one (the more quantitative study) there were 48 men and 50 falls. The mean elbow flexion was 300 (range 00 to 800) and the mean maximal wrist extension was 800 (range 500 to 1100). The secondary wrist extended less or the same in > 90%. The second wrist only one (of 31) extended > 900 which should minimise the risk of toppling. Falls onto only one wrist gave significantly greater maximal wrist extension. In the second more qualitative study we observed the “upper limb falling reflex” where the response to falling is for the upper limb(s) to align with the direction of falling of the body with the elbow mostly but not fully extended. Initially the wrists extend c. 400–500 with the fingers held mildly flexed. Immediately before impact the fingers hyper-extend with some compensatory wrist flexion to c. 300. The fingertips impact the ground first followed by the hand. Conclusion. These studies confirm wrist extension at impact around 800 but the wrist(s) may hyper-extend risking toppling. Falls on both wrists minimise the risk of toppling. The “upper limb falling reflex” is defined; it is a rapid dynamic response leading to the fingers impacting the ground first on falling. Declaration of Interest. (a) fully declare any financial or other potential conflict of interest

Aims. Patient engagement in adaptive health behaviours and interactions with their healthcare ecosystem can be measured using self-reported instruments, such as the Patient Activation Measure (PAM-13) and the Effective Consumer Scale (ECS-17). Few studies have investigated the influence of patient engagement on limitations (patient-reported outcome measures (PROMs)) and patient-reported experience measures (PREMs). First, we assessed whether patient engagement (PAM-13, ECS-17) within two to four weeks of an upper limb fracture was associated with limitations (the Quick Disabilities of the Arm, Shoulder and Hand questionnaire (QuickDASH), and Patient-Reported Outcome Measurement Information System Upper Extremity Physical Function computer adaptive test (PROMIS UE PF) scores) measured six to nine months after fracture, accounting for demographic, clinical, and psychosocial factors. Secondly, we assessed the association between patient engagement and experience (numerical rating scale for satisfaction with care (NRS-C) and satisfaction with services (NRS-S) six to nine months after fracture. Methods. A total of 744 adults with an isolated fracture of the proximal humerus, elbow, or distal radius completed PROMs. Due to multicollinearity of patient engagement and psychosocial variables, we generated a single variable combining measures of engagement and psychosocial factors using factor analysis. We then performed multivariable analysis with p < 0.10 on bivariate analysis. Results. Patient engagement and psychosocial factors combined to form a single factor (factor 1) accounting for 20% (QuickDASH, semi-partial R. 2. = 0.20) and 14% (PROMIS UE PF, semi-partial R. 2. = 0.14) of the variation in limitations six to nine months after fracture. Factor 1 also accounted for 17% (NRS-C, semi-partial R. 2. = 0.17) of variation in satisfaction with care, and 21% (NRS-S, semi-partial R. 2. = 0.21) of variation in satisfaction with services. Demographic factors (age, sex, work status) and measures of greater pathophysiology (type of fracture, high-energy injury, post-surgical complications), accounted for much less variation. Conclusion. Patients who actively manage their health and demonstrate effective emotional and social functioning share a common underlying trait. They have fewer limitations and greater satisfaction with care during recovery from upper limb fractures. Future efforts should focus on evaluating initiatives that optimize patient engagement, such as patient education, coaching, and a communication strategy for healthcare professionals. Cite this article: Bone Joint J 2020;102-B(1):42–47

Necrotising soft-tissue infections (NSTIs) of the upper limb are uncommon, but potentially life-threatening. We used a national database to investigate the risk factors for amputation of the limb and death. . We extracted data from the Japanese Diagnosis Procedure Combination database on 116 patients (79 men and 37 women) who had a NSTI of the upper extremity between 2007 and 2010. The overall in-hospital mortality was 15.5%. Univariate analysis of in-hospital mortality showed that the significant variables were age (p = 0.015), liver dysfunction (p = 0.005), renal dysfunction (P < 0.001), altered consciousness (p = 0.049), and sepsis (p = 0.021). Logistic regression analysis showed that the factors associated with death in hospital were age over 70 years (Odds Ratio (OR) 6.6; 95% confidence interval (CI) 1.5 to 28.2; p = 0.011) and renal dysfunction (OR 15.4; 95% CI 3.8 to 62.8; p < 0.001). Univariate analysis of limb amputation showed that the significant variables were diabetes (p = 0.017) mellitus and sepsis (p = 0.001). Multivariable logistic regression analysis showed that the factors related to limb amputation were sepsis (OR 1.8; 95% CI 1.5 to 24.0; p = 0.013) and diabetes mellitus (OR 1.6; 95% CI 1.1 to 21.1; p = 0.038). . For NSTIs of the upper extremity, advanced age and renal dysfunction are both associated with a higher rate of in-hospital mortality. Sepsis and diabetes mellitus are both associated with a higher rate of amputation. Cite this article: Bone Joint J 2014;96-B:1530–4

Aims. The aim of this study is to develop a core set of outcome domains that should be considered and reported in all future trials of childhood limb fractures. Methods. A four-phase study was conducted to agree a set of core outcome domains. Identification of candidate outcome domains were identified through systematic review of trials, and outcome domains relevant to families were identified through semi-structured interviews with 20 families (parent-child pairing or group). Outcome domains were prioritized using an international three-round Delphi survey with 205 panellists and then condensed into a core outcome set through a consensus workshop with 30 stakeholders. Results. The systematic review and interviews identified 85 outcome domains as relevant to professionals or families. The Delphi survey prioritized 30 upper and 29 lower limb outcome domains at first round, an additional 17 upper and 18 lower limb outcomes at second round, and four additional outcomes for upper and lower limb at the third round as important domains. At the consensus workshop, the core outcome domains were agreed as: 1) pain and discomfort; 2) return to physical and recreational activities; 3) emotional and psychosocial wellbeing; 4) complications from the injury and treatment; 5) rturn to baseline activities daily living; 6) participation in learning; 7) appearance and deformity; and 8) time to union. In addition, 9a) recovery of mobility and 9b) recovery of manual dexterity was recommended as a core outcome for lower and upper limb fractures, respectively. Conclusion. This set of core outcome domains is recommended as a minimum set of outcomes to be reported in all trials. It is not an exhaustive set and further work is required to identify what outcome tools should be used to measure each of these outcomes. Adoption of this outcome set will improve the consistency of research for these children that can be combined for more meaningful meta-analyses and policy development. Cite this article: Bone Joint J 2021;103-B(12):1821–1830

Aims. This exploratory randomized controlled trial (RCT) aimed to determine the splint-related outcomes when using the novel biodegradable wood-composite splint (Woodcast) compared to standard synthetic fibreglass (Dynacast) for the immobilization of undisplaced upper limb fractures in children. Methods. An exploratory RCT was performed at a tertiary paediatric referral hospital between 1 June 2018 and 30 September 2019. The intention-to-treat population consisted of 170 patients (mean age 8.42 years (SD 3.42); Woodcast (WCG), n = 84, 57 male (67.9%); Dynacast (DNG), n = 86, 58 male (67.4%)). Patients with undisplaced upper limb fractures were randomly assigned to WCG or DNG treatment groups. Primary outcome was the stress stability of the splint material, defined as absence of any deformations or fractures within the splint during study period. Secondary outcomes included patient satisfaction and medical staff opinion. Additionally, biomechanical and chemical analysis of the splint samples was carried out. Results. Of the initial 170 patients, 168 (98.8%) completed at least one follow-up, and were included for analysis of the primary endpoint. Both treatment groups were well-matched regarding to age, sex, and type and localization of the fracture. Splint breakage occurred in three patients (3.6%; 95% confidence interval (CI), 0.007% to 0.102%) in the WCG and in three children (3.5%, 95% CI 0.007% to 0.09%) in the DNG (p > 0.99). The incidence of splint-related adverse events did not differ between the WCG (n = 21; 25.0%) and DNG (n = 24; 27.9%; p = 0.720). Under experimental conditions, the maximal tensile strength of Dynacast samples was higher than those deriving from Woodcast (mean 15.37 N/mm² (SD 1.37) vs 10.75 N/mm² (SD 1.20); p = 0.002). Chemical analysis revealed detection of polyisocyanate-prepolymer in Dynacast and polyester in Woodcast samples. Conclusion. Splint-related adverse events appear similar between WCG and DNG treatment groups during the treatment of undisplaced forearm fractures. Cite this article: Bone Joint J 2020;102-B(10):1405–1411

Abstract. Nerve transfer has become a common and often effective reconstructive strategy for proximal and complex peripheral nerve injuries of the upper limb. This case-based discussion explores the principles and potential benefits of nerve transfer surgery and offers in-depth discussion of several established and valuable techniques including: motor transfer for elbow flexion after musculocutaneous nerve injury, deltoid reanimation for axillary nerve palsy, intrinsic re-innervation following proximal ulnar nerve repair, and critical sensory recovery despite non-reconstructable median nerve lesions

Injuries to the limb are the most frequent cause of permanent disability following combat wounds. We reviewed the medical records of 450 soldiers to determine the type of upper limb nerve injuries sustained, the rate of remaining motor and sensory deficits at final follow-up, and the type of Army disability ratings granted. Of 189 soldiers with an injury of the upper limb, 70 had nerve-related trauma. There were 62 men and eight women with a mean age of 25 years (18 to 49). Disabilities due to nerve injuries were associated with loss of function, neuropathic pain or both. The mean nerve-related disability was 26% (0% to 70%), accounting for over one-half of this cohort’s cumulative disability. Patients injured in an explosion had higher disability ratings than those injured by gunshot. The ulnar nerve was most commonly injured, but most disability was associated with radial nerve trauma. In terms of the final outcome, at military discharge 59 subjects (84%) experienced persistent weakness, 48 (69%) had a persistent sensory deficit and 17 (24%) experienced chronic pain from scar-related or neuropathic pain. Nerve injury was the cause of frequent and substantial disability in our cohort of wounded soldiers. Cite this article: Bone Joint J 2014;96-B:254–8

The charts and X-rays of one hundred and fifty-nine consecutive children with Osteogenesis imperfecta (OI) were reviewed to evaluate the functional outcome of OI patients with upper limb deformities. The patients were classified according to Sillence classification modified by Glorieux (Type I: 51, Type III: 33, Type IV: 54 and Type V: 21). The functional outcome was measured using Pediatric Evaluation of Disability Inventory (PEDI) based on self care and mobility scores, and results were compared between the patients with upper limb deformities and the ones without upper limb deformities. There was significant negative correlation between the functional outcome and the total deformity angle. Osteogenesis imperfecta is a genetic disorder of bone fragility. There are also some angular deformities of upper and lower limbs secondary to fracture and abnormal structure of bones in many OI patients depending on the severity of their condition. Corrective surgeries to the lower extremities are established interventions and used extensively but surgical correction of upper limb deformities is less frequent. The purpose of this study was to measure the severity of upper limb deformities in children with OI and the child’s functional level in order to answer the question: “Do upper limb deformities significantly affect function and therefore require surgical intervention?”. Upper limb deformities were measured and classified using AP and lateral Xrays of the arms and forearms. The site and direction of deformities were recorded. Total deformity angle was calculated as the sum of right and left arm and forearm deformity angles. Upper limb deformities were classified into four groups according to the severity of deformity angles. The mean self care scores of PEDI were significantly low only in the group with severe and bilateral deformities but mobility scores were dramatically decreased in both the moderate and severe deformity groups. Deformities of the upper limbs in OI limit not only mobility but also self care functions. Therefore they require more attention and it may be necessary to broaden the indications for surgery

Purpose: Vascular injuries occur in approximately 3% of all patients with major civilian trauma and peripheral vascular injuries account for 80% of all cases of vascular trauma. Upper extremity arterial injuries represents about 30% of all cases arterial trauma. The present study was designed to document and analyze the respective role of arterial damage and associated injuries on functional outcomes after upper extremity arterial trauma. Material and Methods: Excluding the arterial injuries resulting in immediate amputation there were 57 patients who sustained arterial trauma of the upper extremity. Their mean age was 33 years (range 4–68 years), and 40 were males and 19 were females. The most frequently injured vessel was the ulnar artery (42%) followed by the brachial artery (29.8%), radial artery (26.3%) and axillary artery (1.7%). Concomitant fractures or nerve injuries were present in 54% and 45% respectively. Results: An average of 5.6 hours elapsed between the time of injury and the time of vessel reconstruction. The most common method of surgical management was end to end anastomosis. Twenty one autogenous vein grafts were employed. Primary nerve repair was carried out in 29 patients and in another 18 secondary repair was performed. None of patients had any residual compromise from the arterial injury. Discussion: Vascular injuries are potentially limb threatening. Improvements in the technical ability to revascularize injured extremities and advances in microsurgery, resulting in the low present day limb loss rate associated with attempted vascular repairs. Associated injuries, rather than vascular injuries, cause long-term disability in the trauma of the upper extremity. Persistent nerve deficits, joint contractures and pain are principal reasons for functional impairment

Purpose: It is known from previous studies that reduced grip strength is associated with tennis elbow; however; assessment of muscular strength over other parts of upper limb, particularly wrist and shoulder, has received a little or no attention in the literature. To address possible other upper extremity muscular strength weakness-imbalances in Tennis Elbow, this study aimed to investigate the strength of various upper limb muscle groups in tennis elbow patients and compare them with those of healthy subjects. Methods: A total of 32 participants were assigned into two groups of Control (N=16) and Tennis Elbow (N=16). In both groups, upper limb maximal isometric muscular of dominant and non-dominant sides was measured at various joints including metacarpophalan-geal (extension & flexion), wrist extension & flexion), grip, and shoulder (internal and external rotation and abduction) using appropriate either commercial or purpose-built dynamometers. Muscular strength and important strength ratios were analyzed and compared in each group (dominant vs non-dominant) and also between Control and Tennis Elbow group using various statistical methods. Results: Significant dominance difference was found in all strength measurements for Control group but not for Tennis Elbow group indicating a generalized and widespread upper limb muscular weakness associated with tennis elbow. In addition, significant differences were found not only for various hand strength measurements but also for shoulder strength between Control and Tennis Elbow groups (p < 0.05). Conclusion: This is the most comprehensive study of upper limb isometric muscular strength assessment in Tennis Elbow during recent years. Distributed upper limb muscle strength weakness exists in Tennis Elbow which needs to be addressed within both preventative and treatment strategies

Introduction. There has been little research into the effect of suffering a simultaneous hip and upper limb fragility fracture. The aim of this study is to describe the characteristics of this important group of patients and to define the effect on outcomes such as mortality and length of stay. Materials and methods. Hip fracture data in our unit is collected prospectively and entered into a database. All study data was taken from this database. Patients under 60 years of age were excluded from the study. Results. Between October 1986 and May 2010 we treated 7225 patients with hip fractures in our unit. 71 (1%) of these patients sustained simultaneous upper limb fractures. There were only 12 (0.2%) simultaneous fractures involving the lower limbs or other sites; 1 pelvis, 2 calcaneum, 1 metatarsal, 2 ankle, 1 tibial plateau, 3 rib and 2 bilateral hip fractures. The average age in the simultaneous fracture group was 80.6 years versus 81.5 years in the isolated hip fracture group. In the upper limb fracture group there were 33 distal radius, 21 humerus, 9 elbow, 6 hand and 2 clavicle fractures. There were also 3 shoulder dislocations. 79.7% of the patients with isolated hip fractures were women, compared with 77.8% in the simultaneous fracture group. 63 (88.7%) upper limb fractures occurred on the ipsilateral side. The mean length of stay in the upper limb fracture group was 21.8 days compared with 23.6 days in the isolated hip fracture group. 30 day and 1 year mortality in the upper limb fracture group was 5 (6.2%) and 16 (19.8%) compared with 573 (8%) and 2069 (29%) in the isolated hip fracture group. Discussion. This is the largest published series of patients with simultaneous hip and upper limb fractures to date. Simultaneous upper limb fractures occur much more frequently than lower limb fractures in patients with hip fractures. We found that length of stay was longer and 30 day and 1 year mortality was higher in the isolated hip fracture group

Aims. To assess the proportion of patients with distal radius fractures (DRFs) who were managed nonoperatively during the COVID-19 pandemic in accordance with the British Orthopaedic Association BOAST COVID-19 guidelines, who would have otherwise been considered for an operative intervention. Methods. We retrospectively reviewed the radiographs and clinical notes of all patients with DRFs managed nonoperatively, following the publication of the BOAST COVID-19 guidelines on the management of urgent trauma between 26 March and 18 May 2020. Radiological parameters including radial height, radial inclination, intra-articular step-off, and volar tilt from post-reduction or post-application of cast radiographs were measured. The assumption was that if one radiological parameter exceeds the acceptable criteria, the patient would have been considered for an operative intervention in pre-COVID times. Results. Overall, 92 patients formed the cohort of this study with a mean age of 66 years (21 to 96); 84% (n = 77) were female and 16% (n = 15) were male. In total, 54% (n = 50) of patients met at least one radiological indication for operative intervention with a mean age of 68 years (21 to 96). Of these, 42% (n = 21) were aged < 65 years and 58% (29) were aged ≥ 65 years. Conclusion. More than half of all DRFs managed nonoperatively during the COVID-19 pandemic had at least one radiological indication to be considered for operative management pre-COVID. We anticipate a proportion of these cases will require corrective surgery in the future, which increases the load on corrective upper limb elective services. This should be accounted for when planning an exit strategy and the restart of elective surgery services. Cite this article: Bone Joint Open 2020;1-10:612–616

Introduction: Intra-uterine vascular deficiency of the upper limbs is very rare. Materials & Methods: Thirty two cases collected by 118 paediatric surgeons (GEOP) over the last 20 years were presented. Results: This series illustrates the large range of presentations of vascular deficiencies, from total ischaemia of both upper limbs to small scars of the hand. Three infants had diabetic mothers; nine children had a cerebral infarction; non disturbed haematologic screening was found; three new born had an intra-uterine thrombotic event. Discussion: Our hypothesis is that such an intra-uterine thrombotic pathology can lead to thromboembolism. The embolus passing through the foramen ovale, arrives in the high pressure circulation and is transported directly to the upper limbs and brain. The size of embolus corresponds with the extent of the necrosis

Aim. To review the natural history of upper limb osteochondromas and assess their functional effect. Materials. We performed a retrospective casenote review of a consecutive patient cohort presenting between 1997–2012 with upper limb osteochondromas. Indications for surgical intervention were noted and considered to be cosmetic, functional (including pain relief) and ‘prophylactic’ in terms of deformity prevention. All patients were invited to complete questionnaires for the PODCI, DASH, OSS and MHS scores. Results. We identified 102 patients (62 male: 40 female; mean age = 13.3 years; range 3–31 years). 84 patients had multiple exostoses whilst 18 had a solitary lesion. 52 patients had shoulder girdle involvement (scapula, clavicle and proximal humerus), 51 forearm (Masada I (n=31) Masada II (n=9) Masada III (n=11)), and 38 hand involvement. 46/102 patients had concurrent lower limb lesions. 56 operative procedures were performed primarily for functional benefit. Shoulder girdle procedures (n=21) improved pressure related pain, scapular pseudowinging/dyskinesia and cuff impingement. Forearm procedures (n=35) were performed for functional and prophylactic reasons and involved excision with ulnar lengthening and radial deformity correction (n=15, Masada I), realignment osteotomy or radial head excision for subluxation (n=7, Masada II) and excision with internal fixation of concomitant osteotomy (n=13, Masada I/III). No hand surgery was performed. Radial head dislocations are associated with large ulnar lesions causing shortening > 0.15 total ulnar length. Osteochondromas of the upper limb are generally well tolerated: functional effects were most commonly present in lesions involving the forearm but significant patient benefit was noted following shoulder girdle procedures. The scoring systems used failed to discriminate well between the various procedures used and the perceived benefit. Conclusion:. Patient outcomes are related to surgical indications. Currently available PROMs are either inappropriate Qs (DASH) and/or non-validated (OSS, MHS) and/or non-specific (PODCI*) only 8 parameters for the upper extremity. Better-validated measures may be required. Level of evidence: IV

We have developed an illustrated questionnaire, the Hand20, comprising 20 short and easy-to-understand questions to assess disorders of the upper limb. We have examined the usefulness of this questionnaire by comparing reliability, validity, responsiveness and the level of missing data with those of the Disabilities of the Arm, Shoulder and Hand (DASH) questionnaire. A series of 431 patients with disorders of the upper limb completed the Hand20 and the Japanese version of the DASH (DASH-JSSH) questionnaire. The norms for Hand20 scores were determined in another cross-sectional study. Most patients had no difficulty in completing the Hand20 questionnaire, whereas the DASH-JSSH had a significantly higher rate of missing data. The standard score for the Hand20 was smaller than the reported norms for the DASH. Our study showed that the Hand20 questionnaire provided validation comparable with that of the DASH-JSSH. Explanatory illustrations and short questions which were easy-to-understand led to better rates of response and fewer missing data, even in elderly individuals with cognitive deterioration

Purpose of the study: The incidence and type of complications observed with arthroscopic procedures remains a timely subject, particularly as the use of new techniques becomes increasingly widespread. Material and methods: In cooperation with the members of ISAKOS, The International Society of Arthroscopy, Knee surgery and Orthopaedic Surgery, we instituted two studies: a retrospective study of upper limb arthroscopy complications and a prospective incidence study during a 30-day inclusion period with patient review at one month and quality-of-life scoring. Results: The retrospective study analyzed complications of 57,604 arthroscopic procedures of the upper limb performed by 99 surgeons from 38 countries. Neurological complications, though generally transient, were the most frequent and were related to traction, locoregional anesthesia or the operative technique. Four deaths were recorded, all anesthesia-related. The prospective study included 364 patients operated on by 50 surgeons. There were 16 initial complications (4.39%): material problem (n=12), three intraoperative bleeding (n=3), atelectasia (n=1). The rate of conversion was 2.47%. At one month, there were five complications reported in 133 patients (3.75%): anesthesia-related problem (n=1), bleeding (n=1), synovial fistula (n=1), reflex dystrophy (n=2). There were no infections and no neurological lesions. The one-month outcome was considered good or excellent by 98.5% of surgeons. Discussion and conclusion: The results of these surveys are in agreement with data in the literature where the rate of complications is higher in prospective studies than in retrospective studies. The prospective study did not disclose any neurological complication while arthroscopy of the upper limb is generally considered to raise the risk of with this type of complication. This study recalls that although arthoscopy has enabled a decreased incidence in complications compared with open surgery, it is not a benign intervention and can produce complications

We evaluated 56 patients for neurological deficit after enucleation of a histopathologically confirmed schwannoma of the upper limb. Immediately after the operation, 41 patients (73.2%) had developed a new neurological deficit: ten of these had a major deficit such as severe motor or sensory loss, or intolerable neuropathic pain. The mean tumour size had been significantly larger in patients with a major neurological deficit than in those with a minor or no deficit. After a mean 25.4 months (12 to 85), 39 patients (70%) had no residual neurological deficit, and the other 17 (30%) had only hypoaesthesia, paraesthesiae or mild motor weakness. This study suggests that a schwannoma in the upper limb can be removed with an acceptable risk of injury to the nerve, although a transient neurological deficit occurs regularly after the operation. Biopsy is not advised. Patients should be informed pre-operatively about the possibility of damage to the nerve: meticulous dissection is required to minimise this

Background: The reconstructive surgery of the upper limb is able to avoid an amputation and a severe functional impairment. Nevertheless the therapeutic challenge is difficult because of the diversity of the injuries and the complex function of the upper limb. Aim: The aim of this study is to assess the results of vascularised fibular bone graft in the immediate and secondary post traumatic reconstructive surgery of the upper limb. Material and method: Between 1985 and 2006, 16 vascularised fibular bone grafts were performed for 15 post traumatic reconstructions of the upper limb. In this study there were 7 females and 8 males, with an average age of 42 years (20–79). The fibular bone grafting was performed in 9 cases in the immediate post traumatic reconstructive surgery. In 7 cases the fibular bone graft was performed after a first failed surgery, as salvage reconstructive surgery. The transfer was composed of bone and skin in 2 cases, of bone and muscle in 6 cases and of only bone in 8 cases. Results: The percentage of bone union was 80%. Eight fibular bone graft healed spontaneously, 2 after a additional iliac crest bone grafting. The average duration of bone healing was 6,5 months, from 4 to 12 months. The functional result was good for 10 patients allowing them to go back to their initial activities. Discussion: In severe bone and soft tissues destruction of the upper limb, a complete reconstruction in one operative session may be performed in order to reduce the time of bone healing and rehabilitation. The micro-vascularized fibular bone grafting may be an excellent therapeutic option. The other techniques as amputation or conventional bone grafting techniques are usually proposed when the vital status of the patient is not compatible with a to extended surgery. The fibular bone grafting appeared as a very reliable technique with a small morbidity on the donor site. Malunions are frequently described in the literature. It might be partially due to the difficulty in having a stable internal fixation. It has to be as less aggressive a possible on the fibular bone graft vascularisation but has also to offer a good stability. The internal fixation used in these cases was not perfectly adapted for this bifocal fixation of the fibular bone graft on the upper limb. A better device should be developed, with an endomedullary fixation and an axial compression effect. Conclusion: We recommend this technique in severe trauma cases of the upper limb as salvage procedure at an early stage when is compatible with the initial general status of the patient

Introduction: It was hypothesized that ipsilateral upper extremity loading will decrease hip abductor activity by decreasing the adductor moment and thus relieving the symptoms of patients with gluteus medius tendinitis. The aim of the study was to test the hypothesis with a electrophysiological and clinical study. Materials and Methods: Seven voluntary men with no hip complaint were included in the electrophysiological phase of the study. The motor unit activities of the gluteus medius were measured for each subject during the consecutive loading of the ipsilateral, contralateral and both upper extremities, with 2, 3, 5 and 7 kilograms. Seventeen patients (age range 34–67) with acute symptoms of gluteus medius tendinitis were included in the clinical phase of the study. Dynamic VAS scores were recorded for each patient during gait with consecutive loading of the ipsilateral, contralateral and both upper extremities, for each 2, 3, 5 and 7 kilograms. Wilcoxon and Mann-Whitney U tests were used in statistical analysis. The p values below 0.05 were considered significant. Results: In the electrophysiologic study the ipsilateral upper extremity loading with 7 kg in 4 patients, and with 5 and 7 kilograms in 2 patients resulted in a motor unit activities with moderate interference, while motor unit activities with full interference were recorded during all other loadings. The motor unit activity interference scores recorded during the ipsilateral upper extremity loading with 5 kilograms of above, were significantly less then all other loading combinations (p < 0.05). In the clinical study, the ipsilateral upper extremity loading with 3 kilograms and above resulted in significantly less VAS scores then the other loading combinations (p< 0.05). Conclusion: Ipsilateral upper extremity loading decrease the motor unit activity of the ipsilateral gluteus medius muscle and relieves the symptoms of the patients with gluteus medius tendinitis. Ipsilateral upper extremity loading can lead up to new strategies in the rehabilitation of gluteus medius tendinitis

This paper describes the presence of tenodesis effects in normal physiology and explores the uses of operative tenodesis in surgery of the upper limb

In cerebral palsy patients, while upper limb function is acknowledged as being important, it has traditionally taken a back seat to lower limb function. This is partly due to inexperience and partly due to difficulty deciding on the best way of improving upper limb function. In Swansea since June 2008 we have been offering a multi-disciplinary service for the assessment and treatment of upper limb problems in cerebral palsy. The core team consists of a consultant orthopaedic surgeon, a consultant plastic surgeon with a special interest in CP upper limb problems, a consultant paediatric neurologist, a community paediatric physiotherapist and a community paediatric occupational therapist. Upon referral, the physiotherapist and occupational therapist carry out initial functional assessment of the patient. This is followed by a joint assessment by the whole team in a special clinic held every 3 months. If required, the child is offered surgery, botox injections or both. Further follow-up is in the special clinic until the child is suitable for follow-up in a normal clinic. We present our initial experience with this multi-disciplinary approach, the problems encountered in setting up the service and our plans for the future

The universal availability of CT scanners has led to lower thresholds for imaging despite significant financial costs and radiation exposure. We hypothesized that this recent trend increased the use of CT for upper limb articular fractures and led to more frequent operative management. A 5-year retrospective study (01/07/2005–30/06/2010) was performed on all adult patients with upper extremity articular fractures (AO: 1.1, 1.3, 2.1 and 2.3) admitted to a Level-1 Trauma Centre. Patients were identified from the institutions prospectively maintained AO classification database. A total of 1651 patients with 1735 upper extremity articular fractures were identified. 1131 (65%) fractures were operated on. 556 (32%) fractures had CT imaging, 429 (77%) of these had operative management. 289 (17%) patients had multiple injuries and 168 (10%) received a scan of at least 1 other body region. There was a gradual increase in CT use and operative management 1.1, 1.3 and 2.1 fractures. Operation rates for 2.3 fractures unchanged but CT imaging frequency declined. In patients younger than 55 years operative management remained stable at 71% throughout the 5-year period considering all four regions. Overall CT use was stable at 38%, however scan rates for distal radius decreased but for proximal forearm increased. The operative management of patients older than 55 years has increased significantly from 56% in 2005, to 70% in 2010. The most marked increase was observed in proximal humerus fractures. Except for 2.3 fractures, CT rates showed similar but less pronounced increases. There is no increase in CT usage and operative management in younger upper limb articular fracture patients. CT utilization is even decreasing in distal radius fractures. Older patients are less likely to get CT scanned but there is a significant increase in operative management of their upper limb articular fractures

Introduction: Upper limb injuries in road traffic accidents (RTAs) have been sparsely investigated and poorly understood. The purpose of this study was to obtain more specific information on upper limb injuries sustained by front seat occupants in car accidents with a view to identifying injuries that are a priority for prevention and further research. Methods: With ethical approval and after obtaining identification of cases from the Transport and Research Laboratory the appropriate hospital records and radiographs were reviewed. Data were analysed to identify the frequency and severity of upper limb injuries, the mechanism of injury and the impairment sustained in accordance with the American Medical Association guide. The costs of management of the upper limb injury and that for the patient in total were calculated. Results: Sixty cases were reviewed (29 male), aged 18–83 years (mean 45 years). There were 19 clavicle fractures of which 17 were right sided, two requiring operative intervention. These injuries were attributed to a “seat-belt” effect. The mean upper limb Abbreviated Injury Score was 1.9 and the overall Injury Severity Score ranged from 1 to 50 (median 12.3). Upper extremity sensory deficit ranged from 0 to 9% and motor deficit 0 to 22.5% giving up to 5% sensory and 13.5% motor “whole person impairment”. The wrist generally suffered a poorer functional outcome compared with the elbow. The mean estimated treatment cost for upper limb management was £2,200 compared with a total injury treatment cost of £11,000 per person. Conclusions: The study demonstrates the significance of upper limb injuries in road traffic accidents and the data has been used in conjunction with crash dynamics data to formulate recommendations for future car safety and further research

Although the Disabilities of the Arm, Shoulder and Hand (DASH) questionnaire was designed, and has been validated, as a measure of disability in patients with disorders of the upper limb, the influence of those of the lower limb on disability as measured by the DASH score has not been assessed. The aim of this study was to investigate whether it exclusively measures disability associated with injuries to the upper limb. The Short Musculoskeletal Functional Assessment, a general musculoskeletal assessment instrument, was also completed by participants. Disability was compared in 206 participants, 84 with an injury to the upper limb, 73 with injury to the lower limb and 49 controls. We found that the DASH score also measured disability in patients with injuries to the lower limb. Care must therefore be taken when attributing disability measured by the DASH score to injuries of the upper limb when problems are also present in the lower limb. Its inability to discriminate clearly between disability due to problems at these separate sites must be taken into account when using this instrument in clinical practice or research

We evaluated the construct validity of the Musculoskeletal Tumour Society rating scale (Enneking score) as a functional measure for patients with sarcoma involving the upper limb. We compared the Enneking score by examining the correlation between two patient-derived outcome measures, the Disability of the Arm, Shoulder, and Hand (DASH) questionnaire and the Medical Outcomes Study Short Form-36 (SF-36) as indicators of functional status in 40 patients with malignant or aggressive benign bone and soft-tissue tumours of the upper limb who had undergone surgical treatment. The frequency distributions were similar among the three scoring systems. As for the validity, Spearman’s rank correlation coefficient of the Enneking score to the DASH questionnaire was −0.79 and that of the Enneking to the SF-36 subscales ranged from 0.38 to 0.60. Despite being a measure from the surgeon’s perspective, the Enneking score was shown to be a valid indicator of physical disability in patients with malignant or aggressive benign tumours of the upper limb and reflected their opinion

Major upper limb arterial injuries sustained in combat are associated with significant trauma. We analysed the survival and complication rates following upper limb vascular injury in Iraq and Afghanistan (2004–2014). Fifty-two soldiers sustained 59 major arterial injuries in 54 limbs. Axillary artery injuries were more likely to be caused by gunshot wounds (86%), whilst brachial and ulnar artery injuries were primarily associated with blasts (72% and 87% respectively); no such correlation was identified with radial artery injuries. Apart from three temporary shunts, all vascular injuries were treated definitively in the local field hospital before repatriation. Proximal injuries were predominantly treated with long saphenous vein grafts and distal injuries with ligation. One soldier required an immediate amputation following failed LSV grafting, however no amputations followed repatriation. There were five identified graft failures (21%), although these were not associated with subsequent perfusion issues. There were no graft failures following temporary shunting. Associated nerve injuries often required operative intervention and have a guarded outcome. 100% of radial fractures went onto non-union if combined with a radial artery injury. Successful immediate re-perfusion of a vascular compromised upper limb correlates with excellent long-term limb survival, despite a significant number of grafts developing secondary failure

Current knowledge regarding upper limb myotomes is based on historic papers. Recent advances in magnetic resonance imaging (MRI) and surgical exploration with intraoperative nerve stimulation now allow accurate identification of nerve root injuries in the brachial plexus. The aim of this study is to identify the myotome values of the upper limb associated with defined supraclvicular brachial plexus injuries. 57 patients with partial supraclavicular brachial plexus injuries were identified from the Scottish brachial plexus database. The average age was 28 years and most injuries secondary to motor cycle accidents or stabbings. The operative and MRI findings for each patient were checked to establish the root injuries and the muscle powers of the upper limb documented. The main patterns of injuries identified involved (C5,6), (C5,6,7), (C5,6,7,8) and (C8, T1). C5, 6 injuries were associated with loss of shoulder abduction, external rotation and elbow flexion. In 30% of the 16 cases showed some biceps action from the C7 root. C5,6,7 injuries showed a similar pattern of weakness with the additional loss of flexor carpi radialis and weakness but not total paralysis of triceps in 85% of cases. C5,6,7,8 injuries were characterised by loss of pectoralis major, lattisimus dorsi, triceps, wrist extension, finger extension and as well as weakness of the ulnar intrinsic muscles. We identified weakness of the flexor digitorum profundus to the ulnar sided digits in 83% of cases. T1 has a major input to innervation of flexors of the radial digits and thumb, as well as intrinsics. This is the largest study of myotome values in patients with surgically or radiologically confirmed injuries in the literature and presents information for general orthopaedic surgeons dealing with trauma patients for the differentiation of different patterns of brachial plexus injuries. In addition we have identified new anatomical relationships not previously described in upper limb myotomes

Background: The purpose of this study was to investigate the relationship between neck pain and upper limb disability. Methodology: This was a secondary analysis of neck pain patients participating in an RCT comparing usual physiotherapy with graded exercise treatment, to investigate the correlation between baseline neck pain and baseline upper limb disability. 151 neck pain patients from High Wycombe, Nottingham, Grimsby and Hull participated in the study. The measure used to assess baseline neck pain/disability was the Northwick Park Neck Pain Questionnaire (NPQ). The measure of baseline upper limb disability was the Disabilities of Arm, Shoulder, Hand (DASH). A range of variables were also measured at baseline as potential confounding variables. These included pain self efficacy, anxiety, depression, fear avoidance beliefs, coping strategies, age, gender, current smoking status, material and social deprivation and activity level. The measures were validated self administered questionnaires. Results: Pair wise analysis revealed a strong positive correlation between NPQ score and DASH score (Pearsons’ r=0.799, p< 0.001 (2 tailed), n=142). Stepwise linear regression indicated that increased severity of upper limb disability was predicted by two baseline variables: higher NPQ scores (B=0.743) and lower pain self efficacy scores (B= – 0.489) {Adjusted R2=0.708; n=100, p< 0.001}. After adjusting for potential confounding variables there remains a strong positive association between NPQ score and DASH score. Conclusions: Patients presenting with high levels of neck pain may also have high levels of upper limb disability. Upper limb disability may need to be assessed and addressed as part of the neck management process

Between 1972 and 2002 74 patients were treated under the combined care of the orthopaedic oncology service and lymphoma clinic with primary bone lymphoma. We reviewed the seventeen cases affecting the upper limb (23%). Of the seventeen patients nine remain alive. Assessment of the patient’s clinical presentation, histopathological definition, treatment and function outcome was made. The nine survivors were assessed clinically and with the Oxford shoulder score and the Toronto extremity salvage score. Average time from first presentation to diagnosis was 7 months. All seventeen were diagnosed as a B –cell non-Hodgkin’s lymphoma, fifteen cases were high grade and two cases were low grade. The scapula was involved in six, humerus eight and clavicle three cases. Seven patients sustained pathological fractures three of which were at presentation; of these two were treated surgically. Eight patients have subsequently died of their disease. Functional outcome in surviving patients after medical treatment was very good with average TESS score of 79% (52%–99%) and OSS of 27 (12–52). The presentation of lymphoma of the shoulder girdle may mimic benign shoulder conditions and lead to a delay in radiological and histopathological diagnosis. Pathological fracture is a common presentation and complication of treatment, however these fractures have a high chance of healing with medical treatment alone. Although shoulder stiffness remains a problem following medical treatment, overall upper limb function is good. There is little evidence that these patients require surgery in the short to medium term

In bone and joint infections, several materials can be used for local antibiotic elution at site of infection. Polymethylmethacrylate (PMMA) cement is often used. Recently the use of antibiotic impregnated dissolvable synthetic pure calcium sulphate beads [Stimulan R]1 has been used as an alternative, due to several perceived advantages. We present our experience of using Calcium sulphate beads in infections involving the upper limb. From Jan 2012 to Jan 2015, we used Calcium sulphate beads in 7 complex upper limb infections including 1 elbow replacement, 2 infected non unions, 2 shoulder replacement, 1 wrist fusion and I ORIF elbow. We used combination of Vancomycin and Gentamicin in the beads, using manufacturer's mixing guide for optimum setting. Arthroplasty infections underwent explantation, addition of antibiotic impregnated calcium sulphate beads in the joint space, followed by a second stage, and systemic antibiotics. Fracture non-union cases had surgical debridement, calcium sulphate beads and systemic antibiotics. Follow up (6months to 2 years) indicate no recurrence of infection in any case. The most common organisms isolated were Coagulase negative staphylococcus and Staphylococcus aureus. Others included Group B Streptococcus, Serratia marscesens and Corynebacterium spp. In 2 of 7 cases there was significant drainage from the wound. This settled without further input. For fracture non-union fixation, there was no need to do second procedure to remove beads as they dissolve. In cases of staged revisions, the beads were inserted at first stage with microbiological clearance at 2nd stage. At present there are no reports in the literature of the use of this product in the upper limb. Our experience suggests use of dissolvable pure Calcium sulphate beads impregnated with selected antibiotics, is an effective adjunct to current treatments. Aseptic drainage has been reported and this was seen in some of our cases. It is postulated that the use of Calcium sulphate beads in more superficial joints may lead to more drainage. It may be necessary to avoid packing any beads in the subcutaneous spaces and using lower volumes in upper limb. Further work will include long-term follow up and any evidence of relapse or recurrence of infection

Upper limb lacerations are a common injury. Traditionally, these have been assessed and treated in the Emergency Department (ED). This has become increasingly rare. A number of different reasons have been postulated. These include the increasingly junior status of those that work within the ED and the 4 hour target within the ED. After referral to the orthopaedic department, these patients are often assessed by increasingly junior staff. Thus, when these patients are assessed by a sufficiently qualified practitioner, there exists no option but to take them to theatre for repair of their injury. The aim of our study was identify the number of patients requiring surgery for hand and wrist lacerations and identify if these patients could be managed without the need for theatre. We collected data in a prospective fashion from 1/9/9 to 3/11/9 at a large district general hospital. Over this period, 36 patients required surgery for their hand or wrist laceration. 27 were male and 9 were female. The average age was 34 years. The average length of procedure from was 21 minutes. 32% of patients were admitted overnight. In two thirds of cases, the operating surgeon felt the procedure could have been performed in a suture room rather than in theatre. Among those patients who could've been operated on within a suture room, 21 would not have required an admission for any other reason. It seems likely that the number of referrals from the ED regarding patients with upper limb lacerations is not likely to decrease. It is, therefore, important to ensure that orthopaedic departments develop new ways of working to try and ensure that patients are treated in a prompt fashion. We believe that the addition of a suture room to the orthopaedic trauma room remains one possible way of achieving this

Introduction and Aim: The metacarpal fractures constitute 10% of skeletal fractures in general affecting mainly children and young adults. There is a lot of discrepancy and lack of evidence with regards to correctly managing the little finger metacarpal fractures. Our study was aimed at investigating the current practice of management little finger metacarpal fractures among upper limb surgeons in United Kingdom. Methods: We conducted an online survey between June 2006 and June 2007 consisting of 10 multiple-choice questions that was e-mailed to 278 upper limb orthopaedic specialist surgeons. The response rate was 58% (n = 158) from the upper limb surgeons. Four questionnaires had to be excluded due to multiple responses to each question or incomplete forms. Results: 43% upper limb surgeons prefer neighbour strapping alone for non-operative management of little finger metacarpal fractures. Ulnar gutter cast or splint was the next choice among 19% upper limb surgeons while 13% respondents apply neighbour strapping to ring finger along with a splint. There was mixed response regarding period of immobilisation. 40% of surgeons were in favour of 3 weeks of immobilisation, 23% for 2 weeks while 28% do not immobilise these fractures at all. With regard to considering the most important indication(s) for surgical intervention, rotational deformity was the most common indication (84%), followed by open fracture (70%), intra-articular fracture (44%), associated 4th metacarpal fracture (26%), shortening > 5mm (21%) and volar angulation – (15%). If treated non-operatively, the most preferred period of fracture clinic follow up was one visit at 3 weeks by 40% while 36% thought that no follow up is required once decision is made to treat them conservatively. Conclusion: Isolated undisplaced fractures of little metacarpal are usually managed conservatively using a plethora of methods of immobilisation. The indications for operative intervention are open fracture, rotational deformity, intra-articular fractures and shortening. Many clinical studies have demonstrated that in the conservative care of boxer’s fractures (casting, with or without reduction), between 20 degrees and 70 degrees of dorsal angulation is acceptable. We conclude that contemporary literature provides no evidence as to whether conservative or operative methods of the treatment of these fractures is superior, but rather suggests that they are equally effective. We conclude from our survey that there is no consensus even among the upper limb surgeons with regards to management of little finger metacarpal fractures in United Kingdom

Neurological examination in children presenting with upper limb fractures is often poorly performed. We aimed to assess the quality of documented neurological examination in children presenting with upper limb fractures and whether this could be improved following introduction of a simple guideline for paediatric neurological assessment. We reviewed the clinical notes of all children presenting to the emergency department with upper limb fractures over a three month period. Documentation of initial neurological assessment and clinical suspicion of any nerve injury were noted. Subsequently, we introduced a guideline for paediatric upper limb neurological examination (‘Rock, Paper, Scissors, OK’) to our own hospital and performed a further 3 month clinical review to detect any resulting change in practice. In the initial study period, 121 patients presented with upper limb fractures. 10 children (8%) had a nerve injury. Neurological examination was documented in 107 (88%) of patients, however, none of the nerve injuries were detected on initial assessment. In patients with nerve injuries, 5 (50%) were documented as being ‘neurovascularly intact’ and 2 (20%) had no documented examination. Following introduction of the guideline, 97 patients presented with upper limb fractures of which 8 children (8%) had a nerve injury. Documentation of neurological examination increased to 98% for patients presenting directly to our own hospital (p=0.02). Within this cohort all nerve injuries with objective motor or sensory deficits were detected on initial examination. Introduction of a simple guideline for neurological examination in children with upper limb fractures can significantly improve the quality of documented neurological assessment and detection of nerve injuries

The management of spasticity of children with cerebral palsy is often complex and challenging. Effective treatment requires a multidisciplinary approach involving paediatricians, orthotists, occupational therapists, physiotherapists and orthopaedic surgeons. Botulinum toxin A therapy in the lower limb has been shown to relieve spasticity and to improve the function in the short term. However, the use of Botulinum toxin A in the upper limb remains controversial, moreover only selected few orthopaedic surgeons have experience in managing it. The aim is to assess the functional improvement following an upper limb Botulinum toxin A injections to the upper limb and then to evaluate the patient’s and parents’ satisfaction after the procedure. During 2007 a total of 36 spastic cerebral palsy patients underwent 47 episodes of Botulinum toxin A injections to the upper limb. There were 22 male and 14 female with an age range between 2 to 17 years (average age was 2 years). Following the surgery, all patients received a course of an intense exercise regime with the physiotherapist and occupational therapist. All patients were prospectively followed-up by the clinic with no loss to follow-up. We also assessed the functional movement of the patients as well as the patient’s and parents’ subjective evaluation of the procedure. Overall, the range of movement of the upper limb has improved following the Botulinum toxin A injection. Most patients/parents were satisfied with the procedure and would consider further injection in the future. Botulinum toxin A injection to the upper limb is generally well received with good short term results. Many would consider further injections to sustain improve function

We prospectively studied 26 consecutive patients with clinically documented sensory or motor deficiency of a peripheral nerve due to trauma or entrapment using ultrasound, and in 19 cases surgical exploration of the nerves was undertaken. The ultrasonographic diagnoses were correlated with neurological examination and the surgical findings. Reliable visualisation of injured nerves on ultrasonography was achieved in all patients. Axonal swelling and hypoechogenity of the nerve was diagnosed in 15 cases, loss of continuity of a nerve bundle in 17, the formation of a neuroma of a stump in six, and partial laceration of a nerve with loss of the normal fascicular pattern in five. The ultrasonographic findings were confirmed at operation in those who had surgery. Ultrasound may be used for the evaluation of peripheral nerve injuries in the upper limb. High-resolution ultrasound can show the exact location, extent and type of lesion, yielding important information that might not be obtainable by other diagnostic aids

Neurological examination in children presenting with upper limb fractures is often poorly performed. In the peripatetic emergency department environment this may be confounded by patient distress or reduced comprehension. We aimed to assess the quality of documented neurological examination in children presenting with upper limb fractures and whether this could be improved following introduction of a simple guideline for paediatric neurological assessment. We reviewed the clinical notes of all children presenting to the emergency department with upper limb fractures over a three month period. Documentation of initial neurological assessment and clinical suspicion of any nerve injury were noted. Subsequently, we introduced a guideline for paediatric upper limb neurological examination (‘Rock, Paper, Scissors, OK’) to our hospital and performed a further 3 month review to detect resulting changes in practice. In the initial study period, 121 children presented with upper limb fractures. 10 (8%) had a nerve injury. Neurological examination was documented in 107 (88%) of patients. However, information on nerves examined was only recorded in 5 (5%) with the majority (85%) documented as ‘neurovascuarly intact’. None of the nerve injuries were detected on initial assessment. Following guideline introduction, 97 patients presented with upper limb fractures of which 8 children (8%) had a nerve injury. Documentation of neurological examination increased to 98% for patients presenting directly to our own hospital (Fisher's Exact Test, p=0.02) with details of nerves examined increasing to 69%. Within this cohort all nerve injuries with objective motor or sensory deficits were detected on initial examination. The recent British Orthopaedic Association Standards for Trauma (BOAST) guideline on peripheral nerve injuries emphasises the importance of clearly recorded neurological assessment in trauma patients. Our study shows that introduction of a simple guideline for neurological examination in children with upper limb fractures can significantly improve the quality of documented neurological assessment and detection of nerve injuries

Upper limb salvage involves treatment of traumatic amputations or devascularization proximal to wrist level. Their management differs from that of more distal lesions because of the muscles involved. We want to report our experience of 25 upper limbs salvage (23 revascularizations and 2 replantations). Four times the lesions were situated at shoulder level, 7 times at arm level, and 12 times at forearm level. Even though several patients were referred for completion of the amputation, all the limbs but two were finally saved. The quality of the functional recovery bore no relationship to patient’s age or duration of the ischemia at the time of the accident

Although there have been many studies of the epidemiology of hip fractures in the older population, including the assessment of bone density and the predictive value of a Cole’s fracture in particular for later hip fracture, there has not previously been an analysis of combined presentation of hip and upper limb fractures. We performed this study to examine the incidence and risk factors of such combined injuries and to assess the impact these have on rehabilitation and subsequent treatment in order to formulate a possible clinical pathway or treatment protocol for such patients. The study was performed retrospectively, with all patients admitted over 3 years with fractured neck of femur being reviewed. Of the 681 patients admitted over this period of time (324 intracapsular and 357 extracapsular fractured necks of femur), 22 were found to have a contemporaneous fracture of the upper limb. The associated upper limb fractures were distal radius (n=11), olecranon (n=5) and neck of humerus (n=6), with the same ratio of intracapsular to extra-capsular fractures as the whole group. The female to male ratio in both isolated hip and combined fracture groups was the same at 3:1. The mean patient age was 77.6 years for isolated hip fractures and 78.4 for the combined group. The usual mechanism of injury in both groups was a fall onto the side, but patients in the combined group also typically described having the arm outstretched for protection. The mean total length of stay in hospital for isolated hip fracture was 10.9 days and for combined fractures was 23.2 days (p< 0.05, ANOVA). Exact details were not retrievable from the nursing homes taking some of these patients, but from the data obtained there was a trend apparent for more of the combined group to require such care and for longer. In summary, it is obvious that patients sustaining combined upper limb and hip fractures can become a significant burden on already busy hospital services. These patients therefore require an even more concerted effort at rehabilitation than those patients with isolated hip fractures. We therefore now recommend the use of a specific clinical pathway or protocol including early fixation, immediate co-ordinated multidisciplinary team involvement and rehabilitation, with everyone involved with the treatment of these patients, doctors, physiotherapists, occupational therapists and others, being aware of these extra requirements. Issues for further analysis in these patients include assessing the contribution of bone density to such double fractures, the associated risk of further fractures and therefore whether such patients require further treatment or protective measures

Neurological examination is essential in patients with upper limb injuries and should be clearly documented. We aimed to assess the quality and documentation of neurological examination performed for children presenting with upper limb fractures to the emergency department. Clinical notes of all children admitted with upper limb fractures over a three month period were reviewed. Documentation of initial neurological assessment was analysed and clinical suspicion of any nerve injury noted. In parallel, we conducted an anonymous survey of emergency doctors evaluating their upper limb neurological examination in children. The casenotes of 121 children with upper limb fractures were reviewed. 10 children (8%) had a nerve injury (median = 4, ulnar = 2, radial = 2, anterior interosseous = 2). Neurological examination was documented in 107 (88%) of patients. However, none of the nerve injuries were detected on initial examination. In patients with nerve injuries, 5 (50%) were documented as being ‘neurovascularly intact’, 2 (20%) as ‘CSM normal’, 1 (10%) as ‘moving fingers’ and 2 (20%) had no documented neurological examination. 30 emergency doctors completed the questionnaires (5 consultants, 9 registrars, 16 foundation doctors). All doctors stated that they routinely performed an upper limb neurological examination and assessed median, ulnar and radial nerves. However, 30% of doctors described incomplete examination of median nerve function, 30% inadequate ulnar nerve assessment and 50% incomplete radial nerve examination. In addition, 75% of doctors failed to identify the need for assessment of anterior interosseous nerve function. While emergency doctors recognise the importance of neurological assessment in children with upper limb injuries, it is often performed inadequately. This in part may be due to difficulties performing neurological examination in paediatric patients. As a result of this study, we have introduced local guidelines to assist neurological assessment in children

The management of upper limb nonunions can be challenging and often with unpredictable outcomes. In the study we present the results of treatment of upper limb nonunions treated in our institution with BMP-7 biological enhancement. Between 2004 and 2011 all consecutive patients who met the inclusion criteria were followed up prospectively. Union was assessed with regular radiological assessment. At the final follow up clinical assessment included the disabilities of the Arm, Shoulder and Hand (DASH) score, range of movement and patient satisfaction. The mean follow up was 12 months (12–36). In total 42 patients met the inclusion criteria with a mean age of 47. Anatomical distribution of the nonunion sites included 19 cases of mid/proximal radius/ulna, 14 humerus, 6 distal radius and 3 clavicles. 5 patients had septic nonunion, 35 had atrophic nonunion, 11 had previous open fractures, and 10 had bone loss (range 1–3 cm). The mean number of operations performed and the mean time from injury to BMP application was 1.5 and 26 months, respectively. 40 patients had both clinical and radiological union whereas 2 had partial radiological union but a pain free range of motion. BMP was applied in isolation in 1 case and 41 cases the application was combined with autologous bone grafting. The range of movement of the affected limb, DASH score and patient satisfaction were optimum at the final follow up. This study supports the use of BMP-7 as a bone stimulating adjunct for the treatment of complex and challenging upper limb nonunions

We report the effect of padding on the efficiency of the pneumatic tourniquet for the upper limb. Varying thicknesses of two commercially-available types of orthopaedic padding (Cellona and Velband) were applied to the arms of 20 volunteers, with three pressure transducers placed directly beneath the padding. A tourniquet was positioned over the padding and inflated to 220 mmHg. Significant reductions in the transmitted pressure were recorded from the transducers with both padding materials. With eight layers of padding, reductions in pressure of 13% (1% to 26%) and 18% (7% to 35%) were seen with Cellona and Velband, respectively. The reduction in pressure with Velband padding correlated with increasing arm circumference (Pearson’s correlation coefficient 0.711, p < 0.001). Studies to date have examined how arm circumference affects the required tourniquet inflation pressure. Our study is the first to investigate the effect of the padding and the findings suggest that using more than two layers results in a significant reduction in the transmitted pressure

Myotome values for the upper limb appear to have been established in the early twentieth century based on historical work. Supraclavicular brachial plexus injuries present with a pattern of neurological loss consistent to the nerve roots affected. Recent advances in radiological imaging and intraoperative nerve stimulation have allowed confirmation of the affected nerve roots. The records of 43 patients with partial injuries to the supraclavicular brachial plexus were reviewed. The injuries covered the full range of injury patterns including those affecting C5, C5-6, C5-7, C5-8, C7-T1 and C8-T1 roots. All cases with upper plexus injuries had surgical exploration of the brachial plexus with the injury pattern being classified on the basis of whether the roots were in continuity, ruptured, or avulsed, and, if seen in continuity, the presence or absence of a response to stimulation. For lower plexus injuries the classification relied on identification of avulsed roots on Magnetic Resonance Imaging. Muscle powers recorded on clinical examination using the MRC grading system. In upper plexus injuries paralysis of flexor carpi radialis indicated involvement of C7 in addition to C5-6, and paralysis of triceps and pectoralis major suggested loss of C8 function. A major input from T1 was confirmed for flexor digitorum superficialis, flexor digitorum profundus (FDP) to the radial digits, and extensor pollicis longus. C8 was the predominant innervation to the ulnar side of FDP and intrinsic muscles innervated by the ulnar nerve with some contribution from C7. A revised myotome chart for the upper limb is proposed

Introduction Ewing’s sarcoma family of tumors was first described by James Ewing in 1921. It is a rare tumor and no one center can hope to accrue sufficient numbers over a reasonable period of time to accurately review them. Objectives A retrospective analysis of all Ewing’s sarcomas of the upper limb from the Scottish Bone Tumor registry (1940–2000), is presented. Attempts have been made to elaborate on prognostic factors, and to document improvements in survival with trends in local therapy over the study period. Results The registry included 23 patients with Ewing’s sarcoma of the upper limb bones. Age at diagnosis ranged from 7–58 Yrs (mean −21.6 Yrs). 48% of lesions occurred in the second decade and 26 % in the third decade. Male: Female ratio was 2.8: 1. The commonest site involved was the proximal humerus (30%), followed by scapula (21%), radius (17%) and hand bones (13%).Resectable lesions underwent excision and adjuvant radio/chemo therapy. Cumulative 5 year survival for the series was 52%. Forearm and hand lesions which achieved complete excision had best results (75% five year survival). Proximal humeral lesions had 57 % survival. Scapular lesions had the worst prognosis (20% survival). Death was usually due to metastatic disease (diagnosed mean 12mts after initial presentation). Lesions presenting with pathological fractures, or having metastasis at diagnosis had extremely poor survival. There was an increasing use of surgery, and changes to chemotherapy (Euro-Ewing protocol) during the latter part of the study period. There were no toxic deaths reported. Discussion Ewing’s sarcoma is a rare lesion. Any of the upper limb bones can be involved. Majority of lesions occur within the first 3 decades of life (87%). Survival is highly dependent on initial presentation. The key prognostic factor is the presence of detectable metastasis at diagnosis. Increased use of surgery and newer chemotherapeutic agents have decreased the local relapse rate over the period of study

Background: The Ilizarov Method is well established for lower limb trauma and reconstruction. However, although the same principles apply, its use in the upper limb is less well described. Aims of Study: To review indications and outcomes of all Ilizarov arm fixators applied by the two limb reconstruction surgeons in our unit. Methods and Results: All patients treated using an upper limb Ilizarov frame were identified and reviewed. Demographic data, indications and durations of frames collected. Fifty-one cases identified. Average age 43 (17–81). Tertiary referrals in 63%. Previous surgery in 78%. Mechanism of injury included: 37% RTA, 40% simple falls. Reasons for frame usually multifactorial including 22 for non-unions. 43% of fixators applied acutely (< 6 weeks). Average frame time was 152 days (34–343). Over 80% achieved expected outcome –obtaining good function or fracture union. 14 needed further frame surgery including 5 for frame removal, 3 adjustments and 2 corticotomies. Most frames removed in clinic. Complications: 30% superficial pin site infection. No deep wire infections. 1 wrist malunion requiring delayed correction. 2 patients had neurological complications from frame surgery. One radial palsy possibly from humeral plate removal. One median palsy due to pressure from wire. One patient had an above-elbow amputation for persistent infection. Conclusions: The Ilizarov technique appears well tolerated and successful despite often infected or deformed tissues. Indication and intended purpose of arm frames very varied. This technique allows stabilization (with/without bone loss), treatment of non-unions and lengthening/bone transport. The Ilizarov Method is valuable for limb salvage/reconstruction

Purpose. We retrospectively evaluated the outcome of fibula grafts in upper limb post infectious diaphyseal gap nonunions and assessed the following modifiers: age, site, vascularised/ nonvascularised, and length of the graft on time to union, graft incorporation, complication rate and reoperation rate. Methods. Thirty seven paediatric upper limb segmental defects treated over a period of 10 years were identified. Twenty two post septic defects in 21 children were treated with intramedullary fixation and vascularised/ nonvascularised fibula grafting. Union time was assessed from records and radiographs. Graft incorporation was assessed using Pixel value ratio (Hazra et al). Complications were defined as nonunion, delayed union, implant failure, refractures, graft loss and infection. Results. Twenty one children with 22 nonunions, 9 boys and 12 girls, mean age 6.5 years were followed up for a mean of 24 months. Defects (humerus-8, radius-8, ulna-6) ranged from 10 mm to 85 mm before surgery. Seven vascularised grafts(mean length = 69.9 mm) 3 in ulna and 4 in radius and 14 nonvascularised (48.8 mm) were 8 in humerus, 4 in radius, 3 in ulna. Primary union was 81% at a mean of 4.7 months. Mean pixel value for graft incorporation was 1.3 (SD = 0.2) on immediate postoperative radiograph and 1.08 (SD 0.16) at mean of 2 years. Complications included nonunion requiring surgery in 4, delayed union in 6, wire migration in 6, refractures in 4, infection reactivation in 2 with loss of graft in 1. Time to union was 5.5 (SD 2.9) months in nonvascularised and 3.1 (SD 0.6) in vascualrised group (P = 0.04). Complication rate was 1.2 and 0.2 in nonvascularised and vascularised grafts(p = 0.04). Bone, age and the graft length did not significantly affect union time, graft incorporation, complication and reoperation rate. The complication rate was significantly higher in children ≤8 year; however other outcomes were not significantly different. Conclusion. Vascularised grafts and children aged >8 year did significantly better in fibular grafting for post-septic upper limb diaphyseal nonunions

Purpose: Therapeutic options for shaft reconstruction are allografts, shaft prosthesis, and autografts, which may be vascularised or not. The purpose of this work was to assess mid-term results and complications after upper limb reconstructions using a vascularised fibula in children and adolescents undergoing surgery for tumour resection. Material and methods: A vascularised fibular graft was used for reconstruction in ten patients who underwent surgery for resection of upper limb tumours between 1994 and 2000. The patients were seven boys and three girls, aged seven to seventeen years. the vascularised fibula was used for reconstruction after tumour resection in the same operation for eight patients and to salvage a proximal humeral prosthesis in two patients. The eight single-procedure reconstructions concerned four resections of the humeral shaft and four resections of the radius. Tumour histology was: classical osteosarcoma (n=7), low-grade osteosarcoma (n=1), Ewing tumour (n= 1) and aggressive enchondroma (n=1). Six patients were on chemotherapy at the time of the fibular transfer. Graft lengths varied from nine to 21 cm (mean 14 cm). Plate fixation was used in most cases. All patients wore a cast for six to twelve weeks after surgery. Results: Results were analysed retrospectively after 3.9 years follow-up (range 1 – 7 years). Mean time to bone healing was three months (range 1.5 – 5 months). Five of the six humeral shaft reconstructions fractured due to trauma, requiring revision surgery in four cases. All patients who were reoperated achieved bone healing rapidly. One radius had to be revised to add supplementary bone. The mean functional score (MSTS) was 25.5/30 (range 21 – 30). One patient died from lung metastasis and the others exhibited complete tumour remission. Discussion: Vascularised fibula reconstruction of the upper limb provides good radiological results, particularly for the radius. For the humerus, the results are better for younger children because the bone can grow in thickness. Certain mechanical complications may occur if normal sports activities are resumed too early. Functional outcome after these shaft reconstructions is nearly normal

We describe the development of a body-powered upper limb prosthesis fitted with a cosmetic functioning hand. The features and advantages of the new design--the PMR (Princess Margaret Rose) prosthesis--are discussed and the clinical results in 15 patients fitted with the prosthesis after above-elbow amputation are described

Aims: To describe the proþle of patients older than 65 years of age with a fracture of the upper extremity, and the consequence of such an injury. Methods: Retrospective cohort study of 667 patients presenting to the emergency department between January 1999 and December 2000 with a fracture of the upper extremity. Variables included sex, age, location of fracture (± additional fractures), treatment, length of stay (in hospital and convalescent care), and place of habitation before and after injury. Follow-up continued until patientsñ deþnitive residential status. Results: The majority of patients were women with fractures of the wrist and proximal humerus. 42% were treated and returned to their previous residence. 37% were admitted to the hospital, of whom 90% had an operation; 97% returned to their previous residence. 21% of patients did not require an operation, but were unable to function independently and were admitted directly to our Geriatrics Hospital. This group was signiþcantly older and more frequently sustained a fracture of the proximal humerus or 2 fractures. 20% required long-term placement. Conclusions: Fractures of the upper extremity in this age group are frequent. A particular subset of signiþcantly older patients are unable to function independently, thus requiring hospitalization, extended periods of convalescence, and a greater likelihood of a permanent change in habitation

Aims: To examine vibration levels produced by orthopaedic air tools and the prevalence of upper limb symptoms in orthopaedic surgeons. Methods: A preliminary measurement of vibration levels produced by six air powered orthopaedic saws was followed by a national survey of orthopaedic surgeons and controls. A health surveillance questionnaire of symptoms associated with Hand Arm Vibration Syndrome (HAVS) was sent to 1200 orthopaedic surgeons (test group) and 1200 gynaecological surgeons (controls). Results: Measured accelerations of the saws were 3.42 to 10.7 m/sec. 2. using BSI standards and 90.5 to 182 m/sec. −2. using NIOSH standards. These vibration levels are compatible with those reported to cause significant upper limb symptoms. Survey responses were received from 741(61.7%) of the test group and 748 (62.3%) of the control group. A statistically significant increase in the prevalence of the neurological symptoms was seen among orthopaedic surgeons (p< 0.001). A significant increase in musculoskeletal problems (p< 0.008) and muscle pain (p< 0.004) was also found. No significant difference was seen in the prevalence of vascular symptoms. The neurological symptoms were not related to other potential medical causes. Conclusions: Orthopaedic surgeons report an excess of upper limb symptoms and these may be linked to vibration exposure at work

Background: Chondrosarcoma is the second most frequent primary malignant tumor of bone. The biologic evolution of these tumors is slow, requiring long follow up for meaningful survival analysis. Methods: The clinicopathologic profiles of 84 (41 male, 45 female/M: F, 1:1.09) chondrosarcomas of the upper limb from the Scottish Bone Tumor Registry (1940–2000) are presented. Results: The mean age at presentation was 54.8Yrs (range 12–85yrs).The proximal humerus was the most frequent anatomical site (30.2%).21% lesions involved the scapula, and 34% small bones of the hand. Local pain was the most frequently reported initial symptom. All patients were followed up for a minimum 60 mts. Radiographically; chondrosarcomas had a characteristic appearance of bone expansion and cortical thickening. The cumulative 5 year survival was 82.5%. Local recurrence developed in19.7 % (mean 40 mts after initial presentation), and distal metastasis in 16.2%.Hand tumors rarely had metastasis. Tumor breach at time of surgery increased risk of local recurrence. Histological grade was an important factor in predictor of local recurrence and metastasis. Discussion: Chondrosarcomas are highly diverse tumors ranging from slow growing non- metastasizing lesions to highly aggressive metastasizing sarcomas. With adequate initial surgical intervention, chondrosarcoma is primarily a local disease with a low metastatic rate. Hand lesions have best prognosis

Background: The dorsal wrist ganglion is one of the commonest tumours to be found in the upper limb. Aims: We aimed to find out how specialist upper limb surgeons managed this common condition, and to propose best practice guidelines. Methods: We sent a standard questionnaire by email to 100 hand surgeons who were members of the British Society for Surgery of the Hand. Results: 62% returned the completed questionnaire. 93% routinely used a tourniquet, 73% used general anaesthetic. 83% would not use Xray or further imaging. 62% would operate on less than 10 a year or as few as possible. Only 42% routinely sent tissue for histology and 71% used a transverse incision. Discussion and Conclusions: Most upper limb surgeons diagnose a ganglion clinically, use a transverse incision for excision and do not routinely send tissue for histology. We believe that ganglia should be treated like other neoplasms and excised via a longitudinal incision and tissue sent for histology. We present a series of cases which were thought to be simple ganglia, but histology revealed different pathology. The use of a transverse incision, may compromise definitive excision at a later date, if histology revealed a malignant neoplasm. A transverse incision has not been shown to give superior results in terms of cosmesis, and is also associated with an increased risk of painful neuroma formation after damage to the superficial radial nerve

We reviewed 42 consecutive children with a supination deformity of the forearm complicating severe birth lesions of the brachial plexus. The overall incidence over the study period was 6.9% (48 of 696). It was absent in those in Narakas group I (27.6) and occurred in 5.7% of group II (13 of 229), 9.6% of group III (11 of 114) and 23.4% of group IV (18 of 77). Concurrent deformities at the shoulder, elbow, wrist and hand were always present because of muscular imbalance from poor recovery of C5 and C7, inconsistent recovery of C8 and T1 and good recovery of C6. Early surgical correction improved the function of the upper limb and hand, but there was a tendency to recurrence. Pronation osteotomy placed the hand in a functional position, and increased the arc of rotation of the forearm. The supination deformity recurred in 40% (17 of 42) of those treated by pronation osteotomy alone, probably because of remodelling of the growing bone. Children should be followed up until skeletal maturity, and the parents counselled on the likelihood of multiple operations

The Stanford Upper Extremity Model (SUEM) (Holzbauer, Murray, Delp 2005, Ann Biomed Eng) includes the major muscles of the upper limb and has recently been described in scientific literature for various biomechanical purposes including modeling the muscle behavior after shoulder arthroplasty (Hoenecke, Flores-Hernandez, D'Lima 2014, J Shoulder Elbow Surg; Walker, Struk, Banks 2013, ISTA Proceedings). The initial publication of the SUEM compared the muscle moment arm predictions of the SUEM against various moment arm studies and all with the scapula fixed. A more recent study (Ackland, Pak, and Pandy 2008, J Anat) is now available that can be used to compare SUEM moment arm predictions to cadaver data for similar muscle sub-regions, during abduction and flexion motions, and with simulated scapular motion. SUEM muscle moment arm component vectors were calculated using the OpenSim Analyze Tool for an idealized abduction and an idealized flexion motion from 10° to 90° that corresponded to the motions described in Ackland for the cadaver arms. The normalized, averaged muscle moment arm data for the cadavers was manually digitized from the published figures and then resampled into uniform angles matching the SUEM data. Standard deviations of the muscle moment arms from the cadaver study were calculated from source data provided by the study authors. Python code was then used to calculate the differences, percent differences, and root-mean-square (RMS) values between the data sets. Of the 14 muscle groups in the SUEM, the smallest difference in predicted and measured moment arm was for the supraspinatus during the abduction task, with an RMS of the percent difference of 11.4%. In contrast, the middle latissimus dorsi had an RMS percent difference over 400% during the flexion task. The table presents the RMS difference and the RMS of the percent difference for the muscles with the largest abduction and adduction moment arms (during abduction) and the largest flexion and extension moment arms (during flexion). The moment arm data for the SUEM model and the cadaver data (with 1 standard deviation band) during the motion of the same muscles are provided in Figure 1 for the Abduction motion task and in Figure 2 for the Flexion motion task. It is challenging to simulate the three dimensional, time variant geometries of shoulder muscles while maintaining model fidelity and optimizing computational cost. Dividing muscles in to sub regions and using wrapping line segment approximations appears a reasonable strategy though more work could improve model accuracy especially during complex three dimensional motions

Purpose of the study: Clinical assessment of the upper limb in the cerebral palsy child remains difficult, and minimally reproducible. Thus many authors use for the upper limb, as for the lower limb, movement analysis to aid in decision making and obtain an objective measurement of postoperative results. Material and method: Kinematic analysis and EMG were performed with the Vicon system in 27 cerebral palsy children with a spastic upper limb. The patients were compared with data obtained in a control population of 12 children. Eight patients had a second assessment after treatment. The experimental protocol followed the recommendations of the International Society of Biomechanics. The muscles targeted by the treatment were the pronator teres, the flexor carpi ulnaris, and the adductor pollicis (lengthening, transfer, toxin injection). Results: Significant kinematic anomalies (p< 0.05) found were: excessive homolateral inclination and flexion/extension of the trunk, excessive abduction and external rotation of the arm/trunk, excessive elbow flexion, excessive pronation of the forearm, and flexion and ulnar inclination of the wrist. There was significant improvement postoperatively in the group of treated patients (p< 0.05) regarding the kinematics of the trunk, shoulder and elbow, as well as the EMG behaviour of the biceps/triceps couple despite the fact that the procedure had not affected these muscles or joints. Discussion: Kinematic and EMG anomalies involving the trunk, shoulder and elbow represent motor strategies compensating for distal anomalies: – recruitment of the biceps allows improved supination, pulls the elbow in flexion. Since the patient cannot extend the elbow to achieve a task, compensation with the trunk increases the amplitude of the flexion-extension movement; – ‘extrinsic’ supination is achieved via an increase in external rotation of the arm in relation to the trunk and homolateral inclination of the trunk. Conclusion: These observations have therapeutic implications: clinical, kinematic or EMG anomalies involving the trunk, shoulder, and elbow should not be treated per se but reevaluated after treatment of more distal anomalies

Biomechanical models have been successfully applied to screen potential risk factors for injuries and to plan and evaluate the effects of orthopedic surgical procedures.[. 1. ] These models have made apparent the feasibility and necessity for the generation of subject specific models that are aimed at custom clinical applications. In order to develop such models a methods needs to be developed that allows accurate geometrical visualization and reconstruction of position and characteristics of bone and soft tissues, including neurovascular structures.[. 2. ] In this study, we present our approach to obtain both bony as soft tissue features necessary for upper limb modeling from computer tomography alone. As a case study the techniques were applied in a non-anatomic shoulder reconstruction. In order to determine the muscles of the shoulder girdle, ultrathin flexible metallic markers were sutured from origin to insertion according to the fiber directions in all muscles involved in shoulder movement on a total of ten different cadaver shoulders. The plexus brachialis and upper limb nerves were dissected and injected with a iodium contrast containing mixture. A Ct multi-slice image reconstruction was performed from occiput to the hip joint. The software package Mimics® (Materialise NV, Heverlee, Belgium) was used to segment and reconstruct the different anatomical models that included bone, muscle features, nerves and vascular structures. A clustering method algorithm, was used to filter interruptions of the different masks, scattering rustle and small irregularities due to the different contrasting markers used. Vascular tissue could be reconstructed and segmented as air filled structures. We were able to accurately reconstruct nerve tissue in an highly complex configuration such as the plexus brachialis. Analysis of the representations showed that the different morphologic parameters were within the normal anatomical ranges and that our method is suitable to create complete anatomical models based on Ct-imaging alone

INTRODUCTION. Musicians' hand problems are as old as music itself. These problems involve functional motor disorders which have been underestimated by musicians, who do not want to accept the possibility of reducing their professional activity and doctors who are either not knowledgeable about musicians' characteristics or underestimate this artistic activity. The aim of this study is to determine the causes of the pathologies instrumentalist musicians have, and their distribution according to age group, instrument and type of music, and thus infer the main risk factors in the occurrence of medical problems related to musicians' activity. MATERIALS AND METHODS. We consider musicians those who devote themselves to the study, teaching and playing of a musical instrument. In Argentina there are about 50.000 instrumental musicians. Since over 14 years the members of “Las Manos del Músico” have treated 574 musicians. The 84% of the medical problems related to the playing of the instrument. Ages are between 13 and 78 years. The musicians treated belong to different conservatories, symphonic and popular orchestras. Each musician was studied with the same protocol, filled in by the same professional. Variables such as type of music, age, sex, instrument, dominance andrelated variables were taken into account. RESULTS. The 47% of those treated are devoted to popular music and the 53% to classical music. The prevailing age group is 31–40 years, there being a variation between popular and classical performers (43% in the case of classical performers and 39% in that of popular performers). Traumatic pathology is of the 16%, and a clear predominance of chronic pathology (78%) was observed with 43% of musculotendinous injuries, 16% of nervous pathology andb18.% of joint pathology. Focal dystonia affected to 15% of the musicians treated. Within the musculotendinous pathology a 50% was due to overuse syndromes. CONCLUSIONS. In 86% of the cases the causes of injuries in musicians' upper extremity are related to the playing of the instrument. There is a clear predominance of chronic injuries, overuse syndromes, in a young age group (20 to 40 years). The diagnosis of this injuries must be based on an exhaustive physical examination, knowledge of the different instruments and of the most frequent injuries caused by each instrument. In order to get satisfactory results in the treatment and prevention of these injuries, it is necessary to create a space for communication, exchange and interdisciplinary reflection between hand and orthopedic surgeons, physical and occupational therapists and psychologists, as well as musician teachers. The challenge is to combine two parallel experiences, that of specialized medicine with that of the workers of the music culture, generating a link between science and art in order to improve the ways of preventing and treating the injuries of this professional group

1. The indications for the use of lively splints in upper limb paralysis instead of reconstructive surgery are discussed. 2. Examples of lively splints used for the elbow, wrist and hand are described and illustrated

Introduction. Distal radius fractures (DRF) are a common injury in the A&E departments, being a major cause of disability of the upper extremity. The aim of this prospective study is to assess the possible association between objective physical variables such as wrist range of movement (ROM), radiological parameters, and upper extremity disability (measured by the DASH questionnaire), after conservative treatment of DRF. Patients and methods. 44 patients with non-operatively managed DRF were enrolled in a prospective cohort study from July 2007 till September 2009. Inclusion criteria: unilateral DRF in skeletally mature patients, treated non-operatively with closed reduction and cast. Patients who sustained a previous fracture of the wrist, or bilateral wrist fracture, or with dementia, were excluded. After the closed reduction and inmovilization of the fracture in the A&E department we asked the patients to complete the DASH questionnaire, referring to their baseline pre-fracture state. All fractures were classified according to the AO classification. After one year, 36 patients were still available for follow-up purposes. We assesed the following objective physical variables: ROM of both wrists: flexion/extension arc and pronation/supination arch. We recorded the following radiologic parameters: radial angulation, volar angulation and radial shortening. The patient-perceived results were measured by the DASH questionnaire, while pain was measured using the VAS scale. Statistical analysis was performed using the SPSS 15.0. Results. Average follow up: 13,39 months (range 12.3–16.43). Mean age: 62.5 years (18–91). 75% of the fractures were 23A and 24,1% 23B. Average pre-fracture DASH score was 19.6 and 42.1 at the end of follow-up. Radial tilt: 18.18°. Volar tilt: 3,35°. Radial shortening: 5,76mm. ROM for flexion/extension of the involved wrist: 103.6° and non-involved wrist: 131.2°. ROM for pronation/supination involved wrist: 145.7° and non-involved wrist: 173.8°. Post-fracture VAS score: 3.5. We didn't find any significant statistical correlation between the lost of ROM, neither with radiological malaligment nor with patient-perceived outcomes. But we found a significant association between items 24–28 of the DASH (except item 26) questionnaire and the VAS score. Conclusions. The results of the present study show that, conservative treatment of DRF seems to deteriorate the patient self-reported outcomes measured by the DASH questionnaire

Aim: The aim of this study was to look at the presenting features, histological grade, size of primary tumour, method of treatment and patient and doctor delays in upper extremity Ewing sarcoma to observe the effects on local recurrence, metastasis and survival. Methods: 19 patients with upper extremity Ewing sarcoma were identified using the Scottish Bone Tumour Registry which carries clinical, pathological and radiological data on the majority of bone tumours diagnosed in Scotland over the past 50 years. Results: With increasing tumour Enneking grade at presentation there was a significantly higher mortality (X2=8.0606, p=0.0178). Patients with a higher grade also had an increased trend towards local recurrence (X2=5.1154, p=0.0775). Grade did not seem to influence the occurrence of metastasis. Patients with larger tumours tended to have a higher mortality (50% vs 27% dead at 5 years). All patients presented clinically with pain and all but two complained of some sort of swelling. It was found that there was a trend towards a higher grade in patients presenting with a longer duration of symptoms (X2=4.6269,p=0.0989). No difference in survival was noted between patients undergoing surgery and chemotherapy and patients undergoing radiotherapy and chemotherapy. Disease-free survival was 100% at both 5 and 10 years for Enneking Grade IIA, 56% at 5 and 10 years for Grade IIB and 0% at 5 years for Grade III. Conclusions: This study re-emphasises the importance of a delay in diagnosis on outcome. Longer symptom duration results in a higher histological grade at presentation. In turn a higher presenting grade is associated with a higher mortality. In agreement with other studies a larger primary tumour correlates with a poorer outcome. Outcomes in terms of survival are comparable for groups treated with adjuvant radiotherapy or surgery

Introduction. Pneumatic tourniquets (PTs) are commonly used in local anaesthetic cases in the upper limb to provide a bloodless operating field. They give excellent efficacy however their limitations have prompted the introduction of a new single-use sterile silicone ring tourniquet (SRT). The evidence of use of the SRT over the standard PT is limited. Aim. To compare the level of perceived pain, and therefore tolerance, of the Silicone Ring and Pneumatic tourniquets when applied to the upper arm and to evaluate whether there was a clear benefit of use of either tourniquet in local anaesthetic procedures of the upper limb. Materials and methods. 30 volunteers, 15 male and 15 female, with a median age of 42 were recruited to compare the two tourniquets. Pain was measured using a VAS pain scale on application and at 1, 5 and 10 minutes. Results. Volunteers experienced significantly more pain on application and at 1 and 5 minutes with the SRT. This difference in pain perceived was most marked upon application. Two volunteers could not tolerate application of the SRT. Three volunteers experienced bruising of the arm and/or forearm following use of the SRT. There was no difference in pain scores at 10 minutes. Conclusion. Due to the severe pain experienced on application of the SRT it would not be suitable for local anaesthetic procedures in the upper limb. In addition the degree of pain may reduce the patients confidence and adversely affect their experience of the procedure. The PT is more suitable for local procedures. However the SRT may have a role in procedures performed under general anaesthetic

This work examines the Upper limb (UL) blast-mediated traumatic amputation (TA) significance from recent operations in Afghanistan. It is hypothesized that the presence of an UL amputation at any level is an independent predictor of torso injury. A joint theatre trauma registry search was performed to determine the number of British casualties with TA and their associated injuries. UL TA accounted for 15.7% of all amputations; distributed: shoulder disarticulation 2.5%, trans-humeral 30%, elbow disarticulation 10%, trans-radial 20% and hand 37.5%. The presence of an UL amputation was more likely in dismounted casualties (P=0.015) and is a predictor of an increased number of total body regions injured and thoracic injuries (P 0.001 and P 0.026 respectively). An increased Injury Severity Score (ISS) was seen in patients with multiple amputations involving the UL (UL TA present ISS=30, no UL TA ISS=21; P=0.000) and the ISS was not significantly different whether mounted or dismounted (P=0.806). The presence of an upper limb amputation at any level should insight in the receiving clinician a high index of suspicion of concomitant internal injury; especially thoracic injury. Therefore with regards to blast mediated TA the injury patterns observed reflect a primary and tertiary blast mechanism of injury

Aim: To assess the functional outcomes for patients treated by limb salvage surgery for sarcomas of the upper limb and shoulder girdle. Materials and methods: Patients who had undergone limb salvage surgery for upper limb sarcoma between 1997 and 2004 were entered into the study. The operation notes were used to obtain details of the surgery. Pathology reports were consulted to identify the type, grade and margins of the tumour. The Toronto Extremity Salvage Score (TESS) questionnaire was used to assess post-operative function, in a postal survey. Results: A total of 62 patients were identified. Liposarcoma was most common histological diagnosis, and “low” the most common grade (27). Histologically clear margins were achieved in 28 (44%) cases, marginal in 2 (3%), incomplete in 13 (21%) and indeterminate in 20 (32%). 30% had received adjuvant radiotherapy with or without chemotherapy as indicated. A total of 48 (76%) had been treated with excision and primary closure, 7 (11%) with local flaps, and 4 (6%) with endoprostheses. 10 patients had died, and 1 was untraceable. 29 completed TESS questionnaires were returned; with an average follow-up of 33 months post-resection (range 4 to 83). 11 female (38%), 18 male (62%), with an average age at surgery of 55. The average TESS score was 77 +/−10 with a range of 18–100. For the different regions, forearm sarcomas had an average TESS of 81 +/−17, upper arm 76 +/−19 and shoulder 81 +/−14. Discussion: Surgical excision of soft tissue tumours with limb salvage aims to balance morbidity and mortality. Upper limb amputation has greater morbidity than lower limb and thus the argument for limb salvage should be stronger. A limb-salvage procedure should be considered preferable to amputation provided oncological outcomes are not compromised, and the resulting functional outcome is worth the oncological risk. In this cohort, patients had good functional outcomes, as described by the TESS functional assessment score, with no evidence of compromised oncological outcome during the follow up period

Between 1988 and 1998, a total of 12 patients (6 men and six women, of average age 36 years) underwent surgery for schwannoma of the peripheral nerves of the upper extremity. The incidence according to the involved nerve was analyzed and the follow-up results and complications after surgical treatment were reviewed. The median nerve was most frequently involved (6 cases), followed by the ulnar nerve (4 cases) and the radial nerve (2 cases). The average duration of symptoms was 2 years (3 months-8 years). Pain or painful paresthesias were usually the main complains. None of the patients suffered from Recklinhausen’s disease. Magnetic resonance imaging is the preferred exploration technique, particularly useful in case of deep tumor. EMG studies were carried out in all patients. Preservation of nerve continuity is the underlying goal of the therapeutic strategy. Marginal excision was performed in all cases. The tumors were extricable displacing the nerve fiber bundles without penetrating into the bundle itself and it was possible thus to be resected without interrupting the nerve continuity. Postoperatively, 7 patients were pain free, while 5 improved. Neurological deficits were favourably influenced by the operation. Out of 4 patients with motor deficits 3 had complete and 1 had partial recovery. Three out of 6 patients with sensory deficits had complete recovery, 2 remained unchanged, while 1 worsened. One patient developed new motor and another one new sensory deficits. New deficits developed predominantly in patients with large tumorsor longstanding symptoms. There was no reccurence or malignant transformation until the average of 52 months of follow-up

Using a scintigraphic technique based on anautologous injection of . 99m. Tc-labelled erythrocytes, we have evaluated the efficiency of different exsanguination procedures in the upper limb of ten healthy male volunteers. The methods were elevation alone, the use of the Esmarch bandage or a gauze bandage, the Pomidor roll-cuff, the squeeze method and the Urias bag. The various procedures gave the following median percentage reductions of blood volumes: elevation for 5 seconds 44%, 15 seconds 45%, 30 seconds 46%, 60 seconds 46% and 4 minutes 42%, the Esmarch bandage 69%, a gauze bandage 63%, the Pomidor roll-cuff 66%, the squeeze method 53%, and the Urias bag 57%. With regard to elevation alone no significant differences were found. All the external methods were significantly more effective than elevation alone. Overall, the squeeze method was found to be the best method of exsanguination before inflation of a tourniquet, because it is effective, fast, practical and inexpensive

1. Orthotic systems for the upper limb are described. 2. Two patients are described to illustrate the value of the systems

We describe our experience with vascularised bone grafting for the treatment of fibrous dysplasia of the upper limb in eight patients, five men and three women, aged between 17 and 36 years. The site was in the humerus in six and the radius in two. Persistent pain, progression of the lesion and pathological fracture with delayed union were the indications for surgical intervention. We used a vascularised fibular graft after curettage of the lesion. Function and radiological progress were serially monitored. Early radiological union of the graft occurred at periods ranging from 8 to 14 weeks. The mean period for reconstitution of the diameter of the bone was 14 months (12 to 18) predominantly through inductive formation of bone around the vascularised graft, which was a prominent feature in all patients. There were no recurrences and none of the grafts sustained a fracture or failed to unite. After operation function was excellent in three patients and good in five. Vascularised bone grafts provide a safe and reliable means of ensuring good continuity of bone with little risk of recurrence and failure

Complex injuries of upper extremity are among the most challenging cases for the treating physician, especially when comminuted fractures, neurovascular injuries or extensive soft tissue loss are accompanied with. Reconstruction of the skeleton is usually very difficult since plates, screws, or external fixation do not always provide sufficient stability. Recently, flexible titanium intramedullary nails that initially developed for pediatric trauma, were introduced in treatment of open and complex injuries of upper extremity. From 1995 – 2001 20 patients (16 male, 4 female) with a mean age 28 years (15–60 years) were managed at our department with flexible titanium intramedullary nailing. 12 sustained forearm fractures, humeral ones, as well as 4 concomitant fractures of forearm and humerus.Nailing was performed either closed with image intensifier or open through the wound with minimal stripping. Postoperatively a splint was applied. Rehabilitation regime was adjusted to soft tissue care; when severe soft tissue wasn’t encountered, early mobilization of the arm was applied. Union rate was conceivably high, in a relative short time. In 3 cases of segmental fractures of radius, nail removal and subsequent fixation with plate and screws due to nonunion of distal site, was necessitated. Operative technique is simple, fast and reliable providing satisfactory reduction, stable fixation with minimal further tissue trauma and mostly early mobilization

1. A description of the planning for the application of a powered prosthesis to a child with bilateral upper limb deficiency is given. 2. Details of twenty such children are recorded

To review indications and outcomes of all Ilizarov arm fixators applied by the two limb reconstruction surgeons. All patients treated with an upper limb Ilizarov frame were identified. Casenotes were reviewed. Demographic data, indications and duration of frames collected. Forty-seven patients had application of an arm frame. Average age 43 (17–81). Tertiary referrals in 72%. Previous surgery in 79%. Mechanism of injury included: 37% RTA, 40% simple falls. Reasons for frame usually multifactorial. Half of fixators applied acutely (< 6 weeks), 17 for non-unions. Two patients had neurological complications from frame surgery. One radial palsy possibly from humeral plate removal. One median palsy due to pressure from wire. Average frame time was 152 days (34–343). Over 80% achieved expected outcome -obtaining good function or fracture union. One patient had an above elbow amputation for persistent infection. Fourteen needed further frame surgery including 5 for frame removal, 3 adjustments and 2 corticotomies for lengthening. Most frames removed in clinic. The Ilizarov technique appears well tolerated and successful despite often infected or deformed tissues. Indications and intended function of arm frames very varied. This technique allows stabilisation (with/without bone loss), treatment of non-unions and lengthening/ bone transport. The Ilizarov technique is valuable for limb salvage/ reconstruction

Drug injection often results in soft tissue infections of the upper extremity. The purpose of this study was to determine the distinct bacteriologic features of soft tissue abscesses in injecting drug abusers in order to provide guidelines for optimal empiric antibiotic therapy. Admissions to the musculoskeletal infection ward at our institution from 1993 to 2005 were screened to identify patients with a history of injecting illicit drugs and a diagnosis of a soft tissue abscess. Eight hundred fifty-five patients met these criteria and were included in this retrospective study. There were 638 male and 217 female patients with a mean age of 41.5 years (18 to 75 years). In the 694 patients with positive cultures the most common organism was Staphylococcus aureus, identified in 359 patients (52%). A progressive increase in the prevalence of ORSA was observed; ORSA comprised 5% of Staphylococcus aureus infections in 1999, 50% in 2001, 56% in 2003, and 82% in 2005. Microaerophilic Streptococcus was present in 37% of culture-positive cases and other anaerobes in 10%. Infections were monomicrobial in 366 of 694 patients (53%) and polymicrobial in 328 of 694 patients (47%). Staphylococcus aureus is the most common pathogen in soft tissue abscesses in injecting drug abusers with an increasing proportion of ORSA. In addition to surgical decompression of abscesses, broad-spectrum empiric antibiotic therapy may be necessary

A review is presented of 41 patients with traumatic tetraplegia on whom reconstructive surgery of the upper limb was carried out. Twelve patients were followed up for more than 10 years after operation and the average period overall was seven and a half years. Tendon transfers were made with the aim of providing extension of the elbow or restoring a useful grasp or a combination of both. The assessment was carried out on four main aspects: the function of the elbow, the function of the hand, the ability to carry out the activities of daily living and the effect of the surgical reconstruction on the personal and social achievement of the patient

Aims: There are no large published studies examining the complication rates associated with use of Kirschner wires in þxation of a wide variety of paediatric fractures. The aim of this study is to analyse the outcomes of fracture þxation using K-wire in upper limb fractures in children and to critically assess the incidence and type of complications. Methods: This study is a retrospective review of a consecutive series of 107 fractures in 105 paediatric trauma cases treated with K-wire in between 01.09.99 to 10.09.01. Results: The fractures were fractures around Wrist (47%) and around elbow (45%). 66 (61.68%) were performed by closed percutaneous technique, 27 (25.23%) by open method and in 14 (13.08%) combined approach was used. Around there were 13 cases with over-granulation at wound site, 6 cases of Soft tissue infection, 2 cases with tendinitis, 1 case of Osteo-myelitis and 1 case with hyper-sensitive scar. 3 cases found to have postoperative neurapraxia and 1 case with axonotmesis. Metal migration was detected in 4 cases and 14 cases found to have shown wire loosening. 10 fractures have lost position in postoperative period out of which 2 cases were reoperated for Re K-wire, 1 had undergone Re-MUA and 7 left for remodelling. Conclusions: K-wires are versatile but are not inherently benign. We conclude that best results could be achieved if total life of K-wire can be restricted to 3–4 weeks. We recommend one should explain all these risks and complications during consenting for K-wiring procedures

Aim of Study: The clinical and radiological assessment of the results of the operative treatment of fractures of the upper limb with associated soft tissue involvement. Methods: We present a review of 17 patients with fractures, nonunions, pseudarthroses and malunions of the forearm (8) and hand (9) with associated soft tissue involvement. All cases were chronic injuries. Three female and 14 male with average age of 27 (12–43) were operated between 9/1998 and 3/2002. The average time before surgery was 10 months. The causes of the defects were severe trauma in 10 cases, electric injuries in 2, osteomyelitis in 3 and combustion in 2 cases. At follow-up the patients were evaluated for bone unuon, ßap integration, function (AROM, grafting power), complications. In 13 patients we performed an open reduction and internal þxation (ORIF) with Pi-, LC DCP, T-plates; in 4 Ð an external þxation (AO-þxator). The osteosynthesis was accompanied with free ßaps transfer (2), pedicled ßaps (8), free nonvascularized bone grafts (3), local skin ßaps and skin grafting (7). Results: The good and excellent results (bone union, ßap integration) were received in 78% of patients, who we performed the transposition of the pedicled ßaps, in a combination with stabile þxation (ORIF); satisfactory Ð in 22%. We observed the following complications: partial necrosis of ßap (3), and bone graft (2), refracture (1). Conclusions: The combination of stabile þxation of bone fragments and adequate coverage of the soft tissue defects is an efþcient method in the treatment of bone fractures with soft tissue involvement. This combination creates an optimal condition for early rehabilitation and improves results of treatment

The clinical features, management and outcome of bleeding into the muscles of the upper limb of 44 patients are reported. Of 158 episodes of bleeding, 99% were treated within two hours of onset of symptoms and the mean time to complete restoration of function was 2.1 days. The most frequent site of bleeding was the deltoid muscle (24%), followed by the forearm flexors (23.5%), brachioradialis (19.5%), biceps (14%), forearm extensors (11%) and triceps (8%). The majority of bleeds presented with pain, either on movement or at rest, or with tenderness. Bleeds into the biceps required the most transfusions (mean 2.00) and took the longest to resolve (mean 4 days). Bleeding into the flexors and extensors of the forearm resolved most rapidly. The policy of early treatment has been shown to be effective in prompting early and complete recovery

Purpose: Appropriate management of complex trauma of the upper limb (CTUL) is a significant therapeutic challenge. The main difficulty is to determine in an emergency situation when ambitious conservative surgery is legitimate and when amputation in necessary. We propose a prognostic lesion score to determine the best option in the emergency setting. Material and methods: This study included 48 patients operated on between 1987 and 1997. These patients presented total or partial amputation (n=23), devascularising injury with continuous limb (=7), complex non-devascularising injury with continuous limb (n=18) (Gustilo IIIa and IIIb). Isolated hand trauma was excluded. Each patient was attributed retrospectively a lesion score taking into account each tissue (bone, vessels, nerves, muscles, skin). At minimum two-year follow-up, the outcome was evaluated for the amputated or non-amputated limb. For each non-amputated patient, a more precise outcome was established using the Chen classification. Operative procedures used the same protocol for all patients. Results: Considering the functional results, the statistical analysis enabled identifying prognostic factors for amputation among the five variables studied. Analysis using a classification tree enabled development of a decisional algorithm based on the muscle, nerve and skin injuries which provided 64.7% sensitivity and 100% specificity with a 100% positive predictive value and an 83.8% negative predictive value. A multiple logistic model was used to confirm these results and led to the selection of the same variables. Discussion: The CTUL score is easy to use and is the only one in the literature using only variables statistically proven to have significant prognostic value for CTUL. Surgical experience is however indispensable for appropriate decision making in these emergency situations. This score thus provides an important therapeutic aid useful in borderline cases where amputation is discussed. Conclusion: A prospective study including a larger number of patients would be helpful to better detail indications and preserve the 100% specificity for an irreversible therapeutic decision

The concept of non-anatomic reversed arthroplasty is becoming increasingly popular. The design medializes and stabilizes the center of rotation, and lowers the humerus relative to the acromion, and lengthens the deltoid muscle up to 18%. Such a surgically created global distraction of muscles is likely to affect nervous structures. When nerves are stretched up to 5–10%, axonal transport and nerve conduction starts to be impaired. At 8% of elongation, venous blood flow starts to diminish and at 15% all circulation in and out of the nerve is obstructed. [. 1. ] To understand nerve dynamics following reversed arthroplasty, we investigated nerve strain and excursion in a cadaver model. In a formalin-embalmed female cadaver specimen, the brachial plexus en peripheral upper limb nerves were carefully dissected and injected with an iodine containing contrast medium. At the same time 1.2 mm-diameter leaded markers were implanted at topographically crucial via points for later enhanced recognition on CT reconstructions. After the first session of CT scanning a plastic replica of the Delta reversed shoulder prosthesis® was surgically placed followed by re-injection of the plexus with the same solution. The preoperative and the postoperative specimen were studied using a helical CT scan with a 0,5 mm slice increment. The Mimics® (Materialise NV, Belgium) software package was used for visualization and segmentation of CT images and 3D rendering of the brachial plexus and peripheral nerves. After surgery, there was an average increase in nerve strain below physiologically relevant amplitudes. In a few local segments of the brachial plexus an increase in nerve strain exceeding 5–10 % was calculated. The largest increase in strain (up to 19%) was observed in a segment of the medial cord. These results suggest there might be a clinically relevant increase in nerve strain following reversed shoulder arthroplasty

Background: A recent change in the Belgian law lead to the obligation of evaluating the musculoskeletal system among employees using visual display terminal (VDT) during the routine annual visit. We conducted a cross-sectional study to determine prevalence of and risk factors for musculoskeletal symptoms (MSS) and disorders (MSD) in general, and carpal tunnel syndrome (CTS) in particular. Methods: During the routine annual visit all VDT employees of different kinds of companies and occupations were asked about upper extremity MSS by their occupational physician. Participants who met the criteria for MSS within the last month were physically examined in search of a MSD in general, and CTS in particular. Prevalences were calculated, and key risk factors for MSS and CTS were determined using logistic regression analyses. Results: The total prevalence of any upper extremity MSS among 1087 VDT-employees was 31.3%. Neck symptoms (21.6%) were the most frequently reported, followed by shoulder (21.6%), elbow/forearms (4.1%), hands/wrists (7.3%), and finger (5.2%) symptoms. The prevalence of CTS depended on the diagnostic criteria used: 1.8% for symptom-specific CTS (typical anatomical distribution of numbness and paresthesias), 1.2% for examination-confirmed CTS (at least one positive provocative test, Tinel’s nerve percussion test or Phalen’s wrist flexion test), and 0.2% for electrophysiologically-confirmed CTS (abnormal nerve conduction tests). Logistic regression analyses identified increasing age, female gender, the duration of professional VDT use per day, a history of thyroid diseases, and a history of rheumatoid arthritis as significant and independent factors associated with MSS. Adaptation of the work-place was associated with a lower likelihood of MSS. Only increasing age and female gender were identified as significant and independent factors associated with CTS (symptom-specific and examination-confirmed CTS). Job-related factors were not significantly associated with an increased risk for CTS. Conclusions: Our study confirms the high prevalence of MSS among Belgian visual display terminal users (more than 30%). Two work-related factors were clearly associated with MSS: the duration of professional VDT use per day (increased risk) and prior adaptation of the workplace according to advice given by the occupational physician (decreased risk). By contrast, the prevalence of CTS was low (less than 2%), and no job-related risk factors for CTS could be identified among VDT users

Aim: As the shoulder and elbow joints share a common objective – spatial positioning of the hand – can the Modified Constant Score of shoulder function be applied to function at the elbow?. Method & Results: All patients with isolated elbow pathology over an eighteen-month period were assessed. Acute fractures and patients with shoulder and/or wrist pathology were excluded. Upper limb function was assessed using the Modified Constant Score and the Mayo Elbow Performance Index. A total of 48 patients with a variety of elbow pathologies were assessed. The mean patient age was 47.8 years, and 26 patients were male. The correlation between the two scoring systems was highly significant (correlation 0.91, t = < 0.001). Conclusion: The Modified Constant Score may be used as an assessment of both shoulder and elbow function

For decades the treatment of chronic posttraumatic osteomyelitis associated with bone exposure has been one of the most serious problems in the field of orthopedic surgery. “Sterilization” of the osteomyelitic site, that is radical debridement of all infected tissue, is the basic requirement of the treatment; in the past, the remaining defect of the debrided area was closed with skin grafts, which were removed in a further stage, when the infection was ceased; then the defect was filled with muscle flap and bone graft of various types. Both soft tissue and osseous reconstruction took a relatively long period of time requiring several-stage treatment. We performed a retrospective study on 9 patients treated for chronic osteomyelitis of the upper limb (6 forearm – 3 arm) by means of free fibula vascularized bone graft, between 1992 and 2003 (7 male 2 female). All patients had been more than 2 previous surgical attempt with conventional treatment (sterilization and bone graft). In most of them (7 cases) a two-stage treatment was performed (resection and sterilization, eventually with muscle transfer, in the first stage and bone transfer in the second one); in other 3 cases a one-stage treatment was performed. Two cases required a composite tissue transfer with a skin pad to cover the exposure. The length of bone defect after extensive resection of necrotic bone from septic pseudoarthrosis ranged from 5 cm to 12 cm. In all cases there was no evidence of infection recurrence in the follow-up period. The mean period to obtain radiographic bone union was 4.1 months (range 2.5–6 months). In 2 cases secondary procedures have been carried out due to an aseptic non union in one site of synthesis (cruentation and compression plate). Functional results were always satisfactory although in the forearm a complete range of motion has never been achieved (plurioperated patients with DRUJ problems). Fibular grafts allow the use of a segment of diaphyseal bone which is structurally similar to the radius, ulna and humerus of sufficient length to reconstruct most skeletal defects. The vascularized fibular graft is indicated in patients where conventional bone grafting has failed or large bone defects, exceeding 5 cm, are observed. The application of microsurgical fibular transfers for reconstruction of the extremities allows repair of bone and soft-tissue defects when shortening is not possible with good functional results

Introduction: Musculoskeletal tumours and lesions resembling tumours present exceptionally difficult diagnostic and treatment problems in children. Presenting symptoms are usually a poor guide to diagnosis, and are often misleading. Methods: A review of benign bone lesions of the upper limb in the peadiatric age group (0–14 yrs) from the Scottish Bone Tumour Registry is presented. Results: Excluding myelomas and lymphomas, the registry included 154 lesions. 122 (80.2%) were benign including, 25 unicameral bone cysts, 22 aneurysmal bone cysts, 31 chondromas, 15 osteochondromas, 12 diaphyseal aclasis, 7 osteoidosteomas, 2 chondroblastomas, 2 nonossifying fibromas, and 1 each of giant cell tumour, eosinophilic granuloma and chondromyxoid fibroma. Unicameral cysts- Age at presentation ranged from 3–14 yrs (mean 9.4).Male: Female incidence was 7.3:1. 92% involved the proximal humerus. 88 % presented with fracture. Recurrence rate after curettage was 20% at a mean of 10.8 mts. Aneurysmal cysts – Age at presentation ranged from 5–14 yrs (mean 9.3). 55% involved the proximal humerus, and 20% hand bones. 45% presented with fracture. Recurrance rate after curettage was 31.8% at a mean of 15.1mts. Chondromas- Age at presentation ranged from 3–14 yrs (mean 10.4).20 lesions were solitary and 11 multiple. Among solitary lesions, 16 were central (75% hand) and 4 parosteal. Osteochondromas- Age at presentation ranged from 1–14 yrs (mean 10.1).Male: female ratio was 2.75:1. 53.3% involved the proximal humerus. Osteoid Osteoma- Age at presentation ranged from 5–13 yrs (mean 10.14). Male: female ratio was 1:6. 42% involved the hand. Discussion: Benign tumours compose majority of bone neoplasms in this age group. Unicameral and aneurysmal cysts, along with enchondromas were most frequent. Although the age at presentation shows variations with tumour type, the incidence seems to peak at 9–10 Yrs. Careful analysis of the clinical presentation, radiological characteristics and histology are required to distinguish them from malignant lesions

Summary. Upper extremity activity was similar in patients and healthy subjects, showing no significant asymmetry between arms within subjects. Further improvements (e.g. thresholds, filters, inclinometer function) are needed to show the clinical value of AM for patients suffering shoulder complaints. Introduction. Activity monitoring is becoming a popular outcome tool especially in orthopaedics. The suitability of a single 3D acceleration-based activity monitor (AM) for patients with lower-extremity problems has been shown. However less is known about its feasibility to monitor upper-extremity activity. Insight into the amount and intensity of upper-extremity activity of the affected and non-affected arm (asymmetry) may be of added value for diagnostics, therapy choice and evaluating treatment effects. This study investigates the feasibility of a single AM to evaluate (asymmetry in) upper-extremity activity in daily life. Methods. Upper-extremity activity was measured in 12 patients with subacromial impingent syndrome (59±12yr) and 10 healthy subjects (29±11yrs). Subjects wore a single 3D accelerometer at both arms, just above the base of the Hueter triangle, for one day (min. 8 hours). Specific algorithms were used to derive quantity (activity duration, rest periods) and intensity (low-high) activity parameters (% of the day). The ratio in % activity between non-affected (dominant) and affected (non-dominant) arm was calculated. Asymmetry was expressed as the %-difference in activity between arms with regards to the non-affected (dominant) arm. Also popular PROMs were completed: DASH score (range 0–100;0=best) and SST score (range 0–12; 0=best). Independent t-test, Mann-Whitney U test, Pearson's r correlations were performed. Results. No significant differences in activity duration (Healthy: 50%, patients: 57% of the day) and intensity of upper-extremity activity were found between patients and healthy subjects, although PROMs were significantly worse in patients. Patients and healthy subjects use both arms in similar amounts of time per day. This corresponds to the ratio which almost equals 1 and the low asymmetry values (<10%) in both groups. Also the amount activity in low and high intensity was comparable between affected (non-dominant) and non-affected (dominant) arm. No correlations were found between AM data and PROMs. Discussion and Conclusion. Patients and healthy subjects move their upper arms approximately 53% of the day. No differences in amount and intensity of upper-extremity activity were found between healthy subjects and patients, neither between both arms. This suggests that subjects perform daily activities independent of pain, complaints or arm dominance. It could also hint at the algorithm operating with a too low activity threshold to include shuffling or misclassifying excitations from walking as intense arm movement. Both issues can be adjusted by adjusting thresholds and filter settings. The asymmetry in upper-extremity activity of healthy subjects (9.1%) assumes that a 10% asymmetry in arm activity seems natural, which coincides with similar values reported for functional shoulder tests (Koerver et al. CORS 2010). The lack of correlations between AM and PROMs suggests that both measure different outcome dimensions. The AM has some limitations which should be considered when improving the clinical feasibility of upper-extremity activity monitoring. The AM only allows to measure acceleration-related activities (speed, intensity), while upper-extremity activity often involves static force-related activities. However, the inclinometer capacity of accelerometers allows to measure upper-extremity activity at different elevations (upper arm above/below shoulder). This may add qualitative information, relevant for clinical purposes

Following resection of primary malignant bone tumours of the humerus, limb salvage can be performed by vascularized fibula graft for reconstruction of large segmental defects. In 12 patients with malignant bone tumour of the proximal humerus, tumour was resected and the bone defect reconstructed by vascularized fibula graft. Median age of the patients was 23 years. Median follow up was 114 months. In 10 patients humeral head had to be resected and was replaced by fibular transplant including head and shaft of the ipsilateral fibula. Humeral head could be left in place in 2 patients. Median length of transplant was 17.2 cm. Radiographic union could be seen after 8 months in median. In 7 patients partial necrosis of the fibular head occurred, in 4 patients fracture of the transplant happened following trauma. In these 4 cases revision surgery was required. Partial necrosis of the head of fibula had no significant influence on shoulder function. One patient died of disease, the others are disease free. Enneking Index was 61% in median at time of last follow up. At donor side 3 cases of transient peroneal palsy could be seen. We conclude that vascularized fibula graft is a successful surgical procedure for upper limb salvage especially for preservation of joint function also in long term follow up

Background: The overall goal in the treatment of RA is to minimize the loss of function and preserve the quality of life. In addition to drug therapy orthopaedic surgery may offer an opportunity to improve functioning in varies parts of the skeletal system. Objective: To examine the overall magnitude of change in quality of life over a ten years period, with special focus on the changes in physical functioning in different joint areas. Methods: Data from the Oslo RA register with 1600 living patients were used as basis for the study. Self-reported questionnaires were sent to the patients in 1994, 1996, 2001 and 2004, including the SF36, the AIMS2, the MHAQ, and three 100 mm visual analogue scales (pain, fatigue and patient global). 310 patients (mean (SD) age 56.4 (13.0) years, and disease duration 12.0 (9.9) years, 85.5% women) who completed questionnaires at baseline and after 10 years were eligible for the current analyses. Changes in health status were adjusted for age, sex and duration of disease. Magnitude of change was analysed by standardized response mean (SRM), i.e. the change divided by the standard deviation. AIMS2 comprises physical scales for different parts of the body and was used to examine changes in physical functioning in different areas of the musculoskeletal system. Results: The overall physical functioning was deteriorated with MHAQ SRM 0.25 and AIMS2 physical SRM 0.11. Larger average deterioration in physical functioning was seen in mobility and walking and bending, than for upper extremity function (arm and hand finger scales). These results were supported by adjusted SRMs for the individual items of MHAQ: Dressing 0.26, Get out of car 0.24, Walk outdoor 0.22, Bending 0.22, Get in and out of bed 0.16, Lift to mouth 0.13, Turning faucets −0.02. Conclusion: Physical functioning and quality of life deteriorated over 10 years in patients with RA. The largest loss of functioning was seen in the lower limb physical activity (mobility, walking and bending). This finding may give a clue to priorities of resources to surgical procedures in patients with RA

Introduction: Reasons why patients refuse wearing their upper limb prostheses deserve to be studied.

Method: Amputees were recruited from the clinics as well as from health- and accident insurances and Veterans’ Service Offices. Questions covered the patients’ medical history of amputation, their prosthetic supply and their present living conditions. 454 participants returned the anonymous questionnaire and could be entered into the study.

Amputation was caused by war (287), civil trauma or illness (123) and congenital (44). Age ranged from 3 – 96 years, with mean of 67.8. Distribution regarding sex and side was 411m/43 f and and 211 right/223 left. 20 had bilateral amputation. In 216 patients the dominant side was affected. Level of amputation was: wrist 36, BE 164, elbow 9, AE 201, shoulder 23, forequarter 3, unknown 18.

Prosthetic devices were classified as passive (i.e. cosmetic and passive work prostheses) or active, i.e. electrically- or body-powered prostheses as well as the combination of the two.

In the statistical analysis null hypothesis was that no factor influences the acceptance rate. Significant differences are accepted when p< 0.05.

Results: Electrically-powered prostheses were accepted best. Cosmetic prostheses were accepted well when stigmatization in the context of ethnic origin or religious affiliation may be important.

Acceptance rate was influenced by: Country of origin, religious affiliation, sex, learned occupation, therapist involved in training, return to work, incapacity for work, job held after amputation, own initiative in initiating prosthetic care, loss of friends or partners, level of amputation and the combined parameters AE-amputation and non-dominant side.

No influence was found for education, age at amputation, marital status, side of amputation, recommendation of prosthesis, time until first prosthetic fitting, phantom pain and phantom feeling, return to sports or hobbies, consumption of tobacco, alcohol or sedatives.

Discussion: Looking at all patients, the rates of acceptance of the various prosthetic types equals those found in the relevant literature. However, this study is much more detailed, looking at many different parameters and their combinations and can therefore provide some guidance to the successful prescription of upper limb prostheses. Nowadays electrically-powered prostheses are generally better accepted than all other types and should therefore be provided more often.

Purpose of the study: Accidents caused by power-take-off shafts produce different types of injuries. The lesions can vary from simple skin abrasion to amputation or serious, sometimes fatal, limb damage. We present a series of injuries treated in our institution since 1997 in order to analyze the circumstances of these accidents and their pathophysiological mechanisms as well as the most appropriate treatment. We also analyzed the mechanism of the power-take-off shaft with a few fundamental aspects to better understand the potential health hazard.

Material and methods: Ten victims of power-take-off accidents were treated in our institution since 1997. All were men aged 26 to 66 years. In all cases but one, a cord caught on the turning shaft was the cause of the accident. Eight of the patients presented upper limb injuries of variable gravity.

Results: Outcome after treatment depended on several factors: the severity of the injury, the circumstances of the accident and the proximity to a health care center. In general, the sequelae were worse for serious injuries, producing permanent disability.

Discussion: The power-take-off transmits power from the tractor to agriculture machines via a turning shaft. Correct use requires several safety measures. Serious injury, disability or death can result from inadequate protective measures or inadequate knowledge about proper use.

Our aim was to determine if a tourniquet placed on the forearm has any advantage in clinical practice over the usual position on the upper arm. We randomised 50 patients who were undergoing an open operation for carpal tunnel syndrome under local anaesthesia into two groups. One had a tourniquet on the upper arm and the other on the forearm. The blood pressure, pulse, and level of pain were recorded at intervals of five minutes during the operation. The surgeons were also asked to evaluate the quality of the anaesthesia, the bloodless field, and the site of the tourniquet.

The patients tolerated the tourniquet on the upper arm and forearm equally well. The surgeons had some difficulties when it was placed on the forearm. We therefore recommend placement of a tourniquet on the upper arm for operations on the hand and wrist which are carried out under local anaesthesia.