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. 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

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

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

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