Microsurgery in Orthopaedic Practice

Background: Upper limb trauma is an injury caused by cutting, tearing, or crushing which leads to the limb becoming unrecognizable. In essence, there are two treatment options amputation and salvage reconstruction. Objective: The aim of this study was to assess the outcome of reconstructive surgery in upper limb trauma. Patients and Methods: This study was conducted upon 30 patients (24 males and 6 females) with mean age 28.53 ± 9.06 years presented with more than two elements, e..g. bone and tendons, vascular, nerve and skin. They were selected from Al-Azhar University Hospitals. They were admitted in General Surgery Department, Al-Azhar University Hospital, Faculty of medicine (Damietta), between April 2011 and January 2016. After appropriate consent, clinical assessment and radiological evaluation, reconstruction of upper limb trauma by repaired tendons, vascular, skin injuries and bone fixation were done. Postoperative clinical assessments of sensation and function were done. Hand functions were grouped as excellent, good, fair and poor. Nerve injury was tested using both sensory and motor components, while assessment of the hand and fingers vascularity was carried out by original and modified Allan's test. All cases were followed up in first postoperative year for vascularity, sensation and functions of the hand. Results: For 30 patients over a period of a year of clinical follow up, there was marked reduction in morbidity and mortality with satisfactory significant improvement in upper limb and hand functions, and no ischemia, neuroma or tendon ruptures were observed during the follow-up period. Conclusion: Upper limb trauma reconstruction required a thorough understanding of the advantages and limitations of local, regional, distant, and free flap options. Only those wounds with exposed neurovascular structures, tendon, or bone typically require flap coverage. Multidisciplinary team can prevent or at least minimize post-operative functional disability of upper limb.

To examine the incidence of peripheral nerve injury within 90 days of a limb trauma diagnosis in patients who have presented to the hospital or outpatient clinic. This study is a retrospective, descriptive study that uses the 1998 MarketScan Commercial Claims and Encounters Database (The MEDSTAT Group) to track peripheral nerve injuries in extremity trauma. We selected our sample by using ICD9 codes for limb trauma during the first 9 mos of 1998. Nerve injuries within 90 days after limb trauma were the main outcome measure. Finally, we report how the rates of trauma and accompanying nerve injuries were contrasted by gender and age group, using univariate and bivariate statistics. All data analyses were conducted using Stata 9.0 statistical software. Out of 16 million insureds in the database, 220,593 (1.4%) were diagnosed with limb trauma. Eighty-three percent of the patients were less than 55 yrs old, and 50% were male. The total incidence of nerve injuries within 90 days of upper- or lower-limb trauma was 1.64%. The type of extremity trauma with the highest incidence of nerve injury within 90 days of the diagnosis was a crush injury at 1.9%. Approximately 50% of our sample was selected because of a dislocation, which had an associated nerve injury prevalence of 1.46%. When looking at the population sampled, rates for peripheral nerve injury in people incurring limb trauma are low. Crush injuries seem to have the highest rate of associated nerve injury. Further studies are needed to observe outcomes for people with nerve damage after trauma.

Cross-sectional survey of treatments and outcomes among injured adult patients in Kigali, Rwanda

BackgroundLong bone fractures are common injuries caused by trauma. Some studies have demonstrated that ultrasound has a high sensitivity and specificity in the diagnosis of upper and lower extremity long bone fractures.ObjectiveThe aim of this study was to determine the accuracy of ultrasound compared with plain radiography in diagnosis of upper and lower extremity long bone fractures in traumatic patients.MethodsThis cross-sectional study assessed 100 patients admitted to the emergency department of Imam Khomeini Hospital, Ahvaz, Iran with trauma to the upper and lower extremities, from September 2014 through October 2015. In all patients, first ultrasound and then standard plain radiography for the upper and lower limb was performed. Data were analyzed by SPSS version 21 to determine the specificity and sensitivity.ResultsThe mean age of patients with upper and lower limb trauma were 31.43±12.32 years and 29.63±5.89 years, respectively. Radius fracture was the most frequent compared to other fractures (27%). Sensitivity, specificity, positive predicted value, and negative predicted value of ultrasound compared with plain radiography in the diagnosis of upper extremity long bones were 95.3%, 87.7%, 87.2% and 96.2%, respectively, and the highest accuracy was observed in left arm fractures (100%). Tibia and fibula fractures were the most frequent types compared to other fractures (89.2%). Sensitivity, specificity, PPV and NPV of ultrasound compared with plain radiography in the diagnosis of upper extremity long bone fractures were 98.6%, 83%, 65.4% and 87.1%, respectively, and the highest accuracy was observed in men, lower ages and femoral fractures.ConclusionThe results of this study showed that ultrasound compared with plain radiography has a high accuracy in the diagnosis of upper and lower extremity long bone fractures.

PurposeThe lockdown imposed in France to cope with the COronaVIrus Disease 2019 (COVID-19) outbreak has led to major changes in the lifestyle of French citizens. The aim of our study was to study its impact on activity related to emergencies in hand and upper limb trauma in comparison to the same reference period in 2019.Material and methodsAll consecutive patients consulting for upper limb injury requiring urgent care at Georges-Pompidou European Hospital (HEGP), France, during the lockdown period (case group) and the equivalent period in 2019 (control group) were included. In each group, the type of accident, the anatomical location of the injury, and the treatment were reported and compared.ResultsTwo hundred seventy-five patients were included in the case group in comparison to 784 patients in the control group. We observed a two-third decrease in the rate of upper limb emergencies (− 64.9%) in particular a drastic drop in the rate of road, work, and leisure accidents (10.4% vs 14.3%, p = 0.1151; 10.0% vs 22.6%, p < 0.0001; 13.1% vs 30.8%, p < 0.0001, respectively), and a clear increase in domestic accidents (66.5% vs 32.3%, p < 0.0001). The aetiologies were more dominated by lacerations of soft tissues (48.4%, vs 38.3%, p = 0.0034) and infections (8.7% vs 5.1%, p = 0.0299) with an increase in the indications for surgical management (51.2% vs 36.9%, p < 0.0001). Conversely, we observed fewer consultations for joint injuries (20.7% vs 30.7%, p = 0.0015) and fractures (22.2% vs 25.9%, p = 0.2210).ConclusionThe lockdown imposed in France has changes the etiologies and the management of hand and upper limb emergencies.

Introduction: The aim of this study was to evaluate the mechanism and type of upper limb arterial trauma in Iranian population. Methods: Fifty-one patients with upper limb trauma were evaluated over a 4-year period with conventional angiography at the Tabriz Imam Hospital, Iran. Results: Twenty-four patients (19 men, 5 women with a mean age of 27.5 ± 11.8 years) had arterial injuries. Blunt trauma was more frequent than penetrating trauma (87.5%). The most cause of trauma was traffic accidents and the brachial artery was the most frequently affected artery. In 87.5% cases associated bone injuries were observed. Conclusion: Patients with blunt upper limb injuries must be evaluated for vascular integrity timely, especially in traffic accidents because vascular injuries after traffic accidents need to be referred to vascular centers. The results of this article are of potential use and clinical importance because precise diagnosis of vascular insults are essential to restore injured extremities.

For many patients, audio-visual appointments have provided a timely and efficient way of seeking advice, assessment and treatment for their hand injuries during the NHS response to COVID-19. This study aimed to explore the experience of hand units across the UK in determining the safe and judicious use of audio-visual outpatient care for the management of acute upper limb trauma. An online cross-sectional survey was sent to the therapy leads of hand units across the UK. Questions focused on the experience of using audio-visual technology in the management of upper limb trauma, and the relevant factors in determining its appropriate use. A deductive mixed methods analysis was used to identify both common themes and capture community experience and characteristics. A total of 51 out of 76 hand therapy units completed the survey; a response rate of 67%. Of these, 82% (42/51) reported using audio-visual technology to manage upper limb trauma during the UK COVID-19 lockdown. When determining patient suitability for audio-visual consultations, 73% (37/51) of respondents reported the use of COVID-19 guidelines, but only 35% (18/51) reported the use of a clinical decision-making tool. In agreement with our experience at Salisbury Hospital Foundation Trust, 92% (47/51) had concerns relating to the use of audio-visual care. The choice of safely managed remote care or in-person consultation has, to date, largely relied on the discretion of the clinician. A carefully designed clinical decision-making tool for the management of upper limb trauma is needed for use both in clinical practice and in future service planning.

Relación anatómica del abordaje posterior de húmero mínimamente invasivo con el nervio radial. Un estudio descriptivo en cadáveres

مقدمه: آمارهای مختلفی از بروز ترومبوز ورید عمقی و عوارض متعاقب آن حتی پس از درمان ضدانعقادی پیشگیرانه در بیماران با آسیب اندام تحتانی وجود دارد. با توجه به وجود این اختلاف نظرها، مطالعه حاضر با هدف ارزیابی شیوع وقایع ترومبوآمبولیک در بیماران مبتلا به شکستگی اندام تحتانی که تحت درمان ضد انعقادی پیشگیرانه قرار گرفته اند طراحی شده است. روش کار: مطالعه مقطعي گذشته نگر حاضر با هدف ارزیابی میزان شیوع عوارض ترومبوآمبولیک متعاقب شکستگی اندام تحتانی در بیماران مراجعه کننده به بخش اورژانس طی یک سال طراحی شد. بیماران بالای 18 سال با ترومای اندام تحتانی پایین تر از زانو که نیازمند ثابت سازی با آتل یا گچ برای بیش از 2 هفته بودند مورد بررسی قرار گرفتند. یافته ها با استفاده از آماره های توصیفی و نرم افزار آماری SPSS نسخه 21 گزارش شدند. يافته ها: 130 بیمار با میانگین سنی 5/18± 05/40 (92-15) سال مورد مطالعه قرار گرفتند (5/61 درصد مرد). 18 (8/13 درصد) بیمار سابقه سوء مصرف مواد داشتند، 1 (8/0 درصد) بیمار مبتلا به دیابت، 8 (2/6 درصد) بیمار مبتلا به پرفشاری خون، 1 (8/0 درصد) مبتلا به آسم، 1 (8/0 درصد) بیمار مبتلا به سکته مغزی بودند. مکانیسم تروما در 44 (8/33 درصد) مورد سقوط از ارتفاع، 50 (5/38 درصد) مورد سوانح جاده ای و در 36 (7/27 درصد) مورد ترومای مستقیم بود. در نهایت 3 (3/2 درصد) بیمار علی رغم دریافت داروی ضد انعقاد مبتلا به ترومبوز ورید عمقی شدند. متوسط زمان بین ترخیص تا وقوع علائم 6/3 ± 6 روز بود. نتيجه گيری: یافته های مطالعه حاضر حاکی از شیوع 3/2 درصدی حوادث ترومبوآمبولیک در بیماران نیازمند به ثابت سازی اندام تحتانی تحت درمان با هپارین با وزن مولکولی پایین بود. هر سه مورد ترومبوز ورید عمقی در مطالعه حاضر در دو هفته اول بعد از ثابت سازی اتفاق افتاده بودند.

Immediate Tissue Transplantation in Upper Limb Trauma: Spare Parts Reconstruction

Upper extremity trauma and resulting disability is a stressful event and can affect a patient's personality. Several studies have shown that this injury type has serious psychological and/or social consequences. We systematically reviewed the evidence on the consequences of disability after a complex trauma (combination of soft tissue, osseous, vascular, and nerve involvement) of the upper extremity. We tried to find out the potential crucial factors that could determine the final hand function. In addition, we considered the challenges that need to be addressed to eliminate the adverse or negative effects that arise from upper limb trauma. In the literature, there is a growing interest to study changes in patients' quality of life and return to work. Psychological morbidity is an important part of patients' perceived general health. These issues could play an important role in the final functional outcome of the therapy. An early identification and treatment of trauma-related distress in patients may prevent progression of psychological pathology and mitigate negative effects on general health status. It may be important to evaluate the amount of psychological distress when caring for patients with hand injuries.

Upper limb trauma cases vary from simple to high energy impactful injuries, with different etiologies; situations which frequently require unique, demanding and challenging endeavors in order to obtain the most favorable outcome. Experience, good decision-making and knowledge of functional goals are mandatory in order to elaborate a therapeutic plan and execute it accordingly. Although cases differ in nature and prognosis, respecting a set of therapeutic principles whilst dealing with either simple or complex cases, will enhance patient outcome and give the surgeon the confidence to tackle any kind of upper limb trauma. After clearing out vital threat, the emergency surgery represents the first threshold in achieving and restoring normal function and biomechanics, mostly in young and labor active patients, with the mindset to salvage as much tissue as possible, with a thorough debridement and step-by-step approach to different types of tissues. Secondary surgery and reconstructive surgery can be planned timely, with prior discussion with both the therapist and the patient in order to enhance patient’s upper limb function and aesthetic and ensure social reintegration.

Upper limb injuries are common and account for a significant number of emergency department and primary care consultations. While surgery for these injuries is well-documented, nonoperative treatments, particularly the optimal duration of immobilization, remain understudied. These durations are often based on institutional dogma rather than scientific evidence, which have gone unchallenged for years. However, prolonged immobilization can lead to increased morbidity or even complications for patients. The aim of this systematic literature review is to update the recommendations regarding optimal immobilization durations for the most common shoulder and elbow injuries, in order to provide guidelines for primary care and emergency medicine.

Background: The novel coronavirus disease-2019 (COVID-19) has been identified as the cause of a rapidly spreading respiratory illness that is thought to have originated from Wuhan, China in early December 2019. Since then, the free movement of people has decreased, which has thus reduced the number of trauma-related casualties. The Irish governments initiated strict social distancing measures in response to the COVID-19 pandemic in late March 2020. It remains challenging to quantify the impact this had on reducing the spread of the virus. The viral outbreak has led to significant changes in the lifestyle of Irish citizens. The aim of this study was to examine the impact of the pandemic on activity, related to emergencies in trauma and orthopaedics departments. Methods: Patients admitted to the Trauma and Orthopaedic Department at Cork University Hospital (CUH), Cork, Ireland and South Infirmary Victoria University Hospital (SIVUH), Cork, Ireland between the 1st of March and the 15th of April 2020 were documented and compared to the patient admissions from the same time period in 2019. Results: The total numbers of lower limb trauma cases dropped by 20.44% from 137 (females: 87; males: 50) to 109 (females: 74; male: 35), (p=0.72). Of note, there was a 30.00% reduction in the number of male cases (from 50 to 35; p&lt;0.05), in comparison to the 14.94% reduction observed in the female population (from 87 to 74; p&lt;0.05). The total number of upper limb trauma cases increased by 0.14% from 90 (female: 44; men: 46) to 94 (female: 54; male: 40; p=0.14). The increase reported was only applicable to the female population; the number of male cases of upper limb trauma slightly decreased from 46 to 40 (p&lt;0.005). Conclusion: The COVID-19 crisis has led to a decrease in the total numbers of lower limb trauma surgeries but an increase in the number of upper limb fractures. The main reduction was amongst the male patients, while the number of female cases increased.

Working towards safer post-operative care of patients following upper and lower limb trauma: It solutions for operative documentation can improve the quality of multidisciplinary communication