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In the early 1980s Japanese surgeons introduced very long free flaps based on two vascular pedicles from the thoracodorsal and groin territories. Such flaps, vascularized through two pedicles, may be called megaflaps. One or both bundles may be anastomosed as necessary to vascularize the flap. Anatomical studies and clinical experience point to new donor sites for such megaflaps.
A rational approach to the restoration of function of the upper extremity has been outlined for the burned patient. If these guidelines are followed and the joints of the upper extremity approached individually with a goal of restoring as much range of motion as possible, great functional improvement may be anticipated. The surgical procedures must be augmented with vigorous PT and strong patient motivation. With this combination improvement of function of the upper extremity can be provided that is gratifying to both the surgeon and the patient.
The rapidly expanding microsurgical knowledge and technology along with a growing experience in replantation has led the way to new concepts of management that have become essential in the progressive treatment for these complex injuries. Appropriate patient selection, proper modes of limb transportation, injury assessment, surgical technique, and postoperative care are all key components to successful recovery and restoration of function. As the ability to restore vascular flow to amputated digits, hands, and limbs has advanced, critical evaluation of the potential extent of recovery in comparison to amputation revision is imperative. This article discusses the current ideas of the perioperative treatment for replantation with specific attention directed towards these evolving issues.
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In 24 patients, corrosive injuries involving the floor of the mouth, the pharynx, and the esophagus were repaired in two stages using a combined free forearm flap and colon for functional restoration of the alimentary tract. The results were satisfactory. Morbidity was decreased, complications were minimal, and there were no failures. In the first stage, early reconstruction with a forearm flap for the oral floor, the pharynx, and the cervical esophagus can be done safely 3 months after the original injury when the acute inflammation of the tissue has disappeared. The forearm flap is thin and pliable, and has a good blood supply for primary healing without failure or stricture. Dysphagia is eliminated because food passes down by gravity. There is no constriction or hyperperistalsis of the colon, both of which are occasionally seen with the traditional colon interposition. In the second stage, the traditional method is used to finish the reconstruction of the remainder of the esophagus.
We performed an epidemiologic survey to estimate the number of grip lock injuries occurring among male high school and college gymnasts. These injuries occur when dowel grips used by the gymnast become locked on the bar as the gymnast's momentum carries him through the skill being performed. We also questioned injured gymnasts to obtain details of their injuries. Thirty-eight high school coaches reported 17 injuries and 32 college coaches reported 21 injuries for a 10-year period; 36% of the coaches responding reported at least one such injury in their program. Of the 23 injured gymnasts who returned detailed questionnaires, 20 had sustained fractures and 9 required surgery. The distal forearm or wrist were the areas injured most often. Fourteen gymnasts had residual pain, seven had functional limitations, and eight had limited motion in the wrist. Fifteen of the 23 athletes were using a cubital (hyperpronated) grip at the time of injury and 19 were using dowel grips. Among the reasons cited for the injury, 18 gymnasts thought that their grips were either too large, worn, or stretched; 8 said the grips slid up their wrists, and 7 cited technical errors.
This article presents a critical review of the current literature on the stabilization methods of severe open fractures or crush injuries of the forearm. Due to the complexity of the problem, the advantages and disadvantages of the different fixation methods are presented in order to provide the reader with a combination of possibilities for timing and decision-making when confronted with such fractures in clinical practice.
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BACKGROUND: The purpose of this study was to develop an axial loading forearm fracture model and to determine the influence of forearm rotation on the fracture pattern. METHODS: Twenty-six cadaveric arms were thawed in saline solution. Pressure-sensitive film was sealed and was placed through a lateral arthrotomy into the radiocapitellar joint. The arm was potted at the proximal part of the humerus with the elbow in extension. Rotational range of motion was measured with use of a goniometer starting from a supinated position (0 degrees ). Specimens were placed in a vertical position at various angles of forearm rotation, and a 27-kg mass was raised to 90 cm and was dropped onto the distal part of the radius. The pressure film was removed and was analyzed to determine the radiocapitellar joint contact area following impact. Each arm was dissected, and the injury pattern was assessed. RESULTS: Both-bone forearm fractures (proximal radial fractures with concomitant distal ulnar fractures) occurred at 5 degrees +/- 2.6 degrees of rotation, isolated radial head fractures occurred at 44.4 degrees +/- 5.2 degrees of rotation, and Essex-Lopresti fractures (radial head fractures with tearing of the interosseous membrane) occurred at 70 degrees +/- 25.2 degrees of rotation. The distribution of Essex-Lopresti and radial head fractures was significantly different at a cutpoint of 54 degrees of forearm rotation (p = 0.009), and the distribution of radial head fractures and both-bone forearm fractures was significantly different at a cutpoint of 10 degrees of forearm rotation (p = 0.001). The percent contact area of the radial head varied with the injury pattern (p = 0.029). Marginal radial head fractures occurred at 46.7 degrees +/- 6.6 degrees of rotation with a contact area of 30.9% +/- 8.6%, while comminuted radial head fractures occurred at 74.4 degrees +/- 27.2 degrees of rotation with a contact area of 53.9% +/- 8.3%. CONCLUSION: The amount of forearm rotation at the time of axial load impact directly influenced the injury pattern. Furthermore, the radial head contact area and the fracture severity increased in pronation compared with supination.
This case describes an arterial injury that remained unrecognised for 3 days, when a sudden secondary bleed caused acute compartment syndrome of the forearm. We have been unable to find another case of compartment syndrome presenting in this manner. The importance of thorough wound exploration is highlighted and the diagnosis and treatment of the syndrome discussed.
Radial artery grafts for coronary artery bypass surgery have recently gained renewed clinical interest. The procedure has been reported to be successful, with a low incidence of morbidity. Although permanent injury to the sensory nerves of the forearm has not been reported, transient or temporary dysesthesia has been known to occur. Recently, 2 patients were referred for long-standing debilitating dysesthesia in their forearms following radial artery harvesting. Electrical studies documented radial sensory nerve injury in both patients, one of whom underwent surgical treatment. Because radial artery grafting for coronary artery bypass surgery may be increasing in popularity, disability from sensory nerve injury may become more frequent. Because of the susceptibility to injury of the sensory nerves in the forearm, and because of the anatomic variations in this region, surgical personnel performing radial artery harvesting should be familiar with the pertinent anatomy so that this complication can be avoided.
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We treated two children with the unusual complication of ulnar nerve palsy after closed both-bone forearm fractures. Both patients developed an ulnar claw-hand deformity within 7 weeks of injury that resolved spontaneously by 20 weeks postinjury with nonoperative treatment. No patient showed any signs or symptoms of an ischemic compartment syndrome. Both nerve injuries were identified immediately at the time of fracture by a careful neurologic examination. This avoids confusion with a postreduction nerve entrapment injury or ischemic injury after a localized compartment syndrome, which may have considerably different treatments and outcomes. We recommend that a careful neurologic examination be recorded before any manipulative reduction of forearm fractures in children. If an ulnar nerve palsy is detected, it is probably a result of nerve contusion and should resolve without the need for surgical exploration.
This article deals with soft-tissue injuries of the upper extremity incurred by competitive athletes. The authors describe the pathophysiology, conservative and operative management of musculotendinous elbow injuries, entrapment neuropathy, tendinous disorders, vascular injuries, and dermatologic conditions in athletes. Protective gear for many of the aforementioned injuries are also described.
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Acute arterial injuries of the upper extremity account for half of civilian arterial injuries in the United States. The great majority of these injuries are due to penetrating trauma, with stab wounds and gunshot wounds being the most common cause. The history of the injury and a careful physical examination will identify most injuries. Arteriography should be performed when a vascular injury is suspected but not confirmed by physical examination. Reconstruction of critical vascular lesions is essential for restoration of flow distally. Noncritical lesions may be repaired in most cases, with long-term patency rates averaging 50% to 68%. Although amputation is uncommon after upper-extremity vascular injury, long-term disability can be significant in those patients with concomitant nerve injury. Chronic upper-extremity ischemia may be secondary to atherosclerotic occlusive disease, aneurysms, or arteriovenous fistulas. Angiography will delineate the diseased or occluded arterial segment, allowing bypass to be successful in more than 90% of cases. With careful attention to proper diagnosis and treatment, good to excellent long-term relief of symptoms can be obtained.