Concomitant Neurovascular Injury Research Articles

Multiligament instabilities of the knee in sports injuries : An update of the Hamburg concept

Knee dislocation (KD) is arare but severe injury of the knee joint, with ahigh rate of concomitant neurovascular injuries. The severity of the ligamentous injury, which is classified according to the Schenck classification, the mechanism of injury, concomitant injuries and individual factors determine the treatment strategy in KD. Furthermore, aclear differentiation between high-velocity (HV) and low-velocity (LV) injuries is necessary. Generally, surgical treatment within 7-10days should be aspired. Herein, the one-stage hybrid treatment using augmented ligament sutures (ligament bracing) in combination with primary ligament reconstruction (posterolateral and ACL) leads to very good functional results in the mid-term. Ultra-low-velocity (ULV) dislocations and those with concomitant peroneal lesions require amodified approach, due to alimited prognosis. During rehabilitation, the individual progress must be closely monitored and follow an early functional approach. In approximately 20% of all cases, early arthroscopic arthrolysis shows ahigh success rate.

Outcomes of Wide-Awake Flexor Tendon Repairs in 58 Fingers and 9 Thumbs

The purpose of this study was to present the outcomes of wide-awake flexor tendon repairs in zones 1 and 2 in a major hand trauma referral center. Zone 1 and zone 2 wide-awake flexor tendon repairs performed between August 2018 and March 2020 were analyzed retrospectively. Outcomes were assessed by the original Strickland-Glogovac criteria for fingers and Buck-Gramcko scoring system for thumbs. Further descriptive analysis of the groups according to potential negative factors, such as injury mechanism, concomitant neurovascular injury, and the extent of injury in zone 2, were performed. A total of 94 tendons were repaired in 67 digits (58 fingers, 9 thumbs) of the 61 patients included in the study. Satisfactory results were achieved in 89.6% of the fingers and 77.8% of the thumbs. Intraoperative gapping was corrected after active digital extension-flexion test in 1 patient. Rupture was seen in 1 patient for a rate of 1.5%. The tenolysis indication rate was 5.1% for fingers and 11.1% for thumbs. In our series, functional outcome scores, tenolysis, and rupture rates remained similar with findings in the literature. The outcome of a flexor tendon repair is influenced by many factors that cannot be controlled intraoperatively. To assess the effect of performing the repair in a wide-awake setting on the outcome, clinical trials with large patient groups are needed. Therapeutic IV.

Bruise Location in Supracondylar Humerus Fractures Predicts Specific Neurovascular Injuries.

Purpose:The presence of soft tissue injury in pediatric supracondylar humerus fractures (SCHFs) has been shown to be an independent predictor of any neurovascular injury. Potentially expanding this concept, the specific neurovascular structure injured around the elbow is thought to be dependent upon the direction and magnitude of fracture displacement and subsequent soft tissue injury. Therefore, it was hypothesized that the bruise location following SCHF is indicative of the anatomic location of maximal soft tissue injury and therefore is a specific prognosticator of which neurovascular structure may be injured.Methods:Retrospective chart review of all SCHFs treated at a tertiary pediatric hospital from 2007 to 2017 collected information on bruise location, neurovascular injury patterns, and outcomes. Bruise location was classified as anterior, anterolateral, anteromedial, or posterior. Injury radiographs were reviewed by a blinded pediatric orthopaedic surgeon to neurovascular structure injured.Results:Of 2845 SCHFs identified, 267 (9.4%) had concomitant neurovascular injury—of which 128 (47.9%) met inclusion criteria. Among the vascular injuries, all bruising was anteromedial (28/45, 62.2%, P<0.05) or anterior (17/45, 37.8%, P>0.05). Fractures with anteromedial bruising correlated with median nerve injury (24/27, 88.9%, P<0.05), whereas fractures with anterolateral bruising correlated with radial nerve injuries (24/25, 96.0%, P<0.05). Bruising or radiographic evaluation correctly identified 60.2% and 64.1% of neurovascular injuries, respectively, whereas the combination identified 82.0% of neurovascular injuries correctly. Bruise location identified 23 neurovascular injuries not predicted by radiographic evaluation alone.Conclusion:Bruise location is an important physical examination finding that can be used as an adjunct to improve the diagnostic accuracy of neurovascular injury in SCHFs in conjunction with neurovascular physical examination and radiographic evaluation. SCHFs with anterior or anteromedial bruising should raise concern for vascular injury. In addition, anteromedial bruising is predictive of a median nerve injury and anterolateral bruising is predictive of radial nerve injury. This adjunct diagnostic is particularly helpful in a noncooperative child or if performed by a clinician with limited experience in diagnosing neurovascular injuries or interpreting pediatric elbow radiographs.Level of Evidence:Level IV, case series.

How to Manage Pediatric Orthopaedic Patients: Strategies to Provide Safer Care During the COVID-19 Outbreak in Wuhan, People's Republic of China.

How to Manage Pediatric Orthopaedic Patients: Strategies to Provide Safer Care During the COVID-19 Outbreak in Wuhan, People's Republic of China.

The Impact of the Ligamentous Injury Pattern and Associated Neurovascular Injury on Ultimate Knee Function in Patients with Traumatic Knee Dislocations.

The present study aims to investigate whether there is a relationship between the ligamentous injury pattern and concomitant neurovascular injury with long-term functional outcomes in patients with traumatic knee dislocations (TKDs). A total of 42 patients with TKDs were categorized according to the Schenck's classification based on the pattern of ligamentous injury. Concomitant vascular and neural injuries were recorded. Long-term functional outcomes were assessed using several objective and subjective outcome measures. This retrospective study was conducted in two phases: (1) to analyze the impact of ligamentous injury pattern on functional outcomes of patients with TKDs in the overall study population, by comparing all the variables among Schenck's grades; (2) to determine the impact of concomitant vascular and neural injury on ultimate knee function based on the subgroup analyses. In the overall study statistical differences were determined among each pattern of ligamentous injury in the total range of motion (ROM) and scoring systems (chi-squared test, p = 0.254). The overall rates of vascular and neural injury were 26 and 28%, respectively. In subgroup analyses, 40 patients were divided into three subgroups: group A (isolated concomitant neural injury), group B (isolated concomitant vascular injury), group C (without concomitant major vascular or neural injury). The analysis revealed a significant difference in the total ROM (p = 0.005), flexion measurements (p = 0.004), and the loss of extension (p = 0.003). Group A had the lowest total knee ROM and the mean flexion degrees, as well as the highest loss of extension. Concerning functional scoring systems including the combined Knee Society Score (knee score + function score), Lysholm knee scoring scale, and International Knee Documentation Committee score, subgroup analyses revealed significant differences among the groups (p = 0.001, p < 0.01 for all scores). All the scores were found to be lowest in group A. Evidence from the current study showed that the ligamentous pattern and concomitant neurovascular injury both may have a significant impact on ultimate knee function in patients with TKDs. This is a Level III-retrospective comparative study.

Which Risk Factors Predict Knee Ligament Injuries in Severely Injured Patients?-Results from an International Multicenter Analysis.

Introduction: Ligament injuries around the knee joint and knee dislocations are rare but potentially complex injuries associated with high-energy trauma. Concomitant neurovascular injuries further affect their long-term clinical outcomes. In contrast to isolated ligamentous knee injuries, epidemiologic data and knowledge on predicting knee injuries in severely injured patients is still limited. Methods: The TraumaRegister DGU® (TR-DGU) was queried (01/2009–12/2016). Inclusion criteria for selection from the database: maximum abbreviated injury severity ≥ 3 points (MAIS 3+). Participating countries: Germany, Austria, and Switzerland. The two main groups included a “control” and a “knee injury” group. The injury severity score (ISS) and new ISS (NISS) were used for injury severity classification, and the abbreviated injury scale (AIS) was used to classify the severity of the knee injury. Logistic regression analysis was performed to evaluate various risk factors for knee injuries. Results: The study cohort included 139,462 severely injured trauma patients. We identified 4411 individuals (3.2%) with a ligament injury around the knee joint (“knee injury” group) and 1153 patients with a knee dislocation (0.8%). The risk for associated injuries of the peroneal nerve and popliteal artery were significantly increased in dislocated knees when compared to controls (peroneal nerve from 0.4% to 6.7%, popliteal artery from 0.3% to 6.9%, respectively). Among the predictors for knee injuries were specific mechanisms of injury: e.g., pedestrian struck (Odds ratio [OR] 3.2, 95% confidence interval [CI]: 2.69–3.74 p ≤ 0.001), motorcycle (OR 3.0, 95% CI: 2.58–3.48, p ≤ 0.001), and motor vehicle accidents (OR 2.2, 95% CI: 1.86–2.51, p ≤ 0.001) and associated skeletal injuries, e.g., patella (OR 2.3, 95% CI: 1.99–2.62, p ≤ 0.001), tibia (OR 1.9, 95% CI: 1.75–2.05, p ≤ 0.001), and femur (OR 1.8, 95% CI: 1.64–1.89, p ≤ 0.001), but neither male sex nor general injury severity (ISS). Conclusion: Ligament injuries and knee dislocations are associated with high-risk mechanisms and concomitant skeletal injuries of the lower extremity, but are not predicted by general injury severity or sex. Despite comparable ISS, knee injuries prolong the hospital length of stay. Delayed or missed diagnosis of knee injuries can be prevented by comprehensive clinical evaluation after fracture fixation and a high index of suspicion is advised, especially in the presence of the above mentioned risk factors.

What are the differences in outcomes between simple and complicated FSF managed by early IMN?

To compare the outcomes of simple versus complicated femoral shaft fracture (FSF) treated by early intramedullary nail. Retrospective cohort study in level 1 trauma center including patients with FSF. Management consisted of intramedullary nailing (IMN) after adequate resuscitation within 24h. Data were prospectively collected on admission (trauma base) consisted of demographics, biological parameters, associated injuries and injury severity score (ISS). Complicated fractures consisted of type C fracture or any type associated with bilateral femur fracture, floating knee, associated femoral neck fracture, dislocated hip, concomitant neurovascular injury. Simple fractures were Isolated type A and B fracture. Simple and complicated fracture groups were compared using stratification by ISS (ISS < 16; 16 ≤ ISS < 25; ISS ≥ 25). Inclusion of 191 consecutive patients: simple FSF (N = 109) versus complicated FSF (N = 82) (type 32C, n = 36; bilateral, n = 44; associated neck of femur fracture, n = 15; floating knee, n = 36; concomitant femoral artery injury, n = 3 or sciatic nerve injury, n = 7). Complicated fractures were associated with higher rate of associated injuries (thoracic, 56.1 vs. 40.4%, p = 0.04; head 25.6 vs 10.1%, p = 0.005) and ARDS (12.2% vs. 3.7%, p = 0.046); longer ICU stay (12.8 vs. 7.3days, p = 0.019) and hospital stay (24.3 vs. 15.7days, p < 0.001). After stratification, differences in morbidity between simple and complicated FSF were significant solely in range 16≤ISS < 25. Complicated fractures had longer operation duration (297 vs. 151min, p < 0.001) due to additional IMN (tibial, humeral) requirements (24% vs. 1.8%, p < 0.001) and longer femoral IMN duration (133 vs. 104min, p < 0.05). Pseudarthrosis was higher in complicated fracture group (9.6 vs. 3.7%, p = 0.002). Complicated femoral fractures are associated with higher morbidity, especially in less severely injured polytrauma, which eventually results in longer hospital stay. Patients with moderate ISS and complicated fracture may have an increased risk of ARDS.

Clinical Outcomes of Zone 2 Flexor Tendon Repairs Using the Modified Lim/Tsai Technique

The single looped suture modified Lim/Tsai technique is widely used for flexor tendon repairs. It has been shown to possess better biomechanical properties and require less repair time per tendon as compared to the double looped suture original Lim/Tsai technique. However, there is no clinical data on the modified technique. The retrospective study included zone 2 flexor tendon repairs made using the modified Lim/Tsai technique from January 2008 to December 2014. Clinical outcome was assessed using the revised Strickland and Glogovac criteria, which categorises repairs based on the total active motion of the repaired digit. Sixty-two patients with 74 digits were included. The overall mean total active motion was 122°. The overall satisfactory outcome of the modified Lim/Tsai technique was 81.1%. The rupture rate of the modified Lim/Tsai technique was 2.7%. Using multivariate linear regression model, we found that outcomes were negatively influenced by subzone 2C and crush/saw injuries, but not by concomitant neurovascular injuries or post-operative follow-up duration. Based on this retrospective study of patients with zone 2 flexor tendon injuries, the clinical outcomes of modified and original Lim/Tsai techniques are comparable. As such, there is no clinical evidence favouring one over the other.

Simultaneous Bilateral Knee Dislocation During Weight Training

We describe the clinical course and treatment of a patient who sustained simultaneous bilateral knee dislocation under low-velocity atraumatic conditions, and provide a review of the literature. Dislocations of the native knee joint are uncommon orthopaedic injuries but they are true emergencies because of the concern for concomitant neurovascular injury; therefore, they may be limb-threatening injuries. To our knowledge, there are few reports of simultaneous bilateral knee dislocation and no reports of this occurring during weight training. The risk of knee dislocation can be reduced by avoiding locking and hyperextension of the knees during any type of leg press or squatting exercise.

Incidence and Characterization of Major Upper-Extremity Amputations in the National Trauma Data Bank.

Background:There are few recent data examining the epidemiology of severe upper-extremity trauma in non-military patients. We used the National Trauma Data Bank (NTDB) to investigate the epidemiology and descriptive characteristics of upper-extremity amputations in U.S. trauma centers.Methods:We queried the 2009 to 2012 NTDB research datasets for patients undergoing major upper-extremity amputation and extracted characteristics of the patient population, injury distribution, and treating facilities. In addition, multivariable regression models were fit to identify correlates of reoperation, major in-hospital complications, duration of hospitalization, and in-hospital mortality.Results:A total of 1,386 patients underwent a major upper-extremity amputation secondary to a trauma-related upper-extremity injury, representing 46 per 100,000 NTDB trauma admissions from 2009 to 2012. The most frequent definitive procedures performed were amputations through the humerus (35%), forearm (30%), and hand (14%). The average duration of hospitalization for all amputees was 17 days. Thirty-one percent of patients underwent at least 1 reoperation. The rate of reoperation was significantly higher at university-associated hospitals compared with nonteaching or community hospitals (p < 0.0001). Patients who had at least 1 reoperation stayed in the hospital approximately 7 days longer than patients who did not undergo reoperation. The Injury Severity Score, hospital teaching status, concomitant neurovascular injury, and occurrence of a complication were significantly associated with reoperation.Conclusions:The present study provides an updated report on the epidemiology and characteristics of trauma-related major upper-extremity amputation in the U.S. civilian population. Additional work is necessary to assess the long-term outcomes following attempted upper-extremity salvage. The population-level data provided by the present study may help to inform the design and implementation of future studies on the optimum treatment for this survivable but life-altering injury.

Pins in the Shoulder Girdle: Beware Wayward Wires.

As outlined in our January 16, 2013, editorial, “ The Case Report Redefined with JBJS Case Connector ,” 1 important role of JBJS Case Connector is to alert the orthopaedic community about a potentially problematic device or therapy. When 2 or more such cases with similar mechanisms appear, we will identify the procedure or implant as a “watchable” intervention. While this system is not statistically conclusive and may or may not be supported by other published case reports or registry data, the intention is to sharpen the focus of clinicians on the potential for similar problems and thereby enhance clinical outcomes and patient safety. The “Watch” designation may also encourage others to report related difficulties and enlist the orthopaedic community to either demonstrate that these are isolated, unrelated cases or sharpen the focus further on rigorously evaluating the intervention. Where appropriate, we may identify brand, model, or implant-lot specifics. Worldwide, approximately 700,000 proximal humeral fractures occur every year, most of them in patients older than 65 years. The treatment of proximal humeral fractures in the elderly remains controversial. In the U.S., the rate of surgical treatment of these fractures in Medicare patients increased by >25% between 1999 and 2005. This increase in surgical treatment may be explained in part by the advent of locking-plate technology and other device and technique advances. Nevertheless, a substantial number of patients, old and young, who sustain a proximal humeral fracture are still managed with Kirschner wires (K-wires). Surgeons often opt to pin such fractures to protect the repair of a concomitant neurovascular injury, as a temporary strategy to alleviate acute pain, or in cases in which the patient cannot tolerate a more invasive surgery. A frequent and potentially lethal drawback to using wires about the shoulder girdle is the risk of migration. This “Watch” …

Treatment of Peroneal Nerve Injuries in the Multiligament Injured/Dislocated Knee.

Tibiofemoral knee dislocations are typically a consequence of high-energy mechanisms, causing significant damage to the soft tissue and osseous structures of the knee. Concomitant neurovascular injuries such as popliteal artery and peroneal nerve injuries are also common and can have significant long-term consequences. The mechanism typically involves a traction injury to the peroneal nerve subsequent to an extreme varus moment applied to the knee. Complete nerve injuries typically hold a worse prognosis than incomplete palsies. Rates of functional recovery in the setting of a complete palsy following a knee dislocation event have been dismal. A period of observation and nonoperative treatment is initially performed, utilizing orthotic devices to assist with lower extremity deficits. Surgical treatment options include neurolysis, nerve grafting, tendon transfer, arthrodesis, and direct motor nerve transfers. Motor nerve transfers continue to be explored with initial reports showing promising results.

Scapulothoracic dissociation: a rare variant: a case report.

Scapulothoracic dissociation is a rare injury involving separation of scapula from the thorax along with the upper extremity. Majority of the patients have concomitant neurovascular injury and the prognosis is uniformly poor in such cases. We present a case of scapulothoracic dissociation with comminuted fracture of scapula and acromioclavicular joint disruption without neurovascular deficit. There were associated avulsion fractures of the spinous processes of vertebrae (T3-T5). Such presentation is rare in an already rare scapulothoracic dissociation injury. A discussion regarding the probable mechanism of injury, management and prognosis is presented. scapulothoracic dissociation, scapula fracture, brachial plexus injury, vascular injury.

Ultra-Low Velocity Knee Dislocations

Background: Knee dislocations resulting in multiligament knee injuries (MLIs) are usually associated with high-energy mechanisms such as motor vehicle accidents or sports injuries; however, obese patients are at risk of MLIs from simple falls. Termed “ultra-low velocity” (ULV) dislocations, these injuries occur in obese patients during activities of daily living and may be associated with higher associated risks and complications. Hypothesis: Ultra-low velocity knee dislocations occur more commonly in obese female patients, are associated with higher risks of neurovascular injuries, and have more significant perioperative complications compared with other MLIs. Study Design: Case series; Level of evidence, 4. Methods: The records of 215 consecutive patients with MLIs were identified over a 12-year period. Their charts were reviewed to identify a cohort of patients with mechanisms consistent with ULV dislocations (n = 23). This cohort was compared with all patients with MLIs. Additionally, ULV patients with neurovascular injuries were compared with those without neurovascular injuries. Results: The average body mass index (BMI) was significantly higher in the ULV cohort (49.1 kg/m2) compared with all patients with MLIs (34.1 kg/m2). Injuries occurred more commonly in female patients in the ULV cohort (69.6%) compared with all patients with MLIs (24.3%). Peroneal nerve injuries occurred more commonly in the ULV cohort (39.1%) compared with all patients with MLIs (8.4%), as did vascular injuries (28.1% vs 4.7%, respectively). Postoperative complications were common among all ULV-MLI patients regardless of neurovascular injury status. Seventeen patients (6/12 in the intact group and 11/11 in the neurovascular injury group) had significant complications postoperatively. A significantly higher overall complication rate was noted in the ULV-MLI group (73.9%) compared with the entire MLI cohort (21.4%). Additionally, the ULV-MLI cohort had a higher reoperation rate, wound infection rate, deep venous thrombosis rate, and presence of vascular claudication. Conclusion: Ultra-low velocity knee injuries occur in patients with a greater BMI, more frequently in female patients, and with higher rates of concomitant neurovascular injuries compared with other MLIs. Additionally, a significantly greater incidence of postoperative complications can be expected after ligament reconstruction in this population compared with other MLIs.

Suprakondyläre Humerusfrakturen im Kindesalter

Supracondylar fractures are on the of the most common injuries in paediatric patients. Therapeutic consequences depend on the one hand on the degree of the osseous displacement according to the Gartland classification. On the other hand, the diagnosis of concomitant neuro-vascular injuries is crucial to prevent long term impairment. Never the less, clinical diagnosis can be challenging. In-depth knowledge of pediatric supracondylar humerus fractures is a prerequisite to achieve a functionally and cosmetically satisfactory long-term outcome.

Ultra-Low Velocity Knee Dislocations: A Challenging Population of Multiligament Knee Injuries

Objectives:Multiligament knee injuries (MLI) are usually associated with high energy mechanisms such as motor vehicle accidents or sports injuries. However, obese patients are at risk of MLI from simple falls. Termed “ultra-low velocity” (ULV) dislocations, these may be associated with higher associated risks and complications due to the patient’s inherent size. The objectives of this study are to characterize the epidemiology, risk factors, associated neurovascular injuries, and perioperative complications of ULV dislocations to allow surgeons to make informed decisions regarding their care.Methods:Study Design: Retrospective cohort study. 215 consecutive patients with MLI were identified over a 12 year period. Their charts were reviewed to identify a cohort of patients with mechanisms consistent with ULV dislocation (n=23). This cohort was compared to all MLI. Additionally, ULV patients with neurovascular injury were compared to those without neurovascular injury. Analysis: Means and ranges were calculated for continuous variables (age, BMI) and compared between cohorts using Student’s t test. Frequencies for categorical variables were compared using chi square tests.Results:Compared to all patients with MLI, the ULV cohort had significantly higher BMI, greater prevalence of female gender, and higher rates of both peroneal nerve and popliteal artery injury (Table I). Within the ULV cohort, patients with neurovascular injury demonstrated significantly greater post-operative complications (Table II). There was a trend for higher BMI to be predictive of neurovascular injury in ULV dislocations, but patient numbers limited any additional statistical analysis.Conclusion:ULV knee injuries occur in patients with greater BMI, more frequently in females, and with higher rates of concomitant neurovascular injury compared to other MLI. Additionally, a greater incidence of post-operative complications can be expected after ligament reconstruction in this population.

The Use of Ultrasound in Evaluating Flexor Tendons following Surgical Repair

Sir:FigureZone 1 and 2 flexor tendon repairs are associated with difficult repairs and poor outcomes. Clinical scores cannot differentiate between repair rupture and tendon adhesions in a poorly scoring digit. Ultrasound is not used routinely postoperatively but is used when concern regarding the integrity of the repair exists. High-resolution transducers can be used to assess repair integrity, tendon excursion, and adhesions.1,2 This study aimed to assess whether ultrasound can accurately evaluate zone 1 and 2 flexor tendon repairs and whether imaging provided useful clinical information. A series of patients attended postoperatively for ultrasound of their injured digit. Inclusion criteria were zone 1 and 2 complete flexor tendon lacerations. Concomitant neurovascular injuries were included, but patients with additional injuries were excluded. Patients underwent tendon repair with a four-strand core tendon repair using a 3-0 polypropylene suture and a 6-0 polypropylene epitendinous suture. Subjects were splinted dorsally for 6 weeks, and early active mobilization was commenced. Between postoperative weeks 6 and 8, the injured digit(s) and the uninjured contralateral digit were scanned. High-frequency (12-MHz) linear array ultrasound including color flow Doppler was performed at rest and during active flexion and extension. For each tendon repair site, repair integrity, tendon thickness, tendon glide, presence of adhesions, and vascularity were recorded. Corresponding values were obtained from the contralateral uninjured digit. Tendon glide was graded as unimpaired or mildly, moderately, or severely impaired. Vascularity was noted as equal, increased, or decreased compared with normal. A Strickland score was calculated for each injured digit.3 Paired samples t tests were carried out. A value of p ≤ 0.05 was considered significant. Ultrasonic data of the tendon repair were compared with the scanned uninjured tendon and the Strickland score. Fifteen patients participated with a total of 17 injured digits and 23 injured tendons. Nine had neurovascular injuries. Ultrasound scans were obtained at a mean of 50 days postoperatively. The majority of Strickland scores were good/excellent (eight) or fair (six). Three had poor scores. All repairs were imaged intact. Vascularity was increased in two patients. High-quality images of flexor tendons, repair sites, neurovascular bundles, and annular pulleys were obtained consistently (Figs. 1 and 2). When adhesions were present, the distinction between tendon and scar tissue was difficult but possible. On dynamic scanning, tendon glide was easily visualized.Fig. 1: Transverse color Doppler image of a digit in which the radial digital artery but not the ulnar digital artery has been repaired. The flexor tendons are visible in the center of the image, with the two flexor digitorum superficialis slips inferior to the flexor digitorum profundus tendon.Fig. 2: Transverse view of zone 2 flexor digitorum profundus repair close to the proximal interphalangeal joint. The two white spots at the center top part of the image are end-on views of the suture material. The flexor digitorum superficialis slips are directly underneath the repaired flexor digitorum profundus tendon.On average, flexor tendon repair sites were 50 percent thicker in the anteroposterior diameter and 25 percent wider in the radioulnar diameter compared with unrepaired tendons (p = 0.001). Two digits had unimpaired tendon glide, six had mild impairment, six had moderate impairment, and three had severe impairment of glide. Sixty percent of those with good/excellent Strickland scores had good tendon mobility compared with 25 percent of those with fair scores. Ultrasound provided tangible, clinically relevant information about surgical repairs and clinical progress of patients. High-frequency linear array probes of a small size are ideal for hand imaging, providing clear images with excellent resolution of anatomical structures and dynamic images of tendon glide.4,5 Our study confirmed the feasibility of using ultrasound in this patient cohort. Ultrasound is useful in identifying tendon rupture or excessive adhesions, and could be used as a method of stratifying patients with poor outcomes to the appropriate rehabilitation program. Nora Nugent, F.R.C.S.I.(Plast.) Department of Plastic and Reconstructive Surgery Joseph Coyle, M.B., B.Ch. Josephine Barry, M.R.C.P., F.R.C.R. Department of Radiology Michael O'Shaughnessy, F.R.C.S.(Plast.) Department of Plastic and Reconstructive Surgery, Cork University Hospital, Wilton, Cork, Ireland DISCLOSURE No financial support was received for this study and none of the authors has any financial interests to declare.

Brachial artery transection associated with open elbow dislocation in a 12-year-old: a case report

Although acute elbow dislocations are common orthopedic injuries, concomitant neurovascular injury is rare. Brachial artery transection can result from open elbow dislocation and responds well to vascular repair. Rapid evaluation and a high level of suspicion are essential to facilitate immediate treatment. Delay to identify vascular injury after elbow dislocation or reduction can potentially lead to limb ischemia, and potential loss of limb. We present a case of relatively rare transection of the brachial artery, with an accompanying traumatic open elbow dislocation in a 12-year-old boy.

Orthopedic pitfalls in the ED: neurovascular injury associated with posterior elbow dislocations

Posterior elbow dislocations are the most common type of elbow dislocation and are usually caused by a fall on an outstretched hand. Although the incidence of elbow dislocation complications is rare, the emergency physician is responsible for evaluation and identification of concomitant neurovascular injuries. Failure to identify neurovascular compromise after elbow dislocation or reduction can potentially lead to severe morbidity with limb ischemia, neurologic changes, compartment syndrome, and potential loss of limb. Cyanosis, pallor, pulselessness, and marked pain should suggest vascular injury or compartment syndrome, both requiring immediate intervention. Patients in whom it is not clear if there is vascular injury should undergo further imaging with angiography, considered the gold standard for evaluation of arterial damage. It is important for the emergency physician to maintain a high level of suspicion and evaluate for neurovascular compromise on every patient with elbow dislocation despite the low overall incidence of severe injury.

IMMEDIATE VASCULAR AND LIGAMENTOUS REPAIR IN A CLOSED KNEE DISLOCATION

Traumatic dislocation of the knee is a significant injury, and concomitant neurovascular injury generally occurs in greater than one in three cases reported. This paper describes a patient with multiple injuries who sustained a traumatic knee dislocation with vascular compromise. Initial treatment included a vein graft of the arterial injury and reconstruction and reattachment of injured ligaments at the same time as joint stabilization with a Steinmann pin. If arterial injury is present it must be repaired first.