Distal Forearm Research Articles

Median Nerve Neuropathy Caused by Persistent Median Artery Thrombosis

Summary: Persistent median artery thrombosis mimicking carpal tunnel syndrome is rare. Here, we report the pathological, ultrasonography, and intraoperative findings of a case of persistent median artery thrombosis mimicking carpal tunnel syndrome. A 34-year-old man reported to our clinic with a complaint of numbness in his left thumb, index finger, and middle finger, which are innervated by the left median nerve. He also reported that he felt pain in his left wrist and distal forearm while working. Although findings of the usual provocative tests and nerve conduction studies were normal, ultrasonography revealed arterial thrombosis at the carpal tunnel level, whereas magnetic imaging showed persistent median artery thrombosis in the carpal tunnel. Three months after surgical resection of the thrombosed section of the artery, the patient fully recovered with no residual pain or limitations in the use of the affected arm. His patient-reported outcomes improved as well. It is important to investigate the existence of persistent median artery thrombosis if a patient presents with atypical symptoms of carpal tunnel syndrome. Ultrasonography is useful for the diagnosis of persistent median artery thrombosis. Surgical resection of a thrombosed persistent median artery in patients with carpal tunnel syndrome yields good results.

Effectiveness of Planned Teaching Programme on Knowledge regarding Osteoporosis and its Management among Menopausal women in selected rural areas in Bangalore District

Osteoporosis is a systematic progressive disease, is responsible for significant morbidity and mortality in ageing postmenopausal women. It is an important public health problem because of its significant complications, namely fractures of proximal femur, vertebrae, distal forearm, proximal humerus, pelvis and other skeletal sites. Compared with other osteoporotic fractures incur the greatest morbidity and direct medical costs for health services. There are now a variety of treatments available for the management of osteoporosis. Prevention of osteoporosis with identification of risk factors, careful examination and a few simple diagnostic test during teen and early adult years is superior to treatment of old individuals. Methods: The research approach for the present study adopted was Quasi experimental evaluative approach with one group pretest posttest design. The data were collected by using self administered structured knowledge questionnaire from 60 menopausal women who were selected by using convenient sampling technique. Validity of the tool was obtained, by sending the tool to seven experts and reliability of tool was established by, split half method. Pretest was followed by PTP and posttest was conducted after seventh day of the teaching. The data obtained was analysed by using descriptive and inferential statistics. Results: In this study the overall mean knowledge score in the pretest was 47% and 72.56 in the posttest with the enhancement of 25.56% and it is significant at 5% level. Among the demographic variables analyzed in the study it was inferred that there is a significant association between knowledge score and the selected v demographic variables. The result reveals the effectiveness of the PTP. Interpretation: The findings of the study reveal that the knowledge of the menopausal women was not satisfactory before the PTP. The posttest knowledge score shows significant increase in knowledge of menopausal women. Hence, the PTP was an effective method of providing information and improving the knowledge of menopause women. Conclusion: Providing an effective education to the menopausal women enable them to aware about osteoporosis and empowering them with adequate knowledge which in turn contributes, to improve the total quality of their lives.

Do We Need a Strictly Lateral Radiograph for Fracture Management of Forearm Buckle Fractures in Children?

Buckle fractures of the distal forearm are a common fracture entity in children treated conservatively. Diagnostics primarily include radiographs in 2 planes. Inadequate images may occur in the mostly very young patients. Therefore, additional lateral radiographs are often obtained to assess a possible angular tilt. The aim of this study is to investigate whether a strictly lateral x-ray image has an influence on fracture management. Seventy-three children with buckle fractures of the distal forearm were included in this retrospective analysis. All cases were analyzed by quality of radiographs, necessity to obtain an additional lateral radiograph, and what influence on fracture management resulted. Follow-up was performed 2 to 4 weeks after immobilization. Thirty-five girls and 38 boys with a mean age of 7.16 years were included; 40 had fractured right and 33 had fractured left arms, respectively. Isolated distal radius fractures occurred in 48 cases, isolated distal ulna fractures in 6 cases, and both bones in 19 cases. Initial radiographic images were evaluated as inadequate in 25 cases. In each of those cases, an additional lateral image was obtained by fluoroscopy without resulting in an alternated fracture management protocol, which was chosen conservatively in each case and resulted in excellent clinical outcome at follow-up examination. Based on our results, the acquisition of additional lateral radiographs seems to be unnecessary in the diagnostic procedure of buckle fractures of the distal forearm, in case a possible palmar or dorsal angulation cannot be entirely assessed on the initial set of radiographs. An additional lateral image had no influence on fracture management, which was chosen conservatively in every case and led to excellent clinical results.Level of evidence: level III.

The clinical necessity of a distal forearm DEXA scan for predicting distal radius fracture in elderly females: a retrospective case-control study

BackgroundRecent studies have demonstrated that the distal forearm dual-energy X-ray absorptiometry (DEXA) scan might be a better method for screening bone mineral density (BMD) and the risk of a distal forearm fracture, compared with a central DEXA scan. Therefore, the purpose of this study was to determine the effectiveness of a distal forearm DEXA scan for predicting the occurrence of a distal radius fracture (DRF) in elderly females who were not initially diagnosed with osteoporosis after a central DEXA scan.MethodsAmong the female patients who visited our institutes and who were over 50 years old and underwent DEXA scans at 3 sites (lumbar spine, proximal femur, and distal forearm), 228 patients with DRF (group 1) and 228 propensity score-matched patients without fractures (group 2) were included in this study. The patients’ general characteristics, BMD, and T-scores were compared. The odds ratios (OR) of each measurement and correlation ratio among BMD values of the different sites were evaluated.ResultsThe distal forearm T-score of the elderly females with DRF (group 1) was significantly lower than that of the control group (group 2) (p < 0.001 for the one-third radius and ultradistal radius measurements). BMD measured during the distal forearm DEXA scan was a better predictor of DRF risk than BMD measured during the central DEXA (OR = 2.33; p = 0.031 for the one-third radius, and OR = 3.98; p < 0.001 for the ultradistal radius). The distal one-third radius BMD was correlated with hip BMD, rather than lumbar BMD (p < 0.05 in each group).ConclusionPerforming a distal forearm DEXA scan in addition to a central DEXA scan appears to be clinically significant for detecting the low BMD in the distal radius, which is associated with osteoporotic DRF in elderly females.Level of evidenceIII; case-control study.

Radial Arteriovenous Fistula After Coronary Catheterizations

A 57-year-old man with a history of 2 percutaneous coronary interventions through the right radial artery (6 months and 5 months prior) reported a right radial bruit with a palpable thrill. Doppler ultrasound imaging revealed a radial arteriovenous fistula (AVF). Transbrachial angiogram showed blood flow between the radial artery and venous system (Fig. 1). The patient's condition was managed conservatively because it was a case of AVF without pain or heart failure symptoms. Two years later, the patient presented with progressive development of the bruit and new wrist pain. Physical examination revealed local swelling of the right distal forearm (Fig. 2). A worsened AVF with dilated superficial veins was confirmed on Doppler ultrasound imaging (Fig. 3). Consequently, the patient underwent surgical ligation under local anesthesia (Fig. 4). The swelling, thrill, and pain resolved. The patient underwent follow-ups every 3 months for 2 years, and no vascular events occurred during that time.Arteriovenous fistula as a complication of catheterization generally occurs at brachial and femoral arteries/veins. Radial AVF is extremely rare, with an incidence of approximately 0.05% in the transradial approach, according to the SPIRIT of ARTEMIS study.1 Other complications of the transradial approach include radial artery occlusion, perforation, and pseudoaneurysm.1 Radial AVF, which can be generally described as a delayed-onset vascular complication, can cause wrist pain and heart failure symptoms because of left-to-right shunt. The management of radial AVF, which can include surgery, percutaneous intervention, or conservative management, varies according to individual cases, as reported previously.2–4 Conservative management occasionally fails, as noted in this case. Percutaneous intervention is less invasive, but there is a possibility of stent restenosis and stent fracture resulting from excessive wrist and forearm movement. Surgical ligation would enable a repeat transradial approach in coronary reinterventions. In this era of radial access catheterizations, cardiac interventionists should be knowledgeable about appropriate evaluation and management of radial AVF.The authors thank Dr Kazuhiro Yoneda and Dr Masako Okada for helping with the patient's treatment.

The Hand Hug: A Novel Test for Linburg-Comstock Syndrome and Wide-awake Correction of the Anomaly.

In 1979, Linburg and Comstock1 described an inability to flex the interphalangeal joint of the thumb without simultaneously flexing the distal interphalangeal joint of the index finger, caused by a congenital anomalous connection between the flexor pollicis longus tendon and the flexor digitorum profundus tendon to the index finger. The “hand hug test” is a novel clinical test for this condition. The palm of the affected hand of the patient is placed on the ipsilateral palm of the examiner’s hand with all the digits lined up in extension. The thumbs are abducted. The patient is asked to bend the thumb around the examiner’s hand while the examiner does the same action—as if the hands are “hugging.” Because the index finger of the patient and the small finger of the examiner are aligned and blocking each other in extension, the thumb of the patient with the Linburg-Comstock anomaly is not able to make a “hand hug.” We report the case of a 20-year-old, right-hand dominant carpentry student who had a complete inability to move his right thumb and right index finger independently. The patient did have the anomaly on the contralateral side, but it was far less pronounced. Specific activities affected by the anomaly were piano, typing, and rock climbing. The phenomenon had always been present but was progressively becoming more pronounced, with no clear history of an inciting traumatic event. We performed a point-of-care ultrasound examination and observed a pathologic band in both the coronal and sagittal view, which was 4 cm in length. We agree that magnetic resonance imaging or computed tomography scan can be helpful to characterize the anatomy, but high-frequency ultrasonography is sufficient to localize the congenital band.2 We performed wide-awake surgery with subcutaneous local anesthesia infiltration of 10 mL lidocaine 1% with 10 mg/mL of epinephrine with 20 mL saline buffered with 2 mL 8.3% bicarbonate [wide awake local anesthesia no tourniquet (WALANT) technique].3 The local anesthesia was allowed at least 45 minutes to take effect before the procedure. The patient was positioned supine with the affected limb on an arm board without a tourniquet. The surgical field was prepared and draped using field sterility. A linear incision was made along the radial aspect of the distal forearm over the flexor carpi radialis tendon, just proximal to the volar wrist crease. The anomalous connection was confirmed by the synkinesis of the tendons on both active and passive intraoperative testing. We observed the fibrous type anomalous connection, which is the most common type among the classification of Yurasakpong et al.4 We sharply divided the connection, which immediately corrected the anomaly. The thumb and index finger could now move independently, and the patient was able to make the “hand hug” with the surgeon [See Video (online), which displays the preoperative clinical and ultrasound examination, surgical procedure, and final result with the “hand hug test” for each step]. The patient was mobilized immediately, using principles of hand elevation, early cessation of postoperative analgesics, and “pain-guided healing.” Hand therapy was used to encourage independent tendon gliding. He made a complete recovery and was able to return to normal activities without restrictions. {"href":"Single Video Player","role":"media-player-id","content-type":"play-in-place","position":"float","orientation":"portrait","label":"Video 1.","caption":"This video displays the preoperative clinical and ultrasound examination, surgical procedure and final result with the « hand hug test” for each step.","object-id":[{"pub-id-type":"doi","id":""},{"pub-id-type":"other","content-type":"media-stream-id","id":"1_pcsm1wze"},{"pub-id-type":"other","content-type":"media-source","id":"Kaltura"}]} PATIENT CONSENT The patient provided written consent for the use of his image.

Comparison of Outcome of Traditional Radial Artery versus Distal Artery Approach in Patients undergoing Coronary Intervention

Although most interventional cardiologists favor radial artery (RA) access because to its ergonomic practicality, data on distal artery (DRA) access with relation to RA patency has not been compared in major trials. Objective: To compare the access feasibility of distal radial artery vs Forearm radial artery for cardiac catheterization operations. Methods: A cross sectional study of total of 198 patients undergoing radial coronary operations were monitored for radial artery occlusion (RAO) and other local problems with DRA and FRA access. Purposive sampling was performed. The inclusion criteria include all participants who had a palpable distal or proximal radial pulse. The patient was free to choose between the two approaches. Patients having an inappropriate radial pulse were eliminated. Results: The main objective was fulfilled by 11.7% in the FRA and 10.4% in the DRA group (p-value=0.24). Cannulation time was greater in the DRA group compared to the FRA group; however, this had no effect on hemostasis time (254 20 vs. 254 17; p-value=0.72). Hematoma (26.4% vs. 12.5%; OR (95% CI): 3.18 (1.09–5.63); p-value 0.001) was more prevalent with FRA, while radial artery spasm (18.6 % vs. 22.9 %; OR (95 % CI): 0.53 (0.03 – 0.95); p-value=0.01). Conclusions: When compared to Forearm Radial Artery access, Distal Radial Artery access is linked with poorer cannulation success rates and greater RAO rates. It is, however, linked to the production of lower hematomas

Diametaphyseal Distal Forearm Fractures in Children: A STROBE Compliant Comparison of Outcomes of Different Stabilization Techniques Regarding Complications.

Diametaphyseal forearm fractures are difficult to treat because standard methods for long-bone fracture stabilization in the metaphyseal or diaphyseal regions are less effective in this transition zone. We hypothesized that there is no difference in outcomes between conservative and surgical treatment of diametaphyseal forearm fractures. This retrospective analysis included 132 patients who had undergone treatment for diametaphyseal forearm fracture between 2013 and 2020 at our institution. The primary analysis compared complications occurring in patients treated conservatively with those occurring in patients managed surgically (ESIN, K-wire fixation, KESIN stabilization, or open reduction and plate osteosynthesis). In a subgroup analysis, we compared the two most frequently applied surgical stabilization techniques in distal forearm fractures (i.e., ESIN and K-wire) with conservative treatment. The mean age of the patients at the time of intervention was 9.43 ± 3.78 years (mean ± SD). Most patients were male (91; 68.9%), and 70 of 132 (53.1%) patients underwent surgical stabilization. The rate of re-intervention or complications was similar after conservative and surgical treatment, and ESIN or K-wire fixation achieved comparable complication rates. Recurrent displacement of fragments was the most frequent reason for re-interventions (13 of 15 patients; 86.6%). There was no permanent damage as a result of a complication. The median time of exposure to image intensifier radiation was comparable between ESIN (95.5 s) and K-wire fixation (85.0 s), but significantly lower during conservative treatment (15.0 s; p = 0.001).

Clinical Follow-Up without Radiographs Is Sufficient after Most Nonoperatively Treated Distal Radius Fractures in Children

Distal forearm fractures are common in children and are usually treated nonoperatively. No consensus has been reached on how to perform clinical and radiographic follow-up of these fractures. Our aim was to study whether radiographic and clinical follow-up is justified. We included 100 consecutive patients with non-operatively treated distal forearm fractures who were treated at Oulu University Hospital in 2010-2011. The natural history of the fractures during the nonoperative treatment was analyzed by measuring the potential worsening of the alignment during the follow-up period. The limits of acceptable fracture position were set according to the current literature using "strict" or "wide" criteria for alignment. We determined the rate of worsening fracture position (i.e., patients who reached the threshold of unacceptable alignment). In relation to splinting, we evaluated how many patients benefited from clinical follow-up. Most of the fractures (98%) preserved acceptable alignment during the entire follow-up period when wide criteria were used. The application of stricter criteria for alignment in radiographs showed loss of reduction in 19% of the fractures. Worsening of the alignment was recognized at a mean of 13 days (range 5-29) after the injury. One in three (32%) patients needed some intervention due to splint loosening or failure. Radiographic follow-up of nonoperatively treated distal forearm fractures remains questionable. Instead, clinical follow-up is important, as 32% of patients needed their splints fixed.

Occurrence and relative risks for non-vertebral fractures in patients with ankylosing spondylitis compared with the general population: a register-based study from Sweden

ObjectivesTo estimate the incidence of non-vertebral fractures in ankylosing spondylitis (AS) compared with the general population.MethodsNationwide register-based cohort study including patients with AS (n=11 611, 65% men, mean age 48...

Concomitant fractures in patients with proximal femoral fractures lead to a prolonged hospital stay but not to increased complication rates or in-house mortality if treated surgically: a matched pair analysis

BackgroundImpact of concomitant fractures on patients sustaining a proximal femur fracture remains unclear. Rising numbers and patient need for rehab is an important issue. The objective of our study was to investigate the impact of concomitant fractures, including all types of fractures, when treated operatively, for proximal femur fractures on the length of hospital stay, in-house mortality and complication rate.MethodsObservational retrospective cohort single-center study including 85 of 1933 patients (4.4%) with a mean age of 80.5 years, who were operatively treated for a proximal femoral and a concomitant fracture between January 2016 and June 2020. A matched pair analysis based on age, sex, fracture type and anticoagulants was performed. Patient data, length of hospital stay, complications and mortality were evaluated.ResultsThe most common fractures were osteoporosis-associated fractures of the distal forearm (n = 34) and the proximal humerus (n = 36). The group of concomitant fractures showed a higher CCI than the control group (5.87 vs. 5.7 points; p < 0.67). Patients with a concurrent fracture had a longer hospital stay than patients with an isolated hip fracture (15.68 vs. 13.72 days; p < 0.056). Complications occurred more often in the group treated only for the hip fracture (11.8%, N = 20), whilst only 7.1% of complications were recorded for concomitant fractures (p < 0.084). The in-house mortality rate was 2.4% and there was no difference between patients with or without a concomitant fracture.ConclusionsA concomitant fracture to a hip fracture increases the length of hospital stay significantly but does not increase the complication rate or the in-house mortality. This might be due to the early mobilization, which is possible after early operative treatment of both fractures.

Bone health in ambulatory male patients with chronic obstructive airway disease - A case control study from India.

Chronic obstructive airway disease (COPD) is characterized by airflow limitation due to airway and/or alveolar abnormalities with significant extra-pulmonary manifestations. Bone health impairment is an extra-pulmonary complication of COPD which is less well studied in India. Moreover, it can contribute to significant morbidity and mortality. Hence, we aim to estimate the prevalence of osteoporosis and metabolic parameters of adverse bone health in patients with COPD. In this case control study, male subjects aged 40-70 years with COPD attending the respiratory outpatient clinic in a tertiary care hospital were recruited over a period of 2 years and the control population were derived from the historical cohort who were apparently healthy with no obvious diseases. Metabolic parameters of bone health measured from fasting blood samples were calcium, albumin, alkaline phosphatase, phosphorous, parathormone, creatinine, 25-hydroxy vitamin D, and testosterone. Bone mineral density (BMD) was estimated using DXA scan and the World Health Organization (WHO) criteria was used to categorize into osteoporosis, osteopenia, and normal BMD based on the T-score at femoral neck, lumbar spine and distal forearm. Pulmonary function tests and 6 minute walk test were performed if they had not been done in the previous 3 months. The associations of COPD with osteoporosis were analyzed using linear regression analysis and effect size are presented as beta with 95% confidence interval. Of the 67 participants with COPD enrolled in the study, osteoporosis was present in 61% (41/67) and osteopenia in an additional 33% (22/67) of the cases, which was higher when compared to the control population (osteoporosis 20% [50/252] and osteopenia 58% [146/252]). In regression modeling, there was a trend toward adverse bone health with advanced age, low body mass index, low forced expiratory volume in 1second and testosterone deficiency in COPD. Individuals with COPD have a substantially higher prevalence of osteoporosis and osteopenia, up to almost twice that of the general population, with a significant number demonstrating at least one parameter of adverse metabolic bone health on assessment. Hence, bone health assessment should be a part of comprehensive COPD care to prevent adverse consequences due to poor bone health.

Late Distal Radio-Ulnar Joint Instability after Childhood Distal Forearm Fracture

Introduction: Paediatric distal radius fractures are considered benign, and associated ulnar styloid injury is mostly ignored. Although a significant portion evolves to non-union, only a minority present associated complications such as ulnar pain, ulnocarpal abutment, or distal radio-ulnar instability. Distal radio-ulnar dislocations are rare and point to failure of the stabilizing mechanisms of this joint, warranting urgent reduction. Case Report: 18-years old male presents to the emergency department with a volar distal radio-ulnar joint dislocation after a twisting motion of the left wrist. Patient was submitted to urgent closed reduction under general anesthesia and cast immobilization, and surgical repair of ulnar styloid non-union and triangular fibrocartilage complex tear was performed 1 week later. At 6 months follow up the patient as achieved pain free full mobility without instability. Conclusion: The triangular fibrocartilage complex and distal radio-ulnar joint may be affected by seemingly benign injuries, later presenting with acute complications. Fracture and subsequent non-union of the ulnar styloid in the setting of a distal radius fracture is common and underdiagnosed, but clinical significance of and optimal treatment of this injury are still undefined.

Large schwannoma of the median nerve at the distal forearm

Introduction. Schwannoma, also known as neurilemmoma, is a rare but one of the most common tumors of the peripheral nerves. It originates from Schwann cells of the peripheral nerve sheaths. Schwannoma mostly occurs in adults between 20 to 70 years of age. The regions where the tumor most commonly occurs are the head and neck, but it can occur almost anywhere in the body or the organs. Schwannomas are usually up to 2.5 cm in size but may grow to 4?5 cm. In this study, the rare case of large schwannoma of the median nerve in the distal part of the forearm is presented. Case report. A 46-year-old male patient was referred to a plastic surgeon with a diagnosis of lipoma on the anterior side of the distal third of the left forearm. Ultra-sound and magnetic resonance imaging were done, and the surgery was performed after that. An encapsulated tumor of the median nerve was found, and the tumor was completely removed without nerve damage. Histological analysis showed a benign schwannoma of cellular type and biphasic shape. In the postoperative course, there was transient paresthesia. One year after surgery, no tumor recurrence nor neurological deficit was recorded. Conclusion. Schwannoma is the most common benign tumor of peripheral nerves. Schwannomas over 5 cm in size are extremely rare. Appropriate physical examination, pre-operative imaging studies, and histological verification are required for the final diagnosis. The method of choice in treating large schwannomas is complete surgical excision.

Uticaj lokalnih vibracija na mineralnu gustinu kostiju distalne podlaktice

A prolonged, mainly professional, exposure to hand-arm vibration (HAV) may cause a complex chronic disorder of the upper extremities known as Hand-Arm Vibration Syndrome (HAVS). Besides vascular and neurological injuries, such exposure to HAV may cause various bone disorders in the form of cystic changes, exostoses, aseptic necrosis, osteoarthritis, spontaneous fractures and osteoporosis. The objective of this study was to examine whether there were any changes in the bone mineral density in the distal forearm in persons professionally exposed to HAV. In a group of 31 workers professionally exposed to vibrations (29 men and 1 woman) with neurological and/or vascular signs of HAVS, the bone mineral density of the distal part of the radius of both hands was examined by dual X-ray absorptiometry (DXA). The control group consisted of 25 healthy subjects with no history of HAV exposure. Osteopenia was found in 14 subjects (45.16%), which makes a statistically significant difference compared to the control group (p=0.017), where osteopenia was found in 3 subjects (12.0%). Osteoporosis was not found in any of the subjects. Analyzing the value of T score for the dominant (-0.81±0.58 SD) and non-dominant hand (-0.62±0.68SD) in our patients, we found no statistically significant difference in the average T score values of the dominant and non-dominant hand (p=0.269). Changes in bone density at the distal radius are common in persons occupationally exposed to HAV. Distal forearm DXA examination in workers occupationally exposed to HAV can help diagnose HAVS.

Microsurgical interfascicular dissection operation is a viable treatment of carpal tunnel syndrome caused by Lipofibromatous hamartoma: A case report

Lipofibromatous Hamartoma (LFH) is a rare and slow growing benign tumor affecting the peripheral nerves, which usually involves the median nerve. Median nerve involvement commonly causes pain, numbness, paresthesia and carpal tunnel syndrome (CTS). This article describes a case of lipofibromatous hamartoma in a 6-years-old girl, complained of the mass and numbness in her left distal forearm. Microsurgical interfascicular dissection operation was performed to remove the epineural proliferation tissue, numbness disappeared after the operation. At the 12-months follow-up appointment she remained asymptomatic and there was no change in mass size.

Periosteal Nerve Block Vs. Intravenous Morphine in Pain Relief of Distal Radius and Ulna Fracture; a Double-Blind Randomized Clinical Trial.

Distal forearm fractures' realignment and fixation is a painful procedure. This study aimed to compare the efficacy of periosteal nerve block and intravenous morphine in distal radius and ulna fractures' pain management. In the present randomized, parallel, double-blind, controlled clinical trial, patients with distal radius or ulna fractures were divided into two groups. In the first group, for periosteal nerve block, 1% lidocaine was injected at a distance of 6 to 8 cm near the wrist from the lateral radius and medial ulna. In the second group, morphine sulfate at a dose of 0.1 mg/kg was slowly injected through the peripheral vein within 5 minutes. The visual analog scale (VAS) score was evaluated before the intervention and every 15 minutes until 90 minutes after the intervention and was compared between the two groups. 75 subjects were studied (39 in the periosteal nerve block and 36 in the intravenous morphine group). There were no significant differences between the groups in terms of mean age (p = 0.384), gender distribution (p = 0.464), past medical history (p = 0.106), trauma type (p = 0.836), fracture type (p = 0.613), and baseline pain severity on VAS (p = 0.987). Both methods reduced the VAS scores during the 90 minutes of the study. The mean pain scores of the patients in the periosteal nerve block group with 2.56±1.44, 2.15±1.11, 2.66±1.26, and 3±1.27 at 15, 30, 45, and 60 minutes after the analgesic injection, respectively, were significantly lower than those of the intravenous morphine group with 4.75±1.27, 4.22±1.22, 3.97±1.27, and 4.13±1.35, respectively (p < 0.001 for all comparisons). In the present study, no local or systemic complications were observed in the periosteal nerve block group, while the complications of dyspnea, vomiting, and pruritus were reported by 5.5%, 2.8%, and 2.8%, respectively, in the intravenous morphine group. Moreover, the percentage of need for additional analgesia in the intravenous morphine group was higher than that of the periosteal nerve block group. In the first hour after the intervention, pain reduction in periosteal block was significantly higher than intravenous morphine administration. Also, the incidence of complications and the need for additional analgesia were lower in the periosteal block group compared to intravenous morphine administration.

Rupture infected pseudoaneurysm on brachiocephalic AV-fistula: emergency and definitive management

Background: Vascular access bleeding is a rare event that can be fatal in hemodialysis patients. It requires emergency and surgical management to reduce the risk of ischemic events in the patient’s forearm and reduce mortality risk. Objective: To describe the clinical presentation, emergency and surgical intervention, and outcome of rupture-infected anastomotic pseudo aneurysm of the brachiocephalic arteriovenous fistula that underwent a definitive surgical procedure. Case Description: A 55-year-old man presented with bleeding on the AV-fistula surgery site, accompanied with pain and swelling on his forearm that occurred 3 hours before admission to the hospital. The Patient had a history of brachiocephalic AV-fistula surgery 3 weeks earlier. On physical examination, It was found that the surgical site wound looked wet and swollen, with lots of necrotic tissue and pus and lost stitches. In Emergency Departments, the patient was administered intravenous normal saline fluids, bleeding inhibitors and pressure bandages to reduce ongoing bleeding. Then the patient had planned for immediate vascular reconstruction surgery. The brachial artery is repaired using great saphenous vein patch plasty. Results: The patient’s postoperative 30-days follow-up went well, and there was no sign of complication, such as pain, infection, paresthesia, bleeding at the surgical site or ischemia in the distal forearm. Conclusion: Vascular access bleeding can be fatal to hemodialysis patients. Optimal treatment for the patient's life and hemodialysis access is a top priority. A good assessment of the condition of AVF and the choice of subsequent therapy greatly affect the patient's prognosis.

Volumetry of Hand and Forearm: A 3D Volumetric Approach.

Swelling and edema of the hand and forearm may occur in various traumatic and degenerative diseases. So far, no precise measurement protocol exists. The objective of this study was to evaluate an examination protocol with relevant regions of interest (ROIs) measured by a 3-dimensional (3D) scanner to achieve precise, reproducible, and objective measurements for an optimized detection of volumes of the hand and forearm. A 3D scan protocol was developed using an Artec, 3D scanner EVA to measure discrete hand volumes of healthy volunteers. Five areas were defined as ROIs, representing volumes of the finger, metacarpus, wrist, hand, and distal forearm. Contralateral limbs were used for volume comparisons and calculation of volume differences. For this study, 12 individuals (58.3% women, 24 hands and forearms) with a mean age of 27.1 ± 3 years were included. Mean volume values for left and right ROIs correlated with each other, with slightly higher volumes for the right upper extremity. Volume differences showed statistically significant results for the finger region (ROI I; P = .009), the metacarpal region (ROI II; P < .001), hand region (ROI IV; P = .001), and forearm region (ROI V; P = .006), with the exception of the wrist region (ROI III; P = .722). Our results demonstrate that this 3D volumetric approach is a reliable and objective tool for measuring volumes and circumferences in hand and forearm. Based on our determined ROIs, further studies are needed to explore the significance for clinical applications.

New Horizons: Artificial Intelligence Tools for Managing Osteoporosis.

Osteoporosis is a disease characterized by low bone mass and microarchitectural deterioration leading to increased bone fragility and fracture risk. Typically, osteoporotic fractures occur at the spine, hip, distal forearm, and proximal humerus, but other skeletal sites may be affected as well. One of the major challenges in the management of osteoporosis lies in the fact that although the operational diagnosis is based on bone mineral density (BMD) as measured by dual x-ray absorptiometry, the majority of fractures occur at nonosteoporotic BMD values. Furthermore, osteoporosis often remains undiagnosed regardless of the low severity of the underlying trauma. Also, there is only weak consensus among the major guidelines worldwide, when to treat, whom to treat, and which drug to use. Against this background, increasing efforts have been undertaken in the past few years by artificial intelligence (AI) developers to support and improve the management of this disease. The performance of many of these newly developed AI algorithms have been shown to be at least comparable to that of physician experts, or even superior. However, even if study results appear promising at a first glance, they should always be interpreted with caution. Use of inadequate reference standards or selection of variables that are of little or no value in clinical practice are limitations not infrequently found. Consequently, there is a clear need for high-quality clinical research in this field of AI. This could, eg, be achieved by establishing an internationally consented "best practice framework" that considers all relevant stakeholders.