Proximal Forearm Research Articles

The Role of External Fixation in the Management of Upper Extremity Fractures.

External fixation is a powerful tool in the armamentarium of the active orthopaedic surgeon. The upper extremity, however, poses unique challenges in the techniques of external fixation because of the smaller soft-tissue envelope and the proximity of neurovascular structures, which may be entrapped in fracture fragments or traversing in line with pin trajectories. This review article summarizes the indications, techniques, clinical outcomes, and complications of external fixation of the upper extremity in the setting of proximal humerus, humeral shaft, distal humerus, elbow, forearm, and distal radius fractures.

Upper Extremity Soft Tissue Wound Related to Xylazine-laced Fentanyl Intravenous (IV) Drug Abuse: A Case Report

A 35-year-old male abusing intravenous (IV) xylazine-laced fentanyl presented with bilateral forearm wounds. His wounds extended from the wrist to the proximal forearm with exposed muscles and tendons. He was treated with intravenous antibiotics, multiple surgical debridements, and negative pressure wound therapy. He left against medical advice (AMA) and returned with similar, smaller wounds nine months later. The patient was treated and again left AMA and has not followed up since. Xylazine is a veterinary tranquilizer often added to fentanyl to prolong and enhance its effects, whose presence has markedly increased in the illicit drug markets in the United States. It can result in extensive tissue loss from direct toxicity of the drug and/or concomitant infection. Xylazine use may increase morbidity in persons who inject drugs relating to the high prevalence of skin ulcers, soft tissue abscesses, and risk of serious infection necessitating surgical management.

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.

Experience With Proximal Median Nerve Entrapment by the Lacertus Fibrosus.

Unconscious bias of the clinician favors the diagnosis of carpal tunnel syndrome (CTS) in patients with median paresthesia. We hypothesized that more patients in this cohort would be diagnosed with proximal median nerve entrapment (PMNE) by strengthening our cognitive awareness of this alternative diagnosis. We also hypothesized that patients with PMNE may be successfully treated with surgical release of the lacertus fibrosus (LF). In this retrospective study, cases of median nerve decompression at the carpal tunnel and in the proximal forearm for the 2-year periods before and after adopting strategies to mitigate cognitive bias for CTS were enumerated. Patients diagnosed with PMNE and treated by LF release under local anesthesia were evaluated to determine surgical outcome at minimum 2-year follow-up. Primary outcome measures were changes in preoperative median paresthesia and proximal median-innervated muscle strength. There was a statistically significant increase in PMNE cases identified after our heightened surveillance was initiated (z = 3.433, P < .001). In 10 of 12 cases, the patient had previous ipsilateral open carpal tunnel release (CTR) but experienced recurrent median paresthesia. In 8 cases evaluated an average of 5 years after LF release, there was improvement in median paresthesia and resolution of median-innervated muscle weakness. Owing to cognitive bias, some patients with PMNE may be misdiagnosed with CTS. All patients with median paresthesia, particularly those with persistent or recurrent symptoms after CTR, should be assessed for PMNE. Surgical release limited to the LF may be an effective treatment for PMNE.

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...

The Posterior Interosseous Nerve at the Proximal Forearm. Anatomical Study and Clinical Correlation

The Posterior Interosseous Nerve at the Proximal Forearm. Anatomical Study and Clinical Correlation

Morphometric Parameters of the Fibrous Arch of Flexor Digitorum Superficialis: A Cross-sectional Cadaveric Study in the Indian Population

Introduction: The Flexor Digitorum Superficialis arch (FDS arch) serves as a connection between the humero-ulnar and radial heads of the FDS muscle. This arch can potentially compress the median nerve, leading to the development of pronator syndrome. Aim: To describe the morphometric parameters of the FDS arch in the Indian population. Materials and Methods: A two-year cross-sectional cadaveric study was conducted at the Department of Anatomy, Christian Medical College, Vellore, India, from December 2018 to November 2020. Thirty-four forearms from 17 adult cadavers (8 male and 9 female) were included in the study after excluding those with forearm deformities caused by trauma, congenital malformations, or scars. Measurements were taken for the distance from the medial epicondyle to the apex of the FDS arch and the thickness of the arch. The type of FDS arch (tendinous or muscular, distinct or indistinct) was also observed. Descriptive statistics, including means, standard deviations, and range, were calculated using STATA/IC 16.0. Results: Among the specimens, the FDS arch was tendinous in 20 (58.8%) and muscular in 14 (41.2%) cases. The mean distance from the medial epicondyle to the apex of the FDS arch was 65.8±12.8 mm, and the mean thickness was 0.80±0.43 mm. A distinct arch was observed in 25 (73.53%) specimens, while an indistinct arch was found in 9 (26.47%) specimens. Conclusion: The findings of this study contributed valuable insights for surgical interventions aimed at decompressing the median nerve entrapment in the proximal forearm.

Effect of supplemental vitamin D3 on bone mineral density: a systematic review and meta-analysis.

There is still controversy over the effect of vitamin D3 supplementation on bone health. The effects of vitamin D3 supplementation on bone mineral density (BMD) and markers of bone turnover, as well as the dose-response relationship between vitamin D3 and bone health in adults, were evaluated. The PubMed, Scopus, Cochrane, Web of Science, and AGRIS databases were searched for articles published through April 30, 2022. Thirty-nine of the 6409 records identified met the inclusion criteria. Data were extracted from articles by 2 authors, and data extraction was cross-checked independently. A random-effects model was used to estimate the pooled effect size and the associated 95%CI for the effect of vitamin D3 for each outcome. A one-stage random-effects dose-response model was used to estimate the dose-response relationship between vitamin D3 supplementation and BMD. Results of meta-analysis showed a beneficial effect of vitamin D3 at the lumbar spine (standardized mean difference [SMD] = 0.06; 95%CI, 0.01-0.12) and femoral neck (SMD = 0.25; 95%CI, 0.09-0.41). Dose-response analysis revealed a linear relationship between vitamin D3 supplementation doses and BMD at the femoral neck, lumbar spine, and total hip sites. No significant effect of vitamin D3 supplementation on whole-body or total hip BMD was observed (P > 0.05). Vitamin D3 supplementation significantly decreased BMD at both proximal and distal forearm (SMD = -0.16; 95%CI, -0.26 to -0.06). The variables of ethnicity, age, baseline 25-hydroxyvitamin D (25[OH]D), menopause status, vitamin D3 dosing frequency, and bone health status (P interaction = 0.02) altered the effect of vitamin D3 supplementation on BMD. Additionally, a nonlinear relationship between vitamin D3 supplement doses and markers of bone turnover was found. A protective effect of vitamin D3 supplementation on BMD of the lumbar spine, femoral neck, and total hip is implicated. PROSPERO registration number CRD42017054132.

Posterior Interosseous Nerve Compression in the Forearm, AKA Radial Tunnel Syndrome: A Clinical Diagnosis.

Posterior interosseous nerve (PIN) compression in the forearm without motor paralysis is a challenging clinical diagnosis. This retrospective study evaluated the clinical assessment, diagnostic studies, and outcomes following surgical decompression of the PIN in the forearm. This study reviewed 182 patients' medical charts following PIN decompression between 2000 and 2020 by a single surgeon. After exclusion of combined nerve entrapments, polyneuropathy, motor palsy, or lateral epicondylitis, the study included 14 patients. Data collected included: clinical presentation and pain drawings, provocative testing, functional outcomes, and Disabilities of the Arm, Shoulder, and Hand (DASH) scores. There were 15 PIN decompressions (14 patients, mean follow-up = 11.9 months). Clinical presentation included pain (n = 14) (proximal dorsal forearm, n = 14; distal forearm over radial sensory nerve, n = 3) and positive clinical tests (sensory collapse test over the radial tunnel, n = 8; pain with forearm pronation and compression over the radial tunnel, n = 10; Tinel sign, n = 5). Postoperatively, there were significant improvements in Visual Analog Scale pain scores (6.7 to 3.3, P = .0006), quality-of-life scores (74.7 to 32.7, P = .0001), and DASH scores (46.3 to 33.6, P = .02). The PIN compression in the forearm without motor paralysis is a clinical diagnosis supported by pain drawings, pain quality, and provocative tests. Patients with persistent, therapy-resistant dorsal forearm pain should be evaluated for PIN compression. Surgical decompression provides statistically significant quantifiable improvement in pain and quality of life.

Sonography and EMG Biofeedback’s Role in PIN Syndrome After Rehabilitation? A Case Report

The radial nerve divides into two terminal branches the superficial radial nerve and the posterior interosseous nerve. Posterior interosseous nerve entrapment is associated with weakness in the extension of fingers, atrophy of the forearm muscles, and localized pain in the lateral aspect of the elbow and proximal forearm without sensory deficits. A 37-year-old man complained of difficulty of right finger extension (MMT 2) and persistent pain (VAS 5) at the forearm after a fall from a motorcycle six months before admission. We treated the patient with a physical rehabilitation program for three months and a total of 12 visits. Sonography and electromyography (EMG) biofeedback were performed to evaluate improvement after the physical rehabilitation program. After three months, the pain was relieved, and forearm extensor muscle strength increased. This showed that sonography and EMG biofeedback play a role in the detection and evaluation of muscle and nerve abnormality due to posterior interosseous nerve (PIN) syndrome.

Ultrasound is better than injection pressure monitoring detecting the low-volume intraneural injection

IntroductionInadvertent intraneural injection is not infrequent during peripheral nerve blocks. For this reason, injection pressure monitoring has been suggested as a safeguard method that warns the clinician of a potentially...

Some Misconceptions in the Treatment of Cubital Tunnel Syndrome, Radial Tunnel Syndrome, and Median Nerve Compression in the Forearm.

This article discusses ulnar, median, and radial nerve compression in the proximal forearm and elbow and some possible common misconceptions. In particular, the ligament of Struthers extremely rarely causes ulnar neuropathy. Lacertus syndrome and flexor superficialis-pronator syndrome can be diagnosed separately. Surgical release can be through a small incision. Acronyms for compression to radial nerve in proximal forearm can be simplified to radial tunnel syndrome, which includes a mild type (classical radial tunnel syndrome) and a severe type (posterior interosseous nerve (PIN) compression).

Severe spaghetti wrist injury: Should we expand the terminology from wrist to proximal forearm?

Objectives This study aims to point out the key principles for the management of multicomponent soft tissue injuries of the wrist and forearm to discuss whether we should expand the term “spaghetti” from the wrist to forearm in such terrifying cases.Patients and methods Data from a total of 50 patients (44 males, 6 females; mean age: 48.5±25.7 years; range, 10 to 70 years) who were treated for multicomponent soft tissue injuries of the wrist and forearm, including at least one major artery and one major nerve, between February 2020 and December 2021 were retrospectively analyzed. The patients were divided into the wrist injury group (n=30) and forearm injury group (n=20) according to the location of laceration. Demographic characteristics, including age, sex ratio and mechanism and side of injury, total lacerated structures, and outcomes, including tendon function, opposition, intrinsic muscle function, deformities, sensation and grip strength were evaluated.Results In the wrist injury group, a mean of 12.27±3.53 structures at the volar side were injured. It took a mean time of 1.8±0.4 h for emergency surgical repair and, after a mean of 16.6±5.3 month follow-up, most patients received excellent/good outcomes in the six aspects. In the forearm injury group, a mean of 12.95±2.96 structures at the volar side were injured. It took an average time of 2.1±0.4 h for emergency surgical repair and, after a mean of 15.4±6.4 month follow-up, most patients received excellent/good outcomes and were satisfied with the functional recovery. Only surgical time (p=0.018) and final grip strength (p=0.023) between the two groups showed a statistically significant difference.Conclusion We propose to merge the severe wrist and proximal forearm laceration of multiple tendons/muscles with at least one major artery and one major nerve as a whole, namely the spaghettiketchup injury, since the laceration of wrist and that of proximal forearm in this study share similar mechanisms and outcomes after primary repair or reconstruction.

Double-Incision Technique for the Treatment of Distal Biceps Tendon Rupture.

A longitudinal antecubital incision of 3 to 4 cm allows dissection to identify and isolate the lateral antebrachial cutaneous nerve (LABCN). Supination of the forearm protects the posterior interosseus nerve, which often cannot be visualized. The distal portion of the distal biceps should be carefully identified and exposed. A high-resistance nonresorbable suture is sewn with use of a Krackow technique to whipstitch the distal 4 cm of the tendon. Alternatively, 2 sutures (4 strands) can be utilized. A curved forceps is placed in the interosseous space to identify the location for the second 4-cm incision, on the dorsal proximal forearm over the tip of the forceps with the forearm pronated. The radial tuberosity is exposed by bluntly separating the common extensor tendons, followed by transection of the supinator fibers. Two drill holes are made 5 mm apart from one another for suture passage. The tendon is passed across a loop of wire, from the anterior to the posterior incision. With the elbow at 90° of flexion and full pronation, the tendon is docked into the trough and the sutures are tied. Alternatively, the surgical repair of the distal biceps tendon rupture can be performed through a single anterior approach4. The exposure starts with a curved longitudinal antecubital incision, exploiting the interval between the brachioradialis and pronator teres with radial (lateral) retraction of the brachioradialis and medial retraction of the pronator teres. A single anterior incision allows repair through the use of various types of fixation devices, such as suture anchors, cortical buttons, and interference screws, but seems to carry an increased risk of neurological complications, especially in terms of paresthesias in the distribution of the LABCN. Nonoperative treatment might be acceptable for elderly patients with poor functional demands. The double-incision technique with bone-tunnel fixation provides good fixation strength with an expected low rate of neurological complications1. This approach offers a useful treatment option for young and active patients with physically demanding lifestyles. The double-incision technique is an effective and safe procedure to restore elbow functionality in patients with distal biceps tendon rupture. A meta-analysis1,4-16 revealed no significant differences in postoperative functional scores following procedures performed via the single-incision compared with double-incision approach. Although the differences were smaller than the minimal clinically important difference17, the single-incision technique yielded significantly greater flexion (mean ± standard deviation, 136° ± 13°) and pronation range of motion (79° ± 10°) compared with the double-incision technique (133° ± 13° and 75° ± 14°, respectively) at 2 years postoperatively. No differences in extension and supination were observed. Rates of heterotopic ossification ranged from 0.5% to 11% for the single-incision approach and from 1% to 21.4% for the double-incision approach, with significant differences favoring the single-incision technique, although in the majority of cases the heterotopic ossification was an incidental finding. Neurological complications were found in 24.5% and 13.4% cases for the single- and double-incision techniques, respectively, with a significant difference favoring the double-incision technique. When damage to specific nerves was evaluated, the double-incision technique was associated with significantly less risk of LABCN damage. One or 2 high-resistance nonresorbable sutures are sewn with use of a Krackow technique to whipstitch the distal 4 cm of the biceps tendon.A curved forceps is placed in the interosseous space to identify the location for the second incision, on the dorsal proximal forearm over the tip of the forceps.Pronation of the forearm protects the posterior interosseus nerve, which often cannot be visualized during volar dissection and bone fixation.Positioning the tendon more posteriorly on the radial tuberosity allows for optimal biomechanical function. ROM = range of motionCR = conventional radiologyMRI = magnetic resonance imagingUS = ultrasoundLABC = lateral antebrachial cutaneousPIN = posterior interosseous nerveHO = heterotopic ossificationCI = confidence intervalSI = single incisionDI = double incision.

Safe Drill Trajectory for Anatomic Repair of Distal Biceps Tendon Through a Single Incision: A Cadaveric Study

We sought to determine the safest drill trajectory to avoid injury to the posterior interosseous nerve (PIN) when performing a repair of a distal biceps tendon to an anatomic location through an anterior, single-incision approach using cortical button fixation. A standard anterior approach was performed in 10 cadaveric specimens to expose the distal biceps attachment. Three drill holes were made in the radial tuberosity from the center of the anatomic footprint for the distal biceps tendon insertion with the forearm fully supinated. Holes were made in 30° distal, transverse, and 30° proximal directions. Each hole was made by angling the trajectory from an anterior to posterior and ulnar to radial direction, leaving adequate bone on the ulnar side to accommodate an 8-mm tunnel for the purpose of docking the biceps tendon into bone. The proximity of each drill trajectory to the PIN was determined by making a second incision on the dorsum of the proximal forearm. A K-wire was passed through each hole, and the distance between the PIN and K-wire was measured for each trajectory. The distally directed drill hole placed the trajectory wire closest to the PIN (mean distance, 5.4 mm), contacting the K-wire in 3 cases. The transverse drill trajectory resulted in contact with the PIN in 1 case (mean distance, 7.6 mm). The proximal drill trajectory appeared safest, with no PIN contact (mean distance, 13.3 mm). In this cadaveric study, the proximal drill trajectory resulted in the widest clearance from the PIN. When performing repair of a distal biceps tendon to the anatomic location on the tuberosity, the drill trajectory from the center of the biceps footprint should be radial and proximal to provide the greatest separation between the drill guide and the PIN.

Flow mediated dilatation: searching high and low for a technique

Abstract Funding Acknowledgements Type of funding sources: None. Background Endothelial dysfunction has a central role in atherosclerosis physiology. Flow mediated dilatation (FMD) is a non-invasive method for determining endothelial function. Cuff occlusion of forearm for 5 minutes followed by sudden release cause hyperaemia response with increased flow rate and shear stress in brachial artery. FMD measures the ratio of arterial diameter change mediated by nitric oxide (NO) in response to this increase in shear stress. FMD was first defined in 1992 but has not gained wide clinical utility due to contradictory study results. The main reason for inconsistencies is the lack of standardized definition of FMD technique. We need more studies on different steps of FMD procedure. Purpose The optimal cuff position for FMD measurements is not precisely defined. When brachial arterial flow is disturbed by occlusion, different mediators play role in hyperaemia induced dilatation. Occlusion distal to brachial artery causes mainly NO and endothelium mediated dilatation upstream. Therefore, a forearm occlusion cuff position is proposed. Currently, there is no precise definition of the cuff position in forearm. We compared proximal and distal forearm cuff occlusion positions for FMD measurements. Methods We analysed FMD in fifty healthy volunteers (mean age 31,9 ± 9,5 years; 54 % female). The subjects underwent measurements with two different occlusion positions on the same day. The sequence of occlusion cuff position was determined with randomization. We have waited for an appropriate interval between measurements. We made sure that brachial artery has returned to its basal diameter and flow conditions before second measurement. Flow and diameter measurements were made with strict adherence to predefined timelines after cuff release. Same operator performed and recorded all FMD measurements. Results Measurements of basal diameter (p=0,97) and basal flow (p=0,53) were not different. We used random intercept mixed effects model for comparison of proximal and distal occlusion positions. This enabled interpretation of FMD results with refinement of sequence and basal diameter’s possible effects. The FMD values of proximal forearm occlusion cuff position were 2,2 % higher compared to distal position. (p=0,027) The sequence of occlusion cuff position did not have significant effect on consecutive FMD measurements. (p=0,405). Conclusions We have shown that the forearm occlusion cuff position affects FMD measurements. This effect can be responsible for inter-study differences of FMD. Further research is required for interpretation of this difference in terms of molecular mechanisms and its applicability in clinical practice.

"Safe dissection parameters of the anconeus rotational flap for soft tissue coverage at the elbow".

The anconeus is a small muscle located on the posterior elbow originating on the lateral epicondyle and inserting onto the proximal-lateral ulna that functions as an elbow extensor as well as dynamic stabilizer. The blood supply is tri-fold: medial/middle collateral artery (MCA), recurrent posterior interosseous artery (RPIA), and less commonly found, the posterior branch of the radial collateral artery. The anconeus has become a popular option for local soft tissue coverage about the elbow (distal triceps, olecranon, proximal forearm). The average defect size for consideration of local anconeus flap coverage is 5-7cm2. The aim of the study was to determine safe dissection parameters of the anconeus as well as map arterial pedicles to achieve successful local harvest of the muscle without devascularization. 8 fresh frozen cadaveric arms (all male, average age 63 years - 4 left arms, 4 right arms) from scapula to fingertip were obtained. First, the radial, ulnar and axillary arteries were dissected and isolated. The radial and ulnar arteries were transected. 100cc normal saline was injected through the axillary artery, sequentially clamping the radial followed by the ulnar artery so that adequate flow could be seen through all vessels. 100cc mixture of Biodür and hardener (10:1) was mixed and injected into the axillary artery. We first allowed free flow through both the ulnar and radial vessels followed by clamping of these vessels. This allowed the pressure to build up and fill the smaller vessels in the arms. After injection, the axillary artery was then clamped and the specimens were left to harden for 24-48 h. After hardening, dissection was performed by making a curvilinear incision centred over the lateral epicondyle. The anconeus was identified and the interval between the anconeus and ECU was then confirmed. Measurements of the anconeus muscle were taken. Blunt dissection was carried between anconeus and ECU until the RPIA was identified and protected. We isolated the MCA by dissecting proximally. This was found to run with the nerve to the anconeus. Once this vessel had been protected, the muscle reflected from distal to proximal staying along its ulnar border. The branches of the RPIA were ligated and the dissection was continued proximally. Measurements of the distances of the RPIA, MCA were taken. The average distance of olecranon to muscle tip was 95.0mm. The average distance of lateral epicondyle (LE) to muscle tip was 90.8mm. The average distance of LE to olecranon was 49.8mm. The average location of the RPIA was 63.mm when measuring LE to vessel, 68.3mm when measuring olecranon to vessel, 18.3mm when measuring RPIA to muscle tip. The average RPIA diameter was 1.1mm and length was 36.4mm from the initial branching of the posterior interosseous artery. The average MCA diameter was 0.7mm. The posterior branch of the radial collateral artery was only found in 3/8 specimens. The RPIA and MCA were constant in all specimens. Dissection was safely carried to the border of the LE and olecranon without disruption of the MCA. Our conclusions determined that if dissection of the anconeus is undertaken, the RPIA remains constant between the interval of the ECU as well as anconeus at an average distance of 18.3mm from the tip of the muscle measuring proximally; moreover, the MCA was constant in all specimens found directly between the LE and olecranon always running with the nerve to the anconeus. When dissecting and mobilizing to ensure preservation of the MCA, dissection should be taken from distal to proximal as well as dissecting along the ulnar border of the anconeus. Proximal dissection can be taken as proximal as the border of the LE and olecranon as that did not disrupt MCA blood supply.

Epidemiology and Forensic Implications of Complex Proximal Humeral Fractures

Fractures of the proximal humerus account for 7% of all fractures and 80% of humerus fractures, with a higher incidence in women. Among patients aged 65 years and older, proximal humeral fractures are the second most frequent upper extremity fractures and the third most frequent osteoporotic fractures, after proximal femur and distal radius fractures. Studies show that the incidence of proximal humeral fractures increases by approximately 40% every five years. In the United States, an estimated 275,000 patients will present to the emergency department with his proximal humeral level fracture by 2030. Fractures of the proximal humerus increase the risk of subsequent fractures of the proximal femur and distal forearm. The risk of fracture at the proximal femoral level following a fracture of the proximal humerus was 16%, the same as that following a fracture of the distal radius. <br />The forensic implications are important in evaluating the number of days of medical care especially in malpraxis cases. Incorrect treatment of the humeral fractures may lead to an important increase of the time of recovery and as a consequence complex medico-legal implications.

Osteopathic Approach to Treatment of Radial Head Dysfunction: The Radial Head Range of Motion Technique

Abstract Falls on an outstretched hand, overuse, and restriction of motion at the wrist can all contribute to the formation of a radial head somatic dysfunction. Radial head somatic dysfunctions may contribute to or cause painful conditions of the forearm, elbow, and wrist and impact the proper balance of muscular, neural, and circulatory influences. The radial head range of motion technique is a simple and effective osteopathic manipulative treatment (OMT) that can be utilized to address discomfort of the lateral elbow, proximal forearm, and wrist.

Sonographic normal values for the cross-sectional area of the ulnar nerve: a systematic review and meta-analysis

PurposeNerve size is a commonly used sonographic parameter when assessing suspected entrapment of the ulnar nerve. We aimed to create a robust set of normal values, based on a critical review of published normal values.MethodsWe performed a systematic evaluation of studies on normal ulnar nerve sizes, identified in PubMed, Embase, and Cochrane databases. Using meta-analyses, we determined pooled mean cross-sectional area (CSA) values for different anatomical locations of the ulnar nerve throughout the arm. Subgroup analyses were performed for gender, probe frequency, in- or exclusion of diabetic patients, position of the elbow and Asian versus other populations.ResultsWe identified 90 studies of which 77 studies were included for further analyses after quality review, resulting in data from 5772 arms of 3472 participants. Subgroup analyses show lower CSA values at at the wrist crease and proximal to the wrist crease when using low frequency probes (< 15 MHz) and at the wrist crease, proximal to the wrist crease, proximal forearm and the distal upper arm in Asians. CSA values were lower when in flexed position compared to extended position for the cubital tunnel inlet only. No difference was found for gender.ConclusionsOur systematic review provides a comprehensive set of normal values at sites along the entire length of the ulnar nerve. This provides a foundation for clinical practise and upon which future studies could be more systematically compared.