Congenital radioulnar synostosis is a rare congenital anomaly characterized by a failure of segmentation between the proximal radius and ulna during embryonic development, leading to restricted forearm rotation. The condition is often bilateral and may be associated with syndromic disorders. Management varies depending on severity, ranging from observation and physiotherapy to surgical correction. A six-year-old boy presented with bilateral limitation of forearm rotation interfering with daily activities. The right forearm was fixed in 60° pronation and the left in 20° pronation. Radiographs confirmed osseous fusion between the proximal radius and ulna without radial head dislocation, consistent with Cleary and Omer type II congenital radioulnar synostosis. A single-stage rotational osteotomy of the radius and ulna was performed on the right side under general anesthesia. The osteotomies were created distal to the synostosis, and the forearm was rotated to achieve 20-30° of supination without internal fixation. The limb was immobilized in an above-elbow cast for five weeks. Postoperative recovery was uneventful, and at four months, the patient demonstrated union at the osteotomy sites with significant improvement in functional activities such as feeding and self-care. Surgical correction is indicated in cases with significant functional limitation. Performing the osteotomy distal to the synostosis reduces the risk of neurovascular injury. The single-stage rotational osteotomy provided satisfactory correction and improved forearm function without complications. This case highlights the effectiveness and safety of distal single-stage rotational osteotomy in managing congenital radioulnar synostosis in children.

Heart failure is a widespread cardiac disease affecting numerous patients globally, and traditional treatment options are inadequate to meet demand. Interventional blood pumps, as a treatment modality, are widely needed but face significant challenges in the multiobjective optimization of structural design. In this study, we utilized an orthogonal experimental design, CFD simulations and principal component analysis to establish a comprehensive evaluation model for interventional blood pumps. Through regression analysis, we determined the relationships between comprehensive indicators and impeller design variables, enabling optimization of the impeller design. The accuracy of the optimization results was validated through in vitro experiments. Numerical simulations confirmed the effectiveness of the comprehensive evaluation and optimization methods and resulted in the identification of the optimal impeller design. The design emphasized a larger proximal fillet radius and a smaller blood outlet axial length. By comparing simulations with experimental data, we demonstrated that simulations accurately obtained hydraulic performance (flow rate, pressure difference) and efficiency, with an error margin below 5%. The multiobjective comprehensive evaluation and optimization methods proposed in this study can effectively enhance the overall performance of interventional blood pumps.

Background: The radiocapitellar articulation of the elbow joint is particularly susceptible to subluxation and dislocation. Joint stability can be quantified using the stability ratio, a biomechanical parameter of joint stability defined as the ratio of the maximum dislocating force the joint can resist in relation to the joint compressive force. The purpose of this study was to biomechanically assess the stability of the radiocapitellar joint in the anterior and posterior direction across varying degrees of elbow flexion. Methods: Eight fresh-frozen cadaveric elbows, average age 68.9 years (range 61–73 years; 3 males and 5 females; 7 left and 1 right) were tested. The distal humerus and proximal radius were dissected of all soft tissues to isolate the radiocapitellar articulation. The radius and humerus were mounted on a custom jig that allows for positional adjustment and incorporates a material testing machine. Each specimen was mounted at neutral forearm position and tested at 30, 45, and 60 degrees of anatomical elbow flexion. All specimens were subjected to 10 mm of anterior–posterior displacement for 5 cycles at 20 mm per minute with 40 N of compressive load. Subluxation force, displacement at subluxation force, linear stiffness, stability ratio, and energy absorbed were calculated. Results: In all degrees of elbow flexion, the stability ratio in the posterior direction was significantly higher than the anterior direction by an average of 39.8 ± 32.6% (p < 0.025). Maximum subluxation force was also significantly higher in the posterior direction when compared to the anterior direction (p < 0.027). There was no significant difference in any other parameters. Conclusions: The stability ratio and maximum subluxation force of the radiocapitellar joint when positioned in neutral forearm rotation are significantly greater in the posterior direction when compared to the anterior direction. This finding provides quantitative insights and a biomechanical rationale for the propensity of anterior instability in the radiocapitellar joint.

This retrospective study examined the relationship between the clavicle cortical index (CCI) and dual-energy X-ray absorptiometry (DEXA) bone mineral density (BMD). Data from patients undergoing elective spine and hip surgeries were reviewed, focusing on the bilateral clavicles on chest radiographs. Clavicles were divided into distal, middle-distal, middle-proximal, and proximal. Cortical and trabecular thicknesses were measured in these sections, and the CCI was calculated as (cortical + trabecular)/trabecular bone. The Pearson correlation coefficients were used to assess the CCI and BMDs in the proximal femur, lumbar spine, and distal radius. Receiver operating characteristic (ROC) curve analysis was used to assess the predictive value of the CCI for osteoporosis (BMD < 70%) and Hounsfield units. The study included 219 patients (mean age, 68.03 years). Mild but significant correlations were found between the bilateral middle-distal CCI and BMD in the radius (r = 0.409), with weaker correlations in the femur (r = 0.313) and spine (r = 0.209). ROC analyses for osteoporosis diagnosis were moderately accurate: 0.69 (0.55–0.83, femur), 0.716 (0.57–0.861, spine), and 0.834 (0.737–0.931, radius). The area under the curve for the Hounsfield units was 0.74 (0.55–0.89). The middle-distal CCI showed a correlation with BMDs, especially in the radius. The easy calculation of CCI using routine chest radiographs makes it a valuable osteoporosis screening tool.Supplementary InformationThe online version contains supplementary material available at 10.1038/s41598-025-22597-9.

Apex Posterior Overcorrection of the Ulna Increases Radial Head Stability in Anterior Monteggia Fractures: An In Vitro Biomechanical Study.

Accurate preoperative planning is essential for the treatment of complex fractures, but the proportion of patients who have access to this service remains low. Therefore, the purpose was to evaluate the association of computer-assisted preoperative planning via digital telemedicine with the risk of postoperative in-hospital complications for periarticular fractures of the extremities. A multicenter retrospective cohort study was performed from January 2010 to December 2019. A total of 11192 patients (≥18years) with periarticular fractures of the extremities (proximal humerus, distal humerus, distal radius, intertrochanteric, distal femur, tibial plateau, distal tibia, and trimalleolar) were identified and divided into 2 cohorts: 7130 (63.7%) patients received conventional preoperative planning and 4062 (36.3%) patients received computer-assisted preoperative planning via telemedicine. Propensity score matching for 23 baseline characteristics yielded 4050 patient pairs. Primary outcome was in-hospital complications (surgical site infection, urinary tract infection, pneumonia, sepsis, thromboembolic event, stroke, and myocardial infarction). Among 11192 unadjusted patients, the mean (SD) age was 60.2 (12.3) years, and 7052 (63.0%) were female. After propensity score matching (total 8100 patients, 4050 patients in each group), patients with computer-assisted preoperative planning via telemedicine had the lower in-hospital complications (7.9% [318/4050 patients] vs.10.9% [442/4050 patients]; hazard ratio, 0.72 [95% CI, 0.59 to 0.89]; P=0.002) compared with those with conventional method. For patients undergoing complex periarticular fractures of the extremities, the use of computer-assisted preoperative planning via digital telemedicine was associated with lower incidence of in-hospital complications compared with the use of conventional method.

Forensic age estimation is of critical legal importance. This study aimed to assess the utility of ultrasonography (US) as an alternative, safe, non-invasive technique that could replace other roentgenographic modalities in forensic age estimation. Epiphyseal maturation staging of the upper and lower ends of the radius and ulna using US was conducted for 155 Egyptian juveniles and adolescents, showing a mean age of 15.8 ± 3.7 years. Above the age of 17, all females demonstrated complete epiphyseal closure of the proximal bone ends, and above the age of 18, the distal end of ulna was completely united. All males demonstrated complete epiphyseal union of the proximal ulna above 17 years, the proximal radius above 18 years, and distal ulnas above 20 years. A proposed model. [Formula: see text] using a novel total score assessing epiphyseal maturation of all forearm bones could significantly explain 85.6% of age variations, with very low error, where the predicted age deviates from the real age by approximately 1.0 to 1.2 years. We observed a substantial to near-perfect agreement between the estimated and chronological age (coefficients>0.879). The overall score has the highest accuracy in predicting the ages of 15, 16, 17, and 18 years (p < 0.001). Females showed accelerated epiphyseal maturation compared to males, and the proximal forearm bones approached full maturation before the distal ends. Using the proposed novel score assessing the proximal and distal ends of the ulna and radius through US offers a simple and radiation-free approach that could predict age with precision.

Research Type: Level 3 - Retrospective cohort study, Case-control study, Meta-analysis of Level 3 studies Introduction/Purpose: Distal radius fractures, proximal femur fractures, and ankle fractures are among the most frequently encountered fractures in adult orthopedic surgery. While the work Relative Value Unit (wRVU) system aims to quantify and standardize the value of physician services based on the effort, skill, and time required for different procedures, discrepancies in wRVU allocation among different fracture types remain a topic of concerns, suggesting that it may not reflect physician compensation appropriately. This study aims to evaluate the adequacy of compensation across these three common fractures using the National Surgical Quality Improvement Program (NSQIP) database, with a particular focus on assessing potential undercompensating in ankle fracture management. Methods: The NSQIP database (2020–2022) was used to analyze distal radius, proximal femur, and ankle fractures identified by CPT codes. The ankle fracture group included open reduction and internal fixation (ORIF) for unimalleolar, bimalleolar, and trimalleolar fractures (CPT 27792, 27766, 27814, 27822, 27823, 27829), excluding pilon fractures. Procedures with fewer than 150 cases over three years were excluded. Proximal femur fractures included ORIF and hemiarthroplasty for femoral neck, intertrochanteric/subtrochanteric, and greater trochanter fractures (CPT 27236, 27244, 27245, 27248). All ORIF cases for distal radius fractures were included (CPT 25607, 25608, 25609). Compensation adequacy was assessed using wRVUs, operative time (OT), wRVU/hour, and reimbursement rates ($/hour). Postoperative complications within 30 days, including mortality, readmission, reoperation, and secondary complications (wound issues, infections, thromboembolic, respiratory, renal, and cardiac events), were analyzed to compare procedural risk profiles. Additionally, covariance analysis was conducted to adjust for the effect of complication rates on compensation adequacy. Results: Total 79,336 cases were identified, including 15,507 ankle fractures, 51,955 proximal hip fractures, and 11,874 distal radius fractures. Compared to other fractures, ORIF for ankle fractures had a significantly longer operative time (OT) (89.16 vs. 65.32 vs. 71.21 minutes, P&lt;.001) and lower mean wRVU (10.29 vs. 17.94 vs. 11.55, P&lt;.001) and wRVU/hour (10.37 vs. 21.66 vs. 11.393, P&lt;.001). These trends persisted after adjusting for the rates of complication (mortality, readmission, reoperation, wound complications, and thromboembolic events). Post-hoc analysis confirmed that ankle fractures had significantly lower wRVU and wRVU/hour, as well as longer OT, compared to proximal hip and distal radius fractures. Mortality, readmission, and reoperation rates were highest in the proximal hip fracture group, while wound complication rates were highest in the ankle fracture group. Conclusion: Our review indicates that the current wRVU system may not fully account for the surgical workload involved in ankle fracture management compared to proximal femur and distal radius fractures. Although ankle fracture fixation required significantly longer operative times, its wRVU/hour remained significantly lower. While variations in complication rates could contribute to differences in wRVU allocation, even after adjusting for these factors, the ankle fracture group continued to exhibit disproportionately lower wRVU/hour and extended operative duration. These findings suggest a potential need for revisions to the wRVU scale to better align compensation with surgical effort for ankle fracture fixation. Comparative Analysis of work Relative Value Units in Surgical Treatment of Common Orthopaedic Fractures: Ankle Fractures vs Distal Radius Fractures vs Proximal Hip Fractures

Bone graft augmentation of comminuted radial neck fractures improves the initial stability of plate fixation. A biomechanical study.

A 17-year-old adolescent boy with a history of right elbow septic arthritis and osteomyelitis in infancy presented with elbow contracture. He underwent modified Outerbridge-Kashiwagi procedure and radial shortening osteotomy, guided by a 3-dimensional (3D)-printed patient-specific model for preoperative planning and intraoperative reference. At 2 years 8 months postoperatively, range of motion improved by 40° in flexion-extension and 60° in rotation. Transient posterior interosseous nerve (PIN) palsy resolved within 6 months. Infantile elbow infection may cause functional impairment. 3D-assisted modified Outerbridge-Kashiwagi procedure improved motion. Surgeons should be cautious of PIN injury during proximal radius surgery.

ObjectiveRadial neck fractures in children can easily become complicated if not managed properly. Percutaneous reduction using the leverage technique with or without internal fixation with a Kirschner wire (K-wire) is a minimally invasive approach for treating angulated radial neck fractures in children. The study aims to evaluate the radiological and clinical outcomes of percutaneous leverage reduction assisted by elbow arthrography for pediatric radial neck fractures.MethodsFrom January 2016 to June 2020, we treated 47 children with angulated radial neck fractures, including 35 boys and 12 girls. The patient's age ranged from 2 to 13 years, with an average age of 6 years 9 months. According to Judet classification, 21 cases were classified as Type III, 15 cases as Type IVa and 11 cases as Type IVb. To overcome the difficulty of reduction caused by the absence of the ossified radial head centers in young children, we used intraoperative elbow arthrography to assist with the reduction. After achieving satisfactory reduction, one or two K-wires were inserted percutaneously to fix the fracture site and prevent reduction loss.ResultsAll cases were followed up for an average of 43 months, ranging from 24 months to 90 months. No radial head necrosis or synostosis of the proximal ulna and radius was observed during the long-term follow-up. No epiphyseal arrest or valgus of the elbow was noted at the end of the follow-up. According to the Metaizeau reduction classification, 42 cases were rated excellent, and 5 cases as good. Based on the Metaizeau clinical classification, 45 cases were excellent and 2 were good.ConclusionClosed reduction assisted by intraoperative elbow arthrography, combined with percutaneous leverage technique and internal fixation with K-wires, achieved satisfactory reduction and functional outcomes in children with angulated radial neck fractures, even in cases where the radial head ossification centers were not yet visible.

To investigate the surgical technique and preliminary effectiveness of closed reduction and internal fixation (CRIF) using antegrade elastic intramedullary nailing (ESIN) via a novel approach through the proximal radius for treating distal radius metaphyseal-diaphyseal junction (DRMDJ) fractures in children. A retrospective analysis was conducted on 34 children with DRMDJ fractures who met the selection criteria and were treated between January 2020 and June 2023. There were 21 boys and 13 girls, aged 6-14 years (mean, 8.2 years). Injury causes included falls in 11 cases and sports-related trauma in 23 cases. Twenty-six cases were associated with ipsilateral distal ulnar fractures. All patients had failed initial closed reduction in the outpatient clinic. The time from injury to operation ranged from 1 to 15 days (mean, 4 days). All patients underwent CRIF using antegrade ESIN inserted via a novel approach at the proximal one-third of the radius. The operation time, intraoperative fluoroscopy frequency, fracture healing time, and complications were recorded. Fracture reduction was assessed immediately after operation on anteroposterior and lateral X-ray films for residual translation and angulation. Wrist function was evaluated using the modified Mayo wrist score. Surgery was successfully completed in all 34 children. CRIF with ESIN failed in 2 cases with associated ipsilateral distal ulnar fractures, requiring conversion to open reduction of the ulna. Operation time ranged from 15 to 56 minutes (mean, 21 minutes). Intraoperative fluoroscopy frequency ranged from 5 to 21 times (mean, 7 times). Immediate postoperative X-ray films showed residual translation of 0-15% on anteroposterior view and 0-10% on lateral view, and residual angulation of 0°-5° on both anteroposterior and lateral views. All children were followed up 6-18 months (mean, 12 months). There was no complication such as neurovascular injury, incision infection, or limitation of forearm rotation. Follow-up X-ray films showed no fracture displacement, implant loosening, delayed union, or nonunion. Fracture healing time ranged from 4 to 8 weeks (mean, 6 weeks). Implants were removed at 4-6 months postoperatively (mean, 5 months). At last follow-up, all fractures had achieved anatomic or near-anatomic healing. The modified Mayo wrist score ranged from 80 to 100 (mean, 94), with 27 excellent and 7 good results, yielding an excellent and good rate of 100%. CRIF using antegrade ESIN via a novel approach through proximal radius is a safe and effective treatment for pediatric DRMDJ fractures, associated with few postoperative complications and excellent restoration of wrist function.

BackgroundThis study evaluates the accuracy of an Artificial Intelligence (AI) system, specifically a convolutional neural network (CNN), in classifying elbow fractures using the detailed 2018 AO/OTA fracture classification system.MethodsA retrospective analysis of 5,367 radiograph exams visualizing the elbow from adult patients (2002–2016) was conducted using a deep neural network. Radiographs were manually categorized according to the 2018 AO/OTA system by orthopedic surgeons. A pretrained Efficientnet B4 network with squeeze and excitation layers was fine-tuned. Performance was assessed against a test set of 208 radiographs reviewed independently by four orthopedic surgeons, with disagreements resolved via consensus.ResultsThe study evaluated 54 distinct fracture types, each with a minimum of 10 cases, ensuring adequate dataset representation. Overall fracture detection achieved an AUC of 0.88 (95% CI 0.83–0.93). The weighted mean AUC was 0.80 for proximal radius fractures, 0.86 for proximal ulna, and 0.85 for distal humerus. These results underscore the AI system’s ability to accurately detect and classify a broad spectrum of elbow fractures.ConclusionsAI systems, such as CNNs, can enhance clinicians’ ability to identify and classify elbow fractures, offering a complementary tool to improve diagnostic accuracy and optimize treatment decisions. The findings suggest AI can reduce the risk of undiagnosed fractures, enhancing clinical outcomes and radiologic evaluation.Supplementary InformationThe online version contains supplementary material available at 10.1186/s12891-025-09161-2.

Ankle, distal radius, and proximal femur fractures are among the top three most common fractures. Despite the high prevalence and cost of these fractures, the relative valuation of these common fractures within the current US healthcare system has not been evaluated. This study aims to evaluate whether ankle fracture fixation is adequately compensated for in the hospital setting compared with distal radius and proximal femur fractures, using the National Surgical Quality Improvement Program database. Ankle, distal radius, and proximal femur fracture fixations were identified within the National Surgical Quality Improvement Program database from 2020 to 2022 using Current Procedural Terminology codes. The relative valuation between the three fracture fixations was assessed using operative time, work relative value units (wRVUs), wRVU per hour (wRVU/hr), and reimbursement rates ($/hr). A propensity score-matched analysis was performed including age (±2 years) and sex with the ankle fracture group as a reference. Two matched cohorts were constructed: ankle and (1) proximal femur fracture and (2) distal radius fracture. Covariance analysis including postoperative complications and preoperative comorbidities were performed to adjust for their effect on the valuation of compensation metrics. A total of 15,507 ankle fractures, 51,955 proximal hip fractures, and 11,874 distal radius fractures were included. Compared with other fractures, ankle fracture fixation had a significantly longer operative time (89.16 minutes for ankle vs. 65.32 for proximal hip vs. 71.21 for distal radius; respectively, P < 0.001), lower mean wRVU (10.29 vs. 17.94 vs. 11.55, P < 0.001), wRVU/hr (10.37 vs. 21.66 vs. 11.393, P < 0.001), and reimbursement rate (335.32 vs. 700.75 vs. 385.94, P < 0.001). These trends persisted after adjusting for the rates of preoperative comorbidities and postoperative complication as in propensity score-matched analysis. Our findings suggest that ankle fracture fixation is undervalued in the current wRVU system, pointing to the need to reevaluate wRVU allocation more accurately for the surgical treatment in ankle fracture. Level III.

Comparative evaluation of posterior interosseous nerve strain in lateral approach to radial head fixation: a cadaveric study.

Elderly patients with severe osteoporosis present significant challenges in managing multiple concomitant upper extremity fractures, especially when high-energy trauma is involved. The rarity of such cases necessitates a structured approach to achieve optimal outcomes, balancing surgical intervention and early rehabilitation. A 79-year-old woman presented to the emergency department following a severe car accident. She had multiple concomitant fractures, including those of the proximal humerus, proximal ulna, and open fractures of the radius in the ipsilateral upper extremity, as well as multiple organ injuries involving the brain, lung, and liver. The patient was diagnosed with an open fracture of the right proximal radius, a comminuted intra-articular fracture of the proximal ulna, and comminuted intra-articular fractures of the right proximal humerus involving the glenoid and coracoid. Additionally, non-displaced fractures of the left distal clavicle and left sacral body, and minimally displaced fractures of both the superior and inferior rami of the pelvis were confirmed. The patient underwent hemiarthroplasty for the shoulder fracture due to severe comminution, open reduction and internal fixation for the proximal ulna, and intramedullary nailing for the radius. Post-operative management included the sequential administration of teriparatide and denosumab to support bone healing and facilitate early rehabilitation. The patient had a relatively short hospital stay of 5 days and showed favorable outcomes, with early callus formation and bone union confirmed at 6 months. At the 1-year follow-up, the patient demonstrated satisfactory joint stability and improved bone mineral density. This case highlights the potential of combined surgical approaches and bone-strengthening therapies in achieving effective outcomes in elderly polytraumatized patients. Sequential administration of teriparatide and denosumab may be beneficial for promoting bone healing in severe osteoporotic fractures.Level of evidence: Level V, case report.

Prediction of iliac limb occlusion after endovascular aneurysm repair for abdominal aortic aneurysm by anatomical and near-wall hemodynamic characteristics combining numerical simulation and in vitro experiment.

Global ageing has led to a rise in osteoporosis1 and fragility fractures, which are fractures that occur due to low-energy trauma. Upper limb fragility fractures, particularly proximal humerus and distal radius fractures, are known risk factors for future hip fractures.2 Clinical guidelines recommend secondary preventive assessments and interventions after any fragility fracture. These include fall risk evaluation, lifestyle modifications, calcium and vitamin D supplementation, and bone mineral density (BMD) testing to detect and guide osteoporosis treatment.3 However, implementation rates of secondary prevention after upper limb fractures remain poorly studied.

Biomechanical comparison of 2.4-mm locking compression plating radial head plate and tripod fixation in Mason type III radial head fractures: a human cadaveric study.

Abstract Gallbladder cancer (GBC) is a relatively rare cancer associated with poor prognosis due to early direct invasion of adjacent structures and nodal metastasis. Isolated bone metastasis is rarely reported and only a few cases are available in literature. A 42-year-old female presented with forearm pain and mass for 3 months duration. She had undergone open cholecystectomy 4 years ago for cholelithiasis. Excision biopsy with decompression of posterior interosseous nerve showed metastatic adenocarcinoma deposit in bone. Fludeoxyglucose (FDG) avid soft-tissue thickening in postoperative bed along with FDG avid cortical erosion in the left occipital bone and lytic sclerotic lesion in left proximal radius was noted. The patient was started on palliative chemotherapy with gemcitabine and cisplatin. Diagnosis with GBC portends dismal prognosis due to local spread and distant metastasis. Metastasis is common to the liver and regional nodes. Isolated bone metastasis is extremely rare.