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The one bone forearm is a salvage procedure for treatment of painful, instability of the forearm that results from trauma, congenital deformity, tumor, infection, and failed reconstructive efforts. By creating a stable osseous bridge between the ulnohumeral and radiocarpal joints, one bone forearm addresses defects in the bony architecture of the radius and ulna, their articulations, and their associated ligamentous complexes. Global instability of the forearm is a complex clinical pathology with few other answers. Choice of technique should be dictated by adjacent bone loss. This article presents experience with creating a one bone forearm in patients using synostosis procedures.

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Bridge plate fixation has traditionally been described for the treatment of high-energy distal radius fractures with extensive comminution, associated instability, and polytrauma with the need for immediate upper extremity assisted weight bearing. Certain patient populations who may similarly benefit from such effective and expedient stabilization include patients with multiple comorbidities who may have lower-energy fractures, poor bone quality, and a baseline reliance on ambulatory assist devices. This article reviews treatment considerations for distal radius fractures in low-demand patients and explores the rationale and technique of bridge plate fixation in this population.

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Suspected fractures are among the most common reasons for patients to visit emergency departments (EDs), and X-ray imaging is the primary diagnostic tool used by clinicians to assess patients for fractures. Missing a fracture in a radiograph often has severe consequences for patients, resulting in delayed treatment and poor recovery of function. Nevertheless, radiographs in emergency settings are often read out of necessity by emergency medicine clinicians who lack subspecialized expertise in orthopedics, and misdiagnosed fractures account for upward of four of every five reported diagnostic errors in certain EDs. In this work, we developed a deep neural network to detect and localize fractures in radiographs. We trained it to accurately emulate the expertise of 18 senior subspecialized orthopedic surgeons by having them annotate 135,409 radiographs. We then ran a controlled experiment with emergency medicine clinicians to evaluate their ability to detect fractures in wrist radiographs with and without the assistance of the deep learning model. The average clinician's sensitivity was 80.8% (95% CI, 76.7-84.1%) unaided and 91.5% (95% CI, 89.3-92.9%) aided, and specificity was 87.5% (95 CI, 85.3-89.5%) unaided and 93.9% (95% CI, 92.9-94.9%) aided. The average clinician experienced a relative reduction in misinterpretation rate of 47.0% (95% CI, 37.4-53.9%). The significant improvements in diagnostic accuracy that we observed in this study show that deep learning methods are a mechanism by which senior medical specialists can deliver their expertise to generalists on the front lines of medicine, thereby providing substantial improvements to patient care.

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PURPOSE: The Aptis total distal radioulnar joint (DRUJ) prosthesis is a semiconstrained implant designed for treatment of DRUJ arthritis and instability. The purpose of this study was to analyze short-term complications of this device. METHODS: We performed a retrospective chart review of patients undergoing semiconstrained DRUJ arthroplasty from 2007 to 2015 at a single institution. Records were analyzed for complications and the need for subsequent surgical procedures. RESULTS: Two senior hand surgeons at one institution performed 52 semiconstrained DRUJ arthroplasties over 8 years. Nineteen complications necessitating operative management occurred in 15 patients (29%). A total of 26 procedures were undertaken to address these complications. Complications included 4 periprosthetic fractures, 3 infections, 2 instances of aseptic loosening, 2 implant component failures, 1 instance of screw loosening, 3 neuromas requiring neurectomy, 2 instances of finger stiffness necessitating extensor tenolysis, and 2 cases of heterotopic ossification at the DRUJ. Three of the 52 implants were revised (6%) and 2 were explanted (4%); 3 of these (6%) were caused by deep infection. CONCLUSIONS: There is limited literature on outcomes of the semiconstrained DRUJ prosthesis. Prior studies reported low complication rates, with 0% to 5% revisions. In the current clinical series, 29% of patients required further surgery for complications, the most common reasons for which were periprosthetic fracture and infection. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic IV.

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BACKGROUND: The pedicled latissimus flap has been shown to provide effective coverage of wounds around the elbow with an average size of 100 to 147 cm2 but with complication rates of 20% to 57%. We believe the pedicled latissimus dorsi flap is an effective and safe technique that provides reliable and durable coverage of considerably larger soft tissue defects around the elbow and proximal forearm. METHODS: A retrospective review was performed including all patients from Harborview Medical Center between 1998 and 2012 who underwent coverage with pedicled latissimus dorsi flap for defects around the elbow. Demographic information, injury mechanism, soft tissue defect size, complications (minor vs major), and time to surgery were collected. The size of the soft tissue defect, complications, and successful soft tissue coverage were the primary outcome measures. RESULTS: A total of 18 patients were identified with variable mechanisms of injury. Average defect size around the elbow was 422 cm2. Three patients had partial necrosis of the distal most aspect of the flap, which was treated conservatively. One patient required a secondary fasciocutaneous flap, and another required conversion to a free latissimus flap secondary to venous congestion. Two were lost to follow-up after discharge from the hospital. In all, 88% (14 of 16) of the patients had documented (>3-month follow-up) successful soft tissue coverage with single-stage pedicled latissimus dorsi flap. CONCLUSIONS: The pedicled latissimus dorsi flap is a reliable option for large and complex soft tissue injuries around the elbow significantly larger than previous reports. However, coverage of the proximal forearm remains challenging.

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PURPOSE: To investigate the impact of the Orthopaedic Surgery and Sports Medicine Interest Group (OSSMIG) on medical student interest and confidence in core musculoskeletal (MSK) concepts through supplemental education and experiences at a single tertiary, academic institution. METHODS: Medical student OSSMIG members at various levels of training were anonymously surveyed at the beginning and end of the 2014-2015 academic year. RESULTS: Eighteen (N=18) medical student interest group members completed the survey. Significant improvement in their level of training was observed with regard to respondents' self-assessed competence and confidence in MSK medicine (p<0.05). Additionally, respondents' attitudes toward exposure and support from the interest group were significantly higher than those provided by the institution (p<0.05). Members believed OSSMIG increased interest in MSK medicine, improved confidence in their ability to perform orthopedics-related physical exams, strengthened mentorship with residents and attendings, and developed a connection with the Department of Orthopedic Surgery and its residents (median "Strongly Agree", interquartile range one and two scale items). CONCLUSION: Since its inception 8 years ago, OSSMIG has been well received and has positively impacted University of Washington School of Medicine students through various interventions. Surgical interest groups should target both the students interested in primary care and surgery. Medical schools can provide additional exposure to MSK medicine by leveraging interest groups that provide early clinical experiences and supplementary instruction.

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Postburn contractures of the elbow are uncommon debilitating sequelae of severe burn injuries, which result from thermal injury to both deep and superficial tissues. When periarticular heterotopic bone forms in association with burn injuries, severe and rigid contractures may develop that prohibit basic functions of daily living and are often refractory to nonoperative intervention. Surgical intervention is aimed at releasing or excising all pathologic anatomy limiting elbow motion. In patients with proper indications, surgical intervention can result in substantial improvement in elbow motion, allowing patients to return to activities of daily living, employment, and recreational activities.

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PURPOSE: To determine the functional outcomes of patients treated with dorsal spanning distraction bridge plate fixation for distal radius fractures. METHODS: All adult patients at our institution who underwent treatment of a unilateral distal radius fracture using a dorsal bridge plate from 2008 to 2012 were identified retrospectively. Patients were enrolled in clinical follow-up to assess function. Wrist range of motion, grip strength, and extension torque were measured systematically and compared with the contralateral, uninjured wrist. Patients also completed Quick-Disabilities of the Arm, Shoulder, and Hand and Patient-Rated Wrist Evaluation outcomes questionnaires. RESULTS: Eighteen of 100 eligible patients, with a minimum of 1 year from the time of implant removal, were available for follow-up (mean, 2.7 y). All fracture patterns were comminuted and intra-articular (AO 23.C3). There were significant decreases in wrist flexion (43° vs 58°), extension (46° vs 56°), and ulnar deviation (23° vs 29°) compared with the contralateral uninjured wrist. Grip strength was 86% and extension torque was 78% of the contralateral wrist. Comparison of dominant and nondominant wrist injuries identified nearly complete recovery of grip (95%) and extension (96%) strength of dominant-sided wrist injuries, compared with grip (79%) and extension (65%) strength in those with an injured nondominant wrist. Mean Quick-Disabilities of the Arm, Shoulder, and Hand and Patient-Rated Wrist Evaluation scores were 16 and 14, respectively. There were 2 cases of postoperative surgical site pain and no cases of infection, tendonitis, or tendon rupture. CONCLUSIONS: Distraction bridge plate fixation for distal radius fractures is safe with minimal complications. Functional outcomes are similar to those published for other treatment methods. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic IV.

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Volar locking plates have provided surgeons with enhanced capability to reliably repair both simple and complex fractures and avoid the hardware-related complications associated with dorsal plating. However, there have been an increasing number of published reports on the frequency and types of complications and failures associated with volar locked plating of distal radius fractures. An informed, critical assessment of distal radius fracture characteristics will allow surgeons to select an individualized treatment strategy that maximizes the likelihood of a successful outcome. Knowledge of the anatomy, patterns, and characteristics of the diverse types of distal radius fractures and the complications and failures associated with volar locked plating will be helpful to orthopaedic surgeons who treat patients with these injuries.

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Madelung deformity is a rare congenital anomaly of the wrist caused by asymmetric growth at the distal radial physis secondary to a partial ulnar-sided arrest. The deformity is characterized by ulnar and palmar curvature of the distal radius, positive ulnar variance, and proximal subsidence of the lunate. It more commonly occurs in females than males and typically affects both wrists. The deformity can occur in isolation or as part of a genetic syndrome. The pattern of inheritance varies, with some cases following a pseudoautosomal pattern and many others lacking a clear family history. Nonsurgical management is typically advocated in asymptomatic patients. Few studies exist on the natural history of the condition; however, extensor tendon ruptures have been reported in severe and chronic cases. Stiffness, pain, and patient concerns regarding wrist cosmesis have been cited as indications for surgery. Various techniques for surgical management of Madelung deformity have been described, but clear evidence to support the use of any single approach is lacking.

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Complex distal radius fractures are high-energy injuries of the wrist with articular disruption, ligamentous instability, significant comminution, soft tissue injury, and/or neurovascular impairment. The management of these injuries requires a thorough understanding of wrist functional anatomy and familiarity with a wide selection of approach and fixation options. This article reviews an approach that involves structured evaluation, aggressive soft tissue management, early reduction and skeletal stabilization, and a columnar approach to definitive care. Outcome is determined by multiple factors and depends greatly on the soft tissue injury, patient factors, and management and the adequacy of restoration of osseous and ligamentous relationships.

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A 5-month-old previously healthy girl presented to the emergency department with a large palpable nontender mass in the hypothenar soft tissues of her left hand. US revealed a well-demarcated nonvascular soft tissue mass. Subsequent MR imaging showed a rim-enhancing mass with heterogeneous intrinsic signal characteristics. Abscess and necrotic tumor were the primary considerations. Surgery demonstrated a thrombosed aneurysm continuous with the ulnar artery system. The aneurysm was resected and the ulnar artery was ligated at the wrist.

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BACKGROUND: Functional loss of motion is a frequent complication after elbow trauma. The purpose of this study was to determine the effectiveness of open elbow release in restoring functional elbow motion. METHODS: A retrospective chart review of 177 adult patients who underwent open elbow release at our institution by the senior surgeon (D.P.H.) from 2003 to 2010 was performed. Seventy-seven of the elbow contracture releases were performed for posttraumatic elbow stiffness, with loss of flexion-extension. Burns and isolated proximal radioulnar exostosis resections were excluded. The mean age of patients was 45 years (range, 20-76 years), with 68 patients demonstrating radiographic evidence of heterotopic ossification (HO). The mean preoperative flexion-extension arc was 51 degrees. All patients were treated with the same surgical protocol, which included circumferential elbow capsulectomy, HO excision, hardware removal, and ulnar nerve neurolysis with submuscular anterior transposition. RESULTS: At a mean follow-up of 12 months (range, 3-56 months), the mean elbow flexion-extension arc was 109 degrees representing a mean gain of 58 degrees. Sixty-nine percent (53 of 77 patients) achieved a minimum 100-degree functional elbow arc of motion. Six patients (8%) developed recurrent HO, with four undergoing secondary HO excision. One additional patient required manipulation under anesthesia in the early postoperative period. Complications included five infections, one postoperative fracture, one postoperative hematoma, and one radial head implant loosening. CONCLUSION: Open elbow contracture release and HO excision is an effective means of restoring functional elbow range of motion with a low complication rate. Furthermore, recurrent HO formation and elbow arthrofibrosis respond well to repeat surgical excision and contracture release. LEVEL OF EVIDENCE: IV, therapeutic study.

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The distal radioulnar joint (DRUJ) is a complex articulation allowing significant rotational and translational motion. Stability of the DRUJ depends on bony contact, intrinsic stabilizers of the triangular fibrocartilage complex, and extrinsic stabilizers of the distal forearm. Understanding the anatomy of this articulation is paramount in clinical decision making for the treatment of disorders involving the DRUJ.

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PURPOSE: To evaluate internal distraction plating for the management of comminuted, intra-articular distal radius fractures in patients greater than 60 years of age at two level 1 trauma centers. We specifically desired to determine whether patients would have acceptable results from the clinical standpoint of range of motion, Disabilities of the Arm, Shoulder, and Hand (DASH) score, and the radiographic measurements of ulnar variance, radial inclination, and palmar tilt. Our hypothesis was that distraction plating of comminuted distal radius fractures in the elderly would result in acceptable outcomes regarding range of motion, DASH score, and radiographic parameters and would, thereby, provide the upper extremity surgeon with another option for the treatment of these fractures. METHODS: A retrospective review was performed on 33 patients over 60 years of age with comminuted distal radius fractures treated with internal distraction plating at two level 1 trauma centers. Patients were treated with internal distraction plating across the radiocarpal joint. At the time of final follow-up, radiographs were evaluated for ulnar variance, radial inclination, and palmar tilt. Range of motion, complications, and DASH scores were also obtained. RESULTS: We treated 33 patients (mean age, 70 y) with distraction plating for comminuted distal radius fractures. At final follow-up, all fractures had healed, and radiographs demonstrated mean palmar tilt of 5° and mean positive ulnar variance of 0.6 mm. Mean radial inclination was 20°. Mean values for wrist flexion and extension were 46° and 50°, respectively. Mean pronation and supination were 79° and 77°, respectively. At final follow-up, the mean DASH score was 32. CONCLUSIONS: In the elderly, distraction plating is an effective method of treatment for comminuted, osteoporotic distal radius fractures. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic IV.

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The purpose of this retrospective cohort comparison study was to determine the effect of ulnar collateral ligament reconstruction on postoperative range of motion (ROM) in patients undergoing posttraumatic elbow contracture release. Twenty-four consecutive patients underwent elbow arthrolysis. Six patients also underwent simultaneous collateral ligament excision and reconstruction, and 18 did not require ligament excision. All patients followed the same postoperative rehabilitation program. Minimum follow-up was 12 months. Final flexion/extension ROMs were similar in both groups. No subjective reports of postoperative elbow instability occurred in either group. Ligament reconstruction and early postoperative motion can be safely performed in the setting of posttraumatic elbow capsulectomy without sacrificing ROM gain or compromising stability provided by the ligament reconstruction.

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Elbow arthrodesis (EA) is a procedure reserved for the salvage of failed elbow reconstruction or elbow injuries that defy reconstruction of a useful joint. Although arthrodesis of some joints is often straightforward and predictable, EA is technically difficult and associated with a high rate of complications. Furthermore, a successful EA does not translate to a gratifying clinical success. The functional limitations to activities of daily living and personal care are significant.

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