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We present the case of a 47-year-old patient with a congenital positive ulnar variance and elucidate its effects on nearby structures in relation to ulnocarpal abutment syndrome (UAS). While magnetic resonance imaging (MRI) helped to identify soft tissue changes in the wrist, the use of an arthrogram, in this case, allowed for a more comprehensive and detailed analysis of the ligaments and soft tissues. Image findings included a complex degenerative tear of the disc of the triangular fibrocartilage (TFCC), a degenerated triquetrum, and partial tears of the scapholunate and lunotriquetral ligaments. Mild dorsal angulation of the lunate was noted, representing dorsal intercalated segmental instability (DISI), suggesting scapholunate ligament injury. Palmar classification was utilized to classify the extent of the TFCC injury as Type IIE. This case shines a light on the presentation of UAS in a patient that was not the usual demographic affected by this pathology, as well as their UAS affecting the triquetrum rather than the more commonly associated lunate.

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BACKGROUND: Vascular injuries of the upper extremities are considered relatively rare injuries affecting mostly the young population. They often are complex injuries accompanied by other musculoskeletal trauma or trauma in other anatomic locations. Their management is challenging since they can lead to disabilities with major socioeconomic effects. AIM: To analyze data about the mechanism of injury, the management algorithm and functional outcomes of vascular injuries of the upper extremity. METHODS: One hundred and fifteen patients (96 males and 19 females) with arterial injuries of the upper extremity treated in a tertiary trauma center from January 2003 to December 2022 was conducted. Mean patients' age was 33.7 years and the mean follow up time was 7.4 years. Patients with Mangled Extremity Severity Score ≥ 7 and Injury Severity Score ≥ 20, previous upper limb surgery or major trauma and any neuromuscular or psychiatric disease were excluded, from the study. RESULTS: A penetrating trauma was the most common cause of injury. The radial artery was the artery injured in most of the cases (37.4%) followed by the ulnar (29.5%), the brachial (12.1%) and the axillary (6%). A simultaneous injury of both of the forearm's arteries was in 15.6% of the cases. In 93% of the cases there were other concomitant musculoskeletal injuries of the extremity. Tendon lacerations were the most common, followed by nerve injuries. The postoperative functional scores (full Disabilities of the Arm, Shoulder, and Hand and VAS) had very satisfactory values. CONCLUSION: Although vascular injuries of the upper extremity are rare, they may occur in the context of major combined musculoskeletal trauma. Although a multidisciplinary approach is essential to optimize outcome, the ability of trained hand surgeons to repair all injuries in combined vascular and musculoskeletal upper extremity trauma, excluding isolated vascular injuries, ensures shorter operative times and better functional outcomes.

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Injuries to the scapholunate interosseous ligament (SLIL) complex can result in a predictable cascade of incongruous motion in the carpus that leads to radiocarpal degeneration. Both acute traumatic impact and repetitive motion can render the SLIL insufficient. A thorough understanding of SLIL anatomy is required for appropriate diagnosis and treatment. Here, we review scapholunate ligament anatomy, prevention strategies, methods of diagnosis, nonoperative and operative treatments, and outcomes. A myriad of treatment options exist for each stage of the SLIL injury, and management should be an open discussion between the patient and physician.

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Triangular fibrocartilage complex injuries are common in amateur and professional sports. These injuries are mainly caused by acute or chronic repetitive axial loads on the wrist, particularly on the ulnar side and in association with rotations or radial/ulnar deviations. In order to treat professional athletes, a detailed specific knowledge of the pathology is needed. Moreover, the clinician should fully understand the specific and unique environment and needs of the athletes, their priorities and goals, the type of sport, the time of the season, and the position played. An early diagnosis and appropriate management with the quickest possible recovery time are the uppermost goals for both the athlete and the surgeon. A compromise between conservative vs surgical indications, athletes' needs and expectations, and financial implications should be achieved. Arthroscopic procedures should be timely planned when indicated as they could allow early diagnosis and treatment at the same time. Conservative measures are often used as first line treatment when possible. Peripheral lesions are treated by arthroscopic repair, whilst central lesions are treated by arthroscopic debridement. Further procedures (such as the Wafer procedure, ulnar osteotomies, etc.) have specific indications and great implications with regard to rehabilitation.

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Soft tissue defects of the hand may result from trauma, infection, vascular disease, and after resection of tumors. Microsurgery has evolved to a stage where it is relatively commonplace today but procedures such as free flaps still incur significant time, manpower, cost, and material resources. The aim of this article is to articulate the specific situations in hand reconstruction when microsurgery is superior to nonmicrosurgical reconstructive options. The benefits of microsurgical reconstruction include a variety of important metrics, such as improved function, better tissue match, less donor site morbidity, and reduced downtime for the patient.

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Injury to the triangular fibrocartilage complex (TFCC) may result in ulnar wrist pain with or without instability. One component of the TFCC, the radioulnar ligaments, serve as the primary soft-tissue stabilizer of the distal radioulnar joint (DRUJ). Tears or avulsions of its proximal, foveal attachment are thought to be associated with instability of the DRUJ, most noticed during loaded pronosupination. In the absence of detectable instability, injury of the foveal insertion of the radioulnar ligaments may be overlooked. While advanced imaging techniques such as MRI and radiocarpal arthroscopy are well-suited for diagnosing central and distal TFCC tears, partial and complete foveal tears without instability may be missed without a high degree of suspicion. While technically challenging, DRUJ arthroscopy provides the most accurate method of detecting foveal abnormalities. In this annotation the spectrum of foveal injuries is discussed and a modified classification scheme is proposed.Cite this article: Bone Joint J 2023;105-B(1):5-10.

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Distal oblique bundle (DOB) reinforcement for treatment of post-traumatic bidirectional instability of the distal radioulnar joint (DRUJ) has previously been reported. The objective of the current study was to assess the incidence of symptomatic graft failure and the need for secondary wrist procedures at a longer follow-up in an updated patient cohort of 27 patients with 28 DOB reinforcement procedures. Quick Disabilities of the Arm, Shoulder and Hand (QuickDASH) and patient-rated wrist/hand evaluation (PRWHE) outcome measures were also evaluated. At median 82 months follow-up, pre- to postoperative QuickDASH score improved from a mean of 62 (SD 14) to 31 (SD 22) (p < 0.01) and PRWHE score from a mean of 67 (SD 17) to 34 (SD 23) (p < 0.01). Symptomatic graft failure with resultant painful DRUJ instability occurred in four out of 28 procedures, which was better than the published results of alternative surgical options for DRUJ instability. DOB reinforcement presents a relatively safe, effective and durable method for treatment of post-traumatic DRUJ instability.Level of evidence: III.

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PURPOSE: The anterolateral soft tissue envelope of the knee is frequently injured at the time of ACL rupture. This study aims to investigate the MRI injury patterns to the Anterolateral complex and their associations in patients with acute 'isolated ligament' ACL ruptures. METHODS: Professional athletes who underwent ACL reconstruction for complete ACL rupture between 2015 and 2019 were included in this study. Patients' characteristics and intraoperative findings were retrieved from clinical and surgical documentation. Preoperative MRIs were evaluated and the injuries to respective structures of the Anterolateral complex and their associations were recorded. RESULTS: Anterolateral complex injuries were noted in 63% of cases. The majority of injuries were to Kaplan Fibre (39% isolated injury and 19% combined with Anterolateral ligament injury). There was a very low incidence of isolated Anterolateral ligament injuries (2%). Kaplan Fibre injuries are associated with the presence of lateral femoral condyle bone oedema, and injuries to the superficial MCL, deep MCL, and ramp lesions. High grade pivot shift test was not associated with the presence of Kaplan Fibre or Anterolateral ligament injuries. Patients with an intact Anterolateral complex sustained injury to other knee structures (13% to medial ligament complex, 14% to medial meniscus, and 16% to lateral meniscus). CONCLUSION: There is a high incidence of concomitant Anterolateral complex injuries in combination with ACL ruptures, with Kaplan Fibre (and therefore the deep capsulo-osseous layer of the iliotibial band) being the most commonly injured structure. Anterolateral ligament injuries occur much less frequently. These findings reinforce the importance of considering the presence of, and if necessary, treating injuries to structures other than the ACL, as a truly isolated ACL injury is rare.

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PURPOSE: Lack of resources, severe injuries, and logistical flaws force surgeons in low-income countries (LIC) to improvise during surgery and use implants "off-label." These off-label treatments are specific for the work of trauma surgeons in non-governmental (NGO) hospitals in LIC. The aim of this study is to show the need of off-label surgery in an environment of low resources by means of typical examples. METHODS: Off-label treated fractures, the implant used instead, and the reason for off-label treatment were investigated in 367 injuries over a three month period in an NGO hospital in Sierra Leone. RESULTS: Twenty-seven fractures were treated off-label with mostly K-wires (88.89%) and external fixators (51.85%). Three reasons for off-label use could be defined: no suitable implants (N = 14), the condition of soft tissues that did not allow internal osteosyntheses (N = 10), and implants not ready for surgery due to logistic flaws (N = 3). The implants needed were mostly locking plates. CONCLUSION: Surgeons in similar settings must use K-wires and external fixators to treat complex fractures. Using implants off-label can help surgeons to treat fractures otherwise left untreated.

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Background: We aimed to systematically review all papers examining floating elbow injuries in adults. Material and Methods: MEDLINE, Cochrane Bone, Joint and Muscle Trauma, PROSPERO, and Scopus databases were searched up to August 31, 2020. Included studies had as a primary or secondary outcome the functional outcomes after a floating elbow injury on patients aged 17 or older. Methodological quality of the included studies was assessed. Results: Thirty-two studies met the inclusion criteria. Patients were male at 73,1%. Median age of the patients was 33,0 years and median time of follow-up was 19,5 months. Articular surfaces were affected at 24,4%, whereas 51,2% of the fractures was open. Approximately, 34,9% of the patients suffered neural injury. Ipsilateral and multiple-system injuries were present in 34,8% and 76,3 % of the cases, respectively. Multivariate analysis showed that intra-articular and nerve damage, open fractures and multi-system injuries affected range of motion, union and complications. Sex, age, vascular damage and ipsilateral injuries of the patient did not adversely impact the outcome. All of the included studies were classified as very-low quality of evidence. Conclusions: The current knowledge regarding the characteristics of floating elbow in adults is limited, albeit we were able to provide possible pre-operative predictor outcomes.

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The soft tissues surrounding the spine play a primordial role in its stability, the most important of which are located posteriorly and are deemed the posterior ligamentous complex (PLC). Injuries to the PLC in the setting of thoracolumbar trauma are often dreaded and little attention has been given to them in the management protocols of thoracolumbar trauma. This review aims to summarize and contextualize current concepts in PLC injuries of the thoracolumbar spine with the aim to provide a clear guide for clinical management. Injuries to the PLC may be suspected on the clinical exam but are often missed, leading to serious complications, including instability and neurological compromise. The diagnosis is often made indirectly by spinal radiographs and CT-scanning or by direct visualization of soft tissues via magnetic resonance imaging. The latter remains the standard imaging modality and is mandatory for patients with a high suspicion of PLC injury. PLC injuries are associated with vertebral fractures and follow a progressive pattern of severity, depending on the mechanism of injury and extent of trauma. Surgical management is warranted, as PLC damage renders the spine unstable. Although fusion was once the standard of care and remains applicable for certain patients, recent endeavors of temporary spinal fixation without fusion are increasingly gaining traction in patients with PLC injuries. In conclusion, PLC injuries are challenging as they are often missed, poorly understood, and are not easily managed. Proper diagnosis and management are crucial to avoid long-standing complications such as spinal instability. Considering the paucity of available data on such an important topic in thoracolumbar trauma, this review article aims to contextualize current concepts in PLC injuries in order to demystify this sparsely covered subject.

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BACKGROUND: Microsurgical flaps are widely used to treat complex traumatic wounds of upper and lower limbs. Few studies have evaluated whether the vascular changes in preoperative computed tomography angiography (CTA) influence the selection of recipient vessel and type of anastomosis and the microsurgical flaps outcomes including complications. OBJECTIVE: The aim of this study was to evaluate if preoperative CTA reduces the occurrence of major complications (revision of the anastomosis, partial or total flap failure, and amputation) of the flaps in upper and lower limb trauma, and to describe and analyze the vascular lesions of the group with CTA and its relationship with complications. METHODS: A retrospective cohort study was undertaken with all 121 consecutive patients submitted to microsurgical flaps for traumatic lower and upper limb, from 2014 to 2020. Patients were divided into two groups: patients with preoperative CTA (CTA+) and patients not submitted to CTA (CTA-). The presence of postoperative complications was assessed and, within CTA+, we also analyzed the number of patent arteries on CTA and described the arterial lesions. RESULTS: Of the 121 flaps evaluated (84 in the lower limb and 37 in the upper limb), 64 patients underwent preoperative CTA. In the CTA+ group, 56% of patients with free flaps for lower limb had complete occlusion of one artery. CTA+ patients had a higher rate of complications (p = 0.031), which may represent a selection bias as the most complex limb injuries and may have CTA indicated more frequently. The highest rate of complications was observed in chronic cases (p = 0.034). There was no statistically significant difference in complications in patients with preoperative vascular injury or the number of patent arteries. CONCLUSIONS: CTA should not be performed routinely, however, CTA may help in surgical planning, especially in complex cases of high-energy and chronic cases, since it provides information on the best recipient artery and the adequate level to perform the microanastomosis, outside the lesion area.

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BACKGROUND: To present the outcomes of arthroscopic electrothermal shrinkage for partial scapholunate (SL) ligament tears, isolated or with associated triangular fibrocartilage complex (TFCC) injuries. METHODS: A prospective study of 20 patients with symptomatic instability of SL ligament (14 of them also with TFCC wrist injuries) treated with arthroscopic electrothermal shrinkage was conducted using a monopolar radiofrequency probe. No patient showed radiologic signs of static dissociation (mean SL interval 2.2 ± 0.6 mm; mean SL angle 41.4° ± 6.7°) before surgery. All patients underwent follow-up at our clinic regularly for an average of 50.6 months (range 29-80 months). RESULTS: The modified Mayo wrist score improved from a mean of 59 ± 17.1 points preoperatively to 88.3 ± 16.2 points at the final follow-up. At the final clinical examination, a painful Watson scaphoid shift test was found in 3 patients (15%). The mean flexion-extension arc was unchanged (132° ± 19°), and mean grip strength improved 12 kg. No patient showed radiologic signs of arthritis or instability after surgery (mean SL interval 1.9 ± 0.7 mm; mean SL angle 42.7° ± 7.3°). Of the 14 patients with combined TFCC injuries, 3 patients continued complaining of ulnar-sided point tenderness. At the end of the follow-up, 80% of the subjects were satisfied or very satisfied. CONCLUSIONS: SL ligament and TFCC electrothermal shrinkage effectively provided pain relief and grip strength increase for most of the patients treated. LEVEL OF EVIDENCE: Level IV.

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Chopart complex injuries (CCIs) are thought to be uncommon; however, recent literature states the rate of misdiagnosis to be between 20 and 41%. Chopart complex injuries are not ankle injuries, with which they are initially confused due to a similar mechanism of trauma in many cases. Injury to the Chopart complex commonly affects multiple structures. The key to optimal treatment is a high index of clinical suspicion combined with timely accurate imaging studies. Careful diagnostic workup with high-quality radiographs of the foot in neutral position should be obtained. Computed tomography (CT) and/or magnetic resonance imaging (MRI) are recommended to accurately assess bone and soft tissue injury. CCI frequently leads to prolonged swelling, pain and disability. In some cases, it may result in a posttraumatic flatfoot deformity.

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Hand and wrist lesions are relatively common in polytraumatised patients. These subjects sustain a wide range of potential life-threatening conditions and hand and wrist injuries incurred are often not diagnosed or are insufficiently treated. Closed lesions are the most frequently missed diagnosis, but even severe open lesions may be incorrectly treated. Most of these hand and wrist injuries can have a strong negative impact on long-term quality of life, particularly when treatment of these injuries is poor or delayed. Orthopaedic and hand surgeons should be vigilant in their assessment and treatment of patients with multiple injuries and a global approach, based on the advanced trauma life support (ATLS)-protocol, must be applied. The very common association of head, chest, abdomen, bone and soft-tissue lesions in the polytraumatised patient requires a multidisciplinary team approach from the beginning. The energy of trauma in these patients often causes complex injuries to the wrist and hand; these require correct treatment in terms of both timing and techniques. It is not possible to create a practical, useful guideline with a "one lesion-one solution" approach, because every case is different; therefore, this paper describes a spectrum of indications and techniques that may be useful in managing hand and wrist injuries, particularly in polytraumatised patients.

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Traumatic lesions at the elbow involving great loss of substance are uncommon, but represent a significant problem when such cases are referred to a trauma department. Most of these injuries may cause severe final functional impairment, thereby jeopardising future activities, particularly in cases where treatment was delayed or inappropriate. The timing and method of treatment are critical. The trauma may involve soft tissues only, or bone and joint, or several structures at the same time, which results in combined complex tissue defects. Each type of tissue loss should be managed by choosing the most suitable technique from the armamentarium of reconstructive surgery, taking into account different priorities and the optimum timing (immediate or delayed, one- or two-stages). The authors describe a spectrum of indications and techniques that can be useful tools in managing these injuries.

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Multiple casualties and the complex set of injuries in survivors of a terrorist bomb blast poses a real challenge to health care providers. We are presenting three such cases, first case suffered a fracture of both bone lower limb bilaterally along with head injury (foreign bodies were impacted in the scalp and brain parenchyma). Following primary resuscitation, patient shifted to operation theatre after a quick computerized tomography scan and external fixator applied in general anesthesia using the rapid sequence induction. No active neurosurgical intervention was done. As this patient had acute post-traumatic stress response, he was subjected to low pressure hyperbaric oxygen therapy (pressure of 1.5 ATA for 60 min a day for 10 days) and group counseling. He had good recovery except one lost a limb because of extensive neurovascular damage due to blast. Second case had much more extensive damage involving multiple organ systems. He had blast lung, big cerebrovascular hemorrhage along with gut perforation. Despite best possible surgical and intensive care interventions, patent developed multiple organ failure and unfortunately we lost our patient. Third case was of a right sided globe rupture resulted from blast induced flying foreign bodies. After primary survey and initial resuscitation evisceration done for the damaged eye and patient later on discharged with necessary instruction (including warning signs) for follow-up.