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Background: Fractures with large bone defects and non-unions are a great challenge for veterinary orthopaedists. In small dog breeds, this complication is commonly encountered in fractures of the radius and ulna due to poorer vascularisation of the distal antebrachium region. Case Description: A case of radius/ulnar non-union in a 1.5-year-old Pinscher occurring after trauma and two successive unsuccessful osteosyntheses is described. During the operative revision, after the removal of existing bone implants, the bone defect was filled with cortical autologous bone graft. Autocancellous bone mixed with erythropoietin was applied proximally and distally to the cortical autograft for stimulation of bone healing. The post-operative period was without complications. As early as the 9th post-operative week, the animal was able to bear weight on the limb, without signs of lameness, pain, and swelling. Radiologically, a very good bridging of the graft was observed. Fifteen weeks after the operative revision, the fracture was completely healed with excellent clinical outcome. Conclusion: The application of autogenous cortical bone graft and cancellous autograft mixed with erythropoietin demonstrated an excellent therapeutic effect and resulted in complete regeneration of the large bone defect over a 15-week period.

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Objective: The aim of this study was to investigate the clinical efficacy of closed manipulation combined with splinting in the treatment of displaced distal radial and ulnar fractures in children. Methods: A total of 82 children with displaced fractures of the distal radial and ulnar segment who met the inclusion criteria and were treated as outpatients or inpatients in the orthopedic department of Guangzhou Orthopedic Hospital, from January 2016 to June 2022 were randomly divided into an observation group and a control group: 41 children in the observation group were treated with closed manipulation combined with splint fixation; 41 children in the control group were fixed with incisional repositioning elastic nails combined with internal plates. The Anderson efficacy grading, visual analog scale (VAS) score, fracture healing time, treatment cost, hospital days, and complications were observed and compared between the two groups. Result: The efficacy was evaluated according to the Anderson forearm fracture efficacy evaluation criteria, and the results of statistical analysis showed no statistically significant differences between the two groups (P > 0.05). At 3 and 7 weeks after treatment, the VAS scores of children in both groups decreased (P < 0.05), and the VAS scores in the observation group were significantly lower than those in the control group (P < 0.05), indicating that the observation group had a significant advantage in the relief of pain after treatment. The fractures healed in both groups after treatment with the two different methods, and the difference in healing time between the two groups was not statistically significant (P > 0.05). The length of hospital stay, treatment cost, and complication ratio were significantly lower in the observation group than in the control group (P < 0.05). Conclusion: In children with displaced fractures of the distal radial and ulnar segments, treatment by manual repositioning with external splinting can achieve satisfactory results with simple operation, low cost, short hospital stay, and few complications, which is especially suitable to be promoted in primary hospitals and has good social benefits.

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Ipsilateral forearm fractures of both the radius and ulna in children are one of the most common forms of injuries in this population. They often result from axial loading on the hand and wrist following a fall on an outstretched hand. These injuries can often be managed either conservatively or operatively. Non-operative management involves the use of cast immobilisation after satisfactory closed reduction. Most fractures managed conservatively have been noted to have a successful outcome. Surgical options of management include the use of intramedullary nailing (IMN), plates and screws, hybrid techniques and rarely external fixators. The purpose of this systematic review is to critically analyse the functional and radiological outcomes as well as the probability of developing a complication in children that have undergone either IMN or plating of both the radius and ulna in the paediatric population. A comprehensive electronic database search from April 2014 until April 2022 was conducted. Studies from PubMed, EMBASE and Cochrane electronic databases were retrieved. A total of 260 cohort studies with children between the ages of 5 to 17 years old were identified. After the application of both inclusion and exclusion criteria, six articles with a total of 409 patients relevant to this review were identified and analysed. There were no significant inconsistencies statistically in functional and radiological outcomes. Overall complication rate and time to fracture union were similar. Intramedullary nailing was noted to have a shorter operative and anaesthetic time, longer fluoroscopic exposure, and a better cosmetic outcome. Differences in bowing, radial bow magnitude and location had no overall bearing on rotation and daily activity. Considering the methodological limitations of this study, a larger sample size and higher level of evidence such as randomized control studies will yield a more conclusive result to resolve controversies. Based on currently available evidence, both plating and intramedullary nailing are excellent treatment modalities in both-bone forearm fractures.

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The cortex of the limb bones of chinchillas is very thin and brittle, so it is prone to fractures of the limb bones, among which fractures of the tibia, radius and ulna are the most frequent types. When a chinchilla has a closed fracture, it can be immobilized with a splint, cast, or bandage. If the broken end of the fracture pierces the skin, it is best to choose internal fixation or external fixation brackets for treatment. In this report, a 0.661 kg, 2-year-old male uncastrated chinchilla was presented to the Veterinary Teaching Hospital of Huazhong Agricultural University due to an old fracture of the right forearm. With the consent of the owner, we decided to use a 25-gauge needle as an IM pin to fix the fracture. Ten days after surgery, the wound had healed well, and the limb could support body weight, but the palm did not show a grasping position. Twenty four days after the operation, the affected limb had not regained the ability to grasp. The X-ray showed a slight rotation of the IM pin and good callus growth in the ulna, but not in the radius. One month after the operation, it was found that the function of the affected limb of the chinchilla was normal and the grasping ability was restored through follow-up consultation and the return visit.

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А clinical case of non-union in a cat after open fracture repair by intramedullary ostheosynthesis of the radius was described. The patient was presented with non-weight bearing lameness, fistulas with purulent discharge, swelling and severe pain. During the surgical revision, after bone sequestrum removal, the bone defect was filled with cancellous and cortical bone autografts. Osteosynthesis with a modified external bone fixator, made of Duracryl® Plus - a rapidly self-curing metacrylate polymer - and 6 Kirschner wires passing perpendicularly through both radial cortices was performed. The post-operative period was smooth, and after 23 weeks the external fixator was removed. Radiography showed very good bone healing, with excellent clinical result. The use of the ulna as a donor bone was very convenient because it allowed collecting a cortical graft of larger size. The extremely light model of external bone fixator provided adequate strength of fixation elements and proved to be an efficient and not expensive technique for osteosynthesis in cat with non-union fractures of the distal radius and ulna.

Um caso clínico de correção de uma não união de uma fratura exposta em um gato após por osteossíntese intramedular do rádio foi descrito. O paciente apresentou claudicação, fístulas com secreção purulenta, edema e dor intensa. Durante a revisão cirúrgica, após a remoção do sequestro ósseo, o defeito ósseo foi preenchido com autoenxertos de osso esponjoso e cortical. Foi realizada osteossíntese com fixador ósseo externo modificado, confeccionado em Duracryl® Plus ­ polímero metacrilato de rápida autopolimerização ­ e 6 fios de Kirschner passando perpendicularmente por ambas as corticais radiais. O pós-operatório foi tranquilo e após 23 semanas o fixador externo foi removido. A radiografia mostrou boa consolidação óssea, com excelente resultado clínico. A utilização da ulna como osso doador foi muito conveniente, pois permitiu a coleta de um enxerto cortical de maior tamanho. O modelo extremamente leve de fixador ósseo externo proporcionou resistência adequada dos elementos de fixação e mostrou-se uma técnica eficiente e de baixo custo para osteossíntese em gatos com fraturas não consolidadas do rádio distal e ulna.

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Bilateral elbow dislocation associated with bilateral distal forearm fractures is extremely rare, therefore its optimal treatment, complications, and outcomes remain unclear. We present an illustrative case with a 2-year follow up of a patient who sustained a complex injury of the upper extremity and underwent combined surgical and conservative treatment.

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STUDY DESIGN: Retrospective cohort study. OBJECTIVES: To explore the possibility of predicting final body height at maturity based on associating parameters at the time of diagnosing adolescent idiopathic scoliosis (AIS), while examining the effect of curve magnitude and deterioration. METHODS: A total of 284 female patients with AIS (mean age 12.2 ± 1.1 years, 52.5% premenarchal) were followed till skeletal maturity, indicated by ≥Risser stage 4, static body height and arm span over the past 6 months, and postmenarche 2 years. Standing body height, arm span, menarchal status, Risser staging, distal radius and ulna (DRU) classification, Sanders staging (SS), Cobb angles (major and minor curves), and Lenke curve types at initial presentation were examined. Patients with/without curve deterioration were compared. Multiple linear regression was used for predicting final body height (cm), and remaining height increase (%). RESULTS: Baseline body height was 152.1 ± 7.1 cm and major curve Cobb angle was 27.1° ± 7.4°, whereas at maturity they were 159.5 ± 5.4 cm and 32.5° ± 9.3°, respectively. For patients presented at Risser stage 0 or 1, radius grade (R) 6, ulnar grade (U) 5, or SS3, those with curve deterioration exhibited greater height increase potential at initial presentation (P < .05) than those without deterioration. No intergroup difference was found for patients presented at ≥Risser 2, R7, U6, SS4. Predictive baseline parameters were age, body height, Cobb angle (major curve), curve type, and DRU grades. Prediction models of final body height (R 2 = 0.735, P < .001) and remaining height increase (R 2 = 0.742, P < .001) were established. CONCLUSIONS: Final body height prediction model was derived for female patients with AIS, with baseline body height and ulnar grading having larger impacts than other parameters.

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AIMS: The aim of this study was to investigate whether including the stages of ulnar physeal closure in Sanders stage 7 aids in a more accurate assessment for brace weaning in patients with adolescent idiopathic scoliosis (AIS). METHODS: This was a retrospective analysis of patients who were weaned from their brace and reviewed between June 2016 and December 2018. Patients who weaned from their brace at Risser stage ≥ 4, had static standing height and arm span for at least six months, and were ≥ two years post-menarche were included. Skeletal maturity at weaning was assessed using Sanders staging with stage 7 subclassified into 7a, in which all phalangeal physes are fused and only the distal radial physis is open, with narrowing of the medial physeal plate of the distal ulna, and 7b, in which fusion of > 50% of the medial growth plate of distal ulna exists, as well as the distal radius and ulna (DRU) classification, an established skeletal maturity index which assesses skeletal maturation using finer stages of the distal radial and ulnar physes, from open to complete fusion. The grade of maturity at the time of weaning and any progression of the curve were analyzed using Fisher's exact test, with Cramer's V, and Goodman and Kruskal's tau. RESULTS: We studied a total of 179 patients with AIS, of whom 149 (83.2%) were female. Their mean age was 14.8 years (SD 1.1) and the mean Cobb angle was 34.6° (SD 7.7°) at the time of weaning. The mean follow-up was 3.4 years (SD 1.8). At six months after weaning, the rates of progression of the curve for patients weaning at Sanders stage 7a and 7b were 11.4% and 0%, respectively for those with curves of < 40°. Similarly, the rates of progression of the curve for those being weaned at ulnar grade 7 and 8 using the DRU classification were 13.5% and 0%, respectively. The use of Sanders stages 6, 7a, 7b, and 8 for the assessment of maturity at the time of weaning were strongly and significantly associated (Cramer's V 0.326; p = 0.016) with whether the curve progressed at six months after weaning. Weaning at Sanders stage 7 with subclassification allowed 10.6% reduction of error in predicting the progression of the curve. CONCLUSION: The use of Sanders stages 7a and 7b allows the accurate assessment of skeletal maturity for guiding brace weaning in patients with AIS. Weaning at Sanders stage 7b, or at ulnar grade 8 with the DRU classification, is more appropriate as the curve did not progress in any patient with a curve of < 40° immediately post-weaning. Thus, reaching full fusion in both distal radial and ulnar physes (as at Sanders stage 8) is not necessary and this allows weaning from a brace to be initiated about nine months earlier. Cite this article: Bone Joint J 2021;103-B(1):141-147.

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A peri-implant fracture near the volar plate of distal radius represent a very rare injury. The main factor of this lesion is high energy trauma on the wrist. We report a case of a 61-year-old woman with a peri-implant fracture located just proximally to the plate and a fracture of the ulnar head that occurred after a simple fall. The patient was surgically treated by plate and screws removal. The fracture was fixed using a longer volar plate for the radial fracture and a plate for the head ulnar fracture. Different factors such as osteoporosis, BMI and screw position could influence the fracture pattern. However, considering growing use of plates for distal radius fracture fixation, the frequency of these kind of fracture will probably increase.

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La deformidad de Madelung es una alteración poco común de la articulación de las muñecas. Se vincula a mutaciones del gen SHOX y se caracteriza por alteraciones en el radio, carpo y cúbito, con predominio bilateral. Afecta principalmente a pacientes de sexo femenino y aparece al inicio de la adolescencia. Se presenta una paciente de 15 años de edad, con antecedentes de problemas de salud. Al entrar en la adolescencia comenzó a presentar deformidad en ambas muñecas, más marcada en el lado derecho acompañado de dolor. El diagnóstico de deformidad de Madelung se concluyó mediante la clínica asociado a la positividad de los estudios imagenológicos, basados en los criterios radiográficos de Dannenberg y otros. Se decidió tratamiento quirúrgico, mediante osteotomía doble correctora para longitud y fijación externa de la mano derecha, con la resolución completa de la deformidad y seguimiento en la Consulta Externa de Ortopedia(AU)

Madelung's deformity is a rare alteration of the wrist joint. It is linked to mutations of the SHOX gene. It is characterized by alterations in the radius, carpus and ulna, predominantly bilateral. It mainly affects female patients; signs and symptoms are evident at the beginning of adolescence. To present a case of a patient with a diagnosis of Madelung deformity. The case of a 15-year-old female patient with a health history and family history of interest of an equine clubfoot father is presented. When she entered adolescence, she began to present deformity in both wrists, more marked in the right side accompanied by pain. This is a patient with a Madelung deformity. The diagnosis was concluded by the clinic associated with the positivity of the imaging studies(AU)

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One-Bone-Forearm (OBF) is a procedure in which the proximal stump of the ulna is fixed to the distal stump of the radius. Historically, the indications for OBF have been represented by forearm instability due to trauma, infection, tumor resection, and congenital deformities with severe radius and ulna bone loss. When major bone loss prevents direct fixation between ulna and radius a Vascularized Fibular Bone Graft (VFBG) may allow forearm bone reconstruction and fixation. In this study we report our clinical experience in 4 cases of OBF with VFBG performed in 3 patients. Compared to standard OBF technique with direct osteodesis, OBF with VFBG showed similar clinical results and high rate of healing even in case of bone infection. Moreover, composite osteocutaneous VFBG might concurrently allow to treat local soft tissue defects.

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PURPOSE: To determine the capability of the distal radius and ulna (DRU) classification for predicting the scoliosis progression risk within 1 year in patients with adolescent idiopathic scoliosis (AIS) and to develop simple recommendations for follow-up durations. METHODS: Medical records of patients with AIS at two tertiary scoliosis referral centers were retrospectively reviewed for their DRU classification and major curve Cobb angles. Baseline DRU grades and Cobb angles with subsequent 1-year follow-up curve magnitudes were studied for scoliosis progression, which was defined as exacerbation of the Cobb angle by ≥ 6°. The relationship between DRU classification and scoliosis progression risk within 1 year was investigated. Patients were divided into three groups according to the Cobb angle (10°-19°, 20°-29°, ≥ 30°). RESULTS: Of the 205 patients with 283 follow-up visits, scoliosis progression occurred in 86 patients (90 follow-up visits). Radius and ulna grades were significantly related to scoliosis progression (p < 0.001). R6, R7, and U5 grades were significantly related to scoliosis progression risk. The curve progression probability increased as the Cobb angle increased. Cobb angles ≥ 30°, with these grades, led to progression in > 80% of patients within 1 year. Curve progression was less likely for grades R9 and U7. Most patients with more mature DRU grades did not experience progression, even with Cobb angles ≥ 30°. CONCLUSION: With R6, R7, and U5, scoliosis may progress within a short period; therefore, careful follow-up with short intervals within 6 months is necessary. R9 and U7 may allow longer 1-year follow-up intervals due to the lower progression risk.

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PURPOSE: Distal radius and ulna (DRU) classification scheme has been proposed for predicting skeletal maturity in patients with idiopathic scoliosis (IS). However, the utilization of DRU classification scheme in the assessment of growth peak and curve progression in IS was still inconclusive. This study aimed to correlate the distal radius and ulna stages with several indicators for growth potential and to evaluate the predictive value of DRU system for curve progression in braced female IS patients. METHODS: This was a consecutive longitudinal study including physically immature IS girls receiving standardized bracing treatment and regularly followed up every 3-6 months until brace weaning. The following data of each visit were collected: chronologic age, standing height, Cobb angle, spinal length, Risser sign, digital skeletal age (DSA) scores and DRU scores. The height velocity (HV), spinal growth velocity (SGV) and angle velocity (AV) of each visit were calculated. The correlation among radius stage, ulna stage, Risser sign, height, spinal length, HV, SGV and AV was studied. RESULTS: Forty braced IS girls with 349 longitudinal whole spine X-rays were reviewed. The average DRU scores at initial visit were R6.5 ± 1.1 and U4.5 ± 1.2 for radius and ulna, respectively. Both the radius stages between R5 and R8 and ulna stages between U3 and U6 indicated high SGV and high HV. The DSA scores were 402.1 ± 48.8 and 430.8 ± 44.4 at R7 and R8, respectively. The AV values were - 5.9 ± 12.4°/y and - 0.4 ± 1.5°/y at R5 and R6, which increased to 5.9 ± 17.3°/y, 3.1 ± 15.7°/y and 4.2 ± 12.2°/y at R7, R8 and R9, respectively. The DSA scores were 387.3 ± 65.7 for U5 and 432.9 ± 48.5 for U6, respectively. The AV values were - 3.1 ± 0.3°/y at U3, - 1.7 ± 9.3°/y at U4, 2.3 ± 16.1°/y at U5, 5.4 ± 15.5°/y at U6 and 4.4 ± 12.9°/y at U7. CONCLUSIONS: Both distal radius and ulna scores correlate with the longitudinal growth potential, and thus, the DRU scoring scheme is an alternative predictor for growth potential and curve progression in girls with IS. These slides can be retrieved under Electronic Supplementary Material.

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OBJECTIVE: To compare functional and clinical outcomes of open versus closed radius ulna shaft fractures in adults treated by internal fixation. METHODS: A prospective cohort study was conducted on patients presenting with traumatic radius and ulna shaft fractures to Aga Khan University and undergoing internal fixation between July 2015 to June 2019. Data was extracted from an ongoing orthopaedic trauma registry. Functional and clinical outcomes were assessed by Price et al. criteria at 6 weeks, 3, 6 and 12 months follow-up. Outcome scores of open versus closed fractures were compared. RESULTS: Twenty-nine adult patients with isolated radius and ulna shaft fracture were identified. Cause of injury was road traffic accident in 18 (62%) and fall in 11 (38%) patients. Seventeen (59%) were closed and 12 (41%) were open fractures. At 6week follow-up, better outcomes were observed in closed fracture group (p=0.01) with near-full range of motion and activity in 10(83%) patients as compared to 3(27%) in the open fracture group. No significant difference in outcomes was observed at 3 months and thereafter. CONCLUSIONS: Earlier recovery of function at 6 weeks was observed in majority of patients in the closed fracture group. Our data shows that good-excellent functional and clinical results are achievable by internal fixation in both open as well as closed fractures of the shaft of radius and ulna in adults.

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Background: Both bone forearm infective nonunions represent a rare but functionally limb threatening condition. Method: We report a successful salvage of a severe near total both bone diaphysial osteomyelitis by conversion to a one-bone forearm with free fibula flap. A literature review on forearm salvage addressing both bone defects was performed. Results: Bony union was achieved at 4 months with a highly functional extremity salvage in our case. Conclusion: While very little prior experience has been reported for long segmental both bone forearm infected nonunions, we report of this highly satisfactory salvage using one-bone free tissue transfer strategy. We also provided our literature review with history, indication and evolution of individualized treatment options for this difficult surgical condition.

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INTRODUCTION: Adult both bone forearm fractures (BBFF) are common injuries that are typically treated with operative fixation given their instability. Non-displaced fractures can be theoretically treated non-operatively, but there is no literature demonstrating treatment outcomes of such fractures. CASE REPORT: We present a case of non-displaced BBFF in a 23-year-old Caucasian male adult who was treated with cast immobilization and concomitant ultrasound stimulator use; this patient went on to have solid fracture healing without complication. CONCLUSION: Based on this case, we demonstrate that non-operative management of non-displaced BBFF in adult patients is an option if close follow-up is available. This is significant for the fields of both orthopedic and plastic surgery, as there is little concrete evidence of outcomes of such non-displaced fractures in hand surgery literature.

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OBJECTIVE: Emergency department (ED) reduction of pediatric fractures occurs most commonly in the forearm and can be challenging if fluoroscopy is not available. We sought to assess the ability of point of-care ultrasonography (POCUS) to predict adequacy of reduction by fluoroscopy. METHODS: We prospectively enrolled ED patients 0-17 years of age with radial and/or ulnar fractures requiring reduction under fluoroscopic guidance. Post-reduction POCUS (probe dorsal, volar, and coronal) and fluoroscopic (AP and lateral) fracture images were recorded. Fracture angles were compared between blinded POCUS and fluoroscopic measurements and between POCUS measurements by a blinded emergency physician and a blinded radiologist, reporting mean differences and 95% confidence intervals. We calculated sensitivity, specificity, and likelihood ratios of POCUS in the prediction of fluoroscopically detected post-reduction malalignment, as interpreted by a blinded pediatric orthopaedist. RESULTS: The 58 patients were 7.9 ±â€¯3.5 years of age and had 21 radial (36%), 1 ulnar (2%), and 36 radioulnar (62%) fractures. Fluoroscopy and POCUS angles were within a mean of 0.1°-3.2°, depending on the site and surface measured. Radiologist- and emergency physician-interpreted POCUS measurements were within a mean of 1° in all dimensions. POCUS identified inadequate reductions with 100% sensitivity and 92-93% specificity. CONCLUSIONS: Blinded emergency medicine and radiology interpretations of post-reduction POCUS fracture images agree closely. Post-reduction POCUS measurements are comparable to those obtained by fluoroscopy and accurately predict adequacy of reduction. POCUS can be used to guide pediatric fracture reduction when bedside fluoroscopy is not available in the ED.

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STUDY DESIGN: Prospective study. PURPOSE: To determine the risk of clinically significant curve progression in adolescent idiopathic scoliosis (AIS) based on the initial Cobb angle and to test the utility of the distal radius and ulna (DRU) classification in predicting these outcomes. OVERVIEW OF LITERATURE: Determining the remaining growth potential in AIS patients is necessary for predicting prognosis and initiating treatment. Limiting the maturity Cobb angle to <40° and <50° reduces the risk of adulthood progression and need for surgery, respectively. The risk of curve progression is the greatest with skeletally immature patients and thus warrants close monitoring or early intervention. Many parameters exist for measuring the skeletal maturity status in AIS patients, but the DRU classification has been shown to be superior in predicting peak growth and growth cessation. However, its predictive capabilities for curve progression are unknown. METHODS: Totally, 513 AIS patients who presented with Risser 0-3 were followed until either skeletal maturity or the need for surgery, with a minimum 2-year follow-up period. Outcomes of 40° and 50° were used for probability analysis based on the cut-offs of adulthood progression risk and surgical threshold, respectively. RESULTS: At the R6/U5 grade, most curves (probability of ≥48.1%-55.5%) beyond a Cobb angle of 25° progressed to the 40° threshold. For curves of ≥35°, there was a high risk of unfavorable outcomes, regardless of skeletal maturity. Most patients with the R9 grade did not progress, regardless of the initial curve magnitude (probability of 0% to reach the 50° threshold for an initial Cobb angle of ≥35°). CONCLUSIONS: This large-scale study illustrates the utility of the DRU classification for predicting curve progression and how it may effectively guide the timing of surgery. Bracing may be indicated for skeletally immature patients at an initial Cobb angle of 25°, and those with a scoliosis ≥35° are at an increased risk of an unfavorable outcome, despite being near skeletal maturity.