Can ultrasound-guided infraclavicular block be an alternative option for forearm reduction in the emergency department? A prospective randomized study

Objective Ultrasound-guided infraclavicular nerve block (IB) has become a well-established method in several outpatient procedures; however, its use in emergency departments (EDs) remains limited. The aim of this study was to compare procedural sedation and anlagesia (PSA) and IB in the pain management for patients who underwent forearm fracture reduction in the ED.Methods This prospective randomized study included 60 patients aged 18 to 65 years, who visited the ED with forearm fractures. They were randomly divided into two groups: Group PSA (n=30) and Group IB (n=30). The pain scores of patients were evaluated before and during the procedure with the visual analog scale. Complications and patient and operator satisfaction levels were recorded.Results There was no difference between the two groups in terms of demographic characteristics. The median (interquartile range) pain scores observed during the procedures were significantly higher in Group PSA than in Group IB (4 [4–6] vs. 2 [0–2], respectively; P<0.001). Patient and operator satisfaction levels were significantly higher in Group IB (P<0.001). Oxygen desaturation was statistically higher in Group PSA than in Group IB (40.00% vs. 3.33%, respectively; P=0.002).Conclusion IB was an effective alternative for reducing pain and increasing patient satisfaction in ED patients undergoing forearm fracture reduction.

Endogenous DHEAS is Causally Linked with Lumbar Spine Bone Mineral Density and Forearm Fractures in Women

Context A recent pooled analysis of four clinical trials demonstrated that treatment with dehydroepiandrosterone (DHEA) increases lumbar spine BMD (LS-BMD) in women. The causal effect of endogenous adrenal-derived DHEA-sulphate (DHEAS) on LS-BMD and fracture risk in women is unknown. Objective To determine whether circulating DHEAS is causally associated with LS-BMD and fracture risk in women. Methods A two-sample mendelian randomization study using genetic predictors of serum DHEAS derived from the largest available female-specific genome wide association study (GWAS) meta-analysis (n=8 565). Genetic associations with DXA-derived BMD (n=22 900) were obtained from female specific GWAS summary statistics available from the GEFOS consortium while individual-level data of 238 565 women of white ancestry from the UK Biobank were used for associations with fractures (11 564 forearm fractures, 2 604 hip fractures) and estimated heel BMD by ultrasound (eBMD). Results A 1 standard deviation (SD) genetically instrumented increase in log serum DHEAS levels was associated with a 0.21 SD increase in LS-BMD (P-value: 0.01) and a 0.08 SD increase in eBMD (P-value: &lt;0.001). Genetically predicted DHEAS decreased forearm fracture risk (odds ratio (OR): 0.70, 95% confidence interval (CI): 0.55-0.88 per SD increase in DHEAS) while no significant causal association with hip fractures was observed. Conclusions Genetically predicted serum DHEAS increases LS-BMD and decreases forearm fracture risk in women. Based on the results of the present study and previous RCTs of DHEA treatment, we propose that both endogenous adrenal-derived DHEA(S) and pharmacological DHEA treatment improve bone health in women.

Both Bone Forearm Fracture with Complex DRUJ Dislocation: What Are the Odds?

Background Distal radioulnar joint (DRUJ) dislocation can occur as an isolated injury or in association with fracture radius (Galeazzi fracture-dislocation), Essex–Lopresti lesion or, rarely, with fracture of both radius and ulna (termed “Galeazzi type fracture”). DRUJ dislocations can be simple or complex. While simple DRUJ dislocation can be reduced by closed methods once the associated fractures are fixed anatomically, complex dislocation does not reduce by closed means. A complex DRUJ dislocation occurring in a both bone forearm fracture is an extremely unusual pattern of injury. Case Description We describe the clinical presentation, intraop findings, management, and follow-up of two such cases of both bone forearm fracture with complex DRUJ dislocation. In both the cases, the ulnar head was found to be buttonholed through extensor retinaculum between the extensor tendons. Open reduction had to be done via dorsal approach. Timely intervention allowed good results in both the patients. Literature Review Several authors have reported simple DRUJ dislocations in both bone forearm fractures; however, we could come across only three cases of complex DRUJ dislocation in a both bone forearm fracture. A summary of various series and reports on these injuries is presented. Case Relevance Through this case report, we want to highlight this unusual association and emphasize on sequence of fixation, so that this perilous injury pattern is not missed, and favorable outcomes could be obtained through appropriate and timely intervention.

The Concentration of Selected Inflammatory Cytokines (IL-6, IL-8, CXCL5, IL-33) and Damage-Associated Molecular Patterns (HMGB-1, HSP-70) Released in an Early Response to Distal Forearm Fracture and the Performed Closed Reduction With Kirschner Wire Fixation in Children

The evaluation of trauma after surgery through objective analysis of biochemical markers can help in selecting the most appropriate therapy. Thus the aim of the study was the evaluation of the concentration of selected inflammatory cytokines (IL-6, IL-8, CXCL5, IL-33), C-reactive protein (CRP), and damaged-associated molecular patterns (DAMPs): HMGB-1, HSP-70 in the plasma of children in response to bone fracture and 12-14 hours after subsequent surgery performed by closed reduction with percutaneous Kirschner wire fixation (CRKF). The study will answer the question if the CRFK procedure leads to excessive production of inflammatory and damage markers. Blood samples from 29 children with distal forearm fractures were collected 30 min. before CRKF procedure and 12-14 hours after performance of the procedure. The control group was composed of 17 healthy children. IL-6 and CRP concentrations were analyzed using routinely performed in vitro diagnostics tests; the remaining proteins were analyzed with the use of the ELISA method. Increased values of IL-6, CRP, and HSP-70 represented an early inflammatory response to distal forearm fractures classified as SH-II type according to the Salter-Harris classification system. However, the median CRP concentration was within the reference values not indicative of inflammation. The CRKF procedure may be a good solution for the treatment of bone fractures, as damaged associated molecular patterns – HMGB-1 and HSP-70 – did not significantly differ 12-14 hours after the approach was applied as compared to the control group. Moreover, the increase in IL-6 concentration after the CRKF procedure was 1.5-fold to the level before CRKF, while the increase of this marker in response to the distal forearm fracture was 4.3-fold compared to the control group. Based on this data, it appears reasonable to suggest that the CRKF approach caused less damage and inflammatory response in comparison to the response to the fracture itself.

A Review on: 3D Printed Orthopaedic Cast for Improved Forearm Fracture Rehabilitation

Forearm fracture has many management related problems. In order to regain its function anatomical reduction and immobility is very necessary. Traditional cast is not a satisfactory cast as it is heavy, poorly ventilated and often causes fracture related complications. The paper deals with application of 3D printing technique for suitable cast for forearm rehabilitation. Novel 3D printed cast is light weighted, ventilated, custom fit, strong and waterproof and substantial improvement over conventional orthopaedic cast. With the development in technology, it is expected that the cost of fabrication and its manufacturing time will be greatly reduced in the coming future. Keywords: bone fracture, immobility, rehabilitation, 3D printing, orthopaedic cast

Parathyroid Hormone Disturbances in Postmenopausal Women with Distal Forearm Fracture

Background Primary hyperparathyroidism (PHPT) is a common endocrine disorder with a wide range of adverse effects, such as osteoporosis. Many women are not diagnosed due to asymptomatic disease or vague symptoms but are still at risk of severe adverse effects. Early identification of patients with PHPT is therefore of importance. The aim of this study was to determine PHPT prevalence among postmenopausal women with a distal forearm fracture. Methods Recruitment was conducted in conjunction with the occurrence of a distal forearm fracture at Karolinska University Hospital. In total, 161 postmenopausal women were included in a cross-sectional study with repeated evaluations. Analyzes of serum calcium, ionized calcium, phosphate, parathyroid hormone (PTH), and vitamin D were performed. Diagnosis of PHPT was based on clinical evaluations and biochemical definitions of serum calcium and PTH in coherence with previous population prevalence reports. Results Mean age was 64.7 (9.5) years, serum calcium 2.33 (0.10) mmol/L, ionized calcium 1.25 (0.05) mmol/L and PTH 54 (26) ng/L. PTH was elevated in 32 (20%) women. In total, 11 (6.8%) women were diagnosed with PHPT; 6 with classical PHPT and 5 with mild PHPT. The prevalence of PHPT was significantly increased compared to the population prevalence of 3.4% (p = 0.022). Conclusion Screening postmenopausal women in conjunction with low-energy distal forearm fracture revealed a large number of women with parathyroid disturbance. Evaluation of parathyroid hormone and calcium status in this group of patients seems beneficial.

STUDY OF TENS NAIL IN PAEDIATRIC RADIUS AND ULNA FRACTURE

Introduction: Forearm is considered as a functional joint, therefore near anatomical reduction is essential to regain normal supination and pronation. In older children many forearm fractures can be treated conservatively, but failures continue to occur despite good orthopaedic intentions. The fracture which are irreducible or unstable fracture which tends to re-displace needs surgical interventions. Among various surgical treatment one is internal xation using TENS. Various studies in the recent shows excellent to good clinical outcomes using TENS. Aims: Our study is intended to evaluate the clinical and radiological outcomes in paediatric both bone forearm fracture using TENS. Materials and methods: A total of 30 patients are included in our study. All are investigated, undergone preanesthetic check-up and taken for TENS application under image intensier. Nail diameter taken as 33-40% of narrowest diameter of diaphysys were introduced proximally in ulna and distally in radius under image intensier in closed manner. Postoperatively, patients encouraged for active shoulder, elbow and nger movements and suture removal done after 2 weeks. All patients are followed up to 24 week, when implant removal was done. Results: In our study 90% patients show excellent functional results. Conclusion: We conclude that TENS in both bone forearm fractures in adolescent age group in terms of union and range of motion is a minimally invasive and effective method of xation

125 Reducing Displaced Forearm Fractures in Children: Are we following the guidelines?

Primary Subject area Emergency Medicine - Paediatric Background Forearm fractures account for 45% of pediatric fractures, mainly involving the distal third of the forearm. Some will be displaced, requiring a closed reduction and plaster cast immobilization. Re-displacement during follow-up is reported in 7 to 35% of the cases. Objectives To identity discrepancies between hospital guidelines and patient management for forearm fracture reduction in children aged 1 to 17. Design/Methods This retrospective case series was conducted by a medical audit committee of CHU Sainte-Justine for the purpose of improving quality of care. This project aimed to evaluate the clinical course following closed reduction of forearm fractures in patients presenting to the emergency department (ED) or to the orthopedic clinic in a pediatric tertiary care centre. Children aged 1 to 17 years old presenting between January 1 and December 31 2019 were considered for this study. We selected a convenience sample of 50 consecutive cases and reviewed their medical and radiological data from first consultation through follow-ups. The management of these cases was evaluated against established hospital guidelines for primary or secondary fracture reduction (primary outcome). The angulation and displacement of fractures were measured using original imaging taken prior to reduction, and at follow-up. At their last appointment, all patients’ range of motion and angulation were assessed. Complications of sedation and immobilization were also reviewed. Descriptive statistics were performed for all variables. Results From the 106 radiologic files retrieved of closed forearm fracture reduction using fluoroscopy, a convenient sample of 50 cases was reviewed. The mean age was 7 years and 60% of them were boys. Forty-eight (96%) had an initial fracture reduction consistent with the local practice guideline for need of reduction. Sedation adverse events were noted in 10 patients (20%), most often nausea, but no severe adverse event was identified. According to the local practice guideline, 13 (26%) patients suffered re-displacement at follow-up. Of these, 3 underwent a second closed reduction, 4 had a gypsotomy, and 6 had no attempt at a second reduction. Five patients (10%) had a second reduction during follow-up, despite the displacement not meeting the local guideline criteria for reduction. Cast-related issues were reported in 14 patients (28%), with the molding technique accounting for most of the problems observed. At their final follow-up, 40 patients (80%) had an excellent or good functional outcome. In the remaining 10 (20%), the range of motion was more limited, but measurements were done for many of them following immediate cast removal. Forty patients (80%) had either a normal or near normal alignment at their final follow-up. In the remaining 10 (20%), none of these patients had an angulation greater than 20 degrees. Conclusion From this audit of patients presenting with displaced forearm fractures in a pediatric tertiary care centre, the initial management of patients was in accordance with the established guidelines of practice in 96% of cases. Re-displacements at follow-up were identified in a quarter of patients. Nonetheless, angulation and the final range of motion of the wrist were favorable shortly after cast removal. Further improvement in the management could be achieved by improving the technique of cast immobilization.