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Blast injuries affect millions of lives across the globe due to its traumatic after effects on the brain and the whole body. To date, military grade armour materials are designed to mitigate ballistic and shrapnel attacks but are less effective in resisting blast impacts. In order to improve blast absorption characteristics of armours, the first key step is thoroughly understands the effects of blasts on the human body itself. In the last decade, a plethora of experimental and computational work has been carried out to investigate the mechanics and pathophysiology of Traumatic Brain Injury (TBI). However, very few attempts have been made so far to study the effect of blasts on the various other parts of the body such as the sensory organs (eyes and ears), nervous system, thorax, extremities, internal organs (such as the lungs) and the skeletal system. While an experimental evaluation of blast effects on such physiological systems is difficult, developing finite element (FE) models could allow the recreation of realistic blast scenarios on full scale human models and simulate the effects. The current article reviews the state-of-the-art in computational research in blast induced whole-body injury modelling, which would not only help in identifying the areas in which further research is required, but would also be indispensable for understanding body location specific armour design criteria for improved blast injury mitigation. [ABSTRACT FROM AUTHOR]

Lymphedema often is confused with other causes of extremity edema and enlargement. Understanding the risk factors and physical examination signs of lymphedema can enable the health care practitioner to accurately diagnose patients ∼90% of the time. Confirmatory diagnosis of the disease is made using lymphoscintigraphy. It is important to correctly diagnose patients with lymphedema so that they can be managed appropriately. [ABSTRACT FROM AUTHOR]

Background Knee disarticulations (KD) are most commonly employed following trauma or tumor resection but represent less than 2% of all lower extremity amputations performed in the United States annually. KDs provide enhanced proprioception, a long lever arm, preservation of adductor muscle insertion, decreased metabolic cost of ambulation, and an end weight-bearing stump. The role for KDs in the setting of arterial insufficiency or overwhelming infection is less clear. The purpose of this study is to describe technique modifications and report surgical outcomes following KDs at a high-volume Limb Salvage Center. Methods A retrospective study of medical records for all patients who underwent a through-knee amputation performed by the senior author (C.E.A.) between 2004 and 2012 was completed. Medical records were reviewed to collect demographic, operative, and postoperative information for each of the patients identified. Results Between 2004 and 2012, 46 through-knee amputations for 41 patients were performed. The mean patient age was 68 and indications for surgery included infection (56%), arterial thrombosis (35%), and trauma (9%). Postoperative complications included superficial cellulitis (13%), soft tissue infection (4%), and flap ischemia (4%) necessitating one case of surgical debridement (4%) and four trans-femoral amputations (9%). 9 (22%) patients went on to ambulate. Postoperative ambulation was greatest in the traumatic cohort and for patients less than 50 years of age, P

Chondroid syringoma (CS) is a rare benign tumor of the sweat gland. It generally presents as a painless, slowly growing, subcutaneous swelling, typically located on the head and neck region. The majority of the cases develop in middle aged and elderly males. We present a case of CS located over the right thumb of a 25-year-old male. The diagnosis was made initially by cytological evaluation and later confirmed by histopathological examination. There was no recurrence on two year follow up after the complete surgical excision of the tumor.

Copyright of Journal of Anbar University for Law & Political Sciences is the property of Republic of Iraq Ministry of Higher Education & Scientific Research (MOHESR) and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use. This abstract may be abridged. No warranty is given about the accuracy of the copy. Users should refer to the original published version of the material for the full abstract. (Copyright applies to all Abstracts.)

Background:In this study, markers of coagulation and fibrinolysis were assessed during early and delayed microsurgical reconstruction in patients with traumatic defects of their lower legs to analyse whether an imbalance of the hemostasis after trauma might predispose the development of vascular complications. Methods:The prospective study included 70 patients. In 35 patients, surgery was performed within 72 hours after injury. In 35 other patients, delayed free flap transfer was performed between 14–21 days after trauma. In each group, reconstruction was performed with a fasciocutaneous anterior-lateral thigh flap (ALT,n = 18) or a myocutaneous flap (latissimus dorsi flap;n = 17). Blood samples were collected preoperatively, intraoperatively, and 3, 6, 12, 24, 36, 48, 72, 96 and 120 hours after the operation. Analysed parameters included markers of coagulation such as prothrombin fragment 1 + 2 (F1 + 2), thrombin-antithrombin III-complex (TAT), and antithrombin, as well as fibrinolysis markers such as plasminogenactivator inhibitor-I (PAI-1), tissue-plasminogenactivator (t-PA), and plasminogen. Results:Preoperatively, levels of F1 + 2, TAT, and PAI-1 were significantly higher in patients with delayed reconstruction (p < .05). Patients with later vascular complications in this group (n = 5) presented a significant higher concentration of TAT, F1 + 2, and PAI-1 (p < .05). Twelve and 24 hours after free flap surgery, patients with vascular complications presented significant elevated levels of these markers (p < .05). Conclusions:Patients with delayed free flap surgery after lower leg trauma present a hypercoagulable state in their blood due to activation of the coagulation system and hypofibrinolysis. Early reconstruction might minimise the risk of flap failure caused by hypercoagulability. [ABSTRACT FROM AUTHOR]

This article surveys the quantitative literature in coalition foreign policy. Tracing its development back to what we call the 'first generation studies' in Democratic Peace research, we illustrate that its theoretical and methodological foundations distinguish this literature from its predecessors. We then overview the existing studies along three dimensions: the nature of the dependent variables, the content of the key explanatory variables, and the processes that identify and systematise the institutional factors that influence coalition foreign policy. Our suggestions for future research highlight some of the puzzles motivated by the findings of this literature and the promise of multi-method designs. [ABSTRACT FROM AUTHOR]

We investigated the effects of climato-economic harshness on extreme response style. Climato-economic theorising postulates that a more threatening climate in poorer countries, in contrast to countries with a more comforting climate and richer countries with a more challenging climate, triggers intolerance of ambiguity and uncertainty avoidance inherent to conservatism, in-group favouritism and autocracy. Scores of extreme response style at country level, a proxy of this cluster of cultural characteristics, were extracted from students' responses in the Programme for International Student Assessment to test the hypothesis. In a series of hierarchical regression analysis across 64 countries, cold demands, heat demands and GDP per capita showed a highly significant interaction effect on extreme response style, predicting in total 30.7% of the variance. Extreme response style was highest in poorer countries with higher climatic demands, and lowest in richer countries with lower climate demands. Implications are discussed. [ABSTRACT FROM AUTHOR]

Background: Directional preference is a phenomenon that occurs in musculoskeletal disorders. It is associated with improved symptomatic and functional outcomes. Research has shown a 90% increase in the identification of directional preference in the peripheral joints between 2006 and 2012. There is currently no research analyzing if predictive variables exist for establishing directional preference. Case Description: This report presents 19 consecutive patients with wrist pain. These patients were evaluated using a mechanical diagnosis and therapy (MDT)-based assessment. Patients were classified into the mechanical syndromes Derangement, Dysfunction, Postural, and Other. Patients classified with wrist Derangement were assessed for the presence of directional preference. Secondary analysis of predetermined variables was performed for association with directional preference. One case description was included to demonstrate MDT assessment, treatment, and clinical reasoning. Results: Of the 19 patients evaluated, 15 (79%) were classified as having wrist Derangement. All patients with wrist Derangement demonstrated directional preference. Eight movements were found to establish directional preference. Each was unique with varying degrees of direction, load, and force. Discussion: This report found directional preference to be higher (79%) than previously reported values. Historical and physical examination findings were analyzed to determine if there were associated variables of directional preference. Excessive mechanical stress was found to be the most associated factor in predicting directional preference. These findings may lead to a greater understanding of peripheral MDT assessment, which may lead to increased identification of directional preference and improved patient outcomes. Level of Evidence: 4. [ABSTRACT FROM AUTHOR]

Introduction: Extremity joint dysfunctions are a commonplace occurrence within the neonate and infant population. While conditions of greater clinical significance are well documented, there is a disturbing lack of data regarding the prevalence of extremity joint dysfunctions within this population. This study aims to provide the first prevalence data on extremity joint dysfunctions in neonates and infants. Methods: Data was collected from 202 cases of neonates and infants under 12 months of age during the period 1/1/2010 to 31/12/2010 at a paediatric-only chiropractic clinic. Motion palpation findings from four chiropractors with postregistration chiropractic paediatric training were collated. Results: Of the 202 cases, 153 (75.7%) were found to have extremity joint dysfunction. The shoulder was the most frequent (71.8%), followed by the wrist (5.5%), fibula (5.0%) and elbow (2.5%). Conclusion: Extremity joint dysfunction is common and likely to be overlooked aspect of neonatal and infant examination. The high prevalence within this cohort suggests that all neonates and infants attending a chiropractor should be assessed to identify the presence of extremity joint dysfunction and receive appropriate treatment. [ABSTRACT FROM AUTHOR]

Background Peripherally inserted central catheters (PICCs) are ubiquitous in modern hospitals, but are associated with venous thromboembolism (VTE), which includes deep vein thrombosis (DVT) and/or pulmonary embolism (PE). We retrospectively examined this association in hospitalized patients, highlighting anatomically associated VTEs (those with DVT in the PICC extremity). Methods Charts with an International Classification of Diseases, Ninth Revision (ICD9) code for VTE were collected from a discharge database of PICC-managed patients at a tertiary hospital. A sample (52.3%) of the VTE charts was manually reviewed to verify PICC-associated VTE (unverified charts were excluded), and determine such data as the extremity in which each DVT was diagnosed (using ultrasound reports). VTE rates were calculated using an uncorrected method (from charts with VTE ICD9 code) and a corrected method (from charts with manually verified PICC-associated VTE). Results Our uncorrected VTE rate was 3.9% ( P  < .0001), whereas the corrected rate was 1.5%. Among 125 charts with manually verified PICC-associated VTE, 69 (60.5%) out of 114 patients with a DVT had their DVT occur in the PICC extremity, yielding an anatomically associated VTE rate of 0.84%. The most common reason for a chart being excluded (60.2%) was a VTE occurring before PICC placement. Conclusions We found clinically significant rates of PICC-associated VTE. The majority of patients' DVT occurred in the same extremity as their PICC, lending further evidence that PICCs are an independent risk factor for VTE and require judicious use. There was also a discrepancy in VTE rate derived from ICD codes alone vs. manual chart review. [ABSTRACT FROM AUTHOR]

Early amputation is regarded as a life saving procedure after high energy injuries due to war injuries and terrorist attacks. Proper intervention in such injuries requires more experience and algorithmic approach. Moreover appropriate management in war and terrorist attacks-related vascular injuries of the extremities are challenging among many surgeons, especially in our country regarding geopolitical location. Although lİmb salvage surgeries are performed primarily, long-standing and fair outcomes of these procedures may affect patients negatively both physically and emotionally which should be keep in mind in definiive treatment decision. [ABSTRACT FROM AUTHOR]

Copyright of Hungarian Medical Journal / Orvosi Hetilap is the property of Akademiai Kiado and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use. This abstract may be abridged. No warranty is given about the accuracy of the copy. Users should refer to the original published version of the material for the full abstract. (Copyright applies to all Abstracts.)

Background: Children who present to the emergency department (ED) with complaint of fever and new-onset joint or extremity pain can be a diagnostic dilemma for many emergency and consulting physicians.Objectives: The purpose of our study was to identify the etiologies of pediatric fever and extremity pain presenting to a tertiary care pediatric ED and to define factors that were associated with advanced imaging, admission, and surgical intervention.Methods: The electronic medical records of children presenting to our institution's pediatric ED with fever and extremity pain were retrospectively reviewed. Data collected included demographic characteristics, laboratory studies, diagnostic imaging, need for admission, and surgical procedures.Results: The initial ED diagnosis was consistent with the definitive diagnosis 42% of the time. Children with the inability to bear weight on the affected limb were more likely to have a bacterial infection, such as osteomyelitis, septic arthritis, or intramuscular abscess (p = 0.016). An erythrocyte sedimentation rate >36 mm/hour and C-reactive protein levels >60 mg/L were found in children with osteomyelitis or septic arthritis (p = 0.043 and <0.001, respectively). Magnetic resonance imaging was ordered in 63% of children with multiple visits compared to 34% of children with a single visit (p = 0.05).Conclusions: In addition to a thorough history and physical examination, a complete set of laboratory studies and diagnostic imaging is necessary to reach an accurate diagnosis. The inability to bear weight, elevated C-reactive protein levels, and an elevated erythrocyte sedimentation rate are associated with bacterial infection. Magnetic resonance imaging is a useful imaging modality in determining an accurate diagnosis. [ABSTRACT FROM AUTHOR]

Introduction: There is conflicting data regarding if patients with vascular extremity trauma who undergo surgical treatment need to be systematically anticoagulated. We hypothesized that intraoperative systemic anticoagulation (ISA) decreased the risk of repair thrombosis or limb amputation after traumatic vascular injury of the extremities.Methods: We analyzed a composite risk of repair thrombosis and/or limb amputation (RTLA) between patients who did and did not undergo ISA during arterial injury repair. Patient data was collected in the American Association for the Surgery of Trauma PROspective Vascular Injury Treatment (PROOVIT) registry. This registry contains demographic, diagnostic, treatment, and outcome data.Results: Between February 2013 and August 2015, 193 patients with upper or lower extremity arterial injuries who underwent open operative repair were entered into the PROOVIT registry. The majority were male (87%) with a mean age of 32.6 years (range 4-91) and 74% injured by penetrating mechanism. 63% of the injuries were described as arterial transection and 37% had concomitant venous injury. 62% of patients underwent ISA. RTLA occurred in 22 patients (11%) overall, with no significant difference in these outcomes between patients who received ISA and those that did not (10% vs. 14%, p=0.6). There was, however, significantly higher total blood product use noted among patients treated with ISA versus those that did not receive ISA (median 3 units vs. 1 unit, p=0.002). Patients treated with ISA also stayed longer in the ICU (median 3days vs. 1day, p=0.001) and hospital (median 9.5days vs. 6days, p=0.01).Discussion: In this multicenter prospective cohort, intraoperative systemic anticoagulation was not associated with a difference in rate of repair thrombosis or limb loss; but was associated with an increase in blood product requirements and prolonged hospital stay. Our data suggest there is no significant difference in outcome to support use of ISA for repair of traumatic arterial injuries. [ABSTRACT FROM AUTHOR]

Background Extremity compartment syndrome is a recognized complication of trauma. We evaluated its prevalence and outcomes at a suburban level 1 trauma center. Methods The trauma registry was reviewed for all blunt trauma patients aged ≥18 years, admitted between 2010 and 2014. Chart review of patients with extremity compartment syndrome was performed. Results Of 6180 adult blunt trauma admissions, 83 patients developed 86 extremity compartment syndromes; two patients had compartment syndromes on multiple locations. Their ( n = 83) median age was 44 years (interquartile range: 31.5-55.5). The most common mechanism of injury was motor vehicle/motor cycle accident (45.8%) followed by a fall (21.7%). The median injury severity score was 9 (interquartile range: 5-17); 65.1% had extremity abbreviate injury score ≥3. Notably, 15 compartment syndromes did not have an underlying fracture. Among patients with fractures, the most commonly injured bone was the tibia, with tibial plateau followed by tibial diaphyseal fractures being the most frequent locations. Fasciotomies were performed, in order of frequency, in the leg ( n = 53), forearm ( n = 15), thigh ( n = 9), foot ( n = 5), followed by multiple or other locations. Conclusions Extremity compartment syndrome was a relatively uncommon finding. It occurred in all extremity locations, with or without an associated underlying fracture, and from a variety of mechanisms. Vigilance is warranted in evaluating the compartments of patients with extremity injuries following blunt trauma. [ABSTRACT FROM AUTHOR]

High pressure injection injuries are very dangerous type of injuries. In tis paper, we present a patient who admitted with complaints of severe pain, throbbing, tension and functional deficit at the 2nd finger of the right hand due to water based dye accumulation into it. The patient’s symptoms improved after the surgical decompression under local anesthesia in the emergency room. No complications were observed during 6 months postoperative follow-up. [ABSTRACT FROM AUTHOR]

Purpose: This study examined the value of including a venous phase in addition to the initial arterial phase in the CT angiography evaluation of extremity trauma.Methods: CT studies from 157 patients (average age 38 years, age range 18-89 years, male 83%, female 17%) were obtained for trauma to the upper or lower extremity with both arterial and venous phases and retrospectively reviewed. The detection rate and type of vascular injury were evaluated by using the arterial phase alone and compared to the detection rate when interpreting the arterial and venous phases together.Results: Arterial injury was identified in 35 cases (22%), and venous injury was identified in seven cases (5%). Four cases of discrepant diagnoses were identified between image interpretation of the arterial phase alone and interpretation using both phases, all of which were venous injuries that were visible only on the venous phase. None of the four cases of venous injury required a change in surgical management. Overall, no significant difference in diagnosis between the two methods of image interpretation (arterial phase alone, arterial and venous phases) was discovered (p > 0.125; CI 95%).Conclusions: The use of a venous phase in the CT angiography evaluation of extremity trauma does not add significant arterial diagnostic or clinical management value despite its potential of increasing the diagnostic detection rate of venous injury. [ABSTRACT FROM AUTHOR]

Background: Capillary malformation is a cutaneous vascular anomaly that is present at birth, darkens over time, and can cause overgrowth of tissues beneath the stain. The lesion is caused by a somatic activating mutation in GNAQ. In a previous study, we were unable to identify a GNAQ mutation in patients with a capillary malformation involving an overgrown lower extremity. We hypothesized that mutations in GNA11 or GNA14, genes closely related to GNAQ, also may cause capillary malformations. Methods: Human capillary malformation tissue obtained from 8 patients that had tested negative for GNAQ mutations were studied. Lesions involved an extremity ( n = 7) or trunk ( n = 1). Droplet digital PCR (ddPCR) was used to detect GNA11 or GNA14 mutant cells (p.Arg183) in the specimens. Single molecule molecular inversion probe sequencing (smMIP-seq) was performed to search for other mutations in GNA11. Mutations were validated by subcloning and sequencing amplimers. Results: We found a somatic GNA11 missense mutation (c.547C > T; p.Arg183Cys) in 3 patients with a diffuse capillary malformation of an extremity. Mutant allelic frequencies ranged from 0.3 to 5.0%. GNA11 or GNA14 mutations were not found in 5 affected tissues or in unaffected tissues (white blood cell DNA). Conculsions: GNA11 mutations are associated with extremity capillary malformations causing overgrowth. Pharmacotherapy that affects GNA11 signaling may prevent the progression of capillary malformations. [ABSTRACT FROM AUTHOR]

Copyright of Strahlentherapie und Onkologie is the property of Springer Nature and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use. This abstract may be abridged. No warranty is given about the accuracy of the copy. Users should refer to the original published version of the material for the full abstract. (Copyright applies to all Abstracts.)

Background The value of negative-pressure wound therapy as a bridge to definitive closure of traumatic extremity wounds has been established in adults. Negative-pressure wound therapy has been used to assist granulation tissue formation and promote closure of wounds. In this study, we evaluated our experience with negativepressure wound therapy for pediatric extremity wounds requiring delayed closure. Patients and methods A prospective study was conducted on 20 pediatric patients presenting with extremity injuries involving soft-tissue defects not suitable for immediate primary closure. Initial evaluation of the traumatized patient, wound irrigation, debridement, and antibiotic therapy were carried out and a plan for each case was outlined. Negative-pressure wound therapy was established using the vacuum-assisted closure system and dressings were changed every 3 days before definitive closure either by skin graft, Integra dermal matrix followed by skin graft, or local flaps. Results Granulation tissue was noted in all wounds by day 3. The mean duration of vacuum therapy was 12±3.3 days in patients whose wounds were closed by local flap advancement (n=4), 9±3.6 days in patients whose wounds were closed by skin grafts (n=8), and 6±4.8 days in patients whose wounds were closed by Integra dermal matrix (n=8). There was no incidence of skin graft or Integra losses. All local flaps healed completely. The mean follow-up period was 18±6.8 months, during which no complications were noted. Conclusion As a relatively atraumatic wound care technique with little complications, negativepressure wound therapy provides a highly effective option as a bridge for soft-tissue management of extremity trauma in pediatric patients. [ABSTRACT FROM AUTHOR]

Purpose: The purpose of this study is to assess the performance of CT angiography (CTA) in the evaluation of penetrating vascular trauma to the extremities in a large cohort of patients at our level I trauma center.Methods: A retrospective, IRB-approved review of consecutive CTAs for the evaluation of penetrating trauma to the extremities in 446 patients (M/F = 396:50, mean age = 27 years) from 1/1/2005 to 5/1/2015 was performed. Medical records were reviewed to correlate diagnostic imaging findings with clinical history and subsequent interventions. Image quality was quantified by measurement of CT attenuation coefficients in the major arteries of the extremities. The Fisher's exact test was used to analyze the relationships between the presence and type of vascular injury and subsequent clinical management.Results: One hundred and thirty-one (29.4 %) of 446 patients with penetrating trauma demonstrated major vascular injury on CTA, 35 (26.7 %) of whom underwent subsequent surgical repair. None of the patients without vascular injury on CTA underwent subsequent vascular intervention. Fisher's exact test demonstrated a statistically significant difference in management and requirement for vascular repair in those patients with a vascular injury on CTA when compared to those without a vascular injury (p < 0.0001). The mean attenuation values achieved in upper and lower extremity CTAs in this population exceeded 250 HU.Conclusion: Extremity CTA is found to be an accurate tool for surgical triage in patients having sustained penetrating vascular trauma. [ABSTRACT FROM AUTHOR]

Objective: Due to minimal tissue violation in percutaneous core needle biopsy (CNB), in contrast to open biopsy, the risk of tumor seeding and subsequent local recurrence (LR) along the biopsy tract remains unclear in extremity soft tissue sarcoma (STS). This study sought to examine the association of CNB tract resection on LR in a large STS institutional database.Materials and Methods: After a retrospective review of the 116 patients who underwent CNB prior to surgery for previously untreated non-metastatic extremity STS, 36 patients who did not have CNB tracts resected (CNB-NR) were matched with 36 who had CNB tracts resected (CNB-R) for the factors that are known to affect LR.Results: Two patients (6%) developed LR in the CNB-R group, whereas three patients (8%) developed LR in the CNB-NR group (P = 0.643). On Kaplan-Meier analysis, there was no significant difference in LR-free survival between the two groups (94.3% ± 3.9 for the CNB-R group vs. 93.8% ± 4.3 for the CNB-NR group, P = 0.747).Conclusion: Our data suggest any influence of a CNB tract resection on LR, within the limitations of this study, is likely to be of minor clinical importance in extremity STS. Although it would be prudent to resect the CNB tract in most cases, not resecting the CNB tract is a feasible option if identification or removal of the CNB tract proves difficult. [ABSTRACT FROM AUTHOR]

Aim Osteosarcoma is a highly malignant primary bone tumor. The study aim to evaluate the prognostic factors influencing the survival rate in our center. Methods This was a retrospective cohort study of all patients treated between January 2005 and December 2010. Results We included 163 patients with an age range of 6-59 years (median = 19). The median follow-up was 47 months (range 36-84). The overall survival in patients who completed chemotherapy and surgery ( n = 117) was 72% at 2 years and 44% at 5 years. Histologically, 99 (85%) had osteoblastic, 6 (5%) had chondroblastic and 3 (2.5%) had telangiectatic osteosarcoma. Limb salvage surgery was performed in 80 (49%) and 41 (25%) underwent amputation. However, 46 patients (28%) underwent no surgical intervention and incomplete chemotherapy. In total, 38/79 patients had a good chemotherapy response. There was a significantly better survival rate for limb salvage versus amputation. Independent prognostic factors for survival are compliance to treatment and presence of lung metastasis. Conclusion The overall survival of osteosarcoma patients was influenced by the presence of pulmonary metastases and compliance to treatment. Histological subtype, different chemotherapy regimens and histological necrosis after chemotherapy did not significantly influence survival. The patients who did not complete treatment had significantly poorer survival. [ABSTRACT FROM AUTHOR]

Background and objectives Plastic, orthopedic, otolaryngology, and oromaxillofacial surgery specialists rely on fibula grafts to solve reconstructive problems. The aim of this study is to discuss the use and results of vascular fibula flaps in the treatment of bone and soft tissue defects in various regions with different etiologies. Materials and methods In our clinic, we treated 32 patients with osteocutaneous fibular flaps due to bone and soft tissue defects of different etiologies and varying anatomical regions. In our study, age, gender, side, cause of injury, surgical technique, treatment results, and complications were evaluated for each patient. Results Of the 32 patients, 25 were male, and 7 were female. The average age is 37.2 (27-56). The mean bone defect size was 10.45 cm. Bone defect occurred in eight patients due to osteomyelitis, eleven patients due to gunshot wounds, nine patients due to pseudoarthrosis, and four patients due to a giant cell tumor. We applied osteocutaneous fibula flap in 27 patients and vascularized fibular flap in five patients. Bone union could not be achieved in four patients, and bone grafting was performed as a secondary surgery. Local infection occurred in five patients, and their treatment was completed with debridement and antibiotic administration. Wound complications occurred in three patients at the donor site, which were treated with debridement and skin grafting. The mean duration of radiological union was three months, and complete union was achieved in the seventh month. Conclusions We have shown in our case series that free vascularized fibula transfer has gained an important place in the field of skeletal reconstruction and is a reliable method for various bone reconstructions., Competing Interests: The authors have declared that no competing interests exist., (Copyright © 2023, Atilgan et al.)

Background: The use of musculoskeletal ultrasound (US) among hand surgeons appears to be increasing. The purpose of this study was to determine the utilization patterns and attitudes regarding US among American Society for Surgery of the Hand (ASSH) members in 2020 as well as the changes in usage patterns since a previous survey in 2015., Methods: In 2020, an updated and expanded 27-question survey was distributed to 4852 members of the ASSH. Questions assessed respondent demographics, training, and practice patterns, and access, utilization, training, and opinions pertaining to US., Results: A total of 418 surveys (8.6%) were analyzed. Compared to 2015, there was an increase in the percentage of respondents using US for diagnostic purposes (51%-68%), as well as having personal access to US machines (43% to 58%). US use to assist in diagnosing carpal tunnel syndrome increased from 19% to 27%. The most common reason for using US was convenience and practice efficiency, while the most common reasons for not using US was no machine access. In 2020, 33% of respondents performed US-guided injections., Conclusions: Compared to 2015, the majority of responding upper extremity surgeons now have personal access to US machines. Utilization of diagnostic US appears to be increasing, and two-thirds of respondents believed that US use will continue to increase among upper extremity surgeons., Competing Interests: Declaration of Conflicting InterestsThe author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Purpose: This study aimed to analyse extremity combat-related injuries (CRIs) and non-combat related injuries (NCRIs) treated in the French Forward Surgical Team deployed in Gao, Mali., Patients and Methods: A retrospective study was conducted using the French surgical database OpEX (French Military Health Service) from January 2013 to August 2022. Patients operated on for an extremity injury less than one month old were included., Results: During this period, 418 patients with a median age of 28 years [range 23-31 years] were included and totalized 525 extremity injuries. Among them, 190 (45.5%) sustained CRIs and 218 (54.5%) sustained NCRIs. Multiple upper extremity injuries and associated injuries were significantly more common in the CRIs group. The majority of NCRIs involved the hand. Debridement was the most common procedure in both groups. External fixation, primary amputation, debridement, delayed primary closure, vascular repair and fasciotomy were significantly predominant in the CRIs group. Internal fracture fixation and reduction under anaesthesia were statistically more frequent in the NCRIs group. The overall number of procedures and the overall number of surgical episodes were significantly higher in the CRIs group., Conclusion: CRIs were the most severe injuries and did not involve the upper and lower limbs separately. A sequential management was required with application of damage control orthopaedics followed by several procedures for reconstruction. NCRIs were predominant and mostly involved the hand among the French soldiers. This review supports the fact that any deployed orthopaedic surgeon should be trained in basic hand surgery and preferably have microsurgical skills. The management of local patients requires the execution of reconstructive surgery and therefore imposes the presence of adequate equipment., (© 2023. The Author(s), under exclusive licence to Springer-Verlag GmbH Germany.)

Background: Detecting bone marrow edema (BME) as a sign of acute fractures is challenging on conventional computed tomography (CT). This study evaluated the diagnostic performance of a three-material decomposition (TMD) approach for detecting traumatic BME of the extremities on spectral computed tomography (SCT)., Methods: This retrospective diagnostic study included 81 bone compartments with and 80 without BME. A TMD application to visualize BME was developed in collaboration with Philips Healthcare. The following bone compartments were included: distal radius, proximal femur, proximal tibia, distal tibia and fibula, and long bone diaphysis. Two blinded radiologists reviewed each case independently in random order for the presence or absence of BME., Results: The interrater reliability was 0.84 ( p < 0.001). The different bone compartments showed sensitivities of 86.7% to 93.8%, specificities of 84.2% to 94.1%, positive predictive values of 82.4% to 94.7%, negative predictive values of 87.5% to 93.3%, and area under the curve (AUC) values of 85.7% to 93.1%. The distal radius showed the highest sensitivity and the proximal femur showed the lowest sensitivity, while the proximal femur presented the highest specificity and the distal tibia presented the lowest specificity., Conclusions: Our TMD approach provides high diagnostic performance for detecting BME of the extremities. Therefore, this approach could be used routinely in the emergency setting.

Objective: To identify trends in apparent diffusion coefficient (ADC) measurements from diffusion-weighted imaging (DWI) with respect to tumor type classification and other tumor characteristics whether common malignant soft tissue tumors can be distinguished., Materials and Methods: A consecutive series of extremity malignant soft tissue tumors and soft tissue sarcomas (STS) among 78 adult patients with conventional MRI and DWI were included. Each case was evaluated with respect to T1/T2 signal alterations and heterogeneity, presence of peritumoral edema, necrosis, cystic changes, internal hemorrhage, and maximum longitudinal dimension blinded to the histology. The ADC mean and minimum were obtained using a free-hand region of interest of the whole tumor and the darkest (lowest signal area) ADC area of the tumor. Kruskal-Wallis and Wilcoxon Rank-Sum Tests were used to determine associations and significance between tumor subtypes. Intraclass correlation (ICC) and kappa calculations were utilized to assess inter-reader agreements for ADC values and reader diagnosis., Results: Liposarcomas showed more heterogenous T1W images with hyperintense T1W signal when compared to tumors not classified as liposarcoma (P = 0.046 and P = 0.010, respectively). Liposarcomas were relatively consistent in demonstrating an absence of hemorrhage (81.8%) while undifferentiated pleomorphic sarcomas consistently showed intralesional hemorrhage (90%). When comparing individual tumor classifications against the rest of the samples, lymphomas registered lower mean and minimum ADC values in the whole tumor and in the most hypointense area of the tumor for both readers (P < 0.05). The interobserver agreement between the two readers was good to excellent for all four ADC measurements (ICC = 0.65-0.98)., Conclusion: Diffusion-weighted imaging generated ADC measurements are reproducible but currently offer limited insight in being able to differentiate among different malignant soft tissue tumor and sarcoma histologies. T1W and T2W signal characteristics also offer limited insight in differentiating between soft tissue malignancies., (© 2023. The Author(s), under exclusive licence to International Skeletal Society (ISS).)

Background: Ankle injuries are one of the most common presentations in the ED. Although fractures can be ruled out using the Ottawa Ankle Rules, the specificity is low, which means many patients may still receive unnecessary radiographs. Even once fractures are ruled out, assessment of ankle stability is recommended to rule out ruptures, but the anterior drawer test has only moderate sensitivity and low specificity and should be performed only after swelling has receded. Ultrasound could be a reliable, cheap and radiation free alternative to diagnose fractures and ligamentous injuries. The purpose of this systematic review was to investigate the accuracy of ultrasound in diagnosing ankle injuries., Methods: Medline, Embase and the Cochrane Library were searched up to 15 February 2022 to include studies of patients of 16 years or older presenting to the ED with acute ankle or foot injury, who underwent ultrasound and had diagnostic accuracy as outcome. No restrictions were applied for date and language. Risk of bias and quality of evidence using the Grading of Recommendations, Assessment, Development and Evaluations approach were assessed., Results: Thirteen studies evaluating 1455 patients with bony injuries were included. In 10 studies, the reported sensitivity for fracture was >90%, but varied among studies between 76% (95% CI 63% to 86%) and 100% (95% CI 29% to 100%). In nine studies, the reported specificity was at least 91%, but varied between 85% (95% CI 74% to 92%) and 100% (95% CI 88% to 100%).Six studies including 337 patients examined the use of ultrasound for ligamentous injuries and found a sensitivity and specificity >94% and 100%. Overall quality of evidence for both bony and ligamentous injuries was low and very low., Conclusion: Ultrasound has the potential to be a reliable method for diagnosing foot and ankle injuries, however, higher grade evidence is needed., Prospero Registration Number: CRD42020215258., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2023. No commercial re-use. See rights and permissions. Published by BMJ.)