Apple reagiert erst, nachdem Sicherheitsforscher ausführliche Analysen veröffentlichen. Elf Schwachstellen sind mit kritisch eingestuft. Komponenten eines verbreiteten Sicherheitssystems kommunizieren im Firmennetzwerk mit einem fest programmierten Kodierungsschlüssel.
Dadurch ist es einem Angreifer möglich, die Kontrolle des Systems zu übernehmen. Die Schwachstelle kann offenbar aber nur lokal ausgenutzt werden. Im ersten Quartal tauchten alte Bekannte auf: Cyber-Kriminelle verbessern ihr Werkzeug und steigen auf neue Angriffstypen um.
Nachdem die Open-Source-Community gegen restriktive Lizenzbestimmungen protestieren, die unter anderem ein Benchmark-Verbot beinhalteten, hat Intel nun nachgegeben. Das Plug-in überwacht browserseitig die sichere Ausführung von Webprotokollen. Sie gehört zu einer zielgerichteten Spionagekampagne. Die Verteilung erfolgt über eine legitim erscheinende Porno-App. Derzeit nehmen die Hintermänner überwiegend Ziele in Israel ins Visier. Die Kampagne ist Bitdefender zufolge weiterhin aktiv.
Betroffen sind die Versionen CC und Ein Angreifer kann auch ohne Wissen des Nutzers Schadcode einschleusen und ausführen. Angriffe auf die Lücken hält Adobe für unwahrscheinlich. Die Hintermänner sammeln in nur zwei Wochen mehr als Ein Opfer soll bis zu Microsoft übernimmt per Gerichtsbeschluss die Kontrolle über die Domains.
Saransk , Republic of Mordovia Peru: Sochi, Krasnodar Krai Portugal: Ramenskoye , Moscow Oblast Russia: Khimki, Moscow Oblast Saudi Arabia: Kaluga , Kaluga Oblast Serbia: Svetlogorsk , Kaliningrad Oblast South Korea: Krasnodar , Krasnodar Krai Sweden: Gelendzhik, Krasnodar Krai Switzerland: Togliatti , Samara Oblast Tunisia: Pervomayskoye, Moscow Oblast Uruguay: Bor , Nizhny Novgorod Oblast.
FIFA Rules for classification: Group stage tiebreakers H Host. Luzhniki Stadium , Moscow. Central Stadium , Yekaterinburg. Krestovsky Stadium , Saint Petersburg. Rostov Arena , Rostov-on-Don. Cosmos Arena , Samara. Volgograd Arena , Volgograd. Fisht Olympic Stadium , Sochi. Mark Geiger United States. Kazan Arena , Kazan. Mordovia Arena , Saransk. Kaliningrad Stadium , Kaliningrad. Antonio Mateu Lahoz Spain. Otkritie Arena , Moscow. Nizhny Novgorod Stadium , Nizhny Novgorod. Matthew Conger New Zealand.
Joel Aguilar El Salvador. Jair Marrufo United States. Group stage tiebreakers Notes:. Smolov Ignashevich Golovin Cheryshev. Cuadrado Muriel Uribe Bacca. Kane Rashford Henderson Trippier Dier. Smolov Dzagoev Fernandes Ignashevich Kuzyayev. Live It Up Nicky Jam song. Association football portal Russia portal s portal. However FIFA has discussed abolishing the competition.
Harry Kane 6 goals . Mehdi Abid Charef Algeria. Bamlak Tessema Weyesa Ethiopia. Corey Rockwell United States. Ricardo Montero Costa Rica. Bertrand Brial New Caledonia.
Otkritie Arena Spartak Stadium. Krestovsky Stadium Saint Petersburg Stadium. Fisht Olympic Stadium Fisht Stadium. Central Stadium Ekaterinburg Arena. Advance to knockout stage. Group H vs Poland matchday 2; 24 June.
Group C vs France matchday 3; 26 June. Group F vs South Korea matchday 3; 27 June. Group G vs Tunisia matchday 3; 28 June. Round of 16 vs Spain 1 July. Round of 16 vs Switzerland 3 July. Round of 16 vs Brazil 2 July. Round of 16 vs Sweden 3 July. Quarter-finals vs Uruguay 6 July. Quarter-finals vs Belgium 6 July. Quarter-finals vs England 7 July. Semi-finals vs France 10 July.
Harry Kane 6 goals, 0 assists. Antoine Griezmann 4 goals, 2 assists. Romelu Lukaku 4 goals, 1 assist. Visa  Wanda Group . Diking  Luci  Yadea . A Perforator based propeller flap for lower extremity reconstruction: A good solution for the inexperienced surgeons.
A Preoperative handheld Doppler and color Doppler ultrasound in the planning of Freestyle local perforator flaps in orthopedic reconstructive surgery. A Free posterior interosseous artery perforator flap for fingertip resurfacing.
A Study on the use of microsurgery by the Hand Surgeon in Brazil. A Experimental study of histological changes in vascularloops according to the duration of the postoperativeperiod: Application in reconstructive microsurgery. A Reduction of morbidity with a reverse-flow sural flap: A Flap selection for soft tissue coverage of the posterior elbow. A Outcomes of the treatment of hand degloving injuries with greater omentum flaps.
A Treatment of incomplete amputation of the forearm and wrist laceration cases with a dorsal ulnar artery flap. Retrospective Study of 21 Cases. A Hand Dorsum Reconstruction: Thiele, Vincenzo Penna, G. Björn Stark, Steffen U. A Metacarpal shaft reconstruction using medial femoral condyle flap: A The free thin extended lateral arm flap for hand reconstruction; case series and technical modifications.
A Refining the Cross-finger Flap: A Choosing the flap in complex injuries of the hand. A Possibilities of covering simple and complex tissue defects in hand and wrist. A Why do we prefer free fibula flap for the reconstruction of complex clavicular defects? A The Interossea anterior system for pedicled or free flaps in hand surgery — theory and clinical experience.
A Reconstruction of the hand by small free flaps. Boretto, Javier Bennice, Gerardo L. A Salvaging digital replantation: Efficiency of Heparin solution subcutaneous injection in finger replantation. A Effects of a temperature-sensitive, anti-adhesive agent on the clinical outcome of carpal tunnel release surgery. A Replantation of the hand with third degree burns — case report.
A Vascularized fibula flap in orthopaedic surgery. A Palmaris longus tendocutaneous arterialized venous free flap to reconstruct the interphalangea collateral ligament in composite defects. A Composite ALT anterolateral thigh perforator flap with tendon transfer for soft tissue heel defect including Achilles' tendon loss.
A Proximal hand and forearm Replantation: Whiston hospital, Liverpool, UK. Alazhar University Hospitals, Damietta city ,Egypt.
Sterbenz 2 , Melissa J. A Surgical treatment of carpal boss by simple resection: A Arterial aneurysms of the hand. A Treatment of a non viable upper limb amputation with a sequence of operations. A Comparison of two different processing method of detergent decellularization. A Rapid methods of testing and teaching basic knowledge and skills on hand injuries and soft tissue trauma. A Impact of patient-surgeon relationship quality on return to work conditions in patients with trauma or musculoskeletal disorders of the upper limb.
A Wide awake hand surgery - a real revolution. It is possible to reduce the anesthetic doses? A Proximal Row Carpectomy with resurfacing of both lunate fossa and proximal capitate using a femoral osteochondral graft: A Hand and wrist surgery without suspending warfarin or oral antiplatelet —Systematic review.
A Surgical treatment for long-term sequelae after cobra bite. Oriol Segura 1 , A. Sarma 3 , P. Kumar 3 , FJ.
Peris Prat 1 , G. A Lessons for high income health service providers from a reconstructive hand surgery mission in a low income country. A Bioengineering and Regenerative Surgery: A OrthOracle and the acquisition of procedural skills using cognitive simulation. A The science of hand holding.
A Management of ulnar nerve entrapment at the elbow with anterior subcutaneous transposition. The bifid reversed palmaris longus muscle, an extremely rare cause of median nerve compression in a child. A Delayed repair of disconnected thenar branch of median nerve having transligamentous variation after carpal tunnel release: A Preoperative predictors of patient satisfaction after carpal tunnel release. A The prevalence and characteristics of female cubital tunnel syndrome patients.
A Wide-awake approach for open carpal and cubital tunnel release surgery, Is it available? A Subcutaneous and submuscular transposition due to ulnar nerve entrapment at the elbow — analyses of 43 primary and 44 revision cases. Ilka Anker 1 , Gert S. A Study of the traumatic injuries of the hand to the elbow during the period of Carnival celebrations of in Brazil.
Learning Curve and Complications. A Can we replace the electrophysiologic study with the ulatrasonographic examination in the diagnosis of carpal tunnel syndrome? A Prevalence and the influence of trapeziometacarpal arthritis on patients with carpal tunnel syndrome. A Predictive factors in splinting therapy for carpal tunnel syndrome. A Factors involving the clinical profile of carpal tunnel syndrome. A The first rib—clavicular costoclavicular space is not always the narrowest: Osaka City University, Osaka, Japan.
A Comparative study on percutaneous and mini-open CTRs in idiopathic carpal tunnel syndrome. Department of Orthopedic Surgery, Seoul St. A Carpal tunnel syndrome in association with congenital hand anomalies in adults. A Video surgery for recurrent carpal tunnel: Interest and feasibility study.
A Endoscopic exploration of the carpal tunnel during release of the median nerve. A What is the actual definition of carpal tunnel syndrome recurrence? A Can changes in magnetic resonance imaging before and after surgery predict whether nerve conduction velocities improve after carpal tunnel release in chronic hemodialysis-associated carpal tunnel syndrome? A Entrampment of the supraescapular nerve. Results in 30 patients. A Treatment of Thoracic Outlet Syndrome.
A How to improve the effect of Platelet-rich plasma PRP on the peripheral nerve; its use in the carpal tunnel release. A Carpal tunnel syndrome associated with volar locking plate fixation for the distal radius fractures.
A Gender differences in open carpal tunnel releases — a national registry based cohort study. A The treatment of burned hands in the Colectiv Club mass casualty fire. A Carpal tunnel syndrome with space occupying lesion. A Ulnar motor branch entrapment in Alpine skiing. A Chronic carpal tunnel syndrome due to a posttraumatic aneurysm. A The prevalence of carpal tunnel syndrome in athletes of sport for People with a disability.
A Minimal endoscopic decompression of ulnar nerve in the cubital tunnel. A The neurovascular V-Y advancement flap. A novel technique to bridge digital nerve defects up to 1.
A Assessment of current epidemiology and risk factors surrounding brachial plexus birth palsy. A Intraneural fascicular dissection of lipofibromatous hamartoma of the digital branches of the median nerve: A Transfer of a pronator teres motor branch to achieve finger flexion in tetraplegia: A Outcome of nerve allografts in nerve injuries of the hand — single unit experience.
Bauback Safa 1 , Jaimie T. Niacaras 4 , Leon J. Desai 8 , Gregory M Buncke 1. A Cortical changes may be responsible for the limited functional recovery in patients with Obstetrical Brachial Plexus Injury.
Pensy 2 , Walter A. Eglseder 2 , Joshua M. A Neurotisations in brachial plexus injuries — results of 7 years. A The introduction of human adipose derived Mesenchymal Stem Cells to clinically available nerve replacement treatments.
Femke Mathot 1, 2 , Nadia Rbia 1 , A. Bishop 2 , S. Hovius 1 , A. A Brachial Plexus injuries associated with vascular lesions: A Nerve conduits for treating peripheral nerve injuries: A systematic literature review.
A Long-term follow-up after vascularized contralateral ulnar nerve transfer to median nerve in total arm type brachial plexus injury: A Intraoperative monitoring during peripheral nerve surgery under ultrasound guided selective nerve block anesthesia.
Shores 2 ; John V. Ingari 2 , Renata V. Niacaras 6 , Leon J. Nesti 7 , Wesley P. Thayer 8 ; Gregory M. A Analysis of radial nerve paralysis caused by humeral shaft fracture. A Tension at nerve repair sites: What is the effect of trimming a nerve? Abzug 1 , Alexandria L. A Great Occipital Nerve as a motor donor nerve in brachial plexus palsy: A Overuse injuries in patients with brachial plexus injury in the northern Netherlands. A Myo-electricity and gaze tracking data to improve hand prosthetics and neuro-cognitive examination.
A Clinical evaluation of an innovative Polyactic Acid and Carbon Nanostructures interface for the peripheral nerve rigeneration: A The role of ultrasound examination in penetrating nerve injuries. A New method of decellularization of human nerve segments applied to the development of implantable prostheses for the repair of peripheral nerve lesions.
A Injury to the infraclavicular brachial plexus following dislocation of the glenohumeral joint. A Nerve transfer strategies to improve hand outcome in isolated medial cord brachial plexus injuries: Staged motor nerve transfer through a reversed medial cutaneous nerve of forearm vascularised graft. A Supinator branch to lateral cutaneous nerve of forearm in situ staged motor nerve transfer for distal forearm targets in medial cord brachial plexus injury. Research of the More Reliable Method.
A The amnion muscle combined graft AMCG conduits in the repair of wide substance loss of bigger trunks of peripheral nerves of the forearm and wrist. Our clinical and experimental experience. A Treatment of neuroma upper extremity by nerve capping. Unit for reconstructive Surgery in brachial plexus injuries, tetraplegia and cerebral palsy, Unfallkrankenhaus Berlin, Germany.
A Sensate nerve fiber transfer from the dorsal branches of the radial nerve for the 1st space to the deep motor branch of the ulnar nerve to protect intrinsic hand muscles from atrophy; an anatomical and histomorphometric study.
A Brachial plexus impingement secondary to ICD wires: A Restoration of the deltoid by nervous transfer of a triceps motor branch on the axillary nerve. Study of 19 patients. A Use of intercostal nerves in treatment of complete brachial plexus palsy.
A Isolated flexor pollicis longus nerve fascicle injury - a rare differential diagnosis of thumb flexion deficiency. A Nerve wrapping using cephalic and basilica vein for treatment of recurrent chronic nerve scarring of median nerve.
A Management of shoulder internal rotation limitation in obstetrical palsy. A Psychosocial assessment procedure for bionic reconstruction in patients with global brachial plexus injuries. A Iatrogenic injuries of the radial nerve — a frequent problem?
A Tensegrity in the common digital nerves: A Persistent neuropathic pain after nerve repair in the upper extremity. A A case report of early diagnostics and succesful treatment of acute complex regional pain syndrome CRPS.
A Partial wrist arthrodesis in Cerebral Palsy Children. A Revisited HyperSelective Neurectomy in upper limb spasticity.
A Functional outcome of shoulder arthrodesis in brachial plexus palsy patients. E-Posters Browse e-poster abstracts below. Visit E-poster site to see the e-poster files. We present an anomaly not previously described in the literature where the FDP to the ring finger was found to originate from the FPL tendon, causing tight flexion contracture of both due to underlying muscle spasticity.
An year-old boy with Leigh syndrome was under the care of our plastic surgery unit for flexion contractures of his upper limbs. Of note, pre-operatively he had a very tight FPL and wrist flexors but also incidentally a severe flexion deformity of his ring little and fingers which resembled a claw hand.
During surgical exploration and release of the muscles, an anomalous fusiform muscle was found originating from the tendon of the FPL, heading to the ring finger and flexing the distal interphalangeal joint. The accessory muscle was divided and improved the flexion contracture. Anatomically distinct from the anomalous tendon slips described by Linburg and Comstock, this accessory muscle actually originated from the FPL and inserted in the ring finger.
While most anomalous muscles are asymptomatic, ours was causing symptoms particularly due to underlying muscle spasticity. The other clinical relevance of this is that the ring finger FDP usually supplied by the ulnar nerve was in this instance supplied by the median nerve. We present the case of a 28 year old male mechanic who presented with a painful swelling over his right thenar eminence following a road traffic accident.
Shortly afterwards he noticed a swelling in his right palm over the first web space which increased in size with finger flexion. His grip strength was compromised and had reduced abduction of his index finger. Ultrasound and MRI scans were inconclusive. No intrinsic muscle rupture was detected and no mass lesion was detected. Hypertrophy of the index intrinsic muscles was suggested. The swelling increased in size and his overall hand function decreased, so surgical exploration was planned.
At operation, the FDP tendon to the index finger and the intrinsic muscles were intact and of normal appearance. However, an accessory muscle was seen attached to the index finger FDS tendon in zone 3. A tendon ran proximally from this accessory muscle belly into the forearm. The accessory muscle was excised from the FDS tendon and the accessory tendon was sutured end to side on the existing FDS tendon.
Postoperatively, the patient made a full recovery with reduced pain and significantly improved hand function. Anomalous and accessory muscles in the palm are anatomical curiosities until they become symptomatic.
Accessory FDS muscles presenting in the palm are rare and only a few cases have been reported in the literature since they were first described in by Vichare. However, significant functional problems have been reported in conjunction with these anatomical variations, including pain, compression neuropathy, digital triggering and stiffness.
Because of their rarity, their diagnosis is often delayed or initially missed. The authors show clear anatomical photographs of this accessory muscle along with an algorithm for investigating suspected anatomical variations. Two major lunate types have been proposed on the basis of the absence Type I or presence Type II of medial facets. The first purpose of this study was to examine the reliability and reproducibility of the two methods of determining the lunate type: The second purpose was to investigate the compatibility of the radiographic classification of lunate types with MR arthrography MRA findings.
Plain radiographs of a total of wrists were reviewed by three observers. The Cohen kappa and Fleiss kappa statistics were used for estimating the intra- and inter-observer reliabilities.
The compatibility of the lunate types with the MRA findings, as assessed by each observer, was investigated. The overall intra-observer reliability was 0. The overall inter-observer agreement of the three raters was 0. The PA analysis and MRA findings for the detection of medial facets of the lunate were compatible in of the patients On the CTD analysis, 76 Both systems had moderate inter-observer and intra-observer reliabilities.
Although the Type II lunates on both radiographic analyses showed a good compatibility with the MRA findings, clinicians should consider undetected medial facets in Type I lunates on PA analysis. In the musculoskeletal system, structure dictates function and the development of pathology. Interpreting wrist structure is complicated not only by the existence of multiple joints and ligamentous structures but also by variability in bone shapes and anatomical patterns.
A previous study evaluated normal plain radiographs for lunate and capitate shape in the midcarpal joint. This study identified intracarpal measurements related to lunate and wrist type. Assuming that these disparate patterns will transfer forces differently, our purpose was to correlate the forces transferred to the distal radius and ulna with the morphological measurements in cadaver arms.
Radiographs from a database of 49 cadaver wrists previously tested for force transfer between the radius and ulna were examined. The percentage of the compressive force through the distal ulna and radius was determined by mounting load cells to the distal radius and ulna while Each wrist was tested in neutral flexion-extension and radioulnar deviation.
There were 35 lunates type 1 with a mean ulnar force of This has been published in a previous study. This may support that a type 2 wrist transfers forces differently through the wrist.
Nerve section is often present in patients with hand trauma. Section of the digital collateral nerves needs appropriate repair to regain sensibility to support physiological local forces to allow early motion in case of concomitant flexor tendon section.
This study characterizes the mechanical behavior of digital collateral nerve to stablish their healthy mechanical properties. Digital collateral nerves were preserved in sodium chloride 0. A correlation and independence test were applied to the values to explore the relationships between groups each finger: The stress- strain curve and young modulus were shown.
The mean values found for the digital collateral nerves were: The scanty number of samples did not allow to stablish a significant difference between fingers, neither was possible to stablish a correlation between density and Young Modulus. A linear regression model for the scatter plot of nerve specific modulus and specific stress showed a tendency to direct correlation between these variables.
Digital collateral nerves biomechanics are the first step toward a development of a better nerve repair. Data acquired during the experiment can be used to improve simulations of nerves during training and surgical planning.
Further studies should correlate the ex vivo data with non-invasive techniques as in vivo elastography. Allen Buckner Kanavel was an American surgeon, best remembered for describing the cardinal signs of suppurative flexor tenosynovitis. With international concern over antibiotic resistance, it is timely to reconsider the role of surgery preceding the availability of antibiotic medication.
Therefore, better understanding of the way infections in the hands can spread is of paramount importance in managing our patients. To determine the communications between each fascial space, Kanavel injected a solution of radio-opaque dye mixed with diluted Plaster of Paris from different entry points, such as the tendon sheaths, wrists, and deep palmar spaces.
The solution was injected at different pressures into a formalin-hardened hand specimen to observe where infections would spread when the spaces ruptured.
He then took X-rays then the novel Roentgen rays of the injected hand specimens and performed cross-sections to better delineate these spaces. These spaces described will be illustrated by MRI images of current cases. He described two main deep spaces of the hand: The middle palmar space was bounded by the third metacarpal to the radial border of the fifth metacarpal bone, with a thin fibrous septum separating it from the tendons that lie anteriorly.
The thenar space was said to be bounded by the adductor transversus posterolaterally, and the flexor tendons anteriorly. The septa between these two spaces are thick, firm, and essential in preventing spread of infections.
We were initially drawn to his initial study as we noticed it was rare to come across infections of the hand that conformed to his boundaries of the deep fascial spaces in actual clinical practice. Similarly, several later papers had varying descriptions of the boundaries of the deep spaces. For example, Grodinsky performed dissections and injections on 92 hands describing many other spaces with indeterminate septa within.
One possibility for this discrepancy was that cadaveric studies were unable to replicate the erosive and inflammatory processes of an active infection.
Another possibility would be inaccurate interpretation of the dissections, as the spaces were mainly illustrated through hand-drawn images by different artists. Modern imaging should be performed to delineate relevant spaces that are encountered during infections.
The donor vein for constructing AV-loop graft was small saphenous vein graft. Currently there is no anatomical study about size, length and number of branching of small saphenous vein. To study anatomy of small saphenous vein, size and number of its branches and its valves as a vascular graft option for use in AV-loop graft in FFMT reconstruction in BPI with concomitant subclavian artery injury.
The anatomy of the small saphenous vein was studied in 30 legs of fresh and soft cadavers. There were 15 females and 15 males with mean age The total length of small saphenous vein was measured over the complete length of the leg. Recorded location, size and number of branches. We used retrograde saline injection to locate valves direction.
Statistical analysis was performed by SPSS The average length of small saphenous vein taken from distal edge of lateral malleolus to the point where small saphenous vein connect to popliteal vein was The average diameter of proximal and distal end was 0. The average frequency of branches was The average size of branches was 0. The distance from each branch to distal end ranging from 1. Valves of small saphenous vein allow bidirectional flow. Knowledge on the anatomical variations and characteristics of the small saphenous vein can be helpful in clinical practice and surgical operations concerning patient with BPI patients who undergone AV-loop graft in FFMT.
Universitat de Barcelona, Barcelona, Spain Objetives: This study aimed to describe the role of the Pronator Quadratus PQ muscle and the Anterior Interosseous Artery AIA in the vascularity of the distal radius and its relationship with the union in distal radius fractures. Sixteen adult hands from fresh cadavers were dissected. There were 8 male and 8 female with a mean age 72 years range, years.
Dissections were performed using magnifying loupes and vascular anatomy was studied. Hands were processed using soft tissue digestion and bone clearing using Spalteholz technique.
The PQ muscle originates from the ulna by a strong aponeurosis. The muscle is attached to the flexor surface of the distal radius and also on its medial triangular area, proximal to the sigmoid fossa. The distal border of the muscle covered the distal radioulnar joint and is on average 14 mm mm from the lower articulating surface of the radius. The AIA is a terminal branch of the common interosseous artery IA , but it occasionally arises from the ulnar artery.
The AIA is accompanied by its venae comitantes and the anterior interosseous nerve, all of which lie on the flexor surface of the interosseous membrane, deep to the PQ muscle. The artery, along its course gives a series of perforating branches at intervals of 15 mm.
The distal radius was supplied by three main vascular systems: The palmar epiphyseal vessels branched from the radial artery, palmar carpal arch and anterior branch of the AIA. Every specimen studied had one o more palmar metaphyseal arch that coursed through the PQ. In the metaphyseal area we found numerous periosteal branches originating deep in the PQ and the AIA.
These branches provided the main supply to the distal radius. Vessels perforated the bone and formed an anastomotic network. In the diaphyseal area only the nutrient vessel provided intraosseous vascularity in the distal radius.
Numerous metaphyseal branches arise from the deep PQ muscle and the AIA course towards the distal radius. These branches allow the union of the distal radius fractures and they make that the nonunion be an uncommon complication.
The main vascular contribution takes place by deep fibers of the PQ, so that the superficial fibers can be surgically approached for a plate with a minimum risk of injury to the vascularity. Brachial plexus 1 abstracts. There remains a shortage of literature showing what might be achieved with delayed secondary neurotisation following severe extremity trauma.
This case shows what may be achieved if challenging trauma is managed within an effective protocol and timely access to expertise. Case Report A year old male sustained a subtotal amputation of his left arm requiring vein graft revascularisation. Other injuries included a divided axillary artery, fractured clavicle and ruptured musculocutaneous nerve with intact posterior cord of the brachial plexus, median nerve and ulnar nerve. Total ischaemia time was less than 4 hours.
The patient made a good recovery and was discharged two weeks later. Three months post-injury the patient had full hand function and sensation and elbow extension, although he scored M1 for elbow flexion, M3 for trapezius function and M0 for shoulder abduction. He underwent a nerve transfer of a median nerve motor fascicle to the brachialis muscle and received physiotherapy and electrical neuromuscular stimulation post-operatively.
We carried out a nerve transfer of the posterior motor branch of triceps to axillary nerve. He has regained almost full shoulder abduction and returned to his usual pre-morbid employment. Discussion The high volume of severe trauma at our centre has enabled us to develop an effective trauma system which successfully manages candidates for limb salvage.
However, when this patient presented there had been little published utilising delayed nerve transfer following mutilating upper limb injuries. As a result, we had to establish our own practice. We consider three months a reasonable time for secondary procedures as the skin should be supple and swelling-free. For proximal upper limb injuries the restoration of elbow function should take precedence, followed by shoulder stability and active abduction and external rotation.
However, when we operated on this patient, the tissue scarring had made the nerve branch to biceps unavailable. Therefore, we chose to coapt a fascicle of the median nerve to the brachialis muscle branch within unscarred tissue.
In this patient, the outcome resulting from brachialis reinnervation alone was excellent. On returning for review 12 months the patient still needed improvement in shoulder function. As we could not use the spinal accessory nerve transfer to suprascapular nerve, we utilised the nerve branch to triceps to reconstruct the axillary nerve. Physiotherapy and electrostimulation was given post-operatively and after 10 years the patient has regained almost full arm function. Conclusion This case is the first documented case showing an excellent functional outcome in a revascularised limb following nerve transfer at 12 months.
We stress the importance of senior expertise and a clearly defined trauma protocol which minimises ischaemia time. Mutilating upper limb injuries present a challenge, but modern neurotisation techniques, even if delayed, can result in success. At the first visit on the six day after onset, the X - ray was normal. On the same day, MRI findings was osteomyelitis in the middle phalanx.
However, the serum inflammatory response was negative. Serum rheumatic response was also negative, but antinuclear antibody was positive at times. On the 12th day after onset of disease, the vicinity of the epiphyseal line of the middle phalanx became erosive.
At this point, from literature search and pediatric consultation, we got a diagnosis of Microgeodic disease. The antibiotic was discontinued.
Pain was relieved 2. At 4 weeks after onset, the middle phalanx fractured and fixed with the splint. Bone fusion was somewhat late. There was no deformation healing, but the epiphyseal line of middle phalanx and distal phalanx closed. At 7 months after onset, the difference in bone length between bilateral middle phalanges was 2 mm.
The finger healed without dysfunction. Redness and swelling of fingers and toes like frostbite. It is accompanied by mild pain and itching. Predilection age is elementary school age 6 - 12 years old. It is mainly in the middle phalanx. A bone resorption image is recognized in the X-ray image.
The cause is unknown, it is thought to be a transient bone circulation disorder. Prognosis is usually good, it will heal spontaneously in about 6 months.
In this case, owing to attaching a diagnosis at a relatively early stage, appropriate treatment could be done. Microgeodic disease was reported 24 papers in PubMed. Since the arterial arch of the hand is predominant on the ulnar side, it seems that this disease is many in the index finger. Oberg-Manske-Tonkin [OMT]-classification , but none of these describe involvement proximal from the wrist other than radio-ulnar synostosis.
One case of longitudinal cleavage of the upper extremity has been described in the literature. Materials and methods An otherwise healthy 8-month-old infant presented with congenital split right forearm. Results Starting from the elbow joint, the forearm is divided into a superior radial forearm with a thumb and an index finger and an inferior ulnar forearm with two fingers. X-rays showed a radius and two metacarpals in the radial forearm and a hypoplastic ulna and a single metacarpal supporting two digits in the shorter ulnar forearm.
The elbow joint of the radial part had an active and passive extension lag of 60 and 50 degrees, respectively, and an active and passive flexion of and degrees, respectively.
An ulnohumeral synostosis was present and the ulnar forearm showed no motion. Conclusions This is the first reported case of congenital forearm. A possible suggested ethiologic theory would be an error of limb bud specification in the 4th or 5th week of gestation. It has been suggested that the timing of an error in limb bud specification would determine the extent of duplication. An early insult would lead to a more proximal division of the upper limb.
We suggest that the case is a forearm cleavage - less severe than a total of upper extremity cleavage, but more severe as a conventional cleft hand. We suggest that a new category — cleft forearm complex — be added to the OMT —classification. Xuyang Song, Alexandria L. Case, Rory Carrol, Joshua M. Emergency room transfers to a higher level of care are a vital component of modern healthcare, as optimal care of patients requires providing access to specialized personnel and facilities.