Unstable lesions of the forearm: Terminology, evaluative score and synoptic table.

The term "unstable lesions of the forearm" (ULF) was born to more easily describe how a partial or complete instability of the forearm unit might occur due to a traumatic loss of the transverse or longitudinal connection between the radius and ulna. For such an alteration to occur, at least two of the three main osteoligamentous locks (proximal, middle and distal) must be interrupted, often in association with a radial and/or ulnar fracture. Examining the historical patterns (Monteggia, Galeazzi, Essex-Lopresti and criss-cross lesions) and variants described in the literature, out of a total of 586 recorded interventions for forearm trauma, two elbow teams and one wrist team selected 75 cases of ULF. The aim was to describe the instability depending on its clinical and radiographic features, together with the anatomopathological evolution of the lesions based on the time of diagnosis and treatment. The clinical results, evaluated using a new score (FIPS) the Forearm Italian Performance, revealed a correlation between earlier diagnosis and treatment and a better score. The authors suggest a synoptic table that describes 1) the type of instability (proximal transverse, distal transverse, longitudinal and transverse, proximal and distal transverse), 2) classic patterns and variants with characteristic lesions and evolution over time (acute, chronic dynamic, chronic static) and 3) the three forearm constraints and segmental involvement of radius and/or ulna using an alphanumeric classification. Finally, some generic surgical suggestions are proposed.

Targeted Muscle Reinnervation and Osseointegration for Pain Relief and Prosthetic Arm Control in a Woman with Bilateral Proximal Upper Limb Amputation.

BACKGROUND: Bilateral proximal upper limb loss is a dramatic life-changing event. Replacement of the lost function with prosthetic arms, including multiple mechatronic joints, has remained a challenge from the control, comfort, and pain management perspectives. Targeted muscle reinnervation (TMR) is a peripheral nerve surgical procedure proposed to improve the intuitive control of the prosthetic arm and for neuroma and phantom pain management. Moreover, osseointegrated percutaneous implants (OPIs) allow for direct skeletal attachment of the prosthetic arm, ensuring freedom of movement to the patient's residual articulations. CASE DESCRIPTION: We have reported the first combined application of TMR and an OPI to treat a 24-year-old woman with a bilateral amputation at the shoulder level on the right side and at the very proximal transhumeral level on the left side. TMR was performed bilaterally in a single day, accounting for the peculiar patient's anatomy, as preparatory stage to placement of the OPI, and considering the future availability of implantable electromyographic sensors. The 2 OPI surgeries on the left side were completed after 8.5 months, and prosthetic treatment was completed 17 months after TMR. CONCLUSIONS: The use of TMR resolved the phantom pain bilaterally and the right-side neuroma pain. It had also substantially reduced the left side neuroma pain. The actual prosthetic control result was intuitive, although partially different from expectations. At 2 years after TMR, the patient reported improvement in essential activities of daily living, with a remarkable preference for the OPI prosthesis. Only 1 suspected case of superficial infection was noted, which had resolved. Overall, this combined treatment required a highly competent multidisciplinary team and exceptional commitment by the patient and her family.

Diagnosis and treatment of acute Essex-Lopresti injury: focus on terminology and review of literature.

BACKGROUND: Acute Essex-Lopresti injury is a rare and disabling condition of longitudinal instability of the forearm. When early diagnosed, patients report better outcomes with higher functional recovery. Aim of this study is to focus on the different lesion patterns causing forearm instability, reviewing literature and the cases treated by the Authors and to propose a new terminology for their identification. METHODS: Five patients affected by acute Essex-Lopresti injury have been enrolled for this study. ELI was caused in two patients by bike fall, two cases by road traffic accident and one patient by fall while walking. A literature search was performed using Ovid Medline, Ovid Embase, Scopus and Cochrane Library and the Medical Subject Headings vocabulary. The search was limited to English language literature. 42 articles were evaluated, and finally four papers were considered for the review. RESULTS: All patients were operated in acute setting with radial head replacement and different combinations of interosseous membrane reconstruction and distal radio-ulnar joint stabilization. Patients were followed for a mean of 15 months: a consistent improvement of clinical results were observed, reporting a mean MEPS of 92 and a mean MMWS of 90.8. One case complained persistent wrist pain associated to DRUJ discrepancy of 3 mm and underwent ulnar shortening osteotomy nine months after surgery, with good results. DISCUSSION: The clinical studies present in literature reported similar results, highlighting as patients properly diagnosed and treated in acute setting report better results than patients operated after four weeks. In this study, the definitions of "Acute Engaged" and "Undetected at Imminent Evolution" Essex-Lopresti injury are proposed, in order to underline the necessity to carefully investigate the anatomical and radiological features in order to perform an early and proper surgical treatment. CONCLUSIONS: Following the observations, the definitions of "Acute Engaged" and "Undetected at Imminent Evolution" injuries are proposed to distinguish between evident cases and more insidious settings, with necessity of carefully investigate the anatomical and radiological features in order to address patients to an early and proper surgical treatment.