Evaluation of surgical or conservative treatment of forearm fracture in pediatric floating elbow injuries.

OBJECTIVE: Floating elbow, which refers to a humerus fracture in the supracondylar region and a forearm fracture, is a very unusual injury. The purpose of this study is to compare the clinical results of patients with "floating elbows" who underwent surgical therapy and who were given forearm immobilization with a splint as follow-up care. PATIENTS AND METHODS: Fifteen patients who had been diagnosed with floating elbow owing to trauma were scanned retrospectively and followed up for at least a year. Eight individuals who suffered from broken forearms underwent surgical repair. After initial treatment, a lengthy arm splint was used to immobilize seven patients' arms. The modified Flynn criteria were used to analyze the data, and comparisons were made between the groups. RESULTS: The median age and mean follow-up time for patients whose forearms were conservatively followed was 6.1 years and 13.8 months, respectively. The median age of the patients who underwent forearm surgery was 8.5 years, and the average follow-up was 14.2 months. Five of the seven patients whose forearms underwent conservative follow-up had outstanding clinical outcomes, while two had poor and moderate outcomes. Four individuals who got surgical treatment for their forearms had excellent and good clinical outcomes, while the other four had intermediate and poor outcomes. Between the two groups, there was no discernible difference (p = 0.60). CONCLUSIONS: In the pediatric population with floating elbow injuries, using a cast for forearm fractures may not necessarily result in worse outcomes compared to surgical management.

Trends and projection of forearm fractures including elbow fractures of the Olecranon in Sweden: an analysis of 363 968 fractures using public aggregated data.

BACKGROUND: Forearm and olecranon fractures are a common orthopaedic injury. This study aimed to analyse whether the incidence of forearm injury is changing and identifying trends in the number of forearm and olecranon fractures using public aggregated data in Sweden. METHODS: The number of forearm and olecranon fractures as defined by the number of registered diagnoses with the ICD-10 code of S52 were collected and normalized per 100,000 inhabitants and stratified per sex, age, and month. Age-adjusted incidence for forearm and olecranon fractures were calculated using the direct method. Poisson regression was used to analyse monthly, seasonal and yearly change in forearm and olecranon fracture incidence. Logistical regression was used to predict future trends of forearm and olecranon fractures. RESULTS: The findings revealed a slight decreasing trend in forearm and olecranon fractures. The average incidence rate during the study period was 333 with women having a higher incidence rate than men. More fractures occurred in the winter months. Fluctuations in the number of forearm and olecranon fractures were observed during 2020 which may be influenced by the COVID-19 pandemic. Based on current data, forearm and olecranon fractures are expected to decrease in Sweden by 2035. CONCLUSION: This study describes the trend of forearm and olecranon fractures among individuals according to sex and age in Sweden using easily obtainable data. Trends in forearm and olecranon fractures are dependent on sex and age but generally show a decreasing trend. More precise studies are needed in order to properly quantify the specific incidence of various subtypes of forearm and olecranon fractures and associated risk factors.

Epidemiology of forearm fractures in women and men in Norway 2008-2019.

The purpose of this paper is to describe rates of forearm fractures in adults in Norway 2008-2019. Incidence rate of distal forearm fractures declined over time in both sexes. Forearm fracture constitute a significant health burden and prevention strategies are needed. PURPOSE: To assess age- and sex-specific incidence rates, and time trends for forearm fractures in Norway, and compare these with incidence rates in other Nordic countries. METHODS: Data on all patients aged 20-107 years with forearm fractures treated in Norwegian hospitals from 2008 to 2019 was retrieved from the Norwegian Patient Registry. Fractures were identified based on International Classification of Disease 10th revision code S52. Age- and sex-specific incidence rates and changes in incidence rates were calculated. RESULTS: We identified 181,784 forearm fractures in 45,628,418 person-years. Mean annual forearm fracture incidence rates per 100,000 person-years were 398 (95% CI 390-407) for all, 565 (95% CI 550-580) for women, and 231 (95% CI 228-234) for men above 20 years. Mean annual number of forearm fractures was 15,148 (95% CI 14,575-15,722). From 2008 to 2019, age-adjusted total incidence rates of forearm fractures S52 diagnoses declined by 3.5% (incidence rate ratio (IRR) of 0.997 (95% CI 0.994-0.999)) in men. The corresponding decline in women was not significant (IRR: 0.999 (95% CI 0.997-1.002)). In the same period, the age-adjusted incidence rates of distal forearm fractures declined by 7.0% in men (IRR = 0.930; 95% CI 0.886-0.965) and 4.7% in women (IRR = 0.953; 95% CI 0.919-0.976). The incidence rates of distal forearm fractures were similar to rates in Sweden and Finland. CONCLUSION: Age-adjusted incidence rates of distal forearm fractures in both sexes declined over time.

Validation of forearm fracture diagnoses in administrative patient registers.

The validity of forearm fracture diagnoses recorded in five Norwegian hospitals was investigated using image reports and medical records as gold standard. A relatively high completeness and correctness of the diagnoses was found. Algorithms used to define forearm fractures in administrative data should depend on study purpose. PURPOSE: In Norway, forearm fractures are routinely recorded in the Norwegian Patient Registry (NPR). However, these data have not been validated. Data from patient administrative systems (PAS) at hospitals are sent unabridged to NPR. By using data from PAS, we aimed to examine (1) the validity of the forearm fracture diagnoses and (2) the usefulness of washout periods, follow-up codes, and procedure codes to define incident forearm fracture cases. METHODS: This hospital-based validation study included women and men aged ≥ 19 years referred to five hospitals for treatment of a forearm fracture during selected periods in 2015. Administrative data for the ICD-10 forearm fracture code S52 (with all subgroups) in PAS and the medical records were reviewed. X-ray and computed tomography (CT) reports from examinations of forearms were reviewed independently and linked to the data from PAS. Sensitivity and positive predictive values (PPVs) were calculated using image reports and/or review of medical records as gold standard. RESULTS: Among the 8482 reviewed image reports and medical records, 624 patients were identified with an incident forearm fracture during the study period. The sensitivity of PAS registrations was 90.4% (95% CI: 87.8-92.6). The PPV increased from 73.9% (95% CI: 70.6-77.0) in crude data to 90.5% (95% CI: 88.0-92.7) when using a washout period of 6 months. Using procedure codes and follow-up codes in addition to 6-months washout increased the PPV to 94.0%, but the sensitivity fell to 69.0%. CONCLUSION: A relatively high sensitivity of forearm fracture diagnoses was found in PAS. PPV varied depending on the algorithms used to define cases. Choice of algorithm should therefore depend on study purposes. The results give useful measures of forearm fracture diagnoses from administrative patient registers. Depending on local coding practices and treatment pathways, we infer that the findings are relevant to other fracture diagnoses and registers.

Forearm fractures - are we counting them all? An attempt to identify and include the missing fractures treated in primary care.

OBJECTIVE: Norway has a high incidence of forearm fractures, however, the incidence rates based on secondary care registers can be underestimated, as some fractures are treated exclusively in primary care. We estimated the proportion of forearm fracture diagnoses registered exclusively in primary care and assessed the agreement between diagnosis for forearm fractures in primary and secondary care. DESIGN: Quality assurance study combining nationwide data from 2008 to 2019 on forearm fractures registered in primary care (Norwegian Control and Payment of Health Reimbursement) and secondary care (the Norwegian Patient Registry). SETTING AND PATIENTS: Forearm fracture diagnoses in patients aged ≥20 treated in primary care (n = 83,357) were combined with injury diagnoses for in- and outpatients in secondary care (n = 3,294,336). MAIN OUTCOME MEASURES: Proportion of forearm fractures registered exclusively in primary care, and corresponding injury diagnoses for those registered in both primary and secondary care. RESULTS: Of 189,105 forearm fracture registrations in primary and secondary care, 13,948 (7.4%) were registered exclusively in primary care. The proportion ranged from 4.9% to 13.5% on average between counties, but was higher in some municipalities (>30%). Of 66,747 primary care forearm fractures registered with a diagnosis in secondary care, 62% were incident forearm fractures, 28% follow-up controls, and 10% other fractures or non-fracture injuries. CONCLUSION: An overall small proportion of forearm fractures were registered only in primary care, but it was larger in some areas of Norway. Failing to include fractures exclusively treated in primary care could underestimate the incidence rates in these areas.

Norwegian forearm fracture incidence based on secondary care may be underestimated by not including fractures treated exclusively in primary care.The mean proportion of forearm fractures exclusively handled in primary care is 7% and varies from 5% to 14% between counties.Fractures treated in primary care can be considered for more accurate national incidence rates. Correct fracture diagnosis needs further investigation.

How common are refractures in childhood?

Aims: The aim of this study was to describe the incidence of refractures among children, following fractures of all long bones, and to identify when the risk of refracture decreases. Methods: All patients aged under 16 years with a fracture that had occurred in a bone with ongoing growth (open physis) from 1 May 2015 to 31 December 2020 were retrieved from the Swedish Fracture Register. A new fracture in the same segment within one year of the primary fracture was regarded as a refracture. Fracture localization, sex, lateral distribution, and time from primary fracture to refracture were analyzed for all long bones. Results: Of 40,090 primary fractures, 348 children (0.88%) sustained a refracture in the same long bone segment. The diaphyseal forearm was the long bone segment most commonly affected by refractures (n = 140; 3.4%). The median time to refracture was 147 days (interquartile range 82 to 253) in all segments of the long bones combined. The majority of the refractures occurred in boys (n = 236; 67%), and the left side was the most common side to refracture (n = 220; 62%). The data in this study suggest that the risk of refracture decreases after 180 days in the diaphyseal forearm, after 90 days in the distal forearm, and after 135 days in the diaphyseal tibia. Conclusion: Refractures in children are rare. However, different fractured segments run a different threat of refracture, with the highest risk associated with diaphyseal forearm fractures. The data in this study imply that children who have sustained a distal forearm fracture should avoid hazardous activities for three months, while children with a diaphyseal forearm fracture should avoid these activities for six months, and for four and a half months if they have sustained a diaphyseal tibia fracture.

Ballistic diaphyseal forearm fractures result in high incidence of neurovascular injury and compartment syndrome but have low rates of early infection: A single level I trauma center experience.

INTRODUCTION: Ballistic injuries to the upper extremity represent a small subset of injuries, and there is little data to provide guidance on management and outcomes. The purpose of this study is to assess the incidence of neurovascular injuries, compartment syndrome, and early postoperative infection, as well as patient and injury factors predictive of neurovascular injury following ballistic fractures of the forearm. PATIENTS AND METHODS: A retrospective review of operatively treated ballistic forearm fractures at a single level I trauma center between 2010 and 2022 was performed. Thirty-three patients with 36 forearm fractures were identified. Only diaphyseal injuries in patients greater than 18 years old were included. Medical and radiographic records were reviewed to identify pre-injury patient-specific factors, including age, sex, smoking status, and history of diabetes. Injury characteristics, including the type of firearm used, forearm fracture location, and any associated neurologic or vascular injury, as well as compartment syndrome, were collected and analyzed. Short-term outcomes such as post-operative infection and recovery of neurologic function were also collected and analyzed. RESULTS: The median age was 27 years (range: 18-62), with a majority of male patients (78.8%, n = 26). 4 patients (12.1%) sustained high-energy injuries. 4 patients (12.1%) were found to have compartment syndrome pre-operatively or intra-operatively. 11 patients (33.3%) had nerve palsies postoperatively with 8 patients (24.2%) continuing to have nerve palsies at their final follow-up (mean follow-up= 149.9 +/- 187.2 days). The median length of stay was 4 days. There were no patients with infection at follow-up. CONCLUSION: Ballistic forearm fractures are complex injuries and can result in severe complications such as neurovascular injury and compartment syndrome. As such, a comprehensive evaluation and appropriate management of ballistic forearm fractures are essential to minimize the risk of severe complications and optimize patient outcomes. In our experience, when treated operatively, these injuries have a low rate of infection.

Girl predominance in trampoline-related forearm shaft fractures and their increasing incidence since 2000.

BACKGROUND: There are reports of increasing incidence of forearm shaft fractures in children. Their treatment has been preferably nonoperative but surgical fixation has gained popularity due to elastic stable intramedullary nailing. We aimed to study whether the incidence of pediatric both-bone forearm shaft fractures and their operative care have changed since year 2000. Trampoline injuries, in particular, and their treatment, re-displacement and short-term outcomes were the secondary outcomes of the study. METHODS: A population-based study in the geographic catchment area of Oulu University Hospital district in 20-years of time period (2000 - 2019) was performed. Altogether 481 diaphyseal both-bone forearm fractures in children (< 16 years) were included. Age- and sex-related incidence rates were determined, by using the official numbers of the population-in-risk by Statistics Finland. Trampoline jumping and other types of injury were reviewed, as well as particulars of treatment and outcomes. RESULTS: The incidence of diaphyseal both-bone forearm fractures increased from 9.4/100 000 in 2000-2001 to 41.7/100 000 in 2018-2019 (P < 0.001). Surgical treatment increased respectively (from 8.8/100 000 in 2000-2001 to 35.3/100 000 in 2018-2019, P < 0.0001). Trampoline injuries explained one in three (29%) of all fractures; they increased from 0% in 2000-2001 to 36.6% in 2018-2019 (P < 0.001). During the last four years of the study (2016-2019), most trampoline-related injuries occurred among girls (61.2%), compared to boys (38.8%) (P = 0.031). Trampoline-related injuries comprised 46.9% of all fractures in girls, compared to 26.0% among boys (Diff. 20.8%, 4.7% to 36.1%, P = 0.009). The mean age of the patients elevated from 6.4 years (2000-2001) to 8.6 years (2018-2019) (P = 0.015). Boys predominated (69.6%) in 2000-2009 but during the last ten years, there was no statistical difference in distribution between the genders (males 54.6%, P = 0.11). CONCLUSIONS: During the twenty-year's of study period, the incidence of pediatric diaphyseal forearm fractures increased fivefold. Trampolining was the most usual single reason for the fractures. More attention should be focused to increase the safety of trampoline jumping, in particular among the girls.

Change in treatment preferences in pediatric diaphyseal forearm fractures: a Danish nationwide register study of 36,244 fractures between 1997 and 2016.

BACKGROUND AND PURPOSE: The choice between invasive and non-invasive treatment of diaphyseal forearm fractures in children can be difficult. We investigated the trends in choice of treatment of pediatric diaphyseal forearm fractures over a 20-year period.  Patients and methods: This is a population-based register study with data from 1997 to 2016 retrieved from the Danish National Patient Registry. The primary outcome was choice of primary treatment within 1 week divided into non-invasive treatment (casting only or closed reduction including casting) and invasive (Kirshner wires, intramedullary nailing [IMN], and open reduction internal fixation [ORIF]). The secondary outcomes were further sub-analyses on invasive treatment and age groups. RESULTS: 36,244 diaphyseal forearm fractures were investigated, yielding a mean incidence of 172 per 105/year. The proportion of fractures treated invasively increased from 1997 to 2016, from 4% to 23%. The use of Kirschner wires increased from 1% to 9%, IMN increased from 1% to 14%, and ORIF decreased from 2% to 1%. The changes were evident in all age groups but smaller in the 0-3-year age group. CONCLUSION: We found an increase in invasive treatment of pediatric diaphyseal forearm fractures over the investigated period. A change in invasive methods was also found, as the rate of IMN increased over the investigated period and became the predominant surgical treatment choice.

Paediatric forearm fractures manipulated in the emergency department: incidence and risk factors for re-manipulation under general anaesthesia.

AIM: Re-manipulation of paediatric forearm fractures under general anaesthetic may be required following inadequate closed reduction under conscious sedation. Manipulation under general anaesthetic carries significant inherent risks and is preferably avoided. We assessed one institution's experience with paediatric forearm fracture reduction and investigate the incidence of re-manipulation under general anaesthetic of fractures initially managed under conscious sedation without fluoroscopy. METHOD: All paediatric forearm fractures presenting to the children's emergency department of our national children's hospital between 1 January 2019 and 30 June 2019 were studied. Radius and ulna fractures were categorised according to fracture location (distal third, middle third, proximal third), any associated injury, and any plan to proceed to the operating room that was documented prior to manipulation in the emergency department. Univariate and multivariate statistical analysis was carried out to test for differences between discrete and continuous data and odds ratios were calculated. RESULTS: Three-hundred and nine patients presented during the study period with 267 being eligible for analysis. Fifteen point seven percent (42/267) required fracture manipulation in the operating theatre following initial reduction in the children's emergency department. Independent risk factors associated with significantly higher rates of failed reduction under conscious sedation (p<0.001-0004) were patients who had a delay in presentation to hospital, were older, or had a non-distal fracture site. CONCLUSION: There are higher rates of re-manipulation under general anaesthetic in children presenting to the emergency department of our national children's hospital with forearm fractures than seen in comparative international studies. Risk factors which predict an inadequate initial reduction and interventions to improve this are discussed.

Risk Factors for Upper Extremity Refractures in Children.

BACKGROUND: Multiple descriptive studies have been published on refracture patterns, particularly for forearm fractures. However, few large cohorts have been analyzed quantitatively including the odds of refracture, and with a comprehensive assessment of the possible predictive factors associated with refracture. This study aimed to assess the frequency and timing of upper extremity refracture in a large pediatric orthopaedics practice, and to evaluate the strength of association of various patient-level and fracture-related factors with refracture. METHODS: Medical records were reviewed retrospectively for patients 1 to 18 years of age with at least 1 upper extremity fracture (ICD-9 codes 810 to 819) between June 1, 2010 and May 31, 2011. Characteristics of patients and fractures were assessed for the association with refracture using bivariate analysis and multivariable logistic regression. RESULTS: Among 2793 patients with a total of 2902 upper extremity fractures, 2% were treated for refracture within 2 years, at a median of 6 months (188 d) after the initial injury. Midshaft location, and characterization of the fracture as angulated or buckle, were associated with being more likely to refracture. Eighty percent of refractures were the result of a fall, with almost 25% involving a high-energy mechanism and about 15% from monkey bars or other playground equipment. The adjusted odds of refracture were 4 times higher if noncompliance with treatment recommendations was documented, when controlling for insurance type and number of days before orthopaedic evaluation. Forearm fractures were almost 4 times more likely to refracture compared with other bones, controlling for midshaft location, days immobilized, and buckle or torus characterization of the fracture. CONCLUSIONS: Our practice saw a refracture occurrence in 2% of patients, with median time to refracture of ~6 months. The factors most strongly associated with refracture were midshaft fracture location, forearm fracture as opposed to clavicle or humerus, and noncompliance as defined in the study. Falls and high energy activities, such as use of wheeled devices, skis, or trampolines, were important mechanisms of refracture. LEVEL OF EVIDENCE: This study is a Level II prognostic study. It is a retrospective study that evaluates the effect of patient and fracture characteristics on the outcome of upper extremity refracture.

A 40-year Study of the Factors Associated with Diaphyseal Forearm Fractures in Skiers and Snowboarders.

BACKGROUND: Skiing and snowboarding are popular sports that are associated with a high number of orthopaedic injuries. Diaphyseal forearm fractures are an important subset of these injuries. To our knowledge, factors associated with these injuries, the mechanisms that cause them, and their relative frequencies in skiers and snowboarders have not been described. In addition, it has been proposed that the use of wrist guards may increase the risk of sustaining a diaphyseal forearm fracture; therefore, we sought to explore the relationship between wrist guard use and diaphyseal forearm fractures. QUESTIONS/PURPOSES: (1) What are the relative frequencies and types of diaphyseal forearm fractures in skiers and snowboarders? (2) What factors are associated with these injuries? (3) Is the use of wrist guards associated with an increased risk of forearm fractures? METHODS: This was an unmatched case-control study performed with an injury database from a university-run clinic at the base lodge of a major ski resort. Cases were injured skiers and snowboarders; controls were randomly selected uninjured skiers and snowboarders. Data were collected on the mechanism of injury; experience level; equipment; radiographs; skiing or snowboarding habits; and trail type, defined as green circle (easiest), blue square (intermediate), black diamond (difficult), and double black diamond (most difficult). From this database, we identified 84 patients with diaphyseal forearm fractures, one of which was a Monteggia fracture and was excluded. A logistic regression analysis was used to compare the injured and control groups to identify factors associated with diaphyseal forearm fractures, including wrist guard use. RESULTS: When adjusted for participant days, diaphyseal forearm fractures were more common in snowboarders than skiers (0.03 injuries per 1000 person-days versus 0.004 per 1000 person-days). On multivariable analysis, factors associated with forearm fractures in skiers were younger age (odds ratio 1.08 [95% CI 1.05 to 1.14]; p < 0.01), being a man or boy (OR 11.9 [95% CI 2.5 to 57.2]; p < 0.01), lack of movement at the time of falling (OR 18.2 [95% CI 3.2 to 102.5]; p < 0.01), and skiing on green circle trails compared with black diamond trails (OR 3.6 [95% CI 1.4 to 12.5]; p = 0.04). Factors associated with forearm fractures in snowboarders were younger age (OR 1.08 [95% CI 1.02 to 1.15]; p = 0.01), decreased weight (OR 1.02 [95% CI 1.00 to 1.02]; p < 0.01), snowboarding on gentle terrain (OR 8.4 [95% CI 1.6 to 45.0]; p = 0.01), and snowboarding on groomed terrain compared with other (OR 7.2 [95% CI 1.9 to 28.0]; p < 0.01) or wet, heavy snow (OR 24.8 [95% CI 2.5 to 246.7]; p = 0.01). Wrist guard use was not associated with an increased odds of diaphyseal forearm fracture in skiers or snowboarders. CONCLUSION: Diaphyseal forearm fractures occur more frequently in snowboarders than in skiers. Despite speculation in prior evidence that wrist guards may paradoxically increase the risk of sustaining these injuries, our study suggests that this is not the case and wrist guards are not unsafe to wear. LEVEL OF EVIDENCE: Level III, prognostic study.

Does treatment with bisphosphonates protect against fractures in real life? The HUNT study, Norway.

Bisphosphonates reduce fractures in randomized controlled trials (RCT); however, there is less information from real life. In our population including 14,990 women and 13,239 men, use of bisphosphonates reduced risk of fractures in hip and forearm in women. The magnitude of the effect was comparable to results from RCT. INTRODUCTION: The objective was to examine if treatment with bisphosphonates (BPs) was associated with reduced risk of fractures in the hip and forearm in women and men in the general population. METHODS: In a cohort study based on data from the third wave of the population-based HUNT Study (HUNT3), the fracture registry in Nord-Trøndelag, and the Norwegian Prescription Database, 14,990 women and 13,239 men 50-85 years were followed from the date of participating in HUNT3 (2006-2008) until the date of first fracture in the hip or forearm, death, or end of study (31 December 2012). Hazard ratios with 95% confidence intervals for hip and forearm fracture according to use of BPs were estimated using Cox proportional hazards models with time-dependent exposure. Adjustment for individual FRAX® fracture risk assessment scores was included. RESULTS: BPs, predominantly alendronate, were used by 9.4% of the women and 1.5% of the men. During a median of 5.2 years of follow-up, 265 women and 133 men had a hip fracture, and 662 women and 127 men had a forearm fracture. Compared with non-users of BPs, the hazard ratios with 95% confidence interval for a fracture among users of BPs adjusted for age and FRAX® were 0.67 (0.52-0.86) for women and 1.13 (0.50-2.57) for men. Among users of glucocorticoids, the corresponding figures were 0.35 (0.19-0.66) and 1.16 (0.33-4.09), respectively. CONCLUSIONS: Use of BPs was associated with reduced risk of fractures in hip and forearm in women, and the magnitude of effect is comparable to results from RCTs.

One-year prospective analysis of hand and forearm injuries in children.

The primary aim of this study was to assess the epidemiological evaluation of acute pediatric hand injuries frequently encountered in emergency department units. Its secondary aim was to identify the risk factors associated with such injuries. Out of the 1547 acute hand and forearm injury cases admitted to emergency trauma department between March 2017 and March 2018, the 129 injuries pertaining to children were included in the study. Mechanism, time, etiology, injured structures, anatomical regions, cut structures, and occupational accident status were determined in addition to demographic information. The injuries were evaluated according to circadian rhythm in order to ascertain the hours of intensification. The Modified Hand Injury Severity Score (MHISS) was used to assess injury severity. The mean age of 129 patients was 10.1 years. The most injuries were observed in the groups of patients over 12 years of age (57, 44%), and 0-6 years of age (42, 32%), respectively. Nineteen students participating in vocational internships were injured (14%). Twenty-six cases (20%) in the 12-year-old group involved punching glass, and 34 (26%) cases in the 0-6 age groups involved fingertip crush injuries. Temporal injury intensity was seen to have increased between 12.00 and 19.00 hours. The mean MHISS was 41 (8-120). Injury prevention measures need to be increased, particularly for fingertip injuries. A specific injury severity assessment system is also required for pediatric hand injuries, which are often simpler and easier to treat than adult hand injuries. Additionally, training and increasing awareness are believed to be important steps in preventing pediatric hand injuries.

Concurrent musculoskeletal complaints in elbows, shoulders, and necks after common hand and forearm injuries or conditions: A cross-sectional study among 600 patients.

STUDY DESIGN: This is a cross-sectional study among 600 patients. INTRODUCTION: Isolated hand and forearm injuries or conditions are common in the emergency and orthopedic departments. So far, little is known about whether these patients suffer from concurrent musculoskeletal complaints (MSCs) besides their hand and forearm complaints. Neglecting concurrent MSCs in the upper limbs and necks could hamper rehabilitation and prolong the time taken to return to daily and work-related activities. PURPOSE OF THE STUDY: The purpose of this study was to investigate the prevalence of concurrent MSCs in the elbow, shoulder, and neck after common hand and/or forearm injuries or conditions. METHODS: This study included 600 patients with any type of diagnosis referred to rehabilitation after hand and/or forearm injuries or conditions. Basic characteristics, diagnoses, and location of patients' symptoms were collected and analyzed. RESULTS: The overall prevalence of concurrent MSCs was 40%. Twenty-eight percent of the whole sample developed concurrent MSCs after the hand and forearm injury or condition. The gender distribution was 68% women and 32% men. The most common location for complaints was the shoulder (62%), followed by the elbow (49%), and the neck (32%). DISCUSSION: The present results suggest that MSCs from the elbows, shoulders, or necks are very common in patients with hand and/or forearm injuries or conditions. CONCLUSION: Clinicians treating patients with isolated hand and forearm injuries or conditions should be aware of the high prevalence of concurrent MSCs. Future research should investigate if specific rehabilitation, focusing on concurrent MSCs, may influence the outcome in this population.

Low-trauma ankle fractures in Brazil: secular trends in patients over 50 years old from 2004 to 2013.

PURPOSE: The most common sites of low-energy trauma fractures are the femur, vertebra, humerus, and forearm. Ankle fractures have significant morbidity and high costs for surgical procedure. Forearm fractures are common nonvertebral fractures. Forearm fractures are classified as fragility fractures and predictive for fractures at other sites, although do not allow osteoporosis diagnosis. It is controversial whether ankle fractures are osteoporosis fractures. METHODS: Retrospective observational study, with secular trend analysis, in patients over 50 years old admitted in the Brazilian Public Health System, from 2004 to 2013. We collected hospitalization data according to the ICD-10 for low-trauma ankle and forearm fractures. Fracture rate was calculated according to gender, age, and geographic region, performed linear regression analysis, and estimated fracture rates for 2030. Comparison of ankle and forearm rates was also performed, grouping them in 3-year block. ANOVA test was used to compare each block. RESULTS: Ankle fracture rate was 21.39 fractures per 100,000 inhabitants, 23.98 in females and 18.49 in males. Fracture rates were higher in the South and Southeast regions. In absolute numbers, although ankle fracture rate increased with age, there was a significant decrease in the population over 80 years old. Data showed stabilization in ankle fractures from 2004 to 2013, in women and men. In 3-year block analysis, men had higher ankle fracture rates than forearm. However, in women, forearm rates were higher than ankle. CONCLUSION: Our data suggest that ankle fractures in men would be considered as a sentinel fracture with a similar clinical impact of forearm fracture.

Epidemiology of injury and illness in 153 Australian international-level rowers over eight international seasons.

AIM: To report the epidemiology of injury and illness in elite rowers over eight seasons (two Olympiads). METHODS: All athletes selected to the Australian Rowing Team between 2009 and 2016 were monitored prospectively under surveillance for injury and illness. The incidence and burden of injury and illness were calculated per 1000 athlete days (ADs). The body area, mechanism and type of all injuries were recorded and followed until the resumption of full training. We used interrupted time series analyses to examine the association between fixed and dynamic ergometer testing on rowers' injury rates. Time lost from illness was also recorded. RESULTS: All 153 rowers selected over eight seasons were observed for 48 611 AD. 270 injuries occurred with an incidence of 4.1-6.4 injuries per 1000 AD. Training days lost totalled 4522 (9.2% AD). The most frequent area injured was the lumbar region (84 cases, 1.7% AD) but the greatest burden was from chest wall injuries (64 cases, 2.6% AD.) Overuse injuries (n=224, 83%) were more frequent than acute injuries (n=42, 15%). The most common activity at the time of injury was on-water rowing training (n=191, 68). Female rowers were at 1.4 times the relative risk of chest wall injuries than male rowers; they had half the relative risk of lumbar injuries of male rowers. The implementation of a dynamic ergometers testing policy (Concept II on sliders) was positively associated with a lower incidence and burden of low back injury compared with fixed ergometers (Concept II). Illness accounted for the greatest number of case presentations (128, 32.2% cases, 1.2% AD). CONCLUSIONS: Chest wall and lumbar injuries caused training time loss. Policy decisions regarding ergometer testing modality were associated with lumbar injury rates. As in many sports, illness burden has been under-recognised in elite Australian rowers.

Missed hand and forearm injuries in multiple trauma patients: An analysis from the TraumaRegister DGU®.

PURPOSE: Multiple trauma patients have a high risk of missed injuries. The main point of our study was to provide new epidemiological data on hand and forearm injuries in multiple trauma with a focus on those that were missed. Therefore, we used the database of the TraumaRegister DGU®. METHODS: In this study, we evaluated anonymous data from 139931 patients aged 1-100 years with multiple trauma in the TraumaRegister DGU® of the German Society for Trauma Surgery from 2007 to 2017. Patients with hand and forearm injuries documented during hospital stay were identified and analyzed. We included fractures, dislocations, tendon injuries, nerve injuries and vessel injuries. Patients with missed hand and forearm injuries were compared with patients with primary diagnosed injuries in view of gender, age, ISS, Abbreviated Injury Score (AIS), Glasgow Coma Scale (GCS), Glasgow Outcome Scale (GOS), trauma mechanism type of injury, hospital stay, RISC II and mortality rate. Missed injuries were defined as injuries that were recently diagnosed and documented in the intensive care unit (ICU). RESULTS: A total of 50459 multiple trauma patients (36.1%) had hand or forearm injuries, and 89472 patients (63.9%) had neither. Patients with hand injuries were younger and were more often involved in car and motorcycle accidents. Severe head trauma was evaluated less frequently, and severe thorax trauma was evaluated more often in patients with hand injuries. The times of diagnosis of hand injuries were documented in 10971 cases. A total of 727 patients (6.6%) with missed hand injuries were registered. The most commonly missed injuries in multiple trauma were 104 carpal fractures/dislocations (11.2%), 195 nerve injuries (25.4%) and 54 tendon injuries (11.4%). Predisposing factors for missing injuries were multiple diagnoses, primary care in the first hospital and direct from emergency room transfer to the ICU. CONCLUSION: In contrast to previous findings, severely injured patients, especially those with head injuries and GCS of ≤8, were not predisposed to have missed hand injuries compared to patients without severe head trauma. Special attention should be paid to younger patients after traffic accidents with multiple diagnoses and direct transfer to the ICU.

Youth American football quarterback injuries: a descriptive study of 15 years of retrospective data.

Objectives: To describe common injuries of youth American football quarterbacks (QBs) cared for in a regional sports medicine center within the last 15 years. Methods: A retrospective chart review of all male youth American football QB patients who sustained sports-related injuries at a regional pediatric medical center between 01/01/2003 and 10/01/2018. Patients were identified using HoundDog to search the term 'quarterback.' Records were then reviewed to identify all male QBs ≤ 18 years of age. Injures that were not a result of football participation were excluded. Main outcome variables were injured anatomic locations, injury types, surgical status, and settings in which the injury was sustained. Descriptive statistics were used to analyze the outcome variables. Results: A total of 374 QBs (mean age: 14.6 ± 2.1) sustained a total of 423 injuries. The top 5 injured anatomic locations were shoulder (22%), knee (15%) head/neck (14%), elbow (13%), and wrist/hand/lower arm (11%). Most injuries (64.3%) were acute; 35.7% were chronic in nature. Most acute injuries (55.5%) occurred during games. Of the chronic injuries, 47.0% occurred during off-season and 34.4% occurred in-season. Among all injuries, 22.9% were surgical cases, and the top 3 anatomic locations of surgery were knee (35.0%), shoulder (20.7%), and elbow (18.7%). Conclusions: The shoulder is the most commonly injured body part among young QBs seeking care in a regional pediatric medical center, although the knee is the most commonly injured body part that requires surgery. Most QB injuries are acute in mechanism and the majority of these acute injuries occur during games.

Epidemiology of osteoporotic fracture in Kazakhstan and development of a country specific FRAX model.

Retrospective and prospective population-based survey in a region of the Republic of Kazakhstan determined the incidence of fractures at the hip, proximal humerus and distal forearm. The hip fracture rates were used to create a FRAX® model to enhance fracture risk assessment in Kazakhstan. OBJECTIVE: This paper describes the epidemiology of osteoporotic fractures in the Republic of Kazakhstan that was used to develop a country specific FRAX® tool for fracture prediction. METHODS: We carried out a retrospective population-based survey in Taldykorgan in the Republic of Kazakhstan representing approximately 1% of the country's population. Hip, forearm and humerus fractures were identified retrospectively in 2015 and 2016 from hospital registers and the trauma centre. Hip fractures were prospectively identified in 2017 from the same sources and additionally from primary care data. Age- and sex-specific incidence of hip fracture and national mortality rates were incorporated into a FRAX model for Kazakhstan. Fracture probabilities were compared with those from neighbouring countries having FRAX models. RESULTS: The difference in hip fracture incidence between the retrospective and prospective survey indicated that approximately 25% of hip fracture cases did not come to hospital attention. The incidence of hip fracture applied nationally suggested that the estimated number of hip fractures nationwide in persons over the age of 50 years for 2015 was 11,690 and is predicted to increase by 140% to 28,000 in 2050. Hip fracture incidence was a good predictor of forearm and humeral fractures in men but not in women. CONCLUSION: The FRAX model should enhance accuracy of determining fracture probability among the Kazakh population and help guide decisions about treatment.