Hand and wrist injuries are common clinically. Traditional open surgery is likely to damage the complex and delicate ligaments and soft tissues, resulting in functional impairments. Due to small bone volumes, fine anatomical structures of the hand and wrist, and high accuracy required in the surgery which is difficult to master, minimally invasive surgery needs a long learning curve. However, with the advancements in computer navigation, orthopaedic surgery robots, and three-dimensional (3D) printing, computer-assisted orthopaedic surgery has been increasingly utilized for hand and wrist injuries. This article reviews the clinical application of computer-assisted orthopaedic surgery for hand and wrist injuries in recent decades.

Replantation of traumatic amputation in children has its own characteristics. This consensus primarily focuses on the issues related to the treatment of traumatically amputated limb injuries in children. Organised along a timeline, the consensus summarises domestic and international clinical experiences in emergency care and injury assessment of traumatic limb amputation limbs, indications and contraindications for replantation surgery, principles and procedures of replantation surgery, postoperative medication and management, as well as rehabilitation in children. The aim of this consensus is to propose standardise the treatment protocols for limb replantation for children therefore to serve as a reference for clinical practitioners in medical practices, and further improve the treatment and care for the traumatic limb amputations in children.

Metatarsal Bones/surgery* ; Thumb/abnormalities* ; Metacarpal Bones/surgery* ; Plastic Surgery Procedures

Objective:To design a patient self-rating wrist scale suitable for Chinese patients, and evaluate its reliability and validity.Methods:The primary entry pool was established by referring to the existing foreign scales and the opinions of domestic experts. Opinions of 11 hand surgeons and 10 patients with wrist diseases were referred to select better items into the primary scale. During September 2015 to November 2016, 100 inpatients with wrist diseases in the hand surgery department of Beijing Jishuitan Hospital were selected by convenient sampling method, and the primary scale was conducted on them. Eight indices including item response rate, item differentiation, item-dimension attribution, variability, responsiveness, overall item attribution, internal consistency and factor loading were summarized. All the 8 indices were evaluated to establish the wrist patient self-evaluation instrument for Chinese. Test-retest reliability, Cronbach coefficient, expert score, KMO value, explanatory power, χ 2/df, root mean square error of approximation (RMSEA) and comparative fit index (CFI) were used to evaluate the reliability and validity of the scale. Results:A total of 40 subjective items in the primary entry pool were selected to form the primary scale, including 32 items (A1-D4), and 4 dimensions (physiology, safety, pain and emotion). There were 92 valid scale results in 100 cases. All cases' response rate were over 90%. In terms of item differentiation, only the high grouping score [3.20±0.577 points (range, 1-3 points)] and the low grouping score [2.68±0.627 points (range, 2-5 points)] of item B10 had no statistical significance ( t=5.11, P=0.340). There were 17 items: A1, A2, A5, A6, A7, A8, A9, A10, A11, A12, B4, B6, B7, C5, D1, D2, and D3 were considered to be deleted according to the result of item-dimension attribution. A total of 11 items had a variation less than 0.65: A4 (0.645), A7 (0.593), B1 (0.590), B5 (0.617), B8 (0.578), B9 (0.612), B10 (0.526), D1 (0.644), D2 (0.320), D3 (0.169), D4 (0.526). A2, A4, A6, A8, B4, B6, D1, D2, D3, C2, C3, C4, C5, C6 did not meet the reactivity requirements. Items with factor loads less than 0.4: D2 (-0.051), D3 (-0.127), and D4 (0.267). C4 (0.026), C5 (0.023), D1 (0.103), D2 (0.434), D3 (0.387), D4 (0.062) did not meet the internal consistency requirements. In multiple linear regression analysis, 19 items were not included in the final regression equation. Based on the above analysis, D1, D2, and D3 were finally deleted and the rest 29 valid items were remained to form the wrist patient self-evaluation instrument for Chinese. Reliability and validity of the scale: the test-retest reliability of physiology, safety, pain, emotion dimensions were 0.984, 0.976, 0.985 and 0.802 ( P<0.001), respectively. Except for there was only one item in emotion dimension, the Cronbach coefficients of total score, physiology, safety and pain dimensions were 0.943, 0.973, 0.944 and 0.881, respectively. KMO was 0.894 ( P<0.001). Except for there was only one item in emotion dimension, whose validity could not be evaluated. The χ 2/df, CFI, RMSEA results were as follows, physiology: 5.152, 0.817, 0.022, respectively; safety: 5.378, 0.795, respectively; pain: 7.439, 0.865, 0.028, respectively. Conclusion:The wrist patient self-evaluation instrument for Chinese is consisted of 4 dimensions and 29 items. As a subjective wrist self-rating scale suitable for modern Chinese patients, the scale has good reliability and validity, and can be one of the choices of the subjective evaluation for Chinese patients with wrist diseases.

Objective:To evaluate the short-term outcomes of modified reverse Sauvé-Kapandji technique in treating the congenital radioulnar synostosis.Methods:A retrospective analysis was performed on the data of 46 congenital radioulnar synostosis patients were treated with modified reverse Sauvé-Kapandji technique in Beijing Jishuitan Hospital from December 2018 to January 2020, including 38 males (45 sides), 8 females (9 sides), average age 6.6 (3.2, 8.1) years old. All the patients were classified as type III according to Cleary-Omer classification and were followed up for at least 1 year. All the patients were treated with same operation, in which 1.5 cm shaft was resected at the proximal radius, allogeneic graft tendon was used as interposition, and rotational osteotomy was performed in the middle of the ulnar shaft, with intramedullary needle or Kirschner wire fixation, depending on the intramedullary width of ulnar shaft. The radiological features were collected and recorded preoperatively and at the latest follow-up, together with the following evaluation indexes: modified Morrey tasks score, subjective function score, active forearm rotation range without compensation, active forearm rotation range with wrist joint compensation, and active forearm rotation range with wrist and shoulder joint compensation.Results:All patients were followed up for 14.6±3.4 months (range, 11.2-19.5 months). The uncompensated forearm rotation Angle was 0.0°±0.0° before surgery and 62.3°±23.7° after surgery. The forearm rotation angles before and after surgery with wrist compensatory surgery were 86.9°±29.4° and 133.2°±27.9°, respectively. The forearm rotation angles before and after surgery with wrist and shoulder joint compensatory surgery were 205.2°±42.7° and 245.2°±35.8°, respectively. There were statistically significant differences in the above indexes before and after surgery ( t=8.71, P<0.001; t=2.54, P=0.030; t=5.05, P<0.001). Ulnar union was observed in 31 patients (37 sides) after the operation, and the union duration was 6.1±2.3 months. There were 15 patients (17 sides) ulnar shafts faced with postoperative delayed union, the union duration was 8.4±1.6 months and were recovered after prolonging brace fixation and orthopedic shock wave treatment. The scores of subjective function and improved Morrey tasks of the 43 sides with good pseudo-joint were 12.1 (0.0, 20.8) and 0.7 (0.0, 1.0) points, respectively, which were improved compared with 33.9 (25.0, 41.6) and 3.2 (2.0, 4.0) points before surgery. The differences were statistically significant ( Z=-2.44, P=0.015; Z=-2.83, P=0.005). There were 11 forearms with postoperative pseudo-joint re-ankylosis, the average forearm rotation ranges without compensation was 11.4°±10.5°(range, 0°-30°), the average forearm rotation ranges with wrist compensation was 98.6°±15.9° (range, 80°-120°), the average forearm rotation ranges with wrist and shoulder compensation was 231.7°±16.9° (range, 210°-255°). The average subjective function scores was 26.7 (8.3, 39.6). The average modified Morrey tasks scores was 1.2 (0, 2), and there were no other postoperative complications. Conclusion:The reverse Sauvé-Kapandji technique showed a satisfying short-term outcome, and can be a new choice of treatment for type III congenital radioulnar synostosis.

Objective:To introduce a new design of double rotation flap in the treatment of congenital clasped thumb. The clinical effect of this new method to deepen the thumb-index webspace and release the palmar contracture of the first metacarpophalangeal joint (MCP) was assessed.Methods:Retrospective analysis was performed on the data of children with congenital clasped thumb treated by hand surgery in Beijing Jishuitan Hospital from January 2017 to December 2020. All patients presented with a narrow thumb-index webspace and palmar contracture at the first MCP joint. The double rotation flap contains two components, one of which was harvested from the radial-dorsal side of the index and transferred to widen the first webspace. The volar defect was mainly covered by the rotation flap transposed from the ulnar-dorsal side of the thumb. The extensor pollicis brevis was tightened or reconstructed based on the various developmental abnormality and the intrinsic muscle contracture was released to facilitate passive extension of the first MCP joint. Postoperative plaster immobilization was applied for one month and regular rehabilitation was conducted afterward. The survival of the flaps and the healing of the donor sites were followed up, the effect of the first webspace and palmar contracture release and thumb function were evaluated, and the parents’ satisfaction was investigated.Results:A total of 10 children with 11 affected thumbs (4 on the left side and 7 on the right side) were enrolled, with an average age of 26 months (11-36 months). All transposition flaps were survived without tip necrosis. Based on Gilbert’s method of assessment of thumb function, excellent or good improvement was achieved in the abduction of thumb (42°, 38°-43°) and extension of the MCP joint (1.6°, -5°-10°). All parents were satisfied with the appearance and function of the affected hand.Conclusions:The double dorsal-lateral rotation flap can provide sufficient width and depth of the first webspace and adequate coverage of the volar defect of the first MCP joint. This simple design is a reliable procedure for the treatment of congenital clasped thumb.

Objective:To introduce a new design of double rotation flap in the treatment of congenital clasped thumb. The clinical effect of this new method to deepen the thumb-index webspace and release the palmar contracture of the first metacarpophalangeal joint (MCP) was assessed.Methods:Retrospective analysis was performed on the data of children with congenital clasped thumb treated by hand surgery in Beijing Jishuitan Hospital from January 2017 to December 2020. All patients presented with a narrow thumb-index webspace and palmar contracture at the first MCP joint. The double rotation flap contains two components, one of which was harvested from the radial-dorsal side of the index and transferred to widen the first webspace. The volar defect was mainly covered by the rotation flap transposed from the ulnar-dorsal side of the thumb. The extensor pollicis brevis was tightened or reconstructed based on the various developmental abnormality and the intrinsic muscle contracture was released to facilitate passive extension of the first MCP joint. Postoperative plaster immobilization was applied for one month and regular rehabilitation was conducted afterward. The survival of the flaps and the healing of the donor sites were followed up, the effect of the first webspace and palmar contracture release and thumb function were evaluated, and the parents’ satisfaction was investigated.Results:A total of 10 children with 11 affected thumbs (4 on the left side and 7 on the right side) were enrolled, with an average age of 26 months (11-36 months). All transposition flaps were survived without tip necrosis. Based on Gilbert’s method of assessment of thumb function, excellent or good improvement was achieved in the abduction of thumb (42°, 38°-43°) and extension of the MCP joint (1.6°, -5°-10°). All parents were satisfied with the appearance and function of the affected hand.Conclusions:The double dorsal-lateral rotation flap can provide sufficient width and depth of the first webspace and adequate coverage of the volar defect of the first MCP joint. This simple design is a reliable procedure for the treatment of congenital clasped thumb.

Objective:To investigate the clinical effect of free fibular head epiphysis transplantation pedicled with the recurrent branch of the anterior tibial artery in the treatment of children with Bayne-Klug Ⅱ-Ⅲ congenital radial dysplasia.Methods:From February 2013 to September 2018, we retrospectively reviewed and analyzed our prospective database of four patients with Bayne-Klug type Ⅱ-Ⅲ congenital radius dysplasia referred to Beijing Jishuitan Hospital for consideration of free fibular head epiphysis transplantation. All children underwent surgical treatment by stages: (1) Before surgery, the radial soft tissue and wrist joint were gradually stretched by massage and traction braced to maximize the radial space. (2) A free fibular head pedicled with the recurrent branch of the anterior tibial artery was harvested from the ipsilateral lower limb and transferred as a vascularized fibular head composite flap for reconstructing the stable structure of the distal radius and wrist joint. (3) At least six months after the procedure, pollicization was performed on Blauth type Ⅳ and Ⅴ. The treatment effect was evaluated by measuring the radial deviation angle, the growth length of the fibula, and the ratio of the radius/ulna length.Results:A total of 4 boys with right side deformity were enrolled. The ages of the patients ranged from 16 to 62 months, with an average of 30.5 months. The post-operative follow-up period was 19 to 78 months, with an average of 40.5 months. Three children with Blauth type Ⅳ or Ⅴ thumb dysplasia were performed with pollicization about one year after free fibular head epiphysis transplantation. All the grafted bones healed; the radial deviation angle was corrected by an average of 24°; the reconstructed distal radius grew longer, with an average increase of 13.2% when the plate was removed compared with six weeks post-operatively; the ratio of the radius/ulna was an average increase of 13.3% compared with preoperative.Conclusions:The use of fibular head epiphyseal flap pedicled with the recurrent branch of the anterior tibial artery is a good method for the treatment of Bayne-Klug type Ⅱ-Ⅲ radius dysplasia. The reconstructed distal radius has the ability to grow longitudinally, which can effectively correct the radial deviation and avoid the further development of the deformity.

Objective:To investigate the clinical effect of free fibular head epiphysis transplantation pedicled with the recurrent branch of the anterior tibial artery in the treatment of children with Bayne-Klug Ⅱ-Ⅲ congenital radial dysplasia.Methods:From February 2013 to September 2018, we retrospectively reviewed and analyzed our prospective database of four patients with Bayne-Klug type Ⅱ-Ⅲ congenital radius dysplasia referred to Beijing Jishuitan Hospital for consideration of free fibular head epiphysis transplantation. All children underwent surgical treatment by stages: (1) Before surgery, the radial soft tissue and wrist joint were gradually stretched by massage and traction braced to maximize the radial space. (2) A free fibular head pedicled with the recurrent branch of the anterior tibial artery was harvested from the ipsilateral lower limb and transferred as a vascularized fibular head composite flap for reconstructing the stable structure of the distal radius and wrist joint. (3) At least six months after the procedure, pollicization was performed on Blauth type Ⅳ and Ⅴ. The treatment effect was evaluated by measuring the radial deviation angle, the growth length of the fibula, and the ratio of the radius/ulna length.Results:A total of 4 boys with right side deformity were enrolled. The ages of the patients ranged from 16 to 62 months, with an average of 30.5 months. The post-operative follow-up period was 19 to 78 months, with an average of 40.5 months. Three children with Blauth type Ⅳ or Ⅴ thumb dysplasia were performed with pollicization about one year after free fibular head epiphysis transplantation. All the grafted bones healed; the radial deviation angle was corrected by an average of 24°; the reconstructed distal radius grew longer, with an average increase of 13.2% when the plate was removed compared with six weeks post-operatively; the ratio of the radius/ulna was an average increase of 13.3% compared with preoperative.Conclusions:The use of fibular head epiphyseal flap pedicled with the recurrent branch of the anterior tibial artery is a good method for the treatment of Bayne-Klug type Ⅱ-Ⅲ radius dysplasia. The reconstructed distal radius has the ability to grow longitudinally, which can effectively correct the radial deviation and avoid the further development of the deformity.

Objective:To observe the effect of early intervention bundle on clinical prognosis of patients with latent/overt septic shock in emergency department and analyze the risk factors for mortality.Methods:Patients with latent and overt septic shock admitted to the North Hospital of Huashan Hospital Affiliated to Fudan University from January 2018 to December 2019 were retrospectively analyzed and divided into latent shock group and overt shock group. The gender, age, main infection site, the time of shock diagnosis, the indicators of early (3-hour) intervention bundle, 6-hour compliance rate of intervention bundle, the remission time and 28-day prognosis were observed. Logistic regression analysis was used to identify risk factors for 28-day mortality. Receiver operating characteristic (ROC) curve was used to analyze its prognostic value.Results:Totally 181 patients were included in the analysis. There were 102 cases in the latent shock group, and 28-day mortality was 15.69% (16 cases); 79 cases in the overt shock group, and 28-day mortality was 31.65% (25 cases). Compared with the latent shock group, patients in overt shock group had higher compliance rate of early intervention bundle (93.67% vs. 58.82%), higher blood lactate acid at admission [Lac (mmol/L): 7.09±2.08 vs. 5.69±1.27], higher compliance rate of blood culture before antibiotics (93.67% vs. 63.73%), higher proportion of antibiotics use at the first and second hours (45.57% vs. 31.37%, 54.43% vs. 33.33%), higher proportion of rapid fluid resuscitation at the first hour (crystal liquid: 59.49% vs. 11.76%, crystal fluid combined with human serum albumin: 40.51% vs. 0%), and higher proportion of vasoactive use at the first hour (100% vs. 9.80%). The stable time was significantly prolonged (days: 4.40±1.35 vs. 1.49±0.55), while the onset time (days: 1.47±0.97 vs. 2.95±1.61), the time of diagnosis (minutes: 31.30±12.54 vs. 79.15±13.81), 6-hour lactate clearance [(50.27±21.53)% vs. (61.82±13.12)%], the proportion of antibiotics use at the third hour (0% vs. 35.29%), the proportion of rapid fluid resuscitation at the second and third hour (second hour crystal liquid: 0% vs. 60.78%, second hour crystal fluid combined with human serum albumin: 0% vs. 14.71%, third hour crystal liquid: 0% vs. 12.75%), 6-hour compliance rate of the standard of central venous blood saturation (ScvO 2, 60.76% vs. 78.43%) and the success rate of treatment (28-day mortality: 31.65% vs. 15.69%) were lower than those of the latent shock group (all P < 0.05). Ten patients with latent shock developed into overt shock within 24 hours after admission. All patients with overt shock needed vasoactive drugs to maintain mean arterial pressure (MAP) ≥ 65 mmHg (1 mmHg = 0.133 kPa). Compared with the survival patients, the Lac (mmol/L: 7.59±2.27 vs. 5.92±1.24) and the proportion of vasoactive drugs use (65.85% vs. 44.29%) were significantly increased in the death patients, while the 6-hour lactate clearance [(46.58±15.83)% vs. (59.60±17.92)%], the proportion of antibiotics use in the third hour (4.88% vs. 24.29%), and 6-hour compliance rate of urine volume and ScvO 2 (56.10% vs. 82.86%, 43.90% vs. 78.57%) were significantly decreased (all P < 0.05). Binary Logistic regression analysis showed that Lac at admission, 6-hour lactate clearance, the use of antibiotics at the third hour, rapid fluid resuscitation at the first hour, and 6-hour compliance rate of ScvO 2 were independent risk factors for 28-day mortality [odds ratio ( OR) was 1.618, 0.021, 0.100, 0.307 and 3.018, all P < 0.05]. ROC curve analysis showed that the Lac at admission had the highest predictive value for 28-day mortality, the area under the ROC curve (AUC) was 0.706; followed by 6-hour compliance rate of ScvO 2 (AUC was 0.673). Conclusion:Patients with latent/overt septic shock need early diagnosis and intervention bundle to improve the 6-hour blood lactate clearance and 6-hour compliance rate of ScvO 2 and reduce the mortality.