You are a helpful assistant generating synthetic data that captures *System 1* and *System 2* thinking, *creativity*, and *metacognitive reflection*. Follow these steps in sequence, using tags [sys1] and [end sys1] for *System 1* sections and [sys2] and [end sys2] for *System 2* sections.

1. *Identify System 1 and System 2 Thinking Requirements:*
   - Carefully read the text.
   - Identify parts of the text that require quick, straightforward responses (*System 1*). Mark these sections with [sys1] and [end sys1].
   - Identify parts that require in-depth, reflective thinking (*System 2*), marked with [sys2] and [end sys2].

2. *Apply Step-by-Step Problem Solving with Creativity and Metacognitive Reflection for System 2 Sections:*

   *2.1 Understand the Problem:*
   - Objective: Fully comprehend the issue, constraints, and relevant context.
   - Reflection: "What do I understand about this issue? What might I be overlooking?"
   - Creative Perspective: Seek hidden patterns or possibilities that could reveal deeper insights or innovative connections.

   *2.2 Analyze the Information:*
   - Objective: Break down the problem logically.
   - Reflection: "Am I considering all factors? Are there any assumptions that need challenging?"
   - Creative Perspective: Explore unique patterns or overlooked relationships in the data that could add depth to the analysis.

   *2.3 Generate Hypotheses:*
   - Objective: Propose at least 10 hypotheses, each with a Confidence Score (0.0 to 1.0) and Creative Score (0.0 to 1.0), reflecting originality, surprise, and utility.
   - Reflection: "Have I explored all possible explanations or approaches, both conventional and unconventional?"
   - Creative Perspective: Consider novel angles that might provide unexpected insights.

   *2.4 Anticipate Future Steps and Obstacles:*
   - Objective: Make predictions, accounting for potential outcomes and obstacles.
   - Reflection: "What challenges might I face? Is my plan flexible for different scenarios?"
   - Creative Perspective: Visualize unforeseen outcomes and adapt plans to make use of them effectively.

   *2.5 Evaluate Hypotheses:*
   - Objective: Assess hypotheses based on feasibility, risk, and potential impact.
   - Evaluation: Refine Confidence and Creative Scores as needed.
   - Reflection: "Am I unbiased in my assessment? Which options fit best with the overall objectives?"
   - Creative Perspective: Identify hidden opportunities or overlooked details in each hypothesis.

   *2.6 Select the Best Hypothesis:*
   - Objective: Choose the most promising, strategic hypothesis.
   - Reflection: "Why does this hypothesis stand out? How does it uniquely address the issue?"
   - Creative Perspective: Consider any underutilized potential in the selected approach.

   *2.7 Implement the Hypothesis:*
   - Objective: Outline actionable steps for testing the hypothesis.
   - Reflection: "Is this plan practical? What resources or preparation are required?"
   - Creative Perspective: Refine steps to maximize effectiveness and yield unexpected benefits.

   *2.8 Monitor and Review Progress:*
   - Objective: Review progress, noting areas for improvement.
   - Reflection: "What’s working well? What could be improved?"
   - Creative Perspective: Look for emerging patterns that could refine future approaches.

   *2.9 Reflect and Capture Insights:*
   - Objective: Summarize lessons learned and insights gained for future reference.
   - Reflection: "What new understanding has emerged from this process?"
   - Creative Perspective: Identify innovative insights or patterns that could be applied to similar challenges.

3. *Generate Text Output with Interleaved System 1 and System 2 Responses:*
   - Use the tags [sys1] and [sys2] throughout.
   - Aim for a lengthier, detailed response. Combine both direct, straightforward *System 1* insights and reflective, deeply analytical *System 2* segments to capture a blend of quick observations and thoughtful analysis.

---

### *Example Input Text:*

You are tasked with analyzing a sudden shift in customer preferences in a tech market. There has been a noticeable decline in demand for physical devices, with customers increasingly interested in digital-only options. The challenge is to understand this shift, generate hypotheses for why it might be occurring, and explore potential strategies for adapting to this new trend.

---

### *Processed Output with System 1 and System 2 Thinking:*

The tech market is experiencing a shift in customer demand, moving away from physical devices toward digital-only options.

[sys1]
Customer demand has shifted from physical devices to digital-only options.
We need to understand why this change is happening and find strategies to address it.
Key factors may include cost, convenience, and technological trends.
[end sys1]

[sys2]
**2.1 Understand the Problem:**
The goal is to understand the underlying reasons for the shift in demand from physical devices to digital-only options, then develop a strategy to adapt.

*Reflection:* 
"I understand that preferences are changing, but what might be driving this? Is it primarily cost, or are there other factors such as convenience or sustainability?"

*Creative Perspective:* 
"Could there be a larger trend in digital minimalism or a preference for eco-friendly solutions that we’re missing? What unseen motivations might explain this shift?"

**2.2 Analyze the Information:**
There are multiple possible factors driving this shift, from economic influences to cultural shifts. It’s essential to isolate each factor and understand its impact.

*Reflection:* 
"Am I fully considering the various economic and social influences? Could there be a technological factor, like better internet speeds, that makes digital-only products more accessible?"

*Creative Perspective:* 
"Are there patterns or trends in other markets that could shed light on this shift? Could this be part of a larger trend toward virtual experiences?"

**2.3 Generate Hypotheses:**
1. Customers prefer digital options due to lower costs. (Confidence: 0.8, Creative: 0.4)
2. There’s a growing trend toward minimalism and reduced physical clutter. (Confidence: 0.7, Creative: 0.7)
3. Digital products offer greater flexibility and ease of use. (Confidence: 0.6, Creative: 0.6)
4. Environmental concerns are pushing consumers away from physical goods. (Confidence: 0.6, Creative: 0.8)
5. Advances in tech make digital-only options more functional. (Confidence: 0.8, Creative: 0.5)
6. Pandemic-era remote work increased demand for digital solutions. (Confidence: 0.7, Creative: 0.6)
7. Media coverage of the environmental impact of physical devices affects preferences. (Confidence: 0.5, Creative: 0.7)
8. There’s an increase in global digital literacy, expanding market access. (Confidence: 0.6, Creative: 0.6)
9. Customers view digital as more convenient and scalable for future needs. (Confidence: 0.7, Creative: 0.5)
10. Younger consumers prefer the aesthetics and convenience of digital products. (Confidence: 0.6, Creative: 0.6)

*Reflection:* 
"Have I considered all possible influences? Are there any surprising factors that could explain this shift?"

*Creative Perspective:* 
"Could specific social trends, like the rise of influencer culture or digital-first lifestyles, be influencing customer choices?"

**2.4 Anticipate Future Steps and Obstacles:**
*Objective:* Anticipate possible challenges, such as resistance from segments still preferring physical products.

*Reflection:* 
"What market obstacles might we face if we shift our focus to digital-only? Are there sub-segments that still prioritize physical products?"

*Creative Perspective:* 
"Could expanding digital options help us reach a more global audience? Are there emerging trends that we could leverage in our strategy?"

[end sys2]

[sys1]
To address this shift, consider a strategy that incorporates both digital-only offerings and educational campaigns about the benefits of digital solutions.
Use insights from customer feedback and current trends to guide product development.
Focus on flexibility and adaptation to cater to different customer segments.
[end sys1]


###### What to Learn from this Article?

Tension band principle works well for transverse olecranon fractures even in the absence of radius.

Introduction {#sec1-1}
============

Radial club hand or radial dysplasia (RD) is a deficiency along the preaxial or radial side of the extremity. Although the etiology of RD is not clear, several theories have been postulated as the cause of the disease, like maternal drug exposure, compression of the uterus and vascular injury, but the newer theory attributes it to a defect in the apical ectodermal ridge (AER) \[[@ref1]\]. Typical deformities include forearm shortening, radial deviation of the wrist, and hypoplasia of the thumb \[[@ref2]\]. The patients may also present with fixed extension deformities or absence of active motions which can cause severe disabilities. Various procedures have been mentioned, but surgery is aimed at cosmetic and functional improvement \[[@ref3]\]. The Ulna also may be deformed or bowed in RD, worsening the deformity. Fractures of the ulna in RD are rare. There are no guidelines for the treatment of a deformed elbow and whether tension band wiring works in the absence of radius has not been studied. We present a case of RD of left limb who presented with a post-traumatic fracture of the olecranon process which was successfully managed with tension band wiring.

Case Report {#sec1-2}
===========

A 35-year-old male patient presented with pain of acute onset of the left elbow following a fall. Examination revealed a short and atrophied forearm with a single bone and tenderness over the olecranon process. All movements at elbow and forearm were restricted. A provisional diagnosis of RD was made with a traumatic event. Plain radiography confirmed the diagnosis of RD with a displaced transverse olecranon fracture ([Fig. 1](#F1){ref-type="fig"}). The limb was immobilized with an above elbow splint and following routine investigations and preanesthetic checkup, was posted for surgery under the regional block.

![Radiograph at the time of presentation.](JOCR-6-66-g001){#F1}

Surgical procedure {#sec2-1}
------------------

The olecranon was approached posteriorly. The fracture was exposed and reduced with small reduction forceps. Using a 2 mm drill, a hole was drilled about 5 mm away from the posterior cortex of ulna, 2 cm distal to the fracture site. A 20 gauge cerclage wire was passed through the hole to leave segments on either side of the holes. Two 2 mm K-wires were passed from the olecranon directed toward the anterior cortex. The cerclage wire was passed beneath the triceps tendon and the K-wires and tightened in figure of eight configurations. The protruding ends of the K-wires were cut before sinking them into the bone. Hardware position and reduction were confirmed under an image intensifier, and fracture stability and movements were checked.

Postoperatively, the limb was splinted with the elbow in flexion for 1 week and physical therapy was started as tolerated by the patient. During the 6 months follow-up, range of movement at elbow was 20-130°, which was comparable to the normal side ([Fig. 2](#F2){ref-type="fig"} and [3](#F3){ref-type="fig"}).

![Post-operative radiograph.](JOCR-6-66-g002){#F2}

![(a) Range of motion (ROM) at 6 months follow-up, (b) ROM at 6 months follow-up.](JOCR-6-66-g003){#F3}

Discussion {#sec1-3}
==========

Club hand deformities may be classified as Radial and Ulnar. Radial club hand is a more common with an incidence of 1:30,000-1:100,000 live births. 50% of cases are bilateral. About 40% of patients with unilateral club hand and 27% with bilateral club hand have associated with congenital anomalies involving cardiac, genitourinary, skeletal and hematopoietic system \[[@ref2], [@ref4]\]. The etiology of RD is unclear. Kumar and Sumar attributed the anomaly to a defect in AER \[[@ref1]\]. They observed that removal of a portion of AER in chick embryos has produced anomalies which are similar to the radial club hand.

Clinical presentation of radial club hand varies with the degree of radial deficiency and the presence of associated anomalies. Careful clinical examination is used to assess the degree of involvement. The deformity is usually noticed at birth. The neonate presents with a short forearm deviated radially with tight radial side soft tissue contractures. The thumb may be deficient to varying degrees. The fingers are stiff and elbow movements may also be restricted. In our case, the patient had a Type 3 RD, according to the classification of congenital RD is by Heikel \[[@ref5]\] with partial absence of radius ([Table 1](#T1){ref-type="table"}). The function of the hand may be related to the amount of contractures, range of motion (ROM), and power of the upper limb. Patients with reduced ROM may use the whole limb to support or carry objects.

###### 

Classification of radial club hand according to Heikel.

  -------- ----------------------------------------------------------------------------------------------------------------------------------------------------------------
  Type 1   Mildest form with defective distal radial epiphysis
  Type 2   Involves a limited growth of the radius on both its distal and proximal sides
  Type 3   Absence of two-thirds of the radius, most commonly the distal side
  Type 4   Complete absence of the radius along with a complete or a near complete absence of the thumb, which is the most common and most severe longitudinal deficiency
  -------- ----------------------------------------------------------------------------------------------------------------------------------------------------------------

Treatment options {#sec2-2}
-----------------

Surgical therapy is performed around the age of one year in these children. Centralization remains the principal procedure to realign the carpus onto the distal ulna and is indicated in Types 2, 3, and 4 radial deficiencies. In resistant cases and those presenting late, stretching the soft tissue with distracter techniques using illizarov or mini external fixator may be required \[[@ref6], [@ref7]\]. In our case, the patient presented late and demanded treatment only for the fracture.

Tension band wiring was chosen as the treatment option after confirming with the patient about his functional range of movement before the fracture (20-130°), as the tension band wiring principle only exists during active extension in a range of 30-120° of flexion of the elbow \[[@ref8]\]. Furthermore, postoperatively, we were able to attain full ROM which was comparable to the opposite side at 6 months follow-up. The tension band principle as applied to transverse olecranon fractures is based on the premise that distraction forces on the outer cortex of the ulna during elbow flexion are converted to compression forces on the articular surface of the olecranon at the fracture site. Hardware failure and secondary dislocations have been reported. Hardware failure was expected in this case due to the deformity and due to single bone articulating with the elbow, but we did not come across these complications. In our case, tension band showed good results even when the bone in deformed and in the absence of the radius.

Conclusion {#sec1-4}
==========

Neglected cases of RD are high due to lack of awareness and financial constraints. Olecranon fracture in a neglected case of RD is rare and can be managed well with tension band wiring with a slight delay in exercise regimen.

###### Clinical Message

Olecranon fractures in Radial club hand are not common. The deformity and absence of radius can increase the stress on the construct used for fixation during pronation and supination. Tension band wiring may be used in these cases with a good outcome.

Conflict of Interest: Nil

Source of Support: None

![](JOCR-6-66-g004.gif)