Creation of a replicable anatomic model of terrible triad of the elbow.

BACKGROUND: Terrible triad of the elbow (TTE) is a complex dislocation associating radial head (RH) and coronoid process (CP) fractures. There is at present no reproducible anatomic model for TTE, and pathophysiology is unclear. The main aim of the present study was to create and validate an anatomic model of TTE. Secondary objectives were to assess breaking forces and relative forearm rotation with respect to the humerus before dislocation. METHODS: An experimental comparative study was conducted on 5 fresh human specimens aged 87.4 ± 8.6 years, testing 10 upper limbs. After dissection conserving the medial and lateral ligaments, interosseous membrane and joint capsule, elbows were reproducibly positioned in maximal pronation and 15° flexion, for axial compression on a rapid (100 mm/min) or slow (10 mm/min) protocol, applied by randomization between the two elbows of a given cadaver, measuring breaking forces and relative forearm rotation with respect to the humerus before dislocation. RESULTS: The rapid protocol reproduced 4 posterolateral and 1 divergent anteroposterior TTE, and the slow protocol 5 posterolateral TTE. Mean breaking forces were 3,126 ± 1,066 N for the lateral collateral ligament (LCL), 3,026 ± 1,308 N for the RH and 2,613 ± 1,120 N for the CP. Comparing mean breaking forces for all injured structures in a given elbow on the rapid protocol found a p-value of 0.033. Comparison of difference in breaking forces in the three structures (LCL, RH and CP) between the slow and rapid protocols found a mean difference of -4%. Mean relative forearm rotation with respect to the humerus before dislocation was 1.6 ± 1.2° in external rotation. CONCLUSIONS: We create and validate an anatomic model of TTE by exerting axial compression on an elbow in 15° flexion and maximal pronation at speeds of 100 and 10 mm/min.

The effect of Ding's screws and tension band wiring for treatment of olecranon fractures: a biomechanical study.

Although tension band wiring (TBW) is popular and recommended by the AO group, the high rate of complications such as skin irritation and migration of the K-wires cannot be ignored. Ding's screw tension band wiring (DSTBW) is a new TBW technique that has shown positive results in the treatment of other fracture types. The objective of this study was to evaluate the stability of DSTBW in the treatment of olecranon fractures by biomechanical testing. We conducted a Synbone biomechanical model by using three fixation methods: DSTBW, intramedullary screw and tension band wiring (IM-TBW), and K-wire TBW, were simulated to fix the olecranon fractures. We compared the mechanical stability of DSTBW, IM-TBW, and TBW in the Mayo Type IIA olecranon fracture Synbone model using a single cycle loading to failure protocol or pullout force. During biomechanical testing, the average fracture gap measurements were recorded at varying flexion angles in three different groups: TBW, IM-TBW, and DSTBW. The TBW group exhibited measurements of 0.982 mm, 0.380 mm, 0.613 mm, and 1.285 mm at flexion angles of 0°, 30°, 60°, and 90° respectively. The IM-TBW group displayed average fracture gap measurements of 0.953 mm, 0.366 mm, 0.588 mm, and 1.240 mm at each of the corresponding flexion angles. The DSTBW group showed average fracture gap measurements of 0.933 mm, 0.358 mm, 0.543 mm, and 1.106 mm at the same flexion angles. No specimen failed in each group during the cyclic loading phase. Compared with the IM-TBW and TBW groups, the DSTBW group showed significant differences in 60° and 90° flexion angles. The mean maximum failure load was 1229.1 ± 110.0 N in the DSTBW group, 990.3 ± 40.7 N in the IM-TBW group, and 833.1 ± 68.7 N in the TBW group. There was significant difference between each groups (p < 0.001).The average maximum pullout strength for TBW was measured at 57.6 ± 5.1 N, 480.3 ± 39.5 N for IM-TBW, and 1324.0 ± 43.8 N for DSTBW. The difference between maximum pullout strength of both methods was significant to p < 0.0001. DSTBW fixation provides more stability than IM-TBW and TBW fixation models for olecranon fractures.

Does Early Conversion to Below-elbow Casting for Pediatric Diaphyseal Both-bone Forearm Fractures Adversely Affect Patient-reported Outcomes and ROM?

BACKGROUND: For distal forearm fractures in children, it has been shown that a below-elbow cast is an adequate treatment that overcomes the discomfort of an above-elbow cast and unnecessary immobilization of the elbow. For reduced diaphyseal both-bone forearm fractures, our previous randomized controlled trial (RCT)-which compared an above-elbow cast with early conversion to a below-elbow cast-revealed no differences in the risk of redisplacement or functional outcomes at short-term follow-up. Although studies with a longer follow-up after diaphyseal both-bone forearm fractures in children are scarce, they are essential, as growth might affect the outcome. QUESTIONS/PURPOSES: In this secondary analysis of an earlier RCT, we asked: (1) Does early conversion from an above-elbow to a below-elbow cast in children with reduced, stable diaphyseal forearm fractures result in worse clinical and radiological outcome? (2) Does a malunion result in inferior clinical outcomes at 7.5 years of follow-up? METHODS: In this study, we evaluated children at a minimum of 5 years of follow-up who were included in a previous RCT. The median (range) duration of follow-up was 7.5 years (5.2 to 9.9). The patients for this RCT were included from the emergency departments of four different urban hospitals. Between January 2006 and August 2010, we treated 128 patients for reduced diaphyseal both-bone forearm fractures. All 128 patients were eligible; 24% (31) were excluded because they were lost before the minimum study follow-up or had incomplete datasets, leaving 76% (97) for secondary analysis. The loss in the follow-up group was comparable to the included population. Eligible patients were invited for secondary functional and radiographic assessment. The primary outcome was the difference in forearm rotation compared with the uninjured contralateral arm. Secondary outcomes were the ABILHAND-kids and QuickDASH questionnaire, loss of flexion and extension of the elbow and wrist compared with the contralateral forearm, JAMAR grip strength ratio, and radiological assessment of residual deformity. The study was not blinded regarding the children, parents, and clinicians. RESULTS: At 7.5-year follow-up, there were no differences in ABILHAND-kids questionnaire score (above-elbow cast: 41 ± 2.4 versus above/below-elbow cast: 41.7 ± 0.7, mean difference -0.7 [95% confidence interval (CI) -1.4 to 0.04]; p = 0.06), QuickDASH (above-elbow cast: 5.8 ± 9.6 versus 2.9 ± 6.0 for above-/below-elbow cast, mean difference 2.9 [95% CI -0.5 to 6.2]; p = 0.92), and grip strength (0.9 ± 0.2 for above-elbow cast versus 1 ± 0.2 for above/below-elbow cast, mean difference -0.04 [95% CI -1 to 0.03]; p = 0.24). Functional outcomes showed no difference (loss of forearm rotation: above-elbow cast 7.9 ± 17.7 versus 4.1 ± 6.9 for above-/below-elbow cast, mean difference 3.8 [95% CI -1.7 to 9.4]; p = 0.47; arc of motion: above-elbow cast 152° ± 21° versus 155° ± 11° for the above/below-elbow cast group, mean difference -2.5 [95% CI -9.3 to -4.4]; p = 0.17; loss of wrist flexion-extension: above-elbow cast group 1.0° ± 5.0° versus 0.6° ± 4.2° for above/below-elbow cast, mean difference 0.4° [95% CI -1.5° to 2.2°]; p = 0.69). The secondary follow-up showed improvement in forearm rotation in both groups compared with the rotation at 7 months. For radiographical analysis, the only difference was in AP ulna (above-elbow cast: 6° ± 3° versus above/below-elbow cast: 5° ± 2°, mean difference 1.8° [0.7° to 3°]; p = 0.003), although this is likely not clinically relevant. There were no differences in the other parameters. Thirteen patients with persistent malunion at 7-month follow-up showed no clinically relevant differences in functional outcomes at 7.5-year follow-up compared with children without malunion. The loss of forearm rotation was 5.5ׄ° ± 9.1° for the malunion group compared with 6.0° ± 13.9° in the no malunion group, with a mean difference of 0.4 (95% CI of -7.5 to 8.4; p = 0.92). CONCLUSION: In light of these results, we suggest that surgeons perform an early conversion to a below-elbow cast for reduced diaphyseal both-bone forearm fractures in children. This study shows that even in patients with secondary fracture displacement, remodeling occurred. And even in persistent malunion, these patients mostly showed good-to-excellent final results. Future studies, such as a meta-analysis or a large, prospective observational study, would help to establish the influence of skeletal age, sex, and the severity and direction of malunion angulation of both the radius and ulna on clinical result. Furthermore, a similar systematic review could prove beneficial in clarifying the acceptable angulation for pediatric lower extremity fractures. LEVEL OF EVIDENCE: Level I, therapeutic study.

Acceptable range of forearm deformity derived from relation to three-dimensional analysis and clinical impairments.

This study aimed to investigate deformity patterns that cause clinical impairments and determine the acceptable range of deformity in the treatment of forearm diaphyseal fractures. A three-dimensional (3D) deformity analysis based on computed bone models was performed on 39 patients with malunited diaphyseal both-bone forearm fractures to investigate the 3D deformity patterns of the radius and ulna at the fracture location and the relationship between 3D deformity and clinical impairments. Clinical impairments were evaluated using forearm motion deficit. Cutoff values of forearm deformities were calculated by performing receiver operating characteristic analysis using the deformity angle and the limited forearm rotation range of motion (less than 50° of pronation or supination) resulting in activities of daily living (ADL) impairment as variables. The extension, varus, and pronation deformities most commonly occurred in the radius, whereas the extension deformity was commonly observed in the ulna. A positive correlation was observed between pronation deficit and extension deformity of the radius (R = 0.41) and between supination deficit and pronation deformity of the ulna (R = 0.44). In contrast, a negative correlation was observed between pronation deficit and pronation deformity of the radius (R = -0.44) and between pronation deficit and pronation deformity of the ulna (R = -0.51). To minimize ADL impairment, radial extension deformity should be <18.4°, radial rotation deformity <12.8°, and ulnar rotation deformity <16.6°. The deformities in the sagittal and axial planes of the radius and in the axial plane of the ulna were responsible for the limited forearm rotation.

What Factors Are Associated with Reoperation After Operative Treatment of Terrible Triad Injuries?

BACKGROUND: Terrible triad injuries of the elbow, consisting of posterior ulnohumeral joint dislocation with associated fractures of the radial head and coronoid process, are challenging injuries due to the difficulty in restoring stability to the joint surgically while also attempting to allow early ROM to prevent stiffness. Furthermore, complications are both debilitating and relatively common, frequently requiring reoperation. QUESTIONS/PURPOSES: (1) What patient-, injury-, or surgery-related factors are associated with reoperation after surgical treatment of terrible triad injuries of the elbow? (2) What are the most common causes of reoperation after these injuries? METHODS: Between January 2000 and June 2017, we identified 114 patients who had surgery for terrible triad injuries at two tertiary-care referral centers. Of those, 40% (46 of 114) were lost to follow-up before 1 year, and an additional 5% (6 of 114) were excluded because they underwent the index surgery at an outside institution (n = 4) or underwent closed reduction with or without percutaneous pinning (n = 2). That left 62 patients for analysis in this retrospective study with a minimum of 1-year follow-up (median 22 months; range 12 to 65) or who met the endpoint of reoperation before 1 year. During the study period, indications for surgical treatment of terrible triad injuries of the elbow included joint incongruity or instability precluding early ROM. In our study cohort, 45% (28 of 62) underwent reoperation. Indications for reoperation after surgical treatment included stiffness that interfered with activities of daily life, symptomatic prominent hardware, ulnar neuropathy, instability of the elbow joint at rest or with range of motion, and infection. Patient-related (such as age, sex, race), injury-related (for example, ipsilateral extremity fracture, open fracture), and surgery-related factors (for instance, time to surgery, radial head treatment) as well as outcomes were collected by the treating surgeon at the time of follow-up and ascertained using chart review. The primary outcome measure was reoperation after surgical treatment of a terrible triad injury of the elbow. Bivariate analysis was used to assess whether explanatory variables were associated with reoperation after surgical treatment of terrible triad injuries of the elbow. RESULTS: Of the patient-, injury-, and surgery-related factors that were analyzed, only radial head treatment was associated with an increased reoperation risk (p = 0.03). No other variable met criteria for inclusion in our multivariable logistic regression model (p < 0.10), and therefore, a multivariable logistic regression model was not performed. The most common indication for reoperation was stiffness (21% [13 of 62 patients]), followed by symptomatic hardware (18% [11 of 62 patients]), nerve symptoms (ulnar neuropathy 16% [10 of 62 patients] and incisional neuroma 2% [1 of 62 patients]), instability (6% [4 of 62 patients]), and wound problems (infection 2% [1 of 62 patients]). CONCLUSION: The reoperation risk after surgical treatment of terrible triad injuries of the elbow is high. No patient- or injury-related factors were associated with the reoperation risk. Based on our finding, we recommend fixation of radial head fractures in these injuries when feasible and compatible with early postoperative motion, and we suggest the use of radial head excision or arthroplasty as a secondary options. LEVEL OF EVIDENCE: Level III, therapeutic study.

Acute Distal Radioulnar Joint Instability: Evaluation and Treatment.

This article reviews the anatomy and mechanics of pronation and supination (axial rotation) of the forearm through the distal radioulnar joint (DRUJ), and the proximal radioulnar joint (PRUJ). Injuries to the bones and/or ligaments of the forearm, wrist, or elbow can result in instability, pain, and limited rotation. Acute dislocations of the DRUJ commonly occur along with a fracture to the distal radius, radial metadiaphysis, or radial head. These injuries are all caused by high-energy trauma. Outcomes are predicated on anatomic reduction and restoration of stability to the DRUJ and PRUJ with or without ligamentous repair or reconstruction.

Complex Monteggia Fractures in the Adult Cohort: Injury and Management.

Monteggia fractures involve proximal ulna fracture associated with a radiocapitellar joint dislocation. The Bado classification is primarily based on the direction of the radial head dislocation. The Jupiter subtype classification of Bado II fractures further characterizes the severity of proximal ulna comminution and the involvement of the coronoid fragment. This latter classification can better prognosticate the challenges of surgical reconstruction and clinical outcomes. Surgery for all adult Monteggia fractures is required to restore the anatomic alignment of the ulna, which indirectly reduces the radiocapitellar joint. The complexity of the injury is considerably increased by comminution of the proximal ulna, the degree of radial head fragmentation, the reduction of the radial head, and ulnohumeral instability. Anatomic reduction is considered critical to achieving a favorable outcome.

The ideal implant for Mayo 2A olecranon fractures? An economic evaluation.

BACKGROUND: The ideal implant for stable, noncomminuted olecranon fractures is controversial. Tension band wiring (TBW) is associated with lower cost but higher implant removal rates.On the other hand, plate fixation (PF) is purported to be biomechanically superior, with lower failure and implant removal rates, although associated with higher cost. The primary aim of this study is to look at the clinical outcomes for all Mayo 2A olecranon between PF and TBW. The secondary aim is to perform an economic evaluation of PF vs. TBW. MATERIALS AND METHODS: This is a retrospective study of all surgically treated Mayo 2A olecranon fractures in a tertiary hospital from 2005-2016. Demographic data, medical history, range of motion, and complications were collected. All inpatient and outpatient costs in a 1-year period postsurgery including the index surgical procedure were collected via the hospital administrative cost database (normalized to 2014). RESULTS: A total of 147 cases were identified (94 TBW, 53 PF). PF was associated with higher mean age (P < .01), higher American Society of Anesthesiologists score (P < .01), and higher proportion of hypertensives (P = .04). There was no difference in the range of motion achieved at 1 year for both groups. In terms of complications, TBW was associated with more symptomatic hardware (21.6% vs. 13.7%, P = .24) and implant failures (16.5% vs. none, P < .01), whereas the plate group had a higher wound complication (5.9% vs. none, P = .02) and infection rate (9.8% vs. 3.1%, P = .09). TBW had a higher implant removal rate of 30.9% compared with 22.7% for PF (P = .36). PF had a higher cost at all time points, from the index surgery ($10,313.64 vs. $5896.36, P < .01), 1-year cost excluding index surgery ($5069.61 vs. $3850.46, P = .46), and outpatient cost ($1667.80 vs. $1613.49, P = .27). DISCUSSION AND CONCLUSION: Based on our study results, we have demonstrated that TBW is the ideal implant for Mayo 2A olecranon fractures from both a clinical and economic standpoint, with comparable clinical results, potentially similar implant removal rates as PF's, and a lower cost over a 1-year period. In choosing the ideal implant, the surgeon must take into account, first, the local TBW and PF removal rate, which can vary significantly because of the patient's profile and beliefs, and second, the PF implant cost.

Functional outcomes after treatments for different types of isolated ulnar coronoid fracture: A protocol for systematic review.

BACKGROUND: Optimal treatments for ulnar coronoid fracture have yet to be determined. We aimed to systematically review treatment efficacy assessed by functional outcomes of patients with isolated ulnar coronoid fracture. METHODS: Medline, Cochrane Library, EMBASE, and Google Scholar were searched for studies reporting quantitative outcomes data after surgical treatment for isolated ulnar coronoid fractures up to July 16, 2019. Functional outcomes determined using disabilities of the arm, shoulder and hand score; Mayo elbow performance score (MEPS); and range of motion were systematically reviewed. RESULTS: Six studies with a total of 65 patients with isolated coronoid fracture who had received surgical treatment were included. All studies were of good quality according to a modified Delphi checklist. Most patients had Type II fractures based on Regan-Morrey or O'Driscoll classification. Disabilities of the arm, shoulder and hand scores were reported by 2 studies (mean range 5-17). Four studies reported MEPS (mean range 89-98). One study reported Broberg-Morrey scores, in which 93% patients achieved excellent or good outcomes. Five studies reported range of motion, with mean flexion ranging from 122 to 137 and mean extension ranging from 4.0 to 21 degrees. Quantitative analyses revealed that lateral, medial, or posterior approaches in treating Type II fractures are associated with higher postoperative MEPS and flexion scores than the anteromedial approach. CONCLUSIONS: Treatment efficacy assessed by functional outcomes for isolated ulnar coronoid fractures is overall satisfactory. Whether lateral, medial, or posterior approaches lead to more favorable outcomes than the anteromedial approach is inconclusive. Further prospective studies are warranted.

Association between bone mineral density and ulnar styloid fracture in older Japanese adults with low-energy distal radius fracture.

We investigated the association of the ulnar styloid fracture (USF) with the bone mineral status and fractured radial displacement in elderly patients. The presence of USF correlates with decreased BMD and severe displacement of the radius. These findings are helpful in treating osteoporosis to prevent subsequent fragility fracture. PURPOSE: The pathogenesis of ulnar styloid fracture (USF), which often occurs with distal radius fracture (DRF), is unclear. This study aimed to investigate whether USF concomitant with low-energy DRF was associated with the bone mineral status and the degree of radiographically observed pretreatment radius displacement in Japanese adults above 50 years of age. METHODS: The study subjects were 45 (44 female, 1 male) consecutive patients aged > 50 years with DRF caused by falls from June 2015 to May 2016. Fractures due to high-energy injuries were excluded. Patients were divided into two groups according to the presence or absence of USF. Radius displacement was assessed on anteroposterior and lateral radiographs by measuring ulnar variance, radial inclination, and volar tilt at initial examination before manual reduction of the bone. Bone mineral density (BMD) of the lumbar spine, femoral neck, and distal radius was also measured by dual-energy X-ray absorptiometry within 1 week of injury. RESULTS: Significant differences in the BMD values of femoral neck, ulnar variance, radial inclination, and volar tilt were found between patients with USF and those without USF (all comparisons, p < 0.05). Logistic regression analysis of all subject data identified that volar tilt was significantly associated with the presence of USF (p = 0.048). CONCLUSIONS: The presence of USF in low-energy DRF correlates with the decreased BMD of femoral neck and severe displacement of radius in elderly patients. These findings are helpful for the treatment of osteoporosis to prevent subsequent fragility fracture.

Serious games therapy associated with conventional physical therapy intervention accelerated hand muscles strengthening and hand functioning after complex fracture of the wrist: A case report.

STUDY DESIGN: Case report. INTRODUCTION: A severe wrist fracture can cause permanent physical disabilities and deformities, leading to limit patients in their occupation and social environment. PURPOSE OF THE STUDY: We aim at presenting a treatment protocol and the functional outcome of a patient with severe clinical state after a rare wrist fracture. METHODS: We provided physical therapy intervention associated with serious games for muscle strengthening. RESULTS AND DISCUSSION: There was an increase in strengthening and a decrease in Disability of the Arm, Shoulder and Hand score and Patient Rated Wrist Evaluation scores. The International Classification of Functioning scores have changed from severe to light or to absent in many of the domains. CONCLUSION: The use of serious games combined with a conventional physical therapy intervention played a fundamental role in recovery and return to work activities, and there was also an important recovery of general health condition.

Volar locking plate fixation of distal radius fractures: Isokinetic assessment of the influence of an ulnar styloid process fracture on pronation-supination strength.

Although distal radius fractures (DRF) are frequent, the management of associated ulnar styloid process (USP) lesions is still controversial. According to recent studies, a fracture of the USP does not appear to affect functional outcomes after treatment of a DRF with plate fixation. We sought to compare the impact of a USP fracture on pronation and supination strength in isometric and isokinetic tests. We included patients with a DRF who underwent volar locking plate fixation. We divided our population into three groups: one group consisted of patients who had a fracture of the USP base, one group composed of patients without USP fracture or with a distal ulnar fracture only, and a control group composed of subjects with normal wrists. Inclusion criteria included an age of 18 to 50 years and a minimum follow-up of 10 months post-surgery. The main exclusion criteria were complex intraarticular fractures and postoperative complications. The assessment was based on clinical examination and recording of forearm rotation strength during pronation and supination in isokinetic and isometric tests. The ratio between the operated and contralateral sides was compared for each patient. Thirty-six participants were included (mean age 31.1±4.5 years). The mean postoperative follow-up was 17.9±6.9 months. Participants with a USP fracture differed from other participants in their peak torque on the isokinetic test at 45°/s for pronation and supination, but not on isokinetic tests at 120°/s or in isometric tests. Isokinetic tests revealed a decrease in pronation-supination strength during sustained effort for patients with associated basal USP fractures. These findings may have clinical implications for management of the USP but need to be specified with further study. LEVEL OF EVIDENCE: prognostic study level III.

Instability of the proximal radioulnar joint in Monteggia fractures-an experimental study.

BACKGROUND: A Monteggia fracture is defined as a fracture of the proximal ulna combined with a luxation of the radial head. The aim of the present work is to evaluate the extent of instability of the radius head in the proximal radioulnar joint (PRUJ) as a function of the severity of elbow fracture and ligamentous injury in an experimental biomechanical approach. METHODS: Eight fresh-frozen cadaver arms were used. All soft tissues were removed except for the ligamentous structures of the PRUJ and forearm. A tensile force of 40 N was exerted laterally, anteriorly or posteriorly onto the proximal radius. The dislocation in the PRUJ was photometrically recorded and measured by two independent examiners. After manual dissection of the ligamentous structures up to the interosseous membrane, the instability was documented and subsequently measured. The following dissection levels were differentiated: intact ligamentous structures, dissection of annular ligament, oblique cord and proximal third of interosseous membrane. RESULTS: An anterior instability remains relatively constant until the proximal third of the interosseous membrane is dissected. The radial head already dislocates relevantly in the posterior direction after dissection of the annular ligament with an additional considerable stability anteriorly and laterally. Subsequently, the posterior instability increases less pronouncedly in regard of distal resected structures. The lateral instability increases constantly during the progressing resection of the ligamentous structures. CONCLUSION: On the one hand, a complete healing of the ligament injury after functional treatment is hardly conceivable with ligamentary damage up to the level of the proximal interosseous membrane. A remaining instability of the proximal radius could therefore be a possible cause for the unsatisfactory clinical results after certain Monteggia fractures. On the other hand, the present study may give a possible explanation (i.e. early dorsal radius head dislocation after dissection of annular ligament) why the Bado II injury is the most frequent type of Monteggia fractures.

Unusual Forearm Deformity Solved by 3D Custom Made Guides.

We report a case of a symptomatic forearm deformity due to a premature distal ulnar fracture solved by 3D custom made cutting guides. Our patient is a sixteen years old girl referred to us due to a forearm deformity and a dysplasic ulnar head associated to pain at the dorsum of the distal ulna and at the radial head at the elbow. Using custom-made cutting guides on a 3D model, a both bone forearm osteotomy was performed. At 18 months of follow up, the range of motion did not improve significantly but our patient referred no pain and she was satisfied with the procedure. The accuracy of single cut osteotomies, utilizing three-dimensional planning and custom patient guides has been previously established. This technique helped with the pain in our case.

Buttress plate fixation of coronoid process fractures via a medial approach.

PURPOSE: To assess the clinical and radiographic outcomes of coronoid process fractures surgically managed with buttress plate fixation via a medial approach. METHODS: A retrospective review of all coronoid fractures surgically fixed in our institution using a buttress plate technique via a medial approach between June 2012 and April 2015 by the senior author was performed. These fractures were all sizeable fractures contributing to persistent elbow instability in terrible triad or varus posteromedial rotatory instability injury patterns. A prospective telephone questionnaire was conducted to assess patient outcomes using the disabilities of the arm, shoulder and hand (DASH) score and Mayo hlbow performance score (MEPS). RESULTS: Twelve patients were included in the study, comprising 10 males and 2 females with an average age of 39 years (range, 19-72 years). Mean follow-up was 16 months (range, 4-18 months). The average time to radiographic union was 4 months (range, 3-7 months). Range of motion measurements at final follow-up were obtained in 11 out of 12 patients, with one patient defaulting follow-up. All 11 patients displayed a functional elbow range of motion of at least 30°-130°, with an average arc of motion of 130° (range, 110° -140°), mean elbow flexion of 134° (range, 110° -140°) and mean flexion contracture of 3° (range, 0° -20°). The mean DASH score was 16 (range, 2.5-43.8) and the mean MEPS was 75 (range, 65-100). Complications observed included one patient with a superficial wound infection which resolved with a course of oral antibiotics and one patient with radiographic evidence of heterotopic ossification which was conservatively managed. No residual elbow instability was observed and no reoperations were performed. CONCLUSION: Buttress plate fixation via a medial approach of coronoid process fractures that contribute to persistent elbow instability represents a reliable method of treatment that produces satisfactory and predictable outcomes.

Coronal shear fracture of distal humerus associated with olecranon fracture: A case report and pathomechanism.

Distal humeral coronal shear fractures are rare and account for around 1% of all fractures at the elbow level and 6% of the distal humeral fractures. Many studies have reported on the associated injuries involving the lateral collateral ligament injuries and radial head fractures in up to 40% and 30% of humeral fractures, but this combination of coronal shear fracture of the trochlea and capitellum associated with olecranon fracture is unusual. Here, we report two cases of distal humerus coronal shear fracture with olecranon fracture treated surgically and establish and discuss the pathomechanisms, diagnosis, and therapeutic issues relating to this fracture.

Direct anterior approach for mini plate fixation of Regan-Morrey type II comminuted ulnar coronoid process fracture.

BACKGROUND: The goal of this study was to evaluate the clinical effect of Regan-Morrey type II comminuted coronoid process fracture treated with mini plate through the direct anterior approach (DAA). METHODS: Ten patients who underwent open reduction and internal fixation (ORIF) with mini plate through the DAA between February 2013 and August 2016 was included. There were three women and seven men, with an average age of 34.4 ± 7.5 years. At the final follow-up, the Mayo Elbow Performance Index (MEPS), Visual Analogue Scale (VAS) score, Disability of the Arm, Shoulder, and Hand (DASH) score, and the elbow range of motion were noted. RESULTS: The mean follow-up was 26.3 ± 2.2 (range 24-31) months. The mean elbow arc of motion was 118.5° with a mean arc of extension of 4° ± 5.2° and flexion of 122.5° ± 7.2°.The mean forearm pronation was 72° ± 7.2°, and the mean supination was 68° ± 6.3° with a mean forearm rotation arc of 140°. The average postoperative score according to the MEPS was 91 ± 5.7 points (range 80-100 points), and all patients achieved satisfactory scores (8 excellent and 2 good). The final average VAS score was 0.6 ± 1 (range 0-3). The final average DASH score was 4.0 ± 1.6 (range 2.3-7.4). None of the patients complained about elbow instability that required secondary surgery. No complications of infection, joint incongruency, fracture nonunion, median nerve palsy, or implant failure were reported. CONCLUSIONS: ORIF with mini plate through the DAA for the treatment of the type II comminuted coronoid process fractures can achieve satisfactory outcomes.

Effect of Elbow Position on Load to Failure in Olecranon Fracture Fixation: A Biomechanical Cadaveric Study.

OBJECTIVES: This study evaluates if relative flexion or extension of the ulnohumeral joint affects the strength of repair in olecranon fractures treated with a precontoured locking plate. METHODS: A cadaveric study was performed in matched pair cadaveric elbows. All soft tissue was dissected from the radius, ulna, and elbow of each specimen, leaving interosseous ligaments and joint capsules intact. Soft tissue from the humerus was dissected away, leaving only the triceps tendon and ulnar insertions intact. An oblique proximal to distal olecranon osteotomy was created in each specimen 1 cm from the tip of the olecranon. Internal fixation with standard precontoured locking plates and a Krackow augmentation suture with #2 FiberWire followed. Specimens were randomized to elbow position of 90 or 20 degrees° and loaded to failure via axial pull through the triceps. Load at failure, displacement at the time of failure, peak load, stiffness, and mechanism of failure was recorded and compared. The study was repeated a second time with the osteotomy more proximal, 0.6 cm creating a smaller fragment with less opportunities for locking screw fixation. This small fragment group was then tested as the large fragment group had. RESULTS: There were no significant differences in load at failure, peak load, or stiffness between the elbow position in the large fragment group. Displacement at time of failure was significantly different, although not clinically relevant. Failure of fixation in this group was a mix of triceps avulsion and failure through fracture site. The smaller fragment group with less points of fixation demonstrated no statistically significant differences in any parameters. A majority of the failures were at the fracture site. CONCLUSIONS: Ulnohumeral position does not significantly affect overall construct strength even in olecranon fractures with small proximal fragments with limited points of fixation.

Use of Mother-Child Screws in the Treatment of Coronoid Fractures in Terrible Triad Injury of the Elbow.

PURPOSE OF THE STUDY This study aims to analyze the clinical and radiographic outcomes of a consecutive series of 18 patients with terrible triad injury. The coronoid fractures of these patients were repaired using Mother-Child screw (MCS). MATERIAL AND METHODS Twelve men and six women (mean age: 47.2 years) with terrible triad injury of the elbow were followed up for a mean of 17.6 months (range: 13-42 months). Surgical treatment consisted of open reduction and internal fixation of coronoid fractures with MCS, radial head fracture with MCS (Mason type II, n = 10), or mini-plate (Mason type III, n = 3). Furthermore, all underwent lateral collateral ligament repair (n = 9, 100%), and in cases of persistent instability, medial collateral ligament repair was performed (n = 3, 33%). RESULTS At last follow-up, average arc of ulnohumeral motion was 130° (range: 65° to 150°), average arc of forearm rotation was 148° (range: 100°-160°), mean Disabilities of the Arm, Shoulder and Hand (DASH) score was 7.1 (range: 0-28.5), and mean Mayo Elbow Performance Score (MEPS) was 92 (range: 70-100). According to the Mayo Elbow Performance Index (MEPI), 10 patients were excellent in, seven patients were good, and one patient was fair. All patients had a stable elbow. No secondary coronoid fragment dislocation or implant failures was reported. Fracture healing was observed in all patients. CONCLUSIONS This study shows that coronoid fracture treatment with MCS may be a new, effective and easy therapeutic option in terrible triad injury. Key words:terrible triad of the elbow, coronoid process, radial head, functional outcome.

Rates of neurovascular injury, compartment syndrome, and early infection in operatively treated civilian ballistic forearm fractures.

PURPOSE: The purpose of this study is to evaluate the incidence of neurovascular injuries, compartment syndrome, early postoperative infection as well as the injury factors predictive of neurovascular injury following ballistic fractures of the radius and ulna. METHODS: A retrospective review was performed to identify all ballistic fractures of the radius and ulna in skeletally mature patients over a 5-year period at a single level-1 trauma center. Chart and radiographic review was performed to identify patient and injury demographics, associated neurologic or vascular injuries, and fracture characteristics. Fracture location was measured on computerized imaging software and fractures were grouped into bone(s) segments involved. Proximal, mid-diaphyseal, and distal locations were used for statistical analysis. RESULTS: Fifty-six extremities in fifty-five patients were identified (mean age 32 years; male to female ratio 9:1). Overall incidence of neurologic injury was 50%, arterial injury 32%, and compartment syndrome 7.1%. Presence of a proximal third forearm fracture was associated with an increased risk for neurologic injury (p < 0.01), with an odds ratio of 5.7 (95% confidence interval, 1.7-18.4). Furthermore, all high velocity/energy ballistic injuries had associated neurologic injuries (p = 0.02). CONCLUSION: Ballistic forearm fractures result in high rates of neurovascular injury. Fractures caused by high velocity/energy firearms have extremely high rates of neurologic injury when compared with low velocity ballistic injuries. Ballistic fractures involving the proximal third of the radius or ulna are five times more likely to be associated with neurologic injury after a ballistic injury and should be assessed carefully on initial evaluation.