Does simultaneous comminuted fracture of both radial ends represent a distinct fracture pattern?

BACKGROUND: Although isolated distal radius and radial head fractures are common injuries, simultaneous ipsilateral fractures are uncommon. They can range from simple undisplaced fractures at either end to severely comminuted ipsilateral proximal and distal radial fractures. Few cases have been reported with concomitant comminuted distal radius and radial head fractures, and no treatment guidelines are available. Decisions are often based on personal recommendations. The purpose of our study is to increase awareness of this injury pattern and to discuss the mechanism of injury, treatment approach, and functional outcome. METHODS: Skeletally mature patients with comminuted simultaneous ipsilateral fractures of the distal and proximal radius from 2016 to 2021 were identified and studied retrospectively. Demographic information, mechanism of injury, treatment approach, and complication rate were analyzed. Radiographic assessment for inadequacy or loss of reduction and radiographic parameters of the distal radius, including radial inclination, radial length, and palmar inclination, was performed immediately postoperatively and at the final follow-up. Clinical outcomes were determined by calculating the Visual Analog Scale (VAS) score, measuring the range of motion in both joints, and using the Quick Disabilities of the Arm, Shoulder and Hand (QuickDASH) score at the final follow-up. RESULTS: A total of 11 patients met the inclusion criteria. All had ipsilateral Mason III radial head fractures and type C (according to the Arbeitsgemeinschaft für Osteosynthesefragen (AO) classification) intra-articular distal radius fracture. On-table radial head reconstruction and fixation with a proximal radius plate were used for radial head fractures, and osteosynthesis with an anatomic volar locking plate was used for distal radius fractures. The mean follow-up duration was 32 months (range 12-65 months). At the final follow-up, osseous union of both the radial head and distal radius was observed in all patients. The mean VAS score was 1.5 (range 0-7) at rest and 3.9 (range 0-9) with activities, while the mean QuickDASH score was 32 (range 12-65). No significant complications were recorded. CONCLUSION: Simultaneous comminuted fractures of the ipsilateral distal radius and radial head represent a distinct injury pattern, most likely resulting from high-energy trauma, such as falling from a height onto an outstretched hand. Greater emphasis should be placed on clinical examination and radiological imaging of the elbow in cases of wrist injuries and vice versa. Treatment involving on-table reconstruction of the radial head and open reduction and internal fixation with a volar plate can lead to good radiological and functional outcomes.

The Relationship between the Bevel of the Radial Head Epiphysis and the Posterior Synovial Fringe During Rotation of the Elbow: An Ultrasonography Study with Possible Implications Regarding the Pathophysiology of Nursemaid's Elbow.

BACKGROUND: Nursemaid's elbow is the most common upper extremity injury in children under 5 years of age. However, the exact pathomechanism underlying the nursemaid's elbow remains elusive, and approximate one-third of patients present with a nonclassical history. Using a high-frequency ultrasound probe, we attempted to determine the relationship between the anterior edge of the posterior synovial fringe and the peripheral rim of the radial head epiphysis during rotation. It is possible that the primary reason for the nursemaid's elbow is due to the pronator position. METHODS: Twenty-one patients had a history of nursemaid's elbow and had a successful reduction before enrollment in this study. A high-frequency linear array 6 to 24 MHz hockey stick transducer was used to detect small morphologic changes in the peripheral rim of the radial head epiphysis and the posterior synovial fringe during rotation of the capitellum-radial joint. RESULTS: In complete pronation, the anterior edge of the posterior synovial fringe contacts the beveled articular surface of the radial head peripheral rim in all 21 patients. In neutral and complete supination, the anterior edge of the posterior synovial fringe contacts the convexly nonarticular surface of the radial head peripheral rim and extends deep into the foveal radius. The posterior synovial fringe and the capsule-aponeurotic membrane were tightened in passive pronation in all 21 cases. The posterior synovial fringe and the capsule-aponeurosis membrane were all loose in the neutral and supination positions. CONCLUSION: The anterior edge of the posterior synovial fringe touches the beveled peripheral rim of the radial head epiphysis during complete pronation, and the tension of the lateral collateral ligament complex during pronation may further cause unstable conditions of the anterior edge of the posterior synovial fringe. We hypothesized that the beveled peripheral rim of the radial epiphysis and its relationship with the anterior edge of the posterior synovial fringe could be the reason why nursemaid's elbow only occurs while the elbow is in the pronator position.

Recurrent Infections After Percutaneous Pinning of a Proximal Radius and Ulna Fracture.

Elbow fractures in the pediatric population are an exceedingly common injury, comprising 5% to 10% of all pediatric fractures, with supracondylar fractures being the most common of the subset. Radial neck fractures are less frequent, comprising only 1% of all pediatric fractures. We provide a case report of a 7-year-old girl with a left radial neck and proximal ulna fracture. A 7-year-old girl presented to the emergency department after falling off a rock wall the day before. Imaging showed a left proximal ulna and proximal radial neck fracture. The patient underwent percutaneous reduction and fixation, complicated by subsequent infection requiring surgical débridement. The patient then developed a recurrent infection 1 year later, requiring repeat irrigation and débridement. The patient has since made a full recovery, returned to activities of daily living, and regained a full range of motion. Radial neck fractures have a low incidence and have been frequently associated with poor outcomes. The main mechanism by which these fractures occur is due to falling on an outstretched arm. Percutaneous pinning is often recommended after unsuccessful attempts at closed reduction because open reduction is often complicated by postoperative stiffness. As with any procedure that involves breaking the skin, there is a risk of infection. However, there is unclear evidence regarding ideal perioperative management to prevent postoperative infection.

Comminuted lunate fracture combined with distal radius fracture and scaphoid fracture: A case report.

RATIONALE: Incidence of lunate fractures is very low, less than 1% of all fractures. Lunate fractures generally come from high-energy injuries, often combined with other wrist fractures. Simple lunate fractures can be fixed with screws or Kirschner wires. However, Comminuted lunate fractures are difficult to reduce and fixe by conventional methods. PATIENT CONCERNS: Here we report a 42-year-old male construction worker who was crushed by an excavator bucket and presented with comminuted lunate fracture combined with distal radius fracture and scaphoid fracture. DIAGNOSES: Comminuted lunate fracture, distal radius fracture, and scaphoid fracture. INTERVENTIONS: The posterior approach was used to reconstruct the radial lunate bone with polymethylmethacrylate cement, and cannulated screws were used to fix the scaphoid and distal radius fractures. OUTCOMES: At the 3rd month after surgery, the movement of the right wrist joint improved. At the sixth month after surgery, the patient returned to the building site and began working at the same intensity as before the injury. LESSONS: Although the incidence of comminuted lunate fractures is very low, they occur sometimes. For comminuted lunate fractures, early identification and intervention can preserve most of the function of the wrist joint.

[Monteggia-like injuries : Pitfalls of surgical treatment]. / Monteggia-like-Verletzungen : Pitfalls der operativen Versorgung.

The term Monteggia-like lesions or Monteggia equivalent injuries includes fractures of the proximal ulna with dislocation and dislocation fractures of the radial head from the proximal radio-ulnar joint. The complexity of the injury requires a dedicated understanding of the anatomical structures and their biomechanical properties. Particularly due to the rarity, the complication and revision rates are high. A conservative treatment is not usually effective. Three-dimensional imaging by computed tomography is part of the surgical preparation. The goal of surgical treatment is osteosynthetic reconstruction of the fractures and restoration of joint congruency. In cases of nonreconstructable radial head fractures, radial head arthroplasty may be necessary. In addition to reconstruction of the bony stabilizers, refixation of the ligamentous structures is essential for treatment success. The combination of complex fracture patterns and possible dislocation positions in the ulnohumeral, radiohumeral and proximal radio-ulnar joints poses a great challenge to the surgeon. The most frequent complications are peri-implant infections, implant failure, loss of reduction, stiffness or instability. Especially the anatomical configuration of the proximal ulna is complex and requires accurate reconstruction. Therefore, reconstruction of the proximal ulna in length and rotation, including the coronoid process, is considered to be a key factor in the surgical treatment of Monteggia-like injuries.

Risk of radial head arthroplasty revision is correlated with radial head diameter: a multicenter analysis of 405 cases.

BACKGROUND: Radial head arthroplasty (RHA) is commonly used for the treatment of comminuted radial head fractures. Indications as well as implant types continue to evolve. RHA has had good outcomes with midterm longevity. The literature is limited to small case series with varying implant types, and larger studies are needed to determine the optimal implant type and radial head diameter. METHODS: A retrospective analysis of RHA cases performed by 75 surgeons at 14 medical centers in an integrated health care system between 2006 and 2017 was completed. Patient demographics, comorbidities, implant type and head diameter, and indications for revision were recorded. Patients' in-person clinical visit data were recorded. Patients were also contacted via telephone at a minimum of 2 years to obtain abbreviated Disabilities of the Arm, Shoulder, and Hand questionnaire and Oxford scores. Implant survivorship was also captured within our integrated system. RESULTS: 405 cases met our inclusion criteria. Mean age was 51.5 ± 15.5 years (range 16-88 years) and more common in females (62%). Chart review and telephone follow-up was performed at a mean of 68.9 ± 31.5 months (range 24-146 months). Our study found that revision rate was positively correlated with increasing radial head diameter. A 26-mm head had 7.7 odds of revision compared to a size 18-mm head (95% confidence interval 1.2-150.1). More than 95% of revision cases were performed within the first 36 months of the index procedure. Obese patients had a significantly lower mean postoperative Oxford score (35.5) compared to controls (38.3) (P = .02). There was a significantly higher overall reoperation rate for terrible triad (18.4%) vs. isolated injuries (10.4%) (P = .04). There was no difference between Acumed Anatomic and Evolve radial head implants in overall reoperation, implant revision, postoperative range of motion, or patient-reported outcomes. CONCLUSIONS: Risk of revision is directly correlated with implanted radial head diameter. There were no differences in outcomes and complications between the 2 main implants used. Individuals who did not undergo a revision by 3 years' time tend to retain the implant. Terrible triad injuries had a higher all-cause reoperation rate than isolated radial head fractures, but no difference in the rate of RHA revision. These data reinforce the practice of downsizing radial head implant diameter.

A Case of Acute Plastic Deformation of the Forearm in a Medieval Hispano-Mudejar Skeleton (13-14th Centuries AD).

INTRODUCTION: Acute plastic deformation refers to a traumatic bending or bowing without a detectable cortical defect. CASE PRESENTATION AND DISCUSSION: We describe a rare case from an individual that was exhumed from the Hispano-Mudejar necropolis in Uceda (Guadalajara, Spain) dated between the 13th and 14th centuries AD. The case corresponds to an adult woman, with a bowing involvement of the left ulna and radius. After making the differential diagnosis with various pathologies likely to present with this alteration, we reached the diagnosis of acute plastic deformation of the forearm through external and radiological examination and comparison with the healthy contralateral forearm. CONCLUSIONS: Acute plastic deformation is a rare traumatic injury, not described until the last century and only rarely described in palaeopathological contexts. We contribute a new case, the first being sufficiently documented, contributing to the knowledge and diagnosis of this type of trauma in the ancient bone, while deepening the knowledge of the living conditions of the medieval Mudejar population of Uceda.

Radial head distalisation with an external ring fixator as a therapy option in children with chronic posttraumatic radiocapitellar dislocations.

PURPOSE: Missed monteggia-type injuries in children can result in chronic radial head dislocation with anatomic changes and osteoarticular remodeling of the radial head. In later stages, joint reconstruction is impossible and a functional radial head distalization can be a therapy option in symptomatic patients. METHODS: From 2010 to 2018, 46 patients (18 female and 28 male, mean age 11.8 (4-20)) with chronic radius head dislocation treated in our institution were retrospectively analyzed. A radial head distalization was performed in symptomatic patients at the time of ulna lengthening and angulation by use of an external ring fixator. We analyzed the surgical and radiographic data as well as the clinical outcome of the patients measured by DASH and Mayo Elbow score. RESULTS: 16 patients (6 female, 10 male) fulfilled the criteria for functional radial head distalization. Main reason was Monteggia injury in 11 cases, and radial head fracture in 5 cases. Average follow-up was 5.1 years (range 1-9, SD 2.1). Mean time from injury was 4.14 years (range: 4 months to 12 years, SD 3.5 years). Mean duration of external fixation was 106 days (range 56-182, SD 31.2), lengthening was 21.3 mm (range 12-42, SD 8.8). Average degree of sagittal angulation 14.8° (0-32°, SD 10.7°), coronal angulation 4.4° (0-25°, SD 7.3°). DASH score showed a good result with 2.4, and the MAYO Elbow Score was excellent (95/100). No secondary luxation of the radius head was detected. CONCLUSION: Radial head distalization with external ring fixator can be a therapy option for chronic radius head dislocations in symptomatic patients without losing stability of the elbow joint in contrast to radial head resection.

[Radial head prosthesis for acute fractures]. / Radiuskopfprothese bei akuten Frakturen ­ wann und welche?

Non-reconstructible radial head fractures with concomitant injuries and resultant instability of the elbow are often treated by implantation of a radial head prosthesis. Various prosthetic designs and implantation techniques are available. Several pitfalls have to be respected during implantation. This article provides tips and tricks for successful implantation and aftercare and gives an overview of long-term outcomes and revision rates.

Healing of a Large Bone Defect Secondary to Tuberculosis in an Infant: A Case Report.

CASE: A 9-month-old male child presented with swelling over the distal radius that was debrided, and histopathology revealed tuberculosis. Curettage left a large bony defect in the distal radius metaphysis. The defect was not surgically addressed because near-complete spontaneous filling of the defect was seen at 3 months' follow-up. The patient was given antituberculous therapy for 12 months and had excellent outcomes at 24 months' follow-up. CONCLUSION: A large bony defect secondary to tuberculosis, in the distal radius metaphysis in an infant, regenerated spontaneously without the need for bone substitutes, bone grafting, or complex microvascular procedures.

[Comparison of Two Minimally Invasive Osteosynthesis Techniques for Radial Head Fractures in Paediatric Patients]. / Porovnání dvou metod miniinvazivní osteosyntézy u zlomenin hlavicky vretenní kosti u detí.

PURPOSE OF THE STUDY Radial head fractures in paediatric patients account for 5-19% of all elbow injuries and approximately 1% of all fractures in children. Non-displaced fractures are treated with plaster cast fixation. If the fracture is displaced, we proceed to closed reduction, or to osteosynthesis in case of unstable fragments. If closed reduction fails, we opt for open reduction and osteosynthesis. The prospective randomised clinical study aims to compare the two methods of minimally invasive osteosynthesis using the pre-bent Kirschner wire or Prévot nail and to identify differences between them. MATERIAL AND METHODS The prospective randomised clinical study was conducted in 2015-2019. The final cohort included 32 patients who met the inclusion criteria. The patients in whom other osteosynthesis implants had been used or in whom open reduction had to be performed were excluded from the study. Also excluded were the patients with serious concomitant injuries of elbow. For patients included in the cohort, demographic data, precise evaluation of the displacement and location of the fracture as well as the duration of plaster cast fixation and osteosynthesis implants used were recorded. In the clinical part, the methods were compared based on the achievement of full range of motion in dependence on the degree of original displacement, use of osteosynthesis implant, and occurrence of early and delayed complications. Clinical and radiological outcomes were compared. In both types of minimally invasive osteosynthesis, Métaizeau surgical technique was used. RESULTS Based on the clinical trial criteria, 26 (81%) excellent, 4 (13%) good and 2 (6%) acceptable outcomes were achieved. In 3 cases the loss of rotation was up to 20°, in 1 case the loss of flexion was up to 10°. In one patient the loss of flexion was 15° and rotation up to 30°. In another patient the loss of rotation was up to 40°. The radiological assessment showed 14 (44%) excellent outcomes, 15 good (47%) and 3 (9%) acceptable outcomes. The statistical analysis of both the groups of the cohort using non-parametric tests revealed no statistically significant differences in individual demographic parameters. The comparisons of both types of osteosynthesis in dependence on the degree of displacement by non-parametric Fisher's exact test showed no statistically significant difference in the radiologic or clinical results. The only statistically significant difference was observed in the duration of metal implant placement. DISCUSSION Comparable studies report excellent or good clinical outcomes in 80-95% of cases (1,13,16). In our cohort, excellent or good clinical outcomes were achieved in 30 patients (94%). In two patients, in whom Prévot nail was used, the outcomes were acceptable. Nonetheless, this fact did not result in any statistical significance when comparing the two methods separately or in comparisons based on the degree of displacement. CONCLUSIONS The comparison of the two methods of minimally invasive osteosynthesis revealed no statistically significant difference, namely not even when both the methods were compared based on the degree of displacement. When Kirschner wire is used, the possibility to remove the metal implant in the outpatient setting is considered to be an advantage. The drawback consists in potential penetration of the sharp Kirschner wire in the radiocapitellar joint, which we did not encounter when the second technique of osteosynthesis was used. The advantage of Prévot nail includes a lower risk of pin-tract infection. Key words: minimally invasive osteosynthesis, radial head, fracture, child.

Traumatic irreducible anterior dislocation of the radio-capitellar joint due to entrapment of the brachialis tendon lateral to the radial head: A case report.

Elbow dislocation is the second most common type of joint dislocation in adults and the most common joint dislocation in children. These dislocations are commonly associated with significant soft tissue injury and/or fractures. Anterior dislocation of the radio-capitellar articulation is uncommon. Failure of relocation of the radial head due to soft tissue imposition requiring open reduction is rare, however, is extremely important to recognise clinically and radiologically. This case report describes a case of anterior dislocation of the radio-capitellar joint due to entrapment of the brachialis tendon lateral to the radial head and discusses the radiological assessment and the spectrum of causes of a clinically irreducible radio-capitellar joint. Misdiagnosis of a dislocation or failed reduction may result in long-term functional sequelae for the patient.

Risk Factors for Distal Radius Osteotomy Nonunion.

BACKGROUND: Osteotomy-site nonunion after distal radius corrective osteotomy is a detrimental complication. This retrospective study aims to identify patient and surgical factors associated with nonunion risk to help mitigate this. The authors hypothesize that patient factors and potentially modifiable surgical factors are contributory. METHODS: Thirty-three patients who underwent corrective osteotomy of the distal radius for prior fracture malunion were identified. Radiographs and patient records were reviewed for demographics, comorbidities, nutritional status, plate position, angle and length of osteotomy correction, and graft used. The primary study outcome was osteotomy nonunion. Descriptive and bivariate statistics were used to identify covariates relevant to nonunion. Backward, stepwise logistic regression was applied to investigate the multivariate effects on outcome, and regression analysis was adjusted for confounders. RESULTS: Seven patients (21 percent) experienced nonunion after initial corrective osteotomy. Risk factors associated with nonunion included correction length of osteotomy of 5 mm or greater and prior treatment with open reduction and internal fixation. Autograft use was protective against nonunion. History of osteoporosis showed a trend toward increased risk. Angle of osteotomy correction, nutritional deficit, age, diabetes, smoking status, and obesity were not identified as risk factors by the multivariate model. CONCLUSIONS: Distraction length at the osteotomy site, graft selection, and prior internal fixation were significant risk factors for distal radius osteotomy nonunion, but other factors traditionally associated with nonunion did not appear to impact risk. The authors recommend using autograft bone augmentation, particularly when distracting the osteotomy beyond 5 mm or after prior internal fixation. CLINICAL QUESTION/LEVEL OF EVIDENCE: Risk, III.

Reparative effect of super active platelet combined with allogeneic bone for large bone defects.

In clinical practice, autologous bone transplantation is usually used to treat large-scale bone defects. However, autologous bone can cause complications such as secondary injury to patients, the scarcity of autografts. In this study, the study of using super active platelet lysate (sPL) and allogeneic bone to treat the 15 mm long bone defect in right radius of rabbits, and provide an experimental basis for the next step of clinical bone defect treatment. The critical-size defect of New Zealand white rabbits was made and divided into three groups: autologous bone group, allogeneic bone group, and sPL group. They were euthanized 1, 2, and 3 months after the operation, perform imaging and histological observation on the repair of bone defect area. The results showed that there were varying degrees of new bone in the bone defect. CT data showed that the bone defect repair rate and new bone mass in each group increased month by month (P <.05). Bone tissue (BV) and bone tissue to the total volume (BV/TV, %) in the sPL group > allogeneic bone group, autologous bone group > allogeneic bone group, with statistical significance (P < .05). Compared with the allogeneic bone group, the sPL group can significantly promote the healing of bone defects, enhance the bone density after fracture healing. The repair effect after 3 months was similar to that of the autogenous bone group. The use of allogeneic bone and sPL therapy may become part of a comprehensive strategy for tissue engineering to treat bone defects.

Irreducible Traumatic Radial Head Dislocation Due to Annular Ligament Interposition in a Child with Ulnar Plastic Deformation: A Case Report.

BACKGROUND: The traumatic dislocation of the radial head in children is commonly treated by closed reduction. Sometimes, however, this strategy of treatment may not be effective due to the location of soft tissues in the radio-shoulder joint. The literature presents a few cases of the irreducible radial head dislocation with ulnar plastic deformation. Because it is a relatively rare condition, such a traumatic dislocation can be easily missed. Neglected injuries can lead to unwanted complications and unpredictable surgical outcomes. CASE PRESENTATION: This study presents a relatively rare case of traumatic radial head dislocation with ulnar plastic deformation in a 3-year-old child, which was successfully treated by open reduction. The examined case did not require osteotomy and ligamentous reconstruction. The initial attempt of closed reduction failed due to annular ligament interposition, which has been detected on MRI. After 3 months of treatment, the range of motion of the operated arm gradually improved. At the 6-month follow-up, the Mayo elbow-performance score indicated an excellent treatment outcome. CONCLUSIONS: The delayed treatment of radial head dislocation with ulnar plastic deformation can hinder the supination and pronation of the forearm, resulting in elbow/forearm deformity. The earlier this condition is detected, the easier it will be to treat it and the better the treatment outcome will be. The examined case of irreversible traumatic dislocation, successfully treated by open reduction, may help to treat radial head dislocation better.

Can intraoperative ultrasound visualize the closed reduction and elastic intramedullary nail fixation processes of double forearm fractures in children?

ABSTRACT: To evaluate the feasibility of utilizing ultrasonography to monitor the fracture reduction and elastic intramedullary nail fixation processes in treating children with double forearm fractures. A retrospective analysis of 30 children with double forearm fractures treated at our hospital between January 2016 and July 2018. The children were aged 3 to 10 years. All patients were treated with closed reduction and internal fixation with elastic intramedullary nails using intraoperative ultrasound monitoring and intermittent radiographic imaging. The closed reduction and fixation were successful in all patients. The operation times ranged from 16 to 30 minutes, averaging 21 minutes. No neurovascular injuries occurred during closed reduction and nail insertion. Moreover, closed reduction was successful in the first attempt in 86.7% of patients. All patient outcomes were optimal, lacking serious complications during follow-ups. Intraoperative ultrasound monitoring can clearly show the shape and changes in fracture ends, distal growth plates, and surrounding soft tissues, and fracture reduction and passage of elastic nail processes at fracture ends during closed reduction; therefore, visualizing closed reductions can be achieved. The combination of intraoperative ultrasound and radiographic imaging can ensure operative effects and significantly reduce radiation exposure for both doctors and patients. An adequately powered prospective randomized trial is required to confirm our findings.

Elastic intramedullary nail treatment of adolescent perihardware radius and ulna refracture.

A 13-year-old girl presented to the clinic with a midshaft refracture of both forearm bones adjacent to the site of a prior forearm fracture that had been treated with plating. She was treated with hardware removal and placement of elastic intramedullary nails. Flexible intramedullary nailing can be successful for a skeletally mature adolescent in treatment of refracture surrounding plate fixation of a midshaft forearm fracture. This technique allows for additional protection of the entire length of the affected bones, while avoiding the extensive dissection needed for extended plating.

Pediatric Radial Neck Fractures: Which Ones Can Be Successfully Closed Reduced in the Emergency Department?

BACKGROUND: The purpose of this study is to examine pediatric patients with a radial neck fracture and determine the factors associated with a failed closed reduction (CR) in the emergency department (ED). METHODS: A total of 70 patients with acute radial neck fractures were retrospectively reviewed. Inclusion criteria were: age 18 years or younger at time of injury, diagnosis of radial neck fracture without other associated elbow fractures, an attempt at CR with manipulation in the ED or immediate surgery, open proximal radial physis, and appropriate imaging to categorize the injury. Charts were reviewed and demographic data was obtained. Initial injury films were reviewed and the Judet classification was used to define fracture types/categories. RESULTS: CR was attempted on 41 patients. Twenty-nine patients went straight to surgery without a CR attempt. Compared with patients that had an attempted CR in the ED, patients that went straight to surgery had longer mean time from injury to ED presentation (5.6 d; P=0.0001), greater mean fracture angulation (55.0 degrees; P=0.001), and greater fracture translation (46.2%; P=0.001). When analyzing the patients that had a CR attempted in the ED, univariate statistical analysis demonstrated that ≥Judet 4 classification (P=0.03), greater amounts of fracture angulation (P=0.003), and a treatment delayed >24 hours from injury (P=0.007) were significant risk factors for failure of CR in the ED. Zero (0/10) patients with fracture angulation ≥60 degrees had a successful CR. Only 1/14 patients presenting >24 hours after injury had a successful CR in the ED. CONCLUSIONS: Circumventing sedation in the ED, and instead splinting for a planned surgical intervention may be a more efficient treatment method for pediatric radial neck fractures that present to the ED>24 hours after injury and/or have angulations ≥60 degrees. Adopting this new strategy may save time, reduce costs, and avoid possible harm/complications associated with sedation in the ED. LEVEL OF EVIDENCE: Level III-prognostic.

[Monteggia-fractures and Monteggia-like Lesions]. / Monteggia-Frakturen und Monteggia-like Lesions.

Monteggia lesions and Monteggia-like lesions involve ulna and radius injuries, which can not be successfully treated using the surgical principles of isolated fractures. Proximal ulnar fracture, radio-humeral dislocation, and additional dislocation in the proximal radioulnar joint result in the disintegration of the functional unit, and there is a complex injury across the elbow to the forearm, resulting in poor clinical outcomes. Thus, addressing all osteo-ligamentous injuries is essential for the long-term course.

Suspected Radial Head Subluxation in Infants: The Need for Radiologic Evaluation.

ABSTRACT: Radial head subluxation ("pulled elbow" or "nursemaid's elbow") is a common pediatric condition in children aged 1 to 4 years, although it is an uncommon finding in nonambulatory infants. It is a clinical diagnosis, and further investigations such as x-ray are not routinely done. We present a case series of 2 nonambulatory infants with forearm fractures that were initially diagnosed as radial head subluxation. Current literature supports the use of x-ray in children with atypical or unclear history prior to an attempted pulled elbow reduction. We suggest that this recommendation should be extended to all nonambulatory infants, given the unlikely diagnosis of radial head subluxation, and the necessity for early recognition of injuries that may be indicators of abuse.