Surgical management of elbow dislocation associated with non-reparable fractures of the radial head.

BACKGROUND: The "terrible triad" of the elbow is the combination of an elbow dislocation, radial head and a coronoid process fracture. Because of a combined sagittal, frontal and transverse instability, these injuries are notoriously difficult to treat. We report our results with a technique for reconstruction of "terrible triad" injuries with either no facture or a type I fracture of the coronoid process in addition to a non-reparable radial head fracture. The hypothesis of this study was that standard surgical treatment of this lesion using a "deep to superficial" stabilisation by a single lateral approach and radial head replacement enables early and reliable functional results. PATIENTS: From June 2004 to January 2007, 13 patients with an average age of 40 years at the date of trauma (range 18-77) underwent reconstruction of a "terrible triad" injury of the elbow with the same technique. The mean follow-up was 25 months (range 15-48). RESULTS: Eighty-four percent of the patients were very satisfied and satisfied. Average flexion was 131 degrees (110-140). Average extension was -11 degrees (-30-0). Average pronation was 72 degrees (40-80). Average supination was 70 degrees (50-80). The grip strength averaged 75% of that of the non-injured side (50-105). All elbows were stable at review. Eight complications occurred. CONCLUSION: Our results suggest that some terrible triad injuries can be successfully managed with deep to superficial stabilisation by lateral approach, consisting in three-dimensional stabilisation done by anterior capsular reinsertion with absorbable anchors, radial head replacement and lateral collateral ligament repair. This standard management provides enough stability to allow early active rehabilitation, preventing post-operative instability and stiffness. This procedure appears to be reliable and reproducible.

Transolecranon anterior fracture dislocation.

Between January 1996 and July 2003, 93 consecutive patients operated on with a diagnosis of olecranon fractures were identified from our trauma unit files. Fourteen transolecranon fracture-dislocations were found after a retrospective X-radiographic evaluation. Eight patients were women and six were men, with a mean age of 54 years. There were 4 noncomminuted olecranon fractures, treated with K-wires and single tension-band wiring. The remaining 10 fractures were complex fractures, treated in 3 cases with multiple K-wires and single tension-band wiring, in 2 by use of one-third tubular plates, in 1 with a 3.5-mm dynamic compression plate, and in the remaining 4 with 3.5-mm reconstruction plates. Ligament repair was not performed in any case. Three patients needed reoperation because of early failure of primary fixation. Patients were reviewed at a mean follow-up of 3.6 years. Two reported difficulties in daily activities, none with any symptoms of elbow instability. According to the Broberg and Morrey score, 4 patients had excellent results, 6 had good results, 2 had fair results, and 2 had poor results. Four patients showed signs of degenerative arthritis on the radiographs obtained at follow-up. We conclude that transolecranon fracture-dislocation is an underreported and misdiagnosed injury. Various fixation techniques can restore the anatomic relationships and contour of the trochlear notch; the imperative goal is to obtain a good stable primary fixation and allow early active mobilization.

Necrosis of the tongue and unilateral blindness in temporal arteritis.

While blindness is one of the typical clinical presentations of temporal arteritis, tongue necrosis, on the other hand, is an unusual complication of the disease. An 80 year old male patient presenting a sudden massive swelling of the tongue was admitted to the Hospital of Yverdon. The swelling rapidly progressed to a complete necrosis of the tongue within a few days. The clinical presentation, the dramatic evolution of the necrosis, and sudden unilateral blindness despite prompt treatment confirmed our diagnosis of temporal arteritis. However, all the examinations, including biopsy of the right temporal artery, remained non-specific for the disease. Our diagnosis was based on the unusual clinical presentation of the disease.

A new morphological classification for greater tuberosity fractures of the proximal humerus: validation and clinical implications.

In this study, we describe a morphological classification for greater tuberosity fractures of the proximal humerus. We divided these fractures into three types: avulsion, split and depression. We retrospectively reviewed all shoulder radiographs showing isolated greater tuberosity fractures in a Level I trauma centre between July 2007 and July 2012. We identified 199 cases where records and radiographs were reviewed and included 79 men and 120 women with a mean age of 58 years (23 to 96). The morphological classification was applied to the first 139 cases by three reviewers on two occasions using the Kappa statistic and compared with the AO and Neer classifications. The inter- and intra-observer reliability of the morphological classification was 0.73 to 0.77 and 0.69 to 0.86, respectively. This was superior to the Neer (0.31 to 0.35/0.54 to 0.63) and AO (0.30 to 0.32/0.59 to 0.65) classifications. The distribution of avulsion, split and depression type fractures was 39%, 41%, and 20%, respectively. This classification of greater tuberosity fractures is more reliable than the Neer or AO classifications. These distinct fracture morphologies are likely to have implications in terms of pathophysiology and surgical technique.