Obese Children Have Different Forearm Fracture Characteristics Compared With Normal-weight Children.

BACKGROUND: Current estimates suggest that one third of children and adolescents are overweight and 1 in 5 are obese. Obese children are at increased risk of sustaining more complex fractures, failing nonoperative treatment, and experiencing more complications during treatment. The purpose of this study was to compare forearm fracture characteristics, treatment, and complications in grouped overweight and obese [OW+OB; body mass index-for-age percentile (BMI%) ≥85] pediatric patients compared with normal-weight (NW; BMI%≤84) patients. METHODS: This was a retrospective comparative study of patients aged 2 to 17 years old who presented with a forearm fracture resulting from low-energy trauma between January 2010 and September 2017. Patients with incomplete height and weight data; an underlying condition that predisposes to fractures or altered fracture healing; and torus, greenstick, pathologic, and high-energy fractures were excluded. Demographics, fracture characteristics, treatment, and complications were recorded. Descriptive and inferential analyses were conducted. RESULTS: A total of 565 patients (403 NW, 162 OW+OB) met the inclusion criteria. NW children sustained open fractures nearly twice as frequently as the OW+OB children but this was not statistically significant (9.7% vs. 4.9%; P=0.065). Subanalysis showed that NW children were 4.1 times more likely to sustain an open fracture compared with obese (BMI%≥95) children (9.7% vs. 2.4%; P=0.029). A significant relationship was found between BMI% and location of the fracture, the bones involved, and fracture type. The OW+OB children sustained more distal forearm fractures than midshaft and proximal forearm fractures. Isolated radial shaft fractures were more common in the OW+OB group, whereas isolated ulnar shaft fractures were more common in the NW group. There was no difference in associated neurovascular injury, initial nonoperative versus operative management, failure of nonoperative treatment, and treatment complications. CONCLUSIONS: OW+OB children have different forearm fracture characteristics compared with their NW peers. The thick soft tissue envelope in obese children may be protective against an open forearm fracture. In contrast to previous studies, obesity was not associated with failure of nonoperative treatment or a higher rate of complications. LEVEL OF EVIDENCE: Level III-prognostic.

Evaluation of Bone Atrophy After Treatment of Forearm Fracture Using Nonlinear Finite Element Analysis: A Comparative Study of Locking Plates and Conventional Plates.

PURPOSE: Forearm diaphysis fractures are usually managed by open reduction internal fixation. Recently, locking plates have been used for treatment. In the long-term period after surgery, some patients present with bone atrophy adjacent to the plate. However, a comparison of locking and conventional plates as a cause of atrophy has not been reported. The aim of this study was to investigate long-term bone atrophy associated with use of locking and conventional plates for forearm fracture treatment. METHODS: In this study we included 15 patients with forearm fracture managed by either locking or conventional plates and with more than 5 years of follow-up. Computed tomographic imaging of both forearms was performed to assess bone thickness and local bone mineral density and to predict bone strength without plate reinforcement based on finite element analysis. RESULTS: Mean patient age at surgery was 48.0 years. Eight patients underwent reduction with fixed locking plates and were followed up for a mean of 79.5 months; the remaining 7 patients were treated with conventional plates and were followed up for a mean of 105.0 months. Compared with the conventional plate group, the locking plate group had the same fractured limb-contralateral limb ratio of cortex bone thickness, but had significantly lower ratios of mineral density adjacent to the plate and adjusted bone strength. CONCLUSIONS: This study demonstrated bone atrophy after locking plate fixation for forearm fractures. Treatment plans for forearm fracture should take into consideration the impact of bone atrophy long after plate fixation. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic IV.

Concomitant injury of the annular ligament in fractures of the coronoid process and the supinator crest.

BACKGROUND: Fractures of the coronoid process or the supinator crest, as well as arthroscopic resection of osteophytes around the coronoid process, can endanger the attachment of the annular ligament (AL) to the proximal ulna. The purpose of this study was to investigate the corresponding insertional areas of the AL within this context. METHODS: In 30 embalmed human cadaveric elbow specimens, the insertional area of the AL at the anterior and posterior margin of the sigmoid notch was characterized. The distances and relations of the AL insertion anteriorly to the coronoid surface, the coronoid tip, and the depth of the coronoid process, as well as posteriorly to the supinator crest, were evaluated macroscopically. RESULTS: The mean distance of the anterior insertion area was 1.9 ± 0.6 mm (range, 1.0-3.1 mm) to the coronoid articular surface and 6.2 ± 1.7 mm (range, 2.9-10.2 mm) to the tip of the coronoid. The distance of the anterior insertion in relation to the depth of the coronoid process was 44% ± 11% (range, 30%-69%). The distance of the posterior insertion area to the level of the sigmoid notch measured from 3.5 ± 1.5 mm (range, 0.5-6.5 mm) to 17.7 ± 2.9 mm (range, 13.1-25.4 mm). CONCLUSIONS: Coronoid fractures involving 44% or more of the coronoid process and anterolaterally oriented fractures where one-third of the anterolateral facet is affected are accompanied by a complete anterior bony disruption of the AL. Arthroscopic resection of the coronoid tip should be limited to 1 mm distal to the coronoid articular surface to avoid injury to the AL. Fractures of the upper half of the supinator crest place the AL at risk at its posterior insertion.

The effect of strontium ranelate on the healing of a fractured ulna with bone gap in rabbit.

BACKGROUND: Fracture healing in bone gap is one of the major challenges encountered in Orthopedic Surgery. At present, the treatment includes bone graft, employing either internal or external fixation which has a significant impact on the patient, family and even society. New drugs are emerging in the markets such as anabolic bone-forming agents including teriparatide and strontium ranelate to stimulate bone growth. Based on the mechanism of their actions, we embarked on a study on the healing of a fractured ulna with bone gap in a rabbit model. We segregated ten rabbits into two groups: five rabbits in the test group and five rabbits in the control group. We created a 5 mm bone gap in the ulna bone, removing the periosteum as well. Rabbits in the test group received 450 mg/kg of strontium ranelate via oral administration, daily, for six weeks. The x-rays, CT scans and blood tests were performed every two weeks. At the end of six weeks, the rabbits were sacrificed, and the radius and ulna bones harvested for histopathological examination. RESULTS: Based on the x-rays and CT scans, fracture healing or bone formation was observed to be faster in the control group. From the x-ray findings, 80 % of the fracture united and by CT scan, 60 % of the fracture united in the control group at the end of the six-week study. None of the fractures united in the test group. However, the histopathology report showed that a callus of different stages was being formed in both groups, consisting of 80 % of bone. The serum levels of osteocalcin and alkaline phosphatase initially remained similar up to three weeks and changed slightly at the end of six weeks. CONCLUSIONS: We conclude that the strontium effect begins slowly, and while it may not interfere with bone cell proliferation it may interfere in the mineralization and delay the acute stage of fracture healing. We recommend that a larger sample size and a longer duration of the study period be implemented to confirm our finding.

Morphological characteristics of olecranon fractures in adults : a Computed Tomography-based study.

The aim of this study was to identify the fragment's shape by evaluating olecranon fractures. We examined the CT images of 48 olecranon fractures (28 women and 20 men). Mean age was 59.9 years. On the olecranon's posterior surface, we measured the distance between the apex of the olecranon fragment and the radial edge of the flat spot on the short axis and the width of the flat spot on the same short axis. The tip radial ratio (i.e., the tip radial edge to the flat spot width) was derived from these parameters. The mean tip radial edge was 1.96 mm, and the flat spot width was 12.64 mm ; therefore, the tip radial ratio was 0.15 mm. Radial inclination on the articular surface was 30.55°. Our findings confirmed our hypothesis that the fracture lines run from the proximal ulnar side to the distal radial side on the olecranon's posterior and articular surfaces.

Complex proximal ulna fractures: outcomes of surgical treatment.

BACKGROUND: To review the results of plating of various fracture patterns of proximal ulna fractures including isolated olecranon fractures, olecranon fractures combined with a coronoid fracture, and olecranon fractures combined with a coronoid and radial head fracture. MATERIALS AND METHODS: The study included 38 patients with either an isolated olecranon fracture or combined injuries, all treated with open reduction and internal fixation of the olecranon. Other procedures were performed as needed, including radial head fixation or arthroplasty, fixation of the coronoid, and repair of the lateral collateral ligament complex. There were 27 men and 11 women with an average age of 49 years. Clinical and radiographic assessment was obtained at an average follow-up time of 15 and 8.4 months, respectively. RESULTS: All fractures healed within 5 months. The average arc of ulnohumeral motion was 91° (range 0°-140°); average pronation-supination arc was 128° (range 0°-180°). Subgroup analysis showed a statistically significant lower rotational motion arc in patients with associated radial head (73°) or coronoid fractures (68°) compared to isolated olecranon fractures. All other parameters including ulnohumeral motion, complication rate, and revision rate were similar among the groups. CONCLUSIONS: A stable, functional elbow can be restored in most patients with proximal ulna fractures treated with open reduction and internal fixation. Loss of full flexion is likely with high-energy trauma, complex fracture patterns, and concomitant injuries. Fracture patterns involving the coronoid and/or the radial head are associated with restricted forearm rotation. LEVEL OF EVIDENCE: III.

Distal ulna fractures.

In isolation, distal ulna fractures are rare. They are often found in conjunction with distal radius fractures, and the complexity of the interaction of the distal ulna with the radioulnar joint and triangular fibrocartilage complex makes understanding and treatment of distal ulna fractures challenging. Fixation of distal ulna fractures can be problematic owing to comminution making reduction challenging. A thin soft tissue can lead to hardware prominence and necessitate implant removal. In this Current Concepts article, we review the anatomy, pathology, and treatment of distal ulna fractures as well as potential complications and salvage procedures.

Three-dimensional imaging of children with severe limitation of pronation/supination after a both-bone forearm fracture.

INTRODUCTION: Although both-bone forearm fractures in children may result in severe limitation of forearm rotation, finding the cause remains a diagnostic challenge. This study tries to evaluate the role of rotational malunion, bony impingement and contractures of the interosseous membrane. PATIENTS AND METHODS: Children (5-16 years) who suffered from a both-bone forearm fracture in diaphysis or distal metaphysis with a limitation of pronation/supination ≥40° at ≥6 months after trauma were included for analysis with conventional radiographs, computed tomography (CT) and magnetic resonance imaging (MRI). RESULTS: A total of 410 children with a both-bone forearm fracture were prospectively followed in four Dutch hospitals. At a median of 205 days, 7.3 % suffered from a limitation of pronation/supination ≥40°. 14 children were included (median limitation of 40°) and the radiographs revealed a median maximum angular malunion of 16°. CT analysis showed rotational malunion of both radius (median 19°) and ulna (median 9°). MRI analysis revealed neither bony impingement nor contractures of the interosseous membrane. CONCLUSIONS: Three-dimensional imaging of children with a severe limitation of pronation/supination after a both-bone forearm fracture revealed rotational malunions of both radius and ulna without bony impingement or soft tissue contractures. LEVEL OF EVIDENCE: Prospective multicenter study, Level 2.

Anterior approach for fixation of isolated type III coronoid process fracture.

Authors chose anterior approach through the antecubital fossa for better exposure in that case of isolated coronoid process fracture. The objective of the study was to report validity of anterior approach for the Regan and Morrey type III, isolated fracture of the coronoid process of the ulna without residual valgus or varus instability. From January 2007 and January 2010, we evaluated eleven consecutive patients (7 men, 4 women; mean age 44 years; range 25-67 years) who underwent surgical fixation through the anterior approach. The mean follow-up period was 21 months (range 15-34 months). Preoperative and follow-up roentgenograms were evaluated for assessment of the fracture configuration and confirmation of fracture union. Clinical evaluation included an analysis of surgical complication, range of motion, Mayo elbow performance score, and DASH (disability of the arm, shoulder, and hand) score. Fractures were mainly fixed with plate and screws in 8 cases, cannulated screws in 3 cases. There was no residual joint instability after fracture fragment fixation. All fractures were united, and the average union time was 15.2 weeks with a range of 11-20 weeks. Mean flexion contracture of the elbow was 3.6° (range 0°-10°), and further flexion was 130.9° (range 125°-140°) at the last follow-up. Mean Mayo elbow performance score was 92.3 (range 80-100 points), and mean DASH score was 5.9 (range 1.6-8.3 points). In conclusion, Primary fixation of the coronoid process fractures through the anterior approach could be particularly useful in the Regan and Morrey type III isolated coronoid process fractures.

Effect of Escherichia coli-produced recombinant human bone morphogenetic protein 2 on the regeneration of canine segmental ulnar defects.

Because bone morphogenetic protein 2 gene transfected Escherichia coli (E-BMP-2) produce recombinant human BMP-2 (rhBMP-2) more efficiently than mammalian cells (Chinese hamster ovary [CHO]-BMP-2), they may be a more cost-effective source of rhBMP-2 for clinical use. However, use of E-BMP-2 for regenerating long bones in large animals has not been reported. In the current study, we evaluated the healing efficacy of E-BMP-2 in a canine model. We created 2.5-cm critical-size segmental ulnar defects in test animals, then implanted E-BMP-2 and 700 mg of artificial bone (beta-tricalcium phosphate; ß-TCP) into the wounds. We examined the differential effects of 5 E-BMP-2 treatments (0, 35, 140, 560, and 2240 µg) across 5 experimental groups (control, BMP35, BMP140, BMP560, and BMP2240). Radiography and computed tomography were used to observe the regeneration process. The groups in which higher doses of E-BMP-2 were administered (BMP560 and BMP2240) displayed more pronounced bone regeneration; the regenerated tissues connected to the host bone, and the cross-sectional areas of the regenerated bone were larger than those of the originals. The groups in which lower doses of E-BMP-2 were administered (BMP35 and BMP140) experienced relatively less bone regeneration; furthermore, the regenerated tissues failed to connect to the host bone. In these groups, the cross-sectional areas of the regenerated bone were equal to or smaller than those of the originals. No regeneration was observed in the control group. These findings suggest that, like CHO-BMP-2, E-BMP-2 can be used for the regeneration of large defects in long bones and that its clinical use might decrease the cost of bone regeneration treatments.

Exaggerated inflammatory response and bony resorption from BMP-2 use in a pediatric forearm nonunion.

The Food and Drug Administration (FDA) indicates that bone morphogenetic protein (BMP) products are contraindicated in pediatric patients. However, it acknowledges the off-label use of BMP in difficult cases. Although the relative safety of BMP in children has been reported for lower extremity and spine procedures, little information exists for the safety of BMP used in the pediatric upper extremity. We present a case of a massive inflammatory reaction after use of recombinant human BMP-2 for repair of a symptomatic ulnar nonunion in a child. The case illustrates the potential difficulties of using the dose-dependent properties of BMP in the treatment of pediatric upper extremity nonunions when the dose calculations of BMP for children have not yet been defined.

Redefining the cast index: the optimum technique to reduce redisplacement in pediatric distal forearm fractures.

BACKGROUND: The aim of this study was to identify the optimal cast index (CI) level that reduces the risk of fracture redisplacement. The CI is the ratio of sagittal to coronal width from the inside edges of the cast at the fracture site. Previous studies have used 0.7 as the standard. METHODS: Case records and radiographs of 1001 children who underwent a manipulation under anesthesia for a displaced fracture of the distal forearm were studied. Redisplacement was defined as > 15 degrees of angulation and/or > 80% of translational displacement on check radiographs at 2 weeks. Angulation (degrees) and translational displacement (%) were measured on the initial and check radiographs. The CI was measured on the check radiographs. The CI has previously been validated in an experimental study. RESULTS: The adequacy of reduction after manipulation was determined by translation and angulation of the radius and ulna in anteroposterior and lateral plain film radiographs. From the 1001 patients who qualified for the study, fracture redisplacement was seen in 107 (10.6%) cases at the 2-week follow-up. A total of 752 (75%) patients had CIs of ≤ 0.8, whereas 249 (25%) had casting indices of ≥ 0.81. In patients with CIs of ≤ 0.8, the displacement rate was only 5.58%. However, in patients with CIs of ≥ 0.81, the displacement rate was 26%. A high CI was the sole factor that was significantly higher in the redisplacement group. No statistically significant difference was seen for age, sex, or surgeon seniority. Statistical differences were not noted in initial angular deformity or initial displacement. DISCUSSION: The CI is a simple reliable radiographic measurement to predict the redisplacement of forearm fractures in children. A plaster with a CI of > 0.81 is prone to redisplacement. High CIs are associated with redisplacement of fractures and should be avoided when molding casts in distal forearm fractures. LEVELS OF EVIDENCE: Level III--retrospective comparative study.

Risk factors for redisplacement of pediatric distal forearm and distal radius fractures.

BACKGROUND: Fractures of the distal forearm and distal radius represent the most common types of fracture in the pediatric population, with the majority treated by closed reduction and cast. Redisplacement has been known to occur in up to 39% of cases. There have been numerous risk factors and radiologic indices put forward as methods of predicting redisplacement, but this topic remains a matter of debate. This retrospective study aims to further assess the significance of the many factors in redisplacement after treatment with closed reduction. METHODS: This retrospective study included 155 children with distal radius and forearm fractures. Age, sex, location of fracture, angulation, displacement, an associated ulna fracture, obliquity of fracture, and accuracy of reduction were measured for assessment as potential risk factors. In addition, the cast index, padding index, Canterbury index, second metacarpal-radius index, gap index, and 3-point index were measured on postreduction radiographs. RESULTS: Redisplacement occurred in 33 of the 155 cases (21.3%). Initial displacement and accuracy of the reduction were identified as significant risk factors for redisplacement. Initial displacement of >50% (of the radius width) was significantly associated with redisplacement (odds ratio of 5.4). Failure to achieve anatomic reduction was significantly higher in the redisplacement group (odds ratio 3.9). The only radiologic index that differed significantly between groups was the cast index, with more patients without redisplacement meeting the cut-off value (60% vs. 32%, P=0.010). DISCUSSION: Initial displacement of >50% and inability to achieve anatomic reduction are major risk factors for redisplacement. Given its effectiveness and ease of clinical application, the cast index remains the most useful measure of cast molding. LEVEL OF EVIDENCE: Level II--Retrospective prognostic study.

Brachialis insertion measurement: an anatomic cadaver study for plate fixation of the coronoid process fracture.

Detailed assessment of the proximity of the brachialis insertion to the anterior bundle of the medial collateral ligament and its potential influence on plate application for the treatment of the coronoid process fracture has not been reported previously. The purpose of this study was to describe the anatomic interval used for coronoid plate and the measurement of the brachialis insertion to confirm partial release of the insertion site may be required during plate fixation of the coronoid process fracture. After eight fresh-frozen cadaveric elbows were dissected, the interval between the brachialis insertion and the attachment of the anterior bundle of medial collateral ligament was identified, and the gross morphological characteristics of the brachialis insertion were also recorded. The average width of the interval was 4.14 mm, and the brachialis was found to be consisted of a superficial head and a deep head, and insertion of the deep head was composed of three units: a medial aponeurosis, a lateral aponeurosis, and muscle fibers inserted directly into the ulna. The interval between the brachialis insertion and the attachment of the anterior bundle of medial collateral ligament can be used for placement of the coronoid plate regardless of the plate type. Partial release of the brachialis insertion is necessary during the operation, while the width of the plate is larger than that of the interval. This study may provide some useful information on plate application for the treatment of the coronoid process fracture.

Outcomes after terrible triads of the elbow treated with the current surgical protocols. A review.

Dislocation of the elbow associated with radial head and coronoid fracture, the so-called "terrible triad" of the elbow, is challenging to treat and has a history of complicated outcomes. However, advances in the knowledge of elbow kinematics combined with improved implants and surgical techniques during the past few years have led to the development of standard surgical protocols. This review article analyses the results in 137 elbow triad injuries of five studies treated using the current protocols. These include fixation of the coronoid fracture, repair or replacement the radial head, and repair of the lateral ligament complex, reserving medial collateral ligament repair and application of hinged external fixation for patients with residual instability. Treatment of these demanding injuries appeared effective in the majority of cases, i.e. with an average of 31 months of follow-up, overall flexion arc was 111.4°, averaged flexion was 132.5° with forearm rotation of 135.5°, Mayo elbow performance score was 85.6 points, and Broberg-Morrey score was 85 points. Nevertheless, the patient should be informed about the incidence of complications including joint stiffness, ulnar nerve symptoms or post-traumatic arthritis.

Effects of a new allograft processing procedure on graft healing in a canine model: a preliminary study.

Graft healing in vivo can be affected by allograft processing. We asked whether a new processing technique influenced graft-host healing compared with autograft and a standard processing technique in a canine ulna model. We used bilateral intercalary allografts or autografts in the ulna of 13 skeletally mature male coonhounds. Each animal received two allografts, either one autograft and one allograft, or two autografts. At term (90 days), the graft sites were harvested. We assessed union with high-resolution xray imaging. Each specimen was processed for nondecalcified histologic analysis to assess the graft-host interface. Quantitative histomorphometric analysis was performed to determine spatial location and area of bone. Radiographic analysis, histologic analysis, and histomorphometric measures revealed no differences in union, mean total bone area, or total endosteal/intramedullary bone for the new process, standard process, and autografts. Our preliminary data suggest the new processing techniques may increase the safety of allograft transplantation without adversely affecting union when compared with standard processing techniques and autograft in a canine model.

Accuracy of ultrasonography in detecting fragmentation of the medial coronoid process in dogs.

OBJECTIVE: To determine the accuracy of ultrasonography in detecting fragmentation of the medial coronoid process (FMCP) in dogs. DESIGN: Cross-sectional study. ANIMALS: 102 dogs (112 elbow joints) suspected to have FMCP. PROCEDURES: Elbows were examined ultrasonographically prior to surgery for evidence of fragmentation, fissuring, or deformation of the medial coronoid process; thickening of the joint capsule; joint effusion; and secondary new bone formation. Results were compared with intraoperative findings. RESULTS: At surgery, 51 (46%) joints had free fragments, 55 (49%) had nondisplaced fragments, and 6 (5%) did not have any fragments or fissures. Fragments were not seen ultrasonographically in 23 of the 51 (45%) joints in which a free fragment was found during surgery or in 50 of the 55 (91%) joints in which a nondisplaced fragment was found during surgery. Accuracy of using ultrasonographic evidence of any medial coronoid process abnormality (ie, a medial coronoid process fragment, deformation of the medial coronoid process, or both) for diagnosis of medial coronoid process fragmentation was 77%. The kappa coefficient for the level of agreement between ultrasonographic (ie, any medial coronoid process abnormality) and surgical findings was -0.014, indicating that there was no agreement. CONCLUSIONS AND CLINICAL RELEVANCE: Results suggested that ultrasonography was of limited diagnostic value in detecting FMCP in dogs.

Use of suture anchors for coronoid fractures in the terrible triad of the elbow.

PURPOSE: To report outcomes in 6 patients with the terrible triad of the elbow treated with our modified protocol. METHODS: 6 men aged 26 to 54 years underwent surgery for the terrible triad of the elbow by a single surgeon. All the patients had a displaced comminuted fracture of the radius, posterior dislocation of the elbow, and Morrey type-I fracture of the coronoid. They all underwent replacement of the radial head and repair of the lateral collateral ligament to the isometric part of the lateral condyle using suture anchors. Five had an additional capsular fixation to the anterior coronoid using suture anchors; in patient 6 the coronoid was not repaired because it was stable. Functional outcomes were evaluated using the Hospital for Special Surgery (HSS) elbow assessment score. Bone union, implant loosening, heterotopic ossification, and degenerative changes were assessed using anteroposterior and lateral radiographs. RESULTS: After a mean follow-up of 2.2 (range, 1-3) years, the mean arc of flexion-extension was 116 degrees and the mean flexion contracture was 15 degrees. All patients maintained a concentric reduction of both the ulnotrochlear and the radiocapitellar articulation, with isometric fixation of the lateral collateral ligament. No patient had dislocation of the radial-head prosthesis. All had good-to-excellent HSS elbow scores, and none required re-operation. Patient 2 had neuropraxia of the radial nerve, which recovered within 3 months. Patient 4 had a range of movement of only 20 to 100 degrees, but was satisfied with the outcome. CONCLUSION: Repair of the articular capsule using suture anchors in addition to replacement of the radial head and repair of the lateral collateral ligament achieves favourable outcome in patients with the terrible triad of the elbow.

Spectrum of computed tomographic findings in 58 canine elbows with fragmentation of the medial coronoid process.

OBJECTIVE: To describe in detail the computed tomographic findings in elbows of dogs with fragmentation of the medial coronoid process of the ulna. METHODS: Retrospective review of computed tomographic images of 58 elbows that had displaced medial coronoid process fragment(s), non-displaced medial coronoid process fragment or a stable fissure in the articular cartilage of the medial coronoid process at arthroscopy. RESULTS: Bone fragments were observed in 85 per cent elbows with a displaced fragment at arthroscopy, in 18 per cent elbows with a non-displaced fragment and in 29 per cent elbows with a stable fissure. Fissures in the subchondral bone were observed in computed tomographic images of 43 per cent elbows that had a stable fissure at arthroscopy. Abnormal shape, sclerosis and lucency affecting the medial coronoid process, subchondral sclerosis of the ulna and humerus, irregular radial incisure of the ulna and periarticular osteophytes were observed in a similar proportion in dogs regardless of the arthroscopic findings. Kissing lesions affecting the medial aspect of the humeral condyle were mainly associated with displaced fragments. Signs of joint incongruity were observed in dorsal and sagittal reconstructed computed tomographic images in 24 per cent elbows. CLINICAL SIGNIFICANCE: A wide range of abnormalities may be observed in computed tomographic images of dogs with fragmented medial coronoid process. Computed tomographic is moderately sensitive for detection of fragments.

Type-IV variant Monteggia fracture with concurrent proximal radial physeal fracture in a Domestic Shorthaired Cat.

A fracture of the proximal 1/3 of the ulna, with concurrent fractures of the proximal radial physis and the distal 1/3 of the diaphysis of the radius occurred in a three-month-old, male, neutered, Domestic Shorthaired cat. The ulnar fracture was stabilised with an intramedullary pin. The proximal radial physeal fracture was reduced and stabilised with two crossed Kirschner wires. The proximal radius was secured to the ulna with an additional Kirschner wire. The distal radial diaphyseal fracture was stabilised with a five-hole, 2.0 mm dynamic compression plate (DCP). Six weeks postoperatively the cat was using the limb comfortably and demonstrated a full range of motion of the elbow joint. There were radiographic signs of fracture union and the radioulnar pin had migrated. The Kirschner wires were removed. Follow-up at 18 months postoperatively revealed that the cat was using the limb normally without any lameness. A full, pain-free range of motion was present in the joints of the left thoracic limb.