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.

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.

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.

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.

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.

Treatment of posttraumatic bone defects of the forearm with vascularized fibular grafts. Follow up after fourteen years.

BACKGROUND: Among several techniques proposed for the reconstruction of posttraumatic bone defects of the forearm, that of free vascularised fibular graft (FVFG) is one of the most widely used. PATIENTS AND METHOD: We study the long-term outcomes of 14 patients who underwent FVFG between 1994 and 2009, with a minimum follow up of 8 years and a maximum of 23 years (mean: 13.9 years). Demographic, clinical and radiological variables were collected retrospectively. The DASH scale was used for clinical assessment. RESULTS: Fourteen patients were operated on by the same surgeon, applying FVFG for the reconstruction of posttraumatic bone defects of the forearm (three septic non-union of the ulna or radius, five radius fractures, two ulna fractures and four fractures of both bones). The maximum length of the defect was 11 cm and the minimum length was 6 cm. In four cases, reconstruction of the two bones was achieved using the double barrel technique, and in another four cases, an osteoseptocutaneous flap was used. Fixation was performed with 3.5 mm reconstruction plates in thirteen cases and with 3.5 mm screws in one case. Consolidation was obtained in 12 cases (85.7%) after an average time of 4.2 months (range: 2-6.5 months). In one case, consolidation of the proximal ulnar fracture site was not achieved, and in another, following the failure of reconstruction attempts, an arthrodesis was performed. At the end of the follow-up period, the patients had an average DASH score of 17.1 points (range 1.8-68.1). CONCLUSIONS: FVFG is a valid option for the reconstruction of posttraumatic bone defects of the forearm. Its use via the double barrel method or as an osteocutaneous composite graft enables the simultaneous reconstruction of both forearm bones and associated soft tissue injuries. Long-term follow-up of patients who have undergone this technique confirms its satisfactory functional and radiological results.

In Vivo Three-Dimensional Analysis of Malunited Forearm Diaphyseal Fractures with Forearm Rotational Restriction.

BACKGROUND: The aim of this study was to clarify the mechanisms of rotational restriction in malunited forearm diaphyseal fractures. METHODS: We retrospectively analyzed the cases of 18 patients with malunited forearm diaphyseal fractures and rotational restriction. All patients underwent bilateral computed tomography (CT) of the forearm in maximum supination, pronation, and neutral positions. From these images, we created 3-dimensional (3-D) bone surface models. We quantified the 3-D deformities, identified instances of osseous impingement between the radius and the ulna during forearm rotation, calculated the path length of the central band (CB) of the interosseous membrane, and measured forearm range of motion. RESULTS: Sixteen patients had extension deformity of the radius (the RE group) and 2 had flexion deformity (the RF group). In the RE group, extension deformity of the radius and valgus deformity of the ulna had significant negative correlation with pronation range of motion (R = -0.50, p = 0.046) and supination range of motion (R = -0.63, p = 0.027), respectively. Osseous impingement was mainly observed during pronation (15 of 16 patients). The CB path with the largest changes in length originated from the distal CB attachment area of the radius and ran toward the proximal area of the ulna (the transverse CB). The transverse CB significantly increased in length in supination compared with that in pronation (p < 0.001). Therefore, tightness of the transverse CB appeared to cause supination restriction in the RE group. In the RF group, osseous impingement caused supination restriction. The greatest increases in the transverse CB length were observed in pronation in the RF group, which appeared to cause pronation restriction. CONCLUSIONS: In the RE group, pronation restriction was associated with osseous impingement that was due to extension deformity of the radius, and supination restriction was associated with CB tightness that was due to valgus deformity of the ulna. In the RF group, our results suggested that pronation restriction was caused by CB tightness and that supination restriction was caused by osseous impingement. CLINICAL RELEVANCE: Three-dimensional corrective osteotomy for extension deformity of the radius in malunited forearm diaphyseal fractures would improve rotational restriction by relieving osseous impingement during pronation and CB tightness during supination.

The impact of varus angulation on proximal fractures of the ulna.

BACKGROUND: We studied anteromedial varus angulation (VA) in the proximal third of the ulna. The importance of restoration of the anatomical orientation of the ulnar after a proximal fracture is unclear. The purpose of this study was to evaluate the impact of minimal proximal ulna malunion on elbow function after a proximal ulna fracture. METHODS: We reviewed the follow-up of 60 patients who had undergone open reduction with internal fixation (ORIF) of a proximal fracture of the ulna. Patients were divided into two groups, defined as either more or less than 5° of the difference between the VA of the fractured and contralateral ulna. The range of motion(ROM)of elbow flexion, extension and forearm rotation on both sides, Mayo Elbow Performance Score (MEPS) and Visual Analogue Scale (VAS) were measured. RESULTS: The average postoperative time was 3.1 years (1-5 years). Mean VA of the fractured arm was different from the normal side (7.8 ± 3.0 vs 12.7 ± 3.0). Compared to the unfractured arm there was a loss in mean elbow flexion (14.2 ± 4.9 vs 18.0 ± 5.9), extension ROM (7.1 ± 2.5 vs 9.3 ± 1.9, p < 0.05) and forearm rotation ROM (15.6 ± 8.6 vs 21.8 ± 9.5) that were statistically significant (p < 0.05). There were no statistically significant differences in the MEPS and VAS score results between the two groups (p > 0.05). CONCLUSIONS: The function of the elbow and forearm was restricted after VA malunion in the proximal ulna, but the quality of life of these patients had not been significantly affected. We suggest that orthopedic surgeons should assess whether the specialized structures of the proximal ulna are damaged or not before surgery. If the anatomy of the fractured bone cannot be restored through manipulation of the connected end directly, it is better to image the anatomical structure of the healthy side from using an elbow X-ray before surgery, and then reset using a pre-shaped plate to prevent malunion.

The smartphone inclinometer: A new tool to determine elbow range of motion?

BACKGROUND: There are easily accessible tools on smartphones (APP) for measuring elbow range of motion (ROM). The purpose of this study is to evaluate the validity of a particular APP in determining elbow ROM in comparison with the commonly used goniometer (GON), surgeon estimation of range (EST) and measurement on X-ray (XR). METHODS: The study included 20 patients (40 elbows). Flexion, extension, pronation and supination were measured using three different methods: EST, GON and APP. Radiographic measurements were taken using the average humeral diaphysis axis and dorsal midthird of ulna in flexion and extension. RESULTS: The accuracy of the three different methods has been compared to GON using statistical analysis (ANOVA and paired samples test). There was no statistically significant difference for XR flexion measurement (mean of 2.8° ± 1.5°). The APP overestimated flexion (mean of 6.4° ± 1.0°), and EST underestimated it (mean of - 7.9° ± 1.1°). For extension, the mean difference was 2.8° ± 0.7° for EST and - 26.8° ± 3.1° for XR. The APP method did not significantly differ from GON. Supination accuracy was greater with EST (2.7° ± 1.7°) than with APP (5.9° ± 1.9°). There was no difference for pronation measurement with both EST and APP. CONCLUSIONS: This study is the first comparing four measurement techniques of elbow ROM. Our results showed that EST was only accurate for forearm rotation. The XR scored the best for flexion but is less reliable for extension. Surprisingly, compared to GON, APP did not correlate as we expected for flexion and supination, but the other methods were also inaccurate. We found APP to be very useful to measure complete arc of motion (difference between maximal flexion and maximal extension). LEVEL OF EVIDENCE: III, Retrospective review of a prospective cohort of elbow fracture patients: Diagnostic Study.

The Posterior Bundle's Effect on Posteromedial Elbow Instability After a Transverse Coronoid Fracture: A Biomechanical Study.

PURPOSE: There has been increased interest in the role of the posterior bundle of the medial collateral ligament (pMUCL) in the elbow, particularly its effects on posteromedial rotatory stability. The ligament's effect in the context of an unfixable coronoid fracture has not been the focus of any study. The purposes of this biomechanical study were to evaluate the stabilizing effect of the pMUCL with a transverse coronoid fracture and to assess the effect of graft reconstruction of the ligament. METHODS: We simulated a varus and internal rotatory subluxation in 7 cadaveric elbows at 30°, 60°, and 90° elbow flexion. The amount of ulnar rotation and medial ulnohumeral joint gapping were assessed in the intact elbow after we created a transverse coronoid injury, after we divided the pMUCL, and finally, after we performed a graft reconstruction of the pMUCL. RESULTS: At all angles tested, some stability was lost after cutting the pMUCL once the coronoid had been injured, because mean proximal ulnohumeral joint gapping increased afterward by 2.1, 2.2, and 1.3 mm at 90°, 60°, and 30°, respectively. Ulnar internal rotation significantly increased after pMUCL transection at 90°. At 60° and 30° elbow flexion, ulnar rotation increased after resection of the coronoid but not after pMUCL resection. CONCLUSIONS: An uninjured pMUCL stabilizes against varus internal rotatory instability in the setting of a transverse coronoid fracture at higher flexion angles. Further research is needed to optimize graft reconstruction of the pMUCL. CLINICAL RELEVANCE: The pMUCL is an important secondary stabilizer against posteromedial instability in the coronoid-deficient elbow. In the setting of an unfixable coronoid fracture, the surgeon should examine for posteromedial instability and consider addressing the pMUCL surgically.

Factors that predict instability in pediatric diaphyseal both-bone forearm fractures.

The aim of this study was to determine the factors that may predict failure of closed reduction and casting of diaphyseal forearm fractures in children. Demographic and radiographic data of children with closed reduction and casting of these fractures in the emergency department were evaluated. Of 174 patients with adequate follow-up to union, 19 (11%) required a repeat procedure. Risk factors for repeat reduction included translation of 50% or more in any plane, age more than 9 years, complete fracture of the radius, and follow-up angulation of the radius more than 15° on lateral radiographs or of the ulna more than 10° on anteroposterior radiographs.

Is the novel olecranon tension plate a valid alternative to tension band wiring of olecranon fractures? A biomechanical study on cadaver bones.

INTRODUCTION: Tension band wiring (TBW) used for olecranon fractures is afflicted with a high rate of complications. The aim of this study was to compare the stability of the TBW versus an alternative, novel low-profile olecranon tension plate (OTP) with angular stable screws in a simulated complex fracture model. MATERIALS AND METHODS: Nine fresh-frozen pairs of cadaver proximal ulnae with an oblique osteotomy and an additional wedge fragment simulating an unstable fracture were tested. The TBW and OTP were implanted pairwise. The elbow motion was simulated in a single-muscle model and ranged from full extension to 90° of flexion. The pulling force of the triceps tendon ranged from 50 to 200 N. The displacement of the fracture fragments was measured with a video motion analysis system over 304 cycles. Data were assessed statistically using the Wilcoxon signed-rank test. RESULTS: The cyclic loading tests showed mean loosening of the fracture fragments at the articular surface of 0.56 mm using TBW (SD 0.65) and 0.15 mm for OTP (SD 0.39). There was no statistical significance in loosening between the two constructs (p = 0.31). No plate breakage or screw loosening occurred. CONCLUSIONS: The low-profile OTP, using the principles of pre-tensioning, lag, cortical, and angular stable screws together, demonstrated similar stability after olecranon fracture fixation when compared with the TBW technique and a lag screw in the olecranon fracture model with a third wedge fragment.

Ulna fracture and medial meniscal tear resulting from dog-related injuries.

In this article, we present two middle-aged female patients with ulna fracture or medial meniscal tear resulting from dog-related injuries, which are not common. Both patients mentioned that pain started after their dogs pulled away their collar ropes strongly and suddenly. Both patients had postmenopausal osteoporosis and degenerative osteoarthritis. For this reason, ulna fracture and meniscus tear had developed with low-energy trauma resulting from dog-related injuries.

Evaluation of functional outcome after nonsurgical management of terrible triad injuries of the elbow.

BACKGROUND: Terrible triad (TT) is one of the severe injuries of the elbow that generally requires surgery. Nonsurgical treatment has recently been applied in selected cases of TT injury. Evaluation of the results of this treatment was the main aim of this study. METHODS: In a prospective cohort study, 10 patients with a mean follow-up of 30.6 months were evaluated. The inclusion criteria included a congruent joint after closed reduction, no indication for surgery of the coronoid and radial head fractures, no block in supination and pronation up to 60°, no intra-articular fragments, and a free and stable joint with ulnohumeral extension up to a minimum of 45°. Mayo Elbow Performance Index and Disabilities of the Arm, Shoulder, and Hand score were used for assessment of the functional outcome. A standard physical examination to record elbow range of motion was also performed. RESULTS: For the affected and the contralateral elbows, respectively, the mean extension of the elbow was 11° ± 7° and 0.0° ± 2°; the mean flexion was 131° ± 9° and 140° ± 10°; the mean supination was 58° ± 17° and 85 ± 7°; and the mean pronation was 53° ± 23° and 85° ± 7°. The mean Disabilities of the Arm, Shoulder, and Hand score was 4.76 ± 5.17. The mean Mayo Elbow Performance Index was 95 ± 8.16. CONCLUSION: Nonsurgical management of the TT injury can result in acceptable functional outcomes when a patient meets the criteria set for nonsurgical treatment.

Plate Osteosynthesis of Proximal Ulna Fractures-A Biomechanical Micromotion Analysis.

PURPOSE: Double plating has been promoted, in recent years, as an alternative treatment method for proximal ulna fractures. This study aimed to compare the biomechanical properties of double-plate osteosynthesis with posterior plate fixation using a novel investigational design utilizing a 3-dimensional camera system to analyze fracture micromotion. METHODS: Fourteen fresh-frozen specimens were available for this study. Mayo type IIA fractures of the olecranon were created and internal fixation was performed with either an angular stable posterior plate or angular stable double plates. Fracture micromotion was evaluated by means of digital image correlation with a 3-dimensional camera system before and after dynamic cyclic loading from 15° to 90° of elbow flexion with a pulling force of 25 N to 80 N. RESULTS: Micromotion of fragments was less pronounced in double-plate osteosynthesis when compared with single plates before and after cyclic loading. However, overall results were similar. Two of the single plates failed during cyclic loading but there were no failures in the double plates. CONCLUSIONS: This biomechanical analysis shows that single and double plating results in comparable stability of fixation. Although the double-plating technique tends to provide more stable fixation, relevant differences were not observed. CLINICAL RELEVANCE: Double plating potentially represents an efficient option for fixation of proximal ulna fractures. It could decrease the risk of soft tissue complications owing to their low profile and the superior soft tissue coverage.