Open Reduction and Internal Fixation for Supination-External Rotation Type IV Ankle Fractures by Means of Anterolateral and Posterolateral Approaches.

BACKGROUND: The present study aimed to analyze and compare the efficacy of the anterolateral and posterolateral approaches for surgical treatment of supination-external rotation type IV ankle fractures. METHODS: This retrospective study enrolled 60 patients (60 feet) with supination-external rotation type IV ankle fractures, including 30 patients (30 feet) treated by means of the anterolateral approach and 30 patients (30 feet) treated by means of the posterolateral approach. Postoperative clinical efficacy was compared between the groups based on operation time, intraoperative blood loss, postoperative complications, fracture healing time, visual analog scale scores, Short Form-36 Health Survey scores, and American Orthopedic Foot and Ankle Society scores. Comparisons between the two groups were performed using independent-samples t tests and analyses of variance. Intragroup differences were compared using paired t tests, and the χ2 test was used to compare categorical variables. RESULTS: All 60 included patients completed follow-up ranging from 12 to 18 months (mean duration, 14.8 ± 3.5 months). Although baseline characteristics were similar in the two groups, there were significant differences in operation time (86.73 ± 17.44 min versus 111.23 ± 10.05 min; P < .001) and intraoperative blood loss (112.60 ± 25.05 mL versus 149.47 ± 44.30 mL; P < .001). Although fracture healing time (10.90 ± 0.66 weeks versus 11.27 ± 0.94 weeks; P = .087) was shorter in the anterolateral group than in the posterolateral group, the difference was not significant. Postoperative complications occurred in one and three patients in the anterolateral and posterolateral approach groups, respectively. Visual analog scale scores were significantly lower in the anterolateral group than in the posterolateral group (1.43 ± 0.50 versus 1.83 ± 0.75; P = .019), although there was no significant difference in Short Form-36 Health Survey scores between the groups (73.63 ± 4.07 versus 72.70 ± 4.04; P = .377). However, American Orthopedic Foot and Ankle Society scores were higher in the anterolateral group than in the posterolateral group (80.43 ± 4.32 versus 75.43 ± 11.32; P = .030). CONCLUSIONS: Both the anterolateral and posterolateral approaches can achieve good results in the treatment of supination-external rotation type IV ankle fractures. Compared with the posterolateral approach, the anterolateral approach is advantageous for the treatment of supination-external rotation type IV ankle fractures given its safety and ability to reduce trauma, clear field of view revealed, and allow for exploration and repair of the inferior tibiofibular anterior syndesmosis within the same incision.

Comparison of the forearm rotation restriction capacities of four upper-extremity immobilization methods: there is no difference between single and double sugar tong splinting.

BACKGROUND: The aim of this study was to compare the effects of four different immobilization methods [single sugar tong splint (SSTS), double sugar tong splint (DSTS), short arm cast (SAC), and long arm cast (LAC)] commonly used for restricting forearm rotation in the upper extremity. METHODS: Forty healthy volunteers were included in the study. Dominant extremities were used for measurements. Basal pronation and supination of the forearm were measured with a custom-made goniometer, and the total rotation arc was calculated without any immobilization. Next, the measurements were repeated with the SAC, LAC, SSTS and DSTS. Each measurement was compared to the baseline value, and the percentage of rotation restriction was calculated. RESULTS: The most superior restriction rates were observed for the LAC (p = 0.00). No statistically significant difference was detected between the SSTS and DSTS in terms of the restriction of supination, pronation or the rotation arc (p values, 1.00, 0.18, and 0.50, respectively). Statistically significant differences were not detected between the SAC and the SSTS in any of the three parameters (p values, 0.25; 1.00; 1.00, respectively). When the SAC and DSTS were compared, while there was no significant difference between the two methods in pronation (p = 0.50), a statistically significant difference was detected in supination (p = 0.01) and in the total rotation arc (p = 0.03). CONCLUSION: The LAC provides superior results in restricting forearm rotation. The SAC and SSTS had similar effects on forearm rotation. The DSTS, which contains, in addition to the SSTS, a sugar tong portion above the elbow, does not provide additional rotational stability.

Acute blockage of forearm supination due to flap tear of the triangular fibrocartilage disc: A case report.

RATIONALE: Acute blockage of forearm supination has been reported in several studies. It is caused by loose bodies in the wrist joint, extensor carpi ulnaris tendon interposition, and distal radioulnar joint (DRUJ) injuries, including forearm bone fractures. Some studies have reported cases of DRUJ injuries caused by triangular fibrocartilage complex (TFCC) tears.We report a case of acute blockage of forearm supination after minor trauma and suggest a possible TFCC tear when a patient complains of forearm supination blocking. In addition, we present a comparison between our case and other reports on etiology, magnetic resonance imaging (MRI) findings, and arthroscopic findings, and show the specific characteristics of our case. PATIENTS CONCERNS: A 22-year-old male presented with left wrist pain as the chief complaint. He was injured 2 months prior to pushing his left hand on the floor during exercise. Physical examination showed a relative limitation of range of motion (ROM) in the left wrist of about 10° in flexion and about 15° in extension compared with the right side. The patient also complained of supination limitation and volar side wrist pain during supination. The patient showed tenderness in the axial compression test. DIAGNOSES: Plain radiographs showing no abnormalities. MRI showed a TFCC tear in the central portion. A torn flap of the TFCC was interposed on the volar side of the DRUJ. INTERVENTIONS: Arthroscopic surgery of the left wrist joint was performed. Arthroscopic examination revealed a tear in the TFCC on the radial side. A torn flap was interposed on the volar side of the DRUJ. We removed the flap from the DRUJ using an arthroscopic grasper and partially resected it. OUTCOMES: Intraoperative tests showed no locking and the forearm was well supinated. Two months after the surgery, the patient had no pain and showed full forearm supination. LESSONS: DRUJ blocking due to a TFCC tear should be suspected when acute blockage of forearm supination occurs after minor trauma. MRI is helpful for diagnosis; however, we suggest that the diagnosis should be confirmed through arthroscopy. Symptoms can be resolved by surgical treatment using arthroscopy.

Analyzing the reduction quality of the distal radioulnar joint after closed K-wire transfixation in a cadaver model: is supination or neutral position superior?

INTRODUCTION: Distal radioulnar joint (DRUJ) instabilities are challenging and their optimal treatment is controversial. In special cases or when reconstruction of the stabilizing triangular fibrocartilage complex (TFCC) fails, K-wire transfixation can be performed. However, no consensus has been reached regarding the rotational position of the forearm in which this should be done. Therefore, it was investigated whether anatomical reduction would best be achieved by transfixation in neutral position or supination of the forearm. MATERIALS AND METHODS: Twelve cadaveric upper limbs were examined before dissection of the DRUJ stabilizing ligaments and after closed transfixation in both positions by C-arm cone-beam CT. Whether this was first done in neutral position or in supination was randomized. The change in the radioulnar ratio (RR) in percentage points (%points) was analyzed using Student's t-test. RR was used since it is a common and sensitive method to evaluate DRUJ reduction, expressing the ulnar head's position in the sigmoid notch as a length ratio. RESULTS: The analysis showed an increased change in RR in neutral position with 5.4 ± 9.7%points compared to fixation in supination with 0.2 ± 16.1%points, yet this was not statistically significant (p = 0.404). CONCLUSIONS: Neither position leads to a superior reduction in general. However, the result was slightly closer to the anatomical position in supination. Thus, transfixation of the DRUJ should be performed in the position in which reduction could best be achieved and based on these data, that tends to be in supination. Further studies are necessary to validate these findings and to identify influential factors.

Effects of simulated radioulnar synostosis on supination and pronation in cats. A cadaveric study.

OBJECTIVE: To evaluate the effect of an induced synostosis with a screw on pronation and supination in cats. STUDY DESIGN: Ex vivo biomechanical study. SAMPLE POPULATION: A total of 58 feline forelimbs. METHODS: A total of 58 cadaveric feline thoracic limbs were mounted on a custom-built jig with the elbow and carpus flexed at a 90° angle. To exclude any orthopedic disease, radiographs of the forelimbs were performed prior to the mechanical tests. Radioulnar synostosis was imitated with a 2 mm cortical screw through the radius into the ulna in the proximal (Group P; n = 54), middle (Group M; n = 52), and distal (Group D; n = 53) radial diaphysis. The angles of pronation and supination were recorded after manually applying a two-finger tight rotational force to the metacarpus. Rotational tests were performed without a screw (Group N) and with a screw in each of the aforementioned positions. Pairwise comparisons between the groups were performed based on their angles of rotation with a paired t-test with the Benjamini-Hochberg procedure and a mixed model ANOVA. RESULTS: Mean angles of rotation decreased between Group N (129.5 ± 15.9°) and all groups with imitated radioulnar synostosis to a mean angle of 37.5 ± 14.5° (p < .0001). Mean angles of rotation did not differ between the groups with imitated radioulnar synostosis. CONCLUSION: Induced radioulnar synostosis decreases antebrachial rotation by more than two-thirds, regardless of location. CLINICAL SIGNIFICANCE: Implants fixating the radius to the ulna should be avoided in cats, regardless where they are located along the radial diaphysis.

Does a rupture of the lateral ankle ligament need to be repaired in supination-adduction type II (OTA/AO 44A2) fractures?

PURPOSE: To evaluate the outcomes of patients with supination-adduction (SAD) type II (OTA/AO 44A2) fractures who had a lateral ankle ligament rupture repaired compared with patients who did not have a lateral ankle ligament repaired using patients who underwent fibula fracture fixation as a control group. METHODS: A retrospective analysis of all 104 patients diagnosed with SAD type II fractures from January 2011 to December 2020 and managed operatively was performed. The patients were divided into three groups: 32 patients with ruptures of the lateral ligaments that were not repaired (group A), 34 patients with ruptures of the lateral ligaments that were repaired (group B), and 38 patients with fibula fracture fixation acting as the control group (group C). The objective outcomes including radiographic findings, the ankle range of motion, the manual ankle stress tests, and complications were gained from the record of the last time in outpatient clinics. The functional outcomes including the identification of functional ankle instability (IdFAI) scores were collected postoperatively at 12-month intervals to assess clinical outcomes. The Manchester Oxford Foot Questionnaire (MOXFQ) and Karlsson scoring scale were also recorded at the last follow-up. RESULTS: The mean follow-up of the objective and subjective functional outcomes was 23.4 (range, 13-42) and 76.9 (range, 25-134) months, respectively. There was no significant difference in the radiographic findings, the ankle range of motion and complications between the three groups. All ankles were found to be stable using the manual ankle stress test in both group A and group B. The IdFAI scores showed a significant difference between group A and group B (1.12 ± 1.3 vs 0.35 ± 0.69; p < 0.001) in the first year of follow-up and no significant difference after the first year. No differences were noted in MOXFQ scores or Karlsson scores among the groups. CONCLUSION: Directly repairing the lateral ligament could minimize the proportion of the first year of postoperative functional ankle instability, although the final stability of the ankle and clinical outcomes were not significantly different in SAD type II fractures. LEVEL OF EVIDENCE: Level III, retrospective comparative case series.

Comparison of Supination-Adduction Type 2 and Supination-External Rotation Type 4 in Bimalleolar Ankle Fractures: Does Partial Pylon Variant of Supination-Adduction Type Fracture Affect Functional Outcomes?

BACKGROUND: Supination-adduction (SAD) type injuries are pylon variant injuries and lie between partial intra-articular pylon fractures and rotational ankle fractures. We aimed to evaluate functional outcomes of SAD type 2 bimalleolar fractures in comparison to supination-external rotation (SER) type 4 fractures. METHODS: We retrospectively reviewed data of 42 cases with SER type 4 and 20 cases with SAD type 2 injuries. Patients with a history of rheumatic disease, open fractures, pathologic fractures, nonbimalleolar fractures, neuropathic disease, and talus osteochondral lesion, and those operated on after greater than 72 hours because of skin lesion or managed with a two-stage surgical protocol after external fixation, were not included in the study. We compared these two groups in terms of the mean age, follow-up time, visual analog scale pain and American Orthopedic Foot and Ankle Society scores, Kellgren-Lawrence arthrosis classification, union time, and complications. RESULTS: The groups did not differ in terms of mean age (P = .115) and sex (P = .573). There was no significant difference in terms of union time between the groups (P = .686). American Orthopedic Foot and Ankle Society score was significantly higher in the SER group (91.2 ± 9.9) than in the SAD group (86.1 ± 13.2; P = .034). Visual analog scale pain scores were similar in the SAD (0.3 ± 0.92) and the SER (0.26 ± 0.7) groups (P = .897). CONCLUSIONS: Supination-adduction bimalleolar fractures may have worse functional outcomes in the intermediate term than do SER bimalleolar fractures, implying pylon variant fractures as a mechanism of injury. Supination-adduction bimalleolar fractures might be associated with a high rate of intra-articular cartilage impaction, resulting in varus deformity after surgery.

Surgical approach to forearm pronation deformity in patients with cerebral palsy: a systematic review.

Background: Pronation deformity in patients with cerebral palsy can have a major impact on upper limb functionality. There is lack of consensus in the literature about the preferred surgical technique to address this deformity. Study aim: To evaluate and synthesize the outcome of different surgical techniques for pronation deformity in patients with cerebral palsy. Methodology: The databases MEDLINE and Embase were searched for publications up to December 2021. Articles were considered eligible for inclusion when the included patients had a pronation deformity caused by cerebral palsy and results of surgical intervention for pronation deformity were examined. Evaluation of the quality of the retrieved study was conducted using the MINORS tool. Meta-analysis was not possible due to the heterogeneity of interventions and reported outcomes. Results: Nineteen studies, involving 475 patients and eight different techniques were included. All studies reported gain of active supination in most patients. The effect of surgery on functional gain was less clear and there was a large heterogeneity of reported functional outcome measures. There were 46 reported complications. Overall quality of study design was poor, illustrated by the average MINOR score of 6.9/16. Overall, there is a high risk of bias due to poor internal and external validity of the studies. Conclusion: Despite positive reports on gain in supination and functionality after most procedures addressing pronation deformity in CP patients, no conclusions can be drawn concerning the preferred technique due to the low quality of the evidence.

Fractura triplanar de tibia distal: Reporte de un caso y revisión de la literatura / Triplanar fracture of proximal tibia: A case report and literature review

Las fracturas triplanares de tibia distal, son fracturas complejas caracterizadas por afectación multiplanar, clasificándose como Salter Harris tipo IV, en el periodo de cierre fisiario. Son poco frecuentes, representando el 5-15% de las fracturas pediátricas. El mecanismo de lesión que ocurre con mayor frecuencia, consiste en supinación y rotación externa. La tomografía computarizada es actualmente el Gold Standard para el diagnóstico de este tipo de fractura, nos permite evaluar todos los planos, siendo la radiografía simple insuficiente para el diagnóstico ya que puede pasar desapercibida. Paciente de 14 años de edad con fractura triplanar en 2 partes de tibia distal, con resolución quirúrgica. Nuestro caso es un ejemplo de una fractura triplanar de tibia distal, la cual es de baja frecuencia, difícil diagnostico e interpretación. Presentamos imágenes preoperatorias, intraoperatorias y postoperatorias del manejo de esta lesión, obteniendo resultados satisfactorios clínicos, funcionales y en estudios de imágenes. Es indispensable lograr una reducción anatómica de la superficie articular para lograr una evolución satisfactoria. Se recomienda una tomografía computarizada para diagnosticar y manejar esta lesión de manera adecuada. El seguimiento postoperatorio es crucial para el manejo de este paciente, ya que se espera una discrepancia en la longitud de las extremidades y/o deformidad(AU)

Triplane fractures of the distal tibia are complex fractures characterized by multiplane effects. They are classified in the Salter-Harris system as type IV in the period of physeal closure. These fractures are rare and represent 5-15% of pediatric fractures. The most common mechanism of injury is supination and external rotation. Computed tomography is currently the Gold Standard for the diagnosis of this type of fracture since it allows us to evaluate all planes, while plain radiography is insufficient because the fracture can go unnoticed. The objective is to report the clinical case of a 14-year-old patient with triplanar fracture in 2 parts of the distal tibia with surgical resolution. This case is an example of a triplanar fracture of the distal tibia, which is of low frequency, and difficult to diagnose and interpret. Preoperative, intraoperative and postoperative images of the management of this lesion are presented, obtaining satisfactory clinical, functional and imaging study results. It is essential to achieve an anatomical reduction of the joint surface to achieve a satisfactory evolution. A CT scan is recommended to properly diagnose and manage this injury. Postoperative follow-up is crucial for the management of this patient, as a limb length discrepancy and/or deformity is expected(AU)

Can we safely place the distal volar locking plate screws into the subchondral zone of a distal radius fracture using a 45° supination oblique view under fluoroscopic guidance?

INTRODUCTION: Careful distal locking screw insertion into the subchondral zone is necessary to obtain proper mechanical strength of unstable distal radius fractures using volar locking plating. However, subchondral zone screw insertion increases the risk of intra-articular screw penetration, which may remain unrecognized during surgery due to complex distal radial anatomy. The purpose of this study was to evaluate the role of fluoroscopic guidance with a 45° supination oblique view technique for placing distal screws into the subchondral zone during volar locking plating for unstable distal radius fractures and to explore the factors associated with poor screw placement. METHODS: We retrospectively analyzed 171 wrists of 169 patients treated with variable-angle volar locking plates for unstable radius fractures. The subchondral zone was defined as the metaphyseal area within 4 mm of the articular margin of the distal radius. The location of the distal locking screws and radiographic parameters, including the teardrop angle, were measured using computed tomography scans and X-rays. Clinical and radiographic factors were examined to determine their possible associations with screw placement failure. RESULTS: Of 581 distal screws inserted, 559 screws (96.2%) were inserted into the subchondral zone and 17 screws into the metaphyseal zone (2.9%). Five screws (0.7%) in three wrists showed intra-articular placement: four screws were placed into the lunate fossa and one into the scaphoid fossa. These three wrists also exhibited significantly reduced teardrop angles. The distal screws were significantly closer to the joint line in the lunate fossa than the scaphoid fossa (1.9 ± 0.9 mm vs. 2.8 ± 1 mm, P < 0.000). CONCLUSION: The 45° supination oblique view technique is a useful fluoroscopic guiding technique for accurate and safe distal screw placement in the subchondral zone in volar locking plate fixation for distal radial fractures. However, a decreased teardrop angle or extended lunate fossa should be corrected before distal screw insertion to avoid intra-articular screw placement.

Comparison of different treatment methods for supination-lateral rotation ankle fractures.

OBJECTIVES: This study aims to compare the therapeutic effects of fixation with fibular approach, fixation with posterolateral fibular approach, and conservative therapy on supination-lateral rotation ankle fractures. PATIENTS AND METHODS: A total of 189 patients (103 males, 86 females; mean age: 45.7±4.7 years; range, 40 to 51 years) with supination-lateral rotation ankle fractures treated in our hospital between March 2020 and March 2021 were included in this prospective study. The patients were assigned into conservative therapy, fibular approach, and posterolateral approach groups including 63 patients in each group. Clinical conservative therapy was performed for conservative therapy group, while fibular approach and posterolateral approach groups were given fixation with fibular approach and posterolateral fibular approach, respectively. Their routine parameters, body stress, ankle function, treatment efficacy and safety were compared. RESULTS: The length of hospital stay was shorter in the fibular approach and posterolateral approach groups than the conservative therapy group, particularly in the fibular approach group (p<0.05). The pain stress and oxidative stress were lower in the fibular approach and posterolateral approach groups than the conservative therapy group, particularly in the posterolateral approach group (p<0.05). Compared to the conservative therapy group, the fibular approach and posterolateral approach groups had significantly recovered ankle function, with better recovery in the posterolateral approach group (p<0.05). The response rate was higher in the fibular approach and posterolateral approach groups than the conservative therapy group, being higher in the posterolateral approach group (p<0.05). CONCLUSION: For patients with supination-lateral rotation ankle fractures, fixation with posterolateral fibular approach is more effective for expediting the recovery of ankle joints than conservative therapy and fixation with fibular approach, accompanied by higher safety.

Kinematic analysis of forearm rotation using four-dimensional computed tomography.

This study aimed to quantify forearm kinematics with a focus on the forearm rotation axis. Ten healthy volunteers were included in the study. One three-dimensional computed tomographic scan and two four-dimensional computed tomographic scans were done in all the arms to capture forearm joint motion. After image processing, the rotation axis and the movement of the radius with respect to various axes were quantified. The rotation axis was calculated using finite helical axis analysis and a circle fitting approach. The mean error of the rotation axis found through circle fitting was 0.2 mm (SD 0.1) distally and 0.1 mm (SD 0.1) proximally, indicating an improvement in precision over the finite helical axis approach. The translations of the radius along the ulnar axis and the forearm rotation axis were 2.6 (SD 0.8) and 0.6 mm (SD 0.9), respectively. The rotation of the radius around the radial axis was 7.2°. The techniques presented provide a detailed description of forearm kinematics.

Preoperative radius head dislocation affects forearm rotation after mobilization of congenital radioulnar synostosis.

BACKGROUND: The present study was carried out to answer three questions: 1) How much forearm rotation can be expected after mobilization of congenital radioulnar synostosis (CRUS)? 2) Does preoperative radius head dislocation affect forearm rotation after mobilization? 3) What factors other than radius head dislocation affect postoperative forearm rotation? METHODS: We performed mobilization of CRUS with a free vascularized fascio-fat graft and a radius osteotomy (Kanaya's procedure) on 26 forearms of 25 patients. The age at the surgery ranged from 5.3 to 13.4 years. The follow-up duration ranged 24-111 months. We classified CRUS into 3 groups according to the dislocation of the radius head: posterior dislocation (N = 13), anterior dislocation (N = 9) and no dislocation (N = 4). Since major complaints of patients and parents were poor forearm rotation and lack of supination, they were evaluated separately. RESULTS: Mean preoperative forearm ankylosis angle was 34.8° (range; neutral to 90° pronation). Preoperative pronation ankylosis angle was higher in the posterior dislocation group (mean 55.3°) than the anterior dislocation (mean 11.6°) and no dislocation groups (mean 5.0°). There was no re-ankylosis after mobilization and the mean postoperative active range of motion (ROM) was 86.5°. The mean active ROM was 75.7° in the posterior dislocation group, 96.1° in anterior dislocation group and 100.0° in no dislocation group. The mean active supination was 6.9, 33.9 and 47.5° respectively. The posterior dislocation group showed less ROM and less supination than other groups. Preoperative pronation ankylosis angle showed negative correlation with postoperative ROM (ρ = - 0.59) and postoperative supination (ρ = - 0.73). CONCLUSION: The mean postoperative active ROM of this mobilization was 86.5°. Posterior dislocation group showed higher pronation ankylosis angle preoperatively, and less postoperative ROM and less supination than anterior and no dislocation groups. Preoperative pronation ankylosis angle showed negative correlation with postoperative ROM and supination.

The effects of maximal radial bowing on forearm rotation in pediatric diaphyseal forearm fractures.

PURPOSE: To evaluate the effects of radial bowing on forearm rotation in forearm fractures compared with healthy children. METHODS: A retrospective study was conducted on children aged 1-16 years old. Group 1 was children with history of diaphyseal forearm fractures, and group 2 was healthy children. Children in group 1 with ≤ 70° forearm pronation and/or ≤ 80° supination on affected side are defined as "case." In group 2, children with forearm pronation > 70° and/or supination > 80° are defined as "control." Radial bowing was measured on AP radiograph of the forearm; maximal radial bowing (MRB) and location of the maximal radial bowing (LMRB) were recorded. RESULTS: Total of 112 children were included (group 1 = 70, group 2 = 42). In group 1, there were 28 children with ≤ 70° forearm pronation and/or ≤ 80° forearm supination (case group). In group 2, there were 33 children with > 70° forearm pronation and > 80° forearm supination (control group). Mean age of case and control group was 11.08 ± 3.02 and 7.85 ± 3.93 years, respectively. Average MRB was 6.15 ± 1.93% and LMRB was 61.94 ± 9.41% in case group. In control group, average MRB was 7.23 ± 1.03% and LMRB was 62.08 ± 4.24%. There was statistically significant correlation between children with ≤ 70° forearm pronation and MRB (P = 0.034) compared with control group. Also, there was statistically significant correlation between children with ≤ 80° forearm supination and MRB (P = 0.023) compared with control group. For ROC curve analysis, MRB ≤ 6.84% showed the association with ≤ 70° forearm pronation (72.2% sensitivity and 73.8% specificity) and MRB ≤ 5.75% associated with ≤ 80° forearm supination (54.6% sensitivity and 84.9% specificity). CONCLUSIONS: Children with MRB ≤ 6.84% can result in ≤ 70° forearm pronation, and MRB ≤ 5.75% can be presented with ≤ 80° forearm supination.

Long-Term Outcomes of Biceps Rerouting for Flexible Supination Contractures in Children With Brachial Plexus Birth Injuries.

PURPOSE: Forearm supination contractures occur in 7% of children with brachial plexus birth injuries (BPBI). Biceps rerouting is proposed when pronation has deteriorated but is passively correctable to at least 0° (neutral). The purpose of this investigation was to evaluate long-term outcomes of biceps rerouting for this indication, including magnitude and maintenance of correction, complications, and subsequent osteotomy. METHODS: We conducted a retrospective review of all children with BPBI and forearm supination contractures treated with biceps rerouting alone, for the above indications, from 1993 to 2017 with at least 2 years follow-up. Demographic information, BPBI characteristics, surgical details, and ranges of motion were obtained from medical records. Pre- and postoperative active pronation (AP) and supination (AS), elbow flexion contracture, and arc of forearm rotation (Arc) were analyzed using linear mixed-effect models. RESULTS: Twenty-five children (13 females; 13 left forearms; 15 global BPBI) underwent biceps rerouting at age 7 ± 3 years and were followed for 6 ± 3 years. Before surgery, the mean AP and AS were 6° ± 29° and 62° ± 27°, respectively. At the final follow-up, the mean AP, AS, and Arc were 39° ± 36°, 18° ± 34°, and 57° ± 42°, respectively. AP was significantly improved and AS was significantly decreased by 2 years after surgery and at the final follow-up. Neither Arc nor elbow flexion contracture changed significantly. Two of 25 (8%) children underwent subsequent forearm osteotomy. CONCLUSIONS: Biceps rerouting in children with BPBI improves the forearm position when pronation is deteriorating by shifting the arc from supination to pronation without decreasing the arc of motion or worsening elbow flexion contractures. There is a low risk of complications and a limited need for subsequent forearm osteotomy. These results are maintained over time. When performed before passive pronation is reduced beyond neutral, this procedure may prevent severe supination contractures and reduce the need for forearm osteotomy. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic IV.

[Anterior tibialis tendon transfer for the treatment of dynamic supination in patients with clubfoot. Analysis of clinical outcomes and complications]. / Transferencia del tendón tibial anterior para el tratamiento de la supinación dinámica en el pie bot. Análisis de los resultados clínicos y las complicaciones.

INTRODUCTION: our aim was to evaluate the clinical outcomes and complications of anterior tibialis tendon transfer (ATTT) in children with dynamic supination after clubfoot treatment. MATERIAL AND METHODS: children with dynamic supination after initial treatment with Ponseti method or surgery who underwent ATTT between 2008 and 2020 were included for evaluation. Demographic data, previous treatment, associated procedures and fixation method were analyzed. Functional results were evaluated with the grading system described by Thompson. Complications and their treatment were analyzed. RESULTS: a total of 39 patients (57 feet) were analyzed. 70% received previous treatment with Ponseti method, 19.3% underwent surgical posteromedial release, and 10.7% another type of surgical treatment. 88% of cases required associated procedures including Achilles tendon lengthening or tenotomy, plantar fasciotomy, tibial osteotomy, lateral column shortening, posterior release. The predominant type of fixation was the pull-out button method (96.5%). The average follow-up was 31.5 months. According to the Thompson grading system, 52 patients presented good results, two fair and three poor. 98.2% of the feet showed active contraction of the transferred tibialis anterior tendon. There were four complications: plantar irritation, synovial cyst in the dorsum of the foot and deep infection. Two feet required unplanned surgery. CONCLUSION: anterior tibialis tendon transfer is an effective technique to correct residual dynamic supination in patients with clubfoot.

INTRODUCCIÓN: el objetivo de este estudio fue evaluar los resultados clínicos y complicaciones de la transferencia del tendón tibial anterior (TTTA) en niños con pie bot y supinación dinámica. MATERIAL Y MÉTODOS: se incluyeron niños con recurrencia dinámica del pie bot después de tratamiento con método Ponseti o cirugía, que se sometieron a TTTA entre 2008 y 2020. Se analizaron datos demográficos, tratamientos previos, procedimientos asociados y método de fijación. Los resultados funcionales fueron evaluados con el sistema de graduación descrito por Thompson. Se analizaron las complicaciones y su tratamiento. RESULTADOS: se analizaron 39 pacientes (57 pies). Setenta por ciento recibió tratamiento previo con método Ponseti, a 19.3% se le realizó liberación posteromedial y a 10.7% otro tipo de tratamiento quirúrgico. Ochenta y ocho por ciento de los casos requirió procedimientos asociados: tenotomía o alargamiento del tendón de Aquiles, fasciotomía plantar, osteotomía desrotadora de tibia, acortamiento de columna lateral, liberación posterior. El tipo de fijación predominante fue pull-out con botón (96.5%). El seguimiento promedio fue de 31.5 meses. De acuerdo al sistema de Thompson, 52 pacientes presentaron resultados buenos, dos regulares y tres malos. 98.2% de los pies mostraron contracción activa del tendón del tibial anterior transferido. Se presentaron cuatro complicaciones: irritación plantar, quiste sinovial en dorso e infección profunda. Dos pies requirieron cirugía no programada. CONCLUSIÓN: la transferencia del tendón del tibial anterior es una técnica eficaz para corregir la supinación dinámica residual en pacientes con pie bot.

Natural history of elbow flexion and forearm rotation contractures in obstetric brachial plexus injury.

A prospective database study was undertaken to investigate the severity and progression of elbow and forearm contractures in patients with obstetric brachial plexus injury. One-hundred and fifty-nine patients, who had not undergone nerve repair (mean age 12 years at last follow-up) (56 Narakas Group 1, 66 Group 2, 27 Group 3, 10 Group 4) were studied. Mean fixed flexion of the elbow at last follow-up was 13° for Group 1, 15° for Group 2, 19° for Group 3 and 24° for Group 4. Severe contracture of 30° or more developed in 31 children (mean age 118 months), with poorer active shoulder abduction being a significant risk factor. Onset of contracture was before the age of 5 years but did not increase substantially beyond 12 years. Active and passive pronation and supination tended to decrease with increasing injury severity. Seventeen children developed severe restriction of passive pronation (supination contracture) (mean age 69 months), and 12 developed severe restriction of passive supination at a mean of 137 months.Level of evidence: III.

Measuring Deltoid Insufficiency After Supination-External Rotation Ankle Fracture With Lateral Talar Subluxation on Gravity Stress View.

BACKGROUND: Stress-view radiographs are frequently obtained to evaluate supination-external rotation (SER) variant ankle fractures. Measurement of the ankle medial clear space (MCS) is a surrogate of medial structure integrity as part of overall ankle stability. Measurement of the lateral talus displacement with respect to the incisura may be a sensitive and specific method to assess joint subluxation. METHODS: Retrospective review of acute SER-variant isolated lateral malleolar fractures with gravity stress views (GSVs) were performed for 103 patients. GSV analysis was performed with standardized measurements of the MCS, superior clear space (SCS), and 2 new novel measurements of lateral talus subluxation (LTS). Decision for surgery was obtained by surgeons who reviewed masked injury radiographs for predictive performance analysis of the LTS vs MCS. RESULTS: MCS, SCS, and LTS measurements were performed on 103 patients. Mean MCS, SCS, and LTS within the operative group was increased. MCS ≥5 mm and LTS >4 mm had equal sensitivity (95%), with higher specificity for LTS (75% vs 60%). Receiver operating characteristic analysis demonstrates an area under the curve of 0.786 for MCS ≥5 mm vs 0.918 for LTS >4 mm. CONCLUSION: We found LTS to be superior to MCS for medial ankle structure stability on gravity stress views of SER-variant ankle fractures. We propose this as a useful tool for clinicians to consider when evaluating SER-variant ankle fractures. LEVEL OF EVIDENCE: Level II, prospective comparative study of radiographs.

The influence of sagittal deformity of the distal radius on pronosupination: a cadaver study.

We performed a cadaver study using seven fresh-frozen adult upper limbs to assess the impact of increasingly larger distal radial deformity in the sagittal plane on the range of motion in pronation/supination. Three palmar (20°, 30° and 40° angulations) and three dorsal (10°, 20° and 30° angulations) tilt deformities, without any radial shortening, were simulated by performing a radial osteotomy and using custom-made three-dimensional-printed anterior plates. We measured the maximum unconstrained pronation and supination before the osteotomy and after each induced deformation. There was a decrease in the median pronation and supination values for all palmar and dorsal tilt deformities. The pronation range was more impaired than the supination range, and dorsal tilt deformities caused the greatest loss in forearm rotation. Our results suggest that forearm rotation in both pronation and supination is reduced as soon as 10° to 20° distal radial deformity occurs in the palmar or dorsal direction.

Biomechanical assessment of the central band of the interosseous membrane using shear wave elastography: reliability and reproducibility.

The interosseous membrane of the forearm is an essential structure for the stability of the forearm skeleton, the most important part being the central band. The purpose of this study was to determine if shear wave elastography, a non-invasive ultrasound technique, can be used to measure shear wave speed in the central band and quantify stiffness. Fifteen healthy adult subjects were included (30 forearms). The participants forearms were positioned on an articulated plate, with their hand in neutral, pronated and then supinated positions of 30°, 60° and 90°. The shear wave speed was highest in 90° pronation (4.4 m/s (SD 0.3)) and 90° supination (4.4 m/s (SD 0.27)) indicating maximum stiffness in these positions. Its minimum value was in the neutral position, and either in 30° pronation or supination (3.5 m/s (SD 0.3)). Intra- and interobserver agreement was excellent, regardless of probe positioning or forearm mobilization. This study presents a reliable shear wave elastography measurement protocol to describe the physiological function of the central band of the interosseous membrane in healthy adults.Level of evidence: IV.