The diagnostic value of sonographic findings in pediatric elbow fractures: A systematic review and meta-analysis.

BACKGROUND: Sonography is a beneficial imaging modality for detecting elbow fractures in children, considering the lack of radiation exposure and time efficiency. This systematic review aims to determine the diagnostic value and clinical applicability of sonography and each sonographic finding in detecting pediatric elbow fractures. METHODS: Pubmed, Scopus, and WOS databases were searched for related original articles until February 25, 2023, and data related to diagnostic performance were extracted. We used the Bivariate model and hierarchic summary receiver operating characteristic (HSROC) approach to calculate pooled diagnostic values. Cochrane Q test and I-squared were performed to evaluate heterogeneity. We assessed heterogeneity with meta-regression. RESULTS: Eight studies were included, which involved a total number of 880 patients. According to meta-analysis, sonography demonstrated a pooled sensitivity of 97% (91-99%) and specificity of 90% (80-95%), positive likelihood ratio(LR+) of 9.82 (4.59-20.97), and negative likelihood ratio (LR-) of 0.03 (0.01-0.10). For the sonographic posterior fat pad sign as a sole diagnostic sign, we calculated a Pooled Sensitivity of 80% (70-88%), Specificity of 97% (87-99%), LR+ of 28.8 (6-139.3), and LR- of 0.2 (0.13-0.31). Also, lipohemarthrosis demonstrated a pooled sensitivity of 80% (70-88%), specificity of 97% (87-99%), LR+ of 28.8 (6-139.3), and LR- of 0.2 (0.13-0.31). The sensitivity of detecting fractures with cortical line disruption was significantly higher in studies that utilized a comprehensive technique compared to a conventional technique. CONCLUSIONS: Sonography is a valuable diagnostic tool for the assessment of pediatric elbow injuries, and it can be capable of confirmation or exclusion of the diagnosis.

Management Principles and Current Debates Surrounding Common Pediatric Elbow Fractures.

Elbow fractures are among the most common fractures sustained in pediatric patients. A specific set of pediatric elbow fractures (olecranon, radial neck, and lateral condyle fractures) comprises the ones that occur most often. It is important to review commonly accepted principles in the evaluation and treatment of these injuries as well as highlight some debates that exist within the literature regarding the optimal management of these injuries. Although management of pediatric olecranon, radial neck, and lateral condyle fractures has been well described, controversy persists among orthopaedic surgeons regarding the surgical indications and preferred fixation techniques for these injuries.

Regional distribution prevalence of heterotopic ossification in the elbow joint: a 3D study of patients after surgery for traumatic elbow injury.

BACKGROUND: Heterotopic ossification (HO) is a common complication after elbow fracture surgery and can lead to severe upper extremity disability. The radiographic localization of postoperative HO has been reported previously. However, there is no literature examining the distribution of postoperative HO at the three-dimensional (3D) level. This study aimed to investigate 1) the distribution characteristics of postoperative HO and 2) the possible risk factors affecting the severity of postoperative HO at a 3D level. METHODS: A retrospective review was conducted of patients who presented to our institution with HO secondary to elbow fracture between 13 January 2020 and 16 February 2023. Computed tomography scans of 56 elbows before elbow release surgery were reconstructed in 3D. HO was identified using density thresholds combined with manual identification and segmentation. The elbow joint and HO were divided into six regions according to three planes: the transepicondylar plane, the lateral ridge of the trochlear plane, and the radiocapitellar joint and coronoid facet plane. The differences in the volume of regional HO associated with different initial injuries were analyzed. RESULTS: Postoperative HO was predominantly present in the medial aspect of the capsule in 52 patients (93%), in the lateral aspect of the capsule in 45 patients (80%), in the medial supracondylar in 32 patients (57%), and in the lateral supracondylar, radial head, and ulnar region in the same number of 28 patients (50%). The median and interquartile range volume of total postoperative HO was 1683 (777-4894) mm3. The median and interquartile range volume of regional postoperative HO were: 584 (121-1454) mm3 at medial aspect of capsule, 207 (5-568) mm3 at lateral aspect of capsule, 25 (0-449) mm3 at medial supracondylar, 1 (0-288) at lateral supracondylar, 2 (0-478) at proximal radius and 7 (0-203) mm3 at the proximal ulna. In the subgroups with Injury Severity Score > or = 16, Gustilo-Anderson II, normal uric acid levels, elevated alkaline phosphatase, and body mass index > or = 24, the median HO volume exceeds that of the respective control groups. CONCLUSION: The medial aspect of the capsule was the area with the highest frequency and median volume of postoperative HO among all initial elbow injury types. Patients with higher Gustilo-Anderson grade, Injury Severity Score, alkaline phosphatase or Body Mass Index had higher median volume of postoperative HO.

Analysis of the associated factors in postoperative wound infection following open reduction and internal fixation for elbow fracture.

Postoperative wound infections (PWIs) following open reduction and internal fixation (ORIF) for elbow fractures can significantly affect patient outcomes. Identifying associated risk factors is crucial for improving clinical practices and patient care. A retrospective analysis (June 2020-June 2023) at our institution involved 90 patients who underwent elbow ORIF. Thirty patients developed PWIs (case group), compared to 60 who did not (control group). Variables like anaemia, operation duration, hospital stay, blood loss, body mass index (BMI), age, hypoalbuminemia, smoking status, diabetes mellitus and open fractures were examined. Univariate and multivariate analyses determined the impact of these variables on PWI incidence, with statistical significance set at p < 0.05. The main pathogens identified were Escherichia coli among Gram-negative bacteria (59.46%) and Staphylococcus aureus among Gram-positive bacteria (40.54%). In the univariate analysis, hypoalbuminemia, anaemia, and lifestyle factors such as smoking showed higher prevalence in patients with PWIs. However, age and length of hospital stay did not significantly influence infection rates. The multivariate analysis further elucidated that anaemia, smoking, diabetes mellitus and open fractures were independent, significant predictors of PWIs. These findings highlight the complexity of factors influencing infection risk post-ORIF, underscoring the importance of both individual health conditions and surgical complications in patient outcomes. Anaemia, smoking, diabetes mellitus and open fractures significantly increase the risk of PWI after elbow ORIF. Early identification and management of these risk factors are imperative to reduce infection rates and improve postoperative recovery.

Evaluating the Clinical Utility of Brachial Plexus Block for Reducing Opioid Exposure in Pediatric Elbow Fracture Surgery: A Retrospective Cohort Study.

Background and Objectives: Reducing opioid exposure in common pediatric surgeries is of paramount importance. This study aimed to assess the efficacy of regional nerve blocks in reducing opioid exposure while preserving high success rates. Materials and Methods: We conducted a retrospective matched cohort study (1:1) including patients with elbow fractures < 12 years old who underwent treatment with percutaneous pinning. Patients were divided into general-anesthesia (GA) and GA-followed-by-supraclavicular-brachial-plexus-block (GA-SCB) groups. The primary outcome was the number of patients administered postoperative rescue opioids. The secondary outcomes included intraoperative and postoperative opioid administration, the time to first request for rescue analgesia, pain scores, block success rate, block performing time, and block-related complications. Results: In a total of 478 patients, 363 underwent percutaneous pinning, and 86 were cohort-matched (GA: n = 43, GA-SCB: n = 43). On the first postoperative day, 34 (79.0%) patients in the GA group were administered postoperative rescue opioids, compared with 12 (27.9%) in the GA-SCB group (p < 0.001). All the patients in the GA-SCB group were opioid-free during the intraoperative period. No SCB-associated complications were observed. Total opioid consumption was significantly lower in the GA-SCB group than in the GA group until the first postoperative day (GA vs. GA-SCB, 3.2 ± 3.0 mg vs. 0.9 ± 1.8 mg, p < 0.001). Conclusions: SCB application in pediatric patients who underwent elbow fracture surgery significantly reduced opioid exposure and had a high success rate when performed using ultrasound guidance by an expert. Furthermore, the complication risk and surgical delay were minimal.

The Boyd approach: a valuable alternative to treating simple to complex elbow fractures and dislocations.

BACKGROUND: The Boyd approach is a single-incision posterior approach to the proximal radius and ulna based on a lateral anconeus muscle reflection and release of the lateral collateral ligamentous complex. This approach remains a lesser-used technique following early reports of proximal radioulnar synostosis and postoperative elbow instability. Although limited by small case series, recent literature does not support these early reported complications. This study presents a single surgeon's outcomes using the Boyd approach for the treatment of simple to complex elbow injuries. METHODS: Following institutional review board approval, a retrospective review of all patients with simple to complex elbow injuries treated consecutively using a Boyd approach by a shoulder and elbow surgeon was conducted from 2016 to 2020. All patients with at least 1 postoperative clinic visit were included. Data collected included patient demographics, injury description, postoperative complications, elbow range of motion, and radiographic findings including heterotopic ossification and proximal radioulnar synostosis. Categorical and continuous variables were reported using descriptive statistics. RESULTS: A total of 44 patients were included with an average age of 49 years (range 13-82 years). The most commonly treated injuries were Monteggia fracture-dislocations (32%) and terrible triad injuries (18%). Average follow-up was 8 months (range 1-24 months). Final average elbow active arc of motion was from 20° (range 0°-70°) of extension to 124° (range 75°-150°) of flexion. Final supination and pronation were 53° (range 0°-80°) and 66° (range 0°-90°), respectively. There were no cases of proximal radioulnar synostosis. Heterotopic ossification contributing to less than functional elbow range of motion occurred in 2 (5%) patients who elected conservative management. There was 1 (2%) case of early postoperative posterolateral instability due to repair failure of injured ligaments that required revision using a ligament augmentation procedure. Five (11%) patients experienced postoperative neuropathy, including 4 (9%) with ulnar neuropathy. Of these, 1 underwent ulnar nerve transposition, 2 were improving, and 1 had persistent symptoms at final follow-up. CONCLUSIONS: This is the largest case series available demonstrating the safe utilization of the Boyd approach for the treatment of simple to complex elbow injuries. Postoperative complications including synostosis and elbow instability may not be as common as previously understood.

Are outdoor playgrounds the real culprit for elbow fractures in children? A lesson learned from COVID-19 sanitary measures.

BACKGROUND: The association between elbow fractures and outdoor playgrounds has always been anecdotal. We sought to determine the impact of closing outdoor playgrounds and other play areas during the COVID-19 lockdown on elbow fractures in a pediatric population. METHODS: We conducted a retrospective cohort study of all elbow fractures from a single pediatric referral hospital between 2016 and 2020 for the months of April and May. The months chosen corresponded to the COVID-19 lockdown during which outdoor playgrounds were closed. Inclusion criteria were elbow fracture diagnosis based on radiography and age younger than 18 years. Fracture type, where the injury occurred and the mechanism of injury were recorded. RESULTS: A total of 370 fractures were reported, with an average of 83 (95% confidence interval [CI] 83-84) per year for 2016-19 and only 36 recorded in 2020. The average annual number of fractures before 2020 was 17 (95% CI 16-17) for schools, and 33 (95% CI 31-34) for outdoor playgrounds, including 22 (95% CI 21-24) falls from playground structures. No fracture was reported in schools in 2020, and only 3 were reported from outdoor playgrounds (including 1 associated with falling from playground structures). CONCLUSION: We found an association between elbow fractures in a pediatric population and outdoor playground accessibility, but also with indoor public locations. Our findings emphasize the importance of safety measures in those facilities.

The outcome of Radial Neck Fracture Treated with Closed/ Open Reduction and Retrograde Kirschner Wires Fixation in the Paediatric Age Group.

Background Radial neck fractures in children are rare injuries, representing 1 to 5% of all elbow pediatric fractures. Most of them are non-displaced or slightly displaced and treated conservatively. Severely displaced or angulated radial neck fractures (Judet type III and IV fractures or O'Brien type III radial neck fractures) requires surgical treatment. Objective To study the clinical and radiological outcomes of fractures following closed or open reduction and percutaneous intramedullary stabilization of the displaced radial neck fracture in children. Method There were 24 children with displaced radial neck fracture Judet type II, III and IV fractures O'Brien type II, III who underwent closed reduction and retrograde intramedullary stabilization with Kirschner wires. Functional outcomes were evaluated based on of Mayo Elbow Performance Score. Result The mean age of patients was 8.42 ± 1.82 years with boys 15(62.5%) and girls 9(37.5%) in number. An excellent result was seen in 5(20.8%) cases and good results in 15(62.5%) cases according to the Mayo elbow performance score. Analyzing a passive and active range of motion, 5 had excellent results, 15 had good results and 4 had fair results compared to the normal side. Radiological evaluation showed fracture healing in excellent or good alignment according to Ursei radiological evaluation classification. Conclusion Closed reduction and retrograde intramedullary Kirschner wires stabilization for the displaced radial neck fracture provide excellent clinical and radiological results with few complications.

External validation of an artificial intelligence solution for the detection of elbow fractures and joint effusions in children.

PURPOSE: The purpose of this study was to conduct an external validation of an artificial intelligence (AI) solution for the detection of elbow fractures and joint effusions using radiographs from a real-life cohort of children. MATERIALS AND METHODS: This single-center retrospective study was conducted on 758 radiographic sets (1637 images) obtained from consecutive emergency room visits of 712 children (mean age, 7.27 ± 3.97 [standard deviation] years; age range, 7 months and 10 days to 15 years and 10 months), referred for a trauma of the elbow. For each set, fracture and/or effusion detection by eleven senior radiologists (reference standard) and AI solution was recorded. Diagnostic performance of the AI solution was measured via four different approaches: fracture detection (presence/absence of fracture as binary variable), fracture enumeration, fracture localization and lesion detection (fracture and/or a joint effusion used as constructed binary variable). RESULTS: The sensitivity of the AI solution for each of the four approaches was >89%. Greatest sensitivity of the AI solution was obtained for lesion detection (95.0%; 95% confidence interval: 92.1-96.9). The specificity of the AI solution ranged between 63% (for lesion detection) and 77% (for fracture detection). For all four approaches, the negative predictive values were >92% and the positive predictive values ranged between 54% (for fracture enumeration and localization) and 73% (for lesion detection). Specificity was lower for plastered children for all approaches (P < 0.001). CONCLUSION: The AI solution demonstrates high performances for detecting elbow's fracture and/or joint effusion in children. However, in our context of use, 8% of the radiographic sets ruled-out by the algorithm concerned children with a genuine traumatic elbow lesion.

Enhanced Muscle Endurance Through Self-regulated Dual-Task Exercises in Elbow Fracture Rehabilitation: A Cross-sectional Study.

OBJECTIVE: The main objective of this study was to investigate the effect of a self-regulated dual task on muscle endurance within a single rehabilitation session in patients recovering from an elbow fracture. DESIGN: This is a cross-sectional study of individuals recovering from elbow fractures ( N = 20). Muscle endurance was tested using elastic bands at Borg's CR10 intensity 3-during four conditions: single-task and dual-task for elbow flexion and extension. RESULTS: The cognitive condition significantly influenced muscle endurance ( P < 0.001), while the type of elbow exercise (flexion or extension) did not show significant differences ( P = 0.592). The perceived difficulty of the tasks showed a significant interaction effect ( P = 0.032). The dual-task condition showed an average increase of about 15 repetitions. A moderate negative correlation was found between the differences in repetitions and the perceived difficulty of the flexion exercise ( r = 0.677, P = 0.001). CONCLUSIONS: Dual-task with self-regulation enhances muscle endurance among patients recovering from an elbow fracture. However, the improvements seem to depend on the perceived difficulty of the cognitive task. Future randomized controlled trials are required to understand the therapeutic implications of dual-tasking.

Entrapment of median nerve after elbow fracture dislocations: expected surgical time frame based on cadaver study.

INTRODUCTION: Median nerve injuries occur in approximately 3% of pediatric elbow fracture dislocations. These rare injuries can be difficult to diagnose, and the results are poor in delay cases. Surgical timing is one of the most important prognostic factors. We aimed to present three patients with median nerve palsy who were referred to our clinic late, and according to these cases, we emphasized the expected time frame for exploration based on our anatomical cadaver study. MATERIALS AND METHODS: Between 2008 and 2010, three patients were referred to our clinic because of median nerve paralysis after a treated elbow dislocation. The mean interval between injury and referral was 15 (min: 13-max: 18) months, and the mean age of the patients was 15 (13-18) years. Neurolysis was performed in two patients, and for the third patent, after neurolysis, axonal continuity was observed to be disrupted so sural nerve grafting was performed with four cables. Tendon transfers were performed in all patients. A total number of 20 upper extremities of 10 cadavers were dissected. Due to its proximal innervation and ease of assessment, the muscle innervation of the flexor pollicis longus (FPL) was planned to be evaluated. The distance from the medial epicondyle is calculated in the cadaver study where the nerve injury is found. RESULTS: The mean length from the medial epicondyle to the motor innervation of FPL was calculated in each specimen and found to be 101.99 millimeters (mm) (range: 87.5-134.2). The mean longest innervation of FPL was 110.83 mm from (range 87.5-148.1) the medial epicondyle calculated by including each specimens longest nerve length. Knowing that the healing time of a nerve lesion is 1 mm per day, we calculated that the recovery of FPL would take approximately 4 months. CONCLUSION: When nerve healing is expected to be 1 mm a day in axonotmesis type injury, after the median nerve palsy following elbow dislocation, thumb flexion should be achieved in the following 4 months generally if the nerve was not entrapped in the joint. This cadaver-based study objectively defined how long to wait for the innervation of the FPL in median nerve injuries in elbow fracture dislocations.

Complex elbow fracture-dislocations- what factors are associated with a poor post-operative outcome?

PURPOSE: Despite standardized treatment algorithms, patients with complex elbow fracture-dislocation frequently suffer from poor post-operative elbow function leading to reduced quality of life. Up to now, there is no valuable data regarding risk factors that lead to poor post-operative outcome after surgical reconstruction of complex elbow fracture-dislocations. METHODS: From 06/2010 to 12/2020 134 patients (51.3 ± 15.1 years, 44% women) undergoing surgical treatment of complex elbow fracture-dislocations could be included in this study. Follow-up period was 4.4 years (SD 2.5). All patients were clinically evaluated for elbow movement, elbow stability and common elbow scores (MEPS, OES, DASH-Score). Potential risk factors for poor post-operative outcome were identified using bi- and multivariate analyses. RESULTS: Overall good post-operative outcome has been achieved, mean MEPS was 88.8 ± 17.6. Post-operative complications occurred in 31.3% of the cases, while 25.4% required surgical revision. Patients with transolecranon dislocation fractures showed the significantly worst functional outcomes (p = 0.01). In addition, it has been shown that a patient's age of more than 70 years (OR = 10, p = 0.003) and a BMI of more than 35 kg/m2 (OR = 7.6, p = 0.004) are independent risk factors for a poor post-operative outcome. In contrast, gender and time to surgery showed no significant influence on post-operative outcome. CONCLUSION: In most cases, good post-operative functional results can be achieved using standardized treatment protocols. However, complication and revision rates remain high. Patients older than 70 years of age or with a BMI over 35 kg/m2 are at risk for an inferior outcome and require close follow-up monitoring.

Tripolar Dislocation: Elbow Terrible Triad-Essex-Lopresti Injury-Trans-scaphoid Perilunate Dislocation: A Case Report.

CASE: A 23-year-old man presented with a right upper limb injury after a 10-m fall. Initial evaluation demonstrated a terrible triad elbow injury associated with a trans-scaphoid perilunate dislocation. Elbow stabilization with radial head replacement and carpal fixation was performed. Radiographs on postoperative day 7 demonstrated an ipsilateral Essex-Lopresti injury, which had been initially missed, and revision surgery was performed to reconstruct the interosseous membrane. CONCLUSION: Surgeons should maintain a high degree of suspicion for an ipsilateral Essex-Lopresti injury in patients with a terrible triad elbow fracture-dislocation in combination with a trans-scaphoid perilunate dislocation. Both preoperative imaging, including the contralateral side, and intraoperative evaluation are recommended to rule out longitudinal instability of the forearm in the setting of combined wrist and elbow fracture-dislocations.

Complex Elbow Fracture-Dislocations: An Algorithmic Approach to Treatment.

Elbow stability arises from a combination of bony congruity, static ligamentous and capsular restraints, and dynamic muscular activation. Elbow trauma can disrupt these static and dynamic stabilizers leading to predictable patterns of instability; these patterns are dependent on the mechanism of injury and a progressive failure of anatomic structures. An algorithmic approach to the diagnosis and treatment of complex elbow fracture-dislocation injuries can improve the diagnostic assessment and reconstruction of the bony and ligamentous restraints to restore a stable and functional elbow. Achieving optimal outcomes requires a comprehensive understanding of pertinent local and regional anatomy, the altered mechanics associated with elbow injury, versatility in surgical approaches and fixation methods, and a strategic rehabilitation plan.

How high is the quality of the videos about children's elbow fractures on Youtube?

OBJECTIVE: Pediatric elbow fractures are children's most common fractures. People use the internet to get information about their illnesses and also to search for treatment options. Videos uploaded to Youtube do not go through the review process. The aim of our study is to determine the quality of videos related to child elbow fractures on Youtube. MATERIAL METHOD: The study was carried out with the data obtained from the video-sharing site www.youtube.com on 01.12.2022. Pediatric elbow fractures are written in the search engine section. Information about the number of views of the videos, upload date, view rate (number of views per day), number of comments, number of likes and dislikes, duration, whether they contain animation and the publishing source were evaluated. The videos are divided into 5 groups according to their sources: medical society/non-profit organization, physician, healthrelated website, university/academic, and patient/independent user/other. The quality of the videos was evaluated using the Global Quality Scale (GQS). All videos have been evaluated by 2 researchers. RESULTS: In the study, 50 videos were included. In the statistical evaluation, no significant correlation was found between the modified discern score and GQS found by both researchers, and the number of views, the rate of views, comments, likes and dislikes, video duration and VPI. In addition, when the GQS and modified discern scores were compared according to the source of the video, it was found that the patient/independent user/other group scores were lower numerically, but there was no statistically significant difference in comparison. CONCLUSION: Most of the videos about child elbow fractures have been uploaded by healthcare professionals. Therefore, we concluded that the videos are quite informative in terms of accurate information and quality content.

Application of ultrasound in the management of TRASH (the radiographic appearance seemed harmless) fractures in preschool children: A review.

Elbow fracture is one of the most common fractures in preschool children, and the secondary ossification center appears regularly with age increasing. Transphyseal separation of the distal humerus, medial humeral condyle fracture, lateral humeral condyle fracture, radial head osteochondral separation, and Monteggia fracture (minimal ulnar bow type) are difficult to diagnose based on X-ray films alone because of the unossified secondary ossification center or a suspicious non-alignment of the anatomical cartilage of the elbow joint in preschool children. These 5 fractures above are defined as The Radiographic Appearance Seemed Harmless fractures in preschool children (TRASH-PS). The TRASH-PS fractures must be taken into consideration when there is swelling at the injured site without fracture feature on X-ray. Additionally, relevant misdiagnosis or unsuitable management can lead to elbow dysfunction and deformity. Therefore, this work reviews the application of ultrasound in the management of TRASH-PS fractures.

A 10-Year National Analysis of Pediatric Elbow Fractures.

Elbow fractures comprise 15% of all fractures in children. Our study identifies risk factors and consumer products that contribute to pediatric elbow fractures. The National Electronic Injury Surveillance System was used to collect demographic and consumer product information between 2010 and 2019 for patients younger than 17 years who presented to the emergency department with elbow fractures. Of the 458,433 elbow fractures, the average age of the patients was 7.4 ± 4.1 years and 55.6% were male children. The most common consumer product was sports and recreation equipment, followed by home furnishings. Male patients (P < .0001) and patients 8 years and older (79.2% vs 51.1%, P < .0001) experienced significantly greater rates of injury with sports and recreation equipment. This study evaluates the products associated with pediatric elbow fractures and highlights the importance of safe sports and recreation equipment use and the role of parental counseling in preventing falls from furniture.

Supracondylar elbow fracture management (Supra Man) : a national trainee collaborative evaluation of practice.

AIMS: Management of displaced paediatric supracondylar elbow fractures remains widely debated and actual practice is unclear. This national trainee collaboration aimed to evaluate surgical and postoperative management of these injuries across the UK. METHODS: This study was led by the South West Orthopaedic Research Division (SWORD) and performed by the Supra Man Collaborative. Displaced paediatric supracondylar elbow fractures undergoing surgery between 1 January 2019 and 31 December 2019 were retrospectively identified and their anonymized data were collected via Research Electronic Data Capture (REDCap). RESULTS: A total of 972 patients were identified across 41 hospitals. Mean age at injury was 6.3 years (1 to 15), 504 were male (52%), 583 involved the left side (60%), and 538 were Gartland type 3 fractures (55%). Median time from injury to theatre was 16 hours (interquartile range (IQR) 6.6 to 22), 300 patients (31%) underwent surgery on the day of injury, and 91 (9%) underwent surgery between 10:00 pm and 8:00 am. Overall, 910 patients (94%) had Kirschner (K)-wire) fixation and these were left percutaneous in 869 (95%), while 62 patients (6%) had manipulation under anaesthetic (MUA) and casting. Crossed K-wire configuration was used as fixation in 544 cases (59.5%). Overall, 208 of the fixation cases (61%) performed or supervised by a paediatric orthopaedic consultant underwent lateral-only fixation, whereas 153 (27%) of the fixation cases performed or supervised by a non-paediatric orthopaedic consultant used lateral-only fixation. In total, 129 percutaneous wires (16%) were removed in theatre. Of the 341 percutaneous wire fixations performed or supervised by a paediatric orthopaedic consultant, 11 (3%) underwent wire removal in theatre, whereas 118 (22%) of the 528 percutaneous wire fixation cases performed or supervised by a non-paediatric orthopaedic consultant underwent wire removal in theatre. Four MUA patients (6%) and seven K-wire fixation patients (0.8%) required revision surgery within 30 days for displacement. CONCLUSION: The treatment of supracondylar elbow fractures in children varies across the UK. Patient cases where a paediatric orthopaedic consultant was involved had an increased tendency for lateral only K-wire fixation and for wire removal in clinic. Low rates of displacement requiring revision surgery were identified in all fixation configurations.Cite this article: Bone Joint J 2023;105-B(1):82-87.

[Terrible triad injuries]. / Terrible-Triad-Verletzungen.

The complex injury pattern of a posterior elbow dislocation with concomitant radial head and coronoid fractures is usually referred to as a terrible triad injury. Due to the concomitant compromise of several osteoligamentous structures of the elbow joint relevant for stability, these injuries pose a particularly major challenge to the treating trauma surgeons. For this reason, a careful preoperative analysis of all relevant injury components is mandatory in order to make an adequate treatment decision. In most cases, surgical treatment addressing all elements relevant for stability is necessary to achieve a stable and congruent elbow joint. Only this enables early functional follow-up treatment and minimizes the complication rate. Delayed or even insufficient treatment with persistent (sub)dislocation must be avoided at all costs, otherwise there is a high risk of serious posttraumatic functional disorders of the elbow with rapid progression of osteoarthritis.