Preoperative Three-Dimensional Planning of Screw Length is not Reliable in Osteotomies of the Humerus and Forearm.

Objectives: Pediatric upper extremity fractures are seen frequently and sometimes lead to malunion. Three-dimensional (3D) surgery planning is an innovative addition to surgical treatment for the correction of post-traumatic arm deformities. The detailed planning in three dimensions allows for optimization of correction and provides planning of the exact osteotomies which include the advised material for correction and fixation. However, no literature is available on the precision of this computerized sizing of implants and screws. This study aimed to investigate the differences between 3D planned and surgically implanted screws in patients with a corrective osteotomy of the arm. Methods: Planned and implanted screw lengths were evaluated in patients who underwent a 3D planned corrective osteotomy of the humerus or forearm using patient-specific 3D printed drill- and sawblade guides. Postoperative information on implanted hardware was compared to the original planned screw lengths mentioned in the 3D planned surgery reports. Results: Of the 159 included screws in 17 patients, 45% differed >1 mm from the planned length (P<0.001). Aberrant screws in the radius and ulna were often longer, while those in the humerus were often shorter. Most aberrant screws were seen in the proximity of the elbow joint. Conclusion: This study showed that 3D-planned screws in corrective osteotomies of the humerus and forearm differ significantly from screw lengths used during surgery. This illustrates that surgeons should be cautious when performing osteotomies with 3D techniques and predefined screw sizes.

Which radial head fractures are best treated surgically?

Despite the common occurrence of radial head fractures, there is still a lack of consensus on which radial head fractures should be treated surgically. The radial head is an important secondary stabilizer in almost all directions. An insufficient radial head can lead to increased instability in varus-valgus and posterolateral rotatory directions, especially in a ligament-deficient elbow. The decision to perform surgery is often not dictated by the fracture pattern alone but also by the presence of associated injury. Comminution of the radial head and complete loss of cortical contact of at least one fracture fragment are associated with a high occurrence of associated injuries. Nondisplaced and minimally displaced radial head fractures can be treated non-operatively with early mobilization. Displacement (>2 mm) of fragments in radial head fractures without a mechanical block to pronation/supination is not a clear indication for surgery. Mechanical block to pronation/supination and comminution of the fracture are indications for surgery. The following paper reviews the current literature and provides state-of-the-art guidance on which radial head fractures should be treated surgically.

Radial head volume measurements using quantitative three-dimensional computed tomography images for radial head deformation following missed Monteggia lesions.

Background: In chronic radial head dislocation cases, the radial head may enlarge and become dome-shaped. To date, there is no validated tool to quantify radial head deformation and predict its influence on surgical outcomes. This study assesses the potential value of volume and surface calculations obtained by quantitative three-dimensional computed tomography scanning (Q3DCT) in the workup for a corrective surgery in pediatric patients with missed Monteggia lesions. Material and methods: Ten consecutive pediatric patients with a missed Monteggia lesion were included (2012-2020). The volume and articular surface size of the radial head were calculated using Q3DCT, and a three-dimensional reconstruction of the articular surface relief was depicted in a heat map. The head-neck ratio was calculated and compared to Q3DCT data of missed Monteggia patients and their age-/sex-matched controls. Results: The radial head volume and radial articular surface size did not differ significantly between patients with missed Monteggia lesions and age-/sex-matched controls (volume 1487 mm3 vs. 1163 mm3, P = .32; articular surface size 282 mm3 vs. 236 mm3, P = .33). Optically, heat maps of the articular surface of missed Monteggia patients did not differ notably from control heat maps. A higher head-neck ratio correlated to a larger radial head volume (Pearson r = 0.73; P = .2). Discussion and conclusion: Q3DCT may be an interesting tool in the preoperative workup of pediatric missed Monteggia lesions. Prospective research with larger cohort sizes and data that compares the affected side to the contralateral elbow is needed to assess its true clinical potential.

Fractures around the shoulder in the skeletally immature: A scoping review.

Fractures around the shoulder girdle in children are mainly caused by sports accidents. The clavicle and the proximal humerus are most commonly involved. Both the clavicle and the proximal humerus have a remarkable potential for remodeling, which is why most of these fractures in children can be treated conservatively. However, the key is to understand when a child benefits from surgical management. Clear indications for surgery of these fractures are lacking. This review focuses on the available evidence on the management of clavicle and proximal humerus fractures in children. The only strict indications for surgery for diaphyseal clavicle fractures in children are open fractures, tenting of the skin with necrosis, associated neurovascular injury, or a floating shoulder. There is no evidence to argue for surgery of displaced clavicle fractures to prevent malunion since most malunions are asymptomatic. In the rare case of a symptomatic malunion of the clavicle in children, corrective osteosynthesis is a viable treatment option. For proximal humerus fractures in children, treatment is dictated by the patient's age (and thus remodeling potential) and the amount of fracture displacement. Under ten years of age, even severely displaced fractures can be treated conservatively. From the age of 13 and onwards, surgery has better outcomes for severely displaced (Neer types III and IV) fractures. Between 10 and 13 years of age, the indications for surgical treatment are less clear, with varying cut-off values of angulation (30-60 degrees) or displacement (1/3 - 2/3 shaft width) in the current literature.

Computer-Assisted Surgical Anatomical Mapping of the Antebrachial Cutaneous Nerves: An Anatomical Study with a Proposition for Alternative, Cutaneous Nerve-Sparing Anterior Elbow Incisions.

It is common practice to assess the distance from nerves to anatomical structures in centimeters, but patients have various body compositions and anatomical variations are common. The purpose of this study was therefore to assess the relative distance from cutaneous nerves around the elbow to surrounding anatomical landmarks by providing a stacked image that displays the average position of cutaneous nerves around the elbow. The aim was to research possibilities for adjusting common skin incisions in the anterior elbow so that cutaneous nerve injury may be avoided. Methods: The lateral antebrachial cutaneous nerve (LABCN) and medial antebrachial cutaneous nerve (MABCN) were identified in the coronal plane around the elbow joint in 10 fresh-frozen human arm specimens. Marked photographs of the specimens were analyzed using computer-assisted surgical anatomical mapping (CASAM). Common anterior surgical approaches to the elbow joint and the distal humerus were then compared with merged images, and nerve-sparing alternatives are proposed. Results: The arm was divided longitudinally, from medial to lateral in the coronal plane, into 4 quarters. The LABCN crossed the central-lateral quarter of the interepicondylar line (i.e., was somewhat lateral to the midline at the level of the elbow crease) in 9 of 10 specimens. The MABCN ran medial to the basilic vein and crossed the most medial quarter of the interepicondylar line. Thus, 2 of the quarters were either free of cutaneous nerves (the most lateral quarter) or contained a distal cutaneous branch in only 1 of 10 specimens (the central-medial quarter). Conclusions: The Boyd-Anderson approach, which is often used to access anteromedial structures of the elbow, should be placed slightly further medially than traditionally advised. The distal part of the Henry approach should deviate laterally, so that it runs over the mobile wad. In distal biceps tendon surgery, the risk of cutaneous nerve injury may be reduced if a single distal incision is placed slightly more laterally (in the most lateral quarter), as in the modified Henry approach. If proximal extension is required, LABCN injury may be prevented by using the modified Boyd-Anderson incision, which runs in the central-medial quarter. Clinical Relevance: Cutaneous nerve injury may be prevented by slightly altering the commonly used skin incisions around the elbow on the basis of the safe zones that were identified by depicting the cumulative course of the MABCN and LABCN using CASAM.

Pediatric Radial Neck Fractures: A Systematic Review Regarding the Influence of Fracture Treatment on Elbow Function.

Background: This review aims to identify what angulation may be accepted for the conservative treatment of pediatric radial neck fractures and how the range of motion (ROM) at follow-up is influenced by the type of fracture treatment. Patients and Methods: A PRISMA-guided systematic search was performed for studies that reported on fracture angulation, treatment details, and ROM on a minimum of five children with radial neck fractures that were followed for at least one year. Data on fracture classification, treatment, and ROM were analyzed. Results: In total, 52 studies (2420 children) were included. Sufficient patient data could be extracted from 26 publications (551 children), of which 352 children had at least one year of follow-up. ROM following the closed reduction (CR) of fractures with <30 degrees angulation was impaired in only one case. In fractures angulated over 60 degrees, K-wire fixation (Kw) resulted in a significantly better ROM than intramedullary fixation (CIMP; Kw 9.7% impaired vs. CIMP 32.6% impaired, p = 0.01). In more than 50% of cases that required open reduction (OR), a loss of motion occurred. Conclusions: CR is effective in fractures angulated up to 30 degrees. There may be an advantage of Kw compared to CIMP fixation in fractures angulated over 60 degrees. OR should only be attempted if CR and CRIF have failed.

A Case of Silicone and Sarcoid Granulomas in a Patient with "Highly Cohesive" Silicone Breast Implants: A Histopathologic and Laser Raman Microprobe Analysis.

Foreign body giant cell (FBGC) reaction to silicone material in the lymph nodes of patients with silicone breast implants has been documented in the literature, with a number of case reports dating back to 1978. Many of these case reports describe histologic features of silicone lymphadenopathy in regional lymph nodes from patients with multiple sets of different types of implants, including single lumen smooth surface gel, single lumen textured surface gel, single lumen with polyethylene terephthalate patch, single lumen with polyurethane coating, and double lumen smooth surface. Only one other case report described a patient with highly-cohesive breast implants and silicone granulomas of the skin. In this article, we describe a patient with a clinical presentation of systemic sarcoidosis following highly cohesive breast implant placement. Histopathologic analysis and Confocal Laser Raman Microprobe (CLRM) examination were used to confirm the presence of silicone in the axillary lymph node and capsular tissues. This is the first report where chemical spectroscopic mapping has been used to establish and identify the coexistence of Schaumann bodies, consisting of calcium oxalate and calcium phosphate minerals, together with silicone implant material.

[An 85-year-old woman with an kyphosis and dyspnea]. / Een 85-jarige vrouw met een kyfose en dyspneu.

An 85-year-old woman with a severe kyphosis presented at the emergency room because of progressive dyspnea and cough, without other complaints. During auscultation, peristaltic sounds were heard over the thorax. A massive diaphragmatic hernia with intrathoracic stomach, small intestine and colon, was seen on CT-scan.