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.

Imaging and classification of osteochondritis dissecans of the capitellum: X-ray, magnetic resonance imaging or computed tomography?

BACKGROUND: Diagnosing capitellar osteochondritis dissecans (OCD) can be difficult, causing delay in treating young athletes. The main aim of this retrospective diagnostic study was to determine which radiological technique is preferred to identify and classify elbow OCD. METHODS: We identified young patients who underwent elbow arthroscopy because of symptomatic OCD. We included all patients who had pre-operative radiographs, a computed tomography (CT) scan and magnetic resonance imaging (MRI) available. We assessed whether the osteochondral lesion could be identified using the various imaging modalities. All lesions were classified according to previous classifications for X-ray, CT and MRI, respectively. These results were compared with findings at arthroscopy. RESULTS: Twenty-five patients had pre-operative radiographs as well as CT scans and MRI. In six patients, the lesion was not visible on standard X-ray. In 20 patients, one or two loose bodies were found during surgery, consistent with an unstable lesion. Pre-operatively, this was seen on 11 X-rays, 13 MRIs and 18 CT scans. CONCLUSIONS: Capitellar OCD lesions are not always visible on standard X-rays. A CT appears to be the preferred imaging technique to confirm diagnosis of OCD. Loose bodies are often missed, especially on standard X-rays and MRIs.

Osteochondritis dissecans of the humeral capitellum: reliability of four classification systems using radiographs and computed tomography.

BACKGROUND: The radiographic appearance of osteochondritis dissecans (OCD) of the humeral capitellum varies according to the stage of the lesion. It is important to evaluate the stage of OCD lesion carefully to guide treatment. We compared the interobserver reliability of currently used classification systems for OCD of the humeral capitellum to identify the most reliable classification system. METHODS: Thirty-two musculoskeletal radiologists and orthopaedic surgeons specialized in elbow surgery from several countries evaluated anteroposterior and lateral radiographs and corresponding computed tomography (CT) scans of 22 patients to classify the stage of OCD of the humeral capitellum according to the classification systems developed by (1) Minami, (2) Berndt and Harty, (3) Ferkel and Sgaglione, and (4) Anderson on a Web-based study platform including a Digital Imaging and Communications in Medicine viewer. Magnetic resonance imaging was not evaluated as part of this study. We measured agreement among observers using the Siegel and Castellan multirater κ. RESULTS: All OCD classification systems, except for Berndt and Harty, which had poor agreement among observers (κ = 0.20), had fair interobserver agreement: κ was 0.27 for the Minami, 0.23 for Anderson, and 0.22 for Ferkel and Sgaglione classifications. The Minami Classification was significantly more reliable than the other classifications (P < .001). CONCLUSIONS: The Minami Classification was the most reliable for classifying different stages of OCD of the humeral capitellum. However, it is unclear whether radiographic evidence of OCD of the humeral capitellum, as categorized by the Minami Classification, guides treatment in clinical practice as a result of this fair agreement.

Arthroscopic treatment of septic arthritis of the elbow.

HYPOTHESIS: Septic arthritis of the elbow is a serious orthopedic concern associated with high morbidity and mortality rates, traditionally treated with open exposure of the elbow joint. This study was performed to describe the outcome of arthroscopic treatment of septic elbow arthritis. METHODS: From May 2000 through January 2008, 12 patients with septic elbow arthritis were treated arthroscopically at the Mayo Clinic, Rochester, Minnesota, a large medical center. We reviewed the patients' medical records concerning variables such as history and clinical findings, previous elbow history, surgical procedure, cultured organism, and follow-up. Using the Oxford Elbow Score and the Mayo Elbow Score, we examined current level of pain, function, and social-psychological aspects. Six patients died before initiation of this study and were therefore only studied retrospectively. RESULTS: Septic elbow arthritis without pre-existing elbow problems shows excellent outcomes after arthroscopic treatment, with scores for absence of pain, function, social-psychological well-being, and range of motion of 97.9%, 100%, 95.8%, and 100%, respectively. When elbows were treated arthroscopically within 2 days after the onset of clinical symptoms suggesting bacterial elbow arthritis, maximum scores of 100% were noted for all aspects. Positive elbow history before infection and reoperation were associated with poor outcome scores, with 62.5%, 85.4%, and 50% for absence of pain, function, and social-psychological well-being, respectively. CONCLUSION: Septic elbow arthritis occurs often in the debilitated, immunocompromised patient. Arthroscopic intervention is a reasonable alternative to open treatment. In this small series, the acutely septic elbow was successfully treated in the majority of patients, although the overall patient mortality rate remains high.

Osteochondritis dissecans of the capitellum: a review of the literature and a distal ulnar portal.

Osteochondritis dissecans (OCD) of the humeral capitellum most commonly affects young athletes engaged in sports that repetitively stress the elbow. It is characterized by localized injury of subchondral bone of the humeral capitellum. To determine the best treatment option for OCD in young athletes, it is important to differentiate between stable and unstable OCD lesions. Stable lesions can be treated with rest, whereas unstable lesions, as well stable lesions that do not respond to conservative therapy, may require a surgical approach. Magnetic resonance imaging is the diagnostic study of choice to evaluate capitellar OCD lesions and loose bodies and to accurately determine the stability and viability of the OCD fragment. A variety of surgical approaches have been reported, from internal fixation of large fragments to autologous chondrocyte grafts. Arthroscopic surgery is becoming the standard treatment of capitellar OCD. This minimally invasive approach shows good results, a low risk of operative morbidity, and early recuperation postoperatively. The distal ulnar portal we describe here allows for ergonomic exposure to the posterolateral capitellum, providing easier access for drilling, burring, and local debridement of lesions amenable to arthroscopy.