[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.

Forearm Fractures: Diagnosis and Contemporary Treatment Strategies.

Diaphyseal forearm fractures represent a spectrum of injury patterns that include isolated radial shaft fractures, isolated ulnar shaft fractures, both-bone forearm fractures, Galeazzi fracture-dislocations, and Monteggia fracture-dislocations. Although less common than distal radius fractures, diaphyseal forearm fractures are still a frequently encountered clinical entity seen by orthopaedic surgeons, both as isolated injuries and in the patient with polytrauma. It is important to review the epidemiology of diaphyseal forearm fractures and the classification systems used to describe them, as well as to discuss the principles of the initial evaluation and management of these fractures. It is important to know the indications for nonsurgical and surgical management, along with the goals of surgical management, options for internal fixation, and surgical approaches to the forearm.

Management of Geriatric Elbow Injury.

Approximately 4.1% of all fractures in the elderly involve the elbow. Most elbow injuries in geriatric patients occur as the result of low-energy mechanisms such as falls from standing height. Elbow injuries in elderly patients present complex challenges because of insufficient bone quality, comminution, articular fragmentation, and preexisting conditions, such as arthritis. Medical comorbidities and baseline level of function must be heavily considered in surgical decision making.

Common Fractures of the Radius and Ulna.

Fractures of the radius and ulna are the most common fractures of the upper extremity, with distal fractures occurring more often than proximal fractures. A fall onto an outstretched hand is the most common mechanism of injury for fractures of the radius and ulna. Evaluation with radiography or ultrasonography usually can confirm the diagnosis. If initial imaging findings are negative and suspicion of fracture remains, splinting and repeat radiography in seven to 14 days should be performed. Incomplete compression fractures without cortical disruption, called buckle (torus) fractures, are common in children. Greenstick fractures, which have cortical disruption, are also common in children. Depending on the degree of angulation, buckle and greenstick fractures can be managed with immobilization. In adults, distal radius fractures are the most common forearm fractures and are typically caused by a fall onto an outstretched hand. A nondisplaced, or minimally displaced, distal radius fracture is initially treated with a sugar-tong splint, followed by a short-arm cast for a minimum of three weeks. It should be noted that these fractures may be complicated by a median nerve injury. Isolated midshaft ulna (nightstick) fractures are often caused by a direct blow to the forearm. These fractures are treated with immobilization or surgery, depending on the degree of displacement and angulation. Combined fractures involving both the ulna and radius generally require surgical correction. Radial head fractures may be difficult to visualize on initial imaging but should be suspected when there are limitations of elbow extension and supination following trauma. Treatment of radial head fractures depends on the specific characteristics of the fracture using the Mason classification.

Can intraoperative ultrasound visualize the closed reduction and elastic intramedullary nail fixation processes of double forearm fractures in children?

ABSTRACT: To evaluate the feasibility of utilizing ultrasonography to monitor the fracture reduction and elastic intramedullary nail fixation processes in treating children with double forearm fractures. A retrospective analysis of 30 children with double forearm fractures treated at our hospital between January 2016 and July 2018. The children were aged 3 to 10 years. All patients were treated with closed reduction and internal fixation with elastic intramedullary nails using intraoperative ultrasound monitoring and intermittent radiographic imaging. The closed reduction and fixation were successful in all patients. The operation times ranged from 16 to 30 minutes, averaging 21 minutes. No neurovascular injuries occurred during closed reduction and nail insertion. Moreover, closed reduction was successful in the first attempt in 86.7% of patients. All patient outcomes were optimal, lacking serious complications during follow-ups. Intraoperative ultrasound monitoring can clearly show the shape and changes in fracture ends, distal growth plates, and surrounding soft tissues, and fracture reduction and passage of elastic nail processes at fracture ends during closed reduction; therefore, visualizing closed reductions can be achieved. The combination of intraoperative ultrasound and radiographic imaging can ensure operative effects and significantly reduce radiation exposure for both doctors and patients. An adequately powered prospective randomized trial is required to confirm our findings.

The AMANDUS Project PART II-Advanced Microperfusion Assessed Non-Union Diagnostics with Contrast-Enhanced Ultrasound (CEUS): A Reliable Diagnostic Tool for the Management and Pre-operative Detection of Infected Upper-Limb Non-unions.

The management of upper-limb non-unions can be challenging, especially when infection is existent. Thus, pre-operative detection of infection plays a relevant role in non-union treatment. This study investigated in a large cohort the diagnostic potential of contrast-enhanced ultrasound (CEUS) as stand-alone method for differentiating between aseptic and infected upper-limb non-unions. Osseous perfusion of 50 upper-extremity non-unions (radius/ulna, n = 20; humerus, n = 22; clavicle, n = 8) was prospectively assessed with CEUS before revision surgery. The perfusion was quantified via time-intensity curves and peak enhancement (in arbitrary units). Significant perfusion differences between aseptic and infected non-unions could be detected (peak enhancement, p < 0.001). The sensitivity and specificity for the detection of infected upper-limb non-unions were 80% and 94.3% (cutoff peak enhancement: 130.8 arbitrary units). CEUS reliably differentiates between aseptic and infected upper-limb non-unions. Consequently, CEUS should be integrated into the daily diagnostic routine algorithm to plan non-union revision surgery more precisely as a single- or multi-step procedure.

Greenstick fracture of the ulnar shaft following physical therapy in an adult: A case report.

RATIONALE: Greenstick fractures most commonly occur in the pediatric population, especially in those under 10 years of age. Greenstick fractures are "extremely" rare in adults. This report presents the case of a greenstick fracture of the ulnar shaft in an adult following physical therapy for a radial neck fracture and ulnar shaft fracture post-internal fixation. Greenstick fracture can occur during physical therapy near the drill holes created during surgery. PATIENT CONCERNS: A 23-year-old man without any past medical history had sustained a greenstick fracture of the ulnar shaft after rehabilitation for a left radial and ulnar fracture that had been previously treated with internal fixation. DIAGNOSES: Five months after removal of the implants, the patient complained of left elbow tenderness and a "breaking" sound that occurred during physical therapy. The results of a subsequent X-ray revealed a greenstick fracture of the left ulnar shaft. INTERVENTIONS: Splinting of the fracture. OUTCOMES: After 2 months of splint fixation, the pain and range of motion in the affected arm were improved, and sequential X-rays showed callus formation and increased density of the ulnar shaft. LESSONS: Greenstick fractures occur not only in children but also in adults in specific circumstances. The cortex of long bones may be further weakened by drill holes created during surgery, and fractures may occur during physical therapy. During treatment, physicians, and therapists should pay more attention to the patient who has undergone implant removal to avoid greenstick fractures, especially in the locations near drill holes.

Osteochondral reconstruction for post-traumatic coronoid deficiency.

PURPOSE: This study aimed to evaluate the clinical outcome and graft survival following coronoid reconstruction with osteochondral bone grafts for post-traumatic coronoid deficiency treatment. We hypothesized that coronoid reconstruction using an osteochondral bone graft will provide favorable results in treating post-traumatic coronoid deficiency. METHODS: A retrospective review was performed on eight patients (mean age = 45.8 years) who underwent osteochondral bone graft reconstruction indicated for post-traumatic coronoid deficiency. The osteochondral bone grafts were obtained from the radial head remnant (four patients), olecranon tip (two patients), and iliac crest (two patients). All the injuries were terrible triad. The mean duration from injury to surgery was 79.3 weeks. The visual analog scale (VAS) for pain, motion arc, and Mayo elbow performance score (MEPS) were used to evaluate the clinical outcome. Radiologic evaluation of graft healing and integrity was performed using computed tomography at 19 months and plain elbow radiography at 24.1 months after reconstruction. The immediate graft height was measured. RESULTS: VAS and MEPS values improved from 4.1 ± 1.2 to 1.1 ± 0.3 and 34.2 ± 16.9 to 85.0 ± 7.1, respectively (p = 0.018, p = 0.018) after reconstruction. The motion arc significantly improved from 84.2° ± 16.1° to 102.1° ± 18.2° at the final follow-up of 39.1 ± 18.8 months (p = 0.048). All the osteochondral grafts survived, with nonunion in two patients (25%). The mean immediate graft height was 15.4 ± 2.6 mm. Among the eight patients, three (37.5%) developed secondary osteoarthritis of the ulnohumeral joint. CONCLUSIONS: Coronoid reconstruction with osteochondral bone graft may serve as an option to salvage post-traumatic coronoid deficiency. Sufficient graft height was required for graft survival. Secondary osteoarthritis of the ulnohumeral joint should not be underestimated during follow-up.

Ulnar stress reaction in an axillary crutch user.

Ulnar stress fractures have been reported in athletes performing repetitive, high-impact activities, such as baseball pitchers and gymnasts. Crutch-assisted walking also results in cyclical forearm loading. We report the first case of ulnar stress reaction due to axillary crutch use. A 23-year-old right-handed woman experienced right forearm pain and imaging confirmed a right ulnar stress injury. The patient was also found to have mild hypercortisolism, low bone mass and vitamin D deficiency. Crutches were discontinued and physical therapy to normalise weight bearing through the left leg was prescribed. The patient's right forearm symptoms resolved and she was started on oral vitamin D supplementation. Axillary crutch use may result in ulnar stress injury, particularly in vulnerable populations. The addition of an upper extremity injury to someone with impaired mobility may compound disability. As such, clinicians should be aware of the clinical presentation of ulnar stress fractures in the long-term axillary crutch user.

Instability in the Setting of Distal Radius Fractures: Diagnosis, Evaluation, and Treatment.

Distal radius fractures with severe displacement or concomitant triangular fibrocartilage complex tears may be accompanied by distal radioulnar joint instability. Clinicians should examine the distal radioulnar joint closely when managing wrist fractures and treat coexisting instability appropriately. Chronic instability from distal radius malunion may require osteotomy or radioulnar ligament reconstruction. With proper management, most patients recover forearm stability and rotational motion after distal radius fracture.

Elbow Instability: Evaluation and Treatment.

Acute elbow dislocations are commonly seen in clinical practice, and attention to management principles and strategies can help facilitate improved outcomes. Patients may present with simple elbow dislocation, in which nonoperative treatment is highly successful. Alternatively, fracture dislocations can be sometimes easily managed but frequently are associated with the need for surgical intervention and operative and postoperative challenges.

Elbow Fracture-Dislocations: Determining Treatment Strategies.

Elbow dislocations represent common injuries. A quarter of these injuries involve at least 1 fracture. The sequel of elbow fracture-dislocations can be fraught with complications, including recurrent instability, posttraumatic arthritis, elbow contracture, and poor functional results. The 3 main patterns of injury are valgus posterolateral rotatory instability, varus posteromedial rotatory instability, and transolecranon fracture-dislocation. This article discusses each pattern individually, including the anatomy, the typical injury pattern, and treatment strategies. It also discusses common complications that can occur.

COVID-19 with pleural effusion as the initial symptom: a case study analysis.

Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) is a newly identified strain of coronavirus in the human body and was reported in Wuhan at the end of 2019. So far, the epidemic is continuing and very serious, with the number of infections and deaths increasing. Despite active investigations around the world to better understand the dynamics of transmission and the scope of clinical disease, COVID-19 continues to spread rapidly from person to person. The common signs and symptoms of SARS-CoV-2 infection include fever, fatigue, dry cough, and dyspnea; in severe cases, patients may have acute respiratory distress syndrome, septic shock, metabolic acidosis difficult to treat and coagulation disorder. However, some patients who test positive for SARS-CoV-2 in their respiratory tract may not have such clinical signs and symptoms. This report presents a case study analysis of a patient admitted in the Fourth Taiyuan People's Hospital, who had suffered traumatic injuries from a car accident and survived COVID-19, with pleural effusion as the initial symptom. We report a case of 2019-NCOV with pleural effusion as the first symptom. Describe in detail the differential diagnosis, diagnosis, clinical management, and cure of this case. In order to combat the novel CoronaviruscoVID-19 in the process to provide lessons and help.

Olecranon Stress Fracture.

Olecranon stress fractures are a rare upper extremity fracture that primarily affects throwing athletes. The incidence of olecranon stress fractures are increasing owing to the number of patients playing and the volume of engagement in competitive sports, especially in the pediatric population. However, olecranon stress fractures can present a challenge from a management and a rehabilitation perspective owing to their vague presentation, thereby affecting how these patients are diagnosed and managed. Therefore, it is imperative to further evaluate the disease process, diagnosis, and treatment of this condition to best manage our patients.

Trends in fracture development of the upper extremity in Germany-a population-based description of the past 15 years.

BACKGROUND: Recent studies investigating fracture development in Germany are not available especially with regard to demographic change. The primary aim of this study was to report trends in fracture development of the upper extremity in Germany between 2002 and 2017 and to evaluate changes over time. METHODS: Evaluating inpatient data from the German National Hospital Discharge Registry (International Classification of Diseases, ICD-10) between 2002 and 2017. Total count, incidences and percentage changes of the following fracture localizations were analysed: proximal humerus, distal humerus, proximal ulna, proximal radius, ulna diaphysis (including Monteggia lesion) and distal radius. Ten age groups for men and women were formed: 35-44, 45-54, 55-64, 65-74; 75-84; 85-90, and > 90 (years). RESULTS: The total count of proximal humeral fractures increased from 40,839 (2002, men/women 9967/30,872) to 59,545 (2017, men/women 14,484/45,061). Distal humeral fractures increased from 5912 (2002, men/women 1559/4353) to 6493 (2017, men/women1840/4653). The total count of forearm fractures increased from 68,636 (2002, men/women 17,186/51,450) to 89,040 (2017, men/women 20,185/68,855). Women were affected in 70-75% of all cases with rising incidences among nearly every age group in female patients. CONCLUSION: Total count of nearly every evaluated fracture increased. Also, incidences increased especially in the older female age groups. Fracture development already seems to reflect demographic changes in Germany.

Improving Quality in the Treatment of Pediatric Forearm Fractures: Minimizing the Need for Repeat Intervention With Long-arm Extension Casting.

PURPOSE: Repeat intervention for pediatric forearm fractures after closed manipulation is as high as 46% with flexed elbow (FE) long-arm casts. Casting with the elbow extended (EE) has been advocated as an alternative technique. We documented outcomes of patients treated with closed manipulation and casting with EE long-arm casts for displaced, diaphyseal both-bone forearm fractures. METHODS: We retrospectively reviewed charts for patients who had sedated manipulations and casting for closed, diaphyseal forearm fractures. Open fractures, immediate surgical intervention, metabolic bone disease, recurrent fractures, and Monteggia injuries were excluded. Closed manipulations were performed by orthopaedic residents assisted by cast technicians, with sedation provided by emergency department physicians. Radiographic angulation and displacement of the radius and ulna on immediate postreduction radiographs and all follow-up radiographs were recorded. Patients requiring repeat intervention were compared with those who did not by using the Mann-Whitney U and Fisher exact tests. RESULTS: Of 86 patients (7.2±2.8 y) available for analysis, 82 (95.3%) completed treatment after a single-sedated manipulation and placement of an EE long-arm cast. There were no malunions or nonunions. The average follow-up was 50 days. Four (4.7%) patients required repeat interventions (2 had surgery, 1 had a repeat sedated manipulation, and 1 had a nonsedated manipulation). There were no statistically significant differences in age, sex, laterality, fracture position in the diaphysis, or immediate postreduction angulation of the radius or ulna. A literature review showed average repeat intervention rates of 14.9% (range, 0% to 45.9%) for FE casts and 3.3% (range, 0% to 15%) for EE casts. CONCLUSIONS: There was a low rate of repeat interventions (4.7%) in patients with EE casts compared with historical rates for FE casts. Improving the quality of health care involves identifying and implementing practices that provide the best outcomes at the lowest costs. The use of EE long-arm casts following closed manipulation of pediatric forearm fractures may decrease the rate of repeat manipulation or surgery compared with conventional FE casts. LEVEL OF EVIDENCE: Level IV-case series.

Unusual Forearm Deformity Solved by 3D Custom Made Guides.

We report a case of a symptomatic forearm deformity due to a premature distal ulnar fracture solved by 3D custom made cutting guides. Our patient is a sixteen years old girl referred to us due to a forearm deformity and a dysplasic ulnar head associated to pain at the dorsum of the distal ulna and at the radial head at the elbow. Using custom-made cutting guides on a 3D model, a both bone forearm osteotomy was performed. At 18 months of follow up, the range of motion did not improve significantly but our patient referred no pain and she was satisfied with the procedure. The accuracy of single cut osteotomies, utilizing three-dimensional planning and custom patient guides has been previously established. This technique helped with the pain in our case.

Concurrent Proximal Fractures Are Rare in Distal Forearm Fractures: A National Cross-sectional Study.

INTRODUCTION: Distal forearm fractures (DFF) account for 1.5% of emergency department (ED) visits in the United States. Clinicians frequently obtain imaging above/below the location of injury to rule out additional injuries. We sought to determine the incidence of associated proximal fractures (APF) in the setting of DFF and to evaluate the imaging practices in a nationally representative sample of EDs. METHODS: We queried the 2013 National Emergency Department Sample using International Classification of Diseases, 9th edition, diagnostic codes for DFF and APF. Current Procedural Technology codes identified associated imaging studies. We calculated national estimates using a weighted analysis of patient and hospital-level characteristics associated with APF and imaging practices. An analysis of costs estimated the financial impact of additional imaging in patients with DFF using Medicare reimbursement to approximate costs according to the 2018 Medicare Physician Fee Schedule. RESULTS: In 2013, an estimated 297,755 ED visits (weighted) were associated with a DFF, of which 1.6% (4836 cases) had an APF. The incidence of APF was lower among females (odds ratio [OR] (0.76); 95% confidence interval [CI], 0.64-0.91) but higher in metropolitan teaching hospitals compared to metropolitan non-teaching hospitals (OR [2.39]; 95% CI, 1.43-3.99) and Level 1 trauma centers (OR [3.9]; 95%, 1.91-7.96) compared to non-trauma centers. Approximately 40% (n = 117,948) of those with only DFF received non-wrist radiographs and 19% (n = 55,236) underwent non-wrist/non-forearm imaging. Factors independently associated with additional imaging included gender, payer, patient and hospital rurality, hospital region, teaching status, ownership, and trauma center level. Nearly $3.6 million (2018 U.S. dollars) was spent on the aforementioned additional imaging. CONCLUSION: Despite the frequency of proximal imaging in patients with DFF, the incidence of APF was low. Further study to identify risk factors for APF based on mechanism and physical examination factors may result in reduced imaging and decreased avoidable healthcare spending.

Heterotopic Ossification Requiring Revision Surgery for Elbow Contracture After Tension Band Wiring for an Isolated Olecranon Fracture A Case Report.

Olecranon fractures are common trauma presentations, and generally good or excellent functional outcomes are expected after surgical treatment. The development of heterotopic ossification (HO) is a well-known complication, leading to restricted motion, subsequent joint contractures, and marked functional limitation of the upper extremity. Whereas most olecranon fractures complicated by HO have less extensive ossification and limited clinical implications, we report a rare case of HO that required revision surgery for elbow contracture after tension band wiring for an isolated olecranon fracture. Our findings indicate that even patients with isolated olecranon fractures should be notified about the potential risk of HO development, which could result in restricted motion and subsequent joint contractures. The risk factors associated with the development of HO after elbow trauma should be recognized during surgical treatment for olecranon fracture. Fractures of the olecranon are common trauma presentations. 1 Most olecranon fractures are treated surgically, and good or excellent functional outcomes are expected after surgical treatment.1 The development of heterotopic ossification (HO) is a well-known complication after elbow trauma that causes restricted motion, subsequent joint contractures, and marked functional limitation of the affected upper extremity.2 The severity of HO is related to the nature of the injury. Most olecranon fractures complicated by HO have less extensive ossification, and the clinical implications of this type of injury are limited.3 We report a rare case of HO in which revision surgery for the treatment of elbow contracture was required after an isolated olecranon fracture.