Does Surgery Improve Healing After Isolated Diaphyseal Ulna Fractures?

PURPOSE: Isolated diaphyseal ulna fractures can be treated nonsurgically or with open reduction and internal fixation (ORIF). It is unclear whether ORIF provides quicker and/or more predictable healing. The purpose of this study was to compare the healing characteristics of isolated diaphyseal ulna fractures after surgical and nonsurgical treatment. METHODS: All patients treated for an isolated diaphyseal (distal- or middle-third) ulna fracture between 2010 and 2018, with a minimum of 3 months of follow-up, were identified. Electronic medical records were reviewed to record patient demographics, assess the treatments used, and compare outcomes. We determined healing and nonunion rates, complications, reoperations, and final radiographic fracture alignment. RESULTS: Ninety-five patients were included with a median follow-up of 20 weeks. Of these, 56 patients were treated nonsurgically and 39 patients were treated with ORIF. At the time of the final follow-up, 51 of the 56 (91.1%) nonsurgically treated fractures had healed and 38 of the 39 (97.4%) surgically managed fractures had healed. There were 5 nonunions after nonsurgical treatment (8.9%) and 1 nonunion after ORIF (2.6%). Eleven patients (19.6%) treated nonsurgically required conversion to ORIF, whereas 4 patients (10.3%) treated with ORIF required reoperation. Middle-third fractures treated nonsurgically had a higher rate of nonunion (30.8%) compared with distal-third fractures treated nonsurgically (2.3%). CONCLUSIONS: The healing characteristics of isolated ulnar shaft fractures do not appear to differ substantially between surgical and nonsurgical treatment. However, nearly 20% of the patients treated nonsurgically may require eventual ORIF. Distal-third fractures may be at a higher risk of conversion to ORIF, and middle-third fractures may be at a higher risk of nonunion. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic IV.

Diaphyseal Both-Bone Forearm Fracture Due to a Grip Lock Injury in a Female Pediatric Gymnast: A Case Report.

CASE: A 13-year-old female gymnast sustained a diaphyseal both-bone forearm fracture due to a grip lock injury. CONCLUSION: This is a report of a diaphyseal both-bone forearm fracture due to a grip lock injury in a female pediatric gymnast, successfully treated with closed reduction and cast immobilization. The rare mechanism of injury, education, and treatment have been discussed.

Obesity Increases Risk of Loss of Reduction After Casting for Diaphyseal Fractures of the Radius and Ulna in Children: An Observational Cohort Study.

OBJECTIVES: To determine if high body mass index (BMI) increases the risk of loss of reduction (LOR) following closed reduction and casting for displaced concomitant fractures of the radial and ulnar shafts in pediatric patients. DESIGN: Retrospective cohort study. SETTING: A single, tertiary care, urban children's hospital. PATIENTS/PARTICIPANTS: Pediatric patients 2-18 years of age with closed, displaced, concomitant diaphyseal fractures of the radius and ulna (OTA/AO 22-A3) who underwent closed reduction and casting at the study site. MAIN OUTCOME MEASURES: BMI percentile of ≥95 was defined as obese. For nonobese patients, BMI percentile of ≥85 was defined as overweight. BMI percentile category, fracture angulation, sex, age, fracture location, and number of follow-up visits were recorded. Radiographs and health records were reviewed to note clinical and radiographic cases of LOR. The primary outcome was LOR (clinical or radiographic). RESULTS: Overall, 124 subjects (74 male and 50 female subjects) underwent acceptable closed reduction and casting. Median patient age was 7.6 years (range, 2.2-17.8 years). There were 14 cases of LOR. LOR rates were 7.2%, 16.7%, and 44.4% for the nonoverweight, overweight, and obese cohorts, respectively (P = 0.005). Regression analysis revealed that LOR was positively associated with higher BMI category (odds ratio for overweight 4.49; P = 0.082; odds ratio for obese 7.52; P = 0.020) and patient age in years (odds ratio, 1.38; P = 0.001). CONCLUSIONS: Given the high risk of LOR in overweight and obese children with displaced concomitant fractures of the radial and ulnar shafts, our findings suggest that attentive and frequent follow-up is warranted. In these patients, the initial reduction should be closely scrutinized, and a lower threshold for surgical fixation may be considered. LEVEL OF EVIDENCE: Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

Levantamento das complicações de fraturas de rádio e ulna de cães de pequeno porte, com revisão cirúrgica posterior, no Hospital Veterinário Anhembi Morumbi, no período de 2009 a 2015 / Data collection of Radius Ulnar Fractures of small breed dogs, with later surgical revision, in the Hospital Veterinário Anhembi Morumbi, between the period of the years 2009 and 2015 / Estudio de las complicaciones de fracturas de Radio y Cúbito en perros pequeños con revisión quirúrgica más tarde, en el Hospital Veterinario Anhembi Morumbi, en el período de 2009 a 2015

As fraturas de rádio e ulna são afecções frequentes em cães de pequeno porte. Elas são normalmente associadas à alta incidência de má união ou união tardia, o que tem sido relacionado com o precário suprimento sanguíneo nesta região. O objetivo deste trabalho foi realizar um levantamento dos atendimentos de animais de pequeno porte, com fraturas de rádio e ulna com complicações, posteriormente tratadas com cirurgia, entre o período que compreende os anos de 2009 a 2015, no Hospital Veterinário Anhembi Morumbi. Dentro dos parâmetros avaliados, foram detectados 8 casos de complicações, sendo que o tratamento inicial dos mesmos foram: 5 deles tratados com coaptação externa, 1 com osteossíntese com placa subdimensionada associada à coaptação externa, 1 tratado com osteossíntese com placa e 1 com fixador externo. As revisões incluíram 6 tratamentos com placas adequadas e 2 tratamentos com fixadores externos. Concluímos que o uso de placas e de fixadores externos possibilitam maiores sucessos no tratamento de fraturas de rádio e ulna de cães de pequeno porte, enquanto a coaptação externa tem maiores chances de levar ao fracasso nestes casos.(AU)

Radius ulnar fractures occur frequently in small breed dogs. They are normally associated to high incidence of bone nonunion or delayed union. This is related to the poor blood supply of this region. The aim of this study was to realize a collection of data from small breed dogs, with radius ulnar fractures with complications, latterly treated with surgery, between the period of the years 2009 and 2015, in the Hospital Veterinário Anhembi Morumbi. There were detected 8 cases of complications and the initial treatment of them were: 5 of them treated with external coaptatin, 1 with osteosythesis with undersized bone plate associated to external coaptation, 1 with ostheosyntesis with bone plate and one with external fixator. The surgical revisions included 6 treatments with adequate bone plates and 2 treatments with external fixators. In conclusion, the use of bone plates and external fixators enable better success in the treatment of radius ulnar fractures from small breed dogs, and also that external coaptation lead o bigger chances of failures of the treatment.(AU)

Las fracturas de radio y cúbito son trastornos comunes en los perros pequeños. Por lo general se asocian con una alta incidencia de mala unión o unión retardada, que ha sido relacionada con la falta de riego sanguíneo en esta región. El objetivo de este estudio fue realizar un levantamiento de datos de los perros pequeños, con fracturas de radio y cúbito con complicaciones posteriormente tratados con cirugía entre el período que abarca los años 2009-2015, el Hospital Veterinario de Anhembi Morumbi. Dentro de los parámetros evaluados, se detectaron 8 casos de complicaciones y el tratamiento inicial de estos fueron 5 de ellos tratados con coaptación externa, 1 con osteosíntesis con placa de tamaño inferior, asociado con la coaptación externa, 1 tratado con osteosíntesis con placa y uno con fijador externo. Las revisiones incluyeron 6 tratamientos con placas adecuadas y 2 tratamientos con fijadores externos. Llegamos a la conclusión de que el uso de placas y fijadores externos permiten mayores éxitos en el tratamiento de las fracturas de radio y cúbito de perros pequeños, mientras que la coaptación externa es más probable que conduzca a un fallo en estos casos.(AU)

Levantamento das complicações de fraturas de rádio e ulna de cães de pequeno porte, com revisão cirúrgica posterior, no Hospital Veterinário Anhembi Morumbi, no período de 2009 a 2015 / Data collection of Radius Ulnar Fractures of small breed dogs, with later surgical revision, in the Hospital Veterinário Anhembi Morumbi, between the period of the years 2009 and 2015 / Estudio de las complicaciones de fracturas de Radio y Cúbito en perros pequeños con revisión quirúrgica más tarde, en el Hospital Veterinario Anhembi Morumbi, en el período de 2009 a 2015

As fraturas de rádio e ulna são afecções frequentes em cães de pequeno porte. Elas são normalmente associadas à alta incidência de má união ou união tardia, o que tem sido relacionado com o precário suprimento sanguíneo nesta região. O objetivo deste trabalho foi realizar um levantamento dos atendimentos de animais de pequeno porte, com fraturas de rádio e ulna com complicações, posteriormente tratadas com cirurgia, entre o período que compreende os anos de 2009 a 2015, no Hospital Veterinário Anhembi Morumbi. Dentro dos parâmetros avaliados, foram detectados 8 casos de complicações, sendo que o tratamento inicial dos mesmos foram: 5 deles tratados com coaptação externa, 1 com osteossíntese com placa subdimensionada associada à coaptação externa, 1 tratado com osteossíntese com placa e 1 com fixador externo. As revisões incluíram 6 tratamentos com placas adequadas e 2 tratamentos com fixadores externos. Concluímos que o uso de placas e de fixadores externos possibilitam maiores sucessos no tratamento de fraturas de rádio e ulna de cães de pequeno porte, enquanto a coaptação externa tem maiores chances de levar ao fracasso nestes casos.

Radius ulnar fractures occur frequently in small breed dogs. They are normally associated to high incidence of bone nonunion or delayed union. This is related to the poor blood supply of this region. The aim of this study was to realize a collection of data from small breed dogs, with radius ulnar fractures with complications, latterly treated with surgery, between the period of the years 2009 and 2015, in the Hospital Veterinário Anhembi Morumbi. There were detected 8 cases of complications and the initial treatment of them were: 5 of them treated with external coaptatin, 1 with osteosythesis with undersized bone plate associated to external coaptation, 1 with ostheosyntesis with bone plate and one with external fixator. The surgical revisions included 6 treatments with adequate bone plates and 2 treatments with external fixators. In conclusion, the use of bone plates and external fixators enable better success in the treatment of radius ulnar fractures from small breed dogs, and also that external coaptation lead o bigger chances of failures of the treatment.

Las fracturas de radio y cúbito son trastornos comunes en los perros pequeños. Por lo general se asocian con una alta incidencia de mala unión o unión retardada, que ha sido relacionada con la falta de riego sanguíneo en esta región. El objetivo de este estudio fue realizar un levantamiento de datos de los perros pequeños, con fracturas de radio y cúbito con complicaciones posteriormente tratados con cirugía entre el período que abarca los años 2009-2015, el Hospital Veterinario de Anhembi Morumbi. Dentro de los parámetros evaluados, se detectaron 8 casos de complicaciones y el tratamiento inicial de estos fueron 5 de ellos tratados con coaptación externa, 1 con osteosíntesis con placa de tamaño inferior, asociado con la coaptación externa, 1 tratado con osteosíntesis con placa y uno con fijador externo. Las revisiones incluyeron 6 tratamientos con placas adecuadas y 2 tratamientos con fijadores externos. Llegamos a la conclusión de que el uso de placas y fijadores externos permiten mayores éxitos en el tratamiento de las fracturas de radio y cúbito de perros pequeños, mientras que la coaptación externa es más probable que conduzca a un fallo en estos casos.

Neurological and vascular injury associated with supracondylar humerus fractures and ipsilateral forearm fractures in children.

BACKGROUND: Approximately 5% of supracondylar humerus fractures in children are associated with an ipsilateral forearm fracture, often referred to as a floating elbow when both injuries are displaced. Historically, these patients have higher complication rates than patients with an isolated supracondylar humerus fracture. The purpose of this study was to review the acute neurologic and vascular injuries in patients with ipsilateral, operative supracondylar humerus and forearm fractures and compare the findings with a cohort of isolated, operative supracondylar humerus fractures. METHODS: We performed an IRB-approved, retrospective review of all pediatric patients with ipsilateral, operative supracondylar humerus and forearm fractures from a single institution and compared our findings to a cohort of isolated, operative supracondylar humerus fractures. RESULTS: A total of 150 patients with operative supracondylar humerus and ipsilateral forearm fractures were compared with 1228 patients with isolated, operative supracondylar humerus fractures. Twenty-two of the 150 (14.7%) floating elbow patients had documented pretreatment nerve palsies compared with 96/1228 (7.8%) of isolated injury patients (P=0.006). Eighteen of 22 nerve palsies were in patients with forearm fractures that required reduction. The overall incidence of nerve palsy was 18.9% (18/95) when a forearm fracture required reduction compared with only 7.3% (4/55) in a forearm fracture that was not reduced (P=0.05). We did not find a significant difference in the rate of pulseless extremities when comparing the ipsilateral (6/150 4%) and isolated (50/1228 4.1%) injury patients. No compartment syndromes were identified in any patient with an ipsilateral injury. CONCLUSIONS: The rate of acute neurologic injury in ipsilateral supracondylar humerus and forearm fractures is almost twice than that found in patients with isolated supracondylar humerus fractures. This rate increases further when the forearm fracture requires a manipulative reduction. The likelihood of a pulseless extremity was not dependent upon the presence of a forearm injury in our study. The presence of an ipsilateral forearm fracture should alert the surgeon to carefully assess the preoperative neurovascular status of patients with supracondylar humerus injuries. LEVEL OF EVIDENCE: Level III.

Does an ulnar styloid fracture interfere with the results of a distal radius fracture?

BACKGROUND: The ulnar styloid is a supportive structure for the capsular ligament complex of the distal radioulnar joint. The relation between fractures of the ulna and distal radius is not clear, especially in regard to whether ulnar fractures predict worse outcomes for distal radius fractures. The objective of this study was to analyze the influence of ulnar styloid fractures in patients with reducible and unstable distal radius fractures. METHODS: A total of 100 patients with unstable and reducible distal radius fractures, with or without an ulnar styloid fracture, were randomly assigned to treatment with transarticular bridging external fixation or transulnar percutaneous pinning. Follow-up was obtained for 91 patients. For the secondary data analysis, three patient cohorts were created: a no ulnar styloid fracture group with the radius fracture treated by pinning or external fixation (n = 30); an ulnar styloid fracture with radius fracture group treated by external fixation (n = 31); and an ulnar styloid fracture with radius fracture treated by pinning (n = 30). Functional and radiological outcomes were measured at 6 and 24 months. Functional outcome measures included wrist pain (visual analogue scale) and the Disabilities of the Arm, Shoulder, and Hand (DASH) questionnaire. RESULTS: At 24 months, patients with both fractures had worse wrist pain and worse scores on the DASH questionnaire than the patients with an isolated distal radius fracture; and those treated by pinning had less wrist pain and showed better scores on the DASH questionnaire than the patients treated by fixation. CONCLUSIONS: Ulnar styloid fracture may be a predictive factor of worse functional outcome for distal radius fracture. Pinning and above-the-elbow casting, used to treat ulnar styloid fractures, led to better function than fixation.

Infected nonunions of long bones of the upper extremity: staged reconstruction using polymethylmethacrylate and bone graft impregnated with antibiotics.

This case series evaluates 12 patients presenting posttraumatic infected nonunions affecting long bones of the upper extremity, treated with staged reconstruction using polymethylmethacrylate spacers with antibiotics in the first stage and bone graft impregnated with antibiotics in the definitive surgical procedure. Five nonunions affected the humerus, four the ulna and three the radius. All nonunions were atrophic. Patient's age averaged 35.9 years. The size of the bony defect averaged 2.8 cm. Time between original trauma and revision surgery averaged 9.6 months. Follow-up averaged 19 months. All nonunions healed after an average of 5 months. DASH score at last follow-up averaged 15 points. Although two surgical procedures are needed, one to cure infection and another to achieve bony union, this approach for posttraumatic infected nonunions of long bones of the upper extremities represents a valid treatment alternative.

[A prognostic classification of the "floating elbow" in children]. / Una propuesta de clasificación pronóstica del "codo flotante" en niños.

The ipsilateral fracture of the humerus and any bone of the forearm is known as "Floating elbow", being this an infrequent entity in paediatrics. Nevertheless the classification that is proposed is based specifically on clinical findings and on the radiographic appearance resulting. We performed an observational, cross-sectioned and descriptive study from January 1997 to December 2000. We included 29 patients from 4 to 14 years old male and female. All patients received treatment for "floating elbow" and they were evaluated with the application of this proposition to get their prognosis. It was made on the basis of other classifications widely demonstrated such as Holmberg's for supracondylar fractures, Kranhoft and Solgaard's for forearm fractures, Gustilo R.B. and Mendoza R.M.'s for exposed fractures and we also considered the applications of the functional classification index of Broberg and Morrey. We propose a classification system based on mechanism of injury, fracture's level, displacement, time of exposition and related injuries, with six different types, as well as the use of a prognostic classification the physician has to look for a perfect reduction of the fracture and an appropriate stabilization.

Combined Monteggia and Galeazzi fractures in a child's forearm

The Monteggia fracture dislocation and Galeazzi fracture dislocation are well recognized in isolation. The incidence of both of these fractures in the same forearm is rare. Only two other cases have been reported. This case report highlights the importance of early diagnosis and treatment of this combined fracture in a multiple trauma patient.

La operacion de Sauve Kapandji en el tratamiento de las secuelas postraumaticas en antebrazo y muñeca / Sauve Kapandji operation in the treatment of postraumatic sequelae in forearm and wrist

Se evaluaron retrospectivamente 21 pacientes con lesion cronica y definitiva radiocubital inferior tratados con operacion de Sauve Kapandji. Todos los casos eran secuela postraumatica de fracturas de muñeca o de antebrazo. Las principales indicaciones del procedimiento fueron dolor y limitacion de la pronosupinacion. A los 22 meses posoperatorios promedio, los pacientes fueron evaluados clinica y radiologicamente. El dolor mejoro en todos los casos y, en 17 pacientes, desaparecio por completo. La pronosupinacion mejoro del 35 por ciento al 92 por ciento, comparada con la muñeca contralateral sana. La discrepancia de longitud radiocubital, por el acortamiento o angulacion secuelar del radio, fue reducida a valores normales con correcciones de hasta 13 mm. Las complicaciones fueron calcificacion parcial o completa del intervalo cubital resecado y seudoartrosis de la artrodesis radiocubital inferior. Se analizan los factores predisponentes y la resolucion de dichas complicaciones. Ningun caso sufrio inestabilidad del muñon del cubito. Se postula que la indemnidad del tendon del cubital posterior y su vaina es el principal factor para evitar dicha complicacion. Consideramos que el procedimiento de Sauve Kapandji es de eleccion en pacientes jovenes y activos con destruccion secuelar y postraumatica de la articulacion radiocubital inferior con acortamiento del radio y desnivel longitudinal radiocubital

La operacion de Sauve Kapandji en el tratamiento de las secuelas postraumaticas en antebrazo y muñeca / Sauve Kapandji operation in the treatment of postraumatic sequelae in forearm and wrist

Se evaluaron retrospectivamente 21 pacientes con lesion cronica y definitiva radiocubital inferior tratados con operacion de Sauve Kapandji. Todos los casos eran secuela postraumatica de fracturas de muñeca o de antebrazo. Las principales indicaciones del procedimiento fueron dolor y limitacion de la pronosupinacion. A los 22 meses posoperatorios promedio, los pacientes fueron evaluados clinica y radiologicamente. El dolor mejoro en todos los casos y, en 17 pacientes, desaparecio por completo. La pronosupinacion mejoro del 35 por ciento al 92 por ciento, comparada con la muñeca contralateral sana. La discrepancia de longitud radiocubital, por el acortamiento o angulacion secuelar del radio, fue reducida a valores normales con correcciones de hasta 13 mm. Las complicaciones fueron calcificacion parcial o completa del intervalo cubital resecado y seudoartrosis de la artrodesis radiocubital inferior. Se analizan los factores predisponentes y la resolucion de dichas complicaciones. Ningun caso sufrio inestabilidad del muñon del cubito. Se postula que la indemnidad del tendon del cubital posterior y su vaina es el principal factor para evitar dicha complicacion. Consideramos que el procedimiento de Sauve Kapandji es de eleccion en pacientes jovenes y activos con destruccion secuelar y postraumatica de la articulacion radiocubital inferior con acortamiento del radio y desnivel longitudinal radiocubital