The radiological findings in complex elbow fracture-dislocation injuries.

Elbow fracture-dislocation is a complex injury which can lead to significant bony and soft tissue damage. Surgical intervention is guided towards restoring joint stability, allowing early mobilization and preventing long-term joint stiffness. The most common types are posterolateral, posteromedial, Monteggia type (and variants), and anterior trans-olecranon fracture-dislocations. Posterolateral fracture-dislocation is characterized by a radial head fracture (± anterolateral coronoid fracture) and typically capsuloligamentous disruption (lateral collateral ligaments injury is the most common). A posterolateral fracture-dislocation with radial head and coronoid anterolateral facet fractures is termed a terrible triad injury. In posteromedial fracture-dislocation, there is a fracture of the anteromedial facet of the coronoid, typically with proximal avulsion of the lateral collateral ligaments (± injury to the posterior bundle of the ulnar collateral ligament). Monteggia fracture-dislocation injuries demonstrate proximal ulnar fracture (with possible involvement of the olecranon and the coronoid) and radial head dislocation. These can be divided into apex anterior or apex posterior variants. The latter are commonly associated with radial head fractures and lateral ligamentous injury, and have a worse prognosis. In trans-olecranon fracture-dislocation, there is significant disruption of the greater sigmoid notch and the olecranon, with various involvement of the coronoid and the proximal ulna. The article describes the radiological findings and outlines the management principles in complex elbow fracture-dislocation injuries.

The three-column concept of elbow joint stability and the Wrightington elbow fracture-dislocation classification, emphasizing the role of cross-sectional imaging.

Elbow fracture-dislocation is a complex injury with a combination of osseous and soft tissue disruption. Different classification systems have been used to describe the injury pattern and help guide the management. The article describes the important cross-sectional findings in complex elbow fracture-dislocation injuries based on the relatively new Wrightington classification. This includes the various elements and patterns seen in elbow fracture-dislocations providing a simple and comprehensive system to classify these injuries and help guide the surgical management. The article also describes the three-column concept of elbow joint stability, dividing the elbow joint osseous structures into lateral, middle and medial columns. Detailed radiological assessment of the fractures pattern is vital to understand the mechanism of injury, allowing clinicians to predict the associated capsuloligamentous injury and help guide the management decisions. The Wrightington elbow fracture-dislocation classification categorizes the injuries according to the ulnar coronoid process and radial head fractures. Type A is an anteromedial coronoid fracture. Type B is a bifacet or basal coronoid fracture, with B + indicating associated radial head fracture. Type C is a combined anterolateral facet and radial head or comminuted radial head fractures. Type D is a diaphyseal ulnar fracture, with D + indicating associated radial head fracture.

Posteromedial rotatory instability of the elbow: What the radiologist needs to know.

Varus posteromedial rotatory instability of the elbow joint is a relatively new subject described for the first time in 2003. It occurs secondary to axial loading of the elbow with varus force and internal rotation of the forearm. There is usually a specific pattern of osseous and soft tissue injuries that can be recognized on imaging. This includes an anteromedial coronoid fracture and avulsion of the lateral collateral ligament complex from its humeral attachment. Ulnar collateral ligament complex injury is also reported, particularly its posterior bundle which plays an important role in posteromedial elbow joint stability. There is high incidence of early osteoarthritis secondary to the resultant varus instability and increased contact pressure at the ulnohumeral joint. Surgical fixation of the coronoid fracture and ligamentous reconstruction maybe indicated to prevent this recurrent instability. The article reviews the key radiological features of posteromedial rotatory instability with multiple examples from different imaging modalities. The relevant anatomy of the elbow joint stabilising structures will be illustrated, in particular the coronoid process anatomy and the O'Driscoll classification for coronoid process fractures. Radiologists should be familiar with the imaging findings of posteromedial rotatory instability.

Long-Term Results of Arthroscopic Capsular Shrinkage for Palmar Midcarpal Instability of the Wrist.

Background Midcarpal instability is a term for a collection of poorly understood conditions where the proximal row of the carpus is unstable. The most common type of midcarpal instability is palmar midcarpal instability (PMCI). Treatment for PMCI includes nonoperative proprioceptive retraining of the wrist, splints, and strengthening. If this fails, various authors have suggested several different fusions, tenodesis procedures, or capsular shrinkage. There are no long-term case series in the literature. Objective The aim of this study is to assess the long-term results of arthroscopic capsular shrinkage when used for PMCI of the wrist. Methods A prospective cohort study of patients who underwent arthroscopic capsular shrinkage for PMCI was performed. Ethical board approval was given for this study. All patients were followed up and reviewed independently from the operating surgeon. Assessment included a structured questionnaire, disabilities of the arm, shoulder and hand (DASH) questionnaire, and clinical examination using a goniometer. PMCI was assessed objectively with the anterior drawer test and radiological imaging was only performed if clinically relevant to the residual symptoms. Results Thirteen patients (15 wrists) underwent arthroscopic capsular shrinkage for PMCI. Twelve patients (14 wrists) were available for clinical review with a follow-up rate of 92.3%. The mean time from index procedure to final review was 12 years (range: 10-14years). The symptoms of instability had completely resolved in nine wrists (7 patients). Only 2 of the 14 wrists had symptoms that were reproduced with a positive anterior drawer test. All other wrists were stable on objective assessment. The mean DASH score had improved from pre op of 34 to post op of 12.1 and at 12-year follow-up this had deteriorated minimally to 15.3. Assessment of the range of motion showed an average increase in range of flexion/extension by 22 degrees. Patient satisfaction was excellent. The patients rated that nine wrists were much better than presurgery, three as better, one unchanged, and one worse. Discussion/Conclusion There are no studies looking at the long-term natural history of treatments for PMCI. The lead author proposes a grading system for symptomatic PMCI that has been retrospectively applied to this cohort. It is a grading system from 1 to 4 and is based on a treatment algorithm. This is the first long-term study from any joint, where the results of capsular shrinkage have been maintained over time. In this series, we have not seen any deleterious effect from possible mechanoreceptor injury. We suspect that functioning mechanoreceptors are more relevant in the unstable joint, than the structurally stable joint. The authors propose that thermal capsular shrinkage is an effective and durable option for use in mild-to-moderate forms of PMCI.

Focal Myositis of the Deltoid Muscle: The Role of Magnetic Resonance Imaging for Diagnosis.

Introduction: Focal myositis is a rare condition first described by Heffner et al., in 1977, as a self-limiting condition of unknown aetiology. It presents as an inflammatory pseudo tumour in skeletal muscle and can present diagnostic difficulty, being commonly mistaken for tissue of vascular, inflammatory, or neoplastic origin. Diagnosis is traditionally confirmed by muscle biopsy. We present a case where magnetic resonance imaging (MRI) was used to confirm the diagnosis without need for biopsy. Case Presentation: A 19-year year-old female presented with a two2-year history of intermittent swelling of the deltoid associated with pain and tenderness to palpation. . There was no history of trauma or systemic illness. . She was symptomatic with pain, swelling, and tenderness over the left deltoid with no restriction in range of movement of the shoulder or neck. Plain radiographs were normal and MRI magnetic resonance imaging showed diffuse odeamatousedematous signal changes on the proton density weighted sequence within the deltoid muscle and no plexiform neurofibroma. Nerve conduction and electromyography studies were within normal limits excluding an axillary nerve lesion. The patient underwent extensive screening for connective tissue disorders and creatine kinase and lactate dehydrogenase levels were within limits. The patient underwent neuromuscular specialist review confirming that this appeared to be a rare case of focal myositis in the deltoid. . The serial MRI scans confirmed resolution of the condition. Conclusion: Focal myositis of the deltoid is a rare cause of shoulder pain. . We have shown that sequential MRI scanning can obviate the need for muscle biopsy, which has historically been required for diagnostic confirmation. The MRI appearance on the proton density weighted sequence showed diffuse odeamatousedematous signal changes and no plexiform neurofibroma within the deltoid and is a description that has not been previously used for this rare diagnosis.

Long-Term Clinical and Radiological Results After Hook Plate Osteosynthesis of Lateral Clavicle Fractures.

OBJECTIVES: To assess both clinical and radiological long-term outcomes after hook plate osteosynthesis for Neer type II lateral clavicle fractures. DESIGN: Retrospective case series. SETTING: Level-1 trauma center. PATIENTS/PARTICIPANTS: Patients who underwent open reduction internal fixation with a hook plate for displaced fractures of the lateral third of the clavicle (Neer type II) at a single trauma hospital were identified. INTERVENTION: Lateral clavicle open reduction internal fixation with a hook plate. MAIN OUTCOME MEASURES: At the first of 2 long-term follow-up appointments, bilateral magnetic resonance imaging (MRI) scans and strength measurements were performed, Constant-Murley score, subjective shoulder value (SSV), and Oxford shoulder score (OSS) of both shoulders were obtained. At the second follow-up, specific acromioclavicular (AC) score, SSV, and OSS were obtained. RESULTS: Twenty-one patients (mean age, 29.5 ± 9.7 years) could be included who were available for at least 1 of 2 follow-ups after 7.4 years (±2.3) and 13.9 years (±2.2). Bony union was achieved in all patients (100%) at an average of 3.4 months (±1.4). The hook plate was removed at an average of 5.5 months (±3.3) after initial surgery in all patients. No significant side-to-side differences were found in OSS, Constant-Murley score, SSV, and specific AC score and for strength testing and MRI scans. CONCLUSIONS: Long-term outcome after hook plate fixation of Neer type II lateral clavicle fractures demonstrated good clinical results and shoulder strength without higher radiographic rates of AC joint osteoarthritis, subacromial impingement, or rotator cuff lesions. That may be related to a standardized early plate removal after bony fracture union. LEVEL OF EVIDENCE: Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

A cadaveric study of the three different palpation-guided techniques for glenohumeral joint injections.

BACKGROUND: It is not known whether an anterior, posterior or superior approach using the Neviaser portal is more accurate for glenohumeral joint injections. The aim of this study was to evaluate the accuracy of the palpation-guided technique and compare the three different approaches. METHODS: Palpation-guided glenohumeral joint injections were performed in 48 shoulders (24 cadavers) by two operators. Each shoulder was injected by three different approaches with a different coloured latex solution. The three approaches included the anterior, posterior and superior methods. The accuracy and location of unsuccessful injections were assessed through dissection of the shoulders. RESULTS: Posterior injections were the most successful with an accuracy rate of 89.6%, followed by anterior injections (75%) and superior injections (54.2%). Both posterior (p = 0.0001) and anterior injections (p = 0.03) were statistically significantly more accurate than superior injections. The most common failure mode was an intratendinous or intramuscular injection, which occurred most frequently with a superior approach. CONCLUSIONS: Use of a superior approach through the Neviaser portal for the palpation-guided technique for glenohumeral joint injections showed a statistically significant inferior accuracy when compared to both the posterior and anterior approaches and is therefore not recommended. Posterior approached injections were the most accurate.

Arthroscopic Management of Anterior Glenoid Bone Loss.

Anterior glenohumeral instability is a complex problem that requires careful attention to osseous and soft-tissue lesions in order to treat it effectively. The arthroscopic soft-tissue Bankart repair is considered first-line treatment for patients with anterior glenohumeral instability. However, recent long-term outcome studies have shown surprisingly high failure rates, specifically in the setting of anterior glenoid bone loss. The definition of "critical" glenoid bone loss that cannot be overcome by a soft-tissue procedure alone continues to evolve and may in fact be lower than the previously published total of 20%. Arthroscopic reconstruction of the anterior glenoid margin can be performed with either autograft or allograft. The arthroscopic Latarjet procedure has emerged as a reliable and effective technique for autograft augmentation, while the distal aspect of the tibia appears to be a promising source of allograft.

Assessing the resilience of an IT portfolio.

One of the goals of the business impact analysis (BIA) process is to establish recovery objectives. Having established recovery objectives, the next step is to assess whether one's IT portfolio can actually meet those objectives. Unfortunately, there is no well-defined and prescriptive process for this. This article describes a model that can be customised and applied in any organisation to take an IT-centric view to assessing resilience capabilities. The first stage of this process is to gather IT-specific data, either through a questionnaire or by querying the configuration management database directly. The next step is to leverage a set of scoring rubrics in order to assess the capabilities of each application with respect to meeting recovery point objectives, recovery time objectives and service-level targets, as well as the strength of staffing, documentation and disaster recovery plans. The output of the model is a composite score for each application (based upon an aggregate capability score and a weighting factor) that identifies those services in the IT portfolio with the greatest gaps in their capabilities (ie those services in greatest need of remediation). The logic of the model can either be built with spreadsheets or automated through business continuity management planning platforms.

Isolated displaced non-union of a triquetral body fracture: a case report.

INTRODUCTION: Fractures of the body of the triquetral bone are the second most common carpal fractures, and these fractures can be missed on plain X-ray. Although non-union of triquetral body fractures is very rare, such cases are associated with considerable morbidity and reduction in functional activity. CASE PRESENTATION: We report the case of a 29-year-old Caucasian British man who sustained an isolated displaced triquetral body fracture that resulted in non-union, who was treated surgically. We describe an original operative management for this debilitating injury. An open reduction and internal fixation using double headed compression screws was performed, without bone grafting, and with early immobilization of the wrist. CONCLUSIONS: We propose this novel approach and advocate early clinical suspicion of triquetral body fractures in patients with a history of fall on an outstretched hand and ulnar sided wrist pain. We recommend evaluation using computed tomography or magnetic resonance imaging scanning.

Extranasal applications of the bilobed flap.

BACKGROUND: The bilobed flap has proven its utility in the reconstruction of distal nasal defects. The mechanics and geometry of the bilobed flap must be clearly understood to achieve these reproducible results. The novelty of the bilobed flap as it is applied to extranasal reconstruction is that the surgeon has some degree of variance in designing the size of the individual lobules of the flap, with a lower risk of secondary tissue distortion. Several variations of the bilobed flap are described, with emphasis on technique and the unique issues involved in its extranasal application. OBJECTIVE: Our experience with the multiple extranasal applications of the bilobed flap is described to demonstrate the usefulness of this reconstructive technique. METHODS: The general technique of the bilobed flap is described, with emphasis on the extranasal variations. Five anatomic locations are presented, with unique considerations and photographs. RESULTS: The bilobed flap as it is applied to extranasal reconstruction allows the surgeon some degree of variance in designing the size of the individual lobules of the flap (compared with the distal nose), with a lower risk of secondary tissue distortion. The flap must be carefully designed to place the incision lines as close to relaxed skin tension lines as possible. A meticulous suture technique is important in camouflaging the complex suture line of this flap, which in no circumstance completely parallels the relaxed skin tension lines. CONCLUSION: We hope to expand the use of this versatile flap to extranasal locations. It can produce the equivalent excellent functional and esthetic results compared with its more common nasal application.