Operative treatment of Mason Type III radial head fractures - A comparative analysis using PROMIS.

Objectives: The purpose of this study is to evaluate the outcomes of operatively treated Mason Type III radial head fractures. Additionally, this project seeks to assess efficacy of PROMIS in evaluating post-operative outcomes for this patient population. Methods: A total of 143 patients who underwent operative treated Mason Type III radial head fractures were analyzed retrospectively. PROMIS physical function (PF), PROMIS upper extremity (UE), PROMIS pain interference (PI), demographic variables, and range of motion were collected and analyzed over 12-month follow-up. Results: Radial head arthroplasty (RHA) was performed on 89 patients, open reduction and internal fixation (ORIF) was performed on 47 patients, and radial head excision was performed on 7 patients. Among the RHA patients, PROMIS PF, PI and UE demonstrated a change of -1.33 (p < 0.05), -1.48 (p < 0.05), and 2.23 (p < 0.05) respectively from injury to 12-months. Among the ORIF patients, PROMIS PF, PI and UE demonstrated a change of 3.22 (p < 0.05), -1.56 (p < 0.05), and 2.09 (p < 0.05) respectively from injury to 12-months. At the pre-operative and 12-month visits, the RHA group demonstrated lower PROMIS PF scores 34.75 vs 38.02 (p < 0.05) and 33.42 vs 41.24 (p < 0.05) respectively. Ther was no difference in PROMIS PI, UE, or elbow range of motion between the two groups at 6- or 12-month follow-up (p > 0.05). Conclusion: Comparing the RHA and ORIF groups, there was no difference in PROMIS PI or UE scores nor was there a clinically significant improvement at the 6- or 12-month mark. The ORIF group demonstrated improved PROMIS PF at all follow-up periods and did show a clinically significant improvement. Patient Acceptable Symptom State (PASS) correlated only with PROMIS UE at 6- and 12- months for both groups.

Radiographic Comparison of Forearm Symmetry in Healthy Individuals and its Importance in the Diagnosis of Longitudinal Radioulnar Dissociation.

PURPOSE: Longitudinal radioulnar dissociation (LRD) is an injury often missed upon initial presentation. A recent study examined a radiographic screening test in cadavers that showed increased interosseous distance when the interosseous ligament (IOL) was divided. For this test to be clinically useful, it is necessary for uninjured forearms to have similar interosseous spaces. The purpose of this study was to determine the typical differences between right and left interosseous spaces of healthy individuals. METHODS: Anterior-posterior x-rays of bilateral forearms in maximum supination of 28 surgical residents with no history of injury were obtained. These images were uploaded into a picture archiving and communication system and then digitized. The length of the radius was measured (Xr). The maximum interosseous distance (Dmax) between the radius and ulna as well as the interosseous distance at a location 0.3 Xr from the distal radioulnar joint was measured. The right and left arm distances were compared. Also, an outlier analysis was used to evaluate forearm rotational asymmetry between right and left arms. RESULTS: The outlier analysis revealed two sets of forearm x-rays were rotationally different compared to the rest of the group due to asymmetric arm positioning; these data were excluded from the analysis. The average difference in Dmax was 1.7 mm (standard deviation [SD] 1.5) between right and left arms, and this was found at a position of 0.28 Xr on average. The difference in interosseous distance measured at a fixed location 0.3 Xr was 1.6 mm (SD 1.5). No significant difference was found between the paired right and left arms for Dmax or at 0.3 Xr. CONCLUSIONS: There does not appear to be any significant difference between the maximum interosseous distance of right and left arms in healthy individuals. Therefore, analyzing bilateral forearm x-rays may be a simple LRD screening test. CLINICAL RELEVANCE: Understanding the degree of normal variation in the forearm bone spacing might inform evaluation of abnormal forearm bone alignment resulting from LRD.

Midterm outcomes of a short-cemented bipolar radial head arthroplasty, in a cohort of 56 cases with minimum 2-years follow-up.

BACKGROUND: Radial head prostheses are used in comminuted radial head fractures for elbow stabilisation when reduction and internal fixation is not possible. Several implant designs exist, but no large series exist about a short-cemented and bipolar implant. HYPOTHESIS: The hypothesis was that this prosthesis design shows good clinical, functional, and radiological results, with acceptable rate of complications. STUDY DESIGN: This retrospective study included the prostheses with bipolar design and short-cemented stem (Evolutive™), with a minimum 2-years follow-up. MATERIALS AND METHODS: All prosthesis implanted in our Traumatology Center were included, with minimum 2-years follow-up. The evaluation consisted of a clinical and functional evaluation, associated with an independent radiographic assessment. All complications were listed, as long as rate and reasons for implant removal. RESULTS: Fifty-six implants were studied with a mean follow-up of 64.9months (24 to 119). Fifty-three cases were acute injuries with 16% isolated radial head fractures and 76% complex elbow injury such as ulno-humeral, radio-ulnar or longitudinal forearm instability. Fifty (89%) implants were still in place at last follow-up. The main reason for implant removal was during arthrolysis procedure. Ranges of motion were: 126° in flexion, 9° of extension loss, 76° of pronation and 79° of supination. Mean Mayo Elbow Performance Index was 84.1 with 72% of excellent or good results, and the median quick-DASH was rated 18.2. Radiographic evaluation found 12% significant ulno-humeral arthtitis, 64% capitellar osteopenia and 12% loosening. We recorded 5% of implant-related complications. DISCUSSION: The short-cemented stem bipolar radial head prosthesis presents clinical and functional results similar to other radial head prosthesis with low incidence of elbow arthritis, when treating both isolated radial head fracture or complexes elbow injury. This implant should therefore be valid for treating comminuted radial head fractures in all types of traumatological injuries. LEVEL OF EVIDENCE: IV; Retrospective cohort study.

Eponyms for the Description and Classification of Calcaneus Fractures.

There are several eponyms used in the assessment and management of calcaneus fractures. However, the origin of these eponyms is no longer widely known. Named for orthopaedic surgeons who made substantial contributions to the management of calcaneus fractures as well as the field of orthopaedic surgery, understanding the context of how these descriptors were derived helps give context to their use in the present day. The purpose of this review is to provide a historical perspective and comprehensive collection of the most common eponyms related to calcaneus fractures.

To Reconstruct or Not: A Case of Acute Reconstruction of the Forearm Interosseous Membrane with CMC Mini Tight Rope.

Introduction: Essex Lopresti fractures are rare injuries of the forearm. Extent of damage to the interosseous membrane (IOM) in this setting is variable and can lead to disabling sequelae when not recognized and managed appropriately. While chronic reconstruction for longitudinal radioulnar dissociation is well studied, acute reconstruction of the membrane is infrequently documented and surgical techniques vary. There are only five documented cases of acute IOM reconstruction for Essex Lopresti injuries (ELIs). This is the first described case using a mini suture-button construct in conjunction with a radial head replacement and distal radioulnar joint (DRUJ) pinning, while also providing long-term radiographic and functional follow-up of 2 years. Case Report: We present a case of a 40-year-old male who sustained an Essex Lopresti fracture that was acutely recognized and surgically managed with a radial head replacement, DRUJ pinning, and acute reconstruction of the IOM with a Mini TightRope suture button construct. We also provide a post-operative rehabilitation protocol with early range of motion and pin removal. At our final 2-year postoperative follow-up, the patient demonstrated excellent functional outcomes. Conclusion: This case illustrates that a CMC Mini TightRope can be used for acute reconstruction of the IOM in the setting of ELIs which allows for early range of motion and DRUJ pin removal due to the maintenance of longitudinal radioulnar reduction.

Missed Essex-Lopresti Injury-Development of a Combined Proximal and Distal Radio-Ulnar Joint Prosthesis as a Treatment Option and Proof of Concept.

Essex-Lopresti injuries are characterized by injuries to the proximal radio-ulnar joint, the distal radio-ulnar joint, and the interosseous membrane. This can lead to osteoarthritis, impaction syndrome, or instability. If all three structures are injured and lead to instability, the situation is almost unmanageable and many times ends in a one-bone forearm. In this article, we demonstrate a new way to reconstruct the proximal and distal radio-ulnar joint with two patient-specific coupled prostheses. These have been developed with the biomechanical conditions of the forearm in mind, where there are very large forces between the bones. As a result, we are able to present a patient previously severely restricted in the use of his hand and arm via a splint that compressed the forearm, who is now able to perform everyday activities and even light sports, such as badminton, without pain.

Unstable lesions of the forearm: Terminology, evaluative score and synoptic table.

The term "unstable lesions of the forearm" (ULF) was born to more easily describe how a partial or complete instability of the forearm unit might occur due to a traumatic loss of the transverse or longitudinal connection between the radius and ulna. For such an alteration to occur, at least two of the three main osteoligamentous locks (proximal, middle and distal) must be interrupted, often in association with a radial and/or ulnar fracture. Examining the historical patterns (Monteggia, Galeazzi, Essex-Lopresti and criss-cross lesions) and variants described in the literature, out of a total of 586 recorded interventions for forearm trauma, two elbow teams and one wrist team selected 75 cases of ULF. The aim was to describe the instability depending on its clinical and radiographic features, together with the anatomopathological evolution of the lesions based on the time of diagnosis and treatment. The clinical results, evaluated using a new score (FIPS) the Forearm Italian Performance, revealed a correlation between earlier diagnosis and treatment and a better score. The authors suggest a synoptic table that describes 1) the type of instability (proximal transverse, distal transverse, longitudinal and transverse, proximal and distal transverse), 2) classic patterns and variants with characteristic lesions and evolution over time (acute, chronic dynamic, chronic static) and 3) the three forearm constraints and segmental involvement of radius and/or ulna using an alphanumeric classification. Finally, some generic surgical suggestions are proposed.

Minimally Invasive Osteosynthesis of Intraarticular Calcaneus Fracture Augmented by Femoral Head Allograft: A Retrospective Study.

AIM: The aim of this retrospective study is to report the results of minimally invasive osteosynthesis when used for the treatment of intraarticular calcaneus fracture. This old technique is regaining popularity recently with the multiple advances added by different institutes when it is used in the management of intraarticular calcaneus fracture. METHODS: Twenty-four patients who suffered from intraarticular calcaneus fractures between 2014 and 2019 were included. Twelve of them had Sanders II fractures (group A) and 12 had Sanders III + IV fractures (group B). The mean follow-up duration was 37.5 months. The mean age at presentation was 54.23 ± 12.48 years. The skin condition at presentation was poor (blood-filled blisters) in 25% of patients equally distributed between the two groups. The mean time to surgery was 5.6 days where patients with poor skin conditions were treated lately. The technique involved percutaneous ascending proximal-to-distal pinning of the calcaneus after reduction using a 2 cm mini-incision below the lateral malleolus and augmenting the fixation with femoral head cancellous allograft. The primary outcomes variables analyzed in this study are post-operative Bohler angle, post-operative Gissane angle, American Orthopedic Foot and Ankle Society (AOFAS) ankle/hindfoot score at long-term follow-up (Excellent>95, Good 75-94, Fair 51-74, poor 0-50), and the delta angle benefit score. The secondary outcomes included post-operative complications such as infection and osteoarthritis. RESULTS: The radiological results showed significant improvement of Bohler angle from 6.09° ± 21.6 pre-operatively, to 31.79° ± 14.1 postoperatively with a p-value <0.001. An adequate reduction was achieved in 54.16% to 70.8% of patients. There is a trend to normalization of overcorrected fracture especially Sanders II with a mean reduction of 12,71° ± 11,88 at one year post-operatively (p=0.05). AOFAS score at the last follow-up shows 20.83% poor results (AOFAS<50), 50% fair results (AOFAS between 51-74), 16.67% good results (AOFAS 75-94), and 12.5% excellent results (AOFAS>95. The satisfaction rate was 83.3% (45.8% partially satisfied, and 37.5% fully satisfied). The incidence of superficial infection (wound inflammation and pin tract infection) was more prevalent in higher group B (40%) compared to group A (0%) with p=0.014. Other complications including osteoarthritis and varus deformity were found in 95.8% and 58.3% of patients respectively at three-year follow-up. CONCLUSION: The combination of minimally invasive osteosynthesis and femoral head allograft for the treatment of intraarticular calcaneus fractures seems to give fair to good functional results. Radiological data demonstrated that when the Bohler angle is over-reduced >40°, there was a tendency to autocorrection over time. This may be due to progressive depression of the angle over time as weight bearing is authorized; however, this must be analyzed carefully due to the low number of patients who were overreduced (seven patients). Our study demonstrates that this technique has a low early complication rate (especially low infection and soft tissue problems) but carries high long-term complications such as osteoarthritis and hindfoot varus.

Defining acute Essex-Lopresti injuries is problematic and variable: a systematic review.

Purpose: The aim of this study was to systematically review clinical studies on the employed definitions of longitudinal forearm instabilities referred to as Essex-Lopresti (EL) injuries, interosseous membrane (IOM) injuries or longitudinal radioulnar dissociation. Methods: A systematic literature search was performed in MEDLINE, Embase, CINAHL, Web of Science and Cochrane databases, adhering to PRISMA guidelines. All data on diagnosis and treatment were collected. Results: In total, 47 clinical studies involving 266 patients were included. Thirty-nine of 47 studies did not mention an IOM lesion as part of the EL injury. The amount of preoperative positive ulnar variance varied from >1 to >12 mm. Nine studies used some form of dynamic pre-operative or intraoperative test of longitudinal radioulnar instability. Conclusions: There is no accepted definition of EL injury in the literature. In order to prevent underdetection of acute EL injury, a radial head fracture in a patient with wrist and/or forearm pain should raise awareness of the possibility of an EL injury. In this case, comparative radiographic studies and some form of dynamic assessment of longitudinal radioulnar stability should be performed.

[Radial head prosthesis for acute fractures]. / Radiuskopfprothese bei akuten Frakturen ­ wann und welche?

Non-reconstructible radial head fractures with concomitant injuries and resultant instability of the elbow are often treated by implantation of a radial head prosthesis. Various prosthetic designs and implantation techniques are available. Several pitfalls have to be respected during implantation. This article provides tips and tricks for successful implantation and aftercare and gives an overview of long-term outcomes and revision rates.

Acute Essex-Lopresti Syndrome: About a Case of Brachioradialis Tendon Transfer.

Background The classic treatment for acute Essex-Lopresti syndrome is closed reduction percutaneous pinning (CRPP) of the distal radioulnar joint (DRUJ). This work aimed to verify whether it was possible to add a transfer of the brachioradialis tendon to the pinning. Case Description The patient was a 39-year-old right-handed man, climbing instructor, who sustained the Mason II fracture and disjunction of the DRUJ. A transfer of the brachioradialis tendon severed from its muscle attach that was made through a bone tunnel passing through the radius and the neck of the ulna. The clinical and radiological result at the 6-month follow-up was satisfactory. Literature Review and Clinical Relevance Our results in a single case showed that the brachioradialis tendon transfer was useful in acute Essex-Lopresti syndrome.

Elbow Dislocation with Irretrievable Rotating-Rope Injury of the Forearm: Case Report and Literature Review.

BACKGROUND: Simultaneous dislocation of the elbow, radioulnar joint and proximal radius fracture with rotary noose injury to the medial ulna tubercle is extremely rare. An emergency surgery was performed to reduce it. The radial head with the backbone was reset after two hammers were fixed, then the radial capitulum safety was fixed with a locking plate. After the ulnar instability was examined, two Kirschner wires were drilled percutaneously to fix the elbow flexion at 100° under closed reduction, and two Kirschner wires were drilled percutaneously to fix the ulnar joint. Good follow-up results were achieved. To the best of our knowledge, this is the first report on this particular type of injury and on this approach to treating this type of injury. CASE PRESENTATION: We report the case of a 36-year-old male, who extended and landed on his left hand to protect his child in right arm before felling, resulting in severe pain and deformity of his left elbow and wrist and loss of movement in these joints. X-ray examination found proximal distal radioulnar joints, a proximal radial fracture and a dislocation bowstring in the ulna nodule. For a timely diagnosis in an emergency open reduction situation, accurate judgment of this injury is highly important. After 12 months of postoperative follow-up, the patient was symptom-free, and radiographs showed fracture healing. CONCLUSION: We performed emergency reduction and internal fixation of the elbow and successfully saved elbow function, no stability decrease and movement restriction. This case also provides a new reference for the treatment of this type of elbow fracture dislocation.

Combined simple elbow dislocation and forearm joint injuries. A systematic review of the literature with injury patterns and current treatment rationale.

INTRODUCTION: Recent studies have allowed a great improvement in understanding elbow and forearm traumatic injuries. Simple elbow dislocations combined with forearm injuries have been occasionally reported in the literature. The aim of this study was to detect the possible patterns of simple elbow dislocations and forearm fracture-dislocations, providing a classification scheme to guide surgical treatment. MATERIALS AND METHODS: PubMed search was performed to find combination of simple elbow dislocation and forearm joint injury, between 2000 and 2020, including clinical studies and case report. All articles related to pediatric patient or with complex elbow dislocation were excluded. After identification, articles were analyzed for the description of injury patterns reported according to locker-based classification system of forearm joint injuries. RESULTS: Finally, 15 articles were included. Most of the patients sustained high-energy trauma. According to locker-based classification system, simple elbow dislocation was combined with: MRUJ and DRUJ Galeazzi injury (2IR.3), PRUJ and MRUJ injury (1.2I), PRUJ and MRUJ injury with radial shaft fracture (1.2IR), PRUJ and MRUJ injury with ulnar shaft fracture (1.2 IU), PRUJ and MRUJ injury with radial and ulnar shaft fracture (1.2IRU), PRUJ MRUJ DRUJ Essex-Lopresti injury (1.2I.3), and PRUJ MRUJ DRUJ injury with radial shaft fracture (1.2IR.3). Thirteen out of 15 patients undergo surgical treatment. Clinical results were overall favorable. CONCLUSIONS: Simple elbow dislocation combined with forearm joint injury is an uncommon traumatic pattern usually secondary to high-energy trauma. A thorough knowledge of elbow and forearm biomechanics, and classification of anatomical lesion is mandatory for a successful treatment.

Elbow Dislocation With Associated Essex-Lopresti Injury: A Case Treated Conservatively.

A 23-year-old woman suffered a posterior elbow dislocation, distal radius intraarticular fracture, distal radioulnar joint subluxation, and coronoid process fracture, suggesting an Essex-Lopresti injury variant. Closed reduction for the elbow dislocation was performed, and the limb was immobilized at a 90-degree angle with the forearm in a neutral position with a long posterior splint. Three months later complete fracture healing was noted radiologically. One year post-injury full range of motion regarding flexion, pronation, and supination was achieved with only 10 degrees of extension deficit remaining, suggesting a case of Essex-Lopresti injury managed conservatively with excellent results.

Acute Radial Head Resection for Fracture: are We Likely to Miss an Essex-Lopresti Injury?

BACKGROUND: Given the current available evidence, surgical treatment of radial head fracture with acute resection is controversial. The aim of this study was to determine whether acute resection of the radial head for a radial head fracture leads to longitudinal forearm instability due to a missed Essex-Lopresti injury. MATERIAL AND METHODS: A retrospective review was conducted of radial head resections performed for acute radial head fractures at two Level I trauma centers from 2000 to 2018. A total of 11 patients met inclusion criteria. Our primary outcome was a missed Essex-Lopresti injury at time of final clinical follow-up. Long-term telephone follow-up was attempted for QuickDASH, pain scores, and satisfaction scores. RESULTS: Of the 11 radial head fractures in this study, intraoperative radial pull tests were performed and normal in 6 patients. No patient was found to have a missed Essex-Lopresti injury at a mean of 36.2 months' clinical follow-up after radial head resection. At a mean telephone follow-up of 12.6 years in available patients, mean QuickDASH was 3.4, mean satisfaction was 9.75 out of 10, and no further complication or reoperation was reported. CONCLUSION: Our findings challenge the dogma that the radial head cannot be safely excised in the setting of acute fracture, even with elbow instability and/or wrist pain, particularly when intraoperative longitudinal stability is assessed by a stress maneuver.

Results of radial head prostheses implanted during Essex-Lopresti syndrome in multicentric study.

AIMS: The aim was to evaluate the results of radial head prostheses (RHP) in Essex-Lopresti injury (ELI) and to compare results after RHP between acute and chronic ELI. PATIENTS AND METHODS: Thirty-one patients treated with RHP for ELI were selected from a multicenter retrospective series of 310 RHP, with follow-up greater than two years. Two groups were acute ELI group (n=19, average diagnosis = 5+/-9 days) and chronic ELI group (n=12, average diagnosis 8.4+/-7.1 months). RHP was associated in some cases with K-wires: during acute ELI to stabilize the distal radio-ulnar joint (n=4) or during chronic ELI with ulnar osteotomy or palliative surgery (n=4). Clinical and radiologic evaluation was performed including analysis of the complications and revisions rates, pain level, range of motion, and MEPS (Mayo Elbow Performance Score) and DASH score (Disabilities of the Arm, Shoulder and Hand). RESULTS: At last follow-up (71+/-38 months), survival of RHP in the acute ELI group was 84% (16/19) and 92% (11/12) in the chronic ELI group without statistically significant difference. Flexion (acute=131degrees+/-13.4 vs chronic=22+/-12.8, p=0.041) and supination (ELI=71+/-16.8 vs chronic=58+/-17.4; p=0.045) were better in acute ELI group. The DASH score was also better in the acute group (15+/-9.1 versus 24+/-15.2, p=0.048). There was more advanced stage of humero-radial osteoarthritis in the chronic ELI group (0.7+/-0.5 versus 1.4+/-0.6, p=0.041). CONCLUSION: RHP in acute ELIs provide better clinical results, although RHPs are part of the therapeutic arsenal to treat chronic ELI.

Fracture-dislocations of the forearm joint: a systematic review of the literature and a comprehensive locker-based classification system.

BACKGROUND: Monteggia, Galeazzi, and Essex-Lopresti injuries are the most common types of fracture-dislocation of the forearm. Uncommon variants and rare traumatic patterns of forearm fracture-dislocations have sometimes been reported in literature. In this study we systematically review the literature to identify and classify all cases of forearm joint injury pattern according to the forearm joint and three-locker concepts. METHODS: A comprehensive search of the PubMed database was performed based on major pathological conditions involving fracture-dislocation of the forearm. Essex-Lopresti injury, Monteggia and Galeazzi fracture-dislocations, and proximal and/or distal radioulnar joint dislocations were sought. After article retrieval, the types of forearm lesion were classified using the following numerical algorithm: proximal forearm joint 1 [including proximal radioulnar joint (PRUJ) dislocation with or without radial head fractures], middle radioulnar joint 2, if concomitant radial fracture R, if concomitant interosseous membrane rupture I, if concomitant ulnar fracture U, and distal radioulnar joint 3 [including distal radioulnar joint (DRUJ) dislocation with or without distal radial fractures]. RESULTS: Eighty hundred eighty-four articles were identified through PubMed, and after bibliographic research, duplication removal, and study screening, 462 articles were selected. According to exclusion criteria, 44 full-text articles describing atypical forearm fracture-dislocation were included. Three historical reviews were added separately to the process. We detected rare patterns of two-locker injuries, sometimes referred to using improper terms of variant or equivalent types of Monteggia and Galeazzi injuries. Furthermore, we identified a group of three-locker injuries, other than Essex-Lopresti, associated with ulnar and/or radial shaft fracture causing longitudinal instability. In addition to fracture-dislocations commonly referred to using historical eponyms (Monteggia, Galeazzi, and Essex-Lopresti), our classification system, to the best of the authors' knowledge, allowed us to include all types of dislocation and fracture-dislocation of the forearm joint reported in literature. According to this classification, and similarly to that of the elbow, we could distinguish between simple dislocations and complex dislocations (fracture-dislocations) of the forearm joint. CONCLUSIONS: All injury patterns may be previously identified using an alphanumeric code. This might avoid confusion in forearm fracture-dislocations nomenclature and help surgeons with detection of lesions, guiding surgical treatment. LEVEL OF EVIDENCE: V.

Problems of Eponymous Proportions: The History Behind Recognizing Forearm Instability Issues.

Three predictable patterns of forearm fracture-dislocation-Essex-Lopresti, Monteggia, and Galeazzi-can occur and are eponymously labeled for the investigators who appreciated their unique characteristics and offered a framework by which to understand them. Recognition of these injuries and subsequent investigation and increased understanding of these lesions have resulted in improved understanding about forearm anatomy and stability. Management of the component of instability differs based on the type of fracture-dislocation, the timing of intervention, and surgeon preference. Despite advances in understanding and treating these injuries, nuances of these lesions may remain challenging to modern-day surgeons.