Median nerve entrapment during closed reduction of antebrachium fracture in a child.

This is a case report of a four-year-old boy who suffered a forearm fracture managed with closed reduction and casting for six weeks. Postoperatively, the patient showed symptoms of median nerve affection which was misinterpreted as neuropraxia. Ultrasonography of the forearm revealed that the median nerve was trapped in the radius fracture site. The patient underwent a second operation with neurolysis and nerve grafting. This case report highlights the use of ultrasonography in the diagnostics of nerve entrapment neuropathy.

Recurrent Infections After Percutaneous Pinning of a Proximal Radius and Ulna Fracture.

Elbow fractures in the pediatric population are an exceedingly common injury, comprising 5% to 10% of all pediatric fractures, with supracondylar fractures being the most common of the subset. Radial neck fractures are less frequent, comprising only 1% of all pediatric fractures. We provide a case report of a 7-year-old girl with a left radial neck and proximal ulna fracture. A 7-year-old girl presented to the emergency department after falling off a rock wall the day before. Imaging showed a left proximal ulna and proximal radial neck fracture. The patient underwent percutaneous reduction and fixation, complicated by subsequent infection requiring surgical débridement. The patient then developed a recurrent infection 1 year later, requiring repeat irrigation and débridement. The patient has since made a full recovery, returned to activities of daily living, and regained a full range of motion. Radial neck fractures have a low incidence and have been frequently associated with poor outcomes. The main mechanism by which these fractures occur is due to falling on an outstretched arm. Percutaneous pinning is often recommended after unsuccessful attempts at closed reduction because open reduction is often complicated by postoperative stiffness. As with any procedure that involves breaking the skin, there is a risk of infection. However, there is unclear evidence regarding ideal perioperative management to prevent postoperative infection.

Improved forearm rotation even after early conversion to below-elbow cast for non-reduced diaphyseal both-bones forearm fractures in children: a secondary 7.5-year follow up of a randomized trial.

BACKGROUND AND PURPOSE: previous RCT compared short-term results of above-elbow cast (AEC) with early conversion to below-elbow cast (BEC) in children with non-reduced diaphyseal both-bone forearm fractures. After 7 months both groups had comparable function. Our primary aim was to investigate whether forearm rotation improves or worsens over time. Secondary aims were loss of flexion and extension of the elbow and wrist, patient-reported outcomes measures, grip strength ratio, and radiographic assessment. PATIENTS AND METHODS: We performed long-term follow-up (FU) of a previous RCT. All patients were invited again for the long-term FU measurements. Primary outcome was limitation of forearm rotation. Secondary outcomes were loss of flexion and extension of the elbow and wrist compared with the contralateral forearm, the ABILHAND-Kids questionnaire and the Disabilities of the Arm, Shoulder and Hand (DASH) questionnaire, grip strength ratio, and radiographic assessment. RESULTS: The mean FU was 7.5 (4.4-9.6) years. Of the initial 47 children, 38 (81%) participated. Rotation improved in both groups over time, with no significant difference in the final forearm rotation: 8° (SD 22) for the AEC group and 8° (SD 15) for the BEC group with a mean difference of 0° (95% confidence interval -13 to 12). Secondary outcomes showed no statistically significant differences. Finally, children < 9 years almost all have full recovery of function. CONCLUSION: Long-term follow-up showed that loss of forearm rotation after a non-reduced diaphyseal both-bone forearm fracture improved significantly compared with that at 7 months, independent of the initial treatment and children aged < 9 will have almost full recovery of function. This substantiates that the remaining growth behaves like a "friend" at long-term follow-up.

Comparison of buttress plate and cannulated screw in the treatment of anteromedial coronoid fracture with elbow posteromedial rotatory instability.

PURPOSE: The purpose of this study is to compare the effect of buttress plate and cannulated screw in the treatment of anteromedial coronoid fracture with posteromedial rotatory instability (PMRI). METHODS: We retrospectively evaluated patients who were diagnosed with O'Driscoll type 2 fractures combined with elbow posteromedial rotatory instability and underwent surgery for anteromedial coronoid fracture between August 2014 and March 2019. They were divided into buttress plate (n=16) and cannulated screw (n=11) groups. The elbow range of motion, visual analog scale (VAS), Mayo elbow performance score (MEPS), and disabilities of the arm, shoulder, and hand score (DASH) were used for clinical outcome assessment. RESULT: There were no significant differences in clinical outcomes. However, the surgical time was significantly shorter in cannulated screw group (85.45±4.156) compared to the buttress plate group (93.81±8.863, P=0.008), and the surgical time was associated with internal fixation (P=0.008). CONCLUSION: Although there was selection of cases in that small fragments were treated with buttress plate and large fragments with cannulated screw, the buttress plate and cannulated screw have comparable functional outcomes on fixation of the anteromedial coronoid fracture with elbow PMRI. The fixation of the anteromedial coronoid fracture with large fragments using the cannulated screw has a shorter operation time.

Coronoid Fracture Reconstruction with Ipsilateral Olecranon Osteoarticular Autograft in the Acute Setting: A Case Report.

CASE: An 18-year-old male polytrauma patient sustained a high-energy posterior fracture dislocation of his left elbow associated with a comminuted and irreparable O'Driscoll type 2 subtype 3 anteromedial facet coronoid fracture. He underwent early coronoid reconstruction using ipsilateral olecranon osteoarticular autograft with incorporation of the sublime tubercle attachment of the medial collateral ligament and repair of the lateral ulnar collateral ligament. A 3-year follow-up revealed a functional, painless, congruent, and stable elbow. CONCLUSION: Early reconstruction of a highly comminuted coronoid fracture may be a useful salvage option for the polytrauma patient, thereby avoiding complications associated with late reconstruction of posttraumatic elbow instability.

Coronal translation of the forearm, proximal capitate, and ulnar styloid predict radial inclination in distal radius fractures in older female patients.

Aims: The aims of this study were to identify means to quantify coronal plane displacement associated with distal radius fractures (DRFs), and to understand their relationship to radial inclination (RI). Methods: From posteroanterior digital radiographs of healed DRFs in 398 female patients aged 70 years or older, and 32 unfractured control wrists, the relationships of RI, quantifiably, to four linear measurements made perpendicular to reference distal radial shaft (DRS) and ulnar shaft (DUS) axes were analyzed: 1) DRS to radial aspect of ulnar head (DRS-U); 2) DUS to volar-ulnar corner of distal radius (DUS-R); 3) DRS to proximal capitate (DRS-PC); and 4) DRS to DUS (interaxis distance, IAD); and, qualitatively, to the distal ulnar fracture, and its intersection with the DUS axis. Results: In the study (fracture) and control groups, respectively, the mean values were: RI, 17.2° (SD 7.2°; -7° to 35°) and 25.6° (SD 2.6°; 21° to 30°); DRS-U, 13.5 mm (SD 1.7; 4.9 to 20.8) and 15.3 mm (SD 0.72; 13.8 to 16.3); DUS-R, 13.4 mm (SD 2.1; 4.8 to 18.5) and 12.0 mm (SD 0.99; 9.7 to 13.9); DRS-PC (positive value radial to DRS, negative value ulnar), 0.14 mm (SD 5.4; -10.9 to 22.7) and -6.1 mm (SD 1.6; -10.6 to -2.3); and IAD, 25.3 mm (SD 2.5; 17.6 to 31.1) and 27.1 mm (SD 1.5; 24.5 to 31.0). All means were significantly different between the study and control groups. RI correlated strongly with DRS-PC. Ulnar styloid fracture intersection with the DUS axis, reflective of ulnar translation of both radial and ulnar shafts, was associated with significantly lower RI. Conclusion: After DRF, the relationship of the proximal capitate to the DRS axis in the coronal plane correlates with the final radial inclination. Additionally, ulnar styloid intersection with the DUS axis is associated with even lower radial inclination. DRF reduction should seek to restore the normal coronal relationship of both radial and ulnar shafts to their distal counterparts.

[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.

Management of Very Distal Ulna Fractures: A Systematic Review.

OBJECTIVES: To synthesize all-cause complications and reoperations data, and secondary clinical, functional, and radiographic outcomes after the management of very distal ulna fractures (VDUFs) either nonoperatively or operatively. DATA SOURCES: MEDLINE, Embase, and Web of Science were searched for English-language articles from inception to February 17, 2022. STUDY SELECTION: Studies reporting the nonoperative or operative management of VDUFs were eligible for inclusion. VDUFs were defined as either being Q2-Q5 distal ulna fractures using the OTA/AO Comprehensive Classification of Fractures for distal ulna fractures associated with distal radius fractures or being amenable to characterization by the classification system for ulnar head, neck and metaphyseal fractures by Biyani et al. DATA EXTRACTION: Two reviewers independently extracted data from included studies. Study validity was assessed using the methodological index for nonrandomized studies. DATA SYNTHESIS: Seventeen studies (512 VDUFs) were included for analysis. There were 209, 237, and 66 fractures in the nonoperative, open reduction internal fixation (ORIF), and distal ulna resection groups, respectively. Descriptive statistics including weighted mean values, standard deviations, and 95% confidence intervals were calculated. CONCLUSIONS: The treatment of VDUFs with nonoperative management, ORIF, or distal ulna resection may all be acceptable treatment options in specific patient populations. Nonoperative management of VDUFs is a promising treatment strategy even for complex fracture patterns in patients 65 years of age or older. Despite higher reoperation rates, ORIF may be considered for the younger, high-demand patient. Distal ulna resection presents with very favorable functional outcomes in patients 65 years of age or older presenting with a complex VDUF with the lowest reoperation rate across all groups. LEVEL OF EVIDENCE: Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

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.

Distal radius fracture with concomitant ulnar styloid fracture: does distal radioulnar joint stability depend on the location of the ulnar styloid fracture?

INTRODUCTION: Studies are conflicting regarding the relationship between ulnar styloid fracture (USF) location and distal radioulnar joint (DRUJ) instability in patients with distal radius fracture (DRF) and concomitant USF. The objective of this study was to determine the association of USF location with TFCC foveal tear and factors associated with DRUJ instability in patients with both DRF and USF. MATERIALS AND METHODS: Fifty-four patients with both DRF and USF who had wrist MRI examination before surgery were analyzed. USF location (tip or base) and TFCC foveal insertion status (intact, partial tear, or complete tear or avulsion with fractured fragment) were evaluated. DRUJ stability was assessed intra-operatively after fixation of the radius. Factors potentially associated with DRUJ instability, such as age, gender, USF location, USF fragment gap, radioulnar distance, radial shortening, and TFCC foveal tear, were analyzed. RESULTS: Among 54 patients, 37 (69%) and 17 (31%) had USF at the base and the tip, respectively. In patients with base fractures, TFCC foveal insertion was found to be disrupted in 89% (33/37) patients (complete tear in 11 and partial tear in 22) but intact in 11% (4/37). On the contrary, in patients with tip fractures, the insertion was found to be disrupted in 88% (15/17) patients (complete tear in 2 and partial tear in 13) but intact in 12% (2/17). After fixation of the radius, total 52% (28/54) patients showed DRUJ instability. Especially, DRUJ instability was found in 57% (21/37) of ulna styloid process base fracture patients and 41% (7/17) of ulna styloid process tip fracture patients. In univariate analysis, complete tear of TFCC foveal insertion and wider USF fragment distance were associated with DRUJ instability. CONCLUSIONS: Tears of TFCC foveal insertion are common in patients with DRF and concomitant ulnar styloid base fractures. Based on the findings of this study, tear of TFCC foveal insertion seems to be also common in patients with DRF and concomitant ulnar styloid tip fractures. And also, DRUJ instability seems to be associated with a TFCC foveal tear independent of USF location.

Risk Factors for Failure of Closed Forearm Fracture Reduction in the Pediatric Emergency Department.

OBJECTIVES: This study aimed to explore risk factors for failure of forearm fracture closed reduction in the pediatric emergency department (ED) and to suggest indications for initial surgery. METHODS: This retrospective cohort study included all patients aged 0 to 18 years who presented to our pediatric ED with an extraarticular forearm fracture treated with closed reduction between May 2017 and April 2021. We explored risk factors for procedural failure, defined as a need for surgical intervention within 6 weeks of the closed reduction attempt. RESULTS: Of 375 patients (median age 8.1 years, 294 [78.2%] boys), 44 (11.7%) patients sustained a reduction failure, of whom 42 (95.5%) had both radius and ulna fractures. Of the 259 patients with fractures of both bones, the following parameters were independent predictors for reduction failure: refracture (adjusted odds ratio [aOR] 17.6, P < 0.001), open fracture (aOR 10.1, P = 0.007), midshaft fracture (aOR 2.6, P = 0.004), radial translation rate 37% and higher in either plane (aOR 5.1, P = 0.004), and age of 10 years and older (aOR 2.9, P = 0.01). CONCLUSIONS: Most pediatric forearm fractures can be successfully managed by closed reduction in the ED. Two-bone fractures had the strongest association with reduction failure. Refracture, open fracture, midshaft location, initial radius bone translation of 37% and higher (and not initial angulation), and patient age of 10 years and older are independent risk factors for reduction failure in two-bone fractures. We propose a risk score for reduction failure that can serve as a decision-making tool.

Editorial Commentary: In Cases of Concurrent Triangular Fibrocartilage Complex Tears and Ulnar Styloid Process Fracture Nonunions, We May Neither Need to Excise nor Repair the Ulnar Styloid Fracture Nonunion Fragment.

The ulnar-sided wrist contains multiple potential pain generators that may present in isolation. Occasionally, however, wrist trauma results in multiple concurrent and overlapping injuries that make diagnosis and treatment of these conditions challenging. Deep/foveal tears of the triangular fibrocartilage complex (TFCC) may occur in the setting of nonunited ulnar styloid process fractures. Treatment of these injuries has historically included open TFCC repair with fixation or excision of the ulnar styloid fracture nonunion fragment; however, recent literature suggests that addressing the ulnar styloid nonunion fragment may not be as important as we think. Recent research shows that we may not need to excise or repair the ulnar styloid fracture nonunion fragment, which in turn may help preserve the complex ligamentous architecture that stabilizes the ulnar-sided wrist. One thing we know for sure is that foveal tears of the deep fibers of the TFCC, with or without ulnar styloid fracture (Palmer 1B, Atzei class 2 or 3), can produce distal radioulnar joint (DRUJ) instability and wrist dysfunction and should be addressed sooner rather than later to prevent long-term consequences, including DRUJ osteoarthritis. Whether you choose to approach the problem arthroscopically or open, the foveal TFCC tear should be repaired to prevent long-term sequalae.

A Retrospective Analysis from A Single Center Perspective On Complications After Fixing Distal Radius Fracture In Pediatric Population.

Background: The Distal radius fractures in the pediatric age group have similar complications to any other fracture. One interpretation of the high fracture incidence in the distal third of the radius is the relative weakness of the metaphyseal part. Objective: The aim of this study is to provide an evaluation of Surgical complications of distal radius through satisfactory reduction and proper fixation by K-wires through bone growth plates. Methods: A retrospective single-center study in a tertiary hospital in Eastern Saudi Arabia from 2000 to 2021, using the hospital's electronic records system. The Inclusion criteria of this study involve all distal radius fracture cases who underwent surgical fixation by k-wire or plating system and are up to 14 years old. The exclusion criteria include loss of follow-up, incomplete data, and age of more than 14 years. Results: the study included 103 patients. The side of injury was almost equally distributed between the left and right sides. The odds of having at least one complication increase by 2.5 folds if the site of fracture is at the diaphysis. Further, if the distance of the fracture line to the epiphysis is more than 20 mm, the odds of reporting at least one complication post-procedure is 4.4 times higher than if it was at the level of the epiphysis. The majority of diaphyseal fractures required less than 6 weeks for radiological healing, which is significantly different from other sites which were evaluated. Conclusion: Complications of distal radius fracture due to Surgical intervention could be confounded by the complexity of the fracture itself. In our study, we found the distance of the fracture from the physis was inversely proportional to the likelihood of complications. For a comprehensive appreciation of physeal plate, we recommend extended follow-up for those who present with signs of severe distal radius fracture, especially in case of associated ulnar fracture.

Atypical Ulnar Fracture in an Older Woman with Osteoporosis with a Five-Year History of Denosumab Treatment: A Case Report.

Atypical ulnar fracture (AUF) is a rare condition that may occur in patients treated with bisphosphonates. We describe the clinical course of a patient who had an AUF during treatment with denosumab. An 86-year-old woman treated with denosumab for 5 years experienced a complete transverse fracture of the proximal left ulna after falling from a standing height. Intraoperative photographs showed cortical thickening around the fracture site. Therefore, we diagnosed the patient with AUF and performed internal fixation with a locking plate. However, a re-fracture occurred 2.5 months after surgery, which was treated with locking plate replacement with a longer one with a bone graft. One year after the second surgery, the fracture healed. To our knowledge, this is the second case report of an AUF occurring during denosumab treatment. Our case highlights the importance of careful follow-up of patients receiving not only bisphosphonate, but also denosumab. Levels of Evidence: Level V (Therapeutic).

Entrapment of the Ulnar Nerve and Artery Associated with Closed Distal Radius and Ulna Fracture: A Case Report.

CASE: We encountered a case of entrapment of the ulnar nerve and artery associated with displaced distal radius and ulna fracture. After the closed reduction, a patient noted a severe sensory deficit and had claw hand. Intraoperatively, the proximal edge of the fractured radius was positioned in the space between the ulnar artery and the nerve, and the nerve was entrapped. The entrapment was released surgically with a good 1-year outcome. CONCLUSION: In cases of distal radius fracture, there is a possibility of entrapment of the ulnar nerve. When neurological symptoms worsen after the reduction maneuver, early nerve exploration is needed.

Ulna hook plate osteosynthesis for ulna head fracture associated with distal radius fracture.

BACKGROUND: Distal ulna head or neck fracture is commonly associated with distal radius fracture. Treatment of these fractures remains controversial. Plate osteosynthesis is commonly performed. The purpose of this study was to observe clinical and radiological outcomes in ulna hook plate osteosynthesis for distal ulna fracture associated with distal radius fracture. MATERIALS AND METHODS: This retrospective study between 2010 and 2018 included patients presenting combined displaced distal ulna fracture and distal radius fracture who were treated with ulna hook plate osteosynthesis. Patient evaluation included pain measurement with the visual analog scale, wrist range of motion, grip and pinch strengths, Quick Disabilities of the Arm, Shoulder and Hand (Q-DASH) score, and Mayo wrist score. Preoperative radiographs were reviewed to classify the distal ulna fracture according to Biyani. Bone union was evaluated on postoperative X-rays. At final follow-up, the usual radiographic parameters were measured and distal radioulnar joint (DRUJ) osteoarthritis was assessed. RESULTS: A total of 48 patients were included. Mean age was 63 years old and mean follow-up was 28 months. According to the Biyani classification, there were 12 type I, 4 type II, 8 type III, and 24 type IV distal ulna fractures. Wrist flexion was 60°, extension 57°, pronation 85°, and supination 80°. Grip strength was 21 kg (86% of the uninjured opposite side). Pinch strength was 6.6 kg (92% of the uninjured opposite side). Clinical scores were very good to excellent, with a mean Q-DASH of 12 and a Mayo wrist score of 90. Discomfort or pain due to the implant that required implant removal was reported in 29%, and was higher in younger patients. Nonunion was observed in two cases and secondary implant displacement in one case. These three cases required secondary intervention with ulna head resection, which was higher in Biyani type IV. DRUJ osteoarthritis was observed in 12 patients (31%) and was higher in older patients. CONCLUSIONS: Ulna hook plate fixation gives good clinical results and a high rate of fracture union, but complications are common. Implant irritation is a frequent complication, especially in young patients, and often requires implant removal. LEVEL OF EVIDENCE: IV.

Terrible triad injury of the elbow: a historical perspective.

PURPOSE: The aims of this study are to summarize (1) the history of terrible triad injury (TTi) treatment and (2) the clinical and biomechanical data that engendered its evolution. METHODS: A literature search was performed using five electronic databases. Results were discussed as a chronologic review of the relevant literature between 1920 and 2022. RESULTS: In 1962, Osborne was the first to describe a link between elbow dislocation, radial head fracture, and lateral collateral ligament complex injury via a novel mechanism: posterolateral rotatory instability (PLRI). Given that untreated elbow instability leads to post-traumatic osteoarthritis (PTOA), there has been increasing interest in elbow biomechanics since the 1980s. Data from studies in that period revolutionized the approach to elbow instability. The authors demonstrated that TTi could occur via a PLRI mechanism with a disruption of the lateral collateral ulnar ligament and a functionally competent anterior medial collateral ligament (aMCL). Since the 1990s, due to the difficulty in identifying its pathoanatomic features, some began to speculate about a sequence of injuries and mechanisms leading to TTi. However, the clinical literature has largely been unable to reproduce in vitro findings describing the pathomechanics of TTi. Some aspects of treatment remain controversial including systematic coronoid and aMCL repair. CONCLUSION: Despite a growing body of biomechanics data, there is no widely accepted surgical protocol for the treatment of TTi. Functional outcomes among patients have greatly improved. Better diagnosis and treatment of infra-clinical instability after a TTi may be an important stepping stone to prevent the onset of moderate/severe PTOA.

Results of arthroscopically assisted reduction and fixation of anteromedial facet coronoid fractures at short-term follow-up.

BACKGROUND: Varus posteromedial rotatory instability is a typical pattern of elbow injury that involves fracture of the anteromedial facet (AMF) of the coronoid, as well as injuries to the lateral ligament complex and the posterior bundle of the medial collateral ligament. Some authors support the idea that subtype II AMF coronoid fractures require fixation to restore elbow stability, but this topic is still an issue in the literature. The purpose of this study was to assess the clinical and radiologic outcomes of arthroscopically assisted reduction and internal fixation (ARIF) of AMF fractures. METHODS: This retrospective single-center trial evaluated consecutive patients who underwent ARIF of isolated subtype II AMF coronoid fractures between 2014 and 2020. At the final follow-up, the patients were examined for elbow range of motion, stability, and pain. Injury and post-treatment radiographs were reviewed to assess fracture healing and heterotopic ossification. RESULTS: A total of 32 patients (21 male and 11 female patients) with a median age of 47 ± 16 years were included. The average follow-up period was 28 ± 12.4 months. Coronoid process fractures were fixed by cannulated screws in 26 cases (81.25%); in 2 of these cases, additional Kirschner wires were used. Two Kirschner wires were used in 1 case (3.12%), and in the remaining 5 cases (15.62%), osteosuture was used. The lateral ulnar collateral ligament was injured in 27 cases (84.4%) and was always repaired. Other associated lesions were medial collateral ligament injury, osteochondral lesion, and radial head fracture. There were no surgical complications. At the final follow-up, the average Mayo Elbow Performance Score was 98.4 ± 2.7 and the mean Oxford Elbow Score was 47.3 ± 1.4. No cases of nonunion were detected on radiographic assessment. CONCLUSIONS: Although technically demanding, ARIF has several potential advantages in comparison to open surgery: less scarring, a decreased risk of infection, and less postoperative pain.

Outcomes After Operative Treatment of Pediatric Monteggia Fracture-Dislocations: Comparison Between Open and Closed Injuries.

BACKGROUND: Open pediatric Monteggia fracture-dislocations are a relatively uncommon injury pattern, with limited numbers reported in previous series. Open fracture-dislocations frequently represent more severe injury patterns with potential for contamination. We aim to determine differences in long-term clinical and functional outcomes in the operative management of closed versus open pediatric Monteggia fracture-dislocations. METHODS: A retrospective review of operatively treated pediatric Monteggia fracture-dislocations was performed. Closed versus open injuries were compared in both clinical outcomes, as well as patient-reported outcomes through Quick Disabilities of the Arm, Shoulder, and Hand (QuickDASH) questionnaire. RESULTS: Of 30 operatively treated injuries, 12/30 (40%) were open fracture-dislocations. Patients were followed clinically for an average of 15.65 months in open injuries and an average of 4.61 months in closed injuries. A trend toward increased time to union was observed, however, significance was not achieved; open injuries averaged 8.0 versus 5.8 weeks for closed injuries ( P =0.07). Two patients (11%) in the closed fracture group experienced postoperative complications; both were minor. Five patients (42%) in the open fracture-dislocation group experienced a total of 6 postoperative complications; 5 of the 6 complications were major. QuickDASH scores were obtained at an average of 5 years postoperatively; mean QuickDASH scores were higher in the open fracture group, 13.1, compared with the closed fracture group, 5.9 ( P =0.038). Increased QuickDASH scores were independently associated with presence of postoperative complications. QuickDASH score could be expected to increase by 12.5 points in those with major complications ( P =0.044). CONCLUSION: We present the largest single cohort of pediatric open Monteggia fracture-dislocation injuries to date. These injuries are predictive of poorer outcomes including trend toward increased time to union, increased risk of major complication, and can independently predict worse long-term patient-reported functional outcomes. LEVEL OF EVIDENCE: Level III-these data represent a retrospective comparative study of clinical and functional outcomes.