What Factors Are Associated with Reoperation After Operative Treatment of Terrible Triad Injuries?

BACKGROUND: Terrible triad injuries of the elbow, consisting of posterior ulnohumeral joint dislocation with associated fractures of the radial head and coronoid process, are challenging injuries due to the difficulty in restoring stability to the joint surgically while also attempting to allow early ROM to prevent stiffness. Furthermore, complications are both debilitating and relatively common, frequently requiring reoperation. QUESTIONS/PURPOSES: (1) What patient-, injury-, or surgery-related factors are associated with reoperation after surgical treatment of terrible triad injuries of the elbow? (2) What are the most common causes of reoperation after these injuries? METHODS: Between January 2000 and June 2017, we identified 114 patients who had surgery for terrible triad injuries at two tertiary-care referral centers. Of those, 40% (46 of 114) were lost to follow-up before 1 year, and an additional 5% (6 of 114) were excluded because they underwent the index surgery at an outside institution (n = 4) or underwent closed reduction with or without percutaneous pinning (n = 2). That left 62 patients for analysis in this retrospective study with a minimum of 1-year follow-up (median 22 months; range 12 to 65) or who met the endpoint of reoperation before 1 year. During the study period, indications for surgical treatment of terrible triad injuries of the elbow included joint incongruity or instability precluding early ROM. In our study cohort, 45% (28 of 62) underwent reoperation. Indications for reoperation after surgical treatment included stiffness that interfered with activities of daily life, symptomatic prominent hardware, ulnar neuropathy, instability of the elbow joint at rest or with range of motion, and infection. Patient-related (such as age, sex, race), injury-related (for example, ipsilateral extremity fracture, open fracture), and surgery-related factors (for instance, time to surgery, radial head treatment) as well as outcomes were collected by the treating surgeon at the time of follow-up and ascertained using chart review. The primary outcome measure was reoperation after surgical treatment of a terrible triad injury of the elbow. Bivariate analysis was used to assess whether explanatory variables were associated with reoperation after surgical treatment of terrible triad injuries of the elbow. RESULTS: Of the patient-, injury-, and surgery-related factors that were analyzed, only radial head treatment was associated with an increased reoperation risk (p = 0.03). No other variable met criteria for inclusion in our multivariable logistic regression model (p < 0.10), and therefore, a multivariable logistic regression model was not performed. The most common indication for reoperation was stiffness (21% [13 of 62 patients]), followed by symptomatic hardware (18% [11 of 62 patients]), nerve symptoms (ulnar neuropathy 16% [10 of 62 patients] and incisional neuroma 2% [1 of 62 patients]), instability (6% [4 of 62 patients]), and wound problems (infection 2% [1 of 62 patients]). CONCLUSION: The reoperation risk after surgical treatment of terrible triad injuries of the elbow is high. No patient- or injury-related factors were associated with the reoperation risk. Based on our finding, we recommend fixation of radial head fractures in these injuries when feasible and compatible with early postoperative motion, and we suggest the use of radial head excision or arthroplasty as a secondary options. LEVEL OF EVIDENCE: Level III, therapeutic study.

Acute Distal Radioulnar Joint Instability: Evaluation and Treatment.

This article reviews the anatomy and mechanics of pronation and supination (axial rotation) of the forearm through the distal radioulnar joint (DRUJ), and the proximal radioulnar joint (PRUJ). Injuries to the bones and/or ligaments of the forearm, wrist, or elbow can result in instability, pain, and limited rotation. Acute dislocations of the DRUJ commonly occur along with a fracture to the distal radius, radial metadiaphysis, or radial head. These injuries are all caused by high-energy trauma. Outcomes are predicated on anatomic reduction and restoration of stability to the DRUJ and PRUJ with or without ligamentous repair or reconstruction.

Complex Monteggia Fractures in the Adult Cohort: Injury and Management.

Monteggia fractures involve proximal ulna fracture associated with a radiocapitellar joint dislocation. The Bado classification is primarily based on the direction of the radial head dislocation. The Jupiter subtype classification of Bado II fractures further characterizes the severity of proximal ulna comminution and the involvement of the coronoid fragment. This latter classification can better prognosticate the challenges of surgical reconstruction and clinical outcomes. Surgery for all adult Monteggia fractures is required to restore the anatomic alignment of the ulna, which indirectly reduces the radiocapitellar joint. The complexity of the injury is considerably increased by comminution of the proximal ulna, the degree of radial head fragmentation, the reduction of the radial head, and ulnohumeral instability. Anatomic reduction is considered critical to achieving a favorable outcome.

The ideal implant for Mayo 2A olecranon fractures? An economic evaluation.

BACKGROUND: The ideal implant for stable, noncomminuted olecranon fractures is controversial. Tension band wiring (TBW) is associated with lower cost but higher implant removal rates.On the other hand, plate fixation (PF) is purported to be biomechanically superior, with lower failure and implant removal rates, although associated with higher cost. The primary aim of this study is to look at the clinical outcomes for all Mayo 2A olecranon between PF and TBW. The secondary aim is to perform an economic evaluation of PF vs. TBW. MATERIALS AND METHODS: This is a retrospective study of all surgically treated Mayo 2A olecranon fractures in a tertiary hospital from 2005-2016. Demographic data, medical history, range of motion, and complications were collected. All inpatient and outpatient costs in a 1-year period postsurgery including the index surgical procedure were collected via the hospital administrative cost database (normalized to 2014). RESULTS: A total of 147 cases were identified (94 TBW, 53 PF). PF was associated with higher mean age (P < .01), higher American Society of Anesthesiologists score (P < .01), and higher proportion of hypertensives (P = .04). There was no difference in the range of motion achieved at 1 year for both groups. In terms of complications, TBW was associated with more symptomatic hardware (21.6% vs. 13.7%, P = .24) and implant failures (16.5% vs. none, P < .01), whereas the plate group had a higher wound complication (5.9% vs. none, P = .02) and infection rate (9.8% vs. 3.1%, P = .09). TBW had a higher implant removal rate of 30.9% compared with 22.7% for PF (P = .36). PF had a higher cost at all time points, from the index surgery ($10,313.64 vs. $5896.36, P < .01), 1-year cost excluding index surgery ($5069.61 vs. $3850.46, P = .46), and outpatient cost ($1667.80 vs. $1613.49, P = .27). DISCUSSION AND CONCLUSION: Based on our study results, we have demonstrated that TBW is the ideal implant for Mayo 2A olecranon fractures from both a clinical and economic standpoint, with comparable clinical results, potentially similar implant removal rates as PF's, and a lower cost over a 1-year period. In choosing the ideal implant, the surgeon must take into account, first, the local TBW and PF removal rate, which can vary significantly because of the patient's profile and beliefs, and second, the PF implant cost.

Functional outcomes after treatments for different types of isolated ulnar coronoid fracture: A protocol for systematic review.

BACKGROUND: Optimal treatments for ulnar coronoid fracture have yet to be determined. We aimed to systematically review treatment efficacy assessed by functional outcomes of patients with isolated ulnar coronoid fracture. METHODS: Medline, Cochrane Library, EMBASE, and Google Scholar were searched for studies reporting quantitative outcomes data after surgical treatment for isolated ulnar coronoid fractures up to July 16, 2019. Functional outcomes determined using disabilities of the arm, shoulder and hand score; Mayo elbow performance score (MEPS); and range of motion were systematically reviewed. RESULTS: Six studies with a total of 65 patients with isolated coronoid fracture who had received surgical treatment were included. All studies were of good quality according to a modified Delphi checklist. Most patients had Type II fractures based on Regan-Morrey or O'Driscoll classification. Disabilities of the arm, shoulder and hand scores were reported by 2 studies (mean range 5-17). Four studies reported MEPS (mean range 89-98). One study reported Broberg-Morrey scores, in which 93% patients achieved excellent or good outcomes. Five studies reported range of motion, with mean flexion ranging from 122 to 137 and mean extension ranging from 4.0 to 21 degrees. Quantitative analyses revealed that lateral, medial, or posterior approaches in treating Type II fractures are associated with higher postoperative MEPS and flexion scores than the anteromedial approach. CONCLUSIONS: Treatment efficacy assessed by functional outcomes for isolated ulnar coronoid fractures is overall satisfactory. Whether lateral, medial, or posterior approaches lead to more favorable outcomes than the anteromedial approach is inconclusive. Further prospective studies are warranted.

Association between bone mineral density and ulnar styloid fracture in older Japanese adults with low-energy distal radius fracture.

We investigated the association of the ulnar styloid fracture (USF) with the bone mineral status and fractured radial displacement in elderly patients. The presence of USF correlates with decreased BMD and severe displacement of the radius. These findings are helpful in treating osteoporosis to prevent subsequent fragility fracture. PURPOSE: The pathogenesis of ulnar styloid fracture (USF), which often occurs with distal radius fracture (DRF), is unclear. This study aimed to investigate whether USF concomitant with low-energy DRF was associated with the bone mineral status and the degree of radiographically observed pretreatment radius displacement in Japanese adults above 50 years of age. METHODS: The study subjects were 45 (44 female, 1 male) consecutive patients aged > 50 years with DRF caused by falls from June 2015 to May 2016. Fractures due to high-energy injuries were excluded. Patients were divided into two groups according to the presence or absence of USF. Radius displacement was assessed on anteroposterior and lateral radiographs by measuring ulnar variance, radial inclination, and volar tilt at initial examination before manual reduction of the bone. Bone mineral density (BMD) of the lumbar spine, femoral neck, and distal radius was also measured by dual-energy X-ray absorptiometry within 1 week of injury. RESULTS: Significant differences in the BMD values of femoral neck, ulnar variance, radial inclination, and volar tilt were found between patients with USF and those without USF (all comparisons, p < 0.05). Logistic regression analysis of all subject data identified that volar tilt was significantly associated with the presence of USF (p = 0.048). CONCLUSIONS: The presence of USF in low-energy DRF correlates with the decreased BMD of femoral neck and severe displacement of radius in elderly patients. These findings are helpful for the treatment of osteoporosis to prevent subsequent fragility fracture.

Volar locking plate fixation of distal radius fractures: Isokinetic assessment of the influence of an ulnar styloid process fracture on pronation-supination strength.

Although distal radius fractures (DRF) are frequent, the management of associated ulnar styloid process (USP) lesions is still controversial. According to recent studies, a fracture of the USP does not appear to affect functional outcomes after treatment of a DRF with plate fixation. We sought to compare the impact of a USP fracture on pronation and supination strength in isometric and isokinetic tests. We included patients with a DRF who underwent volar locking plate fixation. We divided our population into three groups: one group consisted of patients who had a fracture of the USP base, one group composed of patients without USP fracture or with a distal ulnar fracture only, and a control group composed of subjects with normal wrists. Inclusion criteria included an age of 18 to 50 years and a minimum follow-up of 10 months post-surgery. The main exclusion criteria were complex intraarticular fractures and postoperative complications. The assessment was based on clinical examination and recording of forearm rotation strength during pronation and supination in isokinetic and isometric tests. The ratio between the operated and contralateral sides was compared for each patient. Thirty-six participants were included (mean age 31.1±4.5 years). The mean postoperative follow-up was 17.9±6.9 months. Participants with a USP fracture differed from other participants in their peak torque on the isokinetic test at 45°/s for pronation and supination, but not on isokinetic tests at 120°/s or in isometric tests. Isokinetic tests revealed a decrease in pronation-supination strength during sustained effort for patients with associated basal USP fractures. These findings may have clinical implications for management of the USP but need to be specified with further study. LEVEL OF EVIDENCE: prognostic study level III.

Serious games therapy associated with conventional physical therapy intervention accelerated hand muscles strengthening and hand functioning after complex fracture of the wrist: A case report.

STUDY DESIGN: Case report. INTRODUCTION: A severe wrist fracture can cause permanent physical disabilities and deformities, leading to limit patients in their occupation and social environment. PURPOSE OF THE STUDY: We aim at presenting a treatment protocol and the functional outcome of a patient with severe clinical state after a rare wrist fracture. METHODS: We provided physical therapy intervention associated with serious games for muscle strengthening. RESULTS AND DISCUSSION: There was an increase in strengthening and a decrease in Disability of the Arm, Shoulder and Hand score and Patient Rated Wrist Evaluation scores. The International Classification of Functioning scores have changed from severe to light or to absent in many of the domains. CONCLUSION: The use of serious games combined with a conventional physical therapy intervention played a fundamental role in recovery and return to work activities, and there was also an important recovery of general health condition.

Unusual Forearm Deformity Solved by 3D Custom Made Guides.

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

Instability of the proximal radioulnar joint in Monteggia fractures-an experimental study.

BACKGROUND: A Monteggia fracture is defined as a fracture of the proximal ulna combined with a luxation of the radial head. The aim of the present work is to evaluate the extent of instability of the radius head in the proximal radioulnar joint (PRUJ) as a function of the severity of elbow fracture and ligamentous injury in an experimental biomechanical approach. METHODS: Eight fresh-frozen cadaver arms were used. All soft tissues were removed except for the ligamentous structures of the PRUJ and forearm. A tensile force of 40 N was exerted laterally, anteriorly or posteriorly onto the proximal radius. The dislocation in the PRUJ was photometrically recorded and measured by two independent examiners. After manual dissection of the ligamentous structures up to the interosseous membrane, the instability was documented and subsequently measured. The following dissection levels were differentiated: intact ligamentous structures, dissection of annular ligament, oblique cord and proximal third of interosseous membrane. RESULTS: An anterior instability remains relatively constant until the proximal third of the interosseous membrane is dissected. The radial head already dislocates relevantly in the posterior direction after dissection of the annular ligament with an additional considerable stability anteriorly and laterally. Subsequently, the posterior instability increases less pronouncedly in regard of distal resected structures. The lateral instability increases constantly during the progressing resection of the ligamentous structures. CONCLUSION: On the one hand, a complete healing of the ligament injury after functional treatment is hardly conceivable with ligamentary damage up to the level of the proximal interosseous membrane. A remaining instability of the proximal radius could therefore be a possible cause for the unsatisfactory clinical results after certain Monteggia fractures. On the other hand, the present study may give a possible explanation (i.e. early dorsal radius head dislocation after dissection of annular ligament) why the Bado II injury is the most frequent type of Monteggia fractures.

Buttress plate fixation of coronoid process fractures via a medial approach.

PURPOSE: To assess the clinical and radiographic outcomes of coronoid process fractures surgically managed with buttress plate fixation via a medial approach. METHODS: A retrospective review of all coronoid fractures surgically fixed in our institution using a buttress plate technique via a medial approach between June 2012 and April 2015 by the senior author was performed. These fractures were all sizeable fractures contributing to persistent elbow instability in terrible triad or varus posteromedial rotatory instability injury patterns. A prospective telephone questionnaire was conducted to assess patient outcomes using the disabilities of the arm, shoulder and hand (DASH) score and Mayo hlbow performance score (MEPS). RESULTS: Twelve patients were included in the study, comprising 10 males and 2 females with an average age of 39 years (range, 19-72 years). Mean follow-up was 16 months (range, 4-18 months). The average time to radiographic union was 4 months (range, 3-7 months). Range of motion measurements at final follow-up were obtained in 11 out of 12 patients, with one patient defaulting follow-up. All 11 patients displayed a functional elbow range of motion of at least 30°-130°, with an average arc of motion of 130° (range, 110° -140°), mean elbow flexion of 134° (range, 110° -140°) and mean flexion contracture of 3° (range, 0° -20°). The mean DASH score was 16 (range, 2.5-43.8) and the mean MEPS was 75 (range, 65-100). Complications observed included one patient with a superficial wound infection which resolved with a course of oral antibiotics and one patient with radiographic evidence of heterotopic ossification which was conservatively managed. No residual elbow instability was observed and no reoperations were performed. CONCLUSION: Buttress plate fixation via a medial approach of coronoid process fractures that contribute to persistent elbow instability represents a reliable method of treatment that produces satisfactory and predictable outcomes.

Coronal shear fracture of distal humerus associated with olecranon fracture: A case report and pathomechanism.

Distal humeral coronal shear fractures are rare and account for around 1% of all fractures at the elbow level and 6% of the distal humeral fractures. Many studies have reported on the associated injuries involving the lateral collateral ligament injuries and radial head fractures in up to 40% and 30% of humeral fractures, but this combination of coronal shear fracture of the trochlea and capitellum associated with olecranon fracture is unusual. Here, we report two cases of distal humerus coronal shear fracture with olecranon fracture treated surgically and establish and discuss the pathomechanisms, diagnosis, and therapeutic issues relating to this fracture.

Direct anterior approach for mini plate fixation of Regan-Morrey type II comminuted ulnar coronoid process fracture.

BACKGROUND: The goal of this study was to evaluate the clinical effect of Regan-Morrey type II comminuted coronoid process fracture treated with mini plate through the direct anterior approach (DAA). METHODS: Ten patients who underwent open reduction and internal fixation (ORIF) with mini plate through the DAA between February 2013 and August 2016 was included. There were three women and seven men, with an average age of 34.4 ± 7.5 years. At the final follow-up, the Mayo Elbow Performance Index (MEPS), Visual Analogue Scale (VAS) score, Disability of the Arm, Shoulder, and Hand (DASH) score, and the elbow range of motion were noted. RESULTS: The mean follow-up was 26.3 ± 2.2 (range 24-31) months. The mean elbow arc of motion was 118.5° with a mean arc of extension of 4° ± 5.2° and flexion of 122.5° ± 7.2°.The mean forearm pronation was 72° ± 7.2°, and the mean supination was 68° ± 6.3° with a mean forearm rotation arc of 140°. The average postoperative score according to the MEPS was 91 ± 5.7 points (range 80-100 points), and all patients achieved satisfactory scores (8 excellent and 2 good). The final average VAS score was 0.6 ± 1 (range 0-3). The final average DASH score was 4.0 ± 1.6 (range 2.3-7.4). None of the patients complained about elbow instability that required secondary surgery. No complications of infection, joint incongruency, fracture nonunion, median nerve palsy, or implant failure were reported. CONCLUSIONS: ORIF with mini plate through the DAA for the treatment of the type II comminuted coronoid process fractures can achieve satisfactory outcomes.

Effect of Elbow Position on Load to Failure in Olecranon Fracture Fixation: A Biomechanical Cadaveric Study.

OBJECTIVES: This study evaluates if relative flexion or extension of the ulnohumeral joint affects the strength of repair in olecranon fractures treated with a precontoured locking plate. METHODS: A cadaveric study was performed in matched pair cadaveric elbows. All soft tissue was dissected from the radius, ulna, and elbow of each specimen, leaving interosseous ligaments and joint capsules intact. Soft tissue from the humerus was dissected away, leaving only the triceps tendon and ulnar insertions intact. An oblique proximal to distal olecranon osteotomy was created in each specimen 1 cm from the tip of the olecranon. Internal fixation with standard precontoured locking plates and a Krackow augmentation suture with #2 FiberWire followed. Specimens were randomized to elbow position of 90 or 20 degrees° and loaded to failure via axial pull through the triceps. Load at failure, displacement at the time of failure, peak load, stiffness, and mechanism of failure was recorded and compared. The study was repeated a second time with the osteotomy more proximal, 0.6 cm creating a smaller fragment with less opportunities for locking screw fixation. This small fragment group was then tested as the large fragment group had. RESULTS: There were no significant differences in load at failure, peak load, or stiffness between the elbow position in the large fragment group. Displacement at time of failure was significantly different, although not clinically relevant. Failure of fixation in this group was a mix of triceps avulsion and failure through fracture site. The smaller fragment group with less points of fixation demonstrated no statistically significant differences in any parameters. A majority of the failures were at the fracture site. CONCLUSIONS: Ulnohumeral position does not significantly affect overall construct strength even in olecranon fractures with small proximal fragments with limited points of fixation.

Use of Mother-Child Screws in the Treatment of Coronoid Fractures in Terrible Triad Injury of the Elbow.

PURPOSE OF THE STUDY This study aims to analyze the clinical and radiographic outcomes of a consecutive series of 18 patients with terrible triad injury. The coronoid fractures of these patients were repaired using Mother-Child screw (MCS). MATERIAL AND METHODS Twelve men and six women (mean age: 47.2 years) with terrible triad injury of the elbow were followed up for a mean of 17.6 months (range: 13-42 months). Surgical treatment consisted of open reduction and internal fixation of coronoid fractures with MCS, radial head fracture with MCS (Mason type II, n = 10), or mini-plate (Mason type III, n = 3). Furthermore, all underwent lateral collateral ligament repair (n = 9, 100%), and in cases of persistent instability, medial collateral ligament repair was performed (n = 3, 33%). RESULTS At last follow-up, average arc of ulnohumeral motion was 130° (range: 65° to 150°), average arc of forearm rotation was 148° (range: 100°-160°), mean Disabilities of the Arm, Shoulder and Hand (DASH) score was 7.1 (range: 0-28.5), and mean Mayo Elbow Performance Score (MEPS) was 92 (range: 70-100). According to the Mayo Elbow Performance Index (MEPI), 10 patients were excellent in, seven patients were good, and one patient was fair. All patients had a stable elbow. No secondary coronoid fragment dislocation or implant failures was reported. Fracture healing was observed in all patients. CONCLUSIONS This study shows that coronoid fracture treatment with MCS may be a new, effective and easy therapeutic option in terrible triad injury. Key words:terrible triad of the elbow, coronoid process, radial head, functional outcome.

Rates of neurovascular injury, compartment syndrome, and early infection in operatively treated civilian ballistic forearm fractures.

PURPOSE: The purpose of this study is to evaluate the incidence of neurovascular injuries, compartment syndrome, early postoperative infection as well as the injury factors predictive of neurovascular injury following ballistic fractures of the radius and ulna. METHODS: A retrospective review was performed to identify all ballistic fractures of the radius and ulna in skeletally mature patients over a 5-year period at a single level-1 trauma center. Chart and radiographic review was performed to identify patient and injury demographics, associated neurologic or vascular injuries, and fracture characteristics. Fracture location was measured on computerized imaging software and fractures were grouped into bone(s) segments involved. Proximal, mid-diaphyseal, and distal locations were used for statistical analysis. RESULTS: Fifty-six extremities in fifty-five patients were identified (mean age 32 years; male to female ratio 9:1). Overall incidence of neurologic injury was 50%, arterial injury 32%, and compartment syndrome 7.1%. Presence of a proximal third forearm fracture was associated with an increased risk for neurologic injury (p < 0.01), with an odds ratio of 5.7 (95% confidence interval, 1.7-18.4). Furthermore, all high velocity/energy ballistic injuries had associated neurologic injuries (p = 0.02). CONCLUSION: Ballistic forearm fractures result in high rates of neurovascular injury. Fractures caused by high velocity/energy firearms have extremely high rates of neurologic injury when compared with low velocity ballistic injuries. Ballistic fractures involving the proximal third of the radius or ulna are five times more likely to be associated with neurologic injury after a ballistic injury and should be assessed carefully on initial evaluation.

In Vivo Three-Dimensional Analysis of Malunited Forearm Diaphyseal Fractures with Forearm Rotational Restriction.

BACKGROUND: The aim of this study was to clarify the mechanisms of rotational restriction in malunited forearm diaphyseal fractures. METHODS: We retrospectively analyzed the cases of 18 patients with malunited forearm diaphyseal fractures and rotational restriction. All patients underwent bilateral computed tomography (CT) of the forearm in maximum supination, pronation, and neutral positions. From these images, we created 3-dimensional (3-D) bone surface models. We quantified the 3-D deformities, identified instances of osseous impingement between the radius and the ulna during forearm rotation, calculated the path length of the central band (CB) of the interosseous membrane, and measured forearm range of motion. RESULTS: Sixteen patients had extension deformity of the radius (the RE group) and 2 had flexion deformity (the RF group). In the RE group, extension deformity of the radius and valgus deformity of the ulna had significant negative correlation with pronation range of motion (R = -0.50, p = 0.046) and supination range of motion (R = -0.63, p = 0.027), respectively. Osseous impingement was mainly observed during pronation (15 of 16 patients). The CB path with the largest changes in length originated from the distal CB attachment area of the radius and ran toward the proximal area of the ulna (the transverse CB). The transverse CB significantly increased in length in supination compared with that in pronation (p < 0.001). Therefore, tightness of the transverse CB appeared to cause supination restriction in the RE group. In the RF group, osseous impingement caused supination restriction. The greatest increases in the transverse CB length were observed in pronation in the RF group, which appeared to cause pronation restriction. CONCLUSIONS: In the RE group, pronation restriction was associated with osseous impingement that was due to extension deformity of the radius, and supination restriction was associated with CB tightness that was due to valgus deformity of the ulna. In the RF group, our results suggested that pronation restriction was caused by CB tightness and that supination restriction was caused by osseous impingement. CLINICAL RELEVANCE: Three-dimensional corrective osteotomy for extension deformity of the radius in malunited forearm diaphyseal fractures would improve rotational restriction by relieving osseous impingement during pronation and CB tightness during supination.

Treatment of posttraumatic bone defects of the forearm with vascularized fibular grafts. Follow up after fourteen years.

BACKGROUND: Among several techniques proposed for the reconstruction of posttraumatic bone defects of the forearm, that of free vascularised fibular graft (FVFG) is one of the most widely used. PATIENTS AND METHOD: We study the long-term outcomes of 14 patients who underwent FVFG between 1994 and 2009, with a minimum follow up of 8 years and a maximum of 23 years (mean: 13.9 years). Demographic, clinical and radiological variables were collected retrospectively. The DASH scale was used for clinical assessment. RESULTS: Fourteen patients were operated on by the same surgeon, applying FVFG for the reconstruction of posttraumatic bone defects of the forearm (three septic non-union of the ulna or radius, five radius fractures, two ulna fractures and four fractures of both bones). The maximum length of the defect was 11 cm and the minimum length was 6 cm. In four cases, reconstruction of the two bones was achieved using the double barrel technique, and in another four cases, an osteoseptocutaneous flap was used. Fixation was performed with 3.5 mm reconstruction plates in thirteen cases and with 3.5 mm screws in one case. Consolidation was obtained in 12 cases (85.7%) after an average time of 4.2 months (range: 2-6.5 months). In one case, consolidation of the proximal ulnar fracture site was not achieved, and in another, following the failure of reconstruction attempts, an arthrodesis was performed. At the end of the follow-up period, the patients had an average DASH score of 17.1 points (range 1.8-68.1). CONCLUSIONS: FVFG is a valid option for the reconstruction of posttraumatic bone defects of the forearm. Its use via the double barrel method or as an osteocutaneous composite graft enables the simultaneous reconstruction of both forearm bones and associated soft tissue injuries. Long-term follow-up of patients who have undergone this technique confirms its satisfactory functional and radiological results.

The impact of varus angulation on proximal fractures of the ulna.

BACKGROUND: We studied anteromedial varus angulation (VA) in the proximal third of the ulna. The importance of restoration of the anatomical orientation of the ulnar after a proximal fracture is unclear. The purpose of this study was to evaluate the impact of minimal proximal ulna malunion on elbow function after a proximal ulna fracture. METHODS: We reviewed the follow-up of 60 patients who had undergone open reduction with internal fixation (ORIF) of a proximal fracture of the ulna. Patients were divided into two groups, defined as either more or less than 5° of the difference between the VA of the fractured and contralateral ulna. The range of motion(ROM)of elbow flexion, extension and forearm rotation on both sides, Mayo Elbow Performance Score (MEPS) and Visual Analogue Scale (VAS) were measured. RESULTS: The average postoperative time was 3.1 years (1-5 years). Mean VA of the fractured arm was different from the normal side (7.8 ± 3.0 vs 12.7 ± 3.0). Compared to the unfractured arm there was a loss in mean elbow flexion (14.2 ± 4.9 vs 18.0 ± 5.9), extension ROM (7.1 ± 2.5 vs 9.3 ± 1.9, p < 0.05) and forearm rotation ROM (15.6 ± 8.6 vs 21.8 ± 9.5) that were statistically significant (p < 0.05). There were no statistically significant differences in the MEPS and VAS score results between the two groups (p > 0.05). CONCLUSIONS: The function of the elbow and forearm was restricted after VA malunion in the proximal ulna, but the quality of life of these patients had not been significantly affected. We suggest that orthopedic surgeons should assess whether the specialized structures of the proximal ulna are damaged or not before surgery. If the anatomy of the fractured bone cannot be restored through manipulation of the connected end directly, it is better to image the anatomical structure of the healthy side from using an elbow X-ray before surgery, and then reset using a pre-shaped plate to prevent malunion.

Ulnar Styloid Base Fractures Cause Distal Radioulnar Joint Instability in a Cadaveric Model.

BACKGROUND: The deep portion of the distal radioulnar ligaments (DRUL) inserts on the ulnar fovea and is the most important stabilizer of the distal radioulnar joint (DRUJ). Ulnar styloid base fractures that include the ulnar fovea may cause DRUJ instability. METHODS: DRUJ stability in pronosupination was evaluated in 12 fresh-frozen upper extremities (4 female) aged 52 to 68 years (mean: 58.8 years) using a custom fixture, which allowed free rotation of the radius around the fixed ulna. Optical motion capture was used to record rotation of the radius with respect to the ulna. Each specimen was subjected to 3 N m of torque in both supination and pronation under 4 conditions: intact, ulnar styloid osteotomy with disruption of the foveal insertion of the DRUL, ulnar styloid fixation, and DRUL transection. Group differences were compared using a 1-way repeated-measures analysis of variance and Tukey multiple comparison post hoc tests. RESULTS: When compared with the intact condition, both ulnar styloid osteotomy and DRUL transection significantly increased mean pronation (by 9.40° and 15.21°, respectively) and supination (by 9.05° and 17.42°, respectively) of the forearm. Screw fixation only significantly reduced pronation compared with osteotomy (by 2.62°). Screw fixation did not significantly affect supination. CONCLUSIONS: Ulnar styloid fractures that disrupt the fovea cause instability of the DRUJ in pronation and supination under 3 N m of torque in a cadaveric model. Screw fixation of ulnar styloid base fractures achieves anatomic reduction; however, it only partially returns rotational stability acutely to the DRUJ and only during pronation.