Functional outcomes of pediatric true and equivalent Monteggia fractures - Review of the literature.

BACKGROUND: This study aims to describe the functional outcome of true and equivalent Monteggia fracture-dislocations in the pediatric population. We also provided a review of the literature about the treatment options. METHODS: Five surgically and three conservatively treated patients were identified who were treated in 2009-2021. The study pop-ulation consisted of six female and two male patients. The mean age at the time of treatment was 7. The mean follow-up time was 55 months (range, 12-128). The Mayo Elbow Performance Score and the Oxford Elbow Score were used for outcome evaluation. Range of motion and grip strengths were also evaluated. RESULTS: There were two Bado type 1 and six Monteggia equivalent injuries. Closed reduction and casting were utilized for the two Bado type 1 injuries as the initial treatment. However, one had a radial head re-dislocation and had to be treated operatively. This patient had a radial head re-dislocation after the surgery and was followed up conservatively. Three Monteggia equivalent injuries were treated with closed reduction and casting, with no complications. One patient had a radial head anterior dislocation with plastic deformation of the ulna, and this patient was managed with CORA-based corrective ulnar osteotomy. For Monteggia injuries, the main treatment objective is to restore the ulnar length. Bilateral computed tomography imaging with 3D reconstruction can be utilized in preoperative planning of Monteggia fracture-dislocations to customize the treatment. Close observation is essential to detect radial head subluxation, which needs early intervention before irreversible changes occur. CONCLUSION: The true/equivalent Monteggia fractures' main treatment goal is to restore the ulnar length. Conservative treatment, with a close follow-up, is the first option if closed reduction can be achieved. If closed reduction is not possible, careful preop-erative planning and early rehabilitation are key to success for management of Monteggia fractures.

The association of three anatomical factors with ulnar-sided wrist pain: a radiological study.

BACKGROUND: Ulnar-sided wrist pain is associated with the development of multiple wrist pathologies. But the anatomical etiologies have not been fully understood. PURPOSE: To determine the association of three anatomical factors with ulnar-sided wrist pain, including ulnar variance (UV), distal ulnar volar angle (DUVA), and pisiform-ulnar distance (PUD). MATERIAL AND METHODS: A total of 64 patients who had ulnar-sided wrist pain associated with training injuries were retrospectively studied. A control group included 64 healthy athletes from the same unit. The UV, DUVA, and PUD of each individual was measured on radiographs. RESULTS: The average UV and DUVA of those in the ulnar-sided pain group were 0.84 mm and 174.65°, respectively; the control group values were 0.39 mm and 175.11°. The differences between the two groups had no statistical significance (P > 0.05). The average PUD of the ulnar-sided wrist pain group was shorter than that of the control group (2.37 cm vs. 2.65 cm); the difference had statistical significance (P < 0.05). PUD had a negative correlation with ulnar-sided pain; it was an anatomical protective factor (odds ratio = 0.01; P < 0.00; 95% confidence interval=0.00-0.05). Both UV and DUVA had no significant correlations with ulnar-sided wrist pain (P > 0.05). CONCLUSION: PUD has a significant correlation with ulnar-sided wrist pain. It is the anatomical protective factor. Both the UV and DUVA have no statistical association with ulnar-sided wrist pain, but we cannot ignore their potential pathogenic effects on wrists, and further studies are needed to confirm the results.

A Case of Acute Plastic Deformation of the Forearm in a Medieval Hispano-Mudejar Skeleton (13-14th Centuries AD).

INTRODUCTION: Acute plastic deformation refers to a traumatic bending or bowing without a detectable cortical defect. CASE PRESENTATION AND DISCUSSION: We describe a rare case from an individual that was exhumed from the Hispano-Mudejar necropolis in Uceda (Guadalajara, Spain) dated between the 13th and 14th centuries AD. The case corresponds to an adult woman, with a bowing involvement of the left ulna and radius. After making the differential diagnosis with various pathologies likely to present with this alteration, we reached the diagnosis of acute plastic deformation of the forearm through external and radiological examination and comparison with the healthy contralateral forearm. CONCLUSIONS: Acute plastic deformation is a rare traumatic injury, not described until the last century and only rarely described in palaeopathological contexts. We contribute a new case, the first being sufficiently documented, contributing to the knowledge and diagnosis of this type of trauma in the ancient bone, while deepening the knowledge of the living conditions of the medieval Mudejar population of Uceda.

Postoperative Functional Evaluation in Patients Undergoing Surgical Treatment of the Terrible Triad Injury of the Elbow / Avaliação funcional pós-operatória em pacientes submetidos a tratamento cirúrgico da tríade terrível do cotovelo

Abstract Objective To evaluate the functional results of patients submitted to a surgical approach for the treatment of the terrible triad of the elbow, analyzing the treatment methods used and associated epidemiological variables. Methods Patients who underwent surgical treatment for the terrible triad of the elbow from February 2018 to June 2020 at our service were evaluated. The identified sample consisted of 17 patients, but of these, only 13 completed all stages of the study and, therefore, were considered as the universe to be considered. Epidemiological information of interest was collected: age, sex, hand of dominance, affected side, characteristics and classification of injuries, trauma mechanism, time to surgery, type of procedure performed and range of motion. The Mason classification was used for radial head fractures and the Regan and Morrey classification for the coronoid process. In order to perform a functional analysis, the DASH and BRUCE questionnaires were applied. Results About 77% of the patients were male, 92% of the fracture mechanisms were due to high-energy trauma. Contrary to this, the predominance of the non-dominant side was observed as the most affected. Evaluating the results according to the time to start the treatment, the patients operated within 14 days had statistically better functional results. Conclusion Surgical treatment of TTIE generates acceptable functional results in most cases. The success of the treatment is related to the time interval between the trauma and the first surgery, in addition to the severity of the injuries.

Resumo Objetivo Avaliar os resultados funcionais dos pacientes submetidos a abordagem cirúrgica para o tratamento da tríade terrível do cotovelo, analisando os métodos de tratamento utilizados e variáveis epidemiológicas associadas. Métodos Foram avaliados pacientes submetidos aotratamento cirúrgico de tríade terrível do cotovelo de fevereiro de 2018 a junho de 2020 em nosso serviço. A amostra identificada foi de 17 pacientes, mas destes apenas 13 concluíram todas as etapas das pesquisas e por isso foram considerados como o universo a ser levado em consideração. Coletou-se informações epidemiológicas de interesse: idade, sexo, dominância, lado acometido, características e classificações das lesões, mecanismo do trauma, tempo para cirurgia, tipo de procedimento realizado e o arco de movimento. Foi utilizada a classificação de Mason para a fratura de cabeça do rádio e a de Regan e Morrey, para o processo coronoide. A fim de realizar uma análise funcional, aplicou-se os questionários de DASH e BRUCE. Resultados Cerca de 77% dos pacientes foram do sexo masculino, 92% dos mecanismos de fratura foram por trauma de alta energia. Contrariamente a esta, observou-se a predominância do lado não dominante como o mais afetado. Avaliando os resultados de acordo com o tempo para início do tratamento, os pacientes operados em até 14 dias obtiveram resultados funcionais estatisticamente melhores. Conclusão O tratamento cirúrgico da TTC gera resultados funcionais aceitáveis na maioria dos casos. O sucesso do tratamento está relacionado ao intervalo de tempo entre o trauma e a primeira cirurgia, além de se relacionar com a gravidade das lesões.

Ulnar shortening osteotomy for posttraumatic ulnar impaction syndrome in adolescent (younger than 18 years) - Based on the Cha & Shin assessment.

PURPOSE: We performed ordinary ulnar shortening osteotomy (USO) in patients younger than 18 years old with secondary ulnar impaction syndrome (UIS) after traumatic events. Here, we report the clinical and radiologic outcomes with a review of the previous literature through a retrospective case series. METHODS: Twenty-two adolescents treated by USOs from 2006 to 2018 were investigated. The amount of shortening was classified into three categories. The first category was for a still open physis on the medial half of the radius in those younger than 15. In this category, we osteotomized the ulna for the physis level to be left neutral or negative by 1-2 mm. The second category had no growth potency in the radius. If the patient was younger than 15, we considered only residual growth of the ulna, thus performing USO for the ordinary UV to be negative by 2-3 mm. For patients aged 15-18 years old, if growth potency was nearly absent in the ulna, we performed traditional USO with a neutral ulnar variance (UV). RESULTS: Categories 1, 2, and 3 for the amount of USO were determined for 4, 4, and 14 patients, respectively. All USOs properly healed without substantial complications. The mean preoperative UV was 2.91 mm, and the final value decreased to 0.23 with statistical significance (p < 0.001). The range of wrist motion was improved after USO from 133.86° and 132.73° to 154.77° and 160.68° (all, p < 0.001 in flexion-extension and pronation-supination arcs, respectively). The preoperative VAS and MMWS scores also improved from 2.77 to 75.00 to 0.18 and 88.86, respectively, at the final follow-up (all, p < 0.001). CONCLUSIONS: UIS in adolescent populations after trauma in their children/younger adolescents could be properly treated by USO. Even with an open physis at the ulna, neutral UVs could be achieved, and the clinical outcomes were satisfactory. However, long-term follow-up is still needed regarding TFCC and DRUJ status. LEVEL OF EVIDENCE: Level IV, retrospective case series.

Variant Salter-Harris Type III Distal Ulna "T" Fracture in the Setting of Galeazzi Equivalent Wrist Injury: A Case Report.

CASE: An 11-year-old Caucasian boy presented to the emergency department with a displaced, closed, Galeazzi equivalent (GE) left wrist fracture sustained after a fall. Closed reduction was deemed unsatisfactory because of persistent displacement of the distal ulna epiphysis. An open reduction of the distal ulna and percutaneous fracture pinning was performed. At 1 year, the patient reported return to his preinjury baseline. No evidence of subsequent pathologic growth was detected on follow-up imaging. CONCLUSION: Open anatomic reduction of the distal ulna epiphysis and percutaneous fracture pinning may improve patient outcomes and limit progressive wrist deformity when treating GE wrist injuries.

Chronic Monteggia in pediatric population: A narrative literature review.

Monteggia lesion is a traumatic condition that affects the forearm and is characterized by the association of an ulna fracture with a dislocation of the radius capitellar and proximal radius ulnar joints in the majority of cases. Although several authors have contributed to the understanding of this pathology over the years, it remains a challenge for orthopedists, and if not recognized and treated properly, it can have serious consequences. In these cases, a chronic injury develops, which is even more difficult to manage in terms of timing and treatment options. A narrative review of the literature on missed elbow injuries in children was conducted, and chronic Monteggia was the most frequently encountered injury. The analysis of the articles attempts to clarify some points and draw general conclusions on which to reflect.

Use of Corrective Ulnar Osteotomy and Radial Head Relocation Into Preserved Annular Ligament in the Treatment of Radiocapitellar Instability Secondary to Pediatric Chronic Monteggia Fracture-Dislocation.

PURPOSE: Opening-wedge osteotomy of the ulna restores normal ulnar length and corrects the angulation of the ulna in patients with chronic Monteggia fracture-dislocations. In addition, this eases the reduction of the radial head. Morbidity caused by annular ligament reconstruction surgery can be prevented by preserving the intact annular ligament. After dilatation and mobilization of the annular ligament, reduction of the radial head can be accomplished. This study evaluated the effectiveness of corrective opening-wedge ulnar osteotomy and radial head relocation into the intact annular ligament in the treatment of radiocapitellar instability secondary to pediatric chronic Monteggia fracture-dislocation. METHODS: Fourteen patients diagnosed with radial head dislocation associated with plastic deformation of the ulna or ulnar fracture were included in the study. Radiologic and clinical results of these patients who underwent corrective ulnar osteotomy and radial head relocation into an intact annular ligament were evaluated retrospectively. RESULTS: The mean age of the patients at the time of injury was 7.4 years (range, 3 years to 12 years). The average time between the injury and surgery was 19.1 months (median, 8 months; range, 3 months to 66 months); the average follow-up period was 28.7 months (range, 12 months to 60 months). The mean Kim score was 69.6 (range, 50 to 75) preoperatively and 92.9 (60 to 100) at last follow-up. According to Kim score, the results were considered excellent in 12 cases and poor in 2 cases. Radial head subluxation recurred in 2 separate cases. In addition, chondrolysis changes were seen in 1 case. Reduction loss and osteoarthritic changes in the radiocapitellar joint were considered poor results in follow-up radiographs. CONCLUSIONS: Corrective ulnar osteotomy and relocating the radial head into the intact annular ligament can be safely used for treating chronic Monteggia fracture-dislocation cases without radial head and capitellum deformity. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic IV.

Application of Suspension Fixation with Button Plates for Patients with Distal Radioulnar Joint Dislocation: A Case Series.

OBJECTIVE: The aim of the present study was to assess the effect of suspension fixation with button plates on the reconstruction of the distal radioulnar joint dislocation (DRUJ). METHODS: This was a case series of six patients (two men and four women) who underwent suspension fixation with button plates for DRUJ dislocation between January 2015 and May 2017. Physical examination, radiography, MRI, functional activity of the wrist joint, grip strength of the wrist joint, Garland-Werley wrist score, Mayo wrist score, and visual analog scale (VAS) score were used to evaluate the effect of this procedure. All patients were followed up every 3 months. The evaluation time point was 12 months after the operation. Comparisons of the functional indexes of wrist function before and after the operation were performed using paired statistical tests. RESULTS: The mean range of motion of the affected limb was 70° at forearm pronation and 75° at forearm supination. The subjective assessments and tests of the motor function of the wrist showed improvement after surgery. The Garland-Werley wrist score was 13.50 ± 2.66 preoperatively, the Mayo wrist score was 56.67 ± 18.35, and the VAS score was 4.83 ± 1.17. The Garland-Werley wrist score was 2.83 ± 1.33 postoperatively at 12 months, the Mayo wrist score was 87.5 ± 6.89, and the VAS score was 0.50 ± 0.55. At 12 months, the Garland-Werley wrist score, the Mayo wrist score, and the VAS score showed significant improvements when compared with those before surgery (P = 0.000, P = 0.003, and P = 0.000, respectively). Radiographic examination revealed that the internal fixation device was in place, and no dislocation of the DRUJ could be observed. None of the patients had internal fixation device removal or re-dislocation of the DRUJ. None of the patients had re-dislocation of the DRUJ. No secondary ulnar or radial fractures and nerve injury were reported during and after surgery. No tumor recurrence was observed in patients with giant cell tumors of the tendon sheath. No loosening and displacement of screws were reported. CONCLUSION: The new method of suspension fixation with button plates for the surgical reconstruction of a DRUJ dislocation is simple, with minimal trauma, and maintains the stability of the DRUJ without the need for intra-articular or extra-articular reconstruction of the ligament. Furthermore, it allows early functional exercise and achieves satisfactory postoperative functional recovery.

Irreducible Traumatic Radial Head Dislocation Due to Annular Ligament Interposition in a Child with Ulnar Plastic Deformation: A Case Report.

BACKGROUND: The traumatic dislocation of the radial head in children is commonly treated by closed reduction. Sometimes, however, this strategy of treatment may not be effective due to the location of soft tissues in the radio-shoulder joint. The literature presents a few cases of the irreducible radial head dislocation with ulnar plastic deformation. Because it is a relatively rare condition, such a traumatic dislocation can be easily missed. Neglected injuries can lead to unwanted complications and unpredictable surgical outcomes. CASE PRESENTATION: This study presents a relatively rare case of traumatic radial head dislocation with ulnar plastic deformation in a 3-year-old child, which was successfully treated by open reduction. The examined case did not require osteotomy and ligamentous reconstruction. The initial attempt of closed reduction failed due to annular ligament interposition, which has been detected on MRI. After 3 months of treatment, the range of motion of the operated arm gradually improved. At the 6-month follow-up, the Mayo elbow-performance score indicated an excellent treatment outcome. CONCLUSIONS: The delayed treatment of radial head dislocation with ulnar plastic deformation can hinder the supination and pronation of the forearm, resulting in elbow/forearm deformity. The earlier this condition is detected, the easier it will be to treat it and the better the treatment outcome will be. The examined case of irreversible traumatic dislocation, successfully treated by open reduction, may help to treat radial head dislocation better.

Can intraoperative ultrasound visualize the closed reduction and elastic intramedullary nail fixation processes of double forearm fractures in children?

ABSTRACT: To evaluate the feasibility of utilizing ultrasonography to monitor the fracture reduction and elastic intramedullary nail fixation processes in treating children with double forearm fractures. A retrospective analysis of 30 children with double forearm fractures treated at our hospital between January 2016 and July 2018. The children were aged 3 to 10 years. All patients were treated with closed reduction and internal fixation with elastic intramedullary nails using intraoperative ultrasound monitoring and intermittent radiographic imaging. The closed reduction and fixation were successful in all patients. The operation times ranged from 16 to 30 minutes, averaging 21 minutes. No neurovascular injuries occurred during closed reduction and nail insertion. Moreover, closed reduction was successful in the first attempt in 86.7% of patients. All patient outcomes were optimal, lacking serious complications during follow-ups. Intraoperative ultrasound monitoring can clearly show the shape and changes in fracture ends, distal growth plates, and surrounding soft tissues, and fracture reduction and passage of elastic nail processes at fracture ends during closed reduction; therefore, visualizing closed reductions can be achieved. The combination of intraoperative ultrasound and radiographic imaging can ensure operative effects and significantly reduce radiation exposure for both doctors and patients. An adequately powered prospective randomized trial is required to confirm our findings.

Elastic intramedullary nail treatment of adolescent perihardware radius and ulna refracture.

A 13-year-old girl presented to the clinic with a midshaft refracture of both forearm bones adjacent to the site of a prior forearm fracture that had been treated with plating. She was treated with hardware removal and placement of elastic intramedullary nails. Flexible intramedullary nailing can be successful for a skeletally mature adolescent in treatment of refracture surrounding plate fixation of a midshaft forearm fracture. This technique allows for additional protection of the entire length of the affected bones, while avoiding the extensive dissection needed for extended plating.

[Monteggia-fractures and Monteggia-like Lesions]. / Monteggia-Frakturen und Monteggia-like Lesions.

Monteggia lesions and Monteggia-like lesions involve ulna and radius injuries, which can not be successfully treated using the surgical principles of isolated fractures. Proximal ulnar fracture, radio-humeral dislocation, and additional dislocation in the proximal radioulnar joint result in the disintegration of the functional unit, and there is a complex injury across the elbow to the forearm, resulting in poor clinical outcomes. Thus, addressing all osteo-ligamentous injuries is essential for the long-term course.

Impactación cubitocarpiana / Ulnocarpal impaction

El objetivo de este artículo es actualizar los conocimientos sobre la impactación cubitocarpiana y su tratamiento. Estudios clásicos sobre la biomecánica del borde cubital de la muñeca han demostrado que los cambios milimétricos en la relación de longitud entre el cúbito y el radio alteran significativamente la transferencia de cargas entre los huesos del carpo, el radio y el cúbito. Así, un aumento relativo en la longitud del cúbito generará una carga excesiva sobre la articulación cubitocarpiana que producirá un espectro de cambios degenerativos progresivos en el domo cubital, el semilunar, el piramidal y el complejo del fibrocartílago triangular que finalizarán con artrosis cubitocarpiana y radiocubital distal. La impactación cubitocarpiana, en sus diversos estadios degenerativos, se puede tratar mediante osteotomías que buscan descomprimir la carga cubitocarpiana. Las osteotomías pueden ser extrarticulares o intrarticulares. Entre las extrarticulares, están las diafisarias, las metafisarias sin exposición articular (subcapitales) y las metafisarias distales con exposición articular y, entre las intrarticulares, la cirugía de resección en oblea (wafer), que reseca cartílago y hueso subcondral del domo cubital, y puede ser un procedimiento abierto o artroscópico. Si hay artrosis radiocubital distal, solo se podrá tratar con cirugías de rescate, como Darrach, Sauvé-Kapandji, Bowers, o una prótesis radiocubital distal. Estas técnicas de osteotomía se han analizado detalladamente para lograr definir sus ventajas y desventajas. Finalmente se propone una forma de tipificar la impactación cubitocarpiana, cuyo objetivo es orientar al lector hacia el mejor tratamiento posible, avalado por la bibliografía actual. Nivel de Evidencia: V

The purpose of this article is to provide updated knowledge about ulnocarpal impaction syndrome (UCIS) and its treatment. Classic studies on biomechanics of the ulnar side of the wrist have shown that millimetrical changes in the relative lengths of the ulna and the radius significantly alter the load transmission between the carpal bones, the radius and the ulna. Thus, an increase in the relative length of the ulna will generate an excessive load on the ulnocarpal joint, which will produce a spectrum of progressive degenerative changes in the ulnar dome, lunate, triquetrum, and the triangular fibrocartilage complex (TFCC), that will lead to ulnocarpal and distal radioulnar joint (DRUJ) osteoarthritis. In its various degenerative stages, UCIS can be treated with osteotomies that seek to decompress the ulnocarpal load. These can be extra-articular or intra-articular. Within the extra-articular osteotomies, we find the diaphyseal, metaphyseal without joint exposure (subcapital), and the distal metaphyseal with joint exposure. Within the intra-articular ones, we find the wafer procedure, which resects the cartilage and subchondral bone of the ulnar dome, and can be performed either openly or arthroscopically. If there is associated DRUJ osteoarthritis, it can only be treated with salvage surgeries such as the Darrach, Sauvé-Kapandji, and Bowers procedures, or a DRUJ arthroplasty. These osteotomy techniques will be analyzed in detail in order to define their advantages and disadvantages. Finally, we propose a way to typify the UCIS to guide the reader towards the best possible treatment supported by current literature. Level of Evidence: V

Semiquantitative single-photon-emission computed tomography /computed tomography study to evaluate concomitant ulnar impaction syndrome in patients presenting with triangular fibrocartilage complex tears.

INTRODUCTION: Patients presenting with tears of the triangular fibrocartilage complex (TFCC) can have ulnar positive variance, for which the clinical relevance to concomitant ulnar impaction syndrome (UIS) may be unclear. We hypothesized that maximum standardized uptake value (SUVmax), a semiquantitative single-photon-emission computed tomography/computed tomography (SPECT/CT) value, would distinguish between the traumatic TFCC tear and degenerative TFCC tear associated with the UIS. This study aimed to compare SUVmax between patients with TFCC tear only and patients with TFCC tear and UIS. METHODS: A total of 26 patients presenting with TFCC tears on magnetic resonance imaging (MRI) underwent semiquantitative SPECT/CT examinations. The diagnosis of concomitant UIS was made based on positive ulnar impaction tests and MRI findings. We compared the SUVmax between patients with and without concomitant UIS. We also calculated the cutoff value for the diagnosis of UIS using receiver operating characteristic curve analysis. RESULTS: Of 26 patients, 14 had concomitant UIS, and 12 had TFCC tears only. The SUVmax was significantly higher in patients with concomitant UIS than in those without UIS (p = 0.048). With a SUVmax cutoff value of 4.09 for UIS, sensitivity of 67% and specificity of 82% were obtained. CONCLUSIONS: In the semiquantitative SPECT/CT examinations of patients with TFCC tears, those with concomitant UIS had a higher SUVmax than those without UIS. Semiquantitative SPECT/CT can be helpful in confirming concomitant UIS in patients with TFCC tears.

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.

Ulnar stress reaction in an axillary crutch user.

Ulnar stress fractures have been reported in athletes performing repetitive, high-impact activities, such as baseball pitchers and gymnasts. Crutch-assisted walking also results in cyclical forearm loading. We report the first case of ulnar stress reaction due to axillary crutch use. A 23-year-old right-handed woman experienced right forearm pain and imaging confirmed a right ulnar stress injury. The patient was also found to have mild hypercortisolism, low bone mass and vitamin D deficiency. Crutches were discontinued and physical therapy to normalise weight bearing through the left leg was prescribed. The patient's right forearm symptoms resolved and she was started on oral vitamin D supplementation. Axillary crutch use may result in ulnar stress injury, particularly in vulnerable populations. The addition of an upper extremity injury to someone with impaired mobility may compound disability. As such, clinicians should be aware of the clinical presentation of ulnar stress fractures in the long-term axillary crutch user.