The Adult Monteggia Fracture: Patterns and Incidence of Annular Ligament Incarceration Among 121 Cases at a Single Institution Over 19 Years.

PURPOSE: The purposes of this study were to identify the relative frequency of Monteggia fracture patterns and to investigate the required frequency of open reduction of the proximal radiocapitellar joint. METHODS: We identified 121 Monteggia fractures at a Level I trauma center from 1996 to 2015 and included 119 in this study. These fractures were identified using a database search for the appropriate International Classification of Diseases, Ninth Revision and Current Procedural Terminology codes as well as individual surgeons' logs. Two fellowship-trained hand surgeons reviewed the identified patients' x-rays and operative notes. Each fracture was classified using Bado's original description, excluding transolecranon and Monteggia variants. RESULTS: Bado I lesion represented 68% (81 of 119) of Monteggia fractures. Annular ligament incarceration preventing radial head reduction occurred in approximately 17% (14 of 81) of this Bado type. Revision fixation of the ulna was not necessary (none of 119 cases) and functional range of motion (average arc, 117°) was recovered in most patients. The reoperation rate of 20% (23 of 119) was related to the severity of the presenting injury and hardware prominence. CONCLUSIONS: Most radial head dislocations associated with Monteggia fractures occur anteriorly and will reduce with anatomic plating of the ulna. In cases where the radial head fails to reduce, entrapment of the annular ligament can be expected and open reduction is required. Revision fixation of the ulna to achieve reduction of the radial head is uncommon in our experience. TYPE OF STUDY/LEVEL OF EVIDENCE: Prognostic IV.

Intercondylar Fractures of the Distal Humerus in Patients Younger Than 20 Years: Capsulectomy Results.

Few reports in the literature have been dedicated to young patients with distal fractures of the humerus, and few have addressed subsequent indications to improve range of motion (ROM). This article is a retrospective review of the elbow flexion-extension ROM in 31 patients (age, 12-19 years) who had been treated with open reduction and internal fixation of intercondylar fractures of the distal humerus at a level I trauma center from 1991 through 2013. The ROM of patients who underwent capsulectomy was compared with that of those who did not. Main outcome measures were ROM in degrees and need for capsulectomy. Nine (29%) of the 31 patients had elected to undergo capsulectomy. Eleven did not require capsulectomy. The final flexion-extension arc was improved by 31° compared with the precapsulectomy ROM but did not attain the ROM of those who did not undergo capsulectomy.

Comparison of intramedullary fixation techniques in the maintenance of functional anatomy of the elbow after fixation of the proximal ulna.

The objective of this study was to compare intramedullary (IM) nail and IM screw fixation for reattachment of the proximal ulna. Preserved elbow anatomy served as the primary outcome and was defined as the distance between the coronoid process and the olecranon. A retrospective cohort study of 31 patients treated with IM fixation of the proximal ulna was performed. Radiographs were used to compare displacement distances between the coronoid process and the olecranon, with average follow-up of approximately 5 months. IM nail fixation corresponded to a mean displacement of -0.65 mm between the olecranon and coronoid process, versus 0.23 mm for IM screw fixation. No patients were identified with loss of reduction of bone fragments. Both IM fixation techniques maintained the functional anatomy of the elbow. Minimal displacement of bone fragments and no identified loss of reduction suggest that both techniques could be reasonable alternatives to more traditional approaches.

Articular cartilage thickness at the distal radius: a cadaveric study.

PURPOSE: Articular stepoffs that occur after fracture and are greater in size than the thickness of the articular surface seem to result in arthritis. The thickness of a joint's cartilage may, therefore, set the limit for acceptable stepoff when treating fractures. The goal of our study was to determine the thickness of the articular cartilage at the distal radius. METHODS: We conducted a cadaveric study of 19 wrists to measure the thickness of cartilage at the distal radius. After harvest, we made multiple slices of each radius and used a standardized technique to directly measure the articular cartilage in the scaphoid and lunate fossae and along the interfossal ridge. RESULTS: The average cartilage thickness in our cohort was 0.6 mm. The average articular surface thickness was < 1 mm in all measured areas (scaphoid fossa, 0.7 mm; interfossal ridge, 0.8 mm; lunate fossa, 0.6 mm). Among the samples, 98% had an average thickness of < 1 mm. The maximum recorded thickness was 1.1 mm. CONCLUSIONS: Our study quantifies the thickness of the articular cartilage at the distal radius. Our finding of cartilage thicknesses of < 1 mm is consistent with multiple clinical studies, suggesting that stepoffs of > 1 mm result in radiographic signs of arthritis. This provides further evidence linking the thickness of articular cartilage to radiographic outcomes and, possibly, clinical outcomes. CLINICAL RELEVANCE: Our findings provide anatomic support for using 1 mm or less as an acceptable articular stepoff size in the treatment of fractures of the distal radius.

Small-Fragment Plate Fixation of Humeral Shaft Fractures.

Fixation of humeral shaft fractures is frequently performed with large-fragment (4.5 mm) plates to accommodate immediate weight bearing. Use of small-fragment (3.5 mm) plates as an alternative carries theoretical benefits. We examined nonunion rates and postoperative radial nerve palsy (RNP) rates in a retrospective cohort of patients undergoing open reduction and internal fixation of humeral shaft fractures with 3.5-mm or 4.5-mm plates. Two hundred thirty-six patients with 241 humeral shaft fractures were included. Small 3.5-mm plates were used in 83% of the patients, and large 4.5-mm plates were used in 17% of the patients. Fifty-three percent were made weight bearing as tolerated following surgical fixation. There was a 7% incidence of nonunion and a 10% incidence of RNP in the 3.5-mm plate group. There was a 7% incidence of nonunion and a 15% incidence of RNP in the 4.5-mm plate group. No statistically significant relationship was shown between nonunion or RNP and plate size (P=.74 and P=.39). No relationship was shown between nonunion and postoperative weight-bearing status (P=.45). Subgroup analysis according to plate size additionally showed no association of nonunion with postoperative weight bearing in both the 4.5-mm (P=.55) and the 3.5-mm (P=.25) cohorts. Small-fragment and large-fragment plating of humeral shaft fractures resulted in comparable union and RNP rates, regardless of postoperative weight-bearing status. Our findings suggest that 3.5-mm plate fixation of humeral shaft fractures is a safe alternative to 4.5-mm plate fixation. [Orthopedics. 2023;46(4):198-204.].

Oblique step ulnar shortening osteotomy for management of posttraumatic ulnar impaction.

We describe an oblique step-cut osteotomy technique for ulnar shortening. The technique requires no special instrumentation. It requires only an eight-hole 3.5-mm low-contact dynamic compression plate for fixation. Sixteen patients with posttraumatic ulnar impaction syndrome were treated. The average patient age was 40 years. The mean followup duration was 8 (range, 3 to 28) months. No nonunions occurred. Two patients required hardware removal for symptomatic hardware. Fourteen of the 16 patients reported persistence of occasional pain with some activities, but only 10 had any pain elicited at the time of examination. One patient required revision of the ulnar shortening procedure for persistence of symptoms. Functional outcomes were comparable with ulnar shortening performed by other methods. However, this technique might offer improved union rates compared with those described in the literature and is applicable to treat ulnar impaction syndrome arising from other causes.

Association of Radial Head Fracture Treatment With Long-Term Function.

BACKGROUND: Radial head fractures are often associated with poor outcomes. Both open reduction and internal fixation (ORIF) and radial head arthroplasty (RHA) might be considered in operative cases. This study aimed to compare long-term patient-reported functional outcomes among patients with operatively treated radial head fractures. METHODS: A cross sectional study conducted at a Level I trauma center was used to identify patients with a radial head fracture who underwent ORIF or RHA between 2006 and 2018, and agreed to complete a survey in 2020. The primary outcome measure was the Quick Disabilities of the Arm, Shoulder, and Hand (QuickDASH) score. RESULTS: Seventy-six patients participated in the study. No significant differences in outcomes were observed between groups. QuickDASH scores were similar for both groups (ORIF: mean = 15.7, SD = 18.4; RHA: mean = 22.8, SD = 18.6; mean difference = 0.2 [-9.0 to 9.3], P = .97). Nineteen (37%) ORIF patients and 12 (48%) RHA patients reported a need for pain medication (adjusted odds ratio [OR] = 0.8 [0.3-2.4], P = .70). Thirteen (25%) ORIF patients and 6 (24%) RHA patients required additional surgery (adjusted OR = 1.7 [0.5-6.2], P = .39). A subgroup analysis of multi-fragmentary fractures revealed similar findings. CONCLUSION: Patient-reported outcomes, which included a subgroup analysis of multi-fragmentary fractures, were similar between ORIF and RHA groups at an average of 7.5 years from surgery. Reconstructing the radial head might not result in worse outcomes than RHA when both options are employed according to the best judgment of the operating surgeon.

The effect of distal radius locking plates on articular contact pressures.

PURPOSE: Fractures of the distal radius are among the most common injuries treated in hand surgery practice, and distal radius locking plates have become an increasingly popular method of fixation. Despite widespread use of this technology, it is unknown whether the subchondral placement of locking screws affects the loading profile of the distal radius. Our study was designed to determine whether subchondral locking screws change the articular contact pressures in the distal radius. METHODS: Twelve cadaveric forearms underwent a previously described axial loading protocol in a materials testing machine. We used an intra-articular, real-time computerized force sensor to measure peak contact pressure, total pressure, and contact area in the distal radius. Internal validation of sensor placement and reproducibility was conducted. Each specimen was tested before fixation (control), after application of a palmar distal radius locking plate, and after simulation of a metaphyseal fracture. RESULTS: We identified no statistically significant differences in maximum pressure, total pressure, and contact area among control, plated, and plated and fractured specimens. However, the contact footprint-represented by squared differences in force across the sensor-were significantly different between the control group and both plated groups. CONCLUSIONS: The technique for measuring contact pressures produces highly repeatable values. Distal radius locking plates with subchondral hardware placement do not seem to significantly change articular contact pressures.

Immediate Weight Bearing of Plated Both-Bone Forearm Fractures Using Eight Cortices Proximal and Distal to the Fracture in the Polytrauma Patient Is Safe.

INTRODUCTION: Rehabilitation of trauma patients is facilitated by surgical stabilization permitting weight bearing (WB) of the fractured extremity. Both-bone forearm fracture (BBFx) plate osteosynthesis is an accepted technique with high union and low complication rates; yet, postoperative WB protocols have not been adequately investigated. There exists concern for increased complications in plated BBFx fractures for patients prescribed immediate WB. We hypothesized that immediate WB of surgically treated BBFxs results in acceptable rates of complications. METHODS: Patients presenting to a Level-1 trauma center from 2007 to 2016 with a BBFx were identified retrospectively. Patients were skeletally mature, surgically treated with prescribed immediate WB protocol, and followed for 6 months or to fracture union. Collected data included demographics, fracture characteristics, associated injuries, and WB protocols for all extremities. Complications recorded included nonunion, hardware failure, and infection. Standard statistical comparisons were used to evaluate the risk of complication in polytrauma patients with modified lower extremity WB protocols (polytrauma group) and patients with no lower extremity WB restrictions (isolated group). RESULTS: Two hundred thirteen patients were included with 75 (35%) females and 138 (65%) males. Mean age was 40 years and mean follow-up was 46 weeks. There were 142 (67%) patients in the poly-trauma and 71 (33%) patients in the isolated groups. In the poly-trauma group 21 (10%) patients had bilateral lower extremity WB restrictions. There were 11 (6%) complications noted: 2 non-unions, 4 hardware failures, and 5 infections. Demographics did not vary between the two groups. There was no difference in complications in the isolated (5.7%) versus poly-trauma groups (5.0%) (P = 0.75). CONCLUSION: Immediate WB rehabilitation after BBFx plate osteosynthesis seems to be safe and associated with low nonunion and complication rates. Our results demonstrate that polytrauma patients using ambulatory aids for lower extremity injuries can immediately WB without increased risk compared with isolated BBFx patients.

Early motion protocol for select Galeazzi fractures after radial shaft fixation.

Galeazzi fractures traditionally are treated in long arm casts with the wrist fully supinated for 6 weeks after open reduction and internal fixation. Recent literature suggests that early motion can be permitted for a subset of Galeazzi fractures. Defining a safe postoperative protocol that allows immediate elbow motion, immediate platform weight bearing, and early wrist motion might decrease elbow morbidity, increase range of motion, and improve outcomes. A retrospective review of a prospectively collected database of 26 patients at a level I trauma center was conducted. Early motion protocol was assigned to patients who were radiographically and clinically stable after plate and screw fixation. Elbow flexion and platform weight bearing were allowed immediately; increased wrist rotation was allowed at 2-week intervals. Early motion of elbow and wrist seems to be safe during postoperative rehabilitation of repaired Galeazzi fractures. The postoperative protocol might maximize elbow and wrist range of motion.

Provisional Minifragment Plate Fixation of Acetabular Fractures-A Technical Trick.

SUMMARY: Acetabular fractures may not always be amenable to classic clamp-assisted reductions and interfragmentary lag screw fixation. The routine clamp-assisted reductions with limited osseous territory availability can inhibit typical 3.5-mm reconstruction plate application. Provisional minifragment plate fixation of these fracture patterns with subsequent clamp removal allows for definitive plate application. The provisional minifragment plates may also be retained to theoretically augment fixation. The authors present a step-by-step technique and clinical series of 57 patients demonstrating provisional minifragment fixation of elementary (n = 8) and associated (n = 49) acetabular fractures.

Management of vasopressor induced ischemia.

PURPOSE: We evaluated a cohort of patients who developed vasopressor-induced limb ischemia and the management options to prevent progression or minimize morbidity of digital necrosis. METHODS: We reviewed all current literature on pressor-induced limb ischemia and report options for the management of patients requiring vasopressors who developed limb ischemia. We then retrospectively reviewed presentation, treatment, and short-term outcomes for patients at our tertiary referral academic medical center that developed this complication. Finally, we recommend guidelines for the tiered management of these complex patients. RESULTS: Thirty-six patients were included. Twenty-six patients (72%) required resuscitation with more than one vasopressor. Vasopressors were initiated for septic-shock (52.7%), cardiogenic-shock (16.7%), hypovolemic-shock (13.9%), acute transplant rejection (13.9%), and neurogenic-shock (2.8%). According to the tiered management recommendations, patients were managed with phase 1 care (19%), phase 2 care (8.3%), phase 3 care (50%) or phase 4 care (5.6%). The patient expired in the acute setting in 13.9% of cases. CONCLUSION: Life-saving vasopressors risk digital ischemia and necrosis. Early recognition, reporting, and treatment of this complication are important in minimizing morbidity. Using a tiered approach helps organize the healthcare team's management of this iatrogenic complication while respecting the treatment paradigm of "life over limb," and may be safely performed with acceptable outcomes.

AO types C3.1 and C3.2 distal radius fractures: functional outcomes.

The purpose of the current study was to examine the functional outcomes of C3.1 and C3.2 distal radius fractures. A trauma registry was used to identify patients with C3.1 and C3.2 distal radius fractures (n = 33). Clinical follow-up consisted of completion of the Disabilities of the Arm, Shoulder, and Hand (DASH) questionnaire and assignment of a Gartland and Werley Demerit Point System score. Average follow-up duration was 62 months. Mean DASH score was 14 points; mean Gartland and Werley score was 6 points. Results were 14 excellent, 12 good, 10 fair, and one poor. Patients regained an average of 78% of the flexion-extension arc, 94% of the pronation-supination arc, and 83% of grip strength compared with the uninjured side. Standardized and uniformly applied attempts at reconstruction of the distal radial articular surface led to successful outcomes in the majority of patients.

Timing of Treatment of Open Fractures of the Distal Radius in Patients Younger Than 65 Years.

The authors aimed to characterize surgical and functional outcomes of open fractures of the distal radius in patients younger than 65 years. At their level I trauma center, the authors conducted a retrospective review of 92 patients (age range, 16-64 years) who had 94 open fractures of the distal radius (average follow-up, 30 months; range, 3-95 months). Sixty-four fractures received definitive treatment at the time of initial débridement; 30 received definitive fixation and soft tissue coverage after staged débridement. Primary surgical outcome was development of deep surgical site infection requiring repeat surgical débridement; secondary surgical outcome was surgical complications requiring reoperation. Functional outcome was assessed by wrist range of motion. Overall infection rate was 15% (14 of 94 fractures). Seven (11%) of 64 fractures in the immediate definitive fixation group developed infection compared with 7 (23%) of 30 fractures in the staged treatment group (P=.13). Twenty-one (33%) of 64 fractures in the immediate definitive fixation group required reoperation compared with 15 (50%) of 30 in the staged treatment group (P=.11). Deep surgical site infections and surgical complications associated with open fractures of the distal radius are driven by soft tissue injury. [Orthopedics. 2019; 42(4):219-225.].

Transclavicular approach for brachial plexus reconstruction.

Brachial plexus injuries requiring extensive exposure might benefit from a transclavicular approach. At a level 1 trauma center, 20 patients underwent surgical intervention for brachial plexus injuries, 10 via a transclavicular approach. For 5 patients, the transclavicular approach was accomplished through osteotomy with a technique presented herein, and for the other 5, through an established nonunion. All osteotomies and nonunions healed. No hardware-related complications occurred. We think that in the appropriate setting, a transclavicular approach facilitates exposure, decreases surgical time, and is associated with minimal risk.

Efficacy of Wound Coverage Techniques in Extremity Necrotizing Soft Tissue Infections.

Little data exist about management of wounds created by debridement in necrotizing soft tissue infections (NSTIs). Multiple wound coverage techniques exist, including complete primary wound closure, split-thickness skin grafting, secondary intention, and flap creation. We hypothesized that all wound coverage techniques would be associated with high rates of successful wound coverage and low crossover rates to other wound coverage techniques. NSTIs over a three-year period were retrospectively reviewed. Both the initial and secondary wound coverage techniques (if necessary) were recorded. The primary outcome was the ability to achieve complete wound coverage. Overall, 46 patients with NSTIs had long-term data available. Of the patients undergoing split-thickness skin grafting as the initial wound coverage technique, 8/8 (100%) achieved complete wound coverage; and of those undergoing flap creation, 1/1 (100%) achieved complete wound coverage; and of those undergoing complete primary wound closure, 4/4 (100%) achieved complete wound coverage. Of the patients undergoing secondary intention as the initial wound coverage technique, 5/33 (15.2%) achieved complete wound coverage and 28/33 (84.8%) required a secondary wound coverage technique with split-thickness skin grafting. All 46 patients achieved long-term successful wound coverage. Time to wound coverage did not vary with initial wound coverage technique (P = 0.44). Split-thickness skin grafting, flap creation, complete primary wound closure, and secondary intention are all reasonable choices for initial wound coverage for NSTIs. Although secondary intention had a low success rate as an initial wound coverage technique, all patients ultimately achieved complete wound coverage without a significant increase in time to coverage.

Physiology, not modern operative approach, predicts mortality in extremity necrotizing soft tissue infections at a high-volume center.

BACKGROUND: Multiple factors are associated with mortality in necrotizing soft tissue infection, such as organ dysfunction and underlying medical comorbidities, but are not often modifiable. Operative interventions are an attractive modifiable variable in modern management of extremity necrotizing soft tissue infection, but the influence of amputation and advanced wound management techniques on mortality is unknown. METHODS: A single-institution review was performed of extremity necrotizing soft tissue infection . Admission demographics, organ dysfunction, and operative interventions were investigated. The primary outcome was mortality. Advanced wound management techniques were considered flap creation or use of a dermal matrix substitute for coverage of neurovascular structures, tendon, or bone. RESULTS: Overall, 124 patients with extremity necrotizing soft tissue infection were included, with 112 of 124 (90.3%) patients living and 12 of 124 (9.7%) patients dying. Patients who lived had a lower Sequential Organ Failure Assessment score (1.00 [interquartile range, 5] vs 10.50 [interquartile range, 11], P < .001), but no difference in use of amputation (11.6% vs 25.0%, P = .19) or advanced wound management techniques (12.5% vs 0%, P = 0.36), respectively. Indications for amputation in the 16 patients who underwent amputation included nonsalvageable limb in 13 of 16 (81.3%), medical comorbidity in 2 of 16 (12.5%), and a nonsalvageable limb and medical comorbidity in 1 of 16 (6.3%) patients. In multivariate analysis, only the Sequential Organ Failure Assessment score remained associated with mortality (odds ratio 1.315, 95% confidence interval 1.146-1.509, P < .001) CONCLUSION: Use of amputation or advanced wound management techniques was not associated with mortality in patients with extremity necrotizing soft tissue infection. At centers able to provide the critical care support, aggressive use of limb salvage may not affect mortality.

Brachial Artery Transection After a Closed Traumatic Isolated Medial Epicondyle Fracture in a Pediatric Patient: A Case Report.

BACKGROUND: Medial epicondyle fractures in pediatric patients might be associated with an occult elbow dislocation and neurovascular damage. METHODS: A single case of a medial epicondyle fracture presenting with brachial artery transection was reviewed. Presentation, clinical course, and early outcome are reported. RESULTS: A 14-year-old patient presenting with an apparently isolated medial epicondyle fracture was found to have examination and diagnostic test findings consistent with brachial artery transection. His injury was explored and repaired acutely, resulting in acute return of perfusion. Final follow-up revealed 0° to 130° of flexion-extension arc of motion and full pronation and supination with normal sensory and motor function of the hand. CONCLUSIONS: Pediatric medial epicondyle fractures should alert the clinician to the possibility of an occult dislocation of the elbow, and a full neurovascular assessment should be performed. Early recognition and repair of a vascular injury associated with this fracture can lead to a good outcome.