Refracture Following Operative Treatment of Pediatric Both Bone Forearm Fractures.

INTRODUCTION: Both bone forearm fractures are common injuries in children. Most can be treated with reduction and casting. Those that fail nonoperative management can be treated with a plate or intramedullary fixation; however, refracture remains a problem. The goal of this study is to evaluate the refracture rate in both bone forearm fractures based on the mode of fixation. METHODS: Institutional board review approval was obtained. A retrospective chart review from 2010 to 2021 at a single tertiary care institution was conducted for all operative patients <18 years who sustained a both bone forearm fracture. Groups were stratified based on initial operative fixation type: both bones fixated using nails, 1 bone fixated with a nail; both bones plated, and 1 bone plated. Further review was conducted to identify refractures following initial operative treatment. Statistical analyses were conducted using the χ 2 test of independence and Fisher's exact test. RESULTS: In all, 402 operatively treated both bone forearm fracture patients were identified. Two hundred fifty-six of these patients underwent intramedullary fixation (average age 10.3y/o), while 146 patients received plate fixation (average age 13.8y/o). Fracture location was similar across the nailing and plating cohorts, most often occurring in the mid-shaft region. Patients aged ≤10 years refractured at a significantly higher rate than patients aged >10 years across all operative fixation cohorts (12.5% vs. 2.5%, P <0.001). Among the 256 patients who underwent intramedullary fixation, 61.3% had both bones treated (n=157/256), whereas 38.7% received single bone fixation (n=99/256). Of the 146 plate fixations, 84.4% had both bones fixed (n=123/146), and only 15.8% were treated with single bone fixation (n=23/146). In the intramedullary group, 15 patients sustained refractures, 11 of whom were treated with single bone fixation (11.1%, n=11/99) versus 4 with both both fixation (2.5%, n=4/157). Among the plating group, 7 patients sustained refractures, 6 with both bone fixation (4.9%, n=6/123) and 1 in single bone fixation (4.3%, n=1/23). Refractures were found to be significantly more prevalent among patients treated with single bone compared with both bone intramedullary nail fixation (11.1% vs. 2.5%, P =0.006). By fixated bone, single bone ulna fixations had a higher refracture rate compared with both bone fixations (12.1% vs. 3.6%, P =0.003). CONCLUSION: The overall refracture rate following operative treatment of both bone fractures is 5.5% and is similar between intramedullary and plate fixations. Overall, patients ≤10 years of age had a higher rate of refracture. Among single bone fixations, higher refracture was seen with intramedullary fixations, and when the radius was treated nonoperatively. Surgeons may be able to reduce the refracture rate by performing intramedullary fixation of both bones instead of only one bone. Effective postoperative counseling among younger patients may also decrease refracture rates.

Olecranon Fractures in Pediatric Patients With Osteogenesis Imperfecta.

BACKGROUND: Osteogenesis imperfecta (OI) is a hereditary disorder characterized by an abnormality of the quality or quantity of type I collagen, leading to bone fragility. Fractures in children with OI may result from minor trauma and have atypical patterns. Previous studies have found a strong relationship between olecranon fractures and OI in pediatric populations, but the characteristics of olecranon fractures within the OI patient population have not been fully described. METHODS: We reviewed the records of 358 children with a diagnosis of OI. Of those, 29 had at least 1 olecranon fracture. We collected general information relating to the patient's diagnosis of OI including OI type, fracture history, mobility, and bisphosphonate treatment. Information regarding the fracture, treatment, and the occurrence of bilateral fractures were recorded, as well as weight, height, and axial bone mineral density z-score from the time of the fracture. RESULTS: Within our OI population of 358 patients, we found an incidence of olecranon fracture of 8.1% (29 patients). The olecranon fractures occurred predominantly in the type I population (27 of 29). Within the population of patients specifically with OI type I (200 patients) the incidence is 13.5%, with 6% of OI type I patients sustaining bilateral olecranon fractures. The percentage of children with one olecranon fracture subsequently sustaining another on the contralateral side was 41.4%. The mean time to the second fracture was 5 months. The mean age at the time of the first olecranon fracture was 11.9 years old. The average axial bone mineral density z-score was -2.5 for primary fractures. All 12 patients who suffered a contralateral olecranon fracture had OI type I. CONCLUSIONS: Olecranon fractures in the OI population occur most commonly in patients with type I OI and during early adolescence, a period of rapid growth. There is a high rate of bilateral olecranon fractures, with the contralateral fracture occurring quickly after the primary fracture. Further studies may elucidate risk factors to determine which patients are most likely to fracture the contralateral side and therefore drive treatment and potentially prevention. LEVEL OF EVIDENCE: Level IV-retrospective cohort study.

Pediatric Orthopedic Hoverboard Injuries: A Prospectively Enrolled Cohort.

Hoverboards pose a significant risk of musculoskeletal injury to pediatric riders. A prospectively enrolled cohort yielded 9 pediatric patients injured while riding hoverboards in 2016. Eight of the injuries involved the upper extremity, and one involved the lower extremity. No riders wore any safety equipment and injury patterns modeled those seen in skateboard riders.

Does regional loss of bone density explain low trauma distal forearm fractures in men (the Mr F study)?

The pathogenesis of low trauma wrist fractures in men is not fully understood. This study found that these men have lower bone mineral density at the forearm itself, as well as the hip and spine, and has shown that forearm bone mineral density is the best predictor of wrist fracture. INTRODUCTION: Men with distal forearm fractures have reduced bone density at the lumbar spine and hip sites, an increased risk of osteoporosis and a higher incidence of further fractures. The aim of this case-control study was to investigate whether or not there is a regional loss of bone mineral density (BMD) at the forearm between men with and without distal forearm fractures. METHODS: Sixty-one men with low trauma distal forearm fracture and 59 age-matched bone healthy control subjects were recruited. All subjects underwent a DXA scan of forearm, hip and spine, biochemical investigations, health questionnaires, SF-36v2 and Fracture Risk Assessment Tool (FRAX). The non-fractured arm was investigated in subjects with fracture and both forearms in control subjects. RESULTS: BMD was significantly lower at the ultradistal forearm in men with fracture compared to control subjects, in both the dominant (mean (SD) 0.386 g/cm2 (0.049) versus 0.436 g/cm2 (0.054), p < 0.001) and non-dominant arm (mean (SD) 0.387 g/cm2 (0.060) versus 0.432 g/cm2 (0.061), p = 0.001). Fracture subjects also had a significantly lower BMD at hip and spine sites compared with control subjects. Logistic regression analysis showed that the best predictor of forearm fracture was ultradistal forearm BMD (OR = 0.871 (0.805-0.943), p = 0.001), with the likelihood of fracture decreasing by 12.9% for every 0.01 g/cm2 increase in ultradistal forearm BMD. CONCLUSIONS: Men with low trauma distal forearm fracture have significantly lower regional BMD at the ultradistal forearm, which contributes to an increased forearm fracture risk. They also have generalised reduction in BMD, so that low trauma forearm fractures in men should be considered as indicator fractures for osteoporosis.

The Selfie Wrist - Selfie induced trauma.

The selfie phenomenon has exploded worldwide over the past two years. Selfies have been linked to a large number of mortalities and significant morbidity worldwide. However, trauma associated with selfies including fractures, is rarely publicised. Here we present a case series of upper extremity trauma secondary to selfies across all age groups during the summer period. Four cases of distal radius and ulna trauma in all age groups were reported. This case series highlights the dangers associated with taking selfies and the trauma that can result.

Risk factors for re-fracture in children with diaphyseal fracture of the forearm treated with elastic stable intramedullary nailing.

A retrospective study aims to investigate predisposing factors leading to re-fracture in patients with nails still in place and to identify potential correlations between nail size-to-medullary canal diameter ratio and re-fracture, working to the hypothesis that a higher ratio correlates with a higher risk of re-fracture. Rates of re-fracture with nail still in place after forearm elastic stable intramedullary nailing are higher in younger pediatric patients. Re-fractures occurred at a mean age of 6.7 years (range 5-8.7). While the role of body frame and bone medullary diameter remains unclear, there are grounds for adjusting treatment strategy for age, weight and bone medullary diameter to achieve effective outcome. History of previous forearm fracture and open treatment may also be further risk factors.

Prior ankle fractures in postmenopausal women are associated with low areal bone mineral density and bone microstructure alterations.

UNLABELLED: In a cross-sectional analysis in postmenopausal women, prior ankle fractures were associated with lower areal bone mineral density (BMD) and trabecular bone alterations compared to no fracture history. Compared to women with forearm fractures, microstructure alterations were of lower magnitude. These data suggest that ankle fractures are another manifestation of bone fragility. INTRODUCTION: Whether ankle fractures represent fragility fractures associated with low areal bone mineral density (aBMD) and volumetric bone mineral density (vBMD) and/or bone microstructure alterations remains unclear, in contrast to the well-recognised association between forearm fractures and osteoporosis. The objective of this study was to investigate aBMD, vBMD and bone microstructure in postmenopausal women with prior ankle fracture in adulthood, compared with women without prior fracture or with women with prior forearm fractures, considered as typically of osteoporotic origin. METHODS: In a cross-sectional analysis in the Geneva Retirees Cohort study, 63 women with ankle fracture and 59 with forearm fracture were compared to 433 women without fracture (mean age, 65 ± 1 years). aBMD was measured by dual-energy X-ray absorptiometry; distal radius and tibia vBMD and bone microstructure were measured by high-resolution peripheral quantitative computed tomography. RESULTS: Compared with women without fracture, those with ankle fractures had lower aBMD, radius vBMD (-7.9%), trabecular density (-10.7%), number (-7.3%) and thickness (-4.6%) and higher trabecular spacing (+14.5%) (P < 0.05 for all). Tibia trabecular variables were also altered. For 1 standard deviation decrease in total hip aBMD or radius trabecular density, odds ratios for ankle fractures were 2.2 and 1.6, respectively, vs 2.2 and 2.7 for forearm fracture, respectively (P ≤ 0.001 for all). Compared to women with forearm fractures, those with ankle fractures had similar spine and hip aBMD, but microstructure alterations of lower magnitude. CONCLUSION: Women with ankle fractures have lower aBMD and vBMD and trabecular bone alterations, suggesting that ankle fractures are another manifestation of bone fragility.

Upper extremity fractures among hospitalized road traffic accident adults.

BACKGROUND: Upper extremity fractures (UEFs) associated with road traffic accidents (RTAs) may result in long-term disability. Previous studies have examined UEF profiles with small patient populations. The objective of this study was to examine the injury profiles of UEFs in all mechanisms of injury related to RTAs. METHODS: Data on 71,231 RTA adult patients between 1997 and 2012 whose records were entered in a centralized country trauma database were reviewed. Data on UEFs related to mechanism of injury (car, motorcycle, bicycle, and pedestrian) including associated injuries, multiple UEFs, and frequency of UEF were analyzed. RESULTS: Of 71,231 adult RTA cases recorded in 1997-2012, 12,754 (17.9%) included UEFs. Motorcycle (27%) and bicycle riders (25%) had the greater risk for UEF (P<.0001). Of 12,754 patients with UEFs, 9701 (76%) had other injuries. Pedestrians (86%) and car occupants (81%) had the greater risk for associated injuries (P<.0001). Most of the injuries were head/face/neck (52%), lower extremities (49%), and chest (46%) injuries (P<.0001). Twenty-two percent of all cases had multiple UEFs. The motorcycle riders (27%) had the greater risk for multiple UEFs (P<.0001). Of 12,754 patients with UEFs we found 16,371 UEFs. Most of the fractures were in the radius (22%), humerus (19%), and clavicle (17%) (P<.0001). CONCLUSIONS: This study contributes the largest database on reported adult UEFs related to all mechanisms of injury in RTAs and finds the comparative epidemiology of associated injuries, multiple UEFs, and frequency of UEFs. It is important that the treating surgeon is aware of the complexity of the UEF patient, the strong possibility for associated injury, the possibility for multiple fractures in the upper limbs, and the most common fractures associated with each mechanism of accident.

The Factors Influencing the Refracture of Pediatric Forearms.

PURPOSE: Pediatric forearm fractures are common and usually heal uneventfully. The purpose of this study was to review the refracture rate and to identify trends and risk factors that may lead to a refracture. METHODS: Using current procedure terminology code and subsequent chart review we retrospectively identified 2590 patients who sustained forearm fractures over the past 10 years (2000 to 2010) and were treated at a single, large pediatric orthopaedic practice. RESULTS: We identified 37 patients who met our search criterion which yielded a refracture rate of 1.4%. Average length of immobilization was 72.2 days for initial fractures and 98.2 days for refractures. Average time to refracture after declared healing of initial injury was 128.7 days with 36% of refractures occurring within 6 weeks of clinical clearance. Fractures with ≥ 15 degrees angulation refractured earlier (mean 40 d). Seventy-one percent (71%) of patients with refractures had ≥ 10 degrees residual angulation at the time of union of the initial fracture. There was complete radiographic healing in 72% of patients that subsequently refractured. Forearm fractures that refractured most commonly occurred in the middle third (72%), with 24% in the proximal third and 4% in the distal third. Only 2 of 28 patients required surgical instrumentation of the forearm to achieve union of the refracture. We identified a trend toward longer immobilization and time to clinical clearance following a refracture, 76.4 versus 104.2 days. CONCLUSIONS: Over the past 10 years, our clinical data identifies a 1.4% refracture rate, which is significantly less than the previously published rate of 5%. Fractures with greater residual angulation (> 15 degrees) showed a tendency toward earlier refracture and may warrant longer immobilization. Forearm refractures united in most instances with closed treatment. Our treatment with cast or protective brace immobilization and limitation of activity until complete radiographic union likely influences our improved refracture rates.

Limb Fractures Treated With the Novel Plate Osteosynthesis Application Technique: Second to Minimally Invasive Plates osteosynthesis.

BACKGROUND: The main aim of this article was to propose a new concept of minimally invasive surgery for treating limb fractures, named as second to minimally invasive plates osteosynthesis (STMIPO). METHODS: We have described the STMIPO technique in a step-wise and standardized manner based on our findings from a study involving six patients treated at our institution. All patients with fracture achieved satisfactory outcomes. RESULTS: Ours clinical trials have shown that the STMIPO technique can be successfully applied in various limb fractures, including fibula fractures, tibial fractures, femur fractures, humerus fractures, ulna fractures, and radius fractures. All fracture patients achieved satisfactory outcomes. CONCLUSION: As a new minimally invasive technology, the STMIPO technique can serve as an alternative solution for fractures that are difficult to reduce with minimally invasive plates osteosynthesis (MIPO).

Treatment of an Ulnar Fracture Bone Defect Using Heterotopic Bone Autograft: A Case Report.

CASE: Autologous bone grafting has wide applications for the treatment of bony defects. Generally, cancellous or corticocancellous bone grafts are used depending on the characteristics and size of the bony defect and wound bed. The use of heterotopic bone as a potential source of bone graft has not been widely reported. We present a 56-year-old right-hand-dominant male victim of dog mauling who sustained a right ulnar fracture with a 5-cm bony defect, treated with the use of heterotopic bone autograft. CONCLUSION: Heterotopic bone can be successfully used as an autograft in the treatment of bony defects.

Re-fractures of the paediatric radius and/or ulna: A systematic review.

BACKGROUND: Fractures of the radius and/or ulna are one of the most common injuries in children. Evidence identifying risk factors for refracture, however, has not been summarised in a systematic review. Guidance for counselling patients and parents to minimise the risk of refracture is limited. The aims of this study are to 1) to determine if casting time 6 weeks or less is a risk factor for refracture after paediatric radius and/or ulna fractures, 2) to identify other risk factors for refracture after paediatric radius and/or ulna fractures and 3) to develop more accurate guidelines for counselling parents after a radius and/or ulna fracture in their child. METHODS: A thorough search was performed in accordance with the Joanna Briggs Institute (JBI) guidelines for systematic review. JBI Critical Appraisal checklists were used for risk of bias assessment. RESULTS: Diaphyseal both-bone fractures treated non-surgically should be casted for longer than 6 weeks. Surgically treated patients can be casted for less than 6 weeks. Diaphyseal and greenstick fractures have a higher risk of refracture. Residual angulation and incomplete healing in greenstick fractures may lead to a higher risk of refracture. Gender does not affect refracture risk. Falls, use of wheeled vehicles, playground activities and trampolining confer high-risk of refracture. Refracture risk is greatest up to 9 months from initial fracture. CONCLUSION: Further case-controlled studies with sub-group analysis are required to further investigate risk factors for refracture after radius and/or ulna fractures in children.

Single Modified Posterior Approach through the Space of the Proximal Radioulnar Joint for Terrible Triad Injury: A Comparative Study.

OBJECTIVE: In order to reduce surgical scars and the risk of neurovascular injury for the treatment of terrible triad injuries of the elbow (TTI), minimally invasive and better therapeutic effect approaches are being explored to replace the conventional combined lateral and medial approach (CLMA). This study was performed to compare the clinical effect and security of the modified posterior approach (MPA) through the space of the proximal radioulnar joint vs the CLMA for treatment of TTI. METHODS: This study retrospectively analyzed 76 patients treated for TTI from January 2009 to December 2020 (MPA: n = 44; CLMA: n = 32). Treatment involved plate and screw fixation or Steinmann pin fixation for the radial head and ulnar coronoid process fractures. Surgeons only sutured the lateral ligament because the medial collateral ligament was usually integrated in the TTI. The continuous variables were compared by the independent Student t-test and the categorical variables by the χ2 -test or Fisher's exact test. RESULTS: Both groups of patients attained a satisfactory MEPS after the operation. The MEPS (MPA: 96.82 ± 6.04 vs CLMA: 96.56 ± 5.51) was not significantly different between the two groups (p > 0.05). However, the MPA resulted in better elbow flexion and extension (MPA: 123.98 ± 10.09 vs CLMA: 117.66 ± 8.29), better forearm rotation function (MPA: 173.41 ± 6.81 vs CLMA: 120.00 ± 12.18), and less intraoperative hemoglobin (MPA: 9.34 ± 5.64 vs CLMA: 16.5 ± 8.75) and red cell volume loss (MPA: 3.09 ± 2.20 vs CLMA: 6.70 ± 2.97) (All p < 0.05). Although the CLMA had a shorter surgery time (MPA: 171.73 ± 80.68 vs CLMA: 130.16 ± 71.50) (p < 0.05), it had a higher risk of neurologic damage (MPA: 0 vs CLMA: 4) (p < 0.05). Four patients developed forearm or hand numbness after the CLMA, but no patients developed numbness after the MPA. All 76 patients were followed up for 15 months postoperatively. CONCLUSION: The MPA through the space of the proximal radioulnar joint has more prominent advantages than the CLMA for TTI, including single scar, clear exposure, good fixation, lower risk of neurovascular injury, and better elbow joint motion. It is a safe and effective surgical approach that is worthy of clinical promotion.

Retrospective analysis: risk factors predicting failure of closed reduction in pediatric diaphyseal forearm fractures treated with elastic stable intramedullary nails (ESINs).

LEVEL OF EVIDENCE: Level IV.

Anteroposterior Cannulated Screw Fixation of Coronoid Fractures in Terrible Triad Injuries: A Simple Syringe-guided Technique.

OBJECTIVE: The fixation of the coronoid fractures in terrible triad injuries is quite challenging. In this study, we introduce a minimally invasive technique using a syringe as a guide for insertion of the cannulated screw in an anterior to posterior fashion to fix the coronoid fracture in patients with terrible triad injuries. METHODS: In this retrospective study, clinical data of patients suffering from terrible triad injuries between 2012 and 2019 were analyzed. Fifteen patients with an average age of 38.2 years old (21-56 years) were enrolled in this study, of which 12 were males and three were females. The Regan-Morrey type II and type III coronoid fractures in these patients were treated with cannulated screws, inserted anteriorly using a 1 mL syringe as a guide. Outcome measures included pain, range of motion, stability and daily function using Mayo Elbow Performance scores (MEPs). The anteroposterior and lateral radiographs were used for evaluating a healing fracture. RESULTS: After a mean follow up of 44.2 months (range 13-80), the mean elbow flexion was 128.2°, extension was 12.3°, forearm pronation was 74.6° and supination was 73.6°. A concentric reduction was maintained without severe pain, stiffness, and radiographic evidence of instability in all patients during the follow-up period. The mean MEPs was 89.7 points. CONCLUSION: The anteroposterior cannulated screw fixation via simple syringe guide is a minimally invasive and safe option for surgical treatment of coronoid fractures in terrible triad injuries.

Fracture risk in children with a forearm injury is associated with volumetric bone density and cortical area (by peripheral QCT) and areal bone density (by DXA).

UNLABELLED: Children who sustain a forearm fracture when injured have lower bone density throughout their skeleton, and have a smaller cortical area and a lower strength index in their radius. Odds ratios per SD decrease in bone characteristics measured by peripheral quantitative computed tomography (pQCT) and dual-energy X-ray absorptiometry (DXA) were similar (1.28 to 1.41). INTRODUCTION: Forearm fractures are common in children. Bone strength is affected by bone mineral density (BMD) and bone geometry, including cross-sectional dimensions and distribution of mineral. Our objective was to identify bone characteristics that differed between children who sustained a forearm fracture compared to those who did not fracture when injured. METHODS: Children (5-16 years) with a forearm fracture (cases, n = 224) and injured controls without fracture (n = 200) were enrolled 28 ± 8 days following injury. Peripheral QCT scans of the radius (4% and 20% sites) were obtained to measure volumetric BMD (vBMD) of total, trabecular and cortical bone compartments, and bone geometry (area, cortical thickness, and strength strain index [SSI]). DXA scans (forearm, spine, and hip) were obtained to measure areal BMD (aBMD) and bone area. Receiver operating characteristic (ROC) analyses were used to assess screening performance of bone measurements. RESULTS: At the 4% pQCT site, total vBMD, but not trabecular vBMD or bone area, was lower (-3.4%; p = 0.02) in cases than controls. At the 20% site, cases had lower cortical vBMD (-0.9%), cortical area (-2.8%), and SSI (-4.6%) (p < 0.05). aBMD, but not bone area, at the 1/3 radius, spine, and hip were 2.7-3.3% lower for cases (p < 0.01). Odds ratios per 1 SD decrease in bone measures (1.28-1.41) and areas under the ROC curves (0.56-0.59) were similar for all bone measures. CONCLUSIONS: Low vBMD, aBMD, cortical area, and SSI of the distal radius were associated with an increased fracture risk. Interventions to increase these characteristics are needed to help reduce forearm fracture occurrence.

[Treatment of long bone fractures in 125 newborn calves. A retrospective study]. / Behandlung von Frakturen der langen Röhrenknochen bei 125 neugeborenen Kälbern. Eine retrospektive Untersuchung.

OBJECTIVES: Retrospective study of the causes, location, configuration, treatment and outcome of long bone fractures in newborn calves. MATERIAL AND METHODS: The medical records of 125 calves presented during a 16-year period because of fracture of the humerus (3 calves), radius/ulna (14), femur (50) or tibia (58) were evaluated. The majority of calves (61.6%) sustained the fractures during assisted delivery. Of 125 calves, 107 were treated and 18 were euthanized because of concurrent diseases. Conservative treatment was used in 16 calves and surgical treatment in 91. Four of the latter were euthanized because of muscle contraction which prevented fracture reduction, and five others died in surgery. RESULTS: Fracture healing occurred after conservative treatment in 10 of 16 calves and after surgical treatment in 44 of 82 calves. The outcome was better in calves with plate and clamp-rod internal fixation (37/58 healed) than with intramedullary pinning (4/16 healed) or external fixation (3/8 healed). There were significant associations (chi2-test, p<0.01) between concurrent diseases and choice of therapy and fracture healing. Of 67 calves that developed complications, only 26 could be cured. Common complications were implant loosening and instability, which were often followed by osteomyelitis and sepsis. Implants were removed in 39 of 44 surgically treated calves that survived up to 6 months postoperatively. Long-term follow up (> 6 months postoperatively) by clinical and radiographic re-examination (25 calves) or telephone inquiry (29 calves) revealed that 54 animals were sound and had returned to their intended use. CONCLUSIONS AND CLINICAL RELEVANCE: The treatment of long bone fractures in newborn calves remains difficult because of a high incidence of complications. These are most likely attributable to trauma during delivery, which results in insufficient colostrum intake and predisposes to concurrent diseases. In addition, the characteristics of juvenile bones do not provide sufficient physical strength for implants. Therefore, professional and diligent assistance during forced extraction, particularly in presentations with "stifle lock" or "hip lock", is required to minimize the incidence of long bone fractures in newborn calves. Most cases require surgical fixation, which is time consuming, expensive and carries a guarded prognosis.

Spontaneous bilateral distal ulna fracture: an unusual complication in a rheumatoid patient.

Bilateral ulna stress fractures are extremely rare. Patients with rheumatoid arthritis have osteopenic bone secondary to a variety of causes. We report a case of bilateral stress fractures of the ulna in an elderly patient with rheumatoid arthritis, and literature on this condition is reviewed. Prompt recognition and activity modification are essential to treat this rare injury. Recovery can take up to 12 weeks.

Refracture after plate removal following ulnar shortening osteotomy for ulnar impaction syndrome - a retrospective case-control study.

LEVEL OF EVIDENCE: Level III, case-control study.