Arthroscopic Management of Elbow Fractures

Is partial excision of the radial head safe and effective in all-arthroscopic treatment of terrible triad fractures?

BACKGROUND

Our study aimed to evaluate the clinical and radiologic results of all-arthroscopic treatment of terrible triad injuries followed-up for a minimum of 5 years and investigate how arthroscopic partial excision for radial head fractures affects the results at the final follow-up.

METHODS

We retrospectively reviewed consecutive patients with terrible triad injuries who underwent all-arthroscopic treatment between January 2011 and June 2018. In group I, we performed conservative or arthroscopic fixation of stable radial head fractures, while in group II, arthroscopic partial excision of unstable radial head fractures involving <30%-50% of the articular surface area was performed. Clinical outcomes were measured by visual analog scale score and assessment of instability, range of motion (ROM), and Mayo Elbow Performance Score. Radiological outcomes were evaluated using x-rays, and the integrity of the repaired lateral collateral ligament complex was confirmed through magnetic resonance imaging.

RESULTS

Thirty-two patients with an average age of 49.5±16.2 years met the inclusion criteria and were followed-up for a mean of 82.7±22.2 months. Twenty patients were assigned to group I and 12 patients to group II. Clinical outcomes showed no significant differences between the two groups at the final follow-up (P>0.05). On radiological evaluation, more heterotopic ossifications were found in the radial head excision group (group II, 66.7% vs. group I, 35%; P=0.02); however, there was no significant difference in ROM between the two groups (P>0.05).

CONCLUSIONS

In all-arthroscopic treatment of terrible triad injuries, arthroscopic partial excision of the radial head did not seem to have a significant impact on elbow joint stability. Level of evidence: III.

Clinical Outcomes and Management Strategies for Capitellum and Trochlea Fractures: A Systematic Review

Purpose

Capitellum and trochlea fractures, also referred to as coronal shear fractures of the distal humerus, are infrequent yet challenging intra-articular fractures of the elbow. There are a variety of surgical approaches and fixation methods with often variable outcomes. This systematic review investigates interventions, outcomes and complications of capitellum and trochlea fractures.

Methods

A systematic review of studies published in MEDLINE, EMBASE, Web of Science and Cumulative Index to Nursing and Allied Health literature (CINAHL) was conducted to assess the clinical outcomes of capitellum and trochlea fractures managed surgically. Data on patient demographics, surgical approach, implant usage, postoperative outcomes and complications were compiled.

Results

Forty-one studies met the inclusion criteria with a total of 700 patients. Surgical interventions primarily utilized either the lateral (79%) or antero-lateral (15%) approaches with headless compression screws as the most common fixation method (68%). Clinical outcomes were measured using the Mayo Elbow Performance Index (MEPI) with a mean score of 89.9 (±2.6) and the DASH score with a mean of 16.9 (±7.3). Elbow range of motion showed a mean flexion of 126.3° (±19.4), extension of 5.71° (±11.8), pronation of 75.23° (±12.2), and supination of 76.6° (±9.8). The mean flexion-extension arc was 113.7° (±16.9), and the mean pronation-supination arc was 165.31° (±9.41). Complications occurred in 19.8% of cases, with re-interventions required in 8.3% of cases, mainly due to symptomatic implants and elbow stiffness requiring surgical release. Other complications included implant removal (10.4%), overall reported stiff elbows (6%), nerve palsies (2%), non-union (1.5%), and infection (1.2%).

Conclusion

The treatment of capitellum and trochlea fractures yields satisfactory outcomes but has a considerable rate of complications and reoperations primarily due to symptomatic implants and elbow stiffness. There is noteworthy variability in the achieved range of motion, suggesting unpredictable outcomes. Deficits in functionality and range of motion are common after surgery, especially with more complex injury patterns.

Articular fracture of the distal humerus classified Dubberley 2b: Case report of two patients and review of the literature

Articular fractures of the distal humerus are rare, and even rarer are fractures involving the trochlea and capitellum in a single fragment, with no associated comminution. These fractures are classified as 2a according to the Dubberley classification and are rarely described in the literature. Two cases of Dubberley 2a fractures were treated at our hospital. The first case, involving a 68-year-old patient, was treated with a medial and a lateral approach, combined with posteroanterior fixation using 3 Herbert screws. In the 2nd case, a 16-year-old male was treated with a single lateral approach, permitting fixation with two Herbert screws. One of the two screws is inserted into the bone at the edge of the cartilage, with an anteroposterior trajectory that leaves the cartilage intact. We opted mainly for posteroanterior screw fixation in subchondral bone, which is less damaging to articular cartilage and soft tissues and has already demonstrated its reliability. No associated lesions were found, and no complications were encountered. Results were excellent, with Mayo Elbow Performance Index (MEPI) scores of 95 and 100 respectively. Herbert screw fixation therefore appears to be an option of choice for these fractures, although comparative studies are needed to evaluate the different treatments available.

The role of arthroscopy in the management of adult elbow trauma

Fractures around the elbow are often challenging to treat and in most cases require an extensive approach. Since the development of elbow arthroscopy, most authors have pointed out the potential advantages of a less invasive technique that can be useful for visualization and reduction of the articular fragments with an eventual percutaneous fixation. Arthroscopic techniques provide a limited exposure that may lead to a faster wound healing, lower rate of complications and thus, better recovery of range of motion. However, elbow arthroscopy is also a demanding technique, especially in a swollen and fractured joint, and it is not exempt of risks. The overall rate of complications has been rated from 1.5% to 11% and nerve injury rates from 1.26-7.5%.The objective of this review is to present the arthroscopic setup and general surgical technique for the management of elbow trauma and to define some clear indications. Patient positioning and operating room display is key in order to obtain success. In addition to the arthroscopic equipment, fluoroscopy is almost always necessary for percutaneous fixation and precise preparation is mandatory. In the last decade, literature regarding new portals or surgical tips for arthroscopic treatment of elbow fractures have been published.The main indications for fracture arthroscopic-assisted fixation are those articular fractures involving the coronoid, distal humerus shear fractures in the coronal plane (trochlear and capitellum fractures) and, more controversially, those affecting the radial head. The treatment of these type of fractures all arthroscopically is exponentially demanding as it might also require ligament repair. For coronoid fractures, it can be useful in Morrey type II and III, and O´Driscoll anteromedial facet fractures associated to a posteromedial instability pattern that also require a repair of the LCL. Although excellent results have been published, comparative series are scarce. Radial head fractures can also be approached arthroscopically in simple non-comminute fractures that can be fixed percutaneously.In conclusion, arthroscopy of the elbow is an excellent tool to better understand and visualize articular fractures of the elbow. However, despite the advances in surgical technique, whether it improves clinical and radiological results is still to be proven.

Prevalence, Timing, Locational Distribution, and Risk Factors for Heterotopic Ossification After Elbow Arthroscopy

BACKGROUND

Arthroscopic techniques aim to reduce complications and accelerate recovery of the elbow after treatments for posttraumatic stiffness, arthritis diseases, lateral epicondylitis, ligament reconstruction, and elbow trauma. However, data on the true prevalence and characteristics of heterotopic ossification (HO) formation after elbow arthroscopy are limited.

PURPOSE

To investigate the prevalence, timing, locational distribution, and risk factors of HO after elbow arthroscopy.

STUDY DESIGN

Cohort study; Level of evidence, 4.

METHODS

Data on 205 patients undergoing elbow arthroscopy by a single senior elbow surgeon at a single institution between May 2011 and January 2022 were retrospectively reviewed. The patients were evaluated at 2 weeks, 8 weeks, 6 months, and then annually after surgery or more frequently if HO developed, with a minimum of 1 year of postoperative follow-up. Postoperative anteroposterior and lateral elbow radiographs were taken at 2 weeks to rule out fracture and at 8 weeks to identify HO. The clinical outcomes were evaluated based on the pain visual analog scale; the shortened version of the Disabilities of the Arm, Shoulder and Hand score; Mayo Elbow Performance Score; and the Single Assessment Numeric Evaluation scores before and after surgery. Bivariate logistic regression analyses were used to determine factors affecting HO prevalence.

RESULTS

Thirteen (12 male, 1 female) of 205 (6.3%) patients developed HO, with 10 (76.9%) with HO that formed on the medial compartment of the elbow. Ten (76.9%) patients were diagnosed at 8 weeks after arthroscopic surgery, 1 (7.7%) at 6 months after surgery, and 2 (15.4%) at 12 months after surgery. HO was not found at 2 weeks after surgery in any patient. The mean follow-up time was 3.5 years (range, 1.0-11.8 years). Eleven asymptomatic patients were treated nonoperatively, and 2 symptomatic patients underwent HO excision arthroscopically or had a combination of open surgery and arthroscopy. Age was a protective factor for HO formation (odds ratio [OR], 0.953; 95% CI, 0.910-0.999; P = .047). The risk factors for HO formation were tourniquet time (OR, 1.042; 95% CI, 1.019-1.065; P < .001) and surgical time (OR, 1.026; 95% CI, 1.011-1.041; P < .001).

CONCLUSION

Among 205 patients who underwent elbow arthroscopy, HO was a minor complication of elbow arthroscopy, with a prevalence rate of 6.3%, and was usually located on the medial compartment of the elbow. Although the presence of HO may not affect the clinical outcomes in most patients, it should be carefully monitored for a minimum of 8 weeks postoperatively. Younger age, longer tourniquet time, and longer surgical time contributed to HO formation after elbow arthroscopy.

Arthroscopic-Assisted Fracture Fixation About the Elbow

Arthroscopic-assisted fracture fixation can be used for some adult elbow fractures. In particular, for articular fractures of the anterior elbow (coronoid/capitellum), elbow arthroscopy can provide excellent visualization of fracture fragments using a less invasive surgical exposure. Meticulous adherence to safe techniques and utilization of specialized equipment can help maximize safety and facilitate reproducible surgical results.

Coronoid fractures and traumatic elbow instability

The coronoid process is key to concentric elbow alignment. Malalignment can contribute to post-traumatic osteoarthritis. The aim of treatment is to keep the joint aligned while the collateral ligaments and fractures heal. The injury pattern is apparent in the shape and size of the coronoid fracture fragments: (1) coronoid tip fractures associated with terrible triad (TT) injuries; (2) anteromedial facet fractures with posteromedial varus rotational type injuries; and (3) large coronoid base fractures with anterior (trans-) or posterior olecranon fracture dislocations. Each injury pattern is associated with specific ligamentous injuries and fracture characteristics useful in planning treatment. The tip fractures associated with TT injuries are repaired with suture fixation or screw fixation in addition to repair or replacement of the radial head fracture and reattachment of the lateral collateral ligament origin. Anteromedial facet fractures are usually repaired with a medial buttress plate. If the elbow is concentrically located on computed tomography and the patient can avoid varus stress for a month, TT and anteromedial facet injuries can be treated nonoperatively. Base fractures are associated with olecranon fractures and can usually be fixed with screws through the posterior plate or with an additional medial plate. If the surgery makes elbow subluxation or dislocation unlikely, and the fracture fixation is secure, elbow motion and stretching can commence within a week when the patient is comfortable.

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

BACKGROUND

Varus posteromedial rotatory instability is a typical pattern of elbow injury that involves fracture of the anteromedial facet (AMF) of the coronoid, as well as injuries to the lateral ligament complex and the posterior bundle of the medial collateral ligament. Some authors support the idea that subtype II AMF coronoid fractures require fixation to restore elbow stability, but this topic is still an issue in the literature. The purpose of this study was to assess the clinical and radiologic outcomes of arthroscopically assisted reduction and internal fixation (ARIF) of AMF fractures.

METHODS

This retrospective single-center trial evaluated consecutive patients who underwent ARIF of isolated subtype II AMF coronoid fractures between 2014 and 2020. At the final follow-up, the patients were examined for elbow range of motion, stability, and pain. Injury and post-treatment radiographs were reviewed to assess fracture healing and heterotopic ossification.

RESULTS

A total of 32 patients (21 male and 11 female patients) with a median age of 47 ± 16 years were included. The average follow-up period was 28 ± 12.4 months. Coronoid process fractures were fixed by cannulated screws in 26 cases (81.25%); in 2 of these cases, additional Kirschner wires were used. Two Kirschner wires were used in 1 case (3.12%), and in the remaining 5 cases (15.62%), osteosuture was used. The lateral ulnar collateral ligament was injured in 27 cases (84.4%) and was always repaired. Other associated lesions were medial collateral ligament injury, osteochondral lesion, and radial head fracture. There were no surgical complications. At the final follow-up, the average Mayo Elbow Performance Score was 98.4 ± 2.7 and the mean Oxford Elbow Score was 47.3 ± 1.4. No cases of nonunion were detected on radiographic assessment.

CONCLUSIONS

Although technically demanding, ARIF has several potential advantages in comparison to open surgery: less scarring, a decreased risk of infection, and less postoperative pain.

Coronal Shear Fractures of the Distal Humerus: A Review of Diagnosis, Treatment, and Outcomes

Fractures of the capitellum and trochlea are uncommon fractures of the elbow and can be challenging to treat due to their size, location, and articular nature. Because of their intra-articular nature and predilection toward displacement, these fractures are typically treated operatively. Furthermore, capitellum fractures have high rates of associated injuries, including radial head fractures or lateral collateral ligament injury in ~30% to 60% of patients. In addition to open reduction internal fixation, operative options include fragment excision, arthroscopic assisted reduction and fixation, and elbow arthroplasty. In this article, we undertake a comprehensive literature review of capitellum fractures of the distal humerus, in an attempt to summarize the existing body of evidence and propose areas of future study.

Arthroscopic Repair of a Coronoid Process Fracture: A Case Report

CASE

A 68-year-old woman sustained an isolated type III left coronoid fracture after mechanical ground-level fall. The patient underwent left elbow arthroscopy with minimally invasive arthroscopic reduction and internal fixation of the coronoid fracture using Arthrex Mini TightRope. The patient achieved successful elbow stabilization with a postoperative Mayo Elbow Score of 100.

CONCLUSION

We present a case report of a novel technique in coronoid fracture management with stable fixation, minimal soft-tissue violation, and restoration of highly functional elbow range of motion. Minimal soft-tissue violation with use of arthroscopy and suture button was the key element in successful surgical treatment and outcome.

Arthroscopy of the Pediatric Elbow: Review of the Current Concepts

As surgeons have become more familiar with elbow arthroscopy, the indications for arthroscopy of the pediatric elbow have expanded to include contracture releases, fracture fixation, treatment of osteochondritis dissecans (OCD) lesions, correction of elbow deformity, and debridement of soft tissue and bony pathologies. The treatment of various pathologies via an arthroscopic approach demonstrates equal, if not better, efficacy and safety as open surgery for the pediatric elbow. Arthroscopy provides the unique advantage of enabling the performance of extensive surgeries through a minimally-invasive approach, and it facilitates staged interventions in cases of increased complexity. For fracture work, arthroscopy enables direct visualization to assess reduction for percutaneous fixations. While future research is warranted to better evaluate the indications and outcomes of pediatric elbow arthroscopy, this update article presents a review of the current literature, as well as several innovative cases highlighting the potential of arthroscopy.

Diagnostic and Therapeutic Elbow Arthroscopy Using Small-Bore Needle Arthroscopy

Needle arthroscopy may provide several potential advantages over standard arthroscopy. The smaller camera size and weight allows for a minimally invasive and percutaneous approach with decreased fluid use. As resolution and image quality improve, the potential to expand clinical use for therapeutic applications becomes possible. One promising use is in elbow arthroscopy. Difference in the technology, such as a zero-degree optic and less-rigid instrumentation, necessitate a modified technique to accommodate thorough diagnostic arthroscopy and therapeutic procedures. This manuscript introduces the authors' approach to diagnostic needle arthroscopy of the anterior and posterior elbow compartments and placement of therapeutic instrumentation. This technique could theoretically decrease the risk of iatrogenic neurovascular injuries, reduce postoperative swelling and pain due to decreased fluid use, and potentially lead to faster recovery.

The anterior limited approach of the elbow for the treatment of capitellum and trochlea fractures: Surgical technique and clinical experience in eight cases

When a coronal fracture affects the capitellum and the trochlea, the Kocher lateral approach may be inadequate for the correct visualisation, reduction and fixation of the fracture. In such cases an associated medial elbow approach may be required, or a posterior transolecranon approach may be preferred. The anterior limited approach to the elbow (ALAE) could be a valid option when treating these types of fracture, as it does not involve the detachment of any muscle group or ligament, thereby facilitating the recovery process. We can also treat associated injuries such as fractures of the radial head or coronoid process with this approach. We describe the surgical technique and the functional outcome of eight patients with a mean of 66 years of age (range, 53-76) who where treated with open reduction and internal fixation for capitellar and trochlear fractures through the ALAE. Patient outcomes were assessed with physical and radiological evaluation, range-of-motion measurements with a follow-up from 24 to 60 months. Two different quality of life questionnaires were carried out: the EuroQol Five Dimensions Questionnaire (EQ-5D) and the patient-answered questionnnaire of the Liverpool Elbow Score patient (PAQ-LES). Four fractures involved the capitellum, one involved the capitellum with the lateral ridge of the trochlea, and three involved the capitellum and trochlea as separate fragments. The patients presented a favorable clinical evolution at a median of 33 months (range, 24-60), with an average of motion of 10-138°. Four patients presented a fracture of the head of the radius (Mason type 2) and 3 fractures of the coronoid (Bryan-Morrey Type 1) associated. All the patients presented radiological consolidation without signs of osteonecrosis, being the average EQ-5D 0.857 (range, 0.36-1.0) and the PAQ-LES of 35 (range 17 to 36). Patients with isolated capitellar fractures had better results than those with trochlear involvement. The presence of associated fractures does not seem to worsen the results. We believe that the ALAE is a technical option to consider for the open surgical treatment of a capitellar fracture with or without involvement of the trochlea. LEVEL OF EVIDENCEIS: Therapeutic Level III.

Case Series of All-Arthroscopic Treatment for Terrible Triad of the Elbow: Indications and Clinical Outcomes

PURPOSE

To evaluate the results of all-arthroscopic treatment of the terrible triad of the elbow, a combination of elbow dislocation, radial head dislocation, and coronoid process fracture, and its complications.

METHODS

We performed a retrospective review of consecutive patients with terrible triad who underwent all-arthroscopic treatment between January 2011 and December 2016. All-arthroscopic treatment was performed in the unstable elbows after manual reduction. Clinical evaluation was performed at least 2 years postoperatively. Patients with another fracture in the upper extremity and previous fracture of the affected elbow were excluded. A radial head fracture that was stable enough to reduce or involved less than 25% of the articular surface for partial excision and Regan-Morrey classification type I and type II coronoid process fractures were treated arthroscopically. Range of motion, radiologic outcomes, surgical complications, and the Mayo Elbow Performance Score were evaluated at the final follow-up. The Mann-Whitney test was used for statistical analysis.

RESULTS

A total of 24 patients met the inclusion criteria, and the average age was 47.6 years. Coronoid process fractures were fixed in all patients, by use of Kirschner wires in 15 (62.5%) and pullout sutures in 9 (37.5%). Radial head fractures were treated using screw or K-wire fixation in 4 patients (16.7%); only the fragment of the fracture was resected in 11 patients (45.8%). In all 24 cases (100%), the lateral collateral ligaments were repaired. At the final follow-up, the mean flexion contracture angle was 4.8° ± 1.1° and the mean flexion angle was 132.5° ± 6.3°. Clinical scores were satisfactory, with a mean Mayo Elbow Performance Score of 93 points. However, nonunion of coronoid fractures was observed in 4 patients (16.7%). There was 1 case of pin-site irritation.

CONCLUSIONS

All-arthroscopic treatment for the terrible triad can provide an excellent safety profile without the need for a large incision if the indications are met.

LEVEL OF EVIDENCE

Level IV, therapeutic case series.

Modified anteromedial and anterolateral elbow arthroscopy portals show superiority to standard portals in guiding arthroscopic radial head screw fixation

PURPOSE

Arthroscopic fixation of radial head radial head fractures is an appealing alternative to open reduction and internal fixation, which presents the advantage of minimal surgical trauma. The aim of this study was to evaluate if modifications to the standard anteromedial (AM) and anterolateral (AL) portals could allow screw placement for radial head fracture osteosynthesis closer to the plane of the radial head articular surface.

METHODS

Eight fresh-frozen specimens were prepared to mimic arthroscopic setting. Standard AL (ALst) and AM (AMst) and distal AL (ALdi) and AM (AMdi) portals were established. Eleven independent examiners were asked to indicate the optimal trajectory, when aiming to place a cannulated screw parallel to the radial head surface for radial head osteosynthesis. A three-dimensional digital protractor was used to measure the angle between the indicated position and a Kirschner wire placed parallel to the radial head articular surface (α). The Shapiro-Wilk normality test was used to evaluate the normal distribution of the samples. Means, standard deviations, and 95% confidence intervals (95% CI) were calculated for each portal. A coefficient of variation (CoV) was calculated to determine agreement among observers and intra-observer variability.

RESULTS

Mean α angles were 25.1 ± 11.5° for AMst, 13.8 ± 4.8° for AMdi, 17.1 ± 13.4° for ALst, -2.6 ± 9.2° for ALdi. No overlapping in the 95% CI of ipsilateral standard and distal portals was observed, indicating that the difference between these means was statistically significant. The distal portals showed smaller inter-observer CoV as compared to the standard ones (AMst: 10.0%; AMdi: 4.6%; ALst: 12.5%; ALdi: 10.6%). Intra-observer CoV was similar for all portals (AMst: 5.5%; AMdi: 6.1%; ALst: 7.7%; ALdi: 7.1%).

CONCLUSIONS

The use of distal AM and AL portals permits to obtain α angles closer to the radial head articular surface than standard AM and AL portals. This is expected to allow screw placement in a flatter trajectory, which should correlate with a superior biomechanical performance of fixation. Good reproducibility of Kirschner wire placement from distal portals was observer among different examiners. Modifications to the standard AM and AL elbow arthroscopy portals allow to place screws for radial head fracture osteosynthesis in a position which should guarantee superior biomechanical performance of fixation.

The value of elbow arthroscopy in diagnosing and treatment of radial head fractures

Background

Surgical treatment of radial head fractures is increasingly performed arthroscopically. These fractures often feature concomitant injuries to the elbow joint, which may be under-diagnosed in the radiological examinations. Little is known about the diagnostic value of arthroscopy, the treatment options that arise from arthroscopically assisted fracture fixation and clinical results. We hypothesized that arthroscopy can detect additional concomitant injuries and simultaneously expands the therapeutic options. Therefore aim of this study was to compare arthroscopic and radiologic findings, to assess the distinct arthroscopic procedures and to follow up on the clinical outcomes.

Methods

Twenty patients with radial head fractures were retrospectively included in two study centers. All patients underwent elbow arthroscopy due to at least one of the following suspected concomitant injuries: osteochondral lesions of the humeral capitellum, injuries of the collateral ligaments or loose joint bodies. Preoperative radiological findings were compared to arthroscopic findings. Afterwards, arthroscopic treatment options and clinical outcomes were assessed.

Results

Arthroscopic findings led to revision of the classified fracture type in 70% (p = 0.001) when compared to preoperative conventional radiographs (CR) and in 9% (p = 0.598) when compared to computed tomography (CT) or magnetic resonance imaging (MRI). Diagnosis of loose bodies was missed in 60% (p < 0.001) of the CR and in 18% (p = 0.269) of the CT/MRI scans. Osteochondral lesions were not identified in 94% (p < 0.001) of the CR and in 27% (p = 0.17) of the CT/MRI scans. Percutaneous screw fixation was performed in 65% and partial radial head resection in 10%. Arthroscopy revealed elbow instability in 35%, leading to lateral collateral ligament reconstruction. After a mean follow up of 41.4 ± 3.4 months functional outcome was excellent in all cases (DASH-Score 0.6 ± 0.8; MEPI-Score 98.5 ± 2.4; OES-Score 47.3 ± 1.1).

Conclusions

Elbow arthroscopy has a significant diagnostic value in radial head fractures when compared to standard radiological imaging. Although statistically not significant, arthroscopy also revealed concomitant injuries in patients that presented with an uneventful MRI/CT. Furthermore, all intraarticular findings could be treated arthroscopically allowing for excellent functional outcomes.

Trial registration

Institutional Review Board University of Munich (LMU), Trial Number 507–14.

Comminuted Radial Head Fracture in All-arthroscopic Repair of Elbow Fracture-dislocation: Is Partial Excision of the Radial Head an Acceptable Treatment Option?

Background

In elbow fracture-dislocation, partial excision of the comminuted radial head fracture that is not amenable to fixation remains controversial considering the accompanying symptoms. This study was undertaken to evaluate the results of radial head partial excision when the comminuted radial head fracture involved <50% of the articular surface in all-arthroscopic repair of elbow fracture-dislocation.

Methods

Patients were divided into two groups based on the condition of the radial head fracture. In Group A, the patients had a radial head comminuted fracture involving <50% of the articular surface, and underwent arthroscopic partial excision. Group B was the non-excision group comprising patients with stable and non-displacement fractures. Follow-up consultations were conducted at 6 weeks and at 3, 6, 12, and 24 months after surgery.

Results

In all, 19 patients (Group A: 11; Group B: 8) met the inclusion criteria and were enrolled in the study. At the final follow-up, all 19 patients showed complete resolution of elbow instability. No significant differences were observed in the range of motion, visual analogue scale score, and Mayo elbow performance score between groups. Radiological findings did not show any complications of the radiocapitellar joint. However, nonunion of the coracoid fracture was observed in 3 patients (Group A: 1; Group B: 2), without any accompanying instability and clinical symptoms.

Conclusions

Considering that the final outcome is coronoid fracture fixation and lateral collateral ligament complex repair for restoring elbow stability, arthroscopic partial excision for radial head comminuted fractures involving <50% of articular surface is an effective and acceptable treatment for elbow fracture-dislocation.

Pediatric elbow arthroscopy: indications and safety

BACKGROUND

Elbow arthroscopy is a minimally invasive means by which to treat a variety of acute and chronic elbow conditions. Although the safety and efficacy is well documented in the adult population, comparatively little information is available about the role of elbow arthroscopy in the pediatric population. This study reports the indications for and safety of elbow arthroscopy in a series of pediatric patients.

METHODS

A retrospective review was performed from 2001 to 2015 of a surgical database at a single institution. All elbow arthroscopies performed in patients aged 18 years and younger were reviewed. Indications for surgery, perioperative and postoperative complications, further surgical intervention, and descriptive demographic information were recorded.

RESULTS

We identified 64 elbow arthroscopic procedures in 59 patients. The average age at the time of surgery was 11.8 years. Indications for the arthroscopic surgery included contracture release (45.3%), closed reduction and fixation for fracture (20.3%), treatment of osteochondritis dissecans (20.3%), diagnostic arthroscopy (7.8%), and débridement (6.3%). The overall complication rate was 17.2%, with a major and minor complication rate of 6.3% and 10.9%, respectively.

CONCLUSION

Elbow arthroscopy has applications in the pediatric population with an acceptable safety profile. The techniques and indications continue to evolve.

The limited anterior approach of the elbow for open reduction and internal fixation of capitellum fractures. Surgical technique and clinical experience in 2 cases with more than 2 years follow-up

OBJECTIVE

Fractures involving the capitellum can be treated surgically by excision of the fragment, or by reduction and internal fixation with screws, with or without heads. The lateral Kocher approach is the most common approach for open reduction. We believe that the limited anterior approach of the elbow, could be a valid technique for treating these fractures, as it does not involve the detachment of any muscle group or ligament, facilitating the recovery process.

MATERIAL AND METHOD

A description is presented of the surgical technique, as well as of 2cases with a Bryan-Morrey type 1 fracture (Dubberley type 1A). Two different final quality of life evaluation questionnaires were completed by telephone: the EuroQol Five Dimensions Questionnaire (EQ-5D), and the patient part of the Liverpool Elbow Score (PAQ-LES) questionnaire.

RESULTS

The 2patients showed favourable clinical progress at 36 and 24 months, respectively, with an extension/flexion movement arc of -5°/145° and -10°/145°, as well as a pronosupination of 85°/80° and 90°/90°. The 2patients showed radiological consolidation with no signs of osteonecrosis. The EQ-5D score was 0.857 and 0.910 (range: 0.36-1), and a PAQ-SLE of 35 and 35 (range: 17-36), respectively.

CONCLUSIONS

We believe that the limited anterior approach of the elbow is a technical option to consider for the open surgical treatment of a capitellum fracture, although further studies are needed to demonstrate its superiority and clinical safety compared to the classical lateral Kocher approach.