Functional outcome following elbow release and hardware removal after bicolumnar fixation of distal humeral fractures

INTRODUCTION

Intra-articular fractures of the distal humerus are typically treated with bicolumnar plate fixation. Despite prompt and accurate reduction and fixation, there is a high rate of complications post-surgical fixation. The purpose of this study was to determine the indications, technique, and outcomes of patients who had undergone an elbow release and hardware removal following bicolumnar plate fixation for an intra-articular fracture of the distal humerus.

METHODS

Patients who had undergone an elbow release and hardware removal by a single surgeon following bicolumnar fixation of an intra-articular fracture of the distal humerus were identified. Patients were contacted to participate in a chart review and to return to clinic for a follow-up visit. Patients who returned for a follow-up visit completed the DASH (Disabilities of the Arm, Shoulder and Hand), the MEPS (Mayo Elbow Performance Score), and the SF-36.

RESULTS

Forty-two patients were included in the final analysis. The average time from the original injury to the elbow release procedure was 17.5 months. There was an improvement of 33° in the mean flexion-extension arc following the procedure (p<0.001). The mean DASH score was 21 (SD=19) and the mean MEPS score was 82 (SD=16). There was a high rate of post-traumatic osteoarthritis (n=30). Two patients underwent a total elbow arthroplasty (TEA). One patient sustained a re-fracture of the distal humerus, and subsequently underwent repeat bicolumnar fixation. There were four reoperations (10%): two patients had a revision release of contracture and two patients underwent a closed manipulation.

CONCLUSIONS

It appears safe to remove both plates and to re-intervene relatively early. There is a modest but consistent improvement in flexion-extension arc, and the re-operation rate is low. Although there is a high rate of post-traumatic arthritic change radiographically, TEA was rare, and elbow-based outcome scores were good, although not normal.

Using signal detection theory to model changes in serial learning of radiological image interpretation

Signal detection theory (SDT) parameters can describe a learner's ability to discriminate (d') normal from abnormal and the learner's criterion (λ) to under or overcall abnormalities. To examine the serial changes in SDT parameters with serial exposure to radiological cases. 46 participants were recruited for this study: 20 medical students (MED), 6 residents (RES), 12 fellows (FEL), 5 staff pediatric emergency physicians (PEM), and 3 staff radiologists (RAD). Each participant was presented with 234 randomly assigned ankle radiographs using a web-based application. Participants were given a clinical scenario and considered 3 views of the ankle. They classified each case as normal or abnormal. For abnormal cases, they specified the location of the abnormality. Immediate feedback included highlighting on the images and the official radiologist's report. The low experience group (MED, RES, FEL) showed steady improvement in discrimination ability with each case, while the high experience group (PEM, RAD) had higher and stable discrimination ability throughout the exercise. There was also a difference in the way the high and low experience groups balanced sensitivity and specificity (λ) with the low experience group tending to make more errors calling positive radiographs negative. This tendency was progressively less evident with each increase in expertise level. SDT metrics provide valuable insight on changes associated with learning radiograph interpretation, and may be used to design more effective instructional strategies for a given learner group.

Minimally angulated pediatric wrist fractures: is immobilization without manipulation enough?

BACKGROUND

Emergency department (ED) manipulation of complete minimally angulated distal radius fractures in children may not be necessary, due to the excellent remodeling potential of these fractures.

OBJECTIVES

The primary objective of this study was to determine the proportion of minimally angulated distal radius fractures managed in the ED with plaster immobilization that subsequently required manipulation. Our secondary objective was to document, at follow-up, changes in angulation for each wrist fracture.

METHODS

This retrospective cohort study reviewed consecutive records of all children with bi-cortical minimally angulated (</=15 degrees of angulation in the sagittal plane and </=0.5 cm of displacement) distal metaphyseal radius fractures, alone or in combination with distal ulnar fracture. Details of treatment, radiographic findings, and clinical outcomes during the subsequent orthopedic follow up were recorded.

RESULTS

Of 124 patients included in the analysis, none required manipulation after their ED visit. All but 14 (11.3%) fractures were angulated </=20 degrees within the follow-up period. Two (1.6%) fractures that were initially angulated </=15 degrees progressed to 30 degrees -35 degrees , but remodeled within 2 years to nearly perfect anatomic alignment. By 6 weeks post-injury, no patients had clinically apparent deformity and all had normal function.

CONCLUSIONS

Minimally angulated fractures of the distal metaphyseal radius managed in plaster immobilization without reduction in the ED are unlikely to require future surgical intervention.