Effectiveness of ultrasonography performed at the emergency department for pediatric elbow trauma cases

BACKGROUND

Two-way direct radiography is the first-choice imaging method for pediatric patients presenting to the emergency department with elbow trauma. Although, unlike radiography, ultrasonography (US) is not used routinely, studies show that US can be used in the diagnosis of fractures in pediatric patients.

METHODS

In this single-center prospective observational study, patients under the age of 18 who presented to the emergency department after sustaining elbow trauma constituted the population of the study. Findings of the posterior fat pad sign using bedside US and the result obtained by seven-point assessment of the bone cortex were compared with the final diagnosis.

RESULTS

Of the 128 patients enrolled in the study, 6 patients were excluded due to various reasons. Seventy (57.4%) patients were male, and median age was 7.7 years. On examining the final diagnosis of the patients at the emergency department, fracture diagnosis was observed in 39 patients (32%). It was determined that fracture diagnosis for 94.9% of the patients included in the study could be achieved using US (in the presence of at least the fat pad sign and/or direct findings of fracture based on the seven-point assessment).

CONCLUSION

US should be considered as a diagnostic tool in cases of pediatric elbow traumas owing to its high sensitivity and negative predictive value. US, which is reproducible, ionizing radiation-free, and can be performed at the bedside, can considerably reduce unnecessary radiography in low-risk patients when evaluated along with physical examination findings among patients in the pediatric age group presenting with elbow trauma. We believe that the result of our study will contribute to patient care practices.

Monteggia fractures and Monteggia-like-lesions: a systematic review

Monteggia injuries are rare, but severe injuries of the elbow including various injury patterns. Treatment of these injuries is still topic of debate and strategies differ widely. In this systematic review on Monteggia injuries in adults, we aimed to clarify the incidence of different injury patterns within Monteggia injuries, investigate the main reasons leading to revision surgery and explore which surgical treatments should be favored to achieve satisfactory clinical results.We initially identified 182 publications and ultimately included 17 retrospective studies comprising 651 cases. All patients were classified using the Bado classification, leading to 30.5% Bado type I fractures, 60.4% type II fractures, 5.1% type III and 3.1% type IV fractures. Mean revision rate was 23%. Ulna non-union (28%) and limited range-of-motion (22%) are the main reasons for revision surgery. Meta-analysis shows a trend toward the use of locking plates for ulna fixation which may lead to less revision surgery and fewer ulna non-unions. Further biomechanical and clinical research is necessary to clarify the role of radial head surgery.

Current concepts in the management of "Terrible Triad" injuries of the elbow

Terrible triad injuries of the elbow are complex injuries which can result in long term complications and significant disability. They must be identified correctly, and managed appropriately in order to maximise functional outcomes. A clear understanding of the bony and ligamentous anatomy is essential to plan appropriate surgical reconstruction to provide elbow stability. Urgent reduction of the elbow, followed by 3-dimensional imaging and surgical repair or replacement of the injured structures is the mainstay of treatment in the majority of cases. This review presents a summary of the relevant anatomy and the evidence for the management of these complex injuries.

A new prognostic nomogram for heterotopic ossification formation after elbow trauma : the Shanghai post-Traumatic Elbow Heterotopic Ossification Prediction (STEHOP) model

AIMS

Heterotopic ossification (HO) is a common complication after elbow trauma and can cause severe upper limb disability. Although multiple prognostic factors have been reported to be associated with the development of post-traumatic HO, no model has yet been able to combine these predictors more succinctly to convey prognostic information and medical measures to patients. Therefore, this study aimed to identify prognostic factors leading to the formation of HO after surgery for elbow trauma, and to establish and validate a nomogram to predict the probability of HO formation in such particular injuries.

METHODS

This multicentre case-control study comprised 200 patients with post-traumatic elbow HO and 229 patients who had elbow trauma but without HO formation between July 2019 and December 2020. Features possibly associated with HO formation were obtained. The least absolute shrinkage and selection operator regression model was used to optimize feature selection. Multivariable logistic regression analysis was applied to build the new nomogram: the Shanghai post-Traumatic Elbow Heterotopic Ossification Prediction model (STEHOP). STEHOP was validated by concordance index (C-index) and calibration plot. Internal validation was conducted using bootstrapping validation.

RESULTS

Male sex, obesity, open wound, dislocations, late definitive surgical treatment, and lack of use of non-steroidal anti-inflammatory drugs were identified as adverse predictors and incorporated to construct the STEHOP model. It displayed good discrimination with a C-index of 0.80 (95% confidence interval 0.75 to 0.84). A high C-index value of 0.77 could still be reached in the internal validation. The calibration plot showed good agreement between nomogram prediction and observed outcomes.

CONCLUSION

The newly developed STEHOP model is a valid and convenient instrument to predict HO formation after surgery for elbow trauma. It could assist clinicians in counselling patients regarding treatment expectations and therapeutic choices. Cite this article: Bone Joint J 2022;104-B(8):963-971.

The Unsalvageable Radial Head in Patients Aged 30 Years and Younger

PURPOSE

Concern exists regarding the use of radial head arthroplasty (RHA) in younger patients. This study assessed clinical, functional, and radiographic outcomes of RHA in patients aged 30 years and younger.

METHODS

A retrospective review identified 26 elbows that underwent a smooth stem modular RHA in patients aged 30 years and younger at a median follow-up of 3.3 years clinically and 2.9 years radiographically. The mean age was 24 ± 5 years. Indications were acute trauma in 13 patients and chronic pathologies in the remaining 13, and these 2 groups were evaluated separately. Patients underwent clinical, functional, and radiographic evaluation.

RESULTS

Average arc of motion was 137° ± 16° in the cohort with acute trauma and 120° ± 24° in the cohort with chronic pathologies. Mean Patient-Rated Elbow Evaluation scores were 23 ± 18 (acute) and 31 ± 19 (chronic). Mean Quick Disabilities of the Arm, Shoulder, and Hand scores were 18 ± 15 (acute) and 23 ± 20 (chronic). Average Mayo Elbow Performance Index scores were 90 ± 9 (acute) and 80 ± 13 (chronic). Severe capitellar erosion was present in 1 patient (4%) in the cohort with chronic pathologies. Radiographic stem lucency was seen in all cases with 10 of these (38%) graded as severe. Moderate-to-severe ulnohumeral arthritis developed in 4 patients (15%), 3 of whom were in the chronic reconstruction group. Two patients (8%) required reoperation, 1 for persistent instability and 1 for stiffness, both in the cohort with chronic pathologies.

CONCLUSIONS

For acute trauma and challenging chronic conditions involving the radial head in patients aged 30 years and younger, a smooth stem modular RHA is an option. Although reoperation rates based on this series are low, osteoarthritis is common when used for posttraumatic conditions and severe radiographic stem lucency was seen in greater than one-third of patients. These concerning features warrant close follow-up, and further long-term outcomes are needed.

TYPE OF STUDY/LEVEL OF EVIDENCE

Therapeutic IV.

Dislocations of the elbow - An instructional review

Dislocations of the elbow require recognition of the injury pattern followed by adequate treatment to allow early mobilisation. Not every injury requires surgery but if surgery is undertaken all structures providing stability should be addressed, including fractures, medial and lateral ligament insertion and the radial head. The current concepts of biomechanical modelling are addressed and surgical implications discussed.

Management of Geriatric Elbow Injury

Approximately 4.1% of all fractures in the elderly involve the elbow. Most elbow injuries in geriatric patients occur as the result of low-energy mechanisms such as falls from standing height. Elbow injuries in elderly patients present complex challenges because of insufficient bone quality, comminution, articular fragmentation, and preexisting conditions, such as arthritis. Medical comorbidities and baseline level of function must be heavily considered in surgical decision making.

The changing epidemiology of radial head replacement over a 22-year period in Scotland

BACKGROUND

Radial head replacement is used to confer joint stability in the management of acute unstable elbow fractures and dislocations associated with instability. We determined the annual incidence of radial head replacement over a 22-year period in a defined population.

MATERIALS AND METHODS

Hospital episode statistics were collected prospectively at a national level. This database was retrospectively examined to determine the annual incidence of radial head replacement over the study period in adults over 16 years of age.

RESULTS

A total of 615 radial head replacements were performed over the 22 years studied. The overall incidence was 0.65/100,000/year (95% confidence interval, CI, 0.50-0.71). The average adult population during the period was 4,270,593. There was a steady and statistically significant increase in the incidence of radial head replacement over the study period (r ² = 0.816; p < 0.0001). This incidence was significantly greater in women than men (odds ratio 1.46, 95% CI 1.25-1.72; p < 0.001). The peak incidence in men was 0.87/100,000 population/year in the fifth decade of life while in women the peak incidence was in the seventh decade of life (1.38/100,000 population/year).

CONCLUSION

The incidence of radial head replacement has increased steadily over 22 years. We hypothesise that this represents an evolving understanding of the role of radial head replacement in acute trauma in the context of emerging literature during the study period.

Feasibility and technique of ultrasound traumatic elbow lesion assessment

INTRODUCTION

The present study aimed to describe the technique of ultrasound traumatic elbow lesion assessment performed by an orthopedic surgeon.

METHODS

Nine patients were included in a single-center study. Clinical examination assessed pain, ranges of elbow motion, neurovascular status and elbow ligament testing. Ultrasound was associated to radiography between days 7 and 15, screening for lesions of the bone, medial ligament (in 30-90° flexion), lateral ligament (elbow at 90° in cobra position) and epitrochlear and epicondylar muscle insertions. Ultrasound scanning time and echogenicity were assessed.

RESULTS

Four radial head osteochondral fractures were detected on ultrasound in addition to the 4 fractures seen on radiography, without significant difference (p=0.071). Clinical examination found 2 cases of valgus laxity and 5 of varus laxity. Ultrasound, performed blind to radiography, found 1 medial collateral ligament anterior bundle lesion (in 1 of the 2 patients with valgus laxity) and 4 lateral collateral ligament ulnar bundle lesions (in 4 of the 5 patients with varus laxity). There were no epicondylar or epitrochlear tendon lesions. Scanning time decreased significantly over the study period, from a mean 30minutes in the first 5 cases to a mean 24.8minutes in the last 5 (p=0.046). Three patients could not be put in the cobra position, and 3 showed poor echogenicity.

DISCUSSION

Ultrasound assessment of traumatic elbow lesions could be performed by an orthopedic surgeon on a well-defined protocol. Lesions on ultrasound matched clinical symptomatology. Inter- and intra-observer reproducibility remain to be assessed.

LEVEL OF EVIDENCE

IV.

Proximal radioulnar translocations in adults: a tertiary centre study

We present three cases of proximal radioulnar translocation in adults. Although rare, it is most commonly seen in paediatric cases. There have been three previously documented cases in adults, all requiring surgery and associated with ulnohumeral dislocations. Two of our cases required operative intervention, whilst one was reduced closed and did not require stabilisation. Furthermore, we have for the first time shown that proximal radioulnar translocations can occur in isolation in adults without an ulnohumeral dislocation. LEVEL OF EVIDENCE: Level IV.

The column procedure preserves elbow stability on biomechanical testing

PURPOSE

The effect of open release of a post-traumatic elbow contracture on the stability of the joint has not been so far studied in vivo. Resection of elbow joint capsule, the key element of surgery, was reported to have no effect on the stability of cadaveric elbows. The joint capsule is yet known to participate in maintaining elbow stability as one of secondary stabilizers.

METHODS

We assessed elbow joint laxity in 39 patients who underwent an open contracture release via the 'column procedure' described by B. Morrey and P. Mansat within the preceeding three to nine months. The measurements were taken with an apparatus designed particularly for this experiment according to the predetermined protocol. A preliminary part of the experiment showed that there was no significant difference between laxity of two elbow joints in healthy volunteers. Laxity of the operated elbows could be then compared with the contralateral joints.

RESULTS

Mean absolute difference of laxity between healthy and operated elbows was 1.55° (0.1°-4.1°, SD = 1.1) being significantly lower than 2°, p = 0.0056. The difference of the joint laxity between the operated and healthy elbows did not differ statistically significantly by more than 0.6° from the difference of the laxity of two healthy elbows and, therefore, is not clinically noticeable.

CONCLUSIONS

Our experiment confirmed that the 'column procedure' is a safe procedure which does not compromise the stability of the elbow joint.

Traumatic Elbow Mediolateral Investigatory Screening: The value of the sitting axial mediolateral projection in the diagnosis of radial head fractures

BACKGROUND

Elbow injuries are frequently encountered in hospital practice, while radial head fractures are the commonest result of such trauma. Diagnosis of radial head fractures is based on clinical and radiographic evaluation with a number of X-ray projections being available. A combination of views is chosen, comprising of routine elbow series screenings and modified techniques, as well as the assistance of the fat-pat sign; never the less fractures can still be occult on X-rays.

PURPOSE

This article aims to demonstrate the diagnostic value of the sitting axial mediolateral projection, which in our hospital is referred to as the Traumatic Elbow Mediolateral Investigatory Screening (TEMIS). This projection has been successfully used in our hospital repeatedly for the identification of occult fractures that were missed by other projections.

MATERIALS AND METHODS

62 patients who presented to our Emergency Department due to trauma in the elbow over a six-month period were X-rayed for the identification of fractures. Projections included an anteroposterior, a lateral and TEMIS.

RESULTS

Radial head fractures (Mason type I) were identified in 14 out of 62 patients. 2 of these were only visible on the TEMIS projection, while they were missed by the other two views.

CONCLUSION

Trauma to the elbow is a common type of injury. Minor fractures can be expected to heal with good results; complications, however, should not be underestimated. Improper healing can result in a permanently malfunctioning joint with restricted movement and stiffness. To avoid such consequences the choice of a reliable screening projection is significant. In our case the diagnostic value of the TEMIS projection lies in the fact that it shows all fractures seen on routine screenings and reveals fractures missed by them, also being well tolerated by patients due to comfortable arm placement during the screening. All in all, when a fracture is suspected on the basis of clinical signs but no radiographic evidence is seen on conventional screenings, the TEMIS view is recommended for further investigation.

Novel preclinical murine model of trauma-induced elbow stiffness

BACKGROUND

Peri-articular injury may result in functional deficits and pain. In particular, post-traumatic elbow stiffness is a debilitating condition, precluding patients from performing activities of daily living. As such, clinicians and basic scientists alike, aim to develop novel therapeutic interventions to prevent and treat elbow stiffness; thereby reducing patient morbidity. Yet, there is a paucity of pre-clinical models of peri-articular stiffness, especially of the upper extremity, necessary to develop and test the efficacy of therapeutics. We set out to develop a pre-clinical murine model of elbow stiffness, resulting from soft tissue injury, with features characteristic of pathology observed in these patients.

METHODS

A soft tissue peri-elbow injury was inflicted in mice using cardiotoxin. Pathologic tissue repair was induced by creating an investigator-imposed deficiency of plasminogen, a protease essential for musculoskeletal tissue repair. Functional testing was conducted through analysis of grip strength and gait. Radiography, microcomputed tomography, and histological analyses were employed to quantify development of heterotopic ossification.

RESULTS

Animals with peri-elbow soft tissues injury in conjunction with an investigator-imposed plasminogen deficiency, developed a significant loss of elbow function measured by grip strength (2.387 ± 0.136 N vs 1.921 ± 0.157 N, ****, p < 0.0001) and gait analysis (35.05 ± 2.775 mm vs 29.87 ± 2.075 mm, ***, p < 0.0002). Additionally, plasminogen deficient animals developed capsule thickening, delayed skeletal muscle repair, fibrosis, chronic inflammation, and heterotopic ossification; all features characteristic of pathology observed in patients with trauma-induced elbow stiffness.

CONCLUSION

A soft tissue injury to the peri-elbow soft tissue with a concomitant deficiency in plasminogen, instigates elbow stiffness and pathologic features similar to those observed in humans. This pre-clinical model is valuable for translational studies designed to investigate the contributions of pathologic features to elbow stiffness or as a high-throughput model for testing therapeutic strategies designed to prevent and treat trauma-induced elbow stiffness.

Outcomes of coronoid-first repair in terrible triad injuries of the elbow

BACKGROUND

Clinical outcomes of terrible triad injuries (TTIs) of the elbow are historically poor. To date, it is still debatable whether the coronoid needs to be fixed and if so, how and in which sequence.

METHODOLOGY

Between 2010 and 2013, 13 patients were treated surgically for acute TTIs of the elbow at a Tertiary Level 1 Trauma Centre by a single surgeon, using a standardized protocol, which included coronoid-brachialis complex fixation via pull-through trans-osseous sutures, radial head fixation or prosthetic replacement and a repair of the lateral ulnar collateral ligament. Repair of the medial collateral ligament (MCL) was done if valgus-stress test demonstrated persistent instability. Patients were then followed-up with clinical and radiological evaluation by the senior author until fracture union and elbow range of motion reached a plateau. Outcomes measured were range of motion, DASH scores and MEPS, as well as surgical complications.

RESULTS

Intraoperative stability was achieved in all 13 cases, MCL repair was required in 3 cases and application of external fixation was not required in any case. Patients were followed-up for an average length of 27.7 months and the minimum follow-up period was 12 months. The average age of patients was 46.4 years (range 35-79 years old) at the time of trauma. This included eight Regan-Morrey Type I and five Regan-Morrey Type II coronoid fractures, with ten Mason Type I/II and three Mason Type III radial head fractures. The average arc of ulno-humeral motion was 105.0° (range 80°-135°). The average flexion contracture was 15.0° (range 0°-40°). The average supination-pronation arc was 114.9° (range 0°-180°). The average MEPS was 85 of 100 (range 45-100) and the average DASH score was 21.2 of 100 (range 1.7-61.2). A single case of radio-ulnar synostosis, heterotropic ossification and two cases of recurrent elbow instability were noted.

CONCLUSIONS

The coronoid-first surgical approach, using a suture-lasso fixation method, has technical benefits for us and showed good clinical success in our series. This is important with postero-medial rotatory instability being common in our series of TTIs. We emphasize not to miss a TTI in an apparently isolated low Mason class radial head fracture.

Tension band wiring for simple olecranon fractures: evaluation of surgical technique

Background

In some settings, specific techniques for open reduction and internal fixation are preferred based on the eminence of a surgeon or professional organization. An emphasis on technical aspects of surgery that are not proved superior and vary substantially from surgeon to surgeon can be confusing for trainees. This study applied a numerical grading of the technical aspects of tension band wire (TBW) fixation for olecranon fracture; assessed the interobserver agreement of each criterion; and measured the correlation of the technical grading and objective and subjective long-term outcomes.

Materials and methods

Forty observers were invited to rate the technical aspects of TBW fixation of the olecranon on 26 post-operative radiographs. The interobserver reliability of the rating was measured using the intra-class correlation coefficient. The correlation between the rating and motion, Mayo elbow performance index, and disabilities of the arm, shoulder and hand score was tested with the Spearman’s rank correlation test.

Results

None of the figure-of-eight TBW constructs were considered perfect according to the numerical grading: the majority of observers found three deviations per fixation. The interobserver agreement was only fair for the total number of deviations and no correlation between the number of deviations and long-term objective and subjective outcome was found.

Conclusions

A rating of the technical aspects of TBW for olecranon fractures was unreliable and did not correlate with subjective and objective outcomes. Emphasis on specific technical aspects of fixation might be confusing for trainees and could distract them from the principles of effective treatment.

Level of evidence

Level IV diagnostic study.

Arthroscopic Management of Elbow Fractures

Several types of elbow fractures are amenable to arthroscopic or arthroscopic-assisted fracture fixation, including fractures of the coronoid, radial head, lateral condyle, and capitellum. Other posttraumatic conditions may be treated arthroscopically, such as arthrofibrosis or delayed radial head excision. Arthroscopy can be used for assessment of stability or intra-articular fracture displacement. The safest portals are the midlateral (soft spot portal), proximal anteromedial, and proximal anterolateral. Although circumstances may vary according to the injury pattern, a proximal anteromedial portal is usually established first. Arthroscopy enables a less invasive surgical exposure that facilitates visualization of the fracture fragments in select scenarios.

Plate and Screw Fixation of Bicolumnar Distal Humerus Fractures: Factors Associated With Loosening or Breakage of Implants or Nonunion

PURPOSE

To identify factors associated with reoperation for early loosening or breakage of implants or nonunion after operative treatment of AO type C distal humerus fractures.

METHODS

We retrospectively analyzed 129 adult patients who had operative treatment of an isolated AO type C distal humerus fracture at 1 of 5 hospitals to determine factors associated with reoperation for early loosening or breakage of implants or nonunion.

RESULTS

Within 6 months of original fixation, 16 of 129 fractures (12%) required reoperation for loosening or breakage of implants (n = 8) or nonunion (n = 8). In bivariate analyses, the Charlson comorbidity index, smoking, a coded diagnosis of obesity, diabetes mellitus, and radiographic osteoarthritis were significantly associated with reoperation for early loosening or breakage of implants or nonunion.

CONCLUSIONS

With the numbers available, patient factors rather than technical factors were associated with reoperation for loosening or breakage of implants and nonunion. Because of the relative infrequency of fixation problems and nonunion, a much larger study is needed to address technical deficiencies.

Elbow rehabilitation in traumatic pathology

The elbow, intermediate joint of the upper limb, frequently undergoes to pathological events and is especially prone to stiffness. Rehabilitation plays an important role in recovering functional activities. For the rehabilitation team, this goal always represents a challenge, as the treatment has to be continuously modeled and calibrated on the needs of the individual patient, even many times during the same rehabilitation cycle. Containing the effects of immobilization, avoiding to excessively stress the healing tissues, satisfying specific clinical criteria before moving to the next rehabilitation stage, basing the rehabilitation plan on up-to-date clinical and scientific data that can be adapted to each patient and to his/her needs are the basic principles of the rehabilitation plan, which can be chronologically grouped into four rehabilitation stages. After summarizing the general principles of elbow treatment, the specific principles of rehabilitation after elbow fractures and elbow instability are presented, and then the rehabilitative approach to the most frequent and feared pathological conditions of the elbow, namely stiffness, is described.