Fractures and dislocations about the elbow in the head-injured adult

Of 548 head-injured adults, 16 sustained injuries about the elbow (3%). Sixteen of 18 patients (89%) developed heterotopic ossification (HO). All elbows which had been dislocated developed new bone in the substance or adjacent to the medial or lateral collateral ligaments, or both. Some dislocations also developed significant HO in all planes. Final motion correlated with the amount of HO in the joint. Supracondylar fractures generally developed a moderate amount of anterior or posterior HO, or both. Motion was moderately compromised. Posteriorly located HO developed in olecranon fractures. Range of motion was generally functional. Ectopic bone developed in dislocations of the radial head in the area of the annular ligament, and resulted in mild to moderate loss of motion. Spasticity was not necessarily associated with the development of HO. Two tardy ulnar palsies were noticed and associated with HO in the medial collateral ligament.     

Radiation therapy for heterotopic ossification prophylaxis afer high-risk elbow surgery

Heterotopic ossification (HO) is a common complication of elbow trauma or surgery. HO can impair joint function; when it does, surgical removal is required. Radiotherapy (RT) prevents HO formation in the hip. However, few data exist on the efficacy of RT in preventing HO formation in the elbow. We retrospectively analyzed the outcomes of elbow surgery followed by prophylactic single-fraction RT and use of nonsteroidal anti-inflammatory drugs (NSAIDs). All patients had ectopic bone resected at surgery or significant risk factors for development of ectopic bone. Of the 52 patients who underwent RT after high-risk elbow surgery, 44 had postoperative radiographs of the treated elbow available for evaluation. At a median follow-up of 136 days, 21 patients (48%) had radiographic evidence of HO. In all cases, however, the HO was small and not functionally significant. No complications were attributed to RT use. This retrospective review represents the largest published series of patients who have undergone postoperative RT to prevent HO formation in the elbow. Our findings support the idea that RT, in combination with NSAID use, is safe and efficacious in preventing development of clinically significant HO in the elbow.     

The stability of the elbow following excision of the radial head and transection of the annular ligament. An experimental study

The stabilizing role of the lateral ligament complex and the radial head were investigated in ten osteoligamentous elbow preparations. The annular ligament was the prime stabilizer of the lateral aspect of the elbow. Transection of the annular ligament caused maximal varus and external rotatory instability of 13.7 degrees and 32.8 degrees respectively, with an elbow flexion about 70 degrees. Isolated excision of the radial head caused slight varus and external rotatory instability of 4.8 degrees and 10.4 degrees respectively, with an elbow flexion about 40 degrees. The lateral collateral ligament had only a minor stabilizing function of the elbow. The stability of the elbow after excision of the radial head may be improved by proper preservation of the annular ligament.     

Heterotopic ossification in portal sites following hip arthroscopy

Heterotopic ossification (HO) is a well-known condition that usually occurs after head trauma, burns and open surgical procedures, most commonly around the hip and elbow joints. It is a well-documented complication occurring after open hip surgery; however, there exists limited information regarding its prevalence and clinical importance following hip arthroscopy. We report a case of symptomatic HO formation in portal sites following arthroscopic rim decompression, femoroplasty and labral debridement that was successfully treated with arthroscopic removal.     

The stability of the elbow following excision of the radial head and transection of the annular ligament

Summary The stabilizing role of the lateral ligament complex and the radial head were investigated in ten osteoligamentous elbow preparations. The annular ligament was the prime stabilizer of the lateral aspect of the elbow. Transection of the annular ligament caused maximal varus and external rotatory instability of 13.7° and 32.8° respectively, with an elbow flexion about 70°. Isolated excision of the radial head caused slight varus and external rotatory instability of 4.8° and 10.4° respectively, with an elbow flexion about 40°. The lateral collateral ligament had only a minor stabilizing function of the elbow. The stability of the elbow after excision of the radial head may be improved by proper preservation of the annular ligament.     

Comparing Options for Heterotopic Ossification Prophylaxis following Elbow Trauma: A Systematic Review and Meta-Analysis

Introduction  Heterotopic ossification (HO) can be a potentially serious and devastating complication following traumatic injury to the elbow. HO prophylaxis options include nonsteroidal anti-inflammatory drugs (NSAIDs) and radiation therapy (RT) but neither has been proven more effective. The purpose of this review is to compare effectiveness and outcomes between NSAID and RT prophylaxis for HO about the elbow following a traumatic injury. Materials and Methods  We performed a systematic review of PubMed and Cochrane Library for cases of HO prophylaxis following elbow trauma utilizing PRISMA guidelines to determine the most effective form of prophylaxis. Outcomes of interest included recurrence of HO, range of motion (ROM), and Mayo elbow performance index (MEPI). A total of 36 articles and 826 elbows of which 203 received RT and 623 received NSAID were identified and included in the final analysis. Results  Rates of HO formation or recurrence following elbow trauma were similar between radiation and NSAID prophylaxis (15.6% vs. 22.2%, respectively p = 0.457). ROM was similar in flexion and extension arc (109.0 degrees in radiation vs. 112.8 in NSAIDs, p = 0.459) and in pronation and supination arc (118.9 degrees radiation vs. 134.7 degrees NSAIDs, p = 0.322). MEPI scores were 79.19 in the radiation group and 88.82 in the NSAIDs group at the final follow-up. Conclusion  There is no statistical difference in HO development, recurrence, or final ROM between NSAIDs and RT prophylaxis following trauma to the elbow. We recommend the choice of modality based on patient characteristics, cost, and surgeon preference. Level of Evidence  Level III.     

Total hip arthroplasty for ankylosed hip secondary to heterotopic ossification

Heterotopic ossification (HO) secondary to traumatic brain injury occurs at various sites and most commonly at the elbow, shoulder, and hip. There are few published reports on the assessment and surgical resection techniques of HO. A complete preoperative physical examination and radiologic assessment with a computed tomographic scan are important for the thorough evaluation of a patient. We describe a patient with neurogenic HO of the hip secondary to traumatic brain injury who underwent a total hip arthroplasty (THA). In selected patients with hip HO, THA supplemented with postoperative radiotherapy and indomethacin prophylaxis can facilitate progressive functional movements of the hip. To our knowledge, there is no report in the English literature of a THA being preformed for HO.     

Compression du nerf ulnaire au coude et paraostéoarthropathie neurogène : à propos de cinq cas

Aim

Heterotopic ossification (HO) is common in head-injured patients. Ulnar nerve compression by HO at the elbow is rare. The purpose of this study was to establish a strategy for the management of ulnar nerve compression secondary to HO at the elbow.

Patients and methods

The authors report a retrospective study (2000-2008) of five cases of ulnar nerve compression at the elbow secondary to HO. All patients were male (mean age, 33 years). The HO was secondary to head injury (four cases) and severe burn (one case). According to the Dellon's classification, the ulnar nerve entrapment was severe in two cases and moderate in three. The elbow was ankylosed; the flexion deformity ranged from 60° to 120°. Only in one case was nerve decompression performed before HO maturation. In the other cases, elbow release and nerve decompression were done at the same time, when maturation of HO was achieved. Postoperative outcome assessment was based on the Kleiman and Bishop's score.

Results

At 4 years of follow-up, the neurolysis result was excellent in one case, good in three cases, and poor in one.

Conclusion

It seems that HO is not the direct cause of ulnar nerve compression, but its impairment may be increased by the nerve tension and elbow fixation that it causes. When HO is mature, neurolysis can be combined with elbow release. However, when HO maturation is not achieved early neurolysis associated with anterior transposition should be done without elbow release.     

Heterotopic ossification about the elbow: a therapist's guide to evaluation and management.

Heterotopic ossification (HO) is a form of pathologic bone that often occurs in the elbow after a substantial traumatic injury and can complicate the functional outcome of the affected upper extremity. This article is designed to help the treating therapist better understand the complex process of HO. The pathophysiology, causes, associated risk factors, and signs and symptoms of HO are discussed in depth. The physician's management, including a classification system, diagnostic tools, and prophylactic measures, are explained. An extensive review of the literature regarding the therapist's management of HO reveals current misconceptions about passive range of motion (PROM). Traditional thought has advocated that PROM is a contraindication when HO is present because it can lead to the development or exacerbate the formation of HO. A review of the literature only reveals a few scientific studies that concluded that forcible manipulation of stiff joints can lead to myositis ossification. Most of the articles that have concluded that PROM is contraindicated have been erroneously based on anecdotal findings. This conclusion is misleading because forcible manipulation of a joint is not synonymous with PROM exercises. This article challenges popular belief and offers some alternative thinking for the therapist treating an elbow injury with HO as well as guidelines for the rehabilitation program.     

Snapping annular ligament of the elbow joint in the throwing arms of young brothers

We examined young brothers with symptomatic snapping elbow in the throwing arm. Arthroscopic examination confirmed the mechanism of snapping, in which loose and protruded annular ligament-like tissue covered the volar half of the radial head in elbow extension and uncovered the radial head in deep elbow flexion. Arthroscopic resection of the annular ligament-like tissue was performed in one brother. Histologic examination of the removed tissue showed degenerated ligament tissue. Excision of loose annular ligament abolished snapping. Contralateral elbows of the brothers also showed similar asymptomatic snapping. Researchers suggest that a hereditary factor contributing to loose annular ligament and repetitive microtrauma from throwing is the cause of symptoms.     

牵拉肘机制的有关解剖学观测

目的探讨牵拉肘发病机制与桡骨头颈、环状韧带、滑膜皱襞的关系.方法对16侧婴幼儿和10侧学龄前儿童肘关节桡骨头颈、环状韧带、滑膜皱襞进行解剖观察测量.结果桡骨头矢状径、横径均大于相应桡骨颈矢状径、横径(24%～30%),环状韧带上下缘弧长接近(婴幼儿26.82、26.57 mm,学龄前儿童28.50、27.65 mm),桡骨头后内侧、前外侧滑膜皱襞恒定存在,基底宽大,游离缘长(婴幼儿9.55 mm,学龄前儿童11.38 mm),形态多样.结论环状韧带或滑膜皱襞嵌入肱桡关节间是引起牵拉肘发病的重要因素,该机制可以解释牵拉肘的临床表现.     

Obscure pathology of pulled elbow: dynamic high-resolution ultrasound-assisted classification

Aim

Pulled elbow or nursemaid’s elbow is a radial head subluxation caused by a sudden pull on the extended pronated forearm. Children with pulled elbow usually respond dramatically for reduction, yet others show delayed improvement with no clear pathologic explanation. The aim of our study is to propose an explanation for the varying clinical response after the reduction of pulled elbow aided by ultrasound classification of the underlying pathology and its impact on management.

Patients and methods

Fifty children with a mean age of 3.8 ± 1.1 (standard deviation [SD]) years with pulled elbow were scanned by static and dynamic ultrasound utilizing the other elbow as the standard. The radial annular ligament (RAL) was examined for integrity and interposition, with measurement of the radiocapitellar distance. Reduction was performed following the hyperpronation technique, and postreduction splinting was guided by ultrasound findings. Postreduction scans and 1-year follow up were performed.

Results

Of the 50 included children, 39 (78%) had intact, yet interposed annular ligament (classified as type I) and 11 (22%) had torn annular ligament (classified as type II). The latter underwent splinting for 7 days. Three out of the 50 children had recurrent subluxation and constituted false-negative cases for the detection of torn ligament and represented the reoccurrence rate of 6%. The sensitivity, specificity, and accuracy for the ultrasound diagnosis of torn RAL were 76.9, 92.3, and 92%, respectively.

Conclusion

Pulled elbow is classified as follows: type I, with an interposed RAL, and type II, with torn ligament.     

Ligamentous stabilizers against posterolateral rotatory instability of the elbow.

BACKGROUND: The lateral ulnar collateral ligament, the entire lateral collateral ligament complex, and the overlying extensor muscles have all been suggested as key stabilizers against posterolateral rotatory instability of the elbow. The purpose of this investigation was to determine whether either an intact radial collateral ligament alone or an intact lateral ulnar collateral ligament alone is sufficient to prevent posterolateral rotatory instability when the annular ligament is intact. METHODS: Sequential sectioning of the radial collateral and lateral ulnar collateral ligaments was performed in twelve fresh-frozen cadaveric upper extremities. At each stage of the sectioning protocol, a pivot shift test was performed with the arm in a vertical position. Passive elbow flexion was performed with the forearm maintained in either pronation or supination and the arm in the varus and valgus gravity-loaded orientations. An electromagnetic tracking device was used to quantify the internal-external rotation and varus-valgus angulation of the ulna with respect to the humerus. RESULTS: Compared with the intact elbow, no differences in the magnitude of internal-external rotation or maximum varus-valgus laxity of the ulna were detected with only the radial collateral or lateral ulnar collateral ligament intact (p > 0.05). However, once the entire lateral collateral ligament was transected, significant increases in internal-external rotation (p = 0.0007) and maximum varus-valgus laxity (p < 0.0001) were measured. None of the pivot shift tests had a clinically positive result until the entire lateral collateral ligament was sectioned. CONCLUSIONS: This study suggests that, when the annular ligament is intact, either the radial collateral ligament or the lateral ulnar collateral ligament can be transected without inducing posterolateral rotatory instability of the elbow.     

Repairing the annular ligament is not necessary in the operation of Mason type 2, 3 isolated radial head fractures if the lateral collateral ligament is intact: Minimum 5 years follow-up

Introduction

The repair of annular ligament after open reduction and internal fixation of radial head fracture could produce the irritation or crepitation during range of motion exercise. The purpose of this study is to evaluate the significance of unrepaired annular ligament during fixation of isolated radial head fractures.

Materials and methods

Retrospectively we reviewed the twenty-five patients who underwent surgical fixation with a plate for Mason type 2, 3 isolated radial head fracture without annular ligament repair. All the radial head fracture did not have the associated injuries which could cause the elbow instabilities. The average length of follow-up was 6.9 years. The outcomes were evaluated clinically (range of motions, instabilities, pain VAS, Broberg & Murrey functional rating score, DASH score) and radiographically (bony union, arthritic change, lateral translation of the radial head, humero-ulnar angle with maximum varus stress of elbow, ulnar variance).

Results

The range of motions between affected and contralateral side were not significantly different at last follow-up. No one showed the instabilities of elbow. The mean pain VAS, Broberg & Murrey functional rating score, and DASH score were 2.7 ± 0.5, 95.3 ± 2.5, and 14.8 ± 5.3 points respectively. Bony union was observed for all cases. There was no significant difference in the lateral translation of the radial head, humero-ulnar angle with maximum varus stress of elbow, and ulnar variance between the affected and the contralateral arm.

Conclusion

The isolated role of the annular ligament seems overestimated. We scrutinize that the annular ligament repair is not essential in the operative treatment of isolated radial head fractures if the lateral collateral ligament is intact.     

The usefulness of ultrasound and the posterior fat pad sign in pulled elbow

IntroductionA pulled elbow is a common cause of acute elbow pain that is generally managed by a reduction maneuver without radiographic examination. However, children with atypical presentation with no history of abrupt longitudinal traction should undergo elbow imaging. This study aimed to investigate plain radiography findings and determine the usefulness of ultrasonography (US) in atypical pulled elbow.Materials and methodsWe retrospectively reviewed the medical records and images of 37 (22 males) consecutive patients with pulled elbow who presented with an atypical history or failed reduction between April 2015 and September 2018. Mean age at presentation was 4.34 years (range, 1.25–9.5 years). Of the 37 elbows, 20 were left elbows. The injury mechanism, incidence of the posterior fat pad sign on plain radiographs, and characteristic US findings, pre- and post- reduction, were investigated.ResultsThe original mechanisms of injury included slipping (n = 14), rolling over the arm (n = 7), vague history (n = 6), falling down (n = 6), abrupt longitudinal traction (n = 2), and direct injury (n = 2). On plain radiographs, six of the 37 elbows (16%) showed the posterior fat pad sign. Before the reduction, an entrapped supinator, a pathognomonic sign of pulled elbow, was identified on US in all cases. After reduction, the characteristic US findings showed a disentangled and swollen supinator (100%) and restored annular ligament (100%) in all successful cases. Although a click was not felt in three cases, the reductions were considered successful because the annular ligament was restored on US with free elbow motion.ConclusionPulled elbow may be caused by atypical mechanisms of injury, such as slipping and rolling over the arm. Clinicians should be aware of the possibility of the posterior fat pad sign on plain radiographs of pulled elbow to prevent unnecessary immobilization. In such circumstances, US is a useful method for detecting an entrapped supinator and confirming adequate reduction via restoration of the annular ligament in children with atypical pulled elbow.     

The effect of the annular ligament on kinematics of the radial head

PURPOSE: There is evidence that the radial head translates during pronation and supination. This study measured radial head movement and the location of the pronation-supination axis of the forearm with and without the annular ligament. METHODS: Thirteen cadaveric arms were attached to a custom-built frame. Pronation and supination were achieved by actuation of the pronator teres and biceps tendons, respectively. Motion was captured by video cameras via marker arrays attached to the distal radius, distal ulna, humerus, and radial head. Three pronation-supination trials were performed with the annular ligament intact and the elbow positioned at 90 degrees . The sequence was repeated after transection of the annular ligament. RESULTS: The radial head traveled an average of 2.1 mm in the anteroposterior direction and 1.6 mm in the mediolateral direction during forearm rotation. After annular ligament resection, travel of the radial head increased by an average of 44% in the mediolateral direction and by 24% in the anteroposterior direction. On average, the mean pronation-supination axis (screw displacement axis) passed 1.4 mm +/- 1.9 medial to the center of the capitellum and through the center of the ulnar head. Loss of the annular ligament did not change the location of the pronation-supination axis. CONCLUSIONS: During forearm rotation, the radial head travels to a greater extent in the anteroposterior direction than in the mediolateral direction. Loss of the stabilizing effect of the annular ligament increases the travel mediolaterally more than anteroposteriorly. The pronation-supination axis of the forearm is nearly constant and is not affected by annular ligament transection.     

Low rates of heterotopic ossification after resurfacing hip arthroplasty with use of prophylactic radiotherapy in select patients

Recent reports have noted higher rates of heterotopic ossification (HO) with surface replacement arthroplasty (SRA) than with traditional total hip arthroplasty in the absence of postoperative HO prophylaxis. This study reports rates and grades of HO in 44 SRA patients with at least 1 year of follow-up. Heterotopic ossification prophylaxis was used in 32 (73%) of 44 cases. Heterotopic ossification prophylaxis consisted of radiotherapy (22/32), nonsteroidal anti-inflammatory drugs (8/32), or both (2/32). One case of clinically significant HO was documented in the no-prophylaxis group. This strategy of selective HO prophylaxis in patients felt by orthopedic surgeons to be at high risk of HO resulted in low rates of clinically relevant HO after SRA (1/44, 2.3%). Further study is needed to establish optimal selection criteria for HO prophylaxis after SRA.     

带蒂深筋膜重建环状韧带治疗陈旧性单纯桡骨头脱位

目的 探讨带蒂深筋膜重建环状韧带治疗陈旧性单纯桡骨头脱位的临床效果.方法 2004年1月至2009年1月共治疗10例小儿陈旧性单纯桡骨头脱位.年龄5～16岁,平均9.7岁.采用带蒂深筋膜重建环状韧带,术后按照Broberg-Morrey肘关节评分标准进行功能评价.结果 术后随访1～6年,平均2.5年.肘关节功能评分:优4例(占40%),良5例(占50%),差1例(占10%);优良率为90%.结论 对于小儿陈旧性单纯桡骨头脱位,应用带蒂深筋膜重建环状韧带,有利于维持肱桡、尺桡关节对合关系,可以尽最大可能地恢复肘关节功能.但对于14～16岁以上的少年,尤其在骨骺闭合之后,应慎行此手术.

Abstract：

Objective To evaluate the clinical outcomes of treating chronic isolated radial head dislocation by reconstruction of annular ligament with pedicled deep fascia. Methods Ten children with chronic radial head dislocation were treated between January 2004 and January 2009. The patients varied in age from 5 to 16 years (mean 9.7 years). They were treated by reconstruction of annular ligament with pedicle deep fascia. A clinical and radiographic assessment was undertaken at follow-up. The results were rated according to the Broberg-Morrey scoring for elbow function. Results All cases were follow-up for 1 to 6 years, the average follow-up time being 2.5 years. According to the Broberg-Morrey elbow function scores, the results were rated excellent in 4 cases (40%), good in 5 cases (50%), and poor in 1 case ( 10% ). The overall satisfactory rate was 90%. The range of functional motion and carrying angle was restored in all ten patients. No complications,such as recurrent dislocation, infection, or neurovascular injury were observed. Conclusion Reconstruction of annular ligament with pedicled deep fascia in pediatric chronic isolated radial head dislocation is fundamental to obtain stable reduction of the dislocated radial head, maintain humeroradial and ulnoradial alignment, and restore elbow function. However this procedure should be considered with caution for patients older than 14 to 16 years especially when their epiphyseal plate is closed.     

Elbow joint instability: A kinematic model

The effect of simultaneous ulnar and radial collateral ligament division on the kinematics of the elbow joint is studied in a cadaveric model. Severance of the anterior part of the ulnar collateral ligament and the annular ligament led to significant elbow joint instability in valgus and varus stress and in forced external and internal rotation. The mean maximum laxity in valgus stress and forced external rotation were 5.7° and 13.2°. The forearms of the elbow joint specimens were transfixed in maximum pronation. During valgus and varus stress the corresponding spontaneous ulnar rotation of the specimens was recorded. The reproducibility of the instability pattern suggests that this model is suitable for evaluating stabilizing procedures aimed at correction of elbow joint instability before these procedures are introduced into patient care.