Capitellum Fracture Fragment Excision: a Case Series

Background

Fractures of the capitellum are rare injuries, and few studies have reported the results of fragment excision.

Questions/Purposes

The purpose of this study was to determine range of motion and short-term clinical outcomes for patients treated with capitellum excision.

Methods

A retrospective review was performed to identify all patients with an isolated capitellum fracture who underwent excision as definitive treatment at our institutions. Mechanism of injury, associated elbow injuries, type of capitellum fracture, complications, and postoperative outcomes including final elbow range of motion (ROM), elbow instability, and Disabilities of the Arm, Shoulder and Hand (DASH) score were recorded.

Results

Four patients met the inclusion and exclusion criteria of this study. All patients were female with an average age of 69 years (range 42–85). Based on the Bryan and Morrey classification system, three (75%) fractures were classified as type I and one (25%) fracture as type III. The average clinical follow-up was 11 months. Final examination demonstrated a mean elbow range of motion from 14° (range 0–30) of extension to 143° (range 130–160) of flexion. All patients had full forearm rotation, and there was no clinical evidence of elbow instability. The average DASH score was 18.3 (12.5–24.2) at final follow-up.

Conclusion

Excision of the capitellum, much like excision of the radial head, results in acceptable short-term outcome scores and elbow range of motion in patients with fractures that are not amenable to open reduction and internal fixation.

Electronic supplementary material

The online version of this article (doi:10.1007/s11420-015-9452-x) contains supplementary material, which is available to authorized users.     

Primary total elbow arthroplasty

Background:

Primary total elbow arthroplasty (TEA) is a challenging procedure for orthopedic surgeons. It is not performed as frequently as compared to hip or knee arthroplasty. The elbow is a nonweight-bearing joint; however, static loading can create forces up to three times the body weight and dynamic loading up to six times. For elderly patients with deformity and ankylosis of the elbow due to posttraumatic arthritis or rheumatoid arthritis or comminuted fracture distal humerus, arthroplasty is one of the option. The aim of this study is to analyze the role of primary total elbow arthroplasty in cases of crippling deformity of elbow.

Materials and Methods:

We analyzed 11 cases of TEA, between December 2002 and September 2012. There were 8 females and 3 males. The average age was 40 years (range 30-69 years). The indications for TEA were rheumatoid arthritis, comminuted fracture distal humerus with intraarticular extension, and posttraumatic bony ankylosis of elbow joint. The Baksi sloppy (semi constrained) hinge elbow prosthesis was used. Clinico-radiological followup was done at 1 month, 3 months, 6 months, 1 year, and then yearly basis.

Results:

In the present study, average supination was 70° (range 60-80°) and average pronation was 70° (range 60-80°). Average flexion was 135° (range 130-135°). However, in 5 cases, there was loss of 15 to 35° (average 25°) of extension (45°) out of 11 cases. The mean Mayo elbow performance score was 95.4 points (range 70-100). Arm length discrepancy was only in four patients which was 36% out of 11 cases. Clinico-radiologically all the elbows were stable except in one case and no immediate postoperative complication was noted. Radiolucency or loosening of ulnar stem was seen in 2 cases (18%) out of 11 cases, in 1 case it was noted after 5 years and in another after 10 years. In second case, revision arthroplasty was done, in which only ulnar hinge section, hinge screw and lock screw with hexagonal head were replaced.

Conclusion:

Elbow arthroplasty remains a valuable option for deformed and ankylosed elbows especially in the demanding patients with crippling deformity of the elbow.     

Surgical hip dislocation for treatment of cam femoroacetabular impingement

Background:

Cam femoroacetabular impingement is caused by a misshapen femoral head with a reduced head neck offset, commonly in the anterolateral quadrant. Friction in flexion, adduction and internal rotation causes limitation of the hip movements and pain progressively leading to labral and chondral damage and osteoarthritis. Surgical hip dislocation described by Ganz permits full exposure of the hip without damaging its blood supply. An osteochondroplasty removes the bump at the femoral head neck junction to recreate the offset for impingement free movement.

Materials and Methods:

Sixteen patients underwent surgery with surgical hip dislocation for the treatment of cam femoroacetabular impingement by open osteochondroplasty over last 6 years. Eight patients suffered from sequelae of avascular necrosis (AVN). Three had a painful dysplastic hip. Two had sequelae of Perthes disease. Three had combined cam and pincer impingement caused by retroversion of acetabulum. All patients were operated by the trochanteric flip osteotomy with attachments of gluteus medius and vastus lateralis, dissection was between the piriformis and gluteus minimus preserving the external rotators. Z-shaped capsular incision and dislocation of the hip was done in external rotation. Three cases also had subtrochanteric osteotomy. Two cases of AVN also had an intraarticular femoral head reshaping osteotomy.

Results:

Goals of treatment were achieved in all patients. No AVN was detected after a 6 month followup. There were no trochanteric nonunions. Hip range of motion improved in all and Harris hip score improved significantly in 15 of 16 cases. Mean alpha angle reduced from 86.13° (range 66°–108°) to 46.35° (range 39°–58°).

Conclusion:

Cam femoroacetabular Impingement causing pain and limitation of hip movements was treated by open osteochondroplasty after surgical hip dislocation. This reduced pain, improved hip motion and gave good to excellent results in the short term.     

Modified Combined Approach for Distal Humerus Shaft Fracture: Anterolateral and Lateral Bimodal Approach

Background

Due to the anatomical nature of the radial nerve, dissection and attainment of an adequate operative field in mid to distal humerus fracture is dangerous and limited. We devised a combined anterolateral and lateral approach that ensures protection of the radial nerve. This is achieved by performing bimodal dissection of the proximal humerus anteriorly and the distal humerus laterally.

Methods

Thirty-five consecutive patients were treated using a combined anterolateral and lateral approach for a minimum follow-up period of 24 months. We analyzed time to bony union, time to return to daily work, range of motion, elbow joint function as assessed by the Mayo elbow performance index and complications.

Results

Radiologic bony union was observed at 11.2 weeks (range, 8 to 20 weeks) on average. Four cases of incomplete radial nerve palsy before surgery all recovered. Time to return to work was 10.2 weeks (range, 2 to 32 weeks) on average. The average range of motion of the elbow was 3.3° (range, 0° to 10°) of extension and 135.9° (range, 125° to 145°) of flexion. There were 21 cases of excellent and 13 cases of good or better recovery, comprising over 97.1% on the Mayo elbow performance index. There were no complications of radial nerve palsy, non-union, mal-union, or infection.

Conclusions

Our a modified combined anterolateral and lateral approach is a clinically effective surgical method of achieving protection of the radial nerve and securing easy and firm internal fixation.     

Radial head arthroplasty using a metatarsal osteochondral autograft

Purpose

Treatment of comminuted fractures of the radial head is controversial, and considerable effort has been made to restore optimal function of the elbows, either by surgical reconstruction or prosthetic replacement. This report presents our experiences in treatment of unreconstructable radial head or neck fractures using osteochondral autografts harvested from the base of the second metatarsal bones.

Methods

Five patients with radial head and one with a radial neck fracture underwent treatment with osteochondral autografts. After excision of the unreconstructable radial head, the second metatarsal base was harvested and transplanted to the radius using the intramedullary nailing technique.

Results

The reconstructed elbows were examined clinically and radiographically for a mean period of 44.8 months (range, 24–72 months). At the last follow-up, in flexion-extension, the mean elbow mobility was 130°/10°. In supination-pronation, the mean elbow mobility was 73.3°/66.7°, with a mean loss of supination of 19.2° and loss of pronation of 12.5°. Grip strength was 91%, compared with the contralateral limb. The mean Mayo Elbow Performance Score was 94.2. The mean score of AOFAS rating system to the lesser toe was 93.7 points.

Conclusion

Radial head arthroplasty with an osteochondral autograft from the second metatarsal base appears to be an effective alternative for treatment of unreconstructable radial head fractures. A larger group of patients and a longer follow-up period will be required in order to ease concerns regarding the donor site; however, none of the patients who underwent this procedure showed any complications during follow-up.     

Condylar orientation plating in comminuted intraarticular fractures of adult distal humerus

Background:

The condyles of the distal humerus have characteristic orientation in reference to the diaphysis. Anatomical reduction of the articular surface in intraarticular fractures of adult distal humerus does not always restore preinjury functional status. The purpose of this study was to determine the outcome of treating these fractures with technique of condylar orientation precontoured plating. The principle of the technique is to primarily restore the anatomical orientation of the reconstructed distal humeral condyle with the diaphysis of the humerus apart from anatomical reduction of fracture.

Materials and Methods:

Seventy one consecutive patients with comminuted intraarticular adult distal humerus fractures were treated with the condylar orientation plates, which were specifically designed between 1999 and 2009. 43 fractures were Association for osteosynthesis (AO) type C3, 24 were C2 and 4 were C1. Six were open cases and two were of nonunion distal end humerus. On medial and posterolateral side of the distal humerus, precontoured Sherman plates were applied. Patients were followed up for a mean of 3 years. They were assessed clinically (using mayo elbow performance score [MEPS]) and radio-graphically.

Results:

Sixty (84.5%) patients regained MEPS of 90 or more that is an excellent result (range of movement and functional status). One patient had nonunion with implant failure, and two patients developed heterotopic ossification. The mean MEPS was 95. Average extension and flexion was 15° and 133°. The result was graded as excellent in 60, good in 7, fair in 3 and poor in 1. At the time of most recent followup, 63 elbows were painless, and eight had mild pain.

Conclusion:

Excellent pain free range of motion with a high rate of union can be achieved in comminuted intraarticular distal humerus fractures in adults with the use of condylar orientation precontoured plating technique. Condylar orientation is very important with perfect articular congruity in elbow motion.     

Arthroscopic radial head excision in managing elbow trauma

Purpose

This study describes a case series of 15 patients with radial head fractures who underwent radial head excision using an arthroscopic technique.

Methods

Over a four year period, 15 patients (average age 49.6 years) who had sustained a radial head or radial neck fracture underwent an arthroscopic excision of the radial head. Four patients had an unreconstructable comminuted fracture (early group; EG) and 11 patients had pain and loss of motion with an associated non- or malunion (late group; LG).

Results

The mean time to surgery following injury was three weeks (one to five) for the EG and 27 weeks (eight–58) for the LG. The average visual analogue scale (VAS) was 1.7 (zero to four), and the average Quick Disabilities of the Arm, Shoulder and Hand (Quick-DASH) score was 24.7 (16–44). At final follow-up, average supination was 62.0° (range 45–75°) and pronation was 63.3° (range 45–75°). There were no complications.

Conclusion

This series demonstrates that arthroscopic excision of fractures of the radial head and neck is reliable, reproducible and safe, with similar results to open excision. There may also be additional benefits in the short term with regards to speed of healing and rehabilitation.     

Results of two different surgical techniques in the treatment of advanced-stage Freiberg's disease

Background:

Freiberg''s disease is an osteochondrosis most commonly seen in adolescent women and characterized by pain, swelling and motion restriction in the second metatarsal. The early stages of this disease can be managed with semirigid orthoses, metatarsal bars and short leg walking cast. Number of operative methods are suggested which can be used depending on the pathophysiology of the disease, including abnormal biomechanics, joint congruence and degenerative process. We evaluated the outcomes of the patients with Freiberg''s disease who were treated with dorsal closing-wedge osteotomy and resection of the metatarsal head.

Patients and Methods:

16 patients (11 female, 5 male) with a mean age of 24.5 (range 13–49 years) years who underwent dorsal closing wedge osteotomy or resection of the metatarsal head were included in this retrospective study. Second metatarsal was affected in 13 and third metatarsal in three patients. According to the Smillie''s classification system, ten patients had type IV osteonecrosis and six patients had type V. The results of the patients were evaluated using the lesser metatarsophalangeal-interphalangeal (LMPI) scale.

Results:

According to the LMPI scale, the postoperative scores for the osteotomy and excision groups were 86 (range 64–100) and 72.6 (range 60–85), respectively. In the osteotomy group, mean passive flexion restriction was 18° (range 0°–35°) and mean passive extension restriction was 12° (range 0°–25°). Mean metatarsal shortening was 2.2 mm (range 2–4 mm) in the osteotomy group as opposed to 9.8 mm (range 7–14 mm) in the excision group. Significant pain relief was obtained in both groups following the surgery.

Conclusions:

The decision of performing osteotomy or resection arthroplasty in the patients with advanced-stage Freiberg''s disease should be based on the joint injury and the patients should be informed about the cosmetic problems like shortening which may arise from resection.     

Unstable Simple Elbow Dislocation Treated with the Repair of Lateral Collateral Ligament Complex

Background

Unstable simple elbow dislocation (USED) repair is challenged by the maintenance of joint reduction; hence, primary repair or reconstruction of disrupted ligaments is required to maintain the congruency and allow early motion of the elbow. We evaluated the effectiveness and the outcome of lateral collateral ligament (LCL) complex repair with additional medial collateral ligament (MCL) repair in cases of USED.

Methods

We retrospectively reviewed 21 cases of diagnosed USED without fractures around the elbow that were treated with primary ligament repair. In all cases, anatomical repair of LCL complex with or without common extensor origin was performed using suture anchor and the bone tunnel method. Next, the instability and congruency of elbow for a full range of motion were evaluated under the image intensifier. MCL was repaired only if unstable or incongruent elbow was observed. Clinical outcomes were evaluated using the Mayo elbow performance score (MEPS) and radiographic outcomes on last follow-up images.

Results

All cases achieved a stable elbow on radiographic and clinical results. LCL complex repair alone was sufficient to obtain the stable elbow in 17 of 21 cases. Four cases required additional MCL repair after restoration of the LCL complex. The overall mean MEPS was 91 (range, 70 to 100): excellent in 12 cases, good in 7 cases, and fair in 2 cases. All 17 cases with LCL complex repair only and 2 of 4 cases with additional MCL repair had excellent or good results by MEPS.

Conclusions

USED requires surgical treatment to achieve a congruent and stable joint. If the repair of lateral stabilizer such as LCL complex acquires enough joint stability to maintain a full range of motion, it may not be necessary to repair the medial stabilizer in all cases of USED.     

Olecranon tip osteoarticular autograft transfer for irreparable coronoid process fracture: a biomechanical study

Background

We hypothesized that transfer of the olecranon tip for simulated type III coronoid fracture would restore posterior ulnohumeral translation to a level not different from that in the intact state.

Methods

The collateral ligaments were left intact in 12 fresh-frozen cadaveric elbows, and all other soft tissues were removed. The entire coronoid process was osteotomized flush with the ventral aspect of the ulna and was reconstructed using the tip of the olecranon process. Specimens were tested with an axial load of 100 N at 0.25 mm/s in 15° increments from 15 to 120° of flexion. Intact, osteotomized, and reconstructed posterior ulnohumeral displacement was measured.

Results

The bony reconstruction did not obstruct range of motion of the elbow. Intact translation (mean ± SD) ranged from 0.3 ± 0.1 to 1.1 ± 0.6 mm, and translation in the osteotomized state ranged from 1.3 ± 1.0 to 2.0 ± 1.0 mm. Resection of the coronoid resulted in a significant increase in posterior ulnar translation compared with intact at all flexion angles (p < 0.05) except at 75°. Reconstruction decreased translation versus the osteotomized state at all flexion angles, significantly at 60 and 120°. No significant difference in translation was found between reconstructed and intact states at five of eight positions tested.

Conclusions

In this biomechanical study of irreparable coronoid fracture, autograft olecranon tip transfer restored posterior elbow stability to a level not significantly different from the intact elbow in five of eight elbow positions tested.     

Monobloc radial head prostheses in complex elbow injuries: results after primary and secondary implantation

Purpose

Dislocations of components, loosening of the stem, overstuffing and removal in up to 24 % of common radial head prostheses (RHP) after implantation in complex elbow injuries signal the need for improvement. The latest biomechanical evidence shows advantages for monopolar designs. Clinical results after primary and secondary implantation of the newly designed press-fit monobloc monopolar RHP in cases of complex elbow injury are evaluated.

Methods

Twenty-nine patients [median age 60 years (29–86)] were followed up retrospectively for a median of 25 months (7–54) post-operatively. Subjective parameters, the Mayo Elbow Performance Score (MEPS), the Broberg and Morrey score (BMS), latest radiographs and complications were evaluated.

Results

MEPS and BMS averaged 87.2 ± 12.9 and 81.1 ± 11.9 points, respectively. No case of implant loosening was observed; the RHP had to be removed in one case (3 %). The overall complication and revision rate was higher after secondary (53 %) than after primary (19 %) implantation.

Conclusions

Satisfactory clinical results and low short-term removal rates emphasise the practicality of monobloc monopolar RHP. Differentiated treatment of complex elbow fracture-dislocations is compulsory to avoid the need for secondary RHP implantation which carries a higher complication rate.     

外侧入路联合前内侧入路治疗肘关节“恐怖三联征”的手术疗效

 目的 探讨采用外侧入路联合前内侧入路治疗肘关节“恐怖三联征”的手术疗效。方法 回顾性分析2008年7月至2011年1月,采用外侧入路联合前内侧入路治疗23例肘关节“恐怖三联征”患者,其中21例获得完整随访资料,男17例,女4例;年龄17~63岁,平均38.4岁;坠落伤15例,运动损伤4例,交通伤2例;受伤至手术时间为2~8 d,平均4 d。尺骨冠突骨折O’Driscoll分型：A1型5例,A2型12例,B2型4例;桡骨头骨折Mason分型：Ⅰ型2例,Ⅱ型12例,Ⅲ型7例;软组织损伤仲飙等分型：Ⅰ型6例,Ⅱ型12例,Ⅲ型3例。先采用Kocher入路内固定或人工桡骨小头置换治疗桡骨小头骨折,暂时修补外侧副韧带复合体,而后通过前内侧入路固定冠突骨折并修补内侧副韧带损伤;术后采用铰链式外固定支具辅助固定。术后分别采用Mayo肘关节评分（Mayo elbow performence score, MEPS）和Broberg-Morrey分级评估患者肘关节功能及创伤性关节炎程度。结果 21例患者均获得随访,随访时间24~48个月,平均32个月。末次随访时,患者肘关节屈伸及前臂旋转平均活动度分别为126°（范围,115°~135°）和139°（范围,125°~145°）;MEPS评分为85~100分,平均95分,其中19例评定为优,2例为良,优良率为100%,无一例发生肘关节复发不稳定。术后1周,1例发生伤口浅表感染,经清创及静脉使用抗生素治疗后愈合;术后3个月,发生异位骨化症2例,桡骨头骨折骨不连1例,尺神经麻痹1例,均未行手术处理。结论 采用外侧入路联合前内侧入路治肘关节“恐怖三联征”具有一期同时重建骨结构和恢复软组织稳定性的优势,术后患者能早期进行功能锻炼,利于肘关节功能恢复。     

Does Radiographic Beam Angle Affect the Radiocapitellar Ratio Measurement of Subluxation in the Elbow?

Background

Radial head alignment is the key to determine elbow reduction after treatment of subluxations or Monteggia fractures. The radiocapitellar ratio (RCR) quantifies the degree of subluxation, by evaluating radial head alignment with the capitellum of the humerus; this ratio is reproducible when measured on true lateral radiographs of nonsubluxated elbows. However, the impact of beam angulation on RCR measurement is unknown.

Questions/purposes

Our hypotheses were that the RCR of the nonsubluxated elbow would remain in the normal range as the beam angle changed and that the RCR variability would increase for the subluxated elbow with small deviations in the beam angle.

Methods

Radiographs were taken of six healthy cadaveric extremities using beam angles ranging from −20° to 20° along the inferosuperior axis and from −20° to 20° along the dorsoventral axis. The same views then were taken of the six arms with anterior radiocapitellum subluxation followed by posterior radiocapitellum subluxation. RCRs were measured by one observer. As a reference value, the RCR was measured in the 0° to 0° position and the difference between each RCR in a nonreference position was subtracted from each RCR reference to obtain the delta-RCR. An ANOVA was performed to assess the main and interactive effects on the RCR measured in each C-arm position compared with the RCR measured on a true lateral radiograph.

Results

The RCR remained in the normal range even as the beam angle of the C-arm varied between −20° and 20°. The position of the beam did not affect the RCR in anteriorly subluxated elbows (p = 0.777), whereas RCR variation increased especially in the presence of posterior radial head subluxation when the C-arm position was 10° or more out of plane (p = 0.006). The inferosuperior malposition of the C-arm had a greater impact on quantification of radial head alignment measurement. Despite that, the RCR measurement is reliable in reduced and subluxated elbows on lateral radiographs with a C-arm position deviation of as much as 20°.

Conclusions

Identification of a subluxated elbow could be made on any lateral radiograph with a beam angulation deviation of as much as 20°. This suggests that the RCR is a useful diagnostic tool for clinical and research purposes, although for subluxated elbows, it is important to pay careful attention to the inferosuperior position of the C-arm.     

Repair of the torn distal biceps tendon by endobutton fixation

Background:

A number of techniques have been described to reattach the torn distal biceps tendon to the bicipital tuberosity. We report a retrospective analysis of single incision technique using an endobutton fixation in sports persons.

Materials and Methods:

The present series include nine torn distal biceps tendons in eight patients, fixed anatomically to the radial tuberosity with an endobutton by using a single incision surgical technique; seven patients had suffered the injuries during contact sports. The passage of the endobutton was facilitated by using a blunt tipped pin in order to avoid injury to the posterior interosseous nerve. The patients were evaluated by Disabilities of the Arm, Shoulder and Hand (DASH) score and Mayo elbow score.

Results:

The average age of the patients was 27.35 years (range 21–42 years). Average follow-up was 41.5 months (range 24–102 months). The final average flexion extension arc was 0°–143°, while the average pronation and supination angles were 77° (range 70°–82°) and 81° (range 78°–85°), respectively at the last followup. All the patients had a Disabilities of the Arm, Shoulder and Hand (DASH) score of 0 and a Mayo elbow score of 100 each. All the seven active sports persons were able to get back to their respective game. There was no nerve injury or any other complication.

Conclusions:

The surgical procedure used by us is a simple, safe and reproducible technique giving minimal morbidity and better cosmetic results.     

Medium term outcomes of primary and revision Coonrad-Morrey total elbow replacement

Background:

Total elbow replacement (TER) is indicated in inflammatory arthritis, osteoarthritis and fractures that are not amenable to reconstruction. There is no series in literature, to the best of our knowledge, regarding the results of revision of the Souter-Strathclyde prosthesis (SSP) to the Coonrad-Morrey prosthesis (CMP). The aim of this study is to present the medium term results of primary CMP total elbow replacement and revision of the SSP to CMP.

Materials and Methods:

50 primary CMPs (Group I) and 11 revision CMPs (Group II) were included in the study. Demographic, operative, followup and radiological data were analysed. The indication for revision of the primary implant was peri-prosthetic fracture in six cases, aseptic loosening in four cases and instability in one case.

Results:

The mean age in Group I was 67.28 ± 12.45 years and in Group II was 57.09 ± 11.25 years. The mean period of followup was 8.08 ± 2.95 years and 7.46 ± 2.39. There was a significant improvement in range of motion and pain in both groups. The complications seen were nerve palsy, infection, fractures and heterotopic ossification. The 5-year survival rate in Group I was 94%. The results were good in 36 elbows, fair in 8 elbows and poor in 5 elbows. In Group II, the results were good in 8 elbows, fair in 2 elbows and poor in 1 elbow. The complications seen were nerve palsy, fractures and heterotopic ossification.

Discussion:

Primary CMP TER provides a functionally useful range of movement of 100° which is enough to perform most activities of daily living. It also produces a pain free and stable joint. Similar results are achieved after revision of the SSP to CMP. The unique toggle-hinge mechanism of articulation provides inherent stability and good survivorship.

Conclusion:

Semiconstrained prostheses like CMP provide good functional results and survivorship and are the implant of choice in both primary and revision total elbow replacements.     

Pediatric open elbow dislocation without fracture: A case report

INTRODUCTION

Elbow dislocations in children are rare injuries. These injuries are often in the form of complex injuries that is accompanied by the median nerve damage and medial epicondyle fracture in the pediatric age group. Open elbow dislocation without fracture in the pediatric age group has been reported very rarely in the literature.

PRESENTATION OF CASE

The purpose of this study is to present an 8-year-old patient who has open elbow dislocation without fracture accompanying with brachial artery injury. In the clinical examination of the patient, there was an open wound in the transverse antecubital region. After repair of brachial artery injury, open reduction was performed under general anesthesia. In the postoperative clinical examination at 6 months, left elbow flexion was 140°, extension was full and there were no deficit in the supination and pronation of the forearm.

DISCUSSION

Elbow dislocation without fracture in pediatric patients is a very rare injury. Usually the trauma mechanism of elbow dislocation is falling on outstretched hand with elbow in approximately 30° of flexion. However our patient had fallen on outstretched hand with elbow in full extension. Although this type of trauma mechanism is typical for supracondylar humerus fractures in pediatric age group, in our patient an open posterior elbow dislocation without fracture had occurred.

CONCLUSION

Pediatric elbow dislocations are rare injuries and the management of these injuries can be technically demanding due to concurrent neurovascular injuries. An open dislocation without fracture is very rare and it should be treated with immediate intervention, an effective teamwork and good rehabilitation.     

Unstable Jefferson fractures: Results of transoral osteosynthesis

Background:

Majority of C₁ fractures can be effectively treated conservatively by immobilization or traction unless there is an injury to the transverse ligament. Conservative treatment usually involves a long period of immobilization in a halo-vest. Surgical intervention generally involves fusion, eliminating the motion of the upper cervical spine. We describe the treatment of unstable Jefferson fractures designed to avoid these problems of both conservative and invasive methods.

Materials and Methods:

A retrospective review of 12 patients with unstable Jefferson fractures treated with transoral osteosynthesis of C₁ between July 2008 and December 2011 was performed. A steel plate and C₁ lateral mass screw fixation were used to repair the unstable Jefferson fractures. Our study group included eight males and four females with an average age of 33 years (range 23-62 years).

Results:

Patients were followed up for an average of 16 months after surgery. Range of motion of the cervical spine was by and large physiologic: Average flexion 35° (range 28-40°), average extension 42° (range 30-48°). Lateral bending to the right and left averaged 30° and 28° respectively (range 12-36° and 14-32° respectively). The average postoperative rotation of the atlantoaxial joint, evaluated by functional computed tomography scan was 60° (range 35-72°). Total average lateral displacement of the lateral masses was 7.0 mm before surgery (range 5-12 mm), which improved to 3.5 mm after surgery (range 1-6.5 mm). The total average difference of the atlanto-dens interval in flexion and extension after surgery was 1.0 mm (range 1-3 mm).

Conclusions:

Transoral osteosynthesis of the anterior ring using C₁ lateral mass screws is a viable option for treating unstable Jefferson fractures, which allows maintenance of rotation at the C₁-C₂ joint and restoration of congruency of the atlanto-occipital and atlantoaxial joints.     

Medial Patellofemoral Ligament Reconstruction for Recurrent Patellar Instability Using a Gracilis Autograft without Bone Tunnel

Background

Several tendon graft and fixation methods have been introduced in medial patellofemoral ligament (MPFL) reconstruction for recurrent patellar dislocation. The purpose of this study was to evaluate the results of MPFL reconstruction using a gracilis autograft fixation without bone tunnel in patients with recurrent patellar instability.

Methods

Nine patients (four males and five females) diagnosed with recurrent patellar instability from July 2009 to January 2013 and had MPFL reconstruction using a gracilis autograft were included. The average age of the patients was 24.6 years (range, 13 to 48 years), and the average follow-up period was 19.3 months (range, 12 to 30 months). For every patient, femoral attachment was fixed using suture anchors securing the patella by suturing the periosteum and surrounding soft tissue. Clinical evaluation included the Kujala, Lysholm, and Tegner scores; in addition, patients were examined for any complication including recurrent dislocation. The congruence angle and patella alta were assessed radiologically before and after surgery.

Results

The Kujala score improved from an average of 42.7 ± 8.4 before surgery to 79.6 ± 13.6 (p = 0.008) at final follow-up; the Lysholm score improved from 45.8 ± 5.7 to 82.0 ± 10.5 (p = 0.008); and the Tegner score improved from 2.8 ± 0.8 to 5.6 ± 1.5 (p = 0.007). The Insall-Salvati ratio changed from 1.16 ± 0.1 (range, 0.94 to 1.35) before surgery to 1.14 ± 0.1 (range, 0.96 to 1.29; p = 0.233) at the final follow-up without significance. The congruence angle significantly improved from 26.5° ± 10.6° (range, 12° to 43°) before surgery to -4.0° ± 4.3° (range, -12° to 5°; p = 0.008) at final follow-up. Subluxation was observed in one patient and hemarthrosis occurred in another patient 2 years after surgery, but these patients were asymptomatic.

Conclusions

We achieved good results with a patellar fixation technique in MPFL reconstruction using a gracilis autograft employing soft tissue suturing in patients with recurrent patellar dislocation.     

Elbow Positioning and Joint Insufflation Substantially Influence Median and Radial Nerve Locations

Background

The median and radial nerves are at risk of iatrogenic injury when performing arthroscopic arthrolysis with anterior capsulectomy. Although prior anatomic studies have identified the position of these nerves, little is known about how elbow positioning and joint insufflation might influence nerve locations.

Questions/purposes

In a cadaver model, we sought to determine whether (1) the locations of the median and radial nerves change with variation of elbow positioning; and whether (2) flexion and joint insufflation increase the distance of the median and radial nerves to osseous landmarks after correcting for differences in size of the cadaveric specimens.

Methods

The median and radial nerves were marked with a radiopaque thread in 11 fresh-frozen elbow specimens. Three-dimensional radiographic scans were performed in extension, in 90° flexion, and after joint insufflations in neutral rotation, pronation, and supination. Trochlear and capitellar widths were analyzed. The distances of the median nerve to the medial and anterior edge of the trochlea and to the coronoid were measured. The distances of the radial nerve to the lateral and anterior edge of the capitulum and to the anterior edge of the radial head were measured. We analyzed the mediolateral nerve locations as a percentage function of the trochlear and capitellar widths to control for differences regarding the size of the specimens.

Results

The mean distance of the radial nerve to the lateral edge of the capitulum as a percentage function of the capitellar width increased from 68% ± 17% in extension to 91% ± 23% in flexion (mean difference = 23%; 95% confidence interval [CI], 5%–41%; p = 0.01). With the numbers available, no such difference was observed regarding the location of the median nerve in relation to the medial border of the trochlea (mean difference = 5%; 95% CI, −13% to 22%; p = 0.309). Flexion and joint insufflation increased the distance of the nerves to osseous landmarks. The mean distance of the median nerve to the coronoid tip was 5.4 ± 1.3 mm in extension, 9.1 ± 2.3 mm in flexion (mean difference = 3.7 mm; 95% CI, 2.04–5.36 mm; p < 0.001), and 12.6 ± 3.6 mm in flexion and insufflation (mean difference = 3.5 mm; 95% CI, 0.81–6.19 mm; p = 0.008). The mean distance of the radial nerve to the anterior edge of the radial head increased from 4.7 ± 1.8 mm in extension to 7.7 ± 2.7 mm in flexion (mean difference = 3.0 mm; 95% CI, 0.96–5.04 mm; p = 0.005) and to 11.9 ± 3.0 mm in flexion with additional joint insufflation (mean difference = 4.2 mm; 95% CI, 1.66–6.74 mm; p = 0.002).

Conclusions

The radial nerve shifts medially during flexion from the lateral to the medial border of the inner third of the capitulum. The median nerve is located at the medial quarter of the joint. The distance of the median and radial nerves to osseous landmarks doubles from extension to 90° flexion and triples after joint insufflation.

Clinical Relevance

Elbow arthroscopy with anterior capsulectomy should be performed cautiously at the medial aspect of the joint to avoid median nerve lesions. Performing arthroscopic anterior capsulectomy in flexion at the lateral aspect of the joint and in slight extension at the medial edge of the capitulum could enhance safety of this procedure.