Complex Elbow Injuries Research Articles

Complex Elbow Injury With Delayed Ulnar Nerve Dysfunction In Peadiatric Age Group: A Rare Case Report

Complex Elbow Injury With Delayed Ulnar Nerve Dysfunction In Peadiatric Age Group: A Rare Case Report

Additional Hinged External Fixation in Complex Elbow Injury

169 Copyright c 2015 The Korean Fracture Society. All rights reserved. This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/ by-nc/4.0) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited. Received January 11, 2015 Revised (1st) February 18, 2015, (2nd) April 8, 2015 Accepted May 19, 2015 Address reprint requests to: Tong-Joo Lee, M.D., Ph.D. Department of Orthopedic Surgery, Inha University Hospital, 27 Inhang-ro, Jung-gu, Incheon 400-711, Korea Tel: 82-32-890-3043ᆞFax: 82-32-890-3047 E-mail: TJLEE@inha.ac.kr

A rare paediatric trauma: Lateral condyle humerus fracture with concomitant postero-medial elbow dislocation.

The association of elbow dislocation with fracture of the lateral condyle in paediatrics is considered very rare and only a few isolated cases have been reported in the literature. Due to its rarity, some of the authors have classified this injury as a complex elbow injury and have deemed them technically demanding to repair. A ten-year-old boy presented to us with a lateral condyle humerus fracture [Milch type 2] with concomitant postero-medial elbow dislocation following a fall on his outstretched hand. At 34 months of follow-up, the child regained a full range of motions around the elbow joint without any deformities.This combination injury, although rare, is not technically different or difficult to treat.

Management of distal humeral coronal shear fractures.

Coronal shear fractures of the distal humerus are rare, complex fractures that can be technically challenging to manage. They usually result from a low-energy fall and direct compression of the distal humerus by the radial head in a hyper-extended or semi-flexed elbow or from spontaneous reduction of a posterolateral subluxation or dislocation. Due to the small number of soft tissue attachments at this site, almost all of these fractures are displaced. The incidence of distal humeral coronal shear fractures is higher among women because of the higher rate of osteoporosis in women and the difference in carrying angle between men and women. Distal humeral coronal shear fractures may occur in isolation, may be part of a complex elbow injury, or may be associated with injuries proximal or distal to the elbow. An associated lateral collateral ligament injury is seen in up to 40% and an associated radial head fracture is seen in up to 30% of these fractures. Given the complex nature of distal humeral coronal shear fractures, there is preference for operative management. Operative fixation leads to stable anatomic reduction, restores articular congruity, and allows initiation of early range-of-motion movements in the majority of cases. Several surgical exposure and fixation techniques are available to reconstruct the articular surface following distal humeral coronal shear fractures. The lateral extensile approach and fixation with countersunk headless compression screws placed in an anterior-to-posterior fashion are commonly used. We have found a two-incision approach (direct anterior and lateral) that results in less soft tissue dissection and better outcomes than the lateral extensile approach in our experience. Stiffness, pain, articular incongruity, arthritis, and ulnohumeral instability may result if reduction is non-anatomic or if fixation fails.

Ellenbogenluxationsverletzungen beim Trendsport Bouldern

Bouldering is a new trend sport which has become popular in recent years. From April 2011 to June 2012 a total of 5 patients with elbow dislocations from bouldering were admitted to our level 1 trauma center. The injuries varied from simple elbow dislocations to complex fracture dislocations. Elbow dislocations occurred during falling backwards when patients tried to protect themselves by retroversion of both arms. In all cases the falling height was less than 4 meters. The bouldering injury pattern, the diagnostic and therapeutic management as well as the rehabilitation program are described in detail in this article. To the best of our knowledge this is the first report on the special danger of bouldering for complex elbow injuries.

Radial Head Replacement for Radial Head Fractures

This study aimed to analyze the clinical results after treatment of complex elbow injuries with modular anatomic radial head prosthesis (MARHP), along with ligament repair and fracture fixation. Retrospective. District teaching hospital. The inclusion criteria were all patients with traumatic elbow instability after acute fracture or fracture dislocation, where the radial head was comminuted and irreparable at the time of surgery (Mason type III) and there was associated valgus laxity of the elbow. Of 14 patients, 12 with radial head prosthesis were available for the study. MARHP (Acumed, Hillsboro, OR) was used to replace irreparable and comminuted radial head fractures when it was associated with valgus instability. All patients were evaluated clinically and radiographically for a mean follow-up of 42 months (range, 22-58 months). Patients recovered a similar range of motion between affected and unaffected elbows. Stability was restored to all 12 elbows, and all patients had a good or excellent result according to Mayo Elbow Performance Index and a disability of the arm, shoulder, and hand survey. Radiographic measurement revealed a congruent elbow joint. The MARHP is effectively restoring stability and congruency to the elbow joint. There was no evidence of arthritic radiocapitellar joint, capitellar osteopenia, significant proximal radial migration of the implant, or any major complications. Outcomes were optimized by recognition and addressing the associated injuries. Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Fractures of the Radial Head and Neck

The majority of simple fractures of the radial head are stable, even when displaced 2 mm. Articular fragmentation and comminution can be seen in stable fracture patterns and are not absolute indications for operative treatment. Preservation and/or restoration of radiocapitellar contact is critical to coronal plane and longitudinal stability of the elbow and forearm. Partial and complete articular fractures of the radial head should be differentiated. Important fracture characteristics impacting treatment include fragment number, fragment size (percentage of articular disc), fragment comminution, fragment stability, displacement and corresponding block to motion, osteopenia, articular impaction, radiocapitellar malalignment, and radial neck and metaphyseal comminution and/or bone loss. Open reduction and internal fixation of displaced radial head fractures should only be attempted when anatomic reduction, restoration of articular congruity, and initiation of early motion can be achieved. If these goals are not obtainable, open reduction and internal fixation may lead to early fixation failure, nonunion, and loss of elbow and forearm motion and stability. Radial head replacement is preferred for displaced radial head fractures with more than three fragments, unstable partial articular fractures in which stable fixation cannot be achieved, and fractures occurring in association with complex elbow injury patterns if stable fixation cannot be ensured.

Discussion: Use of the Fix and Flap Approach to Complex Open Elbow Injury: The Role of the Free Anterolateral Thigh Flap

BackgroundComplex elbow injuries with associated nerve, muscle, or joint injury commonly develop post-inury stiffness. In order to preserve function, joint congruency, elbow stability and durable wound coverage must be achieved in a timely manner.MethodsA retrospective review of patients who underwent orthopaedic fixation followed by free anterolateral thigh (ALT) flap soft tissue coverage was performed. Five patients were identified and included in this study.ResultsWe present a series of 5 cases managed with this principle. Soft tissue defects ranged in size from 4×9 cm (36 cm2) to 15×30 cm (450 cm2) and were located either posteriorly (n=4) or anteriorly (n=1). Associated injuries included open fractures (n=3) and motor nerve transection (n=2). Wound coverage was achieved in a mean duration of 18.8 days (range, 11 to 42 day). There were no flap failures and no major complications. The mean postoperative active elbow motion was 102° (range, 45° to 140°).ConclusionsIn our small series we have highlighted the safety and utility of using the free ALT flap in complex elbow injuries. The ALT flap has many advantages which include abundant skin and subcutaneous tissue; vascularised vastus lateralis muscle that was used in our series to obliterate dead space, provide a vascular bed for nerve grafts and combat infection; and, access to fascia lata grafts for reconstruction of the triceps tendon.

Use of the Fix and Flap Approach to Complex Open Elbow Injury: The Role of the Free Anterolateral Thigh Flap

Complex elbow injuries with associated nerve, muscle, or joint injury commonly develop post-inury stiffness. In order to preserve function, joint congruency, elbow stability and durable wound coverage must be achieved in a timely manner. A retrospective review of patients who underwent orthopaedic fixation followed by free anterolateral thigh (ALT) flap soft tissue coverage was performed. Five patients were identified and included in this study. We present a series of 5 cases managed with this principle. Soft tissue defects ranged in size from 4×9 cm (36 cm(2)) to 15×30 cm (450 cm(2)) and were located either posteriorly (n=4) or anteriorly (n=1). Associated injuries included open fractures (n=3) and motor nerve transection (n=2). Wound coverage was achieved in a mean duration of 18.8 days (range, 11 to 42 day). There were no flap failures and no major complications. The mean postoperative active elbow motion was 102° (range, 45° to 140°). In our small series we have highlighted the safety and utility of using the free ALT flap in complex elbow injuries. The ALT flap has many advantages which include abundant skin and subcutaneous tissue; vascularised vastus lateralis muscle that was used in our series to obliterate dead space, provide a vascular bed for nerve grafts and combat infection; and, access to fascia lata grafts for reconstruction of the triceps tendon.

Radial head replacement with the MoPyC pyrocarbon prosthesis

Radial head fractures often pose therapeutic dilemmas. We present the early results of patients who underwent radial head replacement with the MoPyC prosthesis (Bioprofile, Tornier, Saint-Ismier, France). We re-evaluated patients who underwent post-traumatic radial head resection and implantation of the MoPyC prosthesis due to pain and motion restriction. All patients underwent radiographic evaluation. Clinical evaluation was performed using the Broberg-Morrey and the Mayo Elbow Performance Score (MEPS) scales. Thirty-two patients (20 men, 12 women; mean age, 54 years; 22 dominant upper limbs) were evaluated. Twenty had a comminuted radial head fracture (Mason IV, 15; Mason III, 5), 2 from radial head fracture malunion, and 10 had complex elbow injuries (comminuted radial head fractures with ligamentous ruptures with or without coronoid process fractures). Mean follow-up was 27 months (range, 21-46 months). The mean results at the latest follow-up were flexion-extension, 130° (range, 105°-150°); pronation, 74° (range, 60°-80°); and supination, 72° (range, 60°-80°). No laxity was evident during valgus and varus stress tests. Mean grip strength was 96% of the contralateral side. Broberg-Morrey scores were excellent in 33%, good in 44%, and fair in 23%. MEPS results were excellent in 80%, good in 17%, and fair in 3%. There were 6 cases of periprosthetic lucencies or osteolysis of the radius without any clinical signs of loosening. Radial head replacement with the MoPyC pyrocarbon prosthesis (when performed in carefully selected patients) yields satisfactory results regarding range of motion and function of the elbow joint.

요골두 치환술의 임상적 적용

Purpose: Installing a radial head prosthesis has developed into a reliable procedure to replace the native radial head for treating unreconstructible radial head fracture when this is associated with an unstable elbow or forearm. A variety of implants have been developed and these are now commercially available. This article reviews the literature related to the indications, the available implants and the surgical techniques of radial head replacement arthroplasty. Materials and Methods: The main indication for a metallic radial head prosthesis is a comminuted fracture that is not amenable to reconstruction, and particularly if it is associated with complex elbow injuries. Excision of the radial head should be avoided in the presence of combined injured ligaments or interosseous membrane injury. Three different implants are available in Korea, including the bipolar, press fit monopolar and loose fit monopolar radial head prostheses. A primary technical goal of radial head arthroplasty is the insertion of an implant that closely replicates the native radial head. The major pitfall when using a metallic radial head prosthesis is the insertion of a longer implant, which results in overstuffing of the radiocapitellar joint. Results and Conclusion: Satisfactory clinical results can be anticipated when a radial head prosthesis is used for the correct indications and when a systemic approach is undertaken to ensure proper sizing. For the future studies, we need data regarding the long term outcomes and comparison of the various types of prostheses.

Treatment of Complex Elbow Injuries With a Postoperative Custom-Made Progressive Stretching Static Elbow Splint

Complex elbow injuries consist of fractures of one or several of the bony stabilizers of the elbow, including the radial head, proximal ulna, coronoid process, collateral ligaments, and capsular complex. These injuries, if not properly treated, were reported to have a poor prognosis with recurrent instability, stiffness, posttraumatic arthrosis, and pain. This study was conducted to review clinical outcomes after fracture stabilization and ligament repair with a postoperative custom-made progressive stretching (CMPS) elbow splint in the treatment of complex elbow injuries. From December 2001 to October 2006, 14 patients with complex elbow fractures or instability underwent surgery in Far Eastern Memorial Hospital by Chang Chih-Hung, using suture anchors. All patients used our CMPS static elbow splint postoperatively. No hinged elbow external skeletal fixator was necessary. The results were reviewed retrospectively. The patients were followed up for an average of 14 months. The mean (standard deviation) flexion-extension range of motion (ROM) was 116-degree angle (23-degree angle). The mean Mayo Elbow Performance Score was 92 points; the results were excellent in 10 patients, good in three patients, and fair in one patient. The dilemma in managing complex elbow injuries is that extended immobilization leads to stiffness, but without proper reconstruction of the stabilizer, joint instability recurs. Our surgical protocol included removal of all loose bodies within the joint, stable fixation of fracture fragments if possible, and use of suture anchors to repair medial or lateral ulnar collateral ligaments. CMPS static elbow splints provided both postoperative protection and ROM movement. In our experience, if the stabilizers were reconstructed, hinged elbow external skeletal fixator is usually not necessary, and progressive stretching by CMPS splint can result in good ROM.

Radial Nerve Disruption Following Application of a Hinged Elbow External Fixator

A hinged or articulated elbow external fixator is recommended for patients with elbow instability1, as a protective device following extensive capsular release of elbow contractures2, after ligamentous reconstruction3, for distraction interposition arthroplasty4, and in the management of complex elbow fracture-dislocations5. The hinged external fixator permits early postoperative elbow mobilization while maintaining elbow stability. There is a growing recognition of the value of and indications for articulated external fixation of the elbow6, despite the possibility of serious complications. Cheung et al.6 classified complications related to hinged external fixators of the elbow as major and minor. Minor complications, which occurred in 15% of patients, included local erythema and nonpurulent pin-site drainage lasting longer than five days and the need for skin release to decrease tension adjacent to the pins. Major complications, which occurred in 10% of patients, included purulent pin-site drainage, fixator malalignment, pin loosening, and deep infection. Although cases of transient radial nerve palsy are described in the literature1,7, to the best of our knowledge no permanent radial nerve palsy has been documented following application of a hinged external fixator. We present three cases of radial nerve palsy due to complete nerve disruption after application of a hinged external fixator for the treatment of complex elbow injuries. The patients were informed that data concerning their cases would be submitted for publication, and they consented. Case 1. A forty-seven-year-old male gardener fell on the right, dominant arm. No fracture or dislocation was noted. Seven years later, ulnar nerve decompression with a medial epicondylectomy was performed elsewhere (i.e., not at our hospital) to treat posttraumatic irritation of the ulnar nerve. Because the symptoms persisted postoperatively, the patient was seen by an elbow specialist at another …

Treatment of complex elbow injuries with the hinged fixation device DJD II

Treatment of complex elbow injuries with the hinged fixation device DJD II

Additional external hinged fixator after open repositioning and internal fixation of acute elbow instability in non-compliant patients

This is a retrospective analysis of the clinical and radiological outcome in 11 patients with complex acute posttraumatic elbow instability after dislocation. These patients had also been treated with a hinged external fixator after open reduction, capsular and ligamentous reconstruction and internal fixation, because of an expected diminished compliance, to avoid a secondary dislocation of the internal fixation. Concentric stability and a sufficient range of motion of the elbow joint were achieved in all cases. Non-compliant patients were classified by the surgeon as not compliant or not able or not willing to cooperate post-operatively for various reasons, such as alcoholism, drug abuse, mental disability, cerebral trauma or senile dementia. Non-compliant patients had undergone open reduction and internal fixation of an acute posttraumatic unstable elbow. The addition of a hinged external fixator allows early intensive mobilization, and can protect and improve the clinical outcome after these complex elbow injuries. This evaluation remains, of course, largely subjective and decision making is not easy because in most cases, the patient was not known before surgery. Thus, the only patient exclusion criteria in this study was surgeon classification as “compliant”.

Selection of operative approaches for "terrible triad" of the elbow

Objective To discuss selection of operative approaches for treatment ofterrible triad of the elbow(backward dislocation of the elbow combined with fractures of the radial head and ulnar coronoid process). Methods From June 2003 to August 2008,we treated 17 patients withterrible triadof the elbow.11 males and 6 fomales,with an average age of 34.5 years(22 to 48 years).The average interval between injury and surgery was 5.4 days,ranging from 3 to 7 days.Lateral approach was applied in 9 cages,lateral plus medial approaches in 2 cases,and elbow anterior approach in 6 cases.For fractures of the ulnar coronoid process.resection was performed in one case and internal fixation in 16 ca8esI For radial head fractures,internal fixation was performed in 14 cases,excision in one case,and replacement in 2 cases.According to the stability of fracture and internal fixation,continuous passive motion(CPM)or active functional exercises was conducted postoperation.Mayo elbow performance score(MEPS)was used to evaluate the elbow funotions.Remrs The patients were followed up from 12 to 48 months,with an average of 21 months.All incisions healed without bone nonunion or isehemic forearm muscle contracture.Delayed ulnar nerve palsy occurred in one case and heterotopic ossification in 2 cases.MEPS was excellent in 6 cases,good in 8,fair in 2 and poor in one,with an excellent to good rate of 82.4%.All patients but one undergoing radial head resection maintained good elbow stability.The main factors affecting the Mayo score were limitation of movement and partial loss of everyday kinetic capability. Conclusions For terrible triadof the elbow,the complex elbow injuries,selection of the operative approaches should be based on the type of fractures and injuries.Reasonable surgical treatment and active functional exercise may lead to an excellent prognosis. Key words: Elbow ioint; Dislocation; Radius fractures; Ulna fractures; Surgical procedures,operative

Radial head fractures: Loss of cortical contact is associated with concomitant fracture or dislocation

Among radial head fractures displaced greater than 2 mm (Broberg and Morrey modified Mason type 2), separation (complete loss of cortical contact) of at least 1 radial head fracture fragment is associated with a complex injury pattern, meaning that there are other concomitant elbow fractures or ligament injuries. We identified 291 consecutive skeletally mature patients with 296 radial head fractures treated during a 6-year period. Of these, 121 consecutive fractures of part of the radial head displaced greater than 2 mm (type 2) were classified according to whether there was complete lack of cortical contact between a fracture fragment and the rest of the proximal radius. Predictors of isolated vs complex injury pattern were sought in bivariate and multivariable analyses. Of 121 fractures, 30 (25%) were classified as having cortical contact, and 91 (75%) were classified as not having cortical contact. Ten (33%) with cortical contact were part of a complex elbow injury, and 83 of 91 fractures (91%) without cortical contact were part of a complex elbow injury (P < .01). Among the Mason type 2 fractures, loss of cortical contact was a significant predictor of a complex elbow injury in both bivariate and multivariable analyses, with an odds ratio of 21 (95% confidence interval, 7-59). Among Mason type 2 fractures, complete loss of cortical contact of at least one fracture fragment is strongly predictive of a complex injury pattern. 4, Retrospective case series, Treatment study.

Surgical treatment of acute coronoid process fractures

This study was designed to assess the results of surgical treatment for type 2-3 coronoid process fractures and to identify factors that might influence the outcome. Thirteen male patients (mean age 35 years; range 17 to 53 years) were treated with open reduction and internal fixation for displaced coronoid fractures. According to the Regan-Morrey classification, the fractures were type 2 in nine patients (69.2%), and type 3 in four patients (30.8%). Nine patients had associated injuries (elbow dislocation, radial head or olecranon fractures, and/or ligamentous injuries). The mean duration to treatment was 2.3 days (range 1 to 7 days). Functional results were assessed according to the Mayo elbow performance score (MEPS), and signs of arthritis were assessed according to the Broberg-Morrey criteria. The mean follow-up was 41.1 months (range 12 to 96 months). A functional range of motion of the elbow joint was achieved in 10 patients (76.9%). The mean elbow range of motion was 110.7 degrees (range 85 degrees to 130 degrees ) and the mean forearm rotation was 134.2 degrees (range 120 degrees to 155 degrees ). Three patients who had comminuted fractures and associated elbow injuries had decreased range of motion. None of the patients exhibited signs of instability. The mean MEPS was 86.5 (range 75 to 100). The results were excellent in four patients (30.8%; the mean MEPS 98.8) having isolated or noncomminuted coronoid fractures, and good in nine patients (69.2%) with comminuted fractures and/or associated bone or ligament injuries. Post-traumatic arthritis was detected in seven patients (53.9%) whose mean MEPS was 81.4. Patients with an excellent functional result did not develop arthritis. All the patients returned to preinjury activity levels. Coronoid fractures are the most important component of complex elbow injuries. The presence of comminuted fractures, associated bone and ligament injuries, and post-traumatic arthritis affect the outcome adversely.

Anterior Ulnohumeral Compression Plate Arthrodesis for Revision Complex Elbow Injury: A Case Report

Elbow arthrodesis can be used for complex elbow injuries that are complicated or fail other conventional treatment methods. We present a case report of an anterior ulnohumeral compressive plate elbow arthrodesis for a patient with a complex elbow injury from a gunshot wound that failed initial open reduction and internal fixation and posterior ulnohumeral arthrodesis secondary to numerous complications.

요골두 금속 치환물의 국내 사용

Purpose: The aim of this study was to report seven cases of metallic radial head prosthesis and present the limit of use in Korea. Materials and Methods: Metallic radial head arthroplasty was performed on 7 patients between April 2006 and December 2006, who had complex elbow injury including comminuted radial head fracture. Indication, operative findings and outcome were assessed. Availability and payment of implant were investigated. Results: All of the patients had more than one associated injury including coronoid fracture, olecranoan fracture, and ligament ruptures. According to Mason classification, there were three type III and four type IV fractures. All radial head fractures were too comminuted to reconstruct. There were two excellent results, four good, and one poor, as graded by Mayo score. There were no patient with instability and implant related complications. Insufficient supply of implant did not enable to do scheduled surgery in 2 cases. Current medical insurance did not cover charge for radial prosthesis, five patients could not help paying for that by themselves. Conclusion: Metallic radial head implants are useful when the radial head cannot be repaired reliably. Preoperative preparing and coverage by medical insurance based on appropriate indication are helpful for decision for a treatment option.