Elbow Range Of Motion Research Articles

Direct anterior approach for mini plate fixation of Regan–Morrey type II comminuted ulnar coronoid process fracture

The goal of this study was to evaluate the clinical effect of Regan-Morrey type II comminuted coronoid process fracture treated with mini plate through the direct anterior approach (DAA). Ten patients who underwent open reduction and internal fixation (ORIF) with mini plate through the DAA between February 2013 and August 2016 was included. There were three women and seven men, with an average age of 34.4 ± 7.5 years. At the final follow-up, the Mayo Elbow Performance Index (MEPS), Visual Analogue Scale (VAS) score, Disability of the Arm, Shoulder, and Hand (DASH) score, and the elbow range of motion were noted. The mean follow-up was 26.3 ± 2.2 (range 24-31) months. The mean elbow arc of motion was 118.5° with a mean arc of extension of 4° ± 5.2° and flexion of 122.5° ± 7.2°.The mean forearm pronation was 72° ± 7.2°, and the mean supination was 68° ± 6.3° with a mean forearm rotation arc of 140°. The average postoperative score according to the MEPS was 91 ± 5.7 points (range 80-100 points), and all patients achieved satisfactory scores (8 excellent and 2 good). The final average VAS score was 0.6 ± 1 (range 0-3). The final average DASH score was 4.0 ± 1.6 (range 2.3-7.4). None of the patients complained about elbow instability that required secondary surgery. No complications of infection, joint incongruency, fracture nonunion, median nerve palsy, or implant failure were reported. ORIF with mini plate through the DAA for the treatment of the type II comminuted coronoid process fractures can achieve satisfactory outcomes.

Percutaneous cross-pinning versus two lateral entry pinning in Gartland type III pediatric supracondylar humerus fractures

Background Supracondylar humerus fracture is the most common elbow fracture in children aged 5–7 years, affecting boys more than girls and the majority of fractures are of the extension type. These fractures are usually associated with a number of complications including neurovascular injuries, malunion, and elbow stiffness. Gartland type III fractures are usually treated by closed reduction and percutaneous pinning. Patients and methods A prospective study was carried out on children with Gartland type III extension-type supracondylar humerus fractures. The patients were randomized to undergo fixation either with crossed pinning (group A) or two lateral pinning (group B). We compared both groups with regard to their passive elbow range of motion, Flynn’s criteria, Baumann’s angle, change in Baumann’s angle, and Skaggs method of grading of loss of reduction and complications. Results Group A included 33 patients with a mean age of 5.4 years and group B included 34 patients with a mean age of 4.9 years. Group B had a statistically significant shorter operative time and radiation time. At final follow-up, there were no statistically significant differences between group A and group B with respect to the average Baumann’s angle, change in the Baumann angle, range of elbow motion, Flynn’s grade, or Skaggs criteria. There were no cases of iatrogenic ulnar nerve injury in both groups. Conclusion If a standardized operative technique is followed in each method, then the result of both methods will be same in terms of safety and efficacy. Orthopedic surgeons treating unstable pediatric supracondylar humerus fractures should be familiar with both pinning techniqus.

Correction of cubitus varus with lateral closed wedge osteotomy and cross k-wire fixation: results of a prospective series of 19 patients

Background: Cubitus varus is the most common late complication of displaced supracondylar fractures of the humerus in children and may lead to long-term problems such as increased chances of lateral humeral condyle fractures, posterolateral instability of the elbow, and tardy ulnar nerve palsy. Various complex corrective osteotomies have been described in literature with no consensus. We conducted this study to evaluate whether a simple lateral closed wedge osteotomy can give predictably good results in these patients. Materials and Methods: Nineteen children with malunited supracondylar fracture humerus leading to cubitus varus deformity underwent lateral closed wedge osteotomy, which was fixed with cross K-wires. Patients were evaluated for carrying angle, elbow range of motion, complications if any, and radiological correction of humeroulnar angle. Results: Osteotomy healed in all patients by 8 weeks (range 4–8 weeks, mean of 5.5 weeks). Excellent correction was achieved in 18 patients, whereas one patient had inadequate correction. Preoperative varus ranging from 10° to 30° (average – 17°) improved to 0°–12° valgus (average-8°). Two patients had minor complications in the form of pin tract infections which resolved with local care and antibiotics. There was no loss of correction or pin loosening. Sixteen patients had excellent result, whereas three patients had fair result as per Bellemore's criteria. Conclusion: Complex three-dimensional osteotomy is not always necessary for cubitus varus correction and a simple lateral closed wedge osteotomy fixed using cross K-wires can give good results with proper planning and execution.

Pain, function, and patient satisfaction after arthroscopic treatment of elbow in a retrospective series with minimum of 5-year follow-up.

The clinical indications for elbow arthroscopic procedures have expanded through last decades. The aim of the study was to assess the functional results and patient satisfaction after arthroscopic treatment of various elbow conditions after a minimum 5-year follow-up. We conducted a retrospective study of a consecutive patient cohort who had undergone unilateral elbow arthroscopy between 2008 and 2010. The main outcomes were Disabilities of the Arm, Shoulder and Hand (DASH) score and a specific patient-reported outcome measure questionnaire after a minimum 5-year follow-up. In total, there were 93 patients in the cohort with different diagnoses. Majority of patients were suffering from elbow osteoarthrosis. After the average follow-up of 72 months (range 60-96 months), the response rate was 67%. Eighty two percent of patients were satisfied with the pain relief and locking of the elbow was relieved in 70% of patients. Elbow range of motion (ROM) improved in 80% of the 55 patients who had a limited ROM before the operation. The overall patient satisfaction after elbow arthroscopic treatment was good. There were no differences in median DASH score between patients with or without post-traumatic condition, but the median DASH score for patients who had severe (grade 3) osteoarthrosis before the operation was significantly worse. There were no major complications reported in this cohort. Arthroscopic treatment of various elbow conditions was associated with good patient satisfaction and reduced symptoms without major complications. Level of Evidence: Level IV, therapeutic case series.

Assessment of elbow functional outcome after closed reduction and percutaneous pinning of displaced supracondylar humerus fractures in children

Background: The aim of the current study was to establish the functional outcome of Gartland grade III extension-type supracondylar fractures at 24 weeks after closed reduction and percutaneous pinning (CRPP) without physiotherapy. The objectives of this study were 1) to measure the elbow range of motion (ROM) at three, six, 12 and 24 weeks after CRPP for grade III supracondylar fractures; 2) to assess the functional outcome of the injured limb using the Paediatric Outcome Data Collection Instrument (PODCI) score; 3) to compare elbow functional outcome of children less than 7 years old versus children more than 7 years old and 4) to assess other risk factors or complications associated with poor outcomes after CRPP (including age and associated soft tissue injury). Patients and methods: A prospective cohort study was performed. The study included 38 children under the age of 14 years with grade III extension-type supracondylar fractures who had manipulation under anaesthesia (MUA) and crossed K-wire fixation. ROM of the affected elbow (flexion, extension, pronation and supination) was measured at three, six, 12 and 24 weeks after CRPP by the same author (AR) at each visit. The unaffected elbow was used as a control. The PODCI was also recorded. No physiotherapy was prescribed. Results: Thirty-eight children were included in the study. All components of elbow ROM improved at 24 weeks (p<0.001). At 12 but not 24 weeks, the mean elbow extension was reduced in comparison with the controls (p=0.009). Patients less than 7 years of age recovered extension more rapidly (p=0.001). Seventy-six per cent of the children achieved satisfactory PODCI results at the 24-week final follow-up. Nerve palsy (18.4%) and severe soft tissue injuries (7.9%) were the main contributory factors to a poor outcome on the PODCI assessment. Conclusion: The majority of children with displaced supracondylar fractures recover full ROM after CRPP by 24 weeks without physiotherapy. Older children, or those with associated neurovascular and soft tissue injuries had poor functional outcomes. Further studies are needed to assess if these patients will benefit from physiotherapy. Level of evidence: Level 4

Emergency versus delayed definitive management of open distal humeral fractures of Gustilo types I & II

Objective To compare the clinical outcomes between emergency and delayed definitive management of open distal humeral fractures of Gustilo types of Ⅰ&Ⅱ. Methods A retrospective study was conducted of the 24 patients who had been treated at Department of Orthopaedic Trauma, Beiiing Jishuitan Hospital from January 2013 to June 2017 for open distal humeral fractures of Gustilo types Ⅰ&Ⅱ. Of them, 8 received irrigation, debridement and definitive open reduction and internal fixation in the emergency operation room; the other 16 received only irrigation, debridement and wound suture for the emergency management and their definitive open reduction and internal fixation was delayed until recovery of their soft tissues. The 2 groups were compared in terms of elbow range of motion, visual analogue scale (VAS), Mayo Elbow Performance Score (MEPS), Quick Disabilities of the Arm, Shoulder and Hand, (QuickDASH), complications and reoperations at the last follow-up. Results All the patients were followed up for more than one year; the average follow-up time was 40.5 months for the emergency treatment group and 30.9 months for the delayed treatment group. There were no significant differences between the 2 groups regarding elbow range of motion, VAS [0 (0, 1.0) versus 0 (0, 2.0)], MEPS [95.00 (85.00, 100) versus 90.00 (80.00, 98.75)], or QuickDASH [7.96 (2.84, 14.77) versus 3.41 (0, 13.64)] (P >0.05). The 2 groups also had similar rates of complications and reoperations. Conclusions Both emergency and staged definitive management can lead to satisfactory clinical outcomes for open distal humeral fractures of Gustilo types of Ⅰ&Ⅱ. A proper treatment method should depend on the experience of surgeons concerned and the local and general conditions of the patient. Key words: Elbow; Humeral fractures; Fractures, open; Fracture fixation, internal; Debridement

Side-to-side elbow range of movement variability in an ulnar neurodynamic test sequence variant in asymptomatic people.

Background:Range of motion (ROM) asymmetry between sides is one indicator of a positive neurodynamic test, but this has been less well studied for the ulnar nerve.Objective:The purpose of this study was to investigate side-to-side variation in elbow ROM during an ulnar neurodynamic test sequence, including contralateral cervical side flexion, in 40 asymptomatic subjects.Methods:A traditional goniometer was used to measure elbow flexion ROM at two end points, onset of resistance (1) and symptom onset (1). Two repeated measures of 1 and 1 were taken on each side.Results:Reliability for 1 and 1 was found to be good (ICC , SEM ) with no significant difference in mean ROM between sides. A significant relationship between sides was seen ( values ) and values ; this indicates at least 23% of the variance observed in one limb was accounted for by range in the opposite limb. This relationship was slightly stronger for 1 than 1. Lower bound scores indicate that intra-individual ROM difference for 1 and 22° for 1 would exceed normal ROM asymmetry.Conclusion:These findings provide clinicians with background information of ROM asymmetry during the ulnar neurodynamic test.

Outcomes of surgical treatment for osteochondritis dissecans of the elbow: evaluation by lesion location

For treatment of advanced elbow osteochondritis dissecans (OCD), we have used surgical treatment. Although favorable treatment outcomes have been reported for centrally located OCD, treatment outcomes are generally questionable and the choice of surgical method is controversial for laterally located OCD. Our purpose was to evaluate the treatment outcomes based on lesion location. The patients were 30 young (mean age, 14 years) male athletes who underwent surgical treatment of elbow OCD and were monitored for more than 1 year. Osteochondral autografts harvested from the knee were transplanted to centralized (13 patients) or lateral localized (9 patients) OCD lesions. For lateral widespread (8 patients) OCD lesions, a detached osteochondral fragment was fixed using small osteochondral plugs. When the remaining cartilage defect was large after fragment fixation, a large-sized osteochondral plug was transplanted to the defect. Treatment outcomes were evaluated by the Japanese Orthopaedic Association score, elbow range of motion (ROM), and radiographic findings. The Japanese Orthopaedic Association score significantly improved in patients with centralized, lateral localized, and lateral widespread types of OCD. ROM significantly improved in patients with centralized and lateral localized, and they returned to playing sports within 6 months. However, patients with lateral widespread OCD exhibited no significant ROM improvement, and returning to sports was difficult for 3 patients because of poor osseous integration of the fixed osteochondral fragment. Osteochondral autograft transplantation provided favorable outcomes for centralized and lateral localized elbow OCD lesions. However, for lateral widespread OCD lesions, reconstruction of the entire capitellar lesion area may be necessary.

Position as Well as Velocity Dependence of Spasticity-Four-Dimensional Characterizations of Catch Angle.

We investigated the muscle alterations related to spasticity in stroke quantitatively using a portable manual spasticity evaluator.Methods: Quantitative neuro-mechanical evaluations under controlled passive elbow stretches in stroke survivors and healthy controls were performed in a research laboratory of a rehabilitation hospital. Twelve stroke survivors and nine healthy controls participated in the study. Spasticity and catch angle were evaluated at 90°/s and 270°/s with the velocities controlled through real-time audiovisual feedback. The elbow range of motion (ROM), stiffness, and energy loss were determined at a slow velocity of 30°/s. Four-dimensional measures including joint position, torque, velocity and torque change rate were analyzed jointly to determine the catch angle.Results: The catch angle was dependent on the stretch velocity and occurred significantly later with increasing velocity (p < 0.001), indicating position dependence of spasticity. The higher resistance felt by the examiner at the higher velocity was also due to more extreme joint position (joint angle) since the spastic joint was moved significantly further to a stiffer elbow position with the higher velocity. Stroke survivors showed smaller ROM (p < 0.001), higher stiffness (p < 0.001), and larger energy loss (p = 0.005). Compared to the controls, stroke survivors showed increased reflex excitability with higher reflex-mediated torque (p < 0.001) and at higher velocities (p = 0.02).Conclusion: Velocity dependence of spasticity is partially due to joint angle position dependence with the joint moved further (to a stiffer position where higher resistance was felt) at a higher velocity. The “4-dimensional characterization” including the joint angle, velocity, torque, and torque change rate provides a systematic tool to characterize catch angle and spasticity quantitatively.

Qualitative and quantitative change in the kinematics of learning a non-dominant overarm throw

This study investigated changes in non-dominant overarm throw technique over practice from the perspective of three distinct though potentially complementary approaches to motor skill acquisition. Ten participants (mean ± SD age 22 ± 2 yrs, stature 1.71 ± 0.60 m, mass 73 ± 14 kg) completed 9-practice sessions (each 10 trials), during which whole-body kinematic data were collected. In line with the motor learning model of Newell (1985), we examined changes in the coupling between the centre-of-mass (CoM) and wrist motion. During initial practice, coupling was initially in-phase moving to wrist-led coupling with whole-body motion. With practice a more complex backwards wrist-led coupling that progressed to forward wrist-led coupling was observed. Secondly, in line with Bernstein’s (1967) notion of freezing before freeing degrees of freedom; a significant increase in joint angle range of motion (ROM) at the lower limb joints and shoulder, and significant decrease in elbow and wrist ROM was observed. Thirdly, ROM changes coincided with the time course of changes in the four components of technique change in overarm throwing action proposed by Robertson and Halverson (1984). Participants began in mid to high action levels for the torso/arm components, while the step component progressed to higher action levels with practice. Common practice induced changes in the collective posture-ball release dynamics and were supported by individual strategies at the joint ROM level revealing the complementarity nature of the three approaches and their key dependent variables to the analysis of learning to throw.

Pedicled Vascularized Bone Graft of the Distal Radius for Recalcitrant Nonunion of the Distal Humerus.

To analyze the clinical and radiological outcomes of a series of patients treated with a pedicled vascularized bone graft (VBG) of the distal radius for the treatment of recalcitrant atrophic nonunions of the distal humerus. Retrospective clinical study. University-affiliated teaching hospital. Fifteen patients with supracondylar humeral atrophic nonunions with at least 3 previous failed surgical interventions were included. Debridement of the distal humerus nonunion through a posterior elbow approach with provisional fixation was performed. Then, a pedicled VBG was harvested from the distal radius and tunneled back into the humeral bone defect. Iliac crest was used as needed, both for the nonunion and to stabilize the radius. Finally, definitive fixation with 2 locked plates was performed. Radiological results, complications, elbow range of motion, Mayo elbow performance score, and subjective pain were evaluated. There were 4 male and 11 female patients, with a mean age of 51 (range, 28-73) years. The mean follow-up period was 46 (range, 37-72) months with a minimum of 3 years. Radiological consolidation was achieved in all patients. Elbow range of motion was >100 degrees in 11 patients and between 50 and 100 degrees in 4 patients. Preoperative Mayo scores were poor in all patients. At final follow-up, Mayo scores were excellent in 3, good in 9, and fair in 3 patients. The mean postoperative visual analog scale score was 1.2 (range 0-3). Pedicled VBG of the distal radius was shown to be a reliable and effective alternative for the treatment of recalcitrant atrophic nonunions of the distal humerus, when other methods have failed. Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Exposed versus Buried Kirschner Wires Used in Displaced Pediatric Fractures of Lateral Condyle of Humerus.

Background:Comparision of results and complications of exposed versus buried Kirschner wires (K-wires) after open reduction of lateral condyle fractures is scarce and mainly from western population; hence, we envisaged to study the safety and efficacy of exposed and buried K-wires used for fixation of displaced pediatric fracture of the lateral condyle of humerus in Indian setup.Materials and Methods:A prospective, nonrandomized, comparative study was conducted in 50 patients with age <12 years, presenting with displaced fracture of lateral condyle of humerus of <2 weeks duration, without associated ipsilateral upper limb injury, who were treated by open reduction and internal fixation with either exposed or buried K-wires (n = 25 in each group). At a minimum followup of 3 months, status of fracture reduction, union, evidence of osteomyelitis, carrying angle at the elbow, and elbow range of motion (ROM) were assessed clinicoradiologically.Results:Four (16%) patients in exposed group and 1 (4%) in buried group had superficial infection, while 3 (12%) patients in exposed group and 2 (8%) in buried group had deep infection. All the patients with infection responded well to oral antibiotics and regular dressings. Buried group had higher incidence of secondary skin and wire-related complications.Conclusion:There was no statistical difference between the two groups but exposed K wires are easy to remove so are preferred over buried K wires.

Efficacy of Physiotherapy in Improving the Range of Motion of Elbow after the Treatment of Pediatric Supracondylar Humeral Fracture

Introduction: Temporary stiffness of elbow range of motion (ROM) after treatment of supracondylar humeral fracture in children is often a parental concern.Objectives: We examined the role of physiotherapy in improving the elbow ROM in management of supracondylar humeral fracture in children.Methodology: Sixty-four patients were randomly divided into intervention and control groups. Then intervention group patients received regular physiotherapy sessions while control group patients were not sent for physiotherapy. We assessed the outcome according to Flynn criteria during their follow-ups at two, six and 12 weeks, after removal of cast/k-wires.Results: In intervention group, 77.4% children had excellent outcome, and in control group, 80.6% children had excellent outcome. However, we did not find any statistically significant association between physiotherapy and outcome at 12 weeks, after controlling for baseline characteristics in multivariable regression model.Conclusion: Children managed by close reduction for uncomplicated supracondylar humeral fracture with immobilization for three weeks regain their functional ROM within 12 weeks of mobilization by themselves, with no added benefit from physiotherapy.BJHS 2018;3(2)6: 432-436.

Virtual Reality Computer Gaming with Dynamic Arm Support in Boys with Duchenne Muscular Dystrophy.

In boys with Duchenne muscular dystrophy (DMD), loss of upper limb function becomes more evident after the onset of wheelchair-dependency, because of the inability to lift the arms against gravity. With an increasing population of older wheelchair-dependent boys with DMD it is worthwhile to know whether training can delay the loss of upper limb functions. Dynamic arm supports may enable boys with impaired arm function to train their muscles without becoming exhausted by providing external mechanical compensation for muscle weakness. This study investigated the effect of gravity-compensated 3D-training for the arms on the functional abilities in boys with DMD. An explorative RCT was conducted among boys with DMD with impaired arm function (n = 16). Boys in the intervention group (n = 7) trained their arms by playing virtual reality games while using dynamic arm support during 20 weeks. The primary endpoint was the difference in change in Performance of the Upper Limb (PUL) score between the intervention and control group (n = 9) after 20 weeks. Secondary outcome measures were at the different ICF-CY levels. No significant group differences were found for the PUL. Elbow range of motion (p = 0.018) and extension strength (p = 0.038) improved in the intervention group and worsened in the control group. Although this study did not show a significant effect of training on the primary outcome measure, there are indications that training may decline the loss of range of motion and strength. This may prolong the functional abilities on long-term. Netherlands Trial Register 3857.

Effects of Real-Time (Sonification) and Rhythmic Auditory Stimuli on Recovering Arm Function Post Stroke: A Systematic Review and Meta-Analysis.

Background: External auditory stimuli have been widely used for recovering arm function post-stroke. Rhythmic and real-time auditory stimuli have been reported to enhance motor recovery by facilitating perceptuomotor representation, cross-modal processing, and neural plasticity. However, a consensus as to their influence for recovering arm function post-stroke is still warranted because of high variability noted in research methods.Objective: A systematic review and meta-analysis was carried out to analyze the effects of rhythmic and real-time auditory stimuli on arm recovery post stroke.Method: Systematic identification of published literature was performed according to PRISMA guidelines, from inception until December 2017, on online databases: Web of science, PEDro, EBSCO, MEDLINE, Cochrane, EMBASE, and PROQUEST. Studies were critically appraised using PEDro scale.Results: Of 1,889 records, 23 studies which involved 585 (226 females/359 males) patients met our inclusion criteria. The meta-analysis revealed beneficial effects of training with both types of auditory inputs for Fugl-Meyer assessment (Hedge's g: 0.79), Stroke impact scale (0.95), elbow range of motion (0.37), and reduction in wolf motor function time test (−0.55). Upon further comparison, a beneficial effect of real-time auditory feedback was found over rhythmic auditory cueing for Fugl-meyer assessment (1.3 as compared to 0.6). Moreover, the findings suggest a training dosage of 30 min to 1 h for at least 3–5 sessions per week with either of the auditory stimuli.Conclusion: This review suggests the application of external auditory stimuli for recovering arm functioning post-stroke.

Physiological Loading of the Coonrad/Morrey, Nexel, and Discovery Elbow Systems: Evaluation by Finite Element Analysis.

Wear of polyethylene bearings represents a limiting factor in the long-term success of total elbow prostheses. Bearing stress is 1 factor contributing to accelerated wear. Physiological loading of total elbow prostheses and implant design influence upon bearing stresses have not been well described. This study evaluates bearing stresses in 3 commercially available implant designs under loads associated with daily living. Motion tracking from a healthy volunteer helped establish a musculoskeletal model to simulate flexor and extensor muscle activation at 0°, 45°, and 90° of shoulder abduction with a 2.3-kg weight in hand-forces and moments were measured at the elbow. Resulting physiological joint reaction forces and moments were applied to finite element models of 3 total elbow bearing designs (Coonrad/Morrey, Nexel, and Discovery) to evaluate contact area and polyethylene stresses. Increasing shoulder abduction resulted in minimal changes to the elbow joint reaction force but greater joint moments. All implants showed greater peak stresses with increasing shoulder abduction-elbow varus. Discovery and Nexel achieved greater contact area (23% vs > 100%) and demonstrated up to 39% lower peak polyethylene stresses compared with the Coonrad/Morrey design. Shoulder abduction results in a varus moment at the elbow. Newer bearing designs (Nexel and Discovery) provide a combination of higher contact area, improved load sharing, reduced edge loading, and lower stresses through elbow range of motion when compared with a cylindrical hinge-bearing design (Coonrad/Morrey). Although the Coonrad/Morrey is a clinically successful prosthesis, our physiological loading model shows that Discovery and Nexel provide greater contact area, better load sharing and lower peak stresses. This may lead to a decrease in polyethylene wear rates and the eventual risks of osteolysis and aseptic loosening. Further studies are needed to determine how these findings translate clinically.

Protective myoelectric activity at performing upper limb neurodynamic test 1 in breast cancer survivors. A cross-sectional observational study

Myoelectric activity and range of motion during ULNT1 were recorded in 62 breast cancer (BC) survivors who had axillary lymph node dissection (n = 30) or sentinel lymph node biopsy (n = 32) within the previous 18 months, and 63 age-matched healthy women. BC survivors' symptoms were reproduced by ULNT1 and exhibited greater myoelectric activity in the biceps brachii than healthy women (MD (95% CI): 21,26 (10,83-31,70)). No differences between the axillary lymph node dissection and sentinel lymph node biopsy groups (MD (95% CI): 8,47 (−7,84-24,79)) were found. Myoelectric activity in the triceps brachii was greater in the sentinel lymph node biopsy group (MD (95% CI): 2,70 (−2,06–7,60)). BC survivors exhibited less shoulder and elbow range of motion during ULNT1 than healthy women. Increased upper limb nerve mechanosensitivity in BC survivors was associated with a greater protective muscle response during ULNT1.

Our 35 years’ experience on postburn heterotopic ossification: A three-step treatment

Our retrospective study of burn patients presents a three-step treatment of heterotopic ossification: excision surgery, early rehabilitation, and analgesia. We included patients admitted to the department for treatment of postburn heterotopic ossification between January1, 1979, and September30, 2015. The mean age at the time of the burn was 43.3years. Men accounted for the majority of burn patients who developed an osteoma (70.8%). The mean total skin area burned was 38.4%. No osteoma justifying surgery was found for any patient with a total burned skin area less than 19%. The burned zones were related to the osteoma development in 94.3% of cases. On average, the surgery took place 10.8months after the burn. The osteotomy was accompanied by surgical treatment of a contracture in 37.1% of patients. Most of the osteomata were found at the elbows (30), followed by the shoulders (3), and finally the knees (2). Rehabilitation began on D0 after the surgery, except if a flap or a thin-skin graft was used. Regarding analgesia, opiates were prescribed systematically during the immediate postoperative period. Elbow range of motion on flexion improved by a mean of 84.1°. During the postoperative period, we found 2recurrences of osteoma and 1elbow hematoma in two separate patients. There were no postoperative infections or neurological sequelae. Our retrospective French study confirmed results found in the international literature. The three-step treatment -excision surgery, early rehabilitation, and antalgia- seems to be the best means of treating osteoma with satisfactory results. Surgery is indicated only in the case of functional impairment and not simply based on imaging.

Functional Classification of the Medial Ulnar Collateral Ligament: An In Vivo Kinematic Study With Computer-Aided Design.

Background:It has been widely accepted that the anterior and posterior bundles of the medial ulnar collateral ligament (MUCL) tighten at extension and flexion, respectively. However, this belief is based on anatomic data acquired from cadaveric studies. The advancement of 3-dimensional (3D) model technology has made possible the simulation of dynamic movement that includes each ligament bundle fiber to analyze its functional properties. To date, no study has analyzed ligament kinematics at the level of the fibers while also focusing on their functional properties.Purpose:To propose a new classification for functional properties of the MUCL based on its kinematic pattern.Study Design:Descriptive laboratory study.Methods:Five healthy elbow joints were scanned by use of computed tomography, and 3D models were rendered and translated into vertex points for further mathematical analysis. The humeral origin and ulnar insertion of the MUCL fiber groups were registered. Each vertex point on the origin side was randomly connected to the insertion side, with each pair of corresponding points defined as 1 ligament fiber. Lengths of all the fibers were measured at 1° increments of elbow range of motion (ROM). Ligament fibers were grouped according to their patterns. Mean coverage area for each group, expressed as the percentage of ligament fibers per group to the total number of fibers, was calculated.Results:Four major bundle groups were found based on fiber length properties. Kinematic simulation showed that each group had a different kinematic function throughout elbow ROM. Mean coverage area of groups 1, 2, 3, and 4 was 8% ± 4%, 10% ± 5%, 42% ± 6%, and 40% ± 8%, respectively. Each group acted as a dominant stabilizer in certain arcs of motion. Reciprocal activity was observed between groups 1 and 3 along with groups 2 and 4 to produce synergistic properties of maintaining elbow stability.Conclusion:Detailed analysis of fibers of the MUCL allows for further understanding of its kinematic function. This study provides MUCL group coverage area and kinematic function for each degree of motion arc, allowing selective reconstruction of the MUCL according to mechanism of injury.Clinical Relevance:Understanding the dominant functional fibers of the MUCL will benefit surgeons attempting MUCL reconstruction and will enhance further anatomic study.

Operative Management of late Presented Displaced Lateral Condyle Fracture of Humerus in Children

Management of late presented displaced fracture of lateral condyle of humerus in children is controversial, many recommend conservative management due to fear of complications like avascular necrosis but recently many are advocating for operative management with good results hence we studied the outcome of operative management in late presented displaced lateral condyle fracture of humerus in children. We studied 22 children aged between 4 to 11 years, presenting 3 to 16 weeks from injury. All underwent open reduction and internal fixation with Kirschner wires with or without additional screw and followed up for average 18.05 months. Elbow range of motion, angular or local deformity, premature fusion of physis, avascular necrosis and fracture union were noted and analyzed using modified Aggarwal et al criteria. We had 9 (40.91%) excellent, 5 (22.73%) good, 5 (22.73%) fair, 3 (13.63%) poor result. Overall satisfactory results were seen in 19 (86.37%); 3 (13.63%) had poor result , one due to AVN, two due to premature fusion of physis and visible local deformity. All poor result were seen among delay of operation 6 weeks or later. There was significant improvement of elbow range of motion and all fracture united. Outcome of operation without bone grafting on lateral condyle fracture of humerus in children who presents late up to 5 weeks are excellent; whereas outcome of delayed operation up to 16 weeks also gives good functional recovery and union.