Posterior Splint Research Articles

Foot Pain - Baseball

HISTORY: A 38-year-old Major League Baseball player presented after feeling a pop in the plantar aspect of his left foot. Four days prior to injury, he noticed tightness in the arch of his foot medially and laterally. He experienced a pop through the center of his foot after batting when rolling his ankle while planting foot to run out of batter’s box. After diving back to the base on a pick-off attempt, he experienced pain on the lateral side of his foot going up his lateral leg. PHYSICAL EXAMINATION: Left lower extremity neurovascularly intact with no atrophy or deformity. Exam demonstrated peroneal longus tendon weakness with weakness of eversion and weakness of plantarflexion of the 1st metatarsal bone. Peroneal brevis tendon was palpable upon eversion and intact. No instability. The left heel strike is 5 to 10 degrees of varus with splinting secondary to pain without correction to neutral with ambulation. Contralateral side neutrally aligned and achieves 5 degrees of valgus with ambulation. Increased abduction and more lateral heel strike of the left heel. Foot progression angle on the left side is about 10 degrees, compared to zero. DIFFERENTIAL DIAGNOSIS: 1. Peroneal longus tear 2. Peroneal brevis tear 3. Peroneal tenosynovitis 4. Fracture/diastasis of os peroneum 5. Peroneal subluxation 6. Stress fracture 7. Sural neuritis TEST AND RESULTS: 1. Foot radiographs demonstrate no abnormalities 2. MRI: rupture of peroneus longus tendon with retraction to lateral margin of calcaneus. FINAL WORKING DIAGNOSIS: Peroneal longus rupture TREATMENT AND OUTCOMES: 1. Left peroneal longus tendon debridement with re-attachment to fifth metatarsal with iliac bone marrow aspiration and injection. 2. 10 days post-operatively removed from posterior splint and permitted to invert against resistance to midline but not to cross midline. Eversion allowed but not against resistance. Ambulation in plantarflexion permitted. 3. Return to jogging at two months, progressively increasing exercises of figure-of-8s, A-skips, and agility. 4. Return to full baseball activity at 3 months including baserunning, cutting, and sliding. Minor League rehabilitation delayed due to unrelated baseball injury following hit-by-pitch. 5. Return to Major League Baseball at 4 months at pre-injury activity level prior to conclusion of the season.

Percutaneous Screw Fixation of Lateral Condylar Humeral Fractures.

Lateral condylar humeral fractures are the second most common elbow injury in children and commonly occur between the ages of 5 and 10 years. There are several systems for classification of this fracture, including those of Milch (fracture line location) and Jakob et al. (displacement). Although nonoperative management is indicated for nondisplaced or minimally displaced fractures (<2 mm), operative fixation is indicated for greater displacement. Traditionally, open reduction and internal fixation has been the method used to ensure adequate reduction. However, closed reduction and internal fixation techniques for displaced fractures have been receiving increasing attention, with recent studies showing promising results. Several constructs (multiple smooth pins, a single lag screw, and threaded pins) for closed reduction and internal fixation have been described. Smooth-pin fixation has the advantage of a small diameter and easy removal, whereas threaded pins combine a small diameter with compressive properties. Compression of these small, articular fractures is important, and the optimal mode of fixation for maintaining fracture reduction is debated. Fixation with a partially threaded lag screw works by achieving metaphyseal compression, preventing loss of reduction of the distal fragment. In our experience, the compressive abilities of smooth and threaded pins are limited in the soft osteocartilaginous lateral condyle. Partially threaded lag screw fixation is indicated for pediatric patients with a substantially displaced (Jakob type-II or III) lateral condylar fracture. The major steps of the procedure are (1) preoperative planning with anteroposterior, lateral, and oblique radiographs; (2) supine positioning of the patient with the shoulder in abduction; (3) closed reduction with manual pressure; (4) guide-pin insertion through the lateral column of the distal part of the humerus; and (5) exchange of the guide pin with a lag screw. Postoperatively, the elbow is immobilized with a bivalved long-arm fiberglass cast or a posterior splint. The cast or splint is removed after interval healing is demonstrated on radiographs, and the lag screw is removed after complete fracture union is demonstrated. Complications are rare, and patients are expected to have decreased infection and open-reduction rates compared those treated with pin fixation.

Interventions for treating ankle fractures in children.

Interventions for treating ankle fractures in children.

Posterior Arthroscopic Subtalar Arthrodesis.

Although subtalar joint arthrodesis may be achieved through open or arthroscopic approaches, we have found that posterior arthroscopic subtalar arthrodesis has technical advantages compared with other approaches. Clinically assess the foot and ankle with regard to remaining motion, previous scarring, and associated deformities, ensuring that no concomitant procedure will be needed in the supine position. Use spinal or general anesthesia. Place the posterolateral portal lateral to the Achilles tendon at the level of the tip of the lateral malleolus, according to the original technique described by van Dijk et al. Place the posteromedial portal medial to the Achilles tendon at the level of the tip of the lateral malleolus. With the help of the shaver, look for the landmarks of the posterior arthroscopy, going from the posterolateral part of the subtalar joint toward the flexor hallucis longus tendon, which is medially located, while exposing the tibiotalar joint. Sometimes an accessory portal, just anterior to the tip of the external malleolus, may be needed to achieve a distraction of the anterior part of the subtalar posterior facet. To perform this concomitant step, which generally is not necessary, use an arthroscopic forceps to insert a 5 by 20-mm autograft or allograft in the subtalar joint. Use two cannulated screws with a 7.3-mm diameter; we prefer stabilization screws to compression screws. Always clean out the posterior compartment of the ankle during the PASTA procedure, as is done during surgical treatment for posterior impingement syndrome, and note that both posterior impingement syndrome and subtalar degenerative changes may thereby be easily addressed through this procedure. A short posterior leg splint is worn for three to ten days, followed by another non-weight-bearing cast for another three weeks. Since the appearance of the original article, a total of forty-one unilateral subtalar joints in twenty-five men and sixteen women, seen between May 2007 and December 2012, with isolated subtalar arthritis or talocalcaneal coalition without any other major hindfoot arthritis were treated by posterior arthroscopic subtalar arthrodesis, and all subtalar joints except for two were considered radiographically fused at the first attempt after an average of 6.7 weeks (range, six to ten weeks).IndicationsContraindicationsPitfalls & Challenges.

There is something wrong but where? Dislocation or fracture?

A 23-year-old man was admitted to our emergency department with the complaint of right foot pain and deformity after falling from a 3-m high wall. He could not bear weight on the foot; on physical examination, there was wide swelling with lateral displacement and medical deformity (Fig. 1). There was pain, especially on the medial side of the foot, with ankle movement. Neurovascular examination was normal. Standard antero-posterior and lateral ankle radiographs were obtained (Fig. 2). Fig. 1 Medial deformity at foot. Fig. 2 Antero-posterior (a) and lateral (b) ankle radiographs. Diagnosis: Lateral subtalar dislocation (talonavicular dislocation) A CT scan was acquired and isolated talonavicular dislocation was determined (Fig. 3). The patient was taken to the operating room. Patient was positioned in supine position and sedation was applied. Knee was flexed in order to get rid of the traction force of gastrocnemius muscle. Longitudinal traction was applied while applying lateral pressure on the talus. Talus settled down at talonavicular joint with a “pop” sound. Post reduction radiographs and CT were taken and showed adequate closed reduction (Fig. 4). A short leg posterior splint was applied to follow the disruption of the skin where talus head pressed, and additional interventions like operative fixation were not necessary because talonavicular joint seemed to be stable during stress examinations. Subtalar dislocations occur because of high energy trauma. They are very rare and compromise 1–2% of all luxation (1). The foot is most commonly displaced medially (80%–85%), and lateral dislocation is more rare (15%–20%) (2). It is important to determine the side of dislocation because reduction methods differ, and prognosis of lateral dislocations is worse than medial dislocations (3). AP and lateral ankle X-rays are usually sufficient for diagnosis. Dislocation can be determined at AP graphy, but at lateral graphy overlapping of the bones may hide pathology. Sometimes tomography is needed for diagnosing accompanying injuries. The most important treatment goal is gentle and quick reduction under sedation or spinal anesthesia. Approximately 60% of subtalar dislocations are closed. Simple dislocations with no associated fracture can be reduced easily. Post reduction assessments of foot with standard plus oblique graphics and CT scans, and physical stress examinations provide useful information about whether the joint is stable or not. Operative interventions may be needed when soft tissue interpositions or bony blocks prevent closed reduction or if talonavicular joint is unstable. One of most common complication of this injury is limitation of subtalar joint with pain. Wide soft tissue injury and associated fractures lead to much worse results. This article emphasizes that CT is a useful tool in diagnosing dislocations and treatment type. Quick and proper reduction of talonavicular joint may help to prevent catastrophic clinical results like wound necrosis, persistent pain with joint limitation, or even amputations.

Posterior Migration of a Pediatric Coronoid Fracture: A Case Report.

Coronoid fractures are uncommon, with an incidence of 5.21 per 100,000 patients per year; they typically occur during elbow dislocation1. They are rarely seen in children, and to the best of our knowledge, pediatric cases have been described in only a few previously published case reports2-6. This may be attributed to the low frequency of pediatric elbow dislocations, which represent only 3% of elbow injuries7. The coronoid process is important for elbow stability because it extends the ulnohumeral joint and acts as a buttress to prevent posterior displacement of the ulna. Elbow dislocations occur when an axial load is applied to a hyperextended and externally rotated elbow8. We report a unique pediatric elbow case involving a posteriorly displaced coronoid process and a concomitant lateral condyle fracture; a thorough radiographic analysis was instrumental in the management of the fracture. The patient and his guardian were informed that data concerning the case would be submitted for publication, and they provided consent. A five-and-a-half-year-old boy presented to his primary care provider seven days after a fall from a trampoline and was noted to have a right elbow fracture. He was referred to our orthopaedic clinic for additional evaluation thirteen days after the injury. Upon presentation, the boy held the arm at his side, and mild tenderness was noted along the antecubital fossa. He remained neurovascularly intact but lacked 5° of elbow extension. Elbow radiographs demonstrated a minimally displaced lateral condyle fracture and bone fragmentation anterior to the coronoid process (Fig. 1). The elbow was placed in a posterior splint. Because the lateral condyle and coronoid fractures were concerning for an occult elbow subluxation, magnetic resonance imaging (MRI) with sedation was performed the same day to further delineate the fracture pattern and guide management. …

Low-profile Titanium Plate Construct for Early Weightbearing with First Metatarsophalangeal Joint Arthrodesis

First metatarsophalangeal joint arthrodesis is a useful procedure for various first ray pathologic entities. Multiple constructs for fixation have provided successful fusion. A retrospective study of 21 feet (18 patients) was performed after first metatarsophalangeal joint fusion using crossed Kirschner wires or compression fixation with cannulated screws followed by the application of a 2-hole low-profile partially locking titanium plate. The median age was 59 (range 41 to 76) years, and we had 4 smokers and 3 patients with diabetes in our series. Postoperatively, a compression dressing with a posterior splint was applied. The patients then transitioned to a controlled ankle motion walker, and all patients reported full weightbearing by 2 weeks postoperatively. The mean follow-up duration was 11.43 (range 6 to 27) months. The overall primary fusion rate was 95.24% (20 of 21). Two nonunions occurred; one was asymptomatic and successfully consolidated at 12 months. The second nonunion required revisional surgery with an autogenous bone graft to heal successfully. This patient was noncompliant with the postoperative regimen and had a 48-pack year history of tobacco usage. Our results have shown early weightbearing after first metatarsophalangeal joint arthrodesis can be successfully initiated with splintage or lag screw fixation and a 2-hole, low-profile, partially locking titanium plate.

Novel Posterior Splinting Technique to Avoid Heel Ulcers

Heel ulcers are a costly and preventable complication of lower-extremity immobilization, but they still occur with some regularity. A technique using a short leg posterior splint that suspends the heel away from the splint is described. This modification completely removes pressure the heel to prevent decubitus ulcer formation. This technique is simple, inexpensive, and effective.

Patellar dislocation: cylinder cast, splint or brace? An evidence-based review of the literature

Patellar dislocations are a common injury in the emergency department. The conservative management consists of immobilisation with a cylinder cast, posterior splint or removable knee brace. No consensus seems to exist on the most appropriate means of conservative treatment or the duration of immobilisation. Therefore the aims of this review were first to examine whether immobilisation with a cylinder cast causes less redislocation and joint movement restriction than a knee brace or posterior splint and second to compare the redislocation rates after conservative treatment with surgical treatment. A systematic search of Pubmed, Embase and the Cochrane Library was performed. We identified 470 articles. After applying the exclusion and inclusion criteria, only one relevant study comparing conservative treatment with a cylinder cast, brace and posterior splint remained (Mäenpää et al.). In this study, the redislocation frequency per follow-up year was significant higher in the brace group (0.29; p < 0.05) than in the cylinder cast group (0.12) and the posterior splint group (0.08). The proportion of loss of flexion and extension was the highest in the cylinder cast group and the lowest in the posterior splint group (not significant). The evidence level remained low because of the small study population, difference in duration of immobilisation between groups and use of old braces. Also, 12 studies comparing surgical with conservative treatment were assessed. Only one study reported significantly different redislocation rates after surgical treatment. In conclusion, a posterior splint might be the best therapeutic option because of the low redislocation rates and knee joint restrictions. However, this recommendation is based on only one study with significant limitations. Further investigation with modern braces and standardisation of immobilisation time is needed to find the most appropriate conservative treatment for patellar luxation. Furthermore, there is insufficient evidence to confirm the added value of surgical management.

Distal femoral fractures treated with condylar buttress plate in a West African hospital.

The aim of this retrospective study was to present our experience using condylar buttress plate in the treatment of distal femoral fractures. Thirty-two patients underwent open reduction and internal fixation with condylar buttress plates for distal femoral fractures from October 2000 through May 2010. Patient demographics, type of fracture, treatment, complications, results achieved, and follow-up assessment were reviewed. The fractures were classified with the AO system. The functional outcome was rated according to Schatzker and Lambert criteria. There were 22 men and 10 women with an average age was 44 (range 19-87) years. The fractures were classified as A1 (n=7; 21.8%), A2 (n=4; 12%), A3 (n=5; 15.6%); C1 (n=4; 12.5%), C2 (n=6; 18.8%), and C3 (n=6; 18.8%). The mean delay from injury to operation was 15 (range 1-27) days. Iliac bone graft was performed in four patients. Postoperatively, a posterior splint or a plaster cast was applied for 3 weeks. No patient had an intra-articular step-off of more than 2mm. Sepsis of the operative wound occurred in two patients. Fractures healed in 22 (91.7%) patients with a mean duration of 4 (range 3-8) months. Twenty-four patients were followed up on an average of 15 (range 7-28) months. Varus deformity (>10°) was observed in five (20.8%) patients. Knee flexion was less than 90° in 11 (45.3%) cases. Non-union occurred in two (8.3%) patients. Functional results were good to excellent in 11 (45.8%) patients and considered as fair or failure in 13 (54.2%). The current report also identifies varus deformity as a major concern of this implant. The main finding of this study was the ensuing knee stiffness after a prolonged immobilization and delay in performing surgery and rehabilitation program due to socioeconomic and logistic reasons.

Functional Outcome After Air-Stirrup Ankle Brace or Fiberglass Backslab for Pediatric Low-Risk Ankle Fractures

Pediatric ankle fractures are usually treated by immobilization with either a posterior splint, cast, or ankle brace. We set out to determine if the below-knee fiberglass posterior splint was as effective as the Air-Stirrup ankle brace in returning children with a low risk ankle fracture to their normal level of activity. This was a randomized, single-blinded, noninferiority, controlled trial at the Royal Children's Hospital, Melbourne. Children aged 5 to 15 years presenting acutely with a low-risk ankle fracture were randomized to the Air-Stirrup ankle brace or fiberglass posterior splint. A validated self-reported outcome tool, the Activities Scale for Kids performance (ASKp), was used to measure physical functioning over the 4 week period. Main outcome was ASKp scores at 2 and 4 weeks with secondary outcomes including pain, weight-bearing ability, and acceptability of device. Forty-five patients were randomized: 23 in the posterior splint group and 22 in the Air-Stirrup ankle brace. Study groups were similar in terms of age, fracture type, and baseline pain. More of the posterior splint group were non-weight bearing "at enrollment" (96%) compared with the ankle brace group (77%). The median ASKp score at 4 weeks was 91.9 in the brace group and 84.2 in the posterior splint group. Scores on the ASKp as well as ASKp differences were favorable toward the brace in the 11- to 15-year age group at 2 weeks (69.6 vs 55.6) and 4 weeks (97.5 vs 90.2) but trended toward the posterior splint in the 5- to 10-year age group (47.5 vs 56). There was no difference between the Air-Stirrup ankle brace and the fiberglass posterior splint in returning children to their normal levels of activity.

An uncommon cause of elbow synovitis in an adult haemophilia patient

We present the case of an adult haemophilia patient that at clinical examination showed intense painless synovitis in his left elbow, with full range of movement, which was unresponsive to 1 month of on-demand haematologic treatment at home. Radiological examination demonstrated a spontaneous displaced fracture of the olecranon secondary to severe osteolysis, due to advanced haemophilic arthropathy. Then, the patient was treated with a posterior plaster splint to immobilize the joint for 3 weeks together with secondary prophylaxis (3000 IU twice a week for 3 months). One month later the patient was better, with full range of movement, and the amount of swelling had improved. Regarding the outcome of the fracture, 6 months later there was no healing of the fracture, and the patient developed a painless nonunion that allowed him to return to his preinjury activities of daily living. As far as we know, this rare combination of problems (unresponsive synovitis, severe haemophilic arthropathy, spontaneous elbow fracture) has not been previously published in the literature.

Fractures in Brief: Olecranon Fractures

Olecranon fractures are relatively common injuries, accounting for approximately 10% of upper extremity fractures in adults [26]. These fractures may result from a direct blow to the proximal ulna, or indirectly, via the forceful contraction of the triceps against resistance (typically, during a fall onto an outstretched hand). Less commonly, the olecranon may fracture when the elbow is hyperextended, as the bone is impacted against the olecranon fossa of the distal humerus. For unstable injuries, operative fixation typically is required. Even after recovery, loss of ROM is not uncommon. This article provides an overview of olecranon fractures in adults; therefore, discussion of olecranon fractures in skeletally immature patients is beyond the scope of this article.

Distraction over Nail Using Circular External Fixation for Septic Pseudarthrosis of the Tibia

We present a report of nine patients (eight women and one man; mean age 37 years) from 2010 to 2012 with septic pseudarthrosis of the tibia treated with bone transport over an intramedullary nail using a circular external fixator. The mean follow-up was 15 months (range: 10-21 months). A two stage approach was used. At the first stage, removal of the primary osteosynthesis and extensive bone debridement to healthy, bleeding bone margins was performed. The bone defect was packed with antibiotic loaded cement beads, and stabilization of the tibia was done with a unilateral external fixator or with a long leg posterior splint. The mean size of bone defect was 4 cm (range: 3.5-5.5 cm). At the second stage, two consecutive negative wound cultures and normal values of blood cell count, C-reactive protein (CRP), and estimated sedimentation rate (ESR) were obtained. Then we reamed and locked the intramedullary nailing of the tibia, applied a circular external fixator, and performed percutaneous corticotomy of the tibia opposite the site of the bone defect. Bone distraction over the nail was initiated at the eighth postoperative day at a rate of 1 mm/day. At the last follow-up, union was achieved in all cases without recurrence of bone infection. All patients experienced excellent (n=3) or good (n=6) knee and ankle function, as well as complete return to their daily activities. Two patients experienced pin-tract infection, and one patient experienced anterior knee pain at the entry point of the nail.

Open and subcutaneous recent tibialis anterior tendon ruptures: Does postoperative immobilization method influence outcome?

We report on seven traumatic lesions of the tibialis anterior tendon (one subcutaneous rupture and six open tears) in seven injured patients of mean age 45 years [17-79] all managed by direct suture and immobilization either using a cast boot (four cases) or a lower leg external fixator (three cases). After a mean follow-up of 31 months (6-50), external fixation achieved favourable clinical results with no specific complication. External fixation improves the conditions for suture efficiency, provides full immobilization and facilitates wound care in patients at a high risk of developing cutaneous complications. In accordance with data published in the literature, immobilization by means of a windowed cast boot achieved satisfactory results in patients with no risk factors. This method compatible with early mobilization avoids placement of a posterior splint which could induce slackening and weakening of tendon repair. Retrospective study (Level IV).

Pediatric Elbow Dislocation Associated with Proximal Radioulnar Translocation

Combourieu, Benoit MD1; Thevenin-Lemoine, Camille MD1; Abelin-Genevois, Kariman MD1; Mary, Pierre MD1; Damsin, Jean-Paul MD1; Vialle, Raphaël MD, PhD1 Author Information

Reconstruct coronoid process of ulna with ilium-fascia lata complex tissue

Objective To analyze and explore the operative effect of coraccid process basilar part fractures combined injury of ligamental structure. Methods Use ilium-fascia lata complex tissue to reconstruct coronoid process of ulna and medial collateral ligament, recoverd anterior and wall horn anatomic structure of elbow joint. Total 9 cases of ulna coracoid process fractures concomitancy with elbow posterior dislocation . Among these one with olec-ranon fracture,five patients with head of radius fracture. Anterior trance joint approach was used,removal bone chips, restore defect with ilium-fascia lata complex tissue after cuting and trimming. Once reduction was achieved,fixed with screw. Repaird the collateral ligament and anterior joint capsule use the fascia lata, If there were combined fracture of the radius head or olecranon fracture,fixed through lateral approach,All injured extremities were treated with a posterior plaster splint with functional position for 3 weeks followed by elbow rehabilitation training. Results According to Moneys evaluation method,2 patients were classified as excellent ,5 as good,l as fair and 1 as poor. The excellent and good rate was 77. 8%. Two patients with gently ossifying myositis but no patients with wound infection,internal fixation loosening or break,elbow joint destabilizing orcorpus libemm. Conclusions Coracoid process basilar part fractures was simultaneous with the instability of osteal frame and soft tissue. To attain the favourable anatomical foundation for elbow joint functional recovery, it should rebuild the height and shape of coronoid process first and think highly of repair or rebuild medial collateral ligament and joint capsule. It reconstructed the coronoid process osteal frame and soft tissue instability at the same time to use ilium-fascia lata complex tissue. The operative procedure is simplify with reliability effect and fine functional rehabilitation. Key words: Elbow Joint; Ulna fractures; Bone remodeling; Fascia lata; Ilium

Every Treatment Plan Has Its Consequences

HISTORY: A 24 yo male tri-athlete presents 5 days after an injury while playing ping-pong. The athlete jumped to celebrate a point and landed on the lateral portion of his left foot inverting and twisting it at which point he heard and felt a "pop." Thirty minutes later he still had excruciating pain at the base of his 5th metatarsal and presented to the immediate care center where he was diagnosed with a fracture, and was placed in a posterior splint, given crutches, and told to follow up. At clinic, he had been non-weight-bearing for 4 days and kept his left leg immobilized in a posterior splint. In the past two days he noticed dorsolateral foot numbness following several bouts of intermittent left calf cramping lasting several minutes which was not relieved by massage. Today he notes left foot and ankle joint swelling, stiffness, and weakness. He denied using tobacco, drugs or alternative medicines. PHYSICAL EXAMINATION: General: Muscular, healthy appearing, well tempered male in no acute distress. Left foot: Tender, 5th metatarsal, yellow-brown discoloration, unable to weight-bear due to pain. Left ankle: Erythema, 1+ swelling, slight discoloration, full ROM. Left Calf: Tender to palpation medially, increased calf pain with dorsiflexion. Negative Thompson test. Left knee: normal. Right Foot/Ankle/Calf/Knee: normal findings. Neurological: Numbness/tingling in his left foot post calf cramps, but otherwise no abnormalities. Skin: No petechiae, swelling, erythema, and discoloration only in locations noted earlier DIFFERENTIAL DIAGNOSIS: 5th metatarsal Jones-Type fracture 5th metatarsal stress fracture, lateral ankle sprain Calf pain due to inactivity/immobilization with posterior splint, Deep venous thrombosis, as complication of immobilization Calf strain due to injury TEST AND RESULTS: X-RAY: Foot films consistent with Jones-type fracture. No evidence of stress fracture. Doppler Ultrasound Left lower extremity (LLE): an acute venous thrombus in the LLE Peroneal Vein. FINAL WORKING DIAGNOSIS: 1. Fifth Metatarsal Jones Type Fracture on Left Foot- metaphyseal area 2. Acute DVT LLE in the Peroneal Vein TREATMENT AND OUTCOMES: Placed in a hard shoe with crutches Aspirin 325mg 2x/day Scheduled for a f/u US with Vascular Radiology in 5days.

Revision Arthroscopic Contracture Release in the Elbow Resulting in an Ulnar Nerve Transection

The indications for elbow arthroscopy have expanded over the past several years. Currently, it is used for removal of loose bodies, treatment of lateral epicondylitis, synovectomy, contracture release, and management of osteochondritis dissecans1-4. Although elbow arthroscopy is a relatively safe procedure, the reported complication rate is as high as 10%, which is higher than that seen with knee and shoulder arthroscopy3,5,6. The rate of neurovascular complications is reported to range from 0% to 14%5,6. In a review of a large series of patients treated with elbow arthroscopy, Kelly et al.5 reported a 2.5% rate of neurovascular complication, all of which were transient neurapraxias. In the literature, there are only a few reports of complete nerve transection occurring during elbow arthroscopy7-10. In the present report, we describe a patient who presented, following an arthroscopic release of an elbow contracture, with a complete transection of a previously transposed ulnar nerve. The patient was informed that data concerning the case would be submitted for publication, and he consented. Institutional review board approval was obtained. A forty-five-year-old left-hand-dominant construction worker fell and sustained a small avulsion fracture of the coronoid process of the right ulna without an elbow dislocation. The elbow was immobilized in a posterior splint for four weeks. On removal of the splint, there was a restricted range of motion of the elbow. Intensive physical therapy was initiated with the aid of a turnbuckle-type splint to improve flexion. At four months after the injury, the active and passive ranges of motion were still limited (10° of extension to 70° of flexion, with full forearm rotation). The patient underwent an open release of the contracture and a subcutaneous ulnar nerve transposition with postoperative radiation …

Immobilization Regime Following Lateral Patellar Dislocation: A Systematic Review and Meta-Analysis of the Current Evidence Base.

Historically, patients following patellar dislocation have been immobilized in a cylinder plaster of Paris cast for around 6 weeks. However, there remains controversy over whether immobilization should be advocated following this injury. There also remains debate over the methods and duration for which patients are immobilized. A systematic review was undertaken to assess these questions. The electronic databases MEDLINE, EMBASE, CINAHL, and AMED, in addition to a review of unpublished material, was undertaken. All of the included papers were appraised using the CASP appraisal tool. Two studies were eligible, assessing the outcomes of 177 lateral patellar dislocations. The results suggested that there is no significant difference in clinical outcomes when using a cylinder cast or posterior splint in full extension compared to an elastic bandage. No studies were identified specifically assessing the clinical outcomes of patients immobilized compared to those not immobilized, or assessing different durations of immobilization. The present evidence base is insufficient in both size and methodological quality to justify the use of immobilization for patients following a lateral patellar dislocation.