Proximal Radioulnar Joint Research Articles

The role of radial head morphology in proximal radioulnar joint congruency during forearm rotation.

Congruency of the proximal radioulnar joint (PRUJ) is important in the rotation of the forearm while any compromise would significantly impair the elbow function. The purpose of this study is to determine the morphological features of the radial head and investigate its role in the congruency of the PRUJ during forearm rotation. The hypothesis is that the PRUJ is more congruent in the maximal pronation and supination positions than in the neutral position. Thirty sets of computed tomography images of the elbow were acquired, and a three-dimensional model of the proximal radius and ulna was generated. The radius of curvature of the radial head and the radial head at the maximal pronation, neutral positions and maximal supination were calculated and compared with a one-way analysis of variance. The point on the radial head contacting the middle point of radial head at the maximal pronation and supination was located at the ends of the semi-major axis of the ellipse, while it was located at one end of the semi-minor axis at neutral position. The radii of curvature of the pronation, neutral and supination points of the radial head were 14.72 ± 1.51, 9.74 ± 1.49 and 14.58 ± 1.70 mm, respectively. The value of the neutral point was significantly smaller than that of the pronation and supination points. This study quantitatively evaluated the morphology of the radial head and suggested that the best congruency of the PRUJ was achieved at maximal pronation and supination, while the neutral position was associated with the least congruency. Basic Science Study.

Osteoarthritis of Proximal Radioulnar Joint: Computed Tomography-Based Assessment and Associations with Clinical Findings.

Although many studies have focused on the degenerative changes of the ulnohumeral and radiohumeral joints in osteoarthritis (OA) of the elbow, the proximal radioulnar joint (PRUJ), which facilitates the pronation and supination motions of the forearm, has not been comprehensively evaluated. To assess the prevalence of PRUJ OA in patients diagnosed with OA of the elbow using computed tomography (CT) images and to establish an association between the CT findings and clinical manifestations. Cross-sectional study; Level of evidence, 3. Between 2010 and 2022, a total of 85 consecutive patients who were scheduled to undergo osteocapsular arthroplasty for OA of the elbow and had undergone preoperative CT imaging were included in the study. As a control group, 85 patients who underwent CT scans of the elbow for reasons other than OA of the elbow were selected and matched to patients in the OA group. CT findings of OA in the PRUJ, including osteophytes, joint space narrowing, subchondral cysts, and loose bodies, were evaluated. Inter- and intraobserver agreement analyses for CT findings were performed. The relationship between the CT findings of OA in the PRUJ and OA of the elbow classification systems (Broberg-Morrey, Hasting-Rettig, and Kwak) as well as clinical manifestations (range of motion [ROM], Mayo Elbow Performance Score, and visual analog scale for pain) were evaluated. Patients in the OA group showed osteophytes in the radial notch (81.2%), osteophytes in the radial head (45.9%), joint space narrowing (54.1%), loose bodies (25.9%), and subchondral cysts (23.5%) involving the PRUJ. Both the interobserver (κ = 0.866) and intraobserver agreements (κ = 0.933) for CT findings of PRUJ OA were almost perfect. The CT findings of PRUJ OA were associated with the severity of OA of the elbow in Cochran-Armitage Trend analysis (with Brogberg-Morray, r = -2.624, P = .011; with Hasting-Rettig, r = -3.421, P = .002; with Kwak, r = -2.266, P = .032). The presence of radial notch osteophytes restricted ROM in the flexion-extension arc and pronation-supination arc (P = .009 and P < .001, respectively). PRUJ OA could be identified using CT imaging and showed radial notch osteophytes, joint space narrowing, loose bodies within the joint space, and subchondral cysts. PRUJ OA was related to overall OA of the elbow and may contribute to reduced ROM in the elbow joint. Therefore, preoperative evaluation of PRUJ OA can aid in the surgical planning of osteocapsular arthroplasty for OA of the elbow.

Predictors of Radial Head Dislocation in Patients with Multiple Hereditary Exostoses.

Background: Radial head dislocation in patients with multiple hereditary exostoses (MHE) is associated with loss of function and cosmetic problems. The treatment of the deformity with radial head dislocation is difficult and the timing of surgical intervention is important. The aim of this study was to evaluate the factors predictive of radial head dislocation in patients with MHE. Methods: Patients diagnosed with forearm deformity due to MHE between 1995 and 2021 were retrospectively evaluated. Radiographic parameters including radial bow (RB), ulnar bow (UB), total radial bow (TRB), total ulnar bow (TUB), percent ulnar length (PUL), ulnar shortening (US), radial articular angle (RAA), modified Masada classification and irregularity of proximal radioulnar joint (PRUJ) of the dislocated group (group D), that is subluxation or dislocation of the radial head, and the located group (group L) were compared. Results: A total of 18 patients and 25 limbs (5 girls and 13 boys) with a mean age of 10.5 years were included. There were significant differences in TUB (22.8° ± 5.6° vs. 10.7° ± 6.5°), PUL (97.5% ± 5.5% vs. 108.2% ± 7.7%) between group D and group L (p < 0.05). Moreover, irregularity of PRUJ on radiographs was more in group D (p < 0.05). Conclusions: It is possible that appropriate radiographic assessment in relation to radial head dislocation may prevent delayed surgical treatment of forearm deformities in MHE. Level of Evidence: Level IV (Diagnostic).

Direct anterior bone block grafting for treatment of bone defects and dysplasia of the coronoid process

The aim of the surgery was to treat an elbow instability caused by critical coronoid bone loss (CCBL), lateral ulnar collateral ligament (LUCL) insufficiency,and general hyperlaxity by performing adirect anterior coronoid bone graft (CBG) and LUCL reconstruction in the same setting. In cases with CCBL isolated ligament reconstruction harbors ahigh failure rate, necessitating supplementary bony procedures. The diagnosis of CCBL is confirmed through lateral radiographs and further quantified through computed tomography (CT) imaging. Objective assessment of instability is conducted with standardized arthroscopic tests. Performing an anterior approach for CBG offers distinct advantages, notably in terms of achieving precise positioning of plates and screws and providing access to the proximal radioulnar joint. Usual contraindications to surgery, coronoid bone loss less than 40%. The surgical procedure is thoroughly illustrated with avideo of the operation that can be accessed online: reconstruction of the LUCL with asemitendinosus allograft, harvesting of the graft from the iliac crest, exposure of the coronoid process with adirect anterior approach, freshening up of the graft bed. Temporary fixation of the graft with aKirschner wire. Assessment of joint congruency, stability and range of motion (ROM) prior to definitive fixation with a2.4 mm buttress plate and screws. Nonsteroidal anti-inflammatory drugs (NSAID) to prevent heterotopic ossification. Elbow mobilization in pronation from day1 with an overhead motion protocol. Removable splint for 4weeks, free mobilization at 6weeks, return to sport at 3months. Durable elbow stability was achieved along with free ROM and high patient satisfaction.

Treatment of a patient with massive osteochondral exostosis of the radial neck: clinical case

BACKGROUND: Osteochondroma (osteochondral exostosis) is the most common benign neoplasm of bone tissue, accounting for up to 9% of all bone tumors. Possible manifestations of a single osteochondral exostosis are pain, a limited range of motion, compression of vascular or neural structures, and crepitus. The literature describes several clinical cases of the treatment of patients with osteochondral exostosis of the proximal radius. A distinguishing feature of the proximal radius’s anatomy is the close location of such anatomical structures as the posterior interosseous nerve, the enthesis of the distal biceps tendon, and the proximal radioulnar joint. CLINICAL CASE DESCRIPTION: This clinical case for the first time describes osteochondroma of the radial neck, which causes supination deficiency. CONCLUSION: The surgical treatment allowed us to achieve excellent treatment results with the complete restoration of the function and range of motion in the elbow joint. The key aspect is the knowledge of this segment’s anatomy.

Radioscapholunate Arthrodesis for Management of Madelung Deformity: A Case Report.

A 32-year-old woman with bilateral Madelung deformity presented with severe pain and arthritis of the radiocarpal and distal radioulnar joints. At final follow-up, 17 months for the left and 12 months for the right wrist, she had excellent functional results with no pain. Range of motion was 30° of flexion and 30° of extension with full pronosupination. There is paucity in the literature regarding salvage procedures in adults with this deformity. We demonstrate treatment with distal ulna excision and an radioscapholunate arthrodesis. This procedure may be indicated in Madelung deformity and proximal radiocarpal and distal radioulnar joint arthritis.

Radiological study of carrying angle among male and female and its clinical importance

: The long axes of the ulna and humerus form an acute angle when the upper limb is in its anatomical position and the elbow is fully extended is known as the carrying angle. It is typically larger in females than in males Anthropologists use the carrying angle to predict a person's sex; orthopaedic surgeons use it to surgically treat a variety of elbow disorders; and total elbow prosthetics. The study aimed to assess the carrying angle in an attempt to determine its value in both sexes, proposing a simple and reliable method for measuring it.The elbow radiographs taken in the normal anteroposterior and lateral views were assessed independently and uniformly by anatomists. A total of 70 adult radiographs between the ages of 18 to 76 years, 35 males and 35 females were gathered. To measure the angle, two lines were drawn: one along the mid-axis of the upper limb of the forearm, passing between the radius and ulna through the superior radioulnar joint, and the other along the mid-axis of the lower third of the humerus, where the angle is measured.The carrying angle is statistically more significant in females than in males among 70 radiographs. The p-value was 0.000 and the mean and SD for males were 14.3±2.740, while the mean and SD for females were 21.92±3.170.The current study concludes that there is a significant gender difference between females and males; carrying angle influences secondary sexual characteristics.

Posttraumatic proximal radioulnar synostosis: Current concepts on the clinical presentations, classifications, and open surgical approaches

In the forearm, posttraumatic heterotopic ossification usually forms as a proximal radioulnar synostosis. It can occur after soft tissue injury involving the interosseous membrane or after surgery involving the radio and ulna, such as distal biceps tendon repair. It can also be induced by radial head dislocation or fracture. Screening radiography can be used to select the appropriate time for excision. The synostosis can be resected when the ectopic bone margin and trabeculation appear mature on radiographs. An interval of 6–12 months from the injury is generally recommended based on ectopic bone maturity. Selection of the surgical approach depends on site, extension (elbow joint or proximal radioulnar joint), severity of the initial articular surface, and periarticular tissue injury. The posterolateral approach is indicated for synostoses: at or distal to the bicipital tuberosity, at the level of the radial head, and proximal radioulnar joint. The posterior global approach is recommended when the forearm synostosis is associated with complete bony ankylosis of the elbow involving the distal aspect of the humerus. After surgical resection of a proximal radioulnar synostosis, the exposed bone surfaces can be covered with interposition material to minimize recurrence.

Proximal radioulnar joint, but not posterolateral, instability in patients with symptomatic minor instability of the lateral elbow

IntroductionThe elbow joint is stabilized laterally by a complex of bony and ligamentous structures, such as the lateral ulnar collateral ligament (LUCL) and radial lateral collateral ligament (RLCL). Pathogenesis of many elbow conditions like SMILE (Symptomatic Minor Instability of the Lateral Elbow) is based on ligamentous incompetency. The aim of this study is to measure ligament elongation in SMILE patients and determine the correlation with the development of this pathological condition. Materials and MethodsTwenty-eight patients were included in this study: half of them were operated for suspected SMILE while the others were affected by other elbow diseases. All the patients underwent elbow arthroscopy. During this procedure, four parameters were analyzed: Annular Drive Through (ADT), Ulnar-humeral Stressed Distance (UHSD) at 45° and 30° of flexion, and Loose Collar Sign (LCS). A dedicated arthroscopic mini-spreader introduced through an arthroscopic portal was used to do measurements. Results and DiscussionA statistically significative difference was found for LCS (p value 0,0003) and ADT (p value 0,000002). UHSD at 30° and 45° elbow flexion was slightly higher in SMILE patients, but not significantly. Progressive stretching of the RLCL and annular ligament may lead to their elongation, allowing a pathological antero-posterior shifting of the radial head and a lower congruence between the inner surface of the annular ligament and the radial head cartilage, resulting in proximal radio-ulnar instability. ConclusionsRLCL and annular ligament are elongated in SMILE patients compared to controls, causing instability of the proximal radio-ulnar joint (PRUJ) and confirming that ligament incompetency is involved in SMILE condition.

Distinct patterns of fracture propagation in distal radial fractures and the relationship to the ulnar head

BackgroundThe aim was to assess the direction of distal radius fractures and their relationship to the ulnar head. MethodsWe reviewed the 160 wrist radiographs. The fracture line was measured on the postero-anterior and lateral radiographs relative to the long axis of the forearm and the relationship to the ulnar head. FindingsPA radiographs: the fracture line ran distal ulnar to proximal radial (ulnar to radial) in 11%, transverse in 74% and distal radial to proximal ulnar (radial to ulnar) in 16%. Lateral radiographs: the fracture line ran distal volar to proximal dorsal in 88%, transverse in two 1% and dorsal to volar in 11%. Radial shift (7.5%) only occurred with ulnar to radial or transverse fractures.The ulnar to radial fracture line started at the proximal end of the ulnar head/distal radio-ulnar joint in 88%. The radial to ulnar fracture line started ended a mean of 2.5 mm proximal to the distal radio-ulnar joint (p < 0.01). The transverse fracture line started at the base of the distal radio-ulnar joint in 53% and proximally in 47%. InterpretationThere are two distinct coronal patterns: radial to ulnar ending c. 2 mm proximal to the distal radio-ulnar joint; ulnar to radial starting at the proximal distal radio-ulnar joint. There may be third pattern - transverse fractures; these may be variants of the above. Sagittally the main direction is volar to dorsal but 11% are obverse.This is the first description of distinct fracture patterns in extra-articular distal radius fractures. In addition the fracture patterns appear to correlate with different directions of force transmission which fit with our understanding of falling and the relatively uncontrolled impact of the wrist/hand with the ground.These patterns of fracture propagation help understand how the biomechanics of wrist fractures and may enable prediction of collapse.

Anatomical features of the proximal end of the radius and its implications for implant design.

The proximal radio-ulnar joint allows supination and pronation of the forearm and the humeroradial joint allows flexion and extension movements at the elbow joint. Although the proximal end of the radius is less common than other fractures, it is more common nowadays due to the prolongation of life expectancy, increased incidence of osteoporosis. There have been reports in the literature that success has not been achieved due to the lack of anatomical fit of the prosthesis. Knowledge of the morphometric features of the proximal end of the radius is important for the design of anatomically and biomechanically appropriate prostheses. In this study, measurements of head and neck of radius, and radial tuberosity were measured in 80 dry radii. Parameters important for prosthesis design were analysed and their correlations examined. The shapes of radial head was found 36% oval and 64% circular. The mean heights of the radial head at anterior, posterior, medial, and lateral sides were 8.52 ± 1.32mm, 9.02 ± 1.23mm, 9.20 ± 1.59mm, 8.05 ± 1.13mm, respectively. The mean depth of articular facet were 1.85 ± 0.37mm. It was determined that there was no high correlation between the parameters affecting the prosthesis design. Morphological and morphometric features of the proximal radius are important for prosthesis design and implantation. The ideal radial head prosthesis design is challenging due to numerous parameters, wide ranges and low correlation, although modular designs facilitate compatibility. The widespread use of 3D printing technologies is expected to reduce the potential complications associated with prosthesis applications.

Preventing Proximal Radio-Ulnar Joint Screw Penetration during Coronoid Fracture Fixation: A 3D-Digital Modeling and Cadaver Study.

Intra-articular screw penetration is a probable complication of coronoid fracture fixation. The present study aimed to determine the best radiography technique for visualizing the proximal radioulnar joint (PRUJ) space. Moreover, it aimed to determine the safe angle and length of the screw to avoid PRUJ penetration during coronoid fracture fixation. The Mimics software was used to construct a three-dimensional model of a healthy man's forearm from a computer tomography scan. It was analyzed using the Solidworks software to determine the X-ray angle that clearly showed the PRUJ space to detect penetration of screws from the coronoid process into the PRUJ and determine the maximum screw angle and length that could be used without intra-articular penetration. To verify these findings, a cadaveric study combined with radiographs was conducted. To visualize PRUJ space, the optimal X-ray angle was 13º lateral to the perpendicular line when the forearm was positioned at full supination. If the coronoid process was segmented into zones 1 (closest to the radioulnar joint) to 4 (farthest from the joint), the screw could only be inserted at a right angle in zone 1. In zones 2, 3, and 4, inclination angles less than 15, 35, and 60 would prevent intra-articular penetration, respectively. The X-rays could visualize the PRUJ space with an anteroposterior radiograph at an angle of 13º ulnar deviation from the perpendicular plane. During coronoid process fracture fixation, shorter screws with less lateral inclination were safer when inserting screws in the zones of the coronoid process adjacent to the PRUJ.

What do we need to address when we treat neglected Monteggia fracture in children.

Monteggia fracture is a relatively uncommon injury in pediatric patients, accounting for less than 2% of forearm fractures, characterized by a combination of ulna fracture and radial head dislocation. Neglected Monteggia fractures define as those that have not received treatment within 3 weeks. In children, ulna fractures are easily diagnosed while radial head dislocation may be overlooked, necessitating open reduction after neglecting the Monteggia fracture and potentially causing additional trauma to the child. This study aims to review the pathological characteristics of neglected Monteggia fractures based on the length ratio of the ulna and radius, relative positions between the proximal ends of the ulna and radius, the integrality of annular ligament and the pathological change of proximal radioulnar joint. The findings will provide valuable insights and guidance for managing neglected Monteggia fractures.

Direct Anterior Bone Block Grafting for Coronoid Bone Loss and Dysplasia

Background: Critical coronoid bone loss (CCBL) can be the key factor of elbow instability, making bony reconstruction essential. Coronoid bone grafting (CBG) is challenging, with a paucity of descriptions in the literature. We present direct anterior CBG in a patient with instability, CCBL (&gt;40%), lateral ulnar collateral ligament (LUCL) insufficiency, and ligamentous laxity who underwent LUCL reconstruction in the same setting. Indications: Isolated ligament reconstruction has a high failure rate in cases with CCBL and therefore requires additional bone grafting. The diagnosis of CCBL is made with lateral radiographs and further quantified by computed tomography imaging. Instability can be best assessed objectively during arthroscopy with a switching stick. CBG performed with an anterior approach facilitates direct access with advantages for plate and screw positioning and access to the proximal radio-ulnar joint. Technique Description: First, LUCL reconstruction was performed. After harvesting of the graft from the iliac crest, the coronoid was exposed with a direct anterior approach. The incision starts centrally medial to the biceps tendon (BT) in the flexion crease extending distally (9 cm). Ligation of multiple vessels (leash of Henry) is required. The deep dissection is continued between the bicipital aponeurosis and BT. Blunt and flat Langenbeck-type retractors are used with care, laterally (BT/radial nerve) and medially (aponeurosis/median nerve). The brachialis muscle is exposed and longitudinally split in line with its fibers, gaining access to the capsule. Harmful retraction on either side of the split has to be avoided. The capsule is incised as a Z-plasty, the coronoid exposed from the joint in the distal direction prior to freshening up the graft bed. The graft is held in place with a wire joystick, sculpted, and temporarily fixed. Joint congruency, stability, and a range of motion (ROM) are checked prior to definitive fixation with a 2.4-mm buttress plate and screws. Results: The coronoid process height was successfully reconstructed from &lt;60% to 100% with durable elbow stability (&gt;1 year), free ROM, and high patient satisfaction. Conclusion: CBG can be standardized and facilitated with a direct anterior approach as a key element for successful elbow stabilization in the setting of CCBL. Patient Consent Disclosure Statement: The author(s) attests that consent has been obtained from any patient(s) appearing in this publication. If the individual may be identifiable, the author(s) has included a statement of release or other written form of approval from the patient(s) with this submission for publication.

Morphometrics of the coronoid process and the radial notch of the ulna: implications for fracture assessment

PurposeA comprehensive analysis of the morphology of fractures of the coronoid process (CP) can aid diagnosis and guide treatment. The involvement of the radial notch of the ulna (RN)—e.g., in anterolateral facet fractures and transverse fractures of the CP—may influence the biomechanical conditions of the proximal radioulnar joint. However, the morphometric relation between the CP and the RN and the extent to what the proximal radioulnar joint can be affected in these types of fractures is unknown.MethodsA total of 113 embalmed, cadaveric ulnae were dissected. All soft tissue was removed. Strictly lateral, high-resolution photographs were taken and digitally analyzed. The height of the CP and its relation to the RN was measured. Sex differences and correlations between measured parameters were calculated.ResultsMean height of the CP was 16 mm (range: 12–23 mm; SD: 2). Mean height of the RN was 16 mm (11–25 mm; 2.2). The 50% mark of the CP corresponded to 18% (0–56%; 11.2) of the height of the RN. No significant differences were found between male and female specimens.ConclusionThe RN of the ulna extends only to a small part to the CP. Transverse or anterolateral fractures of less than 50% of the coronoid process may involve only a small portion of the proximal radioulnar joint.

Magnetic Resonance Imaging Manifestations of Annular Ligament Injuries in Children With Monteggia Fractures.

Magnetic resonance imaging (MRI) is commonly performed in children with elbow injuries to visualize soft tissues such as the annular ligament. Herein, we investigated the MRI manifestations of annular ligament injuries in children with Monteggia fractures following attempted closed reduction. The clinical and imaging data of 88 children with acute Monteggia fractures treated at our hospital between 2015 and 2019 were analyzed. Clinically and radiographically, 67 patients achieved radiologic reduction of the radial head at the time of MRI, whereas 21 patients had a failed closed reduction. Annular ligament injury and superior radioulnar joint congruency were analyzed qualitatively, and the maximum superior radioulnar joint gap distance was measured. MRI manifestations of annular ligament injury were primarily characterized as varying degrees of annular ligament displacement, as follows: I degree (10 patients), the annular ligament encircled the radial head without displacement; II degree (5 patients), the annular ligament was partially displaced but visibly encircled the radial head at the level of the radial notch; and III degree (73 patients), the annular ligament was completely displaced. In 15 patients with I and II degrees annular ligament injuries, the annular ligament encircled the radial head (maximum superior radioulnar joint gap distance, 1.2±0.3mm), showing good congruency of the superior radioulnar joint. In 73 patients with III degree annular ligament injury, the annular ligament was displaced and did not encircle the radial head (maximum superior radioulnar joint gap distance, 3.3±2.7mm; P <0.05), showing good congruency of the superior radioulnar joint in 25 of 73 patients, and significantly poor congruency in 48 of 73 patients ( P <0.05). Annular ligament injuries in children with Monteggia fractures exhibit different degrees of displacement of the annular ligament. In I and II degree annular ligament injuries, the annular ligament still encircles the radial head. In III degree annular ligament injuries, the annular ligament is displaced away and is no longer around the radial head. Without the annular ligament restraining the radial head, the superior radioulnar joint is more likely to exhibit poor congruency and increased gap distance. Level II.

Missed Essex-Lopresti Injury-Development of a Combined Proximal and Distal Radio-Ulnar Joint Prosthesis as a Treatment Option and Proof of Concept.

Essex-Lopresti injuries are characterized by injuries to the proximal radio-ulnar joint, the distal radio-ulnar joint, and the interosseous membrane. This can lead to osteoarthritis, impaction syndrome, or instability. If all three structures are injured and lead to instability, the situation is almost unmanageable and many times ends in a one-bone forearm. In this article, we demonstrate a new way to reconstruct the proximal and distal radio-ulnar joint with two patient-specific coupled prostheses. These have been developed with the biomechanical conditions of the forearm in mind, where there are very large forces between the bones. As a result, we are able to present a patient previously severely restricted in the use of his hand and arm via a splint that compressed the forearm, who is now able to perform everyday activities and even light sports, such as badminton, without pain.

Convergent dislocation of the elbow in adults: A retrospective study

BackgroundsThis study aims to evaluate the surgical treatment and clinical outcomes of convergent dislocation of the elbow (CDE) in adults. MethodsBetween January 2017 and September 2022, we performed a retrospective study of patients with CDE presenting in XXX and XXX Hospital and receiving operative treatments after failed closed reductions. The elbow and the forearm's range of motion (ROM) were measured and compared using a paired t-test between pre- and post-operation. Furthermore, the Mayo Elbow Performance Score (MEPS) assessed objective elbow evaluation and functional outcomes. ResultsEleven patients were followed up for an average period of 9.8 months. Four males and seven females were enrolled, aged 31.5 ± 9.0 years. The average ROM of flexion-extension at the elbow was significantly improved after surgery (27.3 ± 12.3° vs. 116.8 ± 23.7°, p < 0.001). The average pronation-supination also showed a similar increase (21.8 ± 9.3° vs. 106.4 ± 23.4°, p < 0.001). The MEPS of the final follow-up was 95.9 ± 7.0 points. However, seven cases were found to have varying degrees of elbow stiffness. Furthermore, secondary procedures were performed in three cases, including the elbow arthrolysis and the anterior transposition of the ulnar nerve. ConclusionsOur study showed several operative methods following failed closed reduction attempts where anatomical reduction of humeroulnar and proximal radioulnar joints and instant rehabilitation obtained relatively satisfactory clinical outcomes.

Diagnostic imaging for elbow TRASH lesions in children and usefulness of ultrasonography using standard planes.

Fractures around the elbow in children should be carefully evaluated because the main portion is cartilaginous, and radiographs are not completely reliable. This study aimed to assess the diagnostic imaging for pediatric elbow fractures that require special attention and consider the usefulness of ultrasonography with seven standard planes for the diagnosis. Patients diagnosed with elbow fractures wherein TRASH (The Radiographic Appearance Seemed Harmless) lesions were evaluated retrospectively. The diagnoses on initial radiographs, final diagnoses, additional imaging excluding radiographs, and the treatments were investigated. The standard planes for ultrasonography to detect elbow fractures included an anterior transverse scan at the level of the capitellum and proximal radioulnar joint, an anterior longitudinal scan at the level of the humeroradial and humeroulnar joints, a longitudinal scan along the lateral and medial border of the distal humerus, and a posterior longitudinal scan at the level of the distal humerus. A total of 107 patients with an average age of 5.8 years (range, 0-12 years) at the time of diagnosis were included. Of 46 (43.0%) patients misdiagnosed at the initial radiograph, 19 (17.8%) needed additional treatments due to inappropriate initial management. Ultrasonography using the standard planes was useful for prompt diagnosis and appropriate treatment. Prompt and appropriate evaluation with ultrasonography can prevent the mismanagement of pediatric elbow injuries. Level of evidence: Level IV-retrospective case series.

Monteggia-like injuries : Pitfalls of surgical treatment

The term Monteggia-like lesions or Monteggia equivalent injuries includes fractures of the proximal ulna with dislocation and dislocation fractures of the radial head from the proximal radio-ulnar joint. The complexity of the injury requires adedicated understanding of the anatomical structures and their biomechanical properties. Particularly due to the rarity, the complication and revision rates are high. A conservative treatment is not usually effective. Three-dimensional imaging by computed tomography is part of the surgical preparation. The goal of surgical treatment is osteosynthetic reconstruction of the fractures and restoration of joint congruency. In cases of nonreconstructable radial head fractures, radial head arthroplasty may be necessary. In addition to reconstruction of the bony stabilizers, refixation of the ligamentous structures is essential for treatment success. The combination of complex fracture patterns and possible dislocation positions in the ulnohumeral, radiohumeral and proximal radio-ulnar joints poses agreat challenge to the surgeon. The most frequent complications are peri-implant infections, implant failure, loss of reduction, stiffness or instability. Especially the anatomical configuration of the proximal ulna is complex and requires accurate reconstruction. Therefore, reconstruction of the proximal ulna in length and rotation, including the coronoid process, is considered to be a key factor in the surgical treatment of Monteggia-like injuries.