Traumatic Elbow Injuries Research Articles

Utility of fast MRIs in pediatric elbow injuries

BackgroundPediatric elbow trauma presents a diagnostic challenge for clinicians. Radiographs may be insufficient in assessing the radiocapitellar alignment and advanced imaging or invasive procedures such as an intraoperative arthrogram may be indicated. The purpose of this study is to describe the application and utility of fast magnetic resonance imaging (MRI) in the diagnosis and management of traumatic elbow injuries in pediatric patients. MethodsWe reviewed pediatric patients who underwent a fast MRI of the elbow between 2014-2022. A fast MRI was defined as an MRI using rapid sequences, accelerated conventional sequences, or fewer conventional sequences than a standard exam. Imaging for chronic or non-traumatic injuries was excluded. We identified patient demographics, MRI scan times, and clinical course. ResultsTwenty-three patients (8 females and 15 males) with fast elbow MRI scans were identified. The mean age was 5 years (range 2-12 years, SD 2 years). All patients had radiographs and four had CT scans prior to MRI. The average scanning time was 14 minutes (SD 6 minutes). Only one patient required anesthesia. Twenty of the 23 patients had a fracture identified on elbow radiographs and 8 were Monteggia fracture-dislocations. Nine of these patients demonstrated subluxation of the radiocapitellar joint requiring operative management in 8 patients, and one additional patient underwent surgery for displaced radial neck fracture. Three patients sustained an elbow dislocation without fracture identified on radiographs; of these, one had persistent radiocapitellar subluxation on MRI requiring surgical management. A total of 13 patients (56.5%) did not require operative management based on fast MRI findings. Outcome data was available for 22 patients with mean follow up was 23.6 months. One patient had residual pain and 8 had some range of motion limitation at final follow-up. All patients had reduced elbow joint on follow-up radiographs. ConclusionsFast MRIs can assist with the clinical evaluation of acute elbow injury in pediatric patients with equivocal radiographic findings and particularly in those with possible radiocapitellar subluxation/dislocation. This novel imaging technique has the potential to change clinical management, decrease the need for unnecessary procedures, and prevent complications of missed injuries.

Regional distribution prevalence of heterotopic ossification in the elbow joint: a 3D study of patients after surgery for traumatic elbow injury

BackgroundHeterotopic ossification (HO) is a common complication after elbow fracture surgery and can lead to severe upper extremity disability. The radiographic localization of postoperative HO has been reported previously. However, there is no literature examining the distribution of postoperative HO at the three-dimensional (3D) level. This study aimed to investigate 1) the distribution characteristics of postoperative HO and 2) the possible risk factors affecting the severity of postoperative HO at a 3D level. MethodsA retrospective review was conducted of patients who presented to our institution with HO secondary to elbow fracture between 13 January 2020 and 16 February 2023. CT scans of 56 elbows before elbow release surgery were reconstructed in three dimensions (3D). HO was identified using density thresholds combined with manual identification and segmentation. The elbow joint and HO were divided into six regions according to three planes: the transepicondylar plane (TEP), the lateral ridge of the trochlear plane (LTP), and the radiocapitellar joint and coronoid facet plane (RCP). The differences in the volume of regional HO associated with different initial injuries were analyzed. ResultsPostoperative HO was predominantly present in the medial aspect of the capsule in 52 patients (93%), in the lateral aspect of the capsule in 45 patients (80%), in the medial supracondylar in 32 patients (57%), and in the lateral supracondylar, radial head, and ulnar region in the same number of 28 patients (50%). The median and interquartile range (IQR) volume of total postoperative HO was 1683 (777∼4894) mm3. The median and IQR volume of regional postoperative HO were: 584 (121∼1454) mm3 at medial aspect of capsule, 207 (5∼568) mm3 at lateral aspect of capsule, 25 (0∼449) mm3 at medial supracondylar, 1 (0∼288) at lateral supracondylar, 2 (0∼478) at proximal radius and 7 (0∼203) mm3 at the proximal ulna. In the subgroups with Injury Severity Score (ISS) >or= 16, Gustilo–Anderson II, normal uric acid levels, elevated alkaline phosphatase (ALP), and Body Mass Index (BMI) >or= 24, the median HO volume exceeds that of the respective control groups. ConclusionThe medial aspect of the capsule was the area with the highest frequency and median volume of postoperative HO among all initial elbow injury types. Patients with higher Gustilo-Anderson grade, ISS, ALP or BMI had higher median volume of postoperative HO.

Improved Understanding of Traumatic Complex Elbow Instability.

Recent advancements in surgical treatment have improved clinical results in complex traumatic elbow injury. There is increasing recognition that conservative treatment and inadequate surgical fixation carry high risk of substantial morbidity in many of these cases. Recent literature displays improved outcomes in complex elbow instability, in part, because of a more complete comprehension of the injury patterns and fixation methods. Prompt surgical management with stable internal fixation, which permits immediate postoperative mobilization, has been a consistent variable across the reports leading to more satisfactory outcomes. This applies to both acute and chronic cases.

Functional outcomes of fixation of radial neck fractures in children by Metaizeau technique: A case series

Radial neck fractures account for 1% of all fractures in children and 5% to 14% of traumatic elbow injuries. They are mainly caused by having fallen onto an out-stretched hand. Classification: O’Brien and Judet classification.The purpose of this study was to review the functional outcomes of the management of radial neck fractures in pediatric age group using Métaizeau technique.A prospective observational analysis was performed on 8 patients who underwent closed reduction and internal fixation with elastic intramedullary nailing using Métaizeau technique for fracture neck of the radius. Pediatric patients in the age group of 3-12 years with Judet type 3 and Judet type 4 radial neck fractures were taken for our study. The patients were followed up for a period of 3 months and thorough radiological and clinical examination was carried out with due attention to any complication. The final results were scored on the basis of Mayo Elbow Score.As per the above criteria we recorded 3 excellent, 2 fair outcomes for type 3 fractures, whereas for type 4 fractures 1 excellent, 1 fair and 1 good outcomes. Neurovascular deficit or deep infection was not reported. We did not notice any penetration of the nail into the joint.With Metaizeau technique, there were reported poor results of about 10% in literature. Our results support the Métaizeau technique and postulate that the usage of a nail with reshaped tip may help in avoiding revision surgery by minimizing the loss of reduction.

Development and validation of the paediatric elbow trauma (PET) rules as a decision rule for radiography in traumatic elbow injuries: a study protocol

BackgroundTraumatic elbow injuries in children occur frequently and are among the most common traumatic injuries seen in the emergency department (ED) and in general practice. The use of a validated...

Prompt Recognition

There is a wide range of traumatic elbow injuries that require prompt recognition and management. Fractures of the elbow are common in children; however, because of the complexity of radiographic evaluation in skeletally immature patients, diagnosis of pathology may be missed or misinterpreted, leading to delay in treatment and complications. Careful history and thorough physical examination and utilization of a systematic approach to radiographic evaluation will reduce the chance of a delayed or missed diagnosis. This article will provide an overview of 5 pediatric elbow injuries not to miss, including potential complications and unique considerations for each fracture type to avoid common pitfalls.

Design of a Smart Elbow Brace as a Home-Based Rehabilitation Device.

Poststroke and traumatic elbow injuries are the most common cause of elbow stiffness, which results in loss of functional range of motion (ROM). Various studies support early mobilization of the elbow joint after injury or after surgery to reduce risks of elbow stiffness development. After hospitalization, patients are required to follow a long-term rehabilitation program during home recovery. Still, most patients do not adhere to their clinical therapy schedule due to either rehabilitation cost, social obligations, negligence, or lack of inspiration. Moreover, the numbers of therapists and assessment equipment are insufficient. This study introduces a smart elbow brace (SEB) as a home-based rehabilitation device that reduces regular in-patient rehabilitation costs and therapist workload and motivates patients to comply with the rehabilitation program that enhances the achievement of rehabilitation goals. Our device has two active degrees of freedom (2-DoF) that allow extension, flexion, pronation, and supination elbow motions. An extra sliding joint between forearm and wrist is added, which helps dump forces concentration at the elbow joint during extension-flexion movement. Mechanical design requirements, motion-tracking systems, and serious game development are described. The feasibility of a proposed SEB device is tested with five healthy subjects playing developed serious games with the device. The results show that subjects can attain maximum and minimum angles of flexion-extension and pronation-supination motion designed for elbow stiffness rehabilitation. The SEB device will be beneficial and be used at home as a complementary tool to support elbow stiffness rehabilitation during long-term home recovery.

The coronoid opening angle: a novel radiographic technique to assess bone loss in coronoid trauma.

Elbow fracture dislocations are complex injuries that often require surgical treatment in order to obtain a stable and congruent elbow joint. The coronoid plays a key role in the stability of this joint. Accurately identifying the degree of coronoid bone loss in the setting of traumatic elbow injuries is challenging. The purpose of this study is to describe a newradiographic measure, the coronoid opening angle (COA), to assist in estimating bone loss in these challenging fractures. Radiographs were drawn from a regional database in a consecutive fashion. Candidate radiographs were excluded on the basis of radiographic evidence of degenerative changes, previous surgery or injury, bony deformity, and inadequate lateral view of the elbow. Normal COA, coronoid height, and calculated COA at varying amounts of bone loss were determined by 3 reviewers. A total of 120 subjects were included. The normal coronoid opening angle was 34° (95% CI 32.9°-34.0°) and the coronoid height, 18.8 mm (18.1-19.6). Ninety-five percent of the population had an opening angle greater than 29° (95% CI 27.2°-29°). The COA limit was calculated at 20%, 33%, and 50% of baseline coronoid height corresponding to degree of bone loss. Coronoid opening angles of 24°, 20°, and 16°, respectively, indicate the minimum bone loss of interest in 95% of the population. The intraclass correlation coefficient was found to be 0.89 or higher. In the setting of elbow trauma, it is often challenging to predict the amount of coronoid bone loss. The coronoid opening angle is a newtechnique and an adjunct for lateral elbow radiographs to predict the minimum coronoid bone loss. This can be used to guide clinical decision making, aid in predicting instability, and guide treatment. Future research will aim to validate this tool in the clinical trauma setting.

Morphometric co-relation of carrying angle to height, sex, age and dominance in children- A quantitative study

Introduction and Aim: The fracture around elbow is the second most common fracture in the paediatric age group. The carrying angle changes with age and height of the child. The knowledge of carrying angle is important for diagnosing, handling and management of paediatric elbows. The objective was to find the age, height, gender and dominant handedness difference in angle of children aged 5-18 years. Materials and Methods: The carrying angle was measured by a goniometer in 290 healthy students of randomly selected schools. Various parameters; age, gender, height, dominance and length of arm and forearm were also measured. The results were statistically analysed and correlated. Results: The mean carrying angle was 8.9° ± 3.6° on the right side and 8.5° ± 3.8° on the left side in females whereas in males it was 7.1° ± 2.9° and 6.4° ± 2.9° on right and left side respectively. The angle was more on the dominant side than on the non-dominant side. Conclusion: The normative data of this study could be useful in management of elbow displacement, fractures and surgical planning of traumatic elbow injuries.

A modified-delphi study establishing consensus in the therapeutic management of posttrauamtic elbow stiffness

Study Design: Web-based modified Delphi study. Background: Therapy is widely considered the first choice of treatment for posttraumatic stiffness of the elbow since loss of motion is a common sequela following traumatic elbow injuries. There is high variability in practice patterns for the management of the posttraumtic elbow. Purpose: The aim of this study is to identify the current therapeutic management of posttraumatic elbow stiffness using expert consensus. Methods: This study surveyed experts using a web-based 3 round modified Delphi method. Quantitative data and comments were collected during the first round. Questions with Likert scaling were used to identify consensus (defined as 75% agreement) with each statement and comment boxes enabled open-ended responses to gather expert opinion. Lack of consensus and data from comments guided the second-round of the survey. This process was repeated after Round 2 to develop the Round 3 survey. Consensus was achieved at Round 3 and no further rounds were needed. Results: Round 1 included 34 experts (response rate 20%), not all experts were able to continue through all rounds. Round 2 included 18 experts and Round 3 included 15 experts. Survey items were categorized as follows: examination procedures, therapeutic interventions, orthotic intervention considerations, contributing patient factors, and clinical decisions and rehabilitation challenges. Twenty-five percent of items achieved consensus after Round 1, 30% after Round 2 and 52% after Round 3. Although most participants agreed that orthotic intervention is critical to patient outcomes, there were conflicting thoughts about the orthotic design and wearing schedule. Conclusions: The findings of this web-based modified Delphi study helped to establish a current body of knowledge using expert consensus to guide practice and identify specific questions that can be studied in future clinical studies on posttraumatic elbow stiffness.

A Woman With Painful Elbow

A 71-year-old woman presented to the emergency department with right elbow pain after a fall. On physical examination, she was conscious and had pain well-localized to the posterior aspect of the elbow without any open wounds or swelling. She was unable to extend her elbow. Other physical examinations were unremarkable. Radiography (Figure 1) and point-of-care ultrasound of the right elbow were performed (Figure 2, Figure 3, Video).Figure 2Point-of-care ultrasound (short-axis view) of the olecranon fossa demonstrating 3 different echogenic bands within the joint fluid, separating into fatty material (arrowhead), serous joint effusion (anechoic collection), and sediment of red blood cells (asterisk). This trilevel appearance of lipohemarthrosis is called the “parfait sign.” O, olecranon fossa.View Large Image Figure ViewerDownload Hi-res image Download (PPT)Figure 3Point-of-care ultrasound (long-axis view) along the sagittal plane showing an elevated posterior fat pad sign (arrowhead) with heterogeneous echotexture consistent with lipohemarthrosis in the olecranon fossa. O, olecranon fossa.View Large Image Figure ViewerDownload Hi-res image Download (PPT) Occult olecranon fracture with elevated posterior fat pad sign and lipohemarthrosis. Point-of-care ultrasound of the right elbow demonstrated an elevated posterior fat pad sign with lipohemarthrosis. Occult olecranon fracture was diagnosed by computed tomography (Figure 4). The patient was discharged with a splint and started rehabilitation on a 1-week follow-up. Geriatric elbow fractures are not uncommon in the ED after low-energy falls. Diagnosis can sometimes be difficult with radiography because of overlapping bones or inappropriate radiographic positions. Point-of-care ultrasound is an ideal and practical tool for rapidly evaluating traumatic elbow injury.1Okumura Y. Maldonado N. Lennon K. et al.Point-of-care ultrasound: sonographic posterior fat pad sign: a case report and brief literature review.J Emerg Med. 2017; 53: 98-101Abstract Full Text Full Text PDF PubMed Scopus (3) Google Scholar Findings of elevated posterior fat pad sign and lipohemarthrosis on point-of-care ultrasound are highly sensitive predictors of intraarticular elbow fractures.2O'Dwyer H. O'Sullivan P. Fitzgerald D. et al.The fat pad sign following elbow trauma in adults: its usefulness and reliability in suspecting occult fracture.J Comput Assist Tomogr. 2004; 28: 562-565Crossref PubMed Scopus (47) Google Scholar, 3Rabiner J.E. Khine H. Avner J.R. et al.Accuracy of point-of-care ultrasonography for diagnosis of elbow fractures in children.Ann Emerg Med. 2013; 61: 9-17Abstract Full Text Full Text PDF PubMed Scopus (64) Google Scholar, 4Costa D.N. Cavalcanti C.F. Sernik R.A. Sonographic and CT findings in lipohemarthrosis.AJR Am J Roentgenol. 2007; 188: W389Crossref PubMed Scopus (12) Google Scholar Lipohemarthrosis is defined as “2 or 3 different echogenic bands seen within the joint fluid,” separating into fatty material, serous joint effusion, and sediment of red blood cells.1Okumura Y. Maldonado N. Lennon K. et al.Point-of-care ultrasound: sonographic posterior fat pad sign: a case report and brief literature review.J Emerg Med. 2017; 53: 98-101Abstract Full Text Full Text PDF PubMed Scopus (3) Google Scholar This trilevel appearance is sometimes called the “parfait sign.” Treatment of nondisplaced elbow fractures involves immobilization for a duration of 1 week. https://www.annemergmed.com/cms/asset/2b8d4b36-a95f-43b2-8942-70edc14a2430/mmc1.mp4Loading ... Download .mp4 (0.86 MB) Help with .mp4 files VideoPoint-of-care ultrasound (short-axis view) of the right elbow revealing a trilevel area of joint fluid within the olecranon fossa, known as lipohemarthrosis (asterisk) (visible from 00:00 to 00:04); long-axis view in the same region presented an elevated posterior fat pad sign (arrowhead) (visible from 00:04 to 00:09).

Investigating the Effects of Physical Therapy Timing, Intensity and Duration on Post-Traumatic Joint Contracture in a Rat Elbow Model.

Post-traumatic joint contracture (PTJC), characterized by loss of motion and permanent stiffness, affects up to 50% of patients following elbow joint dislocation or fracture. Mechanisms governing successful conservative treatment methods aimed at preventing elbow PTJC and avoiding operative treatments (e.g., physical therapy) are poorly understood. Using a previously established rat model of elbow PTJC, the purpose of this study was to explore the effect of varying timing, intensity and duration of active, functional exercise on joint motion outcomes. Following a surgically-induced unilateral elbow dislocation in rats, injured limbs were immobilized in bandages for 42 days followed by free mobilization for 42 additional days producing long-term PTJC. This work summarizes several studies (Phases I-III) that investigated the effects of early versus delayed therapy (timing), free mobilization versus forced treadmill walking (intensity), and limited-time versus unlimited use (duration) on elbow PTJC. Joint motion outcomes in therapy groups showed no improvements compared to non-treated injured animals when therapy began day 14 post-injury or later regardless of timing, intensity or duration. Improved joint range-of-motion was only achieved when bandages were permanently removed at day 3 post-injury, regardless of whether added treadmill walking was performed. Early motion is essential to preserving range-of-motion following traumatic elbow injury in a rat model.

Functional Outcomes of Unstable Traumatic Elbow Injuries: How and When to Fix Them

Complex elbow fractures have a predisposition for undesirable outcomes even with surgical management. The aim of this study was to evaluate the functional outcome of patients with traumatic unstable elbow Injuries that were managed surgically, as well as how to select the proper surgical approach and fixation guided by pre-operative planning. Analyzing their functional outcomes would help formulate future evidence-based guidelines on elbow terrible triad injury management in clinical practice.

Emergency and Trauma of the Elbow.

The elbow is a joint composed of three different articulations all included in the same synovial capsule, with a complex anatomy that allows two kinds of motion: flexion-extension and pronation and supination. Stabilization of the elbow is provided by osseous and ligamentous structures.When assessing the elbow in the traumatic setting, the mechanism of injury determines the pattern of osseous and ligamentous lesion, with potential important implications on elbow instability. The role of the radiologist in the assessment of the traumatic elbow requires an understanding of the most common injury mechanisms in traumatic elbow injuries. This knowledge facilitates the detection of potential secondary occult bone and soft tissue injuries that could lead to chronic instability.We analyze the acute patterns of injury of the osseous, ligamentous, musculotendinous, and neurovascular structures, with a focus on the most commonly used classifications of fractures and fracture-dislocations. We also discuss the therapeutic management of these injuries, with mention of the most frequently used surgical techniques and the commonly expected posttreatment findings.Finally, we review the repetitive microtrauma patterns of injury of the elbow joint structures and the most common pitfalls in the interpretation of elbow imaging.

Heterotopic ossification formation after fracture-dislocations of the elbow

Heterotopic ossification (HO) is a serious complication of traumatic elbow injuries, particularly fracture-dislocations. Limited data exist in the literature regarding the risk factors associated with HO formation in these injuries. The purpose of this study was to review the incidence of HO after fracture-dislocation of the elbow and to identify potential risk factors associated with its formation. Twenty-seven patients (28 elbows) were surgically treated for elbow fracture-dislocations during 8 years, with an average follow-up of 14 months. Records were reviewed with attention paid to several factors: demographic data, comorbidities, time interval from injury to surgical intervention, number of closed reductions attempted before surgery, surgical approach, management of the radial head, treatment of the anterior capsular injury, and coronoid fixation. Of the 28 elbows, 12 (43%) developed HO postoperatively; 9 of 28 elbows underwent multiple attempted closed reductions before definitive surgical stabilization, with HO formation in 7 of the 9 (77%). Time to surgery, age, gender, radial head fixation or replacement, coronoid open reduction and internal fixation, capsular repair, and medical comorbidities were not found to influence HO formation, although the performance of multiple reductions was identified as a risk factor. HO developed in 77% of patients with multiple attempted closed reductions. We found a 43% incidence of HO in patients surgically treated for elbow fracture-dislocations. Neither time to surgery after the injury nor demographic or other factors relating to the manner in which associated osseous or soft tissue injuries were managed influenced the formation of HO.

Olecranon Tip Osteoarticular Autograft Transfer for Irreparable Coronoid Process Fractures. A Biomechanical Study

Coronoid process fractures are common in traumatic elbow injuries and can lead to significant elbow instability. With extensive fracture comminution, few options exist for reconstruction. The olecranon tip, being morphologically similar to the coronoid, may be a suitable option for reconstruction. In this study, we evaluate the morphology, suitability and biomechanics of an olecranon tip transfer procedure for type III coronoid fractures.

CSM 2014 Orthopaedic Section Poster Presentations (OPO1106–OPO1165, OPO2218–OPO2298, OPO3106–OPO3183)

CSM 2014 Orthopaedic Section Poster Presentations (OPO1106–OPO1165, OPO2218–OPO2298, OPO3106–OPO3183)

The Pedicled Reverse-Flow Lateral Arm Flap for Coverage of Complex Traumatic Elbow Injuries

The pedicled reverse-flow lateral arm flap has been described primarily for the reconstruction of nontraumatic elbow wounds. We describe our experience using this flap in staged operations for soft tissue coverage after elbow trauma, including acute coverage of open fractures and salvage of infected hardware. Review of patients who underwent staged pedicled reverse-flow lateral arm flap transfer for coverage of traumatic elbow defects. Three patients were identified; all underwent 2-stage repair with flap delay for coverage of traumatic elbow injuries. Each patient had stable wound coverage with this flap. The only complication was 5% distal flap necrosis in 1 patient. The pedicled reverse-flow lateral arm flap provides reliable soft tissue coverage of traumatic elbow defects with minimal donor-site morbidity.

Traumatic Elbow Injuries: What the Orthopedic Surgeon Wants to Know

Traumatic elbow injuries are commonly encountered in the emergency department setting, but their complexity and clinical significance often go unrecognized at the initial evaluation. Initial imaging in patients with elbow trauma should not only help identify major injuries that require immediate intervention but also allow detection of other, often more subtle injuries that may lead to instability or poor functional outcomes if appropriate treatment is delayed. Awareness and detection of these injuries may be improved by a better-developed and more intuitive understanding of the mechanisms that underlie the most common injury patterns. Ideally, such understanding should prompt appropriate early use of advanced imaging techniques. Traumatic elbow injuries should be described in the radiology report within the context of their clinical significance and their implications for management, information that is often best captured by the injury grading and classification systems used by the orthopedic surgery community. This article reviews the relevant anatomy and functional stability of the elbow and discusses common traumatic elbow injury patterns, including elbow dislocations as well as fractures of the distal humerus, radial head and neck, coronoid process, and olecranon. Less commonly encountered injury constellations that are clinically significant are also described. Injury patterns are explained in the context of the responsible force mechanism by using three-dimensional modeling and animation, with emphasis on the functional impact of associated secondary bone and soft-tissue injuries. The utility of cross-sectional imaging modalities such as computed tomography and magnetic resonance imaging in the acute care setting is discussed, and specific imaging guidelines are provided. Supplemental material available at http://radiographics.rsna.org/lookup/suppl/doi:10.1148/rg.333125176/-/DC1.

Pulmonary embolism following isolated upper limb injury: a rare complication

Pulmonary embolism is usually associated with lower limb and not upper limb orthopaedic procedures [4]. Deep vein thrombosis has been reported previously in upper limb trauma, such as humeral shaft and clavicle fractures, and also following total elbow arthroplasty [3, 6, 7]. To the authors’ knowledge, pulmonary embolism has not been reported following fixation of a traumatic elbow injury. We reported the unique case of a 28-year-old man who underwent fixation of a coronoid fracture with his post-op recovery complicated by a pulmonary embolism.