Ulnar Fracture Research Articles

P05 Osteoporosis in thalassemia; a case with multifactorial aetiology

Abstract Introduction Thalassemia patients are prone to osteoporosis due to multifactorial reasons, including anaemia, bone marrow expansion, iron overload and hypogonadism. Case description A 41-year-old British Asian male with beta thalassemia major was referred to rheumatology in 2018 for osteoporosis. In 2008, aged 27 years, whilst playing football, he developed a distal radial fracture and ulnar styloid process fracture and a DEXA scan had revealed low bone mineral density (BMD) for age. Subsequently, he was started on Ibandronic acid by his haematologist for a total of 10 years. After he was referred to rheumatology in 2018, bisphosphonates were discontinued as he had 5% improvement in BMD, a decade of bisphosphonates and no further fractures. Further assessment revealed multiple contributory factors for his osteoporosis. • Consistency low vitamin D – 9.6 nmol/L in 2009, average value of 20 • He was diagnosed with hypogonadism, poor compliance with IM testosterone injections • He had diabetes which was not optimally controlled • Evidence of iron overload with average serum ferritin of 2000 ug/L with deferasirox While these factors were optimised, it was decided to adopt a watch and wait policy with regards to specific osteoporosis treatment. Review in 2023 revealed serum testosterone level of 20.1 nmol/L (6.9-23.2) with better compliance with testosterone injections. Fructosamine levels were 310 (normal range 200-285) but it has reduced from a peak of 370. Serum ferritin levels have reduced to 776 down from a high of 5600. Normal vitamin D levels were maintained. The DEXA scan in 2023 revealed a spine T score of −2.4 which showed 10.2% increase in bone mineral density. DEXA scan in 2020 revealed T score of −3.1 in spine and −1.9 in hips. The P1NP level was 56 (19-69) which has reduced from 100 in 2021. Improvements in BMD and bone turnover markers were achieved through optimising contributory factors without any specific osteoporosis treatment. He will be monitored with periodic BMD and bone turnover markers. Discussion Anaemia and subsequent bone marrow expansion is a recognised cause for osteoporosis in thalassemia patients. While regular blood transfusions inhibit bone marrow expansion, ineffective erythropoiesis is not fully supressed. This patient received 3 units of blood every 4 weeks. Bone marrow expansion occurs mostly in trabecular bone resulting in low BMD is areas which generally have increased amount of trabecular bone such as the spine. Our patient had a lower BMD in the spine compared to the femoral neck. Iron overload directly disrupts bone formation and can result in endocrinopathies which contributes to osteoporosis. Hypogonadism is another well-recognised cause and is primarily results from iron deposition in pituitary and at times in the gonads. Hormonal replacement therapy reduces bone loss. Studies have shown that hypogonadic patients have more severe osteoporosis and predominant involvement of the femoral neck. Iron overload can cause diabetes mellitus and impaired growth hormone/ insulin growth factor-1 (IGF-1) axis which can contribute to osteoporosis. Our patient did have diabetes but had normal IGF-1 levels when checked previously. Deferoxamine which is one of iron chelating agents have been shown to reduce collagen synthesis and increases osteoblast apoptosis which might contribute to the development of osteoporosis. Vitamin D levels are well known to be low in patients with thalassemia compared to the general population. While there are no RCT’s to show that bisphosphonates reduce fracture risk, surrogate markers such as increased BMD and reduction in bone turnover markers are known to occur. Therefore, current guidance (Standards for the Clinical Care of Children and Adults with Thalassaemia in the UK) recommends bisphosphonates to be considered in patients with a low BMD for age (Z-score < −2.0, T-score < −2.5 if post-menopausal or over 50), if there are fragility fractures or falling BMD despite adequate vitamin D levels, and hormone supplementation. Key learning points Learning point Important to assess for osteoporosis in thalassaemic patients. There are multiple factors contributing to the development of osteoporosis which needs to be addressed together with endocrinologist and haematologist. Bisphosphonates are recommended though further RCT evidence is required to support this

Clinical observation on the treatment of displaced distal radial and ulnar fractures in children by closed manipulation combined with splinting.

The aim of this study was to investigate the clinical efficacy of closed manipulation combined with splinting in the treatment of displaced distal radial and ulnar fractures in children. A total of 82 children with displaced fractures of the distal radial and ulnar segment who met the inclusion criteria and were treated as outpatients or inpatients in the orthopedic department of Guangzhou Orthopedic Hospital, from January 2016 to June 2022 were randomly divided into an observation group and a control group: 41 children in the observation group were treated with closed manipulation combined with splint fixation; 41 children in the control group were fixed with incisional repositioning elastic nails combined with internal plates. The Anderson efficacy grading, visual analog scale (VAS) score, fracture healing time, treatment cost, hospital days, and complications were observed and compared between the two groups. The efficacy was evaluated according to the Anderson forearm fracture efficacy evaluation criteria, and the results of statistical analysis showed no statistically significant differences between the two groups (P > 0.05). At 3 and 7 weeks after treatment, the VAS scores of children in both groups decreased (P < 0.05), and the VAS scores in the observation group were significantly lower than those in the control group (P < 0.05), indicating that the observation group had a significant advantage in the relief of pain after treatment. The fractures healed in both groups after treatment with the two different methods, and the difference in healing time between the two groups was not statistically significant (P > 0.05). The length of hospital stay, treatment cost, and complication ratio were significantly lower in the observation group than in the control group (P < 0.05). In children with displaced fractures of the distal radial and ulnar segments, treatment by manual repositioning with external splinting can achieve satisfactory results with simple operation, low cost, short hospital stay, and few complications, which is especially suitable to be promoted in primary hospitals and has good social benefits.

Validity of distal radius fracture diagnoses in the Swedish National Patient Register

Distal radius fractures are one of the most common fractures in adults. More research is needed to establish evidence-based clinical practice guidelines to generate cost-effective and fair fracture treatment. The Swedish National Patient Register is a principal source for population-based epidemiologic studies in Sweden. The validity of some–but not all–diagnoses in the register is high. Little is known regarding the validity of registration of distal radius fractures.A dataset of cases registered with diagnosis of distal radius fracture (S52.5) or distal radius and ulna fracture (S52.6) were collected from the Swedish National Inpatient and Outpatient Registers. Six cohorts, each containing 240 simple random samples, were constructed. Radiographic reports and medical records were reviewed to confirm or reject the diagnosis as well as, in relevant cases, the surgical intervention. Positive predictive values (PPV) were calculated.The PPV for distal radius fracture in the register ranges between 92 and 100%, lower if coded as S52.6 and higher if there was an adherent code of surgical intervention. Codes for surgical intervention reached a PPV of 95–100%.In conclusion, the validity of the codes for diagnosis and the surgical treatment of distal radius fracture is high in the Swedish National Patient Register. According to our results, the register may be used as a reliable data source for population-based research of distal radius fractures.

To Bury or Not to Bury the K-wires After Fixation of Both Bone Forearm Fractures in Patients Younger Than 11 Years Old: A Randomized Controlled Trial.

The primary objective was to compare the re-fracture incidence of both radius and ulna fracture in 2 groups treated using intramedullary Kirschner wires (K-wires) where the wires were exposed in group I and buried in group II. The secondary objective was to compare the final functional outcomes and complications incidence. Between March 2019 and February 2021, 60 pediatric patients with unstable radius and ulna fractures amenable to surgical intervention using intramedullary K-wires were randomized into group I (K-wires were exposed above the skin by 2cm) or group II (K-wires were buried under the skin). In group I, K-wires were removed in the outpatient clinic, while in group II, they were removed under general anesthesia as a day-case procedure. Functional outcome per Price criteria was reported at 1-year follow-up. Included patients had a mean age of 7.6 years (range: 5 to 10y). The mean operative time was significantly higher in group II (32.33±7.51 vs. 36.77±8.70min, P =0.03), with no difference regarding intraoperative x-ray exposure (43.12±15.52 vs. 41.6±11.96s, P =0.67). Fracture union was achieved after a mean of 44±2.6 days in group I and 43±1.87 days in group II, with no difference between both groups ( P =0.34). One patient had re-fracture in group I and no patients in group II; however, the difference was insignificant ( P =0.12). Infection occurred in 2 patients in each group. All patients reported excellent scores per Price criteria and achieved full wrist and elbow range of motion compared with the contralateral noninjured side. Exposed implants are a safe option when dealing with forearm fractures in patients younger than 11 years old, with the added advantage of fewer hospital admissions. Furthermore, it had a similar complication rate and functional outcomes compared with buried implants. ClinicalTrials.gov, NCT03906929. Level II.

Management of Radius and / Or Ulna Fracture by Screw Intramedullary Nail in Skeletally Mature Patients

The standard nailing of both bone forearm fractures of the radius and ulna poses a possible complication of nail migration androtational instability, despite being one of the best reduction techniques. This study has strived to evaluate how effectively screw elasticintramedullary nail is useful in the therapy for mature diaphyseal fractures of both bone forearms. The issues faced with conventional nailingtechniques for managing forearm fractures have also been discussed. A prospective evaluation of twenty-one cases with forearm fractures (radiusand ulna or isolated fracture of the single bone) was done. Out of the twenty-one cases studied, eighteen patients had undergone closedreduction, and three cases required mini-open reduction. The fracture was categorized as claimed by Arbeitsgemeinschaft furOsteosynthesefragen (AO) Foundation/Orthopedic Trauma Association(OTA). The results were evaluated according to Anderson criteria, inwhich 13 cases had excellent results, 4 had good results, 3 had an unsatisfactory result, and 1 was reported as failure. Also, there was 1 case ofsynostosis and 1 case of delayed union in radius. We concluded that the intramedullary screw nail for forearm fractures in adults could be used asa good internal fixation therapy giving excellent functional and radiological results. This technique is easy to learn, and the implant used is alsocost-effective, thus, providing a good fixation of the fracture. The most accepted technique for forearm fracture, as per current recommendationand AO, are open reductions and internal fixation with plating, but our study is exclusive since it helped to overcome the failure of conventionalnailing of both forearm bones with the potential complication of nail migration and rotational instability in spite the best reduction.

Comparison of a 2.7-mm and 3.5-mm locking compression plate for ulnar fractures: a biomechanical evaluation.

Implant prominence after ulnar fracture fixation may be mitigated by the use of lower profile plates. The biomechanical strength and stability of 2.7-mm and 3.5-mm locking compression plates for fixation were compared. Two fracture conditions, transverse (N = 10) and oblique (N = 10), were evaluated in an in vitro study. Half of the specimens for each condition were fixed with 2.7-mm plates and the other half with 3.5-mm plates, all fixed with conventional dynamic compression mechanisms. Specimens were loaded under ±2 Nm of cyclic axial torsion, then under 10 Nm of cyclic cantilever bending, and bending to failure. Interfragmentary motion and strain were analyzed to determine construct stability as a function of fracture pattern and plate size. Interfragmentary motion was significantly larger in all constructs fixed with 2.7-mm plates, compared with 3.5-mm plates (P < 0.01). The 2.7-mm constructs with transverse fractures had the greatest motion, ranging between 5° and 10° under axial rotation and 5.0-6.0 mm under bending. Motions were the lowest for 3.5-mm constructs with oblique fractures, ranging between 3.2 and 4.2 mm under bending and 2°-3.5° for axial rotation. For oblique fractures, the bending moment at ultimate failure was 31.4 ± 3.6 Nm for the 2.7-mm constructs and 10.0 ± 1.9 Nm for 3.5-mm constructs (P < 0.01). Similarly, for transverse fractures, the bending moment was 17.9 ± 4.0 Nm for the 2.7-mm constructs and 9.7 ± 1.3 Nm for the 3.5-mm constructs (P < 0.01). Although 3.5-mm plates were more effective at reducing fracture motion, they were consistently associated with refracture at the distal-most screw hole under load to failure. By contrast, 2.7-mm plates plastically deformed despite excessive loads, potentially avoiding a subsequent fracture. Level V.

Outcomes and complications of Titanium elastic nailing for forearm bones fracture in children: our experience in a district general hospital in the United Kingdom.

Intramedullary Titanium elastic nailing (TENS) is successfully used for irreducible and displaced forearm bone fractures in children. The purpose of this study was to report the potential complications and functional outcomes associated with paediatric forearm fractures treated with TENS nails. We retrospectively reviewed 65 children with displaced forearm bone fractures treated by TENS nailing with a mean follow-up of 5.84 months (4-12). Data detailing patient demographics, fracture characteristics, associated fractures, injury surgery interval, grade of the operating surgeon, methods of fixation, time to union, the timing of removal of the nail, and complications were collected and analysed. The mean age in our study was 9.13 years. 92% had fractures of both radius and ulna, 83.3% had fixation of both bones, and 16.7% had single bone fixation only. Open reduction was required in 38.5% of cases. The average time to fracture union was 10.34 weeks (6-20). The average time of implant removal was 20.12 weeks (9-32). We observed an overall complication rate of 41.5%. We noted a higher (56% vs 32.5%, p=0.059) complication rate in open reduction cases. According to the Price criteria, we had excellent to good results in over 98% of patients despite a slightly higher complication rate. Titanium elastic nailing is a safe, reliable method of internal fixation for irreducible or unstable fractures of both bones of the forearm in children. Open reduction of fracture was associated with higher complications. Despite higher overall complications, we noted excellent functional results in most cases.

MDCT evaluation of distal radius fractures and their association with carpal and distal ulnar fractures.

The purpose of this study was to evaluate the characteristics of distal radius fractures (DRFs) in patients undergoing multi-detector computed tomography (MDCT) and their association with carpal and distal ulnar fractures. This retrospective study analyzed 120 patients, who underwent MDCT for evaluation of DRFs. Two radiologists independently evaluated the data for various fracture characteristics and for associated carpal and distal ulnar fractures. Out of 120 DRFs, 74 were complete articular, 40 were partial articular and only 6 were extra-articular. Displacement was present in 99 fractures and intra-articular step off was present in 73 fractures. A total of 81 carpal bone fractures were identified in 46 (38.3%) patients, with more than one carpal bone fracture in 21 patients. Distal ulnar fractures were detected in 79 patients (65.8%), out of which 67 involved the ulnar styloid. DRFs with intra-articular step off were more frequently associated with carpal bone fracture (p value: 0.021), while displaced DRFs were more frequently associated with distal ulnar fracture (p value <0.001). Interobserver agreement for detection of carpal bone fractures (κ = 0.807) and distal ulnar fractures (κ = 0.923) was excellent. Majority of DRFs in patients referred for MDCT were complete articular with high incidence of displacement and intra-articular step off. Associated carpal bone and distal ulna fractures were not uncommon.

1106 Epidemiology and Incidence of Upper Limb Fractures, a UK Level 1 Trauma Centre Perspective

Abstract Aim Understanding the incidence and epidemiology can inform clinicians and policymakers about the needs of the population. There is no recent, large UK-based study on the epidemiology of upper limb fractures. Our study reports on the upper limb fractures treated at a major trauma centre over a 7-year period Method We collected data on fracture locations, age, gender, Charlson Comorbidity index (CCI), and treatment options of all upper limb fractures treated at a Level I Trauma Centre from January 2015 to 2022. Humerus, radius, and ulna fractures were each classified as proximal, diaphyseal and distal. Results 9915 patients sustained 12502 fractures, given an overall incidence of 313 fractures per 100,000 patients per year. The incidence of fractures per 100,000 patients/year was: Scapula-16.5, clavicle-30.9, humerus-57.5, radius-84.2, ulna-57.0, carpal-9.5, metacarpal-17.2, phalanges-38.8. The mean age and CCI were 48.2 years and 1.72, respectively. 56.4% of patients were male. All bone fractures distal to the elbow were associated with an age younger than the mean (all p&amp;lt;0.001), with humerus fracture patients having the oldest mean age (54.6). Compared to the mean gender ratio, except for ulna (no association), humerus (55% female) and radius (51% female), all other locations showed significantly higher incidences of males (all p&amp;lt;0.001). Conclusions To our knowledge, this represents the first study of this type in the UK since 2006. We sought to elucidate relative incidence and demographic associations with fractures to highlight changing population needs and allow guidelines and services at a regional and national level to operate with up-to-date information.

Updated Trends of Fractures, A Single Trauma Centre Prospective Observational Study

Background Trauma, specifically physical trauma, is the damage to the body caused by an external force. This may be caused by accidents, falls, hits, weapons, and other causes.In medicine, traumatology is defined as the study of wounds and injuries caused by accidents or violence to a person, together with the surgical therapy and repair of this damage. Aim of the Work This study primarily aims to identify the prevalence of fractures in our population and fracture patterns as regards the age, the gender, the comorbidities of the patients, the mode of trauma, the classification, the associated injuries and the management at our institute. Patients and Methods This study is a cross sectional observational study in which the STROBE layout was used. It was conducted in a university hospital which is considered as a tertiary trauma center “Ain Shams University hospital.”. Data regarding the patients were collected over a period of six months started from the first of January 2021 and ended by the end of June 2021. No follow up was needed for any patients. Results Results showed that most prevalent fractures were femur fractures especially in geriatrics, followed by radius fractures that mainly occurred in pediatric age group, tibial fractures were the third most common fractures and mainly affected adult age group, humeral fractures were the fourth most common with pediatrics age group mainly affected. Malleolar fractures were the fifth prevalent fractures followed by the ulnar fractures. Conclusion Fracture prevalence numbers vary substantially according to age and gender for different locations and presumably the percentage of osteoporotic fractures are on the rise. Careful assessment of fragility fractures is needed, developing a trauma registry and filing systems is mandatory in order to accurately collect and save this important data. Femur fractures especially geriatric femur fractures, radius especially distal end and tibial fractures (especially the shaft), accordingly the learning curve should be guided towards mastering the management of those fractures. Hospital preparation, instrumentation and creation of special dedicated units like the orthogeriatric unit should be encouraged to provide better care for patients along with enhancing the inter-specialty communication and aiming for multi-disciplinary team management. Data from the study should be implemented nationwide to help develop preventative strategies aiming for lowering the occurrence of fractures

Primary Hinged External Fixator for Complex Fracture Dislocations of the Elbow (Systematic Review/Meta-Analysis)

Background High-energy and fracture dislocations with compromise of the medial and lateral ligamentous complex, the joint capsule, and potentially the tertiary stabilizers (i.e., the flexor pronator, extensor supinator masses, and brachialis) often demonstrate residual instability after osseous and ligamentous stabilization. The optimal management of a complex elbow injury should results in restoring joint stability and its full range of motion. However, this is often difficult to achieve by surgical means and a marked restriction of movement remains a frequent con- sequence of severe elbow injury. Aim of the Study The aim of this study is to discuss the results of using a lateral hinged external fixator as an adjunct stabilizer in the treatment of a variety of acute destabilizing elbow injuries as a primary method of fixation not only in chronic or complicated cases. Patients and Methods Types of studies: Randomized controlled trials, including cluster RCTs, controlled (non-randomized) clinical trials or cluster trials, prospective and retrospective comparative cohort studies, and case-control or nested case-control studies. Types of participants: Only studies on human subjects with acute complex elbow fracture dislocation treated by hinged elbow external fixator. Types of interventions: Surgical treatment of acute complex elbow fracture dislocation with hinged external fixation of elbow. Types of outcome measures: Operative details, intra and postoperative complications and final clinical outcome. Literature searches will be conducted using the following databases:” PubMed, Ovid, Web of Science, ScienceDirect, Scopus, Cochrane Library, Google Scholar, Medline” using the following Keywords: acute complex elbow fracture dislocation, hinged external fixator, unstable elbow, terrible triad and long term for published studies from 2010-2021. Results Regarding studies done on the use of a lateral hinged external fixator on the elbow for complex fracture dislocation which are numerous in the last 11 years, we have reviewed the most applicable studies in our review. Regarding the mean flexion-extension arc and pronation-supination arc, the results were 121.5 º and 81 º respectively. Regarding the complications, wound infection was found in 10 patients out of 69 cases (14.4%) including pin tract infection and ORIF wound infection. Secondary humeral and ulnar shaft fractures were found in 3 patients out of 69 cases (4.3%) as a recognized complication of the shanz screws application in both humerus and ulna. Another complication founded was elbow joint incongruity in 5 patients among 69 cases (7.2%) which leads to series consequences like arthritis, progressive pain and instability. Instability as a postoperative complication was found in 1 patient out of 69 cases (1.4%) which shows the huge effect of adding a hinged external fixator to the ORIF construct. In fact, this was the only reason to add a hinged external fixator in the past where it was used in cases of recurrent and chronic instability. Non union was found in 2 patients out of 69 patients (2.8%) while heterotrophic calcification was found in 8 patients out of 69 cases (11.5%). Iordens et al in 2015 was the only paper to calculate the quick-dash score where among 27 patients the score were 30 at 6 weeks and 7 at 1 year. Regarding the mayo elbow performance score (MEPS), among the 69 patients 21 patients (30.4%) were not affiliated while the score was poor in 1 patient (1.4%), fair in 7 patients (10.1%), good in 18 patients (26%) and excellent in 22 patients (31.8%) which shows that above 50% of cases where good to excellent showing the effect of early protected range of motion gained by the addition of a hinged external fixator. Conclusion The best management for complex elbow fracture dislocations is still controversy but the additional use of a hinged external fixator to the ORIF repair shows better outcomes as described.

The ageless approach: Nonoperative mastery competes head-on with surgery for elderly distal radius fractures.

The aim of the current study is to compare the clinical outcomes of cast immobilization (CI) versus surgical treatment after 1 year for distal radius fractures (DRFs) in the elderly population. The cohort included patients aged 70-89 who suffered an acute, closed, and displaced DRF and who were treated conservatively or surgically at our clinic between August 2018 and January 2022. Those who had pathological fractures, open fractures, concomitant ulna fractures (except ulna styloid fractures), were not between the ages of 70 and 89, or refused to participate were excluded from the study. The study gathered data on patient demographics, initial radiological measurements, clinical measurements after 1 year, treatment models employed, and rates of complications. Of the total number of patients (276), CI was used on 77.2% (213), whereas the other 25 had volar-locked plates (VLP), 25 received external fixators with percutaneous pinning (EFPP), and 13 had isolated percutaneous pinning (IPP). 19 of 276 individuals had complications, with Complex Regional Pain Syndrome and Carpal Tunnel Syndrome being the most often documented. EFPP resulted in significantly higher Disability of the Arm, Shoulder, and Hand (DASH) score values than VLP and IPP at the 1st postoperative year (p < 0.05). No statistically significant difference was found between the DASH score and ROM values at the 1st postoperative year for patients who received CI versus those who underwent surgery (p > 0.05). In the first postoperative year, CI still retains its validity and performs similarly to surgery for DRFs in older individuals. VLPP and IPP methods outperformed EFPP surgeries.

Ulnar fracture deriving from metastasis of a primary hepatoblastoma in a Thoroughbred weanling

SummaryAn 8‐month‐old Thoroughbred filly presented for surgical repair of a fracture of the right olecranon. Fixation of the fracture with an orthopaedic plate and screws was attempted, with complications of intraoperative haemorrhage and poor bone viability. The filly was euthanised 5 days after the repair, following a post‐operative secondary fracture. Primary hepatoblastoma of the liver with secondary metastasis of the right humerus, radius and ulna were diagnosed at necropsy. A history of ‘un‐thriftiness’ was later described by the farm manager.

Treatment of type II symptomatic ulnar styloid nonunions with reinsertion of the triangular fibrocartilage complex

PurposeThe purpose of this retrospective study was to introduce an alternative technique for the treatment of type II symptomatic ulnar styloid nonunion by the reinsertion of the triangular fibrocartilage complex and the ulnar collateral ligament.MethodsBetween March 2009 and May 2017, 45 patients (34 males and 11 females) suffering from the nonunion of type II ulnar styloid fractures all underwent the subperiosteal resection of the avulsed fragments and the reinsertion of the TFCC and ulnar collateral ligament. Outcome assessments included the ranges of motion of the wrist, grip strength, pain, and Mayo wrist score. The preoperative and postoperative parameters were compared. A P-value less than 0.05 was considered to be statistically significant.ResultThe mean follow-up period was 21.66 ± 7.93 months (range, 12 to 26 months). At the final follow-up, the mean preoperative flexion and extension were 79.32 ± 4.52° and 74.40 ± 4.36° respectively. The mean preoperative pain score, grip strength, and Mayo wrist score were 32.48 ± 4.00; 23.88 ± 8.38 kg, and 77.72 ± 8.31 respectively. The mean postoperative flexion and extension of the wrist were 80.56 ± 6.32° and 75.43 ± 3.12° respectively. The mean postoperative pain score, grip strength, and Mayo wrist score were 12.41 ± 3.27, 26.31 ± 8.30 kg, and 90.71 ± 7.97 respectively. There were significant differences in pain, grip strength, and Mayo wrist score (P < 0.05), but no significant differences concerning the range of motion of the wrist.ConclusionIn the treatment of the nonunion of type II ulnar styloid fractures, the resection of the avulsed fragments followed by the reinsertion of the TFCC and the ulnar collateral ligament with an anchor was a reliable alternative technique, bringing the satisfactory function of the wrist.

Takotsubo cardiomyopathy following blunt trauma: Early recognition and diagnosis

Takotsubo Cardiomyopathy (TTC) is characterized by reversible left ventricular apical ballooning in the absence of angiographically significant coronary artery disease. While TTC is usually preceded by an emotionally stressful event, physical trauma has been documented as a precipitating incident as well.An 82-year-old female with no past medical history, presented to the emergency department following a motor vehicle collision. Trauma workup was significant for an ulnar fracture, elevated cardiac enzymes, and ST-segment changes. Bedside echocardiogram revealed apical ballooning. She underwent cardiac catheterization, which failed to demonstrate significant coronary artery disease. The patient developed cardiogenic shock and required temporary vasopressor support after failing a trial of intra-aortic balloon pump.Takotsubo Cardiomyopathy is a rare complication of trauma, which presents with signs and symptoms similar to acute coronary syndrome (ACS) but without evidence of obstructive coronary artery disease. Following trauma, signs of ACS in elderly women should raise provider's suspicion for TTC and prompting bedside echocardiography, which can assist with early diagnosis.

Isolated Posterior Dislocation of the Radial Head in the Adult: An Injury not to be Missed

Introduction: Isolated radial head dislocation in the adult is a rare and frequently missed traumatic injury. It is most commonly seen in children as a radial head subluxation. It should be diagnosed and treated without delay to avoid long-term sequelae to the joint. Case Presentation: A 22-year-old male presented to the Emergency Department complaining of persistent pain in his right elbow after a fall one week before. He had been diagnosed with an elbow sprain and arrived to our hospital using an above-elbow cast placed. The radiological evaluation revealed a posterior dislocation of the radial head without associated fractures. The patient was submitted to closed reduction followed by a cast immobilization. The follow-up weeks later showed a full and painless elbow range of motion. Discussion: Isolated posterior dislocation of the radial head in the adult is an infrequent injury, with only a few cases described in the literature. Therefore, a delay in diagnosis of a traumatic radial head dislocation in the absence of a concurrent ulnar fracture may occur. The case presented illustrates how easily the injury can be missed in the first medical evaluation. It also shows how a timely closed reduction can reestablish the joint’s full range of motion. Delay in treatment usually requires open reduction and may result in a poor functional outcome. Conclusion: A high index of suspicion is essential for the diagnosis of isolated posterior dislocation of the radial head. This clinical case demonstrated that early diagnosis and prompt treatment can successfully repair the injury and prevent functional disability of the elbow joint.

Comparison of the efficacy of three types of Kirschner wire tension bands for ulnar olecranal fracture

To compare the clinical effect of three types of Kirschner wire tension band for olecranon fracture. The clinical data of 64 patients with olecranon fracture treated by Kirschner wire tension band fixation from March 2016 to May 2020 were retrospectively analyzed. Among them, 19 patients were treated with intramedullary K-wires fixation(group A) including 8 males and 11 females with an average of (48.2±18.3) years old, 3 patients were typeⅠ, and 16 patients were typeⅡ according to Mayo classification;20 patients were treated with transcortical K-wires fixation (group B) including 13 males and 7 females with an average of (43.5±20.4) years old, 3 patients were typeⅠand 17 patients were typeⅡ according to Mayo classification;25 patients were treated with perforated Kirschner wire(group C) including 15 males and 10 females with an average of (55.2±17.5) years old, 4 patients were typeⅠand 21 patients were typeⅡ according to Mayo classification. The operative time, intraoperative blood loss, times of Intraoperative fluoroscopy, fracture healing time and complications of 3 groups were compared. At the final follow-up, elbow function was assessed using the Mayo Elbow Function Scale. There were differences in operative time, intraoperative fluoroscopy times, postoperative VAS and soft tissue irritation among the three groups(P<0.05). The operative time, intraoperative fluoroscopy times in group A and C was better than that in group B. The postoperative VAS score, skin irritability in group C was better than that of group B. The difference was statistically significant on Mayo elbow function score at the final follow-up among three groups(P<0.05), the scores of group A and C were higher than that of group B. Compared with transcortical K-wires screw fixation, both intramedullary K-wires screw fixation and perforated Kirschner wire fixation, which can significantly reduce the occurrence of soft tissue irritation, reduce surgical complications and shorten the operation time.

Trends in Orthopedic Management of Distal Radius Fractures Among Medicare Beneficiaries From 2019 to 2020: A Claims Analysis

Radius and ulna fractures are among the most common fractures. These fractures are managed through operative or nonsurgical treatment, with varying implications in terms of cost and functional outcome. There are few studies that robustly characterize the management of distal radius fractures (DRFs) in the United States during the COVID-19 pandemic. Furthermore, this has not been studied among the Medicare patient population, who are particularly vulnerable to fragility fractures and COVID-19. The purpose of this study is to analyze the services provided to Medicare beneficiaries both before and during the COVID-19 pandemic to determine how procedure volume was affected in this patient population. We retrospectively analyzed services using the physician or supplier procedure summary data from the Centers for Medicare and Medicaid Services. All services provided by physicians between January 1, 2019, and December 31, 2020, were included. The data were stratified by US census region using insurance carrier number and pricing locality codes. We also compared data between states that maintained governors affiliated with the Democratic or Republican parties for the duration of the study. There was an overall decrease in claims regarding DRFs management from 2019 to 2020. There was a dramatic decline in procedure volume (-6.3% vs-12.9%). Of all distal radius related claims there was a relative increase in the proportion of operatively managed DRFs in 2020, from 50.2% to 52.0%. The Midwest saw the greatest decline in operatively managed DRFs, whereas the West experienced the smallest per-capita decline across all procedures. After separating the data by party affiliation, it was also found that operative and nonsurgical procedure volumes fell more sharply in states with Democratic governors. This study shows a decrease in DRF procedural volume among Medicare beneficiaries. This data suggests that the operative and nonsurgical management of DRFs may have been affected by pandemic factors such as quarantine guidelines and supply chain or resource limitations. This may assist surgeons and health care systems in predicting how similar crises may affect operative volume. Therapeutic IV.

"Mother and baby plate": a strategy to improve stability in proximal fractures of the ulna.

Proximal ulna fractures with a large zone of comminution, such as in the context of Monteggia injuries, require mechanically strong osteosyntheses as they occur in regions with high physiological joint load. Consequently, implant failure and pseudarthrosis are critical and devastating complications, especially with the background of mainly young patients being affected. An effective solution could be provided by adding a small second plate 90° angulated to the standard dorsal plate in the area of non-union. Thus, this study investigates whether, from a biomechanical point of view, the use of such a mini or baby plate is worthwhile. Comminuted fractures distal to the coronoid process, equivalent to Jupiter type IIb fractures, are generated on artificial Sawbones® of the ulna and stabilized using two different plate osteosyntheses: in the first group, a dorsal locking compression olecranon plate is used (LCP group). In the second group, a small, ulnar 5-hole olecranon plate is added as a baby plate in addition to the mother plate at the level of the fracture zone (MBP group). Dynamic biomechanical loading in degrees of flexion from 0° to 90° is carried out to determine yield load, stiffness, displacement, and changes in fracture gap width as well as bending of the dorsal plate. The "mother-baby-plate" osteosynthesis had a significantly higher yield load (p < 0.01) and stiffness (p = 0.01) than the LCP group. This correlates with the increased movement of the proximal fracture element during cyclic testing for the LCP group compared to the MBP group as measured by an optical metrology system. Here, we show evidence that the addition of a small plate to the standard plate is highly effective in increasing the biomechanical stability in severe fractures equivalent to Jupiter type IIb. As it hopefully minimizes complications like pseudarthrosis and implant failure and as the additional preparatory effort leading to compromised blood supply is regarded to be negligible, this justifies and highly advises the use of a mother-baby-plate system.

Isolated intraarticular fracture of distal ulna: Case report of a rare injury

Isolated intraarticular fracture of distal ulna: Case report of a rare injury