Fixation of complex elbow fractures, Part II. Proximal ulna and radius fractures

Complex fractures of the elbow often include significant injury to the proximal ulna and/or proximal radius. Such injuries are often combined with injury to the periarticular soft tissues. Appropriate treatment is dependent on accurate diagnosis, definitive treatment of both the skeletal and ligamentous components of injury, and initiation of rehabilitation programs the stress early motion.     

Volkmann's ischemic contracture of the upper extremity

Upper extremity deformity of ischemic contracture usually includes elbow flexion, forearm pronation, wrist flexion, thumb flexion and adduction, digital metacarpophalangeal joint extension, and interphalangeal joint flexion. Treatment of mild contractures consists of either nonoperative management with a comprehensive rehabilitation program (to increase range of motion and strenght) or operative management consisting of infarct excision or tendon lengthening. Treatment of moderate-to-severe contractures consists of release of secondary nerve compression, treatment of contractures (with tendon lengthening or recession), tendon or free-tissue transfers to restore lost function, and/or salvage procedures for the severely contracted or neglected extremity.     

Intraarticular fractures of the foot. Talus and lesser tarsals

In the absence of historical comparative data for the treatment of tarsal fractures, commonly abided maxims of trauma care are noteworthy. A displaced fracture involving an articular surface or a fracture interrupting a mechanical axis is treated by open reduction and internal fixation. Rigid fixation is followed as early as possible with active and passive mobilization. Unlike long bones, whose motion and fracture patterns (i.e., segmental, transverse, and oblique) are understood, the tarsal bones are small bones with complex shapes and restricted motion. As a result, tarsal injuries most often occur with multiple ligamentous and bony injuries. Articular step-off is difficult to establish roentgenographically, the blood supply is tenuous, and fixation is largely dependent on screws and Kirschner wires. Good outcome can be obtained by following principles of internal fixation established in treatment of major joint injuries.     

Kinematics of the lateral ligamentous constraints of the elbow joint

Thirty osteoligamentous elbow joint specimens were included in a study of the lateral collateral ligament complex (LCLC). The morphologic characteristics of the LCLC were examined, and then three-dimensional kinematic measurements were undertaken after selective ligament dissections were performed. Isolated sectioning of the annular ligament (AL) or the lateral ulnar collateral ligament (LUCL) induced only minor laxity to the elbow joint with a maximum of 2.2 degrees and 4.4 degrees during forced varus and external rotation (supination), respectively. Transsection of the lateral collateral ligament (LCL) caused a maximal laxity of 15.4 degrees and 22.8 degrees during forced varus and external rotation (supination), respectively. Combined ligament dissections showed that total transection of the LCLC at the ulnar or the humeral insertion was important for joint laxity. Total transection of the LCLC at the humeral or the ulnar insertion induced a maximal laxity of 24.5 degrees and 37 degrees during forced varus and external rotation (supination), respectively. This study suggests the AL and the LUCL are of minor importance as constraints when cut separately, whereas the LCL is a significant preventer of elbow joint laxity. The LCLC was observed to be a complex structure of ligamentous fibers rather than discreet bands. The LCLC forms a ligamentous constraint between the lateral humeral epicondyle and the ulna, stabilizing the elbow joint and forming a base for radial head stability and rotation.     

Occipital condyle fractures

OBJECTIVE: Occipital condyle fractures (OCFs) are infrequently recognized. Three recent cases of OCF in our center prompted a review of the incidence, clinical presentation, diagnosis, and treatment of this entity. METHODS: A retrospective review of medical records and radiographic results was performed for 93 of 316 consecutive patients who were victims of trauma, who presented at the Toronto Hospital during a 13-month period, and who had undergone computed tomography of the occiput. RESULTS: A review of the literature regarding OCF revealed that cranial nerve deficits occurred in 31% of the patients with OCFs; of those, the deficits were delayed in 38%. Three new cases of OCF, with neck pain but without cranial nerve deficits, have been reported. The cervical spine x-rays revealed nothing abnormal in 96% of the reported cases. In our retrospective review, asymptomatic OCF was revealed by computed tomography for 1 of the 93 patients. CONCLUSION: OCF is a diagnostic challenge. We suggest that computed tomographic scans of O-C2 be obtained in the following circumstances: presence of lower cranial nerve deficits, associated head injury or basal cranial fracture, or persistent severe neck pain despite normal radiographic results. We propose a new classification system for the management and treatment of OCF based on the stability of the O-C1-C2 joint complex reflected by the presence of displacement of the condyle, computed tomographic or radiographic evidence of O-C1-C2 instability, and magnetic resonance evidence of ligamentous injury. OCFs are divided into the following types: Type 1 (stable), undisplaced fracture; Type 2A (stable), displaced fracture with no ligamentous instability; and Type 2B (unstable), displaced fracture with ligamentous instability.     

Technique for ensuring ulnohumeral reduction during application of the Richards compass elbow hinge

The compass elbow hinge is an externally applied device that allows both active and passive range of motion after placement. It is effective for treatment of posttraumatic elbow contractures and of the arthritic elbow with posttraumatic arthritis and also in cases of acute instability despite radial head replacement or fracture fixation and ligamentous repair. The device is technically challenging to apply and requires that the assistant maintain ulnohumeral reduction during application, particularly of the ulnar pins. We describe a simple technique that ensures reduction and shortens surgical time tremendously.     

The effect of caffeine on the resorption and various central effects of ethanol]

Poor results in treating fractures and dislocations about the elbow may be avoided if the surgeon is aware of the possible injuries, examines good radiographs of both elbows, and treats the injury promptly and appropriately. A displaced fracture of the lateral or medial condyle of the humerus should be suspected if there is a flake fracture of the adjoining metaphysis; open reduction and internal fixation give better results than closed reduction. A shear fracture of the capitulum humeri can only be seen on a lateral radiograph; excision of the fragment, followed by mobilization, is sufficient for a good functional result. Dislocation of the elbow in a child may avulse the medial epicondyle, which sometimes lodges in the joint; it is essential to recognize this and remove the fragment without delay to avoid early degenerative arthritis. An apparently isolated fracture of the ulna should alert the surgeon to the possibility of a dislocation of the radial head; the dislocation and the fracture must be reduced and stabilized to conserve elbow function.     

Lateral subtalar dislocation: review of the literature and case presentation

Lateral subtalar joint dislocations are rare injuries which are usually the result of a violent eversional force, driving the talar head medially and displacing the rest of the foot laterally. Associated fractures and obstruction to closed reduction are more common with lateral than medial dislocations. Avascular necrosis of the talus and navicular as well as subtalar instability may result from these injuries. Severe post-traumatic subtalar arthritis may warrant triple arthrodesis. Prompt closed reduction of lateral subtalar dislocation is recommended to avoid soft-tissue or neurovascular compromise. A short period of immobilization limits loss of subtalar range of motion. Open reduction may be required, particularly with entrapment of the posterior tibial tendon or obstructing fracture fragments. A case of lateral subtalar joint dislocation is presented.     

Pelvic stress injuries: the relationship between osteitis pubis (symphysis pubis stress injury) and sacroiliac abnormalities in athletes

OBJECTIVE: To demonstrate with radiographic imaging the association between pubic stress injury and sacroiliac abnormalities in athletes. DESIGN AND PATIENTS: Eleven athletes (9 men and 2 women), comprising seven male long-distance runners, one male soccer player, one male and two female basketball players, were imaged with plain films for complaints of pubic symphysis pain, sciatica, groin pain, or a combination of these complaints. In addition to the plain films, four patients were imaged with CT, two patients had MR imaging, and a bone scan was performed in three patients. Anteroposterior plain films of the pelvis of 20 patients without back pain or pubic pain were evaluated for comparison as a control group (ages 18-72 years, average 49 years; 11 women and 9 men). RESULTS: All athletes showed plain film evidence of either sclerosis, erosions or offset at the pubic symphysis. Four had avulsion of cortical bone at the site of insertion of the gracilis tendon. Four patients demonstrated sacroiliac joint abnormalities on plain films consisting of sclerosis, erosions and osteophytes, and in one of these athletes, bilateral sacroiliac changes are present. Two patients with normal sacroiliac joints on plain films had a bone scan showing increased radionuclide uptake bilaterally at the sacroiliac joints. One patient with both plain film and CT evidence of sacroiliac abnormalities had an MR examination showing abnormal signal at both sacroiliac joints and at the pubic symphysis. A sacral stress fracture was found on CT in one patient with complaints of sciatica. In the control group, six patients, all over the age of 55 years, had mild sclerosis of the symphysis, but no plain film evidence of sacroiliac abnormalities. CONCLUSION: We have found a group of athletes in whom stress injuries to the pubic symphysis are associated with changes in the sacroiliac joint as demonstrated by degenerative changes or in the sacrum as manifested as a sacral stress fracture. These findings are probably due to abnormal stresses across the pelvic ring structure that lead to a second abnormality in the pelvic ring. The abnormality in the sacrum is not always well seen with conventional imaging. Recognition of the association of stress injury of the symphysis with back pain is important in that it can help avoid inappropriate studies and diagnostic confusion.     

DNA fingerprinting of the lizard Lacerta dahli: isolation of a genomic polymorphism of mini- and microsatellite loci

We performed a lateral approach for the release of post-traumatic stiffness of the elbow in 22 patients using a modified technique designed to spare the lateral ligaments. They were reviewed after a mean interval of 26 months. The total humeroulnar joint movement had increased from a mean of 74 degrees to 129 degrees and forearm rotation from a mean of 135 degrees to 159 degrees. Both pain and function in the elbow had improved significantly. This modified lateral approach allows release of post-traumatic contracture without disruption of the lateral collateral ligament or the origins of the extensor tendon at the lateral epicondyle of the humerus. The advantages include a simplified surgical procedure, less operative morbidity, and unrestricted rehabilitation.     

Angiotensin II inhibits long-term potentiation within the lateral nucleus of the amygdala through AT1 receptors

We have treated 16 patients with recurrent complex elbow instability using a hinged external fixator. All patients had instability, dislocation or subluxation of the ulnohumeral joint. The injuries were open in eight patients and were associated with 20 other fractures and five peripheral nerve injuries. Two patients had received initial treatment from us; 14 had previously had a mean of 2.1 unsuccessful surgical procedures (1 to 6). The fixator was applied at a mean of 4.8 weeks (0 to 9) after the injury and remained on the elbow for a mean of 8.5 weeks (6 to 11). After treatment we found the mean range of flexion-extension to be 105 degrees (65 to 140). At a final follow-up of 23 months (14 to 40), the mean Morrey score was 84 (49 to 96): this translated into one poor, three fair, ten good and two excellent results. Complications included one fractured humeral pin, one temporary palsy of the radial nerve, one recurrent instability, one wound infection, one severe pin-track infection and one patient with reflex sympathetic dystrophy. Although technically demanding, the use of the fixator is an important advance in the management of recurrent complex elbow instability after failure of conventional treatment.     

Posttraumatic elbow arthritis and arthroplasty

Elbow contractures without significant articular injury can be treated with soft-tissue procedures, such as joint capsular releases, resection of heterotropic ossification, and joint debridement. Elbows with significant intra-articular injuries or posttraumatic arthritis require some form of joint reconstruction, such as a distraction arthroplasty, interposition arthroplasty, or implant replacement arthroplasty. With a better understanding of the surgical indications for elbow arthroplasty, improvements in surgical technique, improvements in elbow implants, and increased surgical experience, the results of implant arthroplasty for the posttraumatic elbow continue to improve.     

Rehabilitation of tendon injuries in sport

Clinicians are faced with a growing number of athletes with injured tendons. Treatment of both acute and chronic injuries has proven to be quite complex. It is difficult to maintain the balance between resting the injured tendon and preventing atrophy of the surrounding muscles and joints. Questions also arise as to when the tendon should be strengthened and when the athlete is ready to return to full activity in sport. Through an awareness of the structural and mechanical properties of the tendon, an exercise programme for the rehabilitation of tendon injuries has been developed. It is recommended that this programme be used in combination with ice and other physical modalities. This approach will resolve most tendon injuries within 6 weeks of its implementation. The use of anti-inflammatory medications and surgery can only be recommended in select situations where more conservative measures are inadequate.     

Acute disruption of the posterior tibial tendon associated with open-fracture dislocation of the ankle

A 27-year-old man with a high-energy, open-fracture dislocation of the ankle underwent debridement and open reduction of his injuries. During surgery a disruption-laceration of the posterior tibial tendon at the level of the fracture of the medial malleolus was found. Repair required location of the proximal muscle and tendon and controlled traction of the musculotendinous unit from its retracted position. Common aspects in the nine previously reported instances of this lesion include relatively high energy of the injury and the fracture type, a transverse fracture in the medial malleolus. Unique to this case was the open injury.     

Noncontact knee dislocation in a female basketball player: a case report

Knee ligamentous injuries occur during sport, and when there is extensive injury, they can be associated with subluxation or dislocation. We present the case of a female basketball player who sustained a knee dislocation during noncontact play. An immediate angiogram confirmed vascular integrity, and surgical treatment with ligamentous reconstruction was performed. Peroneal nerve injury was present but resolved in 42 weeks. A review of the literature discussing knee dislocation is presented.     

A radiological sign of entrapment of the median nerve in the elbow joint after posterior dislocation. A report of two cases

Two boys with entrapment of the median nerve in the elbow joint after closed reduction of a posterior dislocation with fracture of the medial epicondyle showed a characteristic radiological sign in the anteroposterior radiograph after two to three months. The sign was a depression in the cortex on the ulnar side of the distal humeral metaphysis, with interruption of the local periosteal reaction. At operation in both patients the depression was found to correspond with the place where the median nerve reached the posterior surface of the humerus. Radiographs taken after transverse section of the nerve above and below the joint capsule and end-to-end suture showed gradual disappearance of the cortical depression.     

One hundred years of orthopedics in the Netherlands. X. Sports injuries

Sports injuries result from frequently repeated similar movements performed with submaximal force. In practice the term is also used, incorrectly, for many other injuries sustained during, or even outside, the practising of sports. Running may lead to injuries of muscles (rupture, chronic compartment syndrome), of tendons (peritendinitis, tendinosis, partial rupture, insertion tendinitis), of bone (stress fracture) and of cartilage (athrosis). Jumping mostly puts the ankle at risk, especially of development of an anterior or posterior impingement syndrome. Throwing puts much strain on the shoulder muscles; possible problems are microruptures in the rotator cuff, avulsion of the glenoid rim, chronic tendinitis of the biceps tendon and entrapment of the suprascapular nerve. The main element of the treatment is rest. If symptoms persist, surgery may be considered. Previous diagnostic imaging may then be of value.     

The long-term changes after the implantation of silicone breast prostheses

For a large scaled test 52 patients with anterior transposition of the ulnar nerve and 62 patients with elbow injuries were examined by questionnaire, physical examination and electroneurography. In conformity with existing literature 24 patients out of 52 suffering from cubital tunnel syndrome had an elbow trauma previously. To our great surprise in seven patients out of 46 with elbow injuries a cubital tunnel syndrome could be found for the first time. The cubital tunnel syndrome appears to be a frequent complication of elbow injuries. Besides the well known fractures of the medial epicondyle and pericondylar fractures leading to cubital tunnel syndrome, in our study fractures of the head of the radius and processus coronoideus were found quite often. Patients having typical anamnesis and complaints should be checked by electroneurography in order to permit a quick operation and to prevent incurable damages of the nerve. The diagnosis leading to operation of the elbow should however be made with greatest care. In case the operation is unavoidable, the ulnar nerve should be thoroughly checked and anterior transposition should be carried out.     

Repair of extensor tendon injuries of the hand

We have presented methods for treating extensor tendon injuries from the interphalangeal joint to the wrist and the musculotendinous junction in the forearm. Early and proper splinting in the treatment of extensor tendon injuries is more important than a specific method of surgical repair. We emphasize the need for prolonged splinting, up to eight weeks in distal injuries. Immobilizing the finger in full extension or hyperextension is necessary at the distal and proximal interphalangeal joints. Correct splinting is mandatory in any method of treatment. Reconstruction of the extensor mechanism is difficult and the results are unpredictable.     

Evaluation of tibial plateau fractures: efficacy of MR imaging compared with CT

OBJECTIVE: CT is often used after plain films to evaluate fractures of the tibial plateau. Because MR imaging can show associated soft-tissue injuries as well as fractures, we hypothesize that MR is superior to CT for imaging these injuries. Accordingly, we compared the efficacy of MR imaging and CT in 22 patients with tibial plateau fractures. SUBJECTS AND METHODS: CT with two-dimensional reconstruction and MR examinations were performed in 22 patients with tibial plateau fractures. The images were interpreted by four radiologists and two orthopedic surgeons. Findings on CT scans and plain films were used to determine the configuration of the fractures and to classify them according to the Schatzker system. This was done with findings on MR images and plain films at a separate session. The MR images were also evaluated for ligamentous and meniscal injuries. A qualitative side-by-side comparison of two-dimensional CT scans and MR images for depiction of fracture configuration was done. Imaging results were correlated with observations from physical examinations in all patients and with surgical findings in 12 patients. RESULTS: All of the six types of fractures of the Schatzker classification were observed in this series. Comparison of two-dimensional CT reconstructions and MR images for depiction of fracture configuration revealed that the two techniques were equal in 14 patients, MR imaging was superior to CT in five patients, and CT was superior to MR imaging in three patients (who had very complex and comminuted fractures). In addition, MR imaging showed 12 complete ligamentous tears and 15 partial ligamentous tears in 15 (68%) of the 22 patients. MR showed meniscal injuries in 12 (55%) of the 22 patients. CONCLUSION: MR imaging was equivalent or superior to two-dimensional CT reconstruction for depiction of fracture configuration in most patients. In addition, MR showed significant soft-tissue injuries. We believe that MR imaging is the preferable imaging technique for most patients with fractures of the tibial plateau.