This study describes the introduction of a virtual pathway for the management of suspected scaphoid fractures and reports patient-reported outcome measures (PROMs) and satisfaction following treatment with this service.

All adult patients that presented with a clinically suspected scaphoid fracture that was not visible on presentation radiographs over a one-year period were eligible for inclusion in the pathway. Demographics, examination findings, clinical scaphoid score (CSS) and standard four view radiographs were collected at presentation. All radiographs were reviewed virtually by a single consultant hand surgeon, with patient-initiated follow-up on request. PROMs were assessed at a minimum of one year post presentation and included the QuickDASH, EQ-5D-5L, the Net Promoter Score (NPS) and return to work.

There were 221 patients referred to the virtual pathway. The mean age was 41 (range 16–87; SD 18.4 years) and there were 99 men (45%). There were 189 (86%) patients discharged with advice and 19 (9%) patients were recalled for clinical review (seven undisplaced scaphoid fractures, six other acute fractures of the hand or wrist, two scapholunate ligament injuries, and four cases where no abnormality was detected). Thirteen patients (6%) initiated follow-up with the hand service; no fracture or ligament injury was identified within this group. PROMs were available for 179 (81%) patients at a mean of 19 months follow-up (range: 13 – 33 months). The median QuickDASH score was 2.3 (IQR, 0–15.9), the median EQ-5D-5L was 0.85 (IQR, 0.73–1.00), the NPS was 76, and 173 (97%) patients were satisfied with their treatment. There were no documented cases of symptomatic non-union one year following injury.

This study reports the introduction of a virtual pathway for suspected scaphoid fractures, demonstrating high levels of patient satisfaction, excellent PROMs, and no detrimental effects in the vast majority of cases.

Aims

The aim of this study was to describe the introduction of a virtual pathway for the management of patients with a suspected fracture of the scaphoid, and to report patient-reported outcome measures (PROMs) and satisfaction following treatment using this service.

Aims

This study evaluated variation in the surgical treatment of stable (A1) and unstable (A2) trochanteric hip fractures among an international group of orthopaedic surgeons, and determined the influence of patient, fracture, and surgeon characteristics on choice of implant (intramedullary nailing (IMN) versus sliding hip screw (SHS)).

Aims

The increase in prescription opioid misuse and dependence is now a public health crisis in the UK. It is recognized as a whole-person problem that involves both the medical and the psychosocial needs of patients. Analyzing aspects of pathophysiology, emotional health, and social wellbeing associated with persistent opioid use after injury may inform safe and effective alleviation of pain while minimizing risk of misuse or dependence. Our objectives were to investigate patient factors associated with opioid use two to four weeks and six to nine months after an upper limb fracture.

Evidence suggests that the alleviation of pain is enhancedby a strong patient-clinician relationship and attending to a patient’s social and mental health. There is a limited role for medication, opioids in particular.

Orthopaedic surgeons can use comprehensive biopsychosocial strategies to help people recover and can work with colleagues who have the appropriate expertise in order to maximize pain alleviation with optimal opioid stewardship.

Preparing patients for elective surgery and caring for them after unplanned injury or surgery can benefit from planned and practiced strategies based in communication science.

Cite this article: Bone Joint J 2020;102-B(9):1122–1127.

Aims

Patient engagement in adaptive health behaviours and interactions with their healthcare ecosystem can be measured using self-reported instruments, such as the Patient Activation Measure (PAM-13) and the Effective Consumer Scale (ECS-17). Few studies have investigated the influence of patient engagement on limitations (patient-reported outcome measures (PROMs)) and patient-reported experience measures (PREMs). First, we assessed whether patient engagement (PAM-13, ECS-17) within two to four weeks of an upper limb fracture was associated with limitations (the Quick Disabilities of the Arm, Shoulder and Hand questionnaire (QuickDASH), and Patient-Reported Outcome Measurement Information System Upper Extremity Physical Function computer adaptive test (PROMIS UE PF) scores) measured six to nine months after fracture, accounting for demographic, clinical, and psychosocial factors. Secondly, we assessed the association between patient engagement and experience (numerical rating scale for satisfaction with care (NRS-C) and satisfaction with services (NRS-S) six to nine months after fracture.

Aims

The purpose of this study was to identify factors associated with limitations in function, measured by patient-reported outcome measures (PROMs), six to nine months after a proximal humeral fracture, from a range of demographic, injury, psychological, and social variables measured within a week and two to four weeks after injury.

The aim of this study was to identify psychosocial factors associated with pain intensity and disability following distal radius fracture (DRF).

We prospectively followed up 216 adult patients with DRF for 9 months. Demographics, injury and treatment details and psychological measures (Hospital Anxiety and Depression Score (HADS), Pain Catastrophising Scale (PCS), Post Traumatic Stress Disorder Checklist – Civilian (PCL-C), Tampa Scale for Kinesiophobia (TSK), Illness Perception Questionnaire Brief (IPQB), General Self-efficacy Scale (GSES) and Recovery Locus of Control (RLOC)) were collected at enrolment. Multivariable linear regression was used to identify factors associated with DASH and Likert pain score.

Ten week DASH was associated with age (β-coefficient (β)= 0.3, p < 0.001), deprivation score (β=0.2, p = 0.014), nerve injury (β=0.1, p = 0.014), HADS depression (β=0.2, p = 0.008), IPQB (β=0.2, p = 0.001) and RLOC (β= −0.1, p = 0.031). Nine month DASH was associated with age (β=0.1, p = 0.04), deprivation score (β=0.4, p = 0.014), number of medical comorbidities (β=0.1, p = 0.034), radial shortening (β=0.1, p = 0.035), HADS depression (β=0.2, p = 0.015) and RLOC (β= −0.1, p = 0.027). Ten week pain score was associated with deprivation score (β=0.1, p = 0.049) and IPQB (β=0.3, p < 0.001). Pain score at 9 months was associated with number of medical comorbidities (β=0.1, p = 0.047).

Psychosocial factors are more strongly associated with pain and disability than injury or treatment characteristics after DRF. Identifying and treating these factors could enhance recovery.

Aims

Outcome measures quantifying aspects of health in a precise, efficient, and user-friendly manner are in demand. Computer adaptive tests (CATs) may overcome the limitations of established fixed scales and be more adept at measuring outcomes in trauma. The primary objective of this review was to gain a comprehensive understanding of the psychometric properties of CATs compared with fixed-length scales in the assessment of outcome in patients who have suffered trauma of the upper limb. Study designs, outcome measures and methodological quality are defined, along with trends in investigation.

The United States and Canada are in the midst of an epidemic of the use, misuse and overdose of opioids, and deaths related to overdose. This is the direct result of overstatement of the benefits and understatement of the risks of using opioids by advocates and pharmaceutical companies. Massive amounts of prescription opioids entered the community and were often diverted and misused. Most other parts of the world achieve comparable pain relief using fewer opioids.

The misconceptions about opioids that created this epidemic are finding their way around the world. There is particular evidence of the increased prescription of strong opioids in Europe.

Opioids are addictive and dangerous. Evidence is mounting that the best pain relief is obtained through resilience. Opioids are often prescribed when treatments to increase resilience would be more effective.

Cite this article: Bone Joint J 2017;99-B:856–64.

Background

There is growing clinical and policy emphasis on minimizing transfusion use in elective joint arthroplasty, but little is known about the degree to which transfusion rates vary across US hospitals. This study aimed to assess hospital-level variation in use of allogeneic blood transfusion in patients undergoing elective joint arthroplasty, and to characterize the extent to which variability is attributable to differences in patient and hospital characteristics.

Background

Inpatient dislocation after total hip arthroplasty (THA) is considered a non-reimbursable “never event” by the Centers for Medicare and Medicaid Services. There is extensive evidence that technical procedural factors affect dislocation risk, but less is known about the influence of non-technical factors. We evaluated inpatient dislocation trends following elective primary THA, and identified patient and hospital characteristics associated with the occurrence of dislocation.

Summary

In contrast to the current literature, myofibroblasts are not present in chronic posttraumatic elbow contractures.

However, myofibroblasts are present in the acute phase after an elbow fracture and/or dislocation. This suggests a physiological role in normal capsule healing and a potential role in the early phase of posttraumatic contracture formation.

Summary

Biomechanical studies comparing fixation constructs are predictable and do not relate to the significant clinical problems. We believe there is a need for more careful use of resources in the lab and better collaboration with surgeons to enhance clinical relevance.

Most fractures of the radial head are stable undisplaced or minimally displaced partial fractures without an associated fracture of the elbow or forearm or ligament injury, where stiffness following non-operative management is the primary concern. Displaced unstable fractures of the radial head are usually associated with other fractures or ligament injuries, and restoration of radiocapitellar contact by reconstruction or prosthetic replacement of the fractured head is necessary to prevent subluxation or dislocation of the elbow and forearm. In fractures with three or fewer fragments (two articular fragments and the neck) and little or no metaphyseal comminution, open reduction and internal fixation may give good results. However, fragmented unstable fractures of the radial head are prone to early failure of fixation and nonunion when fixed. Excision of the radial head is associated with good long-term results, but in patients with instability of the elbow or forearm, prosthetic replacement is preferred.

This review considers the characteristics of stable and unstable fractures of the radial head, as well as discussing the debatable aspects of management, in light of the current best evidence.

Cite this article: Bone Joint J 2013;95-B:151–9.

A prospective study was performed to develop a clinical prediction rule that incorporated demographic and clinical factors predictive of a fracture of the scaphoid. Of 260 consecutive patients with a clinically suspected or radiologically confirmed scaphoid fracture, 223 returned for evaluation two weeks after injury and formed the basis of our analysis. Patients were evaluated within 72 hours of injury and at approximately two and six weeks after injury using clinical assessment and standard radiographs. Demographic data and the results of seven specific tests in the clinical examination were recorded.

There were 116 (52%) men and their mean age was 33 years (13 to 95; sd 17.9). In 62 patients (28%) a scaphoid fracture was confirmed. A logistic regression model identified male gender (p = 0.002), sports injury (p = 0.004), anatomical snuff box pain on ulnar deviation of the wrist within 72 hours of injury (p < 0.001), and scaphoid tubercle tenderness at two weeks (p < 0.001) as independent predictors of fracture. All patients with no pain at the anatomical snuff box on ulnar deviation of the wrist within 72 hours of injury did not have a fracture (n = 72, 32%). With four independently significant factors positive, the risk of fracture was 91%.

Our study has demonstrated that clinical prediction rules have a considerable influence on the probability of a suspected scaphoid fracture. This will help improve the use of supplementary investigations where the diagnosis remains in doubt.

Objectives

To investigate the differences of open reduction and internal fixation (ORIF) of complex AO Type C distal radius fractures between two different models of a single implant type.

Using inaccurate quotations can propagate misleading information, which might affect the management of patients. The aim of this study was to determine the predictors of quotation inaccuracy in the peer-reviewed orthopaedic literature related to the scaphoid. We randomly selected 100 papers from ten orthopaedic journals. All references were retrieved in full text when available or otherwise excluded. Two observers independently rated all quotations from the selected papers by comparing the claims made by the authors with the data and expressed opinions of the reference source. A statistical analysis determined which article-related factors were predictors of quotation inaccuracy. The mean total inaccuracy rate of the 3840 verified quotes was 7.6%. There was no correlation between the rate of inaccuracy and the impact factor of the journal. Multivariable analysis identified the journal and the type of study (clinical, biomechanical, methodological, case report or review) as important predictors of the total quotation inaccuracy rate.

We concluded that inaccurate quotations in the peer-reviewed orthopaedic literature related to the scaphoid were common and slightly more so for certain journals and certain study types. Authors, reviewers and editorial staff play an important role in reducing this inaccuracy.

A suspected fracture of the scaphoid remains difficult to manage despite advances in knowledge and imaging methods. Immobilisation and restriction of activities in a young and active patient must be balanced against the risks of nonunion associated with an undiagnosed and undertreated fracture of the scaphoid.

The assessment of diagnostic tests for a suspected fracture of the scaphoid must take into account two important factors. First, the prevalence of true fractures among suspected fractures is low, which greatly reduces the probability that a positive test will correspond with a true fracture, as false positives are nearly as common as true positives. This situation is accounted for by Bayesian statistics. Secondly, there is no agreed reference standard for a true fracture, which necessitates the need for an alternative method of calculating diagnostic performance characteristics, based upon a statistical method which identifies clinical factors tending to associate (latent classes) in patients with a high probability of fracture.

The most successful diagnostic test to date is MRI, but in low-prevalence situations the positive predictive value of MRI is only 88%, and new data have documented the potential for false positive scans. The best strategy for improving the diagnosis of true fractures among suspected fractures of the scaphoid may well be to develop a clinical prediction rule incorporating a set of demographic and clinical factors which together increase the pre-test probability of a fracture of the scaphoid, in addition to developing increasingly sophisticated radiological tests.

Background: A recent study found that after median term follow-up disability correlated with pain rather than the limited residual impairments in motion and strength. We studied impairment and disability an average of twenty-one years after injury in a cohort of Dutch patient, with the hypothesis that both impairment and disability would be lower in patients that were skeletally immature at the time of injury.

Methods: Seventy-one patients were evaluated an average of 21 years after injury. The majority of the 35 skeletally immature patients were treated conservatively with closed reduction and cast immobilization and the majority of the 36 skeletally mature patients were treated with plate and screw fixation. Objective evaluation included radiographs and measurements of range of motion and grip strength. Questionnaires were used to measure arm-specific disability (Disabilities of the Arm, Shoulder and Hand: DASH), misinterpretation or over interpretation of pain (Pain Catastrophizing Scale-PCS-), and depression (CES-D). Multivariable analysis of variance and multiple linear regression were used to compare patients that were skeletally mature and immature at the time of injury and to identify predictors of arm-specific disability (SPSS 17.0, SPSS inc., Chicago).

Results: There were 44 men and 27 women with a an average age of forty-one at time of follow-up (range, 20 to 81). Fractures were classified as AO/OTA-type A3 in 46 patients (simple), B3 in 18 (including wedge fragment) and C fractures in 7 patients (comminuted). The average DASH score was 8 points (0 to 54) and 73% reported no pain. Both rotation and wrist flexion/extension were 91% of the uninjured side; grip strength was 94%. There were small, but significant differences in rotation (151 versus 169 degrees, p=0.004) and wrist flexion/extension (123 versus 142 degrees, p=0.002), but not disability between skeletally mature and immature patients. The best predictors of DASH score were nerve damage, pain and grip strength, explaining 56% of the variation in DASH scores. Disability did not correlate with depression or misconceptions about pain.

Conclusions: Twenty-one years after initial fracture, both skeletally immature and mature patients have limited impairment (averaging over 90% motion and grip strength) and disability after non operative and operative treatment respectively. Patients that were skeletally immature at the time of injury had better motion, but comparable disability. Disability correlated with pain rather than motion, but did not correlate with psychosocial measures.

Background: Traditionally, non-displaced scaphoid fractures are considered by most as stable with predictable rates of healing with conservative treatment. There is a current trend in orthopedic practice, however, to treat non- or minimal displaced fractures with early open reduction and internal fixation. This trend is not evidence based. In this systematic review and meta-analysis, we pool data from trials comparing surgical and conservative treatment for acute scaphoid fractures, thus aiming to summarize the best available evidence.

Methods: We searched the Cochrane Bone, Joint and Muscle Trauma Group Specialised Register, CENTRAL, MEDLINE, EMBASE, CINAHL and reference list of articles, and contacted researchers in the field. We selected eight randomized controlled trials comparing surgical versus conservative interventions for acute scaphoid fractures in adults. Data were pooled using fixed-effects and randomeffects models with standard mean differences (SMD) and risk ratios for continuous and dichotomous variables respectively. Heterogeneity across studies was assessed with Forest plots and calculation of the I2 statistic.

Results: Four-hundred seventeen patients were included in eight trials (205 fractures were treated surgically and 212 conservatively). Most trials lacked scientific rigor. Four studies assessed functional outcome with validated physician- and patient-based outcome instruments. With the numbers available (200 patients), we found a significant difference according to our primary outcome measure, standardized patient-based outcome in favor of surgical treatment (p< 0.0001). With regard to our secondary parameters, we found heterogeneous results that favored surgical treatment for grip strength, time to union and time off work. In contrast we found no significant differences between surgical and conservative treatment for pain, range of motion, rate of nonunion, malunion, and infection, rate of complications, and total treatment costs.

Conclusions: Patient-rated functional outcome and satisfaction as well as time to return to function favored surgical treatment for acute scaphoid fractures. However, there is no evidence from prospective randomized controlled trials on physician-rated functional outcome, radiographic outcome, complication rates and treatment costs to favor surgical or conservative treatment for acute scaphoid fractures.

Background: Extra-articular fractures of the distal radius in children are most often treated with closed reduction and cast immobilization. The purpose of this retrospective study was to evaluate long term (> 12 years follow-up) objective and subjective outcomes in a consecutive series of pediatric patients treated with closed reduction with standardized outcome instruments. We hypothesized that children treated with closed reduction and cast immobilization have little or no objective functional impairment in later life and therefore subjective factors are the strongest determinants of outcome.

Methods: Twenty-seven patients with an average age at time of injury of 9 years (range, five to sixteen years) were evaluated at an average of twenty-one years (range, twelve to twenty seven years) after injury (patients aged 21 to 39) after closed reduction of an extra-articular distal radius fracture. Patients were evaluated using 2 physician-based evaluation instruments (modified Mayo wrist score; MMWS, and the Sarmiento modification of the Gartland and Werley score; MGWS) and an upper extremity-specific health status questionnaire (Disabilities of the Arm, Shoulder and Hand; DASH) questionnaire. Radiographic measurements were also made. Multivariable analysis of variance and multiple linear regression modelling were used to identify the degree to which various factors affect variability in the scores derived with these measures.

Results: All fractures had healed without significant loss of alignment. Final functional results according to the MGWS were rated as excellent or good in all patients. The average MMWS score was 90 points, and the median DASH score was 0 points. Twenty patients (74%) considered themselves pain free. Bivariate analysis revealed pain -as rated according to scales used in the MMWS- and age at time of injury to be correlated with DASH scores, with pain as the only independent predictor of patient-based outcome in multivariable analysis. This explains almost three quarters of the variability in DASH scores. Pain, range of motion, and radiographic measurement of radial length correlated with the physician based scoring system MMWS;

Conclusions: Twenty-one years after injury 96% of patients have a satisfactory outcome according to physician-based MMWS categorical ratings and patient-based DASH scores. It is remarkable that pain explained 74% of the variation in DASH scores. Perhaps when there is very little impairment, subjective factors are more important determinants of disability.

Background: This study tested the null hypothesis that computed tomography (CT) and magnetic resonance imaging (MRI) have the same diagnostic performance characteristics for triage of suspected scaphoid fractures.

Methods: Thirty-four consecutive patients with a suspected scaphoid fracture (post-injury tenderness of the scaphoid and normal radiographs) underwent CT and MRI within ten days after trauma. CT-reconstructions were made in planes defined by the long axis of the scaphoid. The reference standard for a true fracture of the scaphoid was 6-week follow-up radiographs in four views, based on current literature. A panel including surgeons and radiologists came to a consensus diagnosis for each type of imaging considered in a randomized and blinded fashion, independent of the other types of imaging. We calculated sensitivity, specificity and accuracy as well as positive (PPV) and negative predictive values (NPV) for both imaging modalities.

Results: According to the reference standard there were six true fractures of the scaphoid (prevalence 18%). CT diagnosed fracture of the scaphoid in five patients (15%), with one false positive, two false negative and four true positive results. MRI diagnosed a fracture in seven patients (21%), with three false positive, two false negative and four true positive results. Sensitivity, specificity and accuracy for CT were 67%, 96% and 91%; and for MRI 67%, 89% and 85% respectively. According to the McNemar test for paired binary data for each imaging modality these differences were not significant. The positive predictive values using Bayes’ formula were 76% for CT and 54% for MRI. Negative predictive values were 94% for CT and 93% for MRI.

Conclusions: CT and MRI had comparable diagnostic characteristics. Both were subject to both false positive and false negative interpretations. They were better to rule out a fracture than to rule one in. The best reference standard for a true fracture is debatable

Background: It is well established that unstable fractures of the distal part of the radius may require operative treatment to restore alignment and that failure to restore alignment often leads to wrist and forearm dysfunction. There is ongoing debate in the literature whether or not there is a strict relationship between the quality of anatomical reconstruction and functional outcome. We hypothesize that there is no difference in objective- and subjective functional outcome between patients with AO type B versus more complex AO type C fractures.

Methods: Ninety-four patients with an average age of 42 years (range, 20 to 78 years) at the time of injury were evaluated an average of 20 years (range, 8 to 32 years) after treatment of an intra-articular distal radius fracture. At long-term follow-up patients were evaluated using a physician-based evaluation instruments (modified Mayo wrist score; MMWS and an upper extremity-specific health status questionnaire (Disabilities of the Arm, Shoulder and Hand; DASH) questionnaire. Objective and subjective functional outcome of patients with AO Type B and AO Type C fractures were compared.

Results: An average of 20 years after injury (average age 62 years, range 35 to 90), all fractures healed without significant loss of alignment. There was no difference in physician based outcome measure according to the Mayo score between 17 patients with 18 AO type B fractures (average, 80,3 points; range 45 to 100) and 27 patients with 31 AO type C fractures (average, 75.9 points; range 10 to 95, p=0.42). Differences in subjective DASH scores were not statistically significant either (p = 0.47); average 13 points for Type B patients (range, 0 to 58 points) and an average of 16 points for Type C patients (range, 0 to 71 points).

Groups were statistically comparable. No statistical differences were found in flexion extension arc (average 103 degrees, range 10 to 145 degrees), pronation supination arc (average 150 degrees, range 0 to 180 degrees) or radial ulnar deviation (average 52 degrees, range 0 to 85 degrees), as well as grip strength and osteoarthritis (all p> 0.05)

Conclusions: Twenty years after injury 67% of patients have a satisfactory outcome according to physician-based MMWS categorical ratings. There is no difference in functional long term outcome between patient with more extensive intra-articular comminution (type C fractures) and AO type B fractures. This is consistent with previous long term outcome studies with similar methodology; when more complex injuries are not correlated with decreased long term functional outcome, other (subjective) factors are more important determinants of disability.

In the past, the treatment of acute elbow fracture-dislocations has emphasized repair to the medial collateral ligament (MCL), with favorable results. We report improved results using a strategy based on lateral-sided repair (lateral collateral ligament, radial head, coronoid) without MCL repair. In forty-seven patients, this strategy resulted in a high degree of success with no residual instability (valgus or otherwise). The dynamic stabilizers of the elbow activated through early postoperative motion, are important adjunct to stability. We have devised a reproducible radiographic method to demonstrate this.

To review the surgical treatment of elbow dislocations without surgical MCL repair, and to determine if early active motion aids in restoring stability and concentric joint reduction.

In the setting of acute fracture-dislocation of the elbow, concentric elbow stability with excellent functional results can be achieved using laterally-based surgical strategy without MCL repair. The dynamic stabilizers of the elbow, activated through the early motion, assist in providing joint congruity and stability.

Forty-seven patients with acute elbow fracture-dislocations requiring operative treatment were treated at two university-affiliated teaching hospitals and evaluated an average of twenty-one months after injury. The protocol consisted of repair of the ulna and coronoid, repair or replacement of the radial head, and repair of the LCL, and early motion. The MCL was not routinely repaired. The LCL origin had been avulsed and reattached in all patients. One patient had a second procedure related to malpositioned radial head prosthesis. A stable mobile (average one hundred and one degree arc) articulation was restored in all patients. There was no evidence of valgus instability in any patient. Early motion was initiated at a mean of two weeks postoperatively. Postoperative ulnohumeral joint space opening improved from 4.9 ± 1.2 mm in the early postoperative period to 2.0 ± 0.5 mm (p < 0.00003) at final follow-up. We believe this is due to the effect of the dynamic stabilizers, which were allowed to function through early motion.

Introduction: The aim of this retrospective study is to identify factors that might influence the final result in the treatment of volarly displaced distal radius fractures

Material : 31 patients with an average age of 39 years and a volarly displaced distal radius fracture were treated by ORIF. According to the Comprehensive classification of fractures thee were 3 B3.1, 7 B3.2, and 21 B3.3. All the fractures approached volarly and fixed with a T plate. 3 patients required bone graft. All patients were evaluated with postop radiographs and results were assessed according to the system described by Gartland and Werley.

Results: The average follow up was 50 months. There were twenty excellent, six good and five poor results. Although all fractures healed, six patients had evidence of osteoarthrosis, and there were four early and six late complications, which adversely influenced the final result. Reversal of the volar tilt and evidence of osteoarthrosis found to have a significant association with a fair or poor outcome.

Conclusion: Treatment of such injuries require careful preoperative evaluation and identification of fracture morphology, otherwise the postoperative rate of complications can be quite high, a factor that may negatively influence the final result.

Purpose: Post-traumatic instability of the elbow is defined as a subluxation of the humeroulnar joint at least three weeks after trauma. Treatment is based on restitution of the three elements essential for stability: the coronoid process, the height of the head of the radius, repair of the lateral ligaments. The purpose of this study was to analyse treatment modalities for these unstable elbows and assess mid-term results.

Material and methods: This consecutive series included all patients who underwent surgery between 1992 and 2000. There were 22 patients (twelve men and ten women, mean age, 46 years, age range 26–74 years). The left elbow was involved in 16 cases (two dominant) and the right elbow in six cases (six dominant). The initial trauma was isolated dislocation in six patients, dislocation with fracture of the coronoid process and the head of the radius in nine, trans-olecranon fracture-dislocation in seven. Mean time from trauma to revision for instability was four months. A dynamic external fixator was used for stabilisation in all cases, with or without restoration of the height of the radius with a radial head prosthesis (n=12), and reconstruction of the coronoid process (n=7). Reinsertion of the lateral ligaments was necessary in 17 patients.

Results: Mean follow-up was 33 months. Six patients required a second procedure for transposition of the ulnar nerve in three and arthrolysis of the elbow joint in three. There was one failure requiring total elbow arthroplasty less than one year after revision. At last follow-up, outcome according to the Mayo Clinic classification was excellent in ten patients, good in five, fair in one, and poor in five (four trans-olecranon fracture-dislocations). Twenty patients had a stable elbow. Mean flexion-extension was 113° with a 19° mean extension deficit. At last follow-up, six patients had radiographic signs of osteoarthritis.

Discussion and conclusion: The results were directly correlated with the nature of the initial trauma and the quality of the restoration of he stabilising elements. The poorest results were observed after trans-olecranon fracture-dislocation, which led to osteoarthritic degradation in three out of four cases. In our experience, treatment of sequelae of elbow dislocation, or the terrible triade, can give satisfactory results with an appropriate treatment strategy.

Introduction: The aim of the study was to assess the efficacy of the distal radius π-plate in the surgical treatment of acute, dorsally displaced, unstable distal radius fractures.

Material: 37 patients with an average age of 41 yrs included in the study. Upon dorsal exposure of the fracture and provisional reduction with the aid of a distractor and K-wires, a bending template was used to verify plate length and contour. The plate was then applied and the type, number and location of screws and buttress pins to be used were determined. Eight patients had supplementary fixation. Autologus bone graft was used to fill defects in 28 patients.

Results: The average follow up was 21 months. Radiographic evidence of union was documented at an average of 6 weeks postop. No loss of reduction occurred in any of the patients and no patient complained of residual deformity. The average ROM was 79% of the contralateral side, the average grip strength was 64% of the contralateral wrist and the average pinch strength was 76% of the contralateral hand. No infections, nonunions, wound problems or plate failures occurred. 5 patients developed irritation and 4 had their plates removed.

Concussion: The results of this study verify the safety and the efficacy of the π-plate for the treatment of complex fractures of the distal radius. Furthermore considering the technical advantages of the π,-plate it seems that complex distal radius fractures can effectively be addressed through a dorsal approach and stable internal fixation.

Objective: Deformity post distal radius fracture can be associated with alterations in carpal kinematics. This study presents a review to detect the prevalence and clinical implications of such deformities and the variables that influence the outcome following osteotomy.

Material & Methods: 29 patients with distal radius mal-union, and an average age of 43 yrs, were treated by a single surgeon with a corrective osteotomy. Along with pain scales, wrist motion, and grip strength, pre and post osteotomy radiographs were evaluated. Preoperatively, 18 patients had dorsal deformity, 9 volar and 2 shortening and malrotation alone. 20 patients had carpal malalignment and 9 normal carpal alignment.

Results: The average follow up was 21 months. 24 out of 29 radial deformities were corrected to normal. Overall 17 patients had post-op normal carpal alignment. Three groups resulted; Group I: 11 patients with pre and post-op “fixed” deformities. Group II: 8 patients with normal pre and post-op carpal alignment; and Group III: 9 patients with “lax” pre-op malalignment converted to normal post-op. 1 patient was normal pre-op and converted to DISI at post-op. There was no statistically difference in outcome with regard to pain, forearm rotation, wrist extension, patient age or time to surgery between the three groups. There was statistically significant greater wrist flexion in Group II and III compared to Group I.

Conclusions: Carpal malalignement post radius osteotomy will have a negative effect on the functional outcome compared to those patients with preoperative carpal deformity, which corrects with radius osteotomy. Knowledge of this association will help advice patients of expected outcomes.

We treated 15 patients with atrophic nonunion of a diaphyseal fracture of the humerus with an associated bony defect using an autogenous cancellous bone graft and a plate to bridge the defect. There were nine men and six women with a mean age of 48 years. The mean length of the bony defect was 3 cm.

At a mean follow-up of 30 months only one fracture failed to unite. This suggests that, in the presence of a well-vascularised envelope of muscle, the application of an autogenous cancellous bone graft in conjunction with a bridging plate represents a good alternative to more demanding surgical techniques.

We have treated 42 consecutive complex ununited fractures of the femoral shaft by wave-plate osteosynthesis at five different medical centres. There were 13 with previous infection, 12 with segmental cortical defects, and 3 were pathological fractures. In 39 cases there had been previous internal fixation and 21 patients had had more than one earlier operation.

Union was achieved in 41 patients at an average of six months, although three had required a second bone graft. Two patients had recurrence of infection and in one this resulted in the persistence of nonunion. There were no failures of the implant. All 41 patients with union are now fully weight-bearing, but four have a leg-length discrepancy, one has axial malalignment, and nine have residual stiffness of the knee. These results are surprisingly good, despite the complexity of the initial problem, and appear to confirm the biological and mechanical advantages of the wave plate over the conventional plate for such cases.

We reviewed 36 consecutive patients with Monteggia fracture-dislocations of the forearm; 28 had been treated within 24 hours and 8 had been referred a week or more after the initial injury with persisting or recurrent dislocation of the proximal radio-ulnar joint after treatment elsewhere. We treated 15 of the 16 complete fractures and 3 of the 11 incomplete fractures of the ulna by operative fixation.

All the early fractures and six of the eight late referrals had good or excellent results. The two poor results were in patients with malalignment and dislocation of the radial head persisting for at least two weeks before definitive treatment.

A good outcome after a Monteggia injury in a child requires early diagnosis and prompt, stable, anatomical reduction of the ulnar fracture. In our experience, selective operative fixation of unstable fractures provides reliable reduction and causes few complications.