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PubMed1999

The functional outcome of operative treatment of ununited fractures of the humeral diaphysis in older patients.

Twenty-two elderly patients (average age, seventy-two years) who had an atrophic, unstable, ununited fracture of the humeral diaphysis were managed with plate-and-screw fixation and application of an autogenous bone graft from the iliac crest. Fifteen of the patients had had at least one previous operation in an attempt to obtain union of the fracture. One patient had an active infection and two had a quiescent infection, all with Staphylococcus epidermidis. The average duration of nonunion before the patients were first seen by us was two years and four months (range, five months to sixteen years). Fifteen of the nonunions were synovial. In each patient, at least one modification of the standard technique of plate-and-screw fixation was needed as a result of osteopenia. In order to enhance fixation, the standard protocol incorporated the use of a long plate (with an average of eleven holes and an average length that was 76 percent of that of the bone), a plate with a blade (used in thirteen patients), and replacement of loose, 4.5-millimeter cortical-bone screws with 6.5-millimeter cancellous-bone screws (twelve patients). Spiked nuts (Schuhli nut; Synthes, Paoli, Pennsylvania) that lock the screws to the plate, creating a solid point of fixation analogous to a blade, were incorporated into the protocol when they became available (used in six patients). In five limbs, the nonunion was associated with an osseous defect that could not be addressed by shortening of the bone alone. Three of these limbs were stabilized with a bridge plate that had been contoured to stand away from the bone at the site of nonunion (so-called wave-plate osteosynthesis), and the remaining two limbs were stabilized with a combination of intramedullary and extramedullary plates. In one of these two limbs, the extramedullary plate was contoured (that is, a wave plate). The fracture united in twenty (91 percent) of the patients. There was no progressive loosening or breakage of a fixation device, even in two patients who had radiographs that were suggestive of an incomplete union. Five of the patients were followed for a limited duration (average, one year and six months) as a result of death or illness. They had two excellent results, two good results, and one poor result according to a modification of the rating system of Constant and Murley. The remaining seventeen patients, including the two who had a persistent nonunion, were followed for an average of three years and one month (range, two years to five years and ten months). They had significant improvements in all of the functional scores at the most recent follow-up evaluation: the average score according to the modified system of Constant and Murley increased from 9 to 72 points (p < 0.001), the average score according to the Enforced Social Dependency Scale decreased from 39 to 9 points (p < 0.001), and the average score based on the Disabilities of the Arm, Shoulder, and Hand Questionnaire decreased from 77 to 24 points (p < 0.001). According to the scores based on the Disabilities of the Arm, Shoulder, and Hand Questionnaire, nine of the seventeen patients who had been followed for more than two years had an excellent result, four had a good result, two had a fair result, and the two who had a persistent nonunion had a poor result. Complications included postoperative delirium, a stitch abscess, transient radial nerve palsy, a fracture distal to the plate, and the need for a blood transfusion, in one patient each. Two patients had a fibrous union. There were no major medical complications. An unstable, united fracture of the humeral diaphysis can be extremely disabling and may threaten the ability of an elderly patient to function independently. Operative treatment can be very successful when the techniques of plate-and-screw fixation are modified to address osteopenia and relative or absolute loss of bone. Healing of the fracture substantially improves function and the degree of independence

Activities of Daily Living↗
PubMed2001

Neuropathic arthropathy of the elbow. A report of five cases.

BACKGROUND: Neuropathic arthropathy of the elbow is rare and characterized by a painless but unstable articulation. The functional capacity of patients with this condition has not been reviewed in detail. METHODS: Five male patients, with an average age of fifty-one years, were treated for neuropathic arthropathy of the elbow. The underlying conditions associated with the arthropathy included syringomyelia, insulin-dependent diabetes mellitus, end-stage renal failure, and two cases of polyneuropathy of unknown cause. Four patients sought medical attention after a specific traumatic event. Peripheral sensory and motor dysfunction was present in each patient. Radiographs of the elbow revealed dislocation, fracture fragmentation, and heterotopic ossification. Our management of the neuropathic elbows centered on maintenance of a functional arc of motion through physical therapy aimed at regaining muscle strength and the use of orthoses for support. Operative treatment was performed for an associated ulnar or radial nerve compression syndrome in three patients, and an open reduction and internal fixation of an unstable proximal ulnar nonunion associated with loose implants was performed in one. RESULTS: The patients were followed for an average of nineteen months, with a range of twelve to thirty-six months. All patients had a pain-free elbow with a functional range of motion at the most recent follow-up examination, and none wished to have further treatment. The operatively treated ulnar nonunion united successfully. All three patients treated surgically for an associated nerve compression syndrome had recovery of nerve function. CONCLUSION: In the face of instability and gross distortion of the joint, the patients in this series demonstrated remarkably good function.

Adult↗
PubMed2002

Posterior dislocation of the elbow with fractures of the radial head and coronoid.

BACKGROUND: Posterior dislocation of the elbow with associated fractures of the radial head and the coronoid process of the ulna has been referred to as the "terrible triad of the elbow" because of the difficulties encountered in its management. However, there are few published reports on this injury. METHODS: Eleven patients with this pattern of injury were evaluated after a minimum of two years. The radial head fracture had been repaired in five patients, and the radial head had been resected in four. None of the coronoid fractures had been repaired, and the lateral collateral ligament had been repaired in only three patients. All eleven patients returned for clinical examination, functional evaluation, and radiographs. RESULTS: Seven elbows redislocated in a splint after manipulative reduction. Five, including all four treated with resection of the radial head, redislocated after operative treatment. At the time of final follow-up, three patients were considered to have a failure of the initial treatment. One of them had recurrent instability, which was treated with a total elbow arthroplasty after multiple unsuccessful operations; one had severe arthrosis and instability resembling neuropathic arthropathy; and one had an elbow flexion contracture and proximal radioulnar synostosis requiring reconstructive surgery. The remaining eight patients, who were evaluated at an average of seven years after injury, had an average of 92 degrees (range, 40 degrees to 130 degrees ) of ulnohumeral motion and 126 degrees (range, 40 degrees to 170 degrees ) of forearm rotation. The average Broberg and Morrey functional score was 76 points (range, 34 to 98 points), with two results rated as excellent, two rated as good, three rated as fair, and one rated as poor. Overall, the result of treatment was rated as unsatisfactory for seven of the eleven patients. All four patients with a satisfactory result had retained the radial head, and two had undergone repair of the lateral collateral ligament. Seven of the ten patients who had retained the native elbow had radiographic signs of advanced ulnohumeral arthrosis. CONCLUSIONS: Elbow fracture-dislocations that involve a fracture of the coronoid process in addition to a fracture of the radial head are very unstable and prone to numerous complications. Identification of the coronoid fracture is therefore important, and computed tomography should be used if there is uncertainty. With operative treatment, the surgeon should attempt to restore stability by providing radiocapitellar contact (preserving the radial head when possible and replacing it with a prosthesis otherwise), repairing the lateral collateral ligament, and perhaps performing internal fixation of the coronoid fracture.

Adolescent↗
PubMed2002

Treatment of unreduced elbow dislocations with hinged external fixation.

BACKGROUND: The results of operative treatment of an unreduced elbow dislocation have been regarded with pessimism. Suggested procedures have included tendon-lengthening, tendon transfer, or reconstruction of ligament or bone. METHODS: Three women and two men (average age, forty-nine years) with an unreduced dislocation of the elbow without associated fractures were treated with open relocation of the joint and hinged external fixation at an average of eleven weeks (range, six to thirty weeks) after the initial injury. The lateral soft tissues, including the origin of the lateral collateral ligament complex, were reattached to the lateral epicondyle in three patients, but no attempt was made to reconstruct the ligaments, tendons, or bone. A passive worm gear incorporated into a hinged external fixator was used to mobilize the elbow initially, and active mobilization was gradually introduced. The hinge was removed at an average of five weeks after the procedure. RESULTS: At an average of thirty-eight months (range, twelve to ninety-eight months), a stable, concentric reduction had been maintained in all five patients, with radiographic signs of mild arthrosis in four. The average arc of flexion was 123 degrees, and all patients had full forearm rotation. The average score on the Mayo Elbow Performance Index was 89 points, with two excellent and three good results. The average scores on the Disabilities of the Arm, Shoulder and Hand (DASH) and American Shoulder and Elbow Surgeons outcome instruments (13 and 92 points, respectively) reflected mild residual pain and disability. CONCLUSIONS: Treatment of unreduced elbow dislocations with open reduction and hinged external fixation as much as thirty weeks after the injury can restore a stable, mobile joint without the need for tendon-lengthening or transfer, ligament reconstruction, or deepening of the trochlear notch of the ulna.

Adult↗
PubMed2002

Open reduction and internal fixation of fractures of the radial head.

BACKGROUND: The purpose of this retrospective study was to analyze the functional results following open reduction and internal fixation of fractures of the radial head and to determine which fracture patterns are most amenable to this treatment. METHODS: Fifty-six patients in whom an intra-articular fracture of the radial head had been treated with open reduction and internal fixation were evaluated at an average of forty-eight months after injury. Thirty patients had a Mason Type-2 (partial articular) fracture, and twenty-six had a Mason Type-3 (complete articular) fracture. Twenty-seven of the fifty-six fractures were associated with a fracture-dislocation of the forearm or elbow or an injury of the medial collateral ligament. Fifteen of the thirty Type-2 fractures were comminuted. Fourteen of the twenty-six Type-3 fractures consisted of more than three fragments, and twelve consisted of two or three fragments. The result at the final evaluation was judged to be unsatisfactory when there was early failure of fixation or nonunion requiring a second operation to excise the radial head, <100 degrees of forearm rotation, or a fair or poor rating according to the system of Broberg and Morrey. RESULTS: The result was unsatisfactory for four of the fifteen patients with a comminuted Mason Type-2 fracture of the radial head; all four fractures had been associated with a fracture-dislocation of the forearm or elbow, and all four patients recovered <100 degrees of forearm rotation. Thirteen of the fourteen patients with a Mason Type-3 comminuted fracture with more than three articular fragments had an unsatisfactory result. In contrast, all fifteen patients with an isolated, noncomminuted Type-2 fracture had a satisfactory result. Of the twelve patients with a Type-3 fracture that split the radial head into two or three simple fragments, none had early failure, one had nonunion, and all had an arc of forearm rotation of > or =100 degrees. CONCLUSIONS: Although current implants and techniques for internal fixation of small articular fractures have made it possible to repair most fractures of the radial head, our data suggest that open reduction and internal fixation is best reserved for minimally comminuted fractures with three or fewer articular fragments. Associated fracture-dislocation of the elbow or forearm may also compromise the long-term result of radial head repair, especially with regard to restoration of forearm rotation.

Adolescent↗
PubMed2003

Articular fractures of the distal part of the humerus.

BACKGROUND: The purpose of this retrospective study was to identify the patterns of distal humeral articular fractures and to analyze the results of open reduction and internal fixation of these injuries. METHODS: The cases of twenty-one patients with an articular fracture of the distal part of the humerus were reviewed at an average of forty months after the injury. Five components of the injury were identified: (1) the capitellum and the lateral aspect of the trochlea, (2) the lateral epicondyle, (3) the posterior aspect of the lateral column, (4) the posterior aspect of the trochlea, and (5) the medial epicondyle. All fractures were reduced and were stabilized with implants buried beneath the articular surface. RESULTS: All fractures healed, and no patient had residual ulnohumeral instability or weakness. Ten patients required a second operation: six, for release of an elbow contracture; two, for treatment of ulnar neuropathy; one, for removal of hardware causing symptoms; and one, because of early loss of fixation. The average arc of ulnohumeral motion was 96 degrees (range, 55 degrees to 140 degrees ). The results according to the Mayo Elbow Performance Index were excellent in four patients, good in twelve, and fair in five. CONCLUSIONS: Apparent fractures of the capitellum are often more complex fractures of the articular surface of the distal part of the humerus. Treatment of these injuries with operative reduction and fixation with buried implants can result in satisfactory restoration of elbow function.

Adult↗
PubMed2003

Operative release of complete ankylosis of the elbow due to heterotopic bone in patients without severe injury of the central nervous system.

BACKGROUND: Although uncommon, complete ankylosis of the elbow secondary to heterotopic ossification results in severe disability. The results of surgical management remain unclear. METHODS: A single surgeon used a consistent operative technique to treat complete osseous ankylosis of the elbow in eleven limbs in seven patients after severe burns and in nine elbows in eight patients after trauma. The elbows in the burn cohort were more often ankylosed in extension (average, 47 degrees of flexion) compared with those in the trauma cohort (66 degrees of flexion), and they had more skin problems (three elbows required a free microvascular muscle transfer for coverage) and associated problems of the shoulder, wrist, and hand. RESULTS: Four patients in the burn cohort and three patients in the trauma cohort failed to regain at least 80 degrees of ulnohumeral motion. After a repeat release in three burn patients and three trauma patients, and at an average follow-up of forty months, the average arc of ulnohumeral motion was 81 degrees in the burn cohort and 94 degrees in the trauma cohort. Six of the eleven limbs in the burn cohort and five of the nine in the trauma cohort had a good result. The average score according to the American Shoulder and Elbow Surgeons elbow assessment form was 72 points for the burn cohort and 76 points for the trauma cohort. CONCLUSIONS: Osseous ankylosis of the elbow is a severely disabling problem, and attempts to regain mobility are both worthwhile and safe. The results are comparable when the ankylosis is caused by burns or trauma despite the greater complexity of osseous ankylosis in the burned arm. Patients and surgeons should be aware of the small risk of recurrent heterotopic ossification and the moderate risk of pain or recurrent contracture after operative release.

Adult↗
PubMed2003

Unstable nonunions of the distal part of the humerus.

BACKGROUND: Some nonunions of the distal part of the humerus are so unstable that the hand and the forelimb cannot be supported against gravity. The purpose of the present retrospective study was to analyze the results of open reduction and internal fixation, joint contracture release, and autogenous bone-grafting in the treatment of these unstable nonunions of the distal part of the humerus. METHODS: Fifteen patients (average age, sixty years) with an unstable nonunion of the distal part of the humerus were treated with excision of fibrous and synovial tissues, opening of sclerotic fracture surfaces, internal fixation with multiple plates and screws, and autogenous bone-grafting. The average time from the original fracture to the index treatment of the nonunion was eleven months. Vascularized fibular grafts and supplemental external fixation were necessary in two patients with large bone defects after débridement at the site of a previous infection. RESULTS: Three nonunions failed to heal and were treated with total elbow arthroplasty. Twelve nonunions healed, but six of the twelve required additional surgery because of painful implants, ulnar neuropathy, or elbow contracture. After an average duration of follow-up of fifty-one months (range, twenty-four to 130 months), the twelve patients in whom the nonunion healed had an average arc of ulnohumeral motion of 95 degrees, with an average flexion of 117 degrees and an average flexion contracture of 22 degrees. According to the Mayo Elbow Performance Index, the functional result was rated as excellent in two patients, good in nine, and fair in one. CONCLUSIONS: Unstable nonunions of the distal part of the humerus can be treated successfully in most active, healthy patients with use of rigid internal fixation, joint contracture release, and bone-grafting.

Adult↗
PubMed2003

Norian SRS cement compared with conventional fixation in distal radial fractures. A randomized study.

BACKGROUND: A prospective, randomized multicenter study was conducted to evaluate closed reduction and immobilization with and without Norian SRS (Skeletal Repair System) cement in the management of distal radial fractures. Norian SRS is a calcium-phosphate bone cement that is injectable, hardens in situ, and cures by a crystallization reaction to form dahllite, a carbonated apatite equivalent to bone mineral. METHODS: A total of 323 patients with a distal radial fracture were randomized to treatment with or without Norian SRS cement. Stratification factors included fracture type (intra-articular or extra-articular), hand dominance, bone density, and the surgeon's preferred conventional treatment (cast or external fixator). The subjects receiving Norian SRS underwent a closed reduction followed by injection of the cement percutaneously or through a limited open approach. Wrist motion, beginning two weeks postoperatively, was encouraged. Control subjects, who had not received a Norian SRS injection, underwent closed reduction and application of a cast or external fixator for six to eight weeks. Supplemental Kirschner wires were used in specific instances in both groups. Patients were followed clinically and radiographically at one, two, four, and between six and eight weeks and at three, six, and twelve months. Patients rated pain and the function of the hand with use of a visual analog scale. Quality of life was assessed with use of the Short Form-36 (SF-36) health status questionnaire. Complications were recorded. RESULTS: Significant clinical differences were seen at six to eight weeks postoperatively, with better grip strength, wrist range of motion, digital motion, use of the hand, and social and emotional function, and less swelling in the patients treated with Norian SRS than in the control group (p < 0.05). By three months, these differences had normalized except for digital motion, which remained significantly better in the group treated with Norian SRS (p = 0.015). At one year, no clinical differences were detected. Radiographically, the average change in ulnar variance was greater in the patients treated with Norian SRS (+2.0 mm) than in the control group (+1.4 mm) (p < 0.02). No differences were seen in the total number of complications, including loss of reduction. The infection rate, however, was significantly higher (p < 0.001) in the control group (16.7%) than in the group treated with Norian SRS (2.5%) and the infections were always related to external fixator pins or Kirschner wires. Four patients with intra-articular extravasation of cement were identified; no sequelae were observed at twenty-four months. Cement was seen in extraosseous locations in 112 (70%) of the SRS-treated patients; loss of reduction was highest in this subgroup (37%). The extraosseous material had disappeared in eighty-three of the 112 patients by twelve months. CONCLUSIONS: Our results indicate that fixation of a distal radial fracture with Norian SRS cement may allow for accelerated rehabilitation. A limited open approach and supplemental fixation with Kirschner wires are recommended. Additional or alternate fixation is necessary for complex articular fractures.

Aged↗
PubMed2004

Operative release of ankylosis of the elbow due to heterotopic ossification. Surgical technique.

BACKGROUND: Although uncommon, complete ankylosis of the elbow secondary to heterotopic ossification results in severe disability. The results of surgical management remain unclear. METHODS: A single surgeon used a consistent operative technique to treat complete osseous ankylosis of the elbow in eleven limbs in seven patients after severe burns and in nine elbows in eight patients after trauma. The elbows in the burn cohort were more often ankylosed in extension (average, 47 degrees of flexion) compared with those in the trauma cohort (66 degrees of flexion), and they had more skin problems (three elbows required a free microvascular muscle transfer for coverage) and associated problems of the shoulder, wrist, and hand. RESULTS: Four patients in the burn cohort and three patients in the trauma cohort failed to regain at least 80 degrees of ulnohumeral motion. After a repeat release in three burn patients and three trauma patients, and at an average follow-up of forty months, the average arc of ulnohumeral motion was 81 degrees in the burn cohort and 94 degrees in the trauma cohort. Six of the eleven limbs in the burn cohort and five of the nine in the trauma cohort had a good result. The average score according to the American Shoulder and Elbow Surgeons elbow assessment form was 72 points for the burn cohort and 76 points for the trauma cohort. CONCLUSIONS: Osseous ankylosis of the elbow is a severely disabling problem, and attempts to regain mobility are both worthwhile and safe. The results are comparable when the ankylosis is caused by burns or trauma despite the greater complexity of osseous ankylosis in the burned arm. Patients and surgeons should be aware of the small risk of recurrent heterotopic ossification and the moderate risk of pain or recurrent contracture after operative release.

Ankylosis↗
PubMed2004

Idiopathic arm pain.

BACKGROUND: Arm pain with little or no objective abnormality (referred to herein as idiopathic arm pain) is a common and frustrating problem for both patients and physicians. We investigated the relative effect of idiopathic arm pain and arm pain due to a discrete diagnosis on upper-extremity-specific health status. METHODS: The Disabilities of the Arm, Shoulder and Hand (DASH) questionnaire was completed by 3888 patients seen over a twelve-month period. Scores for the entire sample, for 496 patients diagnosed with idiopathic arm pain, and for 1379 patients diagnosed with one of twenty-one discrete conditions were compared. RESULTS: Patients with idiopathic pain reported substantial and highly variable upper-limb-specific dysfunction (average DASH score [and standard deviation], 36 +/- 24 points). Patients with discrete diagnoses also exhibited substantial variation (average standard deviation, 25; range, 6 to 27) as well as long right tails indicating floor effects, particularly for less severe conditions (Pearson correlation of r = -0.87 between the mean DASH score and skewness). Analysis of variance confirmed the ability of the DASH instrument to discriminate among groups of diagnoses of varying severity, but post hoc Tukey analysis identified ten subgroups with substantial overlap of the DASH scores. CONCLUSIONS: Patients with idiopathic arm pain report substantial and highly variable upper-extremity dysfunction. The wide variations observed in the DASH scores of the patients with idiopathic pain and those with discrete diagnoses are greater than would be expected on the basis of the variations in the objective pathological conditions and may reflect the strong influence of psychological and sociological factors on health status measures.

Arm↗
PubMed2004

Combined dorsal and volar plate fixation of complex fractures of the distal part of the radius.

BACKGROUND: Fractures of the distal part of the radius that are associated with complex comminution of both the articular surface and the metaphysis (subgroup C3.2 according to the Comprehensive Classification of Fractures) are a challenge for surgeons using standard operative techniques. METHODS: Twenty-five patients with subgroup-C3.2 fractures that had been treated with combined dorsal and volar plate fixation were evaluated at an average of twenty-six months after the injury. Subsequent procedures included implant removal in twenty-one patients and reconstruction of a ruptured tendon in two patients. RESULTS: An average of 54 degrees of extension, 51 degrees of flexion, 79 degrees of pronation, and 74 degrees of supination were achieved. The grip strength in the involved limb was an average of 78% of that in the contralateral limb. The average radiographic measurements were 2 degrees of dorsal angulation, 21 degrees of ulnar inclination, 0.8 mm of positive ulnar variance, and 0.7 mm of articular incongruity. Seven patients had radiographic signs of arthrosis during the follow-up period. A good or excellent functional result was achieved for twenty-four patients (96%) according to the rating system of Gartland and Werley and for ten patients (40%) according to the more stringent modified system of Green and O'Brien. CONCLUSIONS: Combined dorsal and volar plate fixation of the distal part of the radius can achieve a stable, mobile wrist in patients with very complex fractures. The results are limited by the severity of the injury and may deteriorate with longer follow-up. A second operation for implant removal is common, and there is a small risk of tendon-related complications.

Adult↗
PubMed2004

Loss of fixation of the volar lunate facet fragment in fractures of the distal part of the radius.

BACKGROUND: The purpose of the present study is to report on a cohort of patients with a volar shearing fracture of the distal end of the radius in whom the unique anatomy of the distal cortical rim of the radius led to failure of support of a volar ulnar lunate facet fracture fragment. METHODS: Seven patients with a volar shearing fracture of the distal part of the radius who lost fixation of a volar lunate facet fragment with subsequent carpal displacement after open reduction and internal fixation were evaluated at an average of twenty-four months after surgery. One fracture was classified as B3.2 and six were classified as B3.3 according to the AO comprehensive classification system. All seven fractures initially were deemed to have an adequate reduction and internal fixation. Four patients required repeat open reduction and internal fixation, and one underwent a radiocarpal arthrodesis. At the time of the final follow-up, all patients were assessed with regard to their self-reported level of functioning and with use of Sarmiento's modification of the system of Gartland and Werley. RESULTS: At a mean of two years after the injury, six patients had returned to their previous level of function. The result was considered to be excellent for one patient, good for four, and fair for two. The average wrist extension was 48 degrees, or 75% of that of the uninjured extremity. The average wrist flexion was 37 degrees, or 64% of that of the uninjured extremity. The one patient who underwent radiocarpal arthrodesis had achievement of a solid union. The four patients who underwent repeat internal fixation had maintenance of reduction of the lunate facet fragment. The two patients who declined additional operative intervention had persistent dislocation of the carpus with the volar lunate facet fragment. CONCLUSIONS: The stability of comminuted fractures of the distal part of the radius with volar fragmentation is determined not only by the reduction of the major fragments but also by the reduction of the small volar lunate fragment. The unique anatomy of this region may prevent standard fixation devices for distal radial fractures from supporting the entire volar surface effectively. It is preferable to recognize the complexity of the injury prior to the initial surgical intervention and to plan accordingly.

Adult↗
PubMed2005

Psychological factors associated with idiopathic arm pain.

BACKGROUND: Psychological and personality factors may be as important as, or more important than, pathological processes in the experience of pain, particularly in patients whose pain has a vague or uncertain source. METHODS: Validated measures of psychological factors were used to prospectively evaluate fifty-six patients with a single, discrete pain complaint and fifty-one patients with vague, diffuse idiopathic arm pain. Pain was assessed with use of 10-point Likert scales, the Pain Anxiety Symptoms Scale, the Pain Catastrophizing Scale, the Wahler Physical Symptom Inventory, the Body Consciousness Questionnaire, and the Multidimensional Health Locus of Control Scale. RESULTS: Patients with idiopathic arm pain reported more severe pain at rest (p = 0.02) and with repeated movements (p = 0.01); exhibited higher levels of cognitive anxiety (p = 0.008); demonstrated greater helplessness (p = 0.002), pain magnification (p = 0.007), and overall catastrophic coping mechanisms for dealing with pain (p = 0.005); and showed a tendency for increased somatic complaining (p = 0.07). A multiple logistic regression model identified the total score on the Pain Catastrophizing Scale as the sole predictor of idiopathic pain complaints. CONCLUSIONS: Pain complaints without a clear physical cause are common and are frustrating for both patients and physicians. Awareness of the psychological factors associated with idiopathic arm pain may lead to more effective interventions designed to improve coping mechanisms while at the same time limiting the use of meddlesome and potentially harmful diagnoses and treatments.

Adaptation, Psychological↗
PubMed2005

Hinged elbow external fixation for severe elbow contracture.

BACKGROUND: When it was first introduced, it was hoped that hinged external fixation with a built-in gear mechanism for applying passive motion and static progressive stretch by turning a dial would improve the arc of ulnohumeral motion, by gradually stretching contracted muscles, after open release of a severe elbow contracture. METHODS: Forty-two patients were evaluated at an average of thirty-nine months after operative release of a severe posttraumatic elbow contracture (defined as < or =40 degrees of motion). Twenty-three patients had been treated, during the early part of the study, with a hinged external fixator that incorporated a worm gear to apply static progressive stretch postoperatively. These patients were compared with nineteen patients who had been treated without hinged external fixation during the later part of the study, when the hinge was used less frequently. The operative techniques did not otherwise change during the study period. Demographic and injury characteristics as well as associated problems were comparable between the two groups. RESULTS: The average gain in the range of motion after the index procedure was 89 degrees in the patients treated with a hinge and 78 degrees in those treated without a hinge, an insignificant difference with the numbers available (p = 0.175). Complications associated with use of the hinge included five pin-track infections, one case of pin-track osteomyelitis, one ulnar fracture through a pin site, two broken Schanz screws, and two cases of irritation of the ulnar nerve. CONCLUSIONS: Open release of a severe elbow contracture results in a substantial gain in motion, with or without hinged elbow fixation. The slightly greater improvement in motion provided by the hinge does not justify the associated increase in risk, expense, and complications.

Adolescent↗
PubMed2005

Corrective osteotomy for intra-articular malunion of the distal part of the radius.

BACKGROUND: Corrective osteotomy is an appealing treatment for malunited articular fractures of the distal part of the radius since articular incongruity may be the factor most strongly associated with arthrosis and diminished function after such fractures. Enthusiasm for osteotomy has been limited by concerns regarding the difficulty of the technique and the potential for additional injury, osteonecrosis, and nonunion. METHODS: Twenty-three skeletally mature patients were evaluated at an average of thirty-eight months after corrective osteotomy for an intra-articular malunion of the distal part of the radius. The indication for the osteotomy included dorsal or volar subluxation of the radiocarpal joint in fourteen patients and articular incongruity of > or =2 mm as measured on a posteroanterior radiograph in seventeen patients. Six patients had combined intra-articular and extra-articular malunion. The average interval from the injury to the osteotomy was six months. The average maximum step-off or gap of the articular surface prior to the operation was 4 mm. RESULTS: One patient had a subsequent partial wrist arthrodesis because of radiocarpal arthrosis, and three patients had additional surgery because of dysfunction of the distal radioulnar joint. One patient had a rupture of the extensor pollicis longus, which was treated with a tendon transfer. The final articular incongruity averaged 0.4 mm, and the final grip strength averaged 85% of that on the contralateral side. The rate of excellent or good results was 83% according to the rating systems of Fernandez and of Gartland and Werley, and 43% according to a modification of the rating system of Green and O'Brien. CONCLUSIONS: The results of corrective osteotomy for the treatment of intra-articular malunion are comparable with those of osteotomy for the treatment of extra-articular malunion. Intra-articular osteotomy can be performed with acceptable safety and efficacy, it improves wrist function, and it may help to limit the need for salvage procedures such as partial or total wrist arthrodesis.

Adolescent↗
PubMed2005

Pain dominates measurements of elbow function and health status.

BACKGROUND: Elbow function can be quantified with use of physician-based elbow-rating systems and health status questionnaires. Our hypothesis was that pain has a strong influence on these scores, which overwhelms the influence of objective factors such as motion. METHODS: One hundred and four patients were evaluated, at a minimum of six months (average, forty-six months) after the latest surgery for an intra-articular fracture of the elbow, with use of three physician-based evaluation instruments (Mayo Elbow Performance Index [MEPI], Broberg and Morrey rating system, and American Shoulder and Elbow Surgeons Elbow Evaluation Instrument [ASES]), an upper-extremity-specific health status questionnaire (Disabilities of the Arm, Shoulder and Hand [DASH]), and a general health status questionnaire (Short Form-36 [SF-36]). Multivariate analysis of variance and regression modeling were used to identify the factors that account for the variability in scores derived with these measures-in other words, which factors have the strongest influence on the final score. RESULTS: Pain alone accounted for 66% of the variability in the MEPI scores, 59% of the variability in the Broberg and Morrey scores, and 57% of the variability in the ASES scores. Models that included other factors accounted for only slightly more variability (73%, 79%, and 79%, respectively), and those that did not include pain accounted for only 22%, 41%, and 41% of the variability. Thirty-six percent of the variability in the DASH scores could be accounted for by pain alone, and 45% could be accounted for by pain and range of motion. Models not including pain accounted for only 17% of the variability in the DASH scores. CONCLUSIONS: Pain has a very strong influence on both physician-rated and patient-rated quantitative measures of elbow function. Consequently, these measures may be strongly influenced by the psychosocial aspects of illness that have a strong relationship with pain, and objective measures of elbow function such as mobility may be undervalued. It may be advisable to evaluate pain separately from objective measures of elbow function in physician-based elbow ratings.

Adult↗