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PubMed1987

Operative management of intra-articular fractures of the distal humerus.

Over a 5-year period (1979-1984), 33 patients with intra-articular fractures of the distal humerus underwent open reduction and internal fixation of their fractures. Twenty-two (67%) of the patients had multiple injuries. Fourteen (42%) of the fractures were open (1 was Grade I, 8 were Grade II and 5 were Grade III). The mean age was 32 years (range: 15-61 years), which is significantly younger than in other series. A subgroup of 25 of the patients was evaluated clinically at a mean of 18.3 months postoperatively. "Excellent" and "good" functional results occurred in 23 patients (92%). "Poor" results were seen in the remaining two patients (8%). Complications occurred in 15 patients (45%). Nine of these complications related to fixation of the transolecranon osteotomy, which was used in 29 patients. The method by which reduction and stabilization was achieved was not as important as obtaining sufficient rigidity, which permitted early motion.

Adolescent↗
PubMed1998

[Prognosis of proximal radius fractures in the growth period].

Fractures of the proximal radius in children may lead to deformities of the radial head and functional disturbance of pro- and supination. However, traumatization is not only caused by the injury itself, but may also occur secondary to surgical reduction, manipulation of fracture fragments and excessive physiotherapy. In a prospective long-term follow-study (2-20 years after trauma) of 38 children with displaced proximal radius fractures we found functional disturbances in 11% of children only. These were not caused by radial head deformities, which were present on 83% of follow-up radiographs. Functional impairment was mainly seen after open reduction or secondary growth disturbances. On follow-up radiographs all conservatively treated fracture angulations up to 60 degrees had corrected themselves spontaneously. In view of the high complication rates after open reduction and the poor functional results, as well as the inconvenience for the pediatric patient and the economic aspects, we recommend a primary conservative treatment concept of proximal radius fractures in children.

Adolescent↗
PubMed2000

Stretch reflex adaptation in elbow flexors during repeated passive movements in unilateral brain-injured patients.

OBJECTIVE: To evaluate the effects of repeated, externally imposed, flexion-extension movements of the elbow on the resulting stretch reflex response in hemiparetic spastic brain-injured patients. These effects were compared within a recording session and across sessions for the same subject to determine the impact of movement history on the quantification of spastic hypertonia using the stretch reflex response. DESIGN: Twenty to 30 sequential, constant velocity flexion-extension movements were applied to the impaired elbow of our cohort, with a 10-second hold interposed between flexion and extension. Movements were applied regularly at 1-minute intervals. Changes in stretch reflex responses were monitored during the applied movements. PARTICIPANTS: We examined a convenience sample of seven hemiparetic brain-injured subjects between the ages of 26 and 60 yrs, with moderate-to-severe spastic hypertonia of elbow muscles (Ashworth score 2-4/4). Subjects participated in 2 to 9 sessions. MEASURES: Elbow torque, position, velocity, and electromyograms of the biceps, brachioradialis, and triceps muscles were recorded for each flexion and extension movement. Stretch reflex torque was calculated by subtracting passive torque from total elbow torque, recorded over large amplitude movements. A linear regression analysis quantified both the initial torque response of the stretch reflex and the ensuing adaptation of the stretch reflex during sequential movements. Intersession variability was characterized both for spastic hypertonia measures and for stretch reflex adaptation. RESULTS: Repeated, externally imposed, sequential flexion-extension movements of the elbow decreased the elbow flexor stretch reflex in six of seven subjects. The mean reduction in reflex torque after 30 movements was 50% of the initial torque values (p = .001, t test vs. 0% change). Intersession stretch reflex responses for each subject were found to vary greatly (SDs of reflex torque ranged from 0.1 to 4.0 Nm), and there were also significant variations in the degree of adaptation between subjects. CONCLUSIONS: Stretch reflex adaptation must be taken into consideration when spastic hypertonia is quantified using repeated joint motion, as is often the case. The magnitude of intersession variation in spastic hypertonia measures suggests that ideally, such measurements should be made across multiple sessions before conclusions are made regarding the efficacy of spastic hypertonia interventions. This study provides quantitative evidence that repeated joint movements may have a significant short-term beneficial effect on spastic hypertonia.

Adaptation, Physiological↗
PubMedDate not supplied

Olecranon fractures in children: Part 1: a clinical review; Part 2: a new classification and management algorithm.

Part 1: A Clinical Review: Fractures of the olecranon in children are uncommon, and the outcome has historically been reported as good. Management varies from simple immobilization to include various methods of internal fixation. Recently a new technique of fracture fixation has been used in an attempt to improve the management of this fracture. This article reviews olecranon fractures seen at two children's hospitals over a 10-year period. The purpose of the study was to review and classify various fracture patterns, different fixation techniques, and to assess medium-term outcomes after this uncommon injury. Part 2: A New Classification and Management Algorithm: A new classification system and management algorithm for fractures of the olecranon in children is presented. This was developed after a 10-year review of olecranon fractures and their management at two children's hospitals (Part 1). Minimally displaced or undisplaced fractures account for 80% of all olecranon fractures, and these are managed with immobilization, rarely requiring hospital admission. Of those fractures admitted to hospital, oblique metaphyseal fractures are most commonly seen and are satisfactorily treated with tension-band techniques, but a wide variety of fracture patterns are less common and may require different management. Previous classifications of this uncommon fracture have not addressed all of the significant features to categorize the fracture accurately or to imply a management pathway. This new anatomically based classification system facilitates accurate classification for research purposes, and its principles are applied in the clinical-management algorithm presented here.

Adolescent↗
PubMed1991

Surgical approaches for resection of heterotopic ossification in traumatic brain-injured adults.

The site of heterotopic ossification (HO) at the elbow or the hip dictates the surgical approach for resection. Three approaches are used for HO resection at the elbow: (1) a posterolateral approach for posterolateral HO; (2) an anterolateral approach for anterior HO; and (3) a medical approach for medial or posteromedial HO or anterior transfer of the ulnar nerve. Two approaches are recommended for resection of HO at the hip: (1) an anterior approach for anterior or inferomedial HO and (2) a posterior approach for posterior HO. Posterior HO is often associated with a hip-flexion contracture, and an anterior soft-tissue release may be necessary as well. Physical examination indicates the prognosis for functional improvement as well as recurrence. Patients with a near normal neurologic recovery have minimal to no HO recurrence with improved limb function and increased joint motion, whereas a poor neurologic recovery and persistent spasticity are associated with recurrence of HO and no functional limb improvement. Standard roentgenograms aid in selecting the appropriate surgical approach. Radiation, indomethacin, and diphosphonates have been administered for prophylaxis. Physical therapy is necessary until range of motion stabilizes.

Adult↗
PubMed2001

Olecranon septic bursitis managed in an ambulatory setting. The Calgary Home Parenteral Therapy Program Study Group.

BACKGROUND: The epidemiology, outcome and management of olecranon septic bursitis (OSB) have not been described in a large cohort of ambulatory patients. METHODS: A retrospective study of all 118 cases of OSB presenting over 21 months to all regional Home Parenteral Therapy Program clinics in Calgary (referral base approximately 1 million). RESULTS: The minimum population annual incidence was 10/100,000. The mean (and standard deviation) age was 44 (13) years, and males predominated (88%). One-third of patients had at least one comorbid illness, with preceding injury in 53% of cases. The most common symptoms were pain (87%), redness (77%) and fever or chills (45%). Common signs included erythema (92%), swelling (85%), edema (75%), tenderness (59%), fluctuance (50%), heat (36%) and reduced range of motion (27%). Fever (body temperature of > or =37.8 degrees C) occurred in 20%. Staphylococcus aureus was identified in 88% of culture-proven cases of OBS. The most common antibiotic regimen was sequential intravenous administration of cefazolin (for a median of 4 d) followed by clindamycin orally (for a median of 8 d). Sixty (51%) patients required a drainage procedure and only 1 patient required admission to hospital. CONCLUSION: OSB is more common than reported and can be treated successfully in ambulatory settings with sequential intravenous therapy followed by oral therapy and drainage in selected cases.

Adult↗
PubMedDate not supplied

Nonclassic history in children with radial head subluxations.

Radial head subluxation (RHS) is a common pediatric orthopedic injury, frequently diagnosed through the classic history of axial traction to the upper extremity of a child. However, not all children with RHS will present with this classic history. This may result in misdiagnosis and delay of appropriate treatment. To evaluate the prevalence of non-classic presentations, a retrospective study was conducted of 45 emergency department patients with RHS. Of these patients, 15 presented with an atypical history. All patients were in minimal distress, holding their affected arms semiflexed and pronated (the nursemaid's position). The classic and nonclassic history groups were equivalent in patient age, spontaneous reductions, and physician reductions. A trend towards more radiographs was noted in the nonclassic group. This study suggests that even in the absence of the classic history of upper extremity traction, radial head subluxation should be suspected in any pediatric patient with an upper extremity complaint who presents with the affected arm in the nursemaid's position.

Accidental Falls↗
PubMed1999

[Concomitant vascular complications in supracondylar humerus fractures in children].

From January 1st 1990 to December 31st 1997, 614 children were treated for supracondylar humerus fracture at the Department of Orthopedic Surgery in the Olga Hospital, Stuttgart. Ten of these children had concomitant vascular complications. The concept of treatment we had chosen was analysed retrospectively. The median patient age of the seven girls and three boys with vascular complications was six years. The vascular injuries were diagnosed after admission to the hospital by palpation of the wrist pulse, clinical appraisal of the vascularity and by registration of the Doppler signal via the arteries of the wrist. The emergency operations carried out initially comprised fragment reposition and fixation with crossed K wires via an access route on the extensor side in all ten children. The subsequent appraisal of the blood flow revealed a pulse restoration (transient vascular occlusion due to dislocation) in two out of the ten children. In eight out of the ten children, the pulse did not return, which is why the vessel had to be explored under emergency conditions. Intraoperatively, we saw a vascular spasm with functional vascular occlusion in one of these eight children. Mechanical vascular occlusion were diagnosed in five of these eight children. In adventitial strangulation (two of these five children), the pulse transmission to the hand occurred immediately after severance of the strangulation connective tissue. In intimal damage (three of these five children), the vascular segment concerned was resected and reconstructed, mostly in the form of an end-to-end-anastomosis with venous patch grafting. We observed a combined vascular occlusion (mechanical-functional occlusion) in two out of these eight children. In the follow-up investigation, the wrist pulses could be palpated in nine children. Nine children had a physiological signal in color duplex sonography, and one child had a pathological monophasic signal over the brachial artery, radial artery as well as the ulnar artery. Late ischemic damage (cold intolerance, claudicatio, Volkmann's contracture) were not detected in any of the children. Appraisal of elbow joint mobility revealed a median extension deficit of 0 degrees (range 0-10 degrees ), a median flexion deficit of 0 degrees (range 0-15 degrees ) and a normal pronation and supination equal on each side. The load-carrying joint axis was normal in a comparison of the sides in all children.

Arm↗
PubMed1991

[Treatment of Monteggia fracture in children].

Described in this paper is a therapeutic concept by which to cope with Monteggia's fracture in childhood. It is based on experience obtained from 72 cases with injuries of that kind and their evaluation in a group study. Therapeutic approach to the individual case was determined by the following criteria: age of infant, localisation and shape of ulnar fracture, reducibility of capitulum radii, and accompanying injuries requiring treatment on the same arm. The need for surgical stabilisation of ulnar fracture was found to increase along with growing age of the affected child. High-stability anatomic reduction of the ulnar fracture proved to be a prerequisite for safe stabilisation of the radial capitulum. Close reduction has proved to be sufficient in many instances. Open reduction and internal fixation were found to be necessary in cases in which an ulnar fracture was irreducible or instable and/or a radial head was not reducible. Minimal osteosynthesis and plaster cast is considered to be an optional therapy for younger children, whereas ulnar stabilisation by means of plates is preferred for children in somewhat advanced age of childhood. The radial head may be fixed by trans-articular Kirschner's wire (WITT) or primary reconstruction of the annular ligament, using a strip of biceps or triceps tendon, or adaptation around the collum radii and ulna of the proximal radio-ulnar joint by means of a sling of Dexon or Vicryl suture.

Child↗
PubMedDate not supplied

Surgical treatment of displaced olecranon fractures in children.

Thirty-five children who had fractures of the olecranon were reviewed. Age at the time of injury ranged from 0 years 2 months to 15 years 4 months. Fractures were retrospectively classified as type I or II according to the amount of displacement apparent on the initial radiographs. Type I fractures were those with < 3 mm of displacement, and type II were those with displacement of > or = 3 mm. Type I fractures (n = 23) were treated with closed methods, and splint or cast immobilization was maintained for an average of 3 weeks. All 23 type I fractures had satisfactory results on follow-up. Type II fractures (n = 12) were treated with open reduction and internal fixation. Greater intraarticular displacement was often seen intraoperatively than had been appreciated radiographically. Ten of 12 patients with type II fractures were available for follow-up; all had satisfactory results. Restoration of the articular surface in children with olecranon fractures optimizes joint function and growth potential. The amount of fracture may be more than is apparent on plain radiographs.

Adolescent↗
PubMed2001

Comparison between closed reduction with percutaneous pinning and open reduction with pinning in children with closed totally displaced supracondylar humeral fractures: a randomized controlled trial.

This was a randomized controlled trial of 28 children 1 year to 12 years of age with closed totally displaced supracondylar humeral fracture. The purpose of the study was to compare closed reduction and pinning (group A) and open reduction and pinning (group B). Each group consisted of 14 children. The general characteristics of both groups (age, sex side, displacement, nerve injury preoperatively) were statistically the same (P > 0.05). All cases healed with good alignment without cubitus varus, without infection and with a good range of motion except for one. The mean +/- standard deviation of the Baumann's angle difference between the injured and uninjured side were 2.32 +/- 1.6 degrees in group A (range, 0-6.5 degrees) and 2.45 +/- 1.8 degrees in group B (range, 0-6.5 degrees). This difference was statistically not significant (P = 0.8). By Flynn criteria, group A had good to excellent results in 100%, and group B had good to excellent results in 93% and fair in 7%. This difference was not statistically significant (P = 1). The satisfaction score (0-10) was significantly higher in group A for both parents' and evaluator's (blinded to treatment) perspective (P = 0.017 and 0.019, respectively). The author concludes that both treatments gave good results. Closed reduction should be performed first and, if it fails, then open reduction can be performed. This will produce good results in the hands of an experienced surgeon.

Child↗
PubMed2005

Supracondylar fractures of the humerus in children.

Supracondylar fractures of the humerus need a precise treatment in order to obtain a satisfactory result because of the low bone remodeling associated with these injuries. It is important to use a systematic procedure for closed reduction and percutaneous fixation. A retrospective review of fractures treated using two K-wires from the lateral side was done in 77 patients with a mean age of 6.7 years (range, 1-13 years). Displacement of the fracture was classified as Gartland Type II in 39 patients (50.6%) and Gartland Type III in 38 patients (49.4%). The results according to Flynn criteria were excellent in 70 patients (90.9%), fair in three patients (3.9%) and poor in four patients (5.2%), with overall satisfactory results in 96.1% of the cases. In four patients there was secondary displacement of the fragments in internal rotation and three of these patients were operated on again, increasing fixation with a third K-wire either from the lateral or medial side. There were two nerve lesions (2.6%), and four patients (5.2%) had a pulseless pink hand that recovered when the fracture was reduced. In three patients (3.9%) infection developed. To obtain satisfactory results using this procedure, enough stability should be achieved, avoiding iatrogenic damage of the ulnar nerve.

Adolescent↗
PubMed2002

Radius pull test: predictor of longitudinal forearm instability.

BACKGROUND: Longitudinal instability of the forearm (the Essex-Lopresti lesion) following radial head excision may be difficult to detect. This cadaveric study examines a stress test that can be performed in the operating room to identify injury to the ligamentous structures of the forearm. METHODS: Twelve cadaveric upper extremities were randomized into two groups and underwent radial head resection. Group 1 underwent sequential transection of the triangular fibrocartilage complex and the interosseous membrane. Group 2 underwent sequential transection of the interosseous membrane and the triangular fibrocartilage complex. Ulnar variance and radial migration were examined with use of fluoroscopy of the wrist before, during, and after the application of a 9.1-kg load via longitudinal traction on the proximal part of the radius. RESULTS: Group 1 demonstrated no significant changes in proximal radial migration with load (compared with the findings after radial head resection alone) after transection of the triangular fibrocartilage complex. However, Group 2 demonstrated significant changes in proximal radial migration with load after transection of the interosseous membrane (p = 0.03; median, 3.5 mm). In both groups, transection of both the triangular fibrocartilage complex and the interosseous membrane resulted in significant changes in proximal radial migration with load (p = 0.001; median, 9.5 mm). When the load was removed, specimens were ulnar positive (median, 3.0 mm), with no specimen returning to the preload position of ulnar variance (p = 0.001). CONCLUSION: After radial head resection, 3 mm of proximal radial migration with longitudinal traction indicated disruption of the interosseous membrane. In all specimens, proximal radial migration of > or =6 mm with load indicated gross longitudinal instability with disruption of all ligamentous structures of the forearm.

Biomechanical Phenomena↗
PubMed2002

[Supracondylar humerus fracture in childhood--an efficacy study. Results of a multicenter study by the Pediatric Traumatology Section of the German Society of Trauma Surgery--I: Epidemiology, effectiveness evaluation and classification].

In this retrospective study of the pediatric trauma group of German trauma society, issued to investigate the state of the art treatment of the supracondylar fracture of the humerus, 13 clinics took part. In this first part of our study we tested the epidemiology and effectivity of therapeutic interventions based on the classification of v. Laer. 886 fractures were included with an average patients age of 5.8 years (+/- 2.9). Causes of trauma was in 45% playing, followed by school/kindergarden and sports injuries. Fractures were initially classified according to v. Laer and showed following displacement: 35.4% Type I, 21.9% Type II, 18.1% Type III and 24.6% Type IV. 10 of the 886 cases (1.1%) were open fractures. Damages to nerves were described in 45 patients (5.1%) and only 7 (0.7%) had primary vessel lesions. 476 patients were treated by reduction of fragments, 72% using a closed technical approach and 28% using an open approach. 6% underwent a second resposition-maneuver, which was mainly observed after crossed Kirschner-wire in type-III-and-IV-fractures. Therapy was changed in 5.1% mostly of the cases were initially closed reduced and then fixed with a collar and cuff sling. 540 patients were seen at follow-up (61%). 81.1% of these patients showed symmetrical axis compared to the uninjured arm. A varus-deformity was noted in 11.7%, a valgus-deformity in 7.2%. Analysis of effectivity showed that the primarily used classification was not sufficient for prediction of the outcome after reposition and retention. Therefore the classification was modified based on 4 groups: Type I undisplaced, Type II displacement in one plane, Type III displacement in two planes and Type IV displacement in three spatial planes. Using this classification we could found that in group II 25% of reduction an 7% of retentions were ineffective. For group III and IV we found that > 20% of the retention proofed to be ineffective.

Adolescent↗
PubMedDate not supplied

Tardy displacement of traumatic radial head dislocation in childhood.

The diagnosis of traumatic dislocation of the radial head, either isolated or as part of a Monteggia fracture-dislocation, was delayed in 10 of the 110 children treated with these injuries during the study period. In eight children, the dislocation was overlooked on the initial radiographs. In two children, the radial head was reduced on the initial elbow radiographs, but it was dislocated 10 days later in one child and 21 days later in the other. The most likely explanation is that the radial head dislocated at the time of impact, spontaneously reduced by the time the first radiographs were obtained, and redislocated while the arm was in a cast. We conclude that radiographic assessments of the radiocapitellar joint, by using the radiocapitellar line, are required in children with elbow and forearm injuries at presentation and when the cast is removed.

Accidental Falls↗
PubMed1977

Total replacement of the elbow joint.

Total replacement of the elbow joint has been performed on 86 elbows at the Mayo Clinic, all but 15 in patients with rheumatoid arthritis. The Mayo design, which replaces both radiohumeral and humeroulnar joints, was used in 41 elbows, almost all in rheumatoid patients, with 71% good results. The Coonrad hinge with polyethylene bushings was used in 34 elbows; it was successful in 64% of rheumatoid patients, but failed in 46% of posttraumatic patients with bone loss. Previous designs have failed because of humeral loosening. Total elbow replacement is a technique still to be perfected in medical centers before general release.

Arthritis, Rheumatoid↗