Background

Over 55,000 spinal operations are performed annually in the NHS. Effective postoperative analgesia facilitates early mobilisation and assists rehabilitation and hospital discharge, but is difficult to achieve with conventional, opioid-based, oral analgesia. The clinical and cost-effectiveness of two alternative techniques, namely intrathecal opioid and the more novel erector-spinae plane blockade, is unknown. The Pain Relief After Instrumented Spinal Surgery (PRAISE) trial aims to evaluate these techniques.

Introduction The goals of this study were to investigate the association between paediatric flexion-distraction fractures of the lumbar spine and abdominal injuries and to analyse the variety of the abdominal injuries seen with this type of fracture.

Methods A retrospective chart review was performed at three hospitals (British Columbia Children’s Hospital, Vancouver, Canada, Mater Children’s Hospital and Royal Children’s Hospital, Brisbane). All patients under the age of fifteen who had suffered a flexion-distraction fracture were included. Data collected from the chart related to seating position, the use of seat belts and the spinal and abdominal injuries. The time elapsed from presentation to the time of diagnosis of abdominal injury was also recorded.

Results Forty one patients were included. There were 16 male and 25 female patients. All injuries were due to motor vehicle accidents. The average age at the time of accident was 9 years and 8 months. Twenty-two of the forty-one patients (53%) suffered an intra-abdominal injury. Twenty-one of these patients required operative intervention for their abdominal trauma. The spectrum of injuries included small bowel, large bowel, mesenteric and solid organ injuries. Eighteen of the twenty-two patients sustained a small bowel injury.

Discussion Abdominal trauma after flexion-distraction fractures of the lumbar spine is common. Often the abdominal trauma is significant and may require a laparotomy. A high index of suspicion should be maintained for all patients who present to the orthopaedic department with this type of injury.

Purpose: The approach chosen for total elbow arthrolysis is crucial. It should allow access to all lesions causing joint stiffness yet avoid excessive mutilation. We report our experience with the transhumeral approach respecting the lateral structures.

Material and methods: Thirteen transhumeral elbow arthrolyses were performed from 1996 to 2002 and reviewed retrospectively at mean 18 months (6–63). Mean age at surgery was 44 years. Stiffness resulted from trauma in five patients and degenerative disease in eight. The SOFCOT classification was severe in two, moderate in ten and minimal in one. Arthroysis was performed by the posterior transtricipital technique. After releasing the fossa and the olecranon beak, the coronoid process and the anterior capsule were released using a transhumeral bone window. Two patients also underwent ulnar nerve transposition. Rehabilitation was initiated early and continued for 17 weeks on average.

Results: At last follow-up, active elbow extension improved from −39±9° to 21±9° and flexion from 109±14° to 129±7°, corresponding to an increase in motion of 38±14° (70° preoperatively and 108° postoperatively). This gain in motion was the same in the trauma and degeneration groups. Pain, evaluated with a visual analogue scale from 0 to 10 improved from 3.2±1.3 to 2.4±2.0 for posttraumatic stiffness and from 7.4±1.3 to 4.1±2.0 for degenerative stiffness. There was on postoperative irritation of the ulnar nerve which regressed partially.

Discussion: Transhumeral arthrolysis allows posterior and anterior release while preserving the lateral structures. This technique has been very effective for olecranon bone blockage, posterior and anterior capsule retraction, and for coronoid anterior block. For degenerative elbows, pain relief was achieved in 70%.

Conclusion: Transhumeral elbow arthrolysis initially proposed for the degenerative elbow can be used for posttraumatic stiffness in patients with a moderate form without limiting pronosupination nor injuring the lateral ligaments. The best indication is fracture of the humeral plate.