Of 48 consecutive children with Gartland III
supracondylar fractures, 11 (23%) had evidence of vascular injury,
with an absent radial pulse. The hand was pink and warm in eight
and white and cold in the other three patients. They underwent colour-coded
duplex scanning (CCDS) and ultrasound velocimetry (UV) to investigate
the patency of the brachial artery and arterial blood flow. In seven
patients with a pink pulseless hand, CCDS showed a displaced, kinked
and spastic brachial artery and a thrombosis was present in the
other. In all cases UV showed reduced blood flow in the hand. In
three patients with a white pulseless hand, scanning demonstrated
a laceration in the brachial artery and/or thrombosis. In all cases,
the fracture was reduced under general anaesthesia and fixed with
Kirschner wires. Of the seven patients with a pink pulseless hand
without thrombosis, the radial pulse returned after reduction in
four cases. The remaining three underwent exploration, along with
the patients with laceration in the brachial artery and/or thrombosis. We believe that the traditional strategy of watchful waiting
in children in whom the radial pulse remains absent in spite of
good peripheral perfusion should be revisited. Vascular investigation
using these non-invasive techniques that are quick and reliable
is recommended in the management of these patients. Cite this article:
In this case report a four-year-old girl with ulnar dimelia is described. She had six digits without mirror symmetry in her right hand. The first pre-axial digit was excised and true pollicisation performed for the second pre-axial digit. The arterial anatomy was abnormal but there was not symmetrical development of the arterial tree.
Mason type III fractures of the radial head are treated by open reduction and internal fixation, resection or prosthetic joint replacement. When internal fixation is performed, fixation of the radial head to the shaft is difficult and implant-related complications are common. Furthermore, problems of devascularisation of the radial head can result from fixation of the plate to the radial neck. In a small retrospective study, the treatment of Mason type III fractures with fixation of the radial neck in 13 cases (group 2) was compared with 12 cases where no fixation was performed (group 1). The mean clinical and radiological follow-up was four years (1 to 9). The Broberg-Morrey index showed excellent results in both groups. Degenerative radiological changes were seen more frequently in group 2, and removal of the implant was necessary in seven of 13 cases. Post-operative evaluation of these two different techniques revealed similar ranges of movement and functional scores. We propose that anatomical reconstruction of the radial head without metalwork fixation to the neck is preferable, and the outcome is the same as that achieved with the conventional technique. In addition degenerative changes of the elbow joint may develop less frequently, and implant removal is not necessary.
We retrospectively assessed the value of identifying
impinging osteophytes using dynamic computer simulation of CT scans
of the elbow in assisting their arthroscopic removal in patients
with osteoarthritis of the elbow. A total of 20 patients were treated
(19 men and one woman, mean age 38 years (19 to 55)) and followed
for a mean of 25 months (24 to 29). We located the impinging osteophytes
dynamically using computerised three-dimensional models of the elbow
based on CT data in three positions of flexion of the elbow. These
were then removed arthroscopically and a capsular release was performed. The mean loss of extension improved from 23° (10° to 45°) pre-operatively
to 9° (0° to 25°) post-operatively, and the mean flexion improved
from 121° (80° to 140°) pre-operatively to 130° (110° to 145°) post-operatively.
The mean Mayo Elbow Performance Score improved from 62 (30 to 85)
to 95 (70 to 100) post-operatively. All patients had pain in the
elbow pre-operatively which disappeared or decreased post-operatively.
According to their Mayo scores, 14 patients had an excellent clinical
outcome and six a good outcome; 15 were very satisfied and five
were satisfied with their post-operative outcome. We recommend this technique in the surgical management of patients
with osteoarthritis of the elbow. Cite this article:
The February 2014 Shoulder &
Elbow Roundup360 looks at: whether arthroscopic acromioplasty is a cost-effective intervention; shockwave therapy in cuff tear; whether microfracture relieves short-term pain in cuff repair; the promising early results from L-PRF augmented cuff repairs; rehabilitation following cuff repair; supination strength following biceps tendon rupture; whether longer is better in humeral components; fatty degeneration in a rodent model; and the controversial acromioclavicular joint dislocation.
Infected nonunion of a long bone continues to
present difficulties in management. In addition to treating the infection,
it is necessary to establish bony stability, encourage fracture
union and reconstruct the soft-tissue envelope. We present a series of 67 infected nonunions of a long bone in
66 patients treated in a multidisciplinary unit. The operative treatment
of patients suitable for limb salvage was performed as a single
procedure. Antibiotic regimes were determined by the results of
microbiological culture. At a mean follow-up of 52 months (22 to 97), 59 patients (88%)
had an infection-free united fracture in a functioning limb. Seven
others required amputation (three as primary treatment, three after
late failure of limb salvage and one for recalcitrant pain after
union). The initial operation achieved union in 54 (84%) of the salvaged
limbs at a mean of nine months (three to 26), with recurrence of
infection in 9%. Further surgery in those limbs that remained ununited
increased the union rate to 62 (97%) of the 64 limbs treated by
limb salvage at final follow-up. The use of internal fixation was
associated with a higher risk of recurrent infection than external
fixation. Cite this article:
Restoration of hand function is rarely achieved after a complete closed traction lesion of the supraclavicular brachial plexus. We describe the injury, treatment, rehabilitation and long-term results of two patients who regained good function of the upper limb and useful function in the hand after such an injury. Successful repairs were performed within six days of injury. Tinel’s sign proved accurate in predicting the ruptures and the distribution of pain was accurate in predicting avulsion. The severe pain that began on the day of injury resolved with the onset of muscle function. Recovery of muscle function preceded recovery of sensation. Recovery of the function of C and Aδ fibres was the slowest of all.
We report the outcome of 84 nonunions involving
long bones which were treated with rhBMP-7, in 84 patients (60 men:
24 women) with a mean age 46 years (18 to 81) between 2003 and 2011.
The patients had undergone a mean of three previous operations (one
to 11) for nonunion which had been present for a mean of 17 months
(4 months to 20 years). The nonunions involved the lower limb in
71 patients and the remainder involved the upper limb. A total of 30
nonunions were septic. Treatment was considered successful when
the nonunion healed without additional procedures. The relationship
between successful union and the time to union was investigated
and various factors including age and gender, the nature of the
nonunion (location, size, type, chronicity, previous procedures,
infection, the condition of the soft tissues) and type of index
procedure (revision of fixation, type of graft, amount of rhBMP-7) were
analysed. The improvement of the patients’ quality of life was estimated
using the Short Form (SF) 12 score. A total of 68 nonunions (80.9%) healed with no need for further
procedures at a mean of 5.4 months (3 to 10) post-operatively. Multivariate
logistic regression analysis of the factors affecting union suggested
that only infection significantly affected the rate of union
(p = 0.004).Time to union was only affected by the number of previous
failed procedures
(p = 0.006). An improvement of 79% and 32.2% in SF-12 physical and
mental score, respectively, was noted within the first post-operative
year. Rh-BMP-7 combined with bone grafts, enabled healing of the nonunion
and improved quality of life in about 80% of patients. Aseptic nonunions
were much more likely to unite than septic ones. The number of previous
failed operations significantly delayed the time to union. Cite this article:
The Motec cementless modular metal-on-metal ball-and-socket
wrist arthroplasty was implanted in 16 wrists with scaphoid nonunion
advanced collapse (SNAC; grades 3 or 4) and 14 wrists with scapholunate
advanced collapse (SLAC) in 30 patients (20 men) with severe (grades
3 or 4) post-traumatic osteoarthritis of the wrist. The mean age of
the patients was 52 years (31 to 71). All prostheses integrated
well radiologically. At a mean follow-up of 3.2 years (1.1 to 6.1)
no luxation or implant breakage occurred. Two wrists were converted
to an arthrodesis for persistent pain. Loosening occurred in one
further wrist at five years post-operatively. The remainder demonstrated close
bone–implant contact. The clinical results were good, with markedly
decreased Disabilities of the Arm Shoulder and Hand (DASH) and pain
scores, and increased movement and grip strength. No patient used
analgesics and most had returned to work. Good short-term function was achieved using this wrist arthroplasty
in a high-demand group of patients with post-traumatic osteoarthritis.
We undertook this study to determine the minimum
amount of coronoid necessary to stabilise an otherwise intact elbow
joint. Regan–Morrey types II and III, plus medial and lateral oblique
coronoid fractures, collectively termed type IV fractures, were
simulated in nine fresh cadavers. An electromagnetic tracking system
defined the three-dimensional stability of the ulna relative to
the humerus. The coronoid surface area accounts for 59% of the anterior articulation.
Alteration in valgus, internal and external rotation occurred only
with a type III coronoid fracture, accounting for 68% of the coronoid
and 40% of the entire articular surface. A type II fracture removed
42% of the coronoid articulation and 25% of the entire articular
surface but was associated with valgus and external rotational changes
only when the radial head was removed, thereby removing 67% of the
articular surface. We conclude that all type III fractures, as defined here, are
unstable, even with intact ligaments and a radial head. However,
a type II deficiency is stable unless the radial head is removed.
Our study suggests that isolated medial-oblique or lateral-oblique
fractures, and even a type II fracture with intact ligaments and
a functional radial head, can be clinically stable, which is consistent
with clinical observation.
The lateral ligament complex is the primary constraint to posterolateral rotatory laxity of the elbow, and if it is disrupted during surgery, posterolateral instability may ensue. The Wrightington approach to the head of the radius involves osteotomising the ulnar insertion of this ligament, rather than incising through it as in the classic posterolateral (Kocher) approach. In this biomechanical study of 17 human cadaver elbows, we demonstrate that the surgical approach to the head can influence posterolateral laxity, with the Wrightington approach producing less posterolateral rotatory laxity than the posterolateral approach.
The aim of this retrospective multicentre study was to report the continued occurrence of compartment syndrome secondary to paediatric supracondylar humeral fractures in the period 1995 to 2005. The inclusion criteria were children with a closed, low-energy supracondylar fracture with no associated fractures or vascular compromise, who subsequently developed compartment syndrome. There were 11 patients (seven girls and four boys) identified from eight hospitals in three countries. Ten patients with severe elbow swelling documented at presentation had a mean delay before surgery of 22 hours (6 to 64). One patient without severe swelling documented at presentation suffered arterial entrapment following reduction, with a subsequent compartment syndrome requiring fasciotomy 25 hours after the index procedure. This series is noteworthy, as all patients had low-energy injuries and presented with an intact radial pulse. Significant swelling at presentation and delay in fracture reduction may be important warning signs for the development of a compartment syndrome in children with supracondylar fractures of the humerus.
We have reviewed five adult patients treated with endoprosthetic reconstruction of the proximal radius following resection of non-traumatic lesions. The patients had a mean age of 33.4 years (20 to 60) at the time of surgery and the mean follow-up was 7.6 years (0.8 to 16). Following surgery, all elbows were clinically stable and there was 100% survivorship of the prosthesis. Evaluation of function was assessed clinically and by the Mayo Elbow Performance Score, achieving a mean of 86% (70 to 100). Results at medium-term follow-up are encouraging with regards to elbow stability, implant survivorship and functional outcome.
The most prevalent disorders of the shoulder are related to the
muscles of rotator cuff. In order to develop a mechanical method
for the evaluation of the rotator cuff muscles, we created a database
of isometric force generation by the rotator cuff muscles in normal
adult population. We hypothesised the existence of variations according
to age, gender and dominancy of limb. A total of 400 healthy adult volunteers were tested, classified
into groups of 50 men and women for each decade of life. Maximal
isometric force was measured at standardised positions for supraspinatus,
infraspinatus and subscapularis muscles in both shoulders in every
person. Torque of the force was calculated and normalised to lean body
mass. The profiles of mean torque-time curves for each age and gender
group were compared.Objectives
Methods
The aim of this study was to determine whether
the high-sensitivity modified Glasgow prognostic score (Hs-mGPS) could
predict the disease-specific survival and oncological outcome in
adult patients with non-metastatic soft-tissue sarcoma before treatment.
A total of 139 patients treated between 2001 and 2012 were retrospectively reviewed.
The Hs-mGPS varied between 0 and 2. Patients with a score of 2 had
a poorer disease-specific survival than patients with a score of
0 (p <
0.001). The estimated five-year rate of disease-specific
survival for those with a score of 2 was 0%, compared with 85.4%
(95% CI 77.3 to 93.5) for those with a score of 0. Those with a
score of 2 also had a poorer disease-specific survival than those
with a score of 1 (75.3%, 95% CI 55.8 to 94.8; p <
0.001). Patients
with a score of 2 also had a poorer event-free rate than those with
a score of 0 (p <
0.001). Those with a score of 2 also had a
poorer event-free survival than did those with a score of 1 (p =
0.03). A multivariate analysis showed that the Hs-mGPS remained
an independent predictor of survival and recurrence. The Hs-mGPS
could be a useful prognostic marker in patients with a soft-tissue
sarcoma. Cite this article:
We report our experience of the use of callus distraction with a monolateral fixator for the treatment of acquired radial club-hand deformity after osteomyelitis. Between 1994 and 2004, 13 patients with a mean age of eight years (4 to 15) were treated by callus distraction with a monolateral fixator after a preliminary period of at least four weeks in a corrective short-arm cast. All patients achieved bony union and were satisfied with the functional and cosmetic outcome. There were no major complications, but three patients required cancellous bone grafting at the docking site for delayed union. Local treatment and oral antibiotics were required for pin-site infection in six patients. There were no deep infection or recurrence of osteomyelitis.
The osteoinductive properties of demineralised
bone matrix have been demonstrated in animal studies. However, its therapeutic
efficacy has yet to be proven in humans. The clinical properties
of AlloMatrix, an injectable calcium-based demineralised bone matrix
allograft, were studied in a prospective randomised study of 50
patients with an isolated unstable distal radial fracture treated
by reduction and Kirschner (K-) wire fixation. A total of 24 patients
were randomised to the graft group (13 men and 11 women, mean age
42.3 years (20 to 62)) and 26 to the no graft group (8 men and 18
women, mean age 45.0 years (17 to 69)). At one, three, six and nine weeks, and six and 12 months post-operatively,
patients underwent radiological evaluation, assessments for range
of movement, grip and pinch strength, and also completed the Disabilities
of Arm, Shoulder and Hand questionnaire. At one and six weeks and
one year post-operatively, bone mineral density evaluations of both
wrists were performed. No significant difference in wrist function and speed of recovery,
rate of union, complications or bone mineral density was found between
the two groups. The operating time was significantly higher in the
graft group (p = 0.004). Radiologically, the reduction parameters
remained similar in the two groups and all AlloMatrix extraosseous leakages
disappeared after nine weeks. This prospective randomised controlled trial did not demonstrate
a beneficial effect of AlloMatrix demineralised bone matrix in the
treatment of this category of distal radial fractures treated by
K-wire fixation. Cite this article:
We assessed the short- to mid-term survival of
metallic press-fit radial head prostheses in patients with radial
head fractures and acute traumatic instability of the elbow. The medical records of 42 patients (16 males, 26 females) with
a mean age of 56 years (23 to 85) with acute unstable elbow injuries,
including a fracture of the radial head requiring metallic replacement
of the radial head, were reviewed retrospectively. Survival of the
prosthesis was assessed from the radiographs of 37 patients after
a mean follow-up of 50 months (12 to 107). The functional results
of 31 patients were assessed using range-of-movement, Mayo elbow
performance score (MEPS), Disabilities of the Arm, Shoulder and
Hand (DASH) score and the RAND 36-item health survey. At the most recent follow-up 25 prostheses were still well fixed,
nine had been removed because of loosening, and three remained implanted
but were loose. The mean time from implantation to loosening was
11 months (2 to 24). Radiolucent lines that developed around the
prosthesis before removal were mild in three patients, moderate
in one and severe in five. Range of movement parameters and mass
grip strength were significantly lower in the affected elbow than
in the unaffected side. The mean MEPS score was 86 (40 to 100) and
the mean DASH score was 23 (0 to 81). According to RAND-36 scores,
patients had more pain and lower physical function scores than normal population
values. Loosening of press-fit radial head prostheses is common, occurs
early, often leads to severe osteolysis of the proximal radius,
and commonly requires removal of the prosthesis.