We reviewed 42 consecutive children with a supination deformity of the forearm complicating severe birth lesions of the brachial plexus. The overall incidence over the study period was 6.9% (48 of 696). It was absent in those in Narakas group I (27.6) and occurred in 5.7% of group II (13 of 229), 9.6% of group III (11 of 114) and 23.4% of group IV (18 of 77). Concurrent deformities at the shoulder, elbow, wrist and hand were always present because of muscular imbalance from poor recovery of C5 and C7, inconsistent recovery of C8 and T1 and good recovery of C6. Early surgical correction improved the function of the upper limb and hand, but there was a tendency to recurrence. Pronation osteotomy placed the hand in a functional position, and increased the arc of rotation of the forearm. The supination deformity recurred in 40% (17 of 42) of those treated by pronation osteotomy alone, probably because of remodelling of the growing bone. Children should be followed up until skeletal maturity, and the parents counselled on the likelihood of multiple operations

Despite being one of the most common injuries around the elbow, the optimal treatment of olecranon fractures is far from established and stimulates debate among both general orthopaedic trauma surgeons and upper limb specialists. It is almost universally accepted that stable non-displaced fractures can be safely treated nonoperatively with minimal specialist input. Internal fixation is recommended for the vast majority of displaced fractures, with a range of techniques and implants to choose from. However, there is concern regarding the complication rates, largely related to symptomatic metalwork resulting in high rates of implant removal. As the number of elderly patients sustaining these injuries increases, we are becoming more aware of the issues associated with fixation in osteoporotic bone and the often fragile soft-tissue envelope in this group. Given this, there is evidence to support an increasing role for nonoperative management in this high-risk demographic group, even in those presenting with displaced and/or multifragmentary fracture patterns. This review summarizes the available literature to date, focusing predominantly on the management techniques and available implants for stable fractures of the olecranon. It also offers some insights into the potential avenues for future research, in the hope of addressing some of the pertinent questions that remain unanswered.

Cite this article: Bone Joint J 2023;105-B(2):112–123.

We have assessed the influence of isolated and combined rotational malunion of the radius and ulna on the rotation of the forearm. Osteotomies were made in both the radius and the ulna at the mid-diaphyseal level of five cadaver forearms and stabilised with intramedullary metal implants. Malunion about the axis of the respective forearm bone was produced at intervals of 10°. The ranges of pronation and supination were recorded by a potentiometer under computer control. We examined rotational malunions of 10° to 80° of either the radius or ulna alone and combined rotational malunions of 20° to 60° of both the radius and ulna. Malunion of the ulna in supination had little effect on rotation of the forearm. Malunion of either the radius or of the ulna in pronation gave a moderate reduction of rotation of the forearm. By contrast, malunion of the radius in supination markedly reduced rotation of the forearm, especially with malunion greater than 60°. Combined rotational malunion produced contrasting results. A combination of rotational malunion of the radius and ulna in the same direction had an effect similar to that of an isolated malunion of the radius. A combination in the opposite direction gave the largest limitation of the range of movement. Clinically, rotational malunion may be isolated or part of a complex angular/rotational deformity and rotational malunion may lead to marked impairment of rotation of the forearm. A reproducible method for assessing rotational malunion is therefore needed

A series of 26 children was referred to our specialist unit with a ‘pink pulseless hand’ following a supracondylar fracture of the distal humerus after a mean period of three months (4 days to 12 months) except for one referred after almost three years. They were followed up for a mean of 15.5 years (4 to 26). The neurovascular injuries and resulting impairment in function and salvage procedures were recorded. The mean age at presentation was 8.6 years (2 to 12). There were eight girls and 18 boys. Only four of the 26 patients had undergone immediate surgical exploration before referral and three of these four had a satisfactory outcome. In one child the brachial artery had been explored unsuccessfully at 48 hours. As a result 23 of the 26 children presented with established ischaemic contracture of the forearm and hand. Two responded to conservative stretching. In the remaining 21 the antecubital fossa was explored. The aim of surgery was to try to improve the function of the hand and forearm, to assess nerve, vessel and muscle damage, to relieve entrapment and to minimise future disturbance of growth. Based on our results we recommend urgent exploration of the vessels and nerves in a child with a ‘pink pulseless hand’, not relieved by reduction of a supracondylar fracture of the distal humerus and presenting with persistent and increasing pain suggestive of a deepening nerve lesion and critical ischaemia

Repeated trauma to the radial head may be one of the causative factors in the genesis of osteochondritis dissecans of the capitellum. We measured the force, contact area and pressure across the radiocapitellar articulation of the elbow before and after radial shortening osteotomy in five fresh-frozen cadaver upper limbs with loads of 45, 90 and 135 N, respectively. Measurements were made on pressure-sensitive film placed in the radiocapitellar articulation with the forearm in the supinated, neutral and pronated positions before and after radial shortening. Radial shortening significantly reduced the mean force and contact area across the radiocapitellar articulation in all positions of the forearm

The December 2023 Children’s orthopaedics Roundup³⁶⁰ looks at: A comprehensive nonoperative treatment protocol for developmental dysplasia of the hip in infants; How common are refractures in childhood?; Femoral nailing for paediatric femoral shaft fracture in children aged eight to ten years; Who benefits from allowing the physis to grow in slipped capital femoral epiphysis?; Paediatric patients with an extremity bone tumour: a secondary analysis of the PARITY trial data; Split tibial tendon transfers in cerebral palsy equinovarus foot deformities; Liposomal bupivacaine nerve block: an answer to opioid use?; Correction with distal femoral transphyseal screws in hemiepiphysiodesis for coronal-plane knee deformity.

Aims

In patients with a failed radial head arthroplasty (RHA), simple removal of the implant is an option. However, there is little information in the literature about the outcome of this procedure. The aim of this study was to review the mid-term clinical and radiological results, and the rate of complications and removal of the implant, in patients whose initial RHA was undertaken acutely for trauma involving the elbow.

We reviewed the clinical and radiological results of six patients who had sustained traumatic separation of the distal epiphysis of the humerus at birth. The correct diagnosis was made from plain radiographs and often supplemented with ultrasonography, MRI and arthrography. An orthopaedic surgeon saw two patients within two days of birth, and the other four were seen at between nine and 30 days. The two neonates underwent unsuccessful attempts at closed reduction. In the remaining patients, seen after the age of eight days, no attempt at reduction was made. All six displaced fractures were immobilised in a cast with the elbow at 90° of flexion and the forearm pronated. When seen at a mean of 58 months (16 to 120) after injury, the clinical and radiological results were excellent in five patients, with complete realignment of the injury. In one patient the forearm lay in slightly reduced valgus with the elbow in full extension. Traumatic separation of the distal epiphysis of the humerus may be missed on the maternity wards and not diagnosed until after discharge from hospital. However, even when no attempt is made to reduce the displaced epiphysis, a good clinical result can be expected

The Essex-Lopresti injury is rare. It consists of fracture of the head of the radius, rupture of the interosseous membrane and disruption of the distal radioulnar joint. The injury is often missed because attention is directed towards the fracture of the head of the radius. We present a series of 12 patients with a mean age of 44.9 years (26 to 54), 11 of whom were treated surgically at a mean of 4.6 months (1 to 16) after injury and the other after 18 years. They were followed up for a mean of 29.2 months (2 to 69). Ten patients had additional injuries to the forearm or wrist, which made diagnosis more difficult. Replacement of the head of the radius was carried out in ten patients and the Sauve-Kapandji procedure in three. Patients were assessed using standard outcome scores. The mean post-operative Disabilities of the Arm, Shoulder and Hand score was 55 (37 to 83), the mean Morrey Elbow Performance score was 72.2 (39 to 92) and the mean Mayo wrist score was 61.3 (35 to 80). The mean grip strength was 68.5% (39.6% to 91.3%) of the unaffected wrist. Most of the patients (10 of 12) were satisfied with their operation and in 11 the pain was relieved. When treating the chronic Essex-Lopresti injury, we recommend accurate realignment of the radius and ulna and replacement of the head of the radius. If this fails a Sauve-Kapandji procedure to arthrodese the distal radioulnar joint should be undertaken to stabilise the forearm while maintaining mobility

Aims

To investigate the risk factors for unsuccessful radial head reduction (RHR) in children with chronic Monteggia fractures (CMFs) treated surgically.

Aims

To propose a new method for evaluating paediatric radial neck fractures and improve the accuracy of fracture angulation measurement, particularly in younger children, and thereby facilitate planning treatment in this population.

The February 2023 Shoulder & Elbow Roundup³⁶⁰ looks at: Arthroscopic capsular release or manipulation under anaesthesia for frozen shoulder?; Distal biceps repair through a single incision?; Distal biceps tendon ruptures: diagnostic strategy through physical examination; Postoperative multimodal opioid-sparing protocol vs standard opioid prescribing after knee or shoulder arthroscopy: a randomized clinical trial; Graft healing is more important than graft technique in massive rotator cuff tear; Subscapularis tenotomy versus peel after anatomic shoulder arthroplasty; Previous rotator cuff repair increases the risk of revision surgery for periprosthetic joint infection after reverse shoulder arthroplasty; Conservative versus operative treatment of acromial and scapular spine fractures following reverse total shoulder arthroplasty.

The August 2024 Trauma Roundup³⁶⁰ looks at: Does topical vancomycin prevent fracture-related infections in closed fractures undergoing open reduction and internal fixation? A randomized controlled trial; Is postoperative splinting advantageous after upper limb fracture surgery?; Does suprapatellar nailing resolve knee pain?; Locking versus non-locking plate fixation in comminuted talar neck fractures: a biomechanical study using cadaveric specimens; Revolutionizing recovery metrics: PROMIS versus SMFA in orthopaedic trauma care; Dorsal hook plating of patella fractures: reliable fixation and satisfactory outcomes; The impact of obesity on subtrochanteric femur fracture outcomes; Low-dose NSAIDs (ketorolac) and cytokine modulation in orthopaedic polytrauma: a detailed analysis.

From the experimental evidence above, it is clear that in the upper four centimetres of the forearm the posterior interosseous nerve moves up to one centimetre or more medially relative to the radius on pronation of the forearm. This movement becomes of importance when considered in relation to methods of operative approach for excision of the radial head. Operative approaches have been described in which emphasis has been placed on the position of incision, but in none of these is there any mention of the position of the forearm. We suggest that the following precautions should be taken. 1) During excision of the radial head the forearm should be kept in full pronation. 2) The incision should be as posterior as possible to ensure that it is well clear of the nerve. 3) With the forearm pronated the incision extends from a little above the lateral epicondyle along the postero-lateral aspect of the forearm for not more than 5 centimetres; proportionately less in a child. 4) The surgical assistant's attention should be brought to the damage that the posterior interosseous nerve might sustain from undue pressure–for instance by retraction, especially by bone levers–in the anterior part of the wound

Aims

The aim of this study was to analyze how proximal radial neck resorption (PRNR) starts and progresses radiologically in two types of press-fit radial head arthroplasties (RHAs), and to investigate its clinical relevance.

An attempt has been made to describe some of the ways in which the element of rotation, which is so important a part of the function of the normal forearm, has a bearing upon the mechanism and treatment of forearm injuries. In particular, distinction is drawn between those injuries in which the shaft of the radius remains in continuity, and those in which there is a complete fracture of the bone. In the former, rotation of the hand in the reduction will be transmitted to the upper end of the radius, and extremes of rotational movement may safely be used to obtain and hold a reduction. In the latter there is likely to be a rotational deformity between the two radial fragments, and the lower radial fragment must be placed in accurate rotational alignment with the upper. In the first group reduction, and in certain cases immobilisation, in full pronation or full supination has been shown to have a place in the treatment of those cases in which a rotation violence has shaped the pattern of the injury. Soft tissues may be used to guide and hold a reduction in a rotational injury, just as in injuries of other types. An injury caused by forced pronation should logically be treated in full supination, for only thus are the intact soft tissues on the "pronation side" of the limb used to the best advantage. In the mechanism of injuries caused by rotation violence it is emphasized that vertical compression is usually the basic force, to which a rotation force may be added by the direction of momentum of the body weight. Such injuries may be grouped into forced rotation injuries (in which the violence applied has taken the limb beyond the normal ranges of rotational movement), and injuries occurring while the limb is pronating or supinating. In the latter group the rotational element determines the pattern of the injury: pronation and flexion are closely allied, and a fracture occurring while the forearm is pronating will develop a backward angulation: so also a supination injury will produce a forward angulation. On the basis of these considerations injuries of the forearm may be classified as follows:. Injuries in which the shaft of the radius remains in continuity. Forced proiiation injuries:. 1) Forward dislocation of the head of the radius. 2) Backward dislocation of the lower end of the ulna. 3) The anterior Monteggia fracture-dislocation. These injuries should be reduced and immobilised in full supination to prevent recurrence of deformity. The lateral and posterior Monteggia injuries are probably variants of dislocation of the elbow and are not caused by rotation violence. In general it is considered that all dislocations of the head of the radius are best treated in full supination. Pronation injuries:. Greenstick fractures of the radius, and of both bones of the forearm, with backward angulation. Reduction of deformity is most easily obtained by manipulating into full supination. Certain fractures may with advantage be immobilised in this position. Supination injuries:. Greenstick fractures of the forearm with forward angulation. Reduction is best obtained by full pronation. Injuries in which the shaft of the radius is in two separate fragments. This group includes all complete fractures of the shaft of the radius and of both bones of the forearm. There is nearly always a rotational deformity between the two radial fragments and its correction is a dominant factor in the treatment

Aims

Osteoporosis (OP) is a metabolic bone disease, characterized by a decrease in bone mineral density (BMD). However, the research of regulatory variants has been limited for BMD. In this study, we aimed to explore novel regulatory genetic variants associated with BMD.

The December 2015 Children’s orthopaedics Roundup. 360 . looks at: Paediatric femoral fractures: a single incision nailing?; Lateral condylar fractures: open or percutaneous?; . Forearm refracture: the risks; Tibial spine fractures; The child’s knee in MRI; The mechanics of SUFE; Idiopathic clubfoot

Aims

Vascular compromise due to arterial injury is a rare but serious complication of a proximal humeral fracture. The aims of this study were to report its incidence in a large urban population, and to identify clinical and radiological factors which are associated with this complication. We also evaluated the results of the use of our protocol for the management of these injuries.

Aims

The aim of the present study was to assess the outcomes of the induced membrane technique (IMT) for the management of infected segmental bone defects, and to analyze predictive factors associated with unfavourable outcomes.