Assessment of Intra-articular Screw Penetration During Radial Head and Olecranon Locking Plate Fixation: A Cadaveric Study.

BACKGROUND: The purpose of this study is to evaluate the role of radiographic and clinical exams in predicting screw penetration into the proximal radioulnar joint and ulnohumeral joint during open reduction and internal fixation of the radial head and proximal ulna. METHODS: Olecranon and radial head plates were applied to 15 cadaveric elbows. Screws were assessed for intra-articular joint penetration using both clinical exam and radiographic evaluation. Clinical exam consisted of evaluation for crepitus. Radiographs demonstrating screws positioned near the joint surface were evaluated for penetration by 3 fellowship trained hand surgeons. Elbows were disarticulated and screw prominence was determined and recorded using standardized calipers. The ability of clinical and radiographic exams to correctly predict a breach in the articular surface was determined by calculating sensitivity, specificity, and predictive values. Consideration was given to screw position. RESULTS: The sensitivity of crepitus was 81.1% for screws in the radial head plate and 72.6% for screws in the olecranon plate. The sensitivity of radiographs was 72.4% for the screws in the radial head plate and 55.0% for screws in the olecranon plate. Correct radiographic assessment of penetration varied but position o-2 on the olecranon plate consistently resulted in the lowest sensitivity of 30.3%. CONCLUSIONS: The study evaluates sensitivity and specificity of clinical and radiographic means when assessing for articular penetration of screws during olecranon and radial head locking plate fixation. Certain screw locations are more difficult to evaluate than others and may go undetected by standard means of assessment used in a surgical setting.

Intermediate-term to long-term outcome of surgically and nonsurgically treated congenital, isolated radial head dislocation.

PURPOSE: Adolescent patients with congenital radial head dislocation presenting with pain and limitation in motion might benefit from radial head excision. We report objective and patient-rated data for patients treated with radial head excision and those followed nonsurgically. We hypothesized that surgery would improve pain and motion and that outcomes and the need for additional surgery would be similar between the 2 groups. METHODS: We reviewed our surgical logs and identified 16 patients (10 treated surgically and 6 treated nonsurgically) for participation. At a mean of 10 years for the surgical group and 16 years after initial office visit for the nonsurgical group, we collected patient-rated and objective data, including range of motion, strength, and pain at the wrist or elbow. RESULTS: Eight of 16 patients had bilateral dislocations. Preoperative and postoperative elbow flexion (137° versus 135°) and extension (27° versus 23°) were unchanged in surgically treated patients. Forearm rotation was improved after surgery (100° versus 119°). Carrying angle was similar between surgical (17°) and nonsurgical (13°) elbows, but surgically treated elbows had significantly different ulnar variance at +4.9 mm compared to -0.4 mm for the nonsurgically treated patients. Surgically treated patients had significant improvement in elbow pain following radial head excision. Final Quick Disabilities of the Arm, Shoulder, and Hand scores were similar between groups, although there were lower mean scores among nonsurgically treated patients. CONCLUSIONS: Radial head excision in patients with symptomatic, isolated, congenital radial head dislocations resulted in substantial pain relief and patient satisfaction but modest improvement in forearm rotation and no improvement in elbow flexion-extension. Furthermore, more than 25% of the surgically treated limbs developed wrist pain and needed additional surgery. The nonsurgical group did not lose motion, develop pain, or need surgery. This information might help make the decision whether to excise the radial head in patients with symptomatic, congenital radial head dislocation.

Screw depth sounding in proximal humerus fractures to avoid iatrogenic intra-articular penetration.

Unstable and displaced proximal humerus fractures remain a treatment challenge. The use of locked plates has improved construct stability, but complication rates remain high. Biomechanical studies have emphasized the importance of anchoring screws in the subchondral bone of the humeral head to improve implant stability. However, the spherical shape of the proximal humerus and the limited tactile sensation of its soft cancellous bone make determining accurate screw length difficult, and reported rates of intraoperative screw penetration are high. Iatrogenic screw penetration, even if recognized and corrected before leaving the operating room, may lead to late failure. We present a simple technique of quickly and safely determining screw length using a blunt-tipped Kirschner wire and instruments found in basic orthopaedic sets.