Functional outcomes of elbow injuries managed according to the Wrightington classification of elbow fracture-dislocations.

Background: This study aims to review the functional outcomes of patients managed by the application of the Wrightington elbow fracture-dislocation classification system and its corresponding management algorithms. Methods: This is a retrospective consecutive case series of patients over the age of 16 with an elbow fracture-dislocation managed according to the Wrightington classification. The primary outcome was the Mayo Elbow Performance Score (MEPS) at the last follow-up. Range of movement (ROM) and complications were collected as a secondary outcome. Results: Sixty patients qualified for inclusion (32 female, 28 male) with a mean age of 48 years (19-84). Fifty-eight (97%) patients completed a minimum of three months follow-up. Mean follow-up was six months (3-18). The median MEPS at the final follow-up was 100 (interquartile range [IQR] 85-100) and median ROM of 123° (IQR 101-130) degrees. Four patients underwent secondary surgery and had improved outcomes with the average MEPS score improving from 65 to 94 following the second surgery. Conclusions: The results of this study show that good outcomes can be achieved for complex elbow fracture-dislocations through pattern recognition and management with an anatomically based reconstruction algorithm as described by the Wrightington classification system.

Reliability and validity of the Wrightington classification of elbow fracture-dislocation.

AIMS: The Wrightington classification system of fracture-dislocations of the elbow divides these injuries into six subtypes depending on the involvement of the coronoid and the radial head. The aim of this study was to assess the reliability and reproducibility of this classification system. METHODS: This was a blinded study using radiographs and CT scans of 48 consecutive patients managed according to the Wrightington classification system between 2010 and 2018. Four trauma and orthopaedic consultants, two post CCT fellows, and one speciality registrar based in the UK classified the injuries. The seven observers reviewed preoperative radiographs and CT scans twice, with a minimum four-week interval. Radiographs and CT scans were reviewed separately. Inter- and intraobserver reliability were calculated using Fleiss and Cohen kappa coefficients. The Landis and Koch criteria were used to interpret the strength of the kappa values. Validity was assessed by calculating the percentage agreement against intraoperative findings. RESULTS: Of the 48 patients, three (6%) had type A injury, 11 (23%) type B, 16 (33%) type B+, 16 (33%) Type C, two (4%) type D+, and none had a type D injury. All 48 patients had anteroposterior (AP) and lateral radiographs, 44 had 2D CT scans, and 39 had 3D reconstructions. The interobserver reliability kappa value was 0.52 for radiographs, 0.71 for 2D CT scans, and 0.73 for a combination of 2D and 3D reconstruction CT scans. The median intraobserver reliability was 0.75 (interquartile range (IQR) 0.62 to 0.79) for radiographs, 0.77 (IQR 0.73 to 0.94) for 2D CT scans, and 0.89 (IQR 0.77 to 0.93) for the combination of 2D and 3D reconstruction. Validity analysis showed that accuracy significantly improved when using CT scans (p = 0.018 and p = 0.028 respectively). CONCLUSION: The Wrightington classification system is a reliable and valid method of classifying fracture-dislocations of the elbow. CT scans are significantly more accurate than radiographs when identifying the pattern of injury, with good intra- and interobserver reproducibility. Cite this article: Bone Joint J 2020;102-B(8):1041-1047.

The use of low-intensity pulsed ultrasound in hand and wrist nonunions.

The management of hand and wrist nonunions is challenging and alternatives or adjuncts to surgery to promote healing are an attractive prospect. Low-intensity pulsed ultrasound (LIPUS) is reported to improve bone healing and is supported for use in nonunions. However, evidence supporting its use for established nonunions is based largely on long bones, with little evidence guiding use in the hand and wrist. The objective of this study is to present our experience using LIPUS in established nonunions of the hand and wrist. This is a retrospective cohort study of hand and wrist nonunions managed with LIPUS in two UK tertiary referral centers. Nonunion was defined as the failure of fracture healing at a minimum of 9 months post injury. Demographic and clinical data including nonunion site, union rates, surgery and time from surgery to LIPUS application were obtained from electronic patient and LIPUS device records. Patients were subcategorized into early or delayed LIPUS applications groups. Twenty-six hand and wrist nonunions were treated with LIPUS alone or as a surgical adjunct. The overall union rate was 62%. Age, sex, fracture characteristics and previous treatment had no significant effect on union rates. There was no association between LIPUS timing and union following adjustment for co-variates. Our findings suggest previously quoted union rates using LIPUS for lower limb nonunions may not be achievable in the hand and wrist. However, LIPUS offers a safe adjunct to surgery and may offer a potential alternative when surgery is not feasible. Further prospective comparative studies are required before the efficacy of LIPUS for hand and wrist nonunions is proven.

Dip and drip, swipe or squeeze? The best method of draining water for optimal strength in a plaster of Paris backslab.

Plaster of Paris backslabs are used post-operatively to provide stability and protect repaired structures. We hypothesized that forceful expulsion of excess water during backslab construction could weaken the backslab by reducing the final gypsum content. Our aim was to compare the final dry mass and strength of backslabs prepared by three different techniques: 'dip and drip', 'swipe' and 'squeeze'. We applied an increasing force until the point of failure of the 30 backslabs prepared by the three methods. Backslabs prepared by swiping or squeezing away excess water were 9% lighter and 26% weaker and 13% lighter and 33% weaker, respectively, in comparison with simple drip drainage, and all results were statistically significant. We conclude that forceful drainage of excess water produces significantly weaker backslabs.

Horizontal cleavage tear of discoid medial meniscus diagnosed on MRI and treated with arthroscopic partial resection.

PURPOSE: To provided an evidence-based summarisation of the discoid medial meniscus in conjunction with a case report describing a novel management approach which includes MRI-assisted pre-operative planning and a limited meniscal resection. METHODS: Case report and structured literature review of Medline referenced articles from 1941 to 2011. RESULTS: Forty-one papers describing 61 patients and 82 discoid medial menisci were identified. Data extracted included patient demographics, diagnostic techniques, operative interventions, and associated pathological findings. These findings were compared with the index case report. A new technique involving MRI-assisted pre-operative planning and limited meniscal resection is described. CONCLUSION: The discoid medial meniscus remains a rare abnormality with significant associated morbidity. It continues to provide physicians with both diagnostic and interventional challenges. MRI-assisted pre-operative planning can provide surgeons with the opportunity to plan for limited resection so as to maximally lessen the probability of early-onset osteoarthritis which may result from loss of meniscal tissue.