Increased articular exposure of the lateral elbow joint with the anconeus approach compared to the Kocher approach: a cadaver study.

INTRODUCTION: The Kocher approach is the workhorse approach to the lateral elbow. However, the exposure is often limited, particularly for open reduction. The purpose of this study is to quantitatively compare the articular exposure of the anconeus and Kocher approaches to the lateral elbow. METHODS: Eight surgical approaches (four Kocher and four Anconeus) were performed on four fresh cadavers. The right elbows of the first two specimens were dissected via the Kocher approach, and the left elbows via the anconeus approach. For the remaining two specimens, the laterality of the approaches was reversed. Access to key articular landmarks were assessed, including the capitellum, humeral trochlea, radial head, olecranon, coronoid process, and greater and lesser sigmoid notches of the ulna. A calibrated digital image was taken from the optimum surgeon's viewing angle of each approach, and these images were analyzed with ImageJ software (NIH, Bethesda, MD, USA) to calculate the area of exposed articular surfaces. RESULTS: The average surface area exposed was 2.9 times greater with the anconeus approach compared with the standard Kocher approach (8.3 vs 3.1 cm2, p value 0.001). All key anatomic landmarks were directly visualized with the anconeus approach in each specimen. Visualization of the humeral trochlea, olecranon, coronoid process, and greater and lesser sigmoid notches of the ulna was not obtained in any of the Kocher approaches. DISCUSSION: The Anconeus approach provides superior exposure of the lateral elbow joint compared with the Kocher approach. We recommend consideration of the anconeus approach for treatment of select traumatic injuries of the lateral elbow requiring increased access to the ulnohumeral and radiocapitellar joints.

Vertical shear pelvic ring injuries: do transsacral screws prevent fixation failure?

OBJECTIVES: To determine the frequency of fixation failure after transsacral-transiliac (TS) screw fixation of vertical shear (VS) pelvic ring injuries (OTA/AO 61C1) and to describe the mechanism of failure of TS screws. DESIGN: Retrospective cohort study. SETTING: Level 1 academic trauma center. PATIENTS/PARTICIPANTS: Twenty skeletally mature patients with unilateral, displaced, unequivocal VS injuries were identified between May 1, 2009 and April 31, 2016. Mean age was 31 years and mean follow-up was 14 months. Twelve had sacroiliac dislocations (61C1.2) and eight had vertical sacral fractures (61C1.3). INTERVENTION: Operative treatment with at least one TS screw. MAIN OUTCOME MEASUREMENTS: Radiographic failure, defined as a change of >1 cm of combined displacement of the posterior pelvis compared with the intraoperative position on inlet and outlet radiographs. RESULTS: Radiographic failure occurred in 4 of 8 (50%) vertical sacral fractures. Posterior fixation was comprised of a single TS screw in 3 of these 4 failures. The dominant mechanism of screw failure was bending. All of these failures occurred early in the postoperative period. No fixation failures occurred among the sacroiliac dislocations. There were no deep infections or nonunions. CONCLUSIONS: This is the first study to describe the mechanism of failure of TS screws in a clinical setting after VS pelvic injuries. We caution surgeons from relying on single TS screw fixation for vertically unstable sacral fractures. Close radiographic monitoring in the first few weeks after surgery is advised. LEVEL OF EVIDENCE: Level IV.

Isolated Segmental Humeral Shaft Fracture Without Vascular Compromise Complicated by Brachial Compartment Syndrome: A Case Report.

CASE: We report an unusual case of a closed humeral shaft fracture, with no vascular compromise, resulting in brachial compartment syndrome. Our patient was successfully treated with fasciotomy and external fixation, followed by staged open reduction and internal fixation and skin grafting. CONCLUSION: Although uncommon in the upper arm, suspicion for compartment syndrome should remain high for patients with unrelieved pain and swelling after humeral shaft fracture. Serial physical examination and invasive monitoring can assist in the diagnosis. Fasciotomy and staged fracture repair can yield good results.