A Prospective Study Evaluating Factors Affecting Functional Outcome in Patients with Floating Elbow Injury.

BACKGROUND: Floating elbow injuries are complex injuries. Due to frequent association with severe soft tissue injuries and polytrauma, they have unpredictable functional outcome. This prospective study is aimed to evaluate the factors affecting functional outcome. METHODS: Thirty patients with floating elbow injuries were treated at a level 1 trauma center from July 2018 to June 2019 with minimum follow-up of 9 months. The outcome was assessed by disability for arm shoulder and hand score (DASH) and mayo elbow performance score (MEPS). RESULTS: The overall incidence was 16.09 per 1000, mostly caused by road traffic accidents and all cases were managed surgically. Age, gender, education, occupation, arm dominance, and mechanism of injury did not significantly affect the outcomes. Open fractures and patients requiring staged procedure were associated with poorer outcomes (p < 0.05); however, delay in surgery for more than 24 h significantly increased the rate of complications. There was no statistical difference in the proportion of patients who had nerve injury pre operatively and post operatively on the final outcome. CONCLUSION: Floating elbow injuries are relatively rare but nowadays the numbers are on the rise. Timely intervention with a multimodal approach and well-supervised rehabilitation can assure better final outcome.

Coexistence of Osteomalacia in Osteoporotic Hip Fractures in More Than 50 Years Age Group.

INTRODUCTION: Osteomalacia is a hitherto common orthopaedic condition and is commonly coexists with osteoporosis. However, the identification of osteomalacia always slips under the radar and more emphasis is given to diagnosis and management of osteoporosis. Identification of osteomalacia is equally relevant as management of the osteoporotic fractures is different with or without osteomalacia. METHODS: This was a prospective study design that included patients 50 years or above of either sex presented with proximal femur fractures. Osteoporosis was identified by DEXA scan of hip and lumbar spine. Metabolic tests including serum calcium, phosphorus, ALP and vitamin D levels were done. Histopathological diagnosis of osteomalacia was performed on bony tissues that were taken during surgery from a site adjacent to the fracture and histological examination was performed on non-decalcified paraffin sections using special stains. RESULTS: A total of 45 patients was included in study. Mean age was 68.7 years (53-85 years). Abnormal values of serum calcium, phosphorus, ALP, vitamin D were noted in 44.4%, 22.2%, 53.3% and 48.9% patients, respectively. On histopathology, 73.17% patients showed osteomalacia. No significant correlation was found between serum biochemical markers and histopathology except with serum Vitamin D (p value - 0.004). CONCLUSION: The majority of patients with osteoporotic hip fractures had coexisting osteomalacia. Abnormal biochemical values were not significantly associated with osteomalacia. Hence, histopathology remains the gold standard for the diagnosis of osteomalacia. Further research is needed to identify a biomarker that may enable the clinician to diagnosis and treat osteomalacia well in time.

Modified cerclage wiring in comminuted transolecranon fracture-dislocations of the elbow.

Transolecranon fracture-dislocations are a result of high-energy trauma, caused due to axial loading of the flexed forearm, with associated anterior dislocation of the ulna with respect to the distal humerus. The usual management of these comminuted and unstable fractures is by using locking compression plates via the dorsal approach. However, plating in cases of poor soft tissue coverage and open wounds can be precarious. In this study, we aimed to evaluate outcomes of cerclage wiring in the management of comminuted trans-olecranon fracture-dislocations in such scenario. A total of seven patients diagnosed with trans-olecranon fracture-dislocation with poor soft tissue coverage who underwent cerclage wiring were included in the study. The aim was to realign the proximal portion of the olecranon to the trochlea and restore the normal ulnohumeral articular relationships accomplished by the anatomical reconstruction of the greater sigmoid notch. Reconstruction of the proximal ulna was started from the distal to the proximal direction so as to convert an unstable fracture into a stable one. After the reduction of the proximal fragment, two long 2 mm K wires were inserted from the tip of the olecranon into the intramedullary canal (with at least 1 wire passed subchondrally), and later cerclage was done. Postoperatively the patient was immobilized for a duration of two weeks and was later started on active assisted mobilization of the elbow. All patients showed fair-to-excellent outcome on the Mayo elbow performance score (MEPS) at the final follow-up (five patients had an excellent score, one had a good score, and one had a fair score). At the final follow-up, the mean extension, flexion, pronation and supination were -20, 117.14, 82.85 and 78.57 degrees respectively. The key components of such management are the restoration of articular congruity, including continuity of the sigmoid cavity, ulnar length, and early initiation of active elbow movements to avoid joint stiffness. Optimal functional results can be achieved with K wire and cerclage when a stable anatomic reconstruction is accomplished, as a feasible alternative to plating.

Functional Outcome of Surgically Treated Isolated Coronoid Fractures With Elbow Dislocation in Young and Active Patients.

Coronoid fractures are less frequent injuries seen in around one-tenth of patients with elbow dislocation. Any injury to the coronoid process can be associated with elbow instability, in which injury to collateral ligaments co-exists, resulting in a loss of congruency of the elbow joint. However, there is a scarcity of evidence regarding patients' management with elbow dislocation and associated coronoid fractures. So, our aim is to assess the functional outcome of the elbow after operative fixation in patients with any type of coronoid fracture with associated elbow dislocation. A total of six patients with closed coronoid fracture of the elbow, with associated elbow dislocation, without any other associated trauma or previous surgery to the same limb, were included in our study. After closed reduction, patients with an incongruent reduction of the elbow joint were operated. The injured structures were repaired in an inside-out sequence: the coronoid fragment was first reduced by using a lasso-type suture. The larger fragments of the coronoid were fixed with either a screw or a plate when deemed necessary. Then, the lateral collateral ligament was repaired either using a suture anchor or transosseous (No. 2 Arthrex; Naples, Florida) sutures. After repair, the elbow was examined for stability radiologically using the hanging arm test; a concentric reduction of the elbow in lateral view during this test indicates a stable elbow. All patients showed a good to excellent outcome on the Mayo elbow performance score (MEPS) at the final follow-up (three patients had an excellent score while three had a good score). At the final follow-up, mean elbow flexion was 124º, loss of extension was 10º in only one patient, mean supination was 80º, and mean pronation was 72º. Isolated fractures of the coronoid associated with elbow dislocation require appropriate evaluation and management. Closed reduction and immobilization alone in young and active patients may not be sufficient, especially in patients with incongruent ulnohumeral joint. Surgical fixation of the coronoid fragment and repair of the collateral ligament, whenever indicated, can provide good functional outcomes.