The posttraumatic stiff elbow: an update.

Posttraumatic elbow stiffness is a disabling condition that remains challenging to treat despite improvement of our understanding of the pathogenesis of posttraumatic contractures and new treatment regimens. This review provides an update and overview of the etiology of posttraumatic elbow stiffness, its classification, evaluation, nonoperative and operative treatment, and postoperative management.

Improvements in elbow motion after resection of heterotopic bone: a systematic review.

Complex elbow trauma, severe burn, or a closed head injury render patients at risk for developing heterotopic ossification around the elbow. When heterotopic ossification restricts elbow motion, some patients request surgical resection. We performed a systematic review of the literature to analyze improvement in elbow motion after resection of heterotopic ossification around the elbow. We found that, on average, etiology had little impact on outcome after resection of heterotopic ossification. Resection of heterotopic bone generally leads to improvement of elbow function.

A randomized controlled trial of nonoperative treatment versus open reduction and internal fixation for stable, displaced, partial articular fractures of the radial head: the RAMBO trial.

BACKGROUND: The choice between operative or nonoperative treatment is questioned for partial articular fractures of the radial head that have at least 2 millimeters of articular step-off on at least one radiograph (defined as displaced), but less than 2 millimeter of gap between the fragments (defined as stable) and that are not associated with an elbow dislocation, interosseous ligament injury, or other fractures. These kinds of fractures are often classified as Mason type-2 fractures. Retrospective comparative studies suggest that operative treatment might be better than nonoperative treatment, but the long-term results of nonoperative treatment are very good. Most experts agree that problems like reduced range of motion, painful crepitation, nonunion or bony ankylosis are infrequent with both nonoperative and operative treatment of an isolated displaced partial articular fracture of the radial head, but determining which patients will have problems is difficult. A prospective, randomized comparison would help minimize bias and determine the balance between operative and nonoperative risks and benefits. METHODS/DESIGN: The RAMBO trial (Radial Head - Amsterdam - Amphia - Boston - Others) is an international prospective, randomized, multicenter trial. The primary objective of this study is to compare patient related outcome defined by the 'Disabilities of Arm, Shoulder and Hand (DASH) score' twelve months after injury between operative and nonoperative treated patients. Adult patients with partial articular fractures of the radial head that comprise at least 1/3rd of the articular surface, have ≥ 2 millimeters of articular step-off but less than 2 millimeter of gap between the fragments will be enrolled. Secondary outcome measures will be the Mayo Elbow Performance Index (MEPI), the Oxford Elbow Score (OES), pain intensity through the 'Numeric Rating Scale', range of motion (flexion arc and rotational arc), radiographic appearance of the fracture (heterotopic ossification, radiocapitellar and ulnohumeral arthrosis, fracture healing, and signs of implant loosening or breakage) and adverse events (infection, nerve injury, secondary interventions) after one year. DISCUSSION: The successful completion of this trial will provide evidence on the best treatment for stable, displaced, partial articular fractures of the radial head. TRIAL REGISTRATION: The trial is registered at the Dutch Trial Register: NTR3413.

Diagnostic accuracy of two-dimensional and three-dimensional imaging and modeling of radial head fractures.

UNLABELLED: To tests the hypothesis that classification and characterization of fractures of the radial head is more accurate with 3D than 2D computed tomography images and radiographs, using a prospective study design with intraoperative inspection as the reference standard. Treating surgeons and first assistants completed a questionnaire assigning a fracture type according to the Broberg and Morrey modification of Mason's classification, evaluating selected fracture characteristics, and electing preferred management based upon radiographs and 2D images alone; then adding 3D-CT; then 3D printed physical models; and finally intra-operative visualization. The addition of the 3D CT and physical models improved the sensitivity for fracture line separating the entire head from the neck, comminution of the radial neck, fracture involving the articular surface, articular fracture gap greater than 2 mm, impacted fracture fragments, greater than 3 articular fragments, and articular fragments judged too small to repair. There were no significant differences in diagnostic performance with the addition of 3D models. The addition of 3D CT and models improved the reliability of Broberg and Morrey classification. We conclude that 3DCT and 3D physical modeling provide more accurate fracture classification and characterization of fracture of the radial head with less proposed variability in treatment. We did not demonstrate a clear advantage for modeling over 3DCT reconstructions. LEVEL OF EVIDENCE: Diagnostic, Level I.

Satisfaction with pain relief after operative treatment of an ankle fracture.

BACKGROUND: American patients are prescribed more opioid pain medication than Dutch patients after operative treatment of an ankle fracture, but it is possible that pain is undertreated in Dutch patients. This study tests if there is a difference in pain and satisfaction with pain relief between Dutch and American patients after operative treatment of ankle fractures. METHODS: Thirty American and 30 Dutch patients were enrolled in a prospective comparative study prior to operative treatment of ankle fractures. Patients rated pain and satisfaction with pain relief on postoperative day 1 (POD1) and at time of suture removal (SR). Pain and satisfaction scores were compared and multivariable analysis identified their predictors. RESULTS: At POD1, a third of Dutch patients used no opioids and a sixth took strong opioids. At SR, only 4 of 30 (13%) were taking tramadol and half were taking no medication. All of the American patients used strong opioid pain medication on POD1 and 19 of 30 (63%) were still taking strong opioids at SR. Patients that did not use opioids and Dutch patients had less pain and equivalent satisfaction with pain relief compared to patients that used opioids and American patients respectively. Nationality was the best predictor of pain intensity at POD1. Opioid medication was the best predictor of pain at SR and decreased satisfaction with pain management. CONCLUSIONS: Pain and satisfaction with pain relief are culturally mediated. Patients that use non-opioid pain medication report less pain and greater satisfaction with pain relief than patients managed with opioid pain medication. LEVEL OF EVIDENCE: Level I, Prognostic Study with more than 80% follow-up.

A prospective randomized controlled trial of dynamic versus static progressive elbow splinting for posttraumatic elbow stiffness.

BACKGROUND: Both dynamic and static progressive (turnbuckle) splints are used to help stretch a contracted elbow capsule to regain motion after elbow trauma. There are advocates of each method, but no comparative data. This prospective randomized controlled trial tested the null hypothesis that there is no difference in improvement of motion and Disabilities of the Arm, Shoulder and Hand (DASH) scores between static progressive and dynamic splinting. METHODS: Sixty-six patients with posttraumatic elbow stiffness were enrolled in a prospective randomized trial: thirty-five in the static progressive and thirty-one in the dynamic cohort. Elbow function was measured at enrollment and at three, six, and twelve months later. Patients completed the DASH questionnaire at enrollment and at the six and twelve-month evaluation. Three patients asked to be switched to static progressive splinting. The analysis was done according to intention-to-treat principles and with use of mean imputation for missing data. RESULTS: There were no significant differences in flexion arc at any time point. Improvement in the arc of flexion (dynamic versus static) averaged 29° versus 28° at three months (p = 0.87), 40° versus 39° at six months (p = 0.72), and 47° versus 49° at twelve months after splinting was initiated (p = 0.71). The average DASH score (dynamic versus static) was 50 versus 45 points at enrollment (p = 0.52), 32 versus 25 points at six months (p < 0.05), and 28 versus 26 points at twelve months after enrollment (p = 0.61). CONCLUSIONS: Posttraumatic elbow stiffness can improve with exercises and dynamic or static splinting over a period of six to twelve months, and patience is warranted. There were no significant differences in improvement in motion between static progressive and dynamic splinting protocols, and the choice of splinting method can be determined by the patients and their physicians.

Fixation of the coronoid process in elbow fracture-dislocations.

BACKGROUND: Terrible triad injuries consist of a posterior dislocation of the elbow, a coronoid fracture, and a radial head fracture. The coronoid plays a pivotal role as an anterior buttress, yet the optimal management of the coronoid fracture remains unknown. We hypothesize that suture lasso fixation of the coronoid fracture leads to fewer complications and improved outcomes compared with screw or suture anchor fixation techniques. METHODS: A retrospective chart review performed at three tertiary care centers identified forty consecutive patients treated for terrible triad injuries of the elbow with a minimum follow-up of eighteen months (mean, twenty-four months; range, eighteen to fifty-three months). All patients were managed with a standard approach consisting of: (1) repair or replacement of the radial head; (2) repair of the lateral ulnar collateral ligament (LUCL) of the elbow; and (3) repair of the coronoid fracture with one of two techniques: Group I (n = 28) consisted of the "lasso" technique and Group II (n = 12) consisted of open reduction and internal fixation (ORIF) with screws or suture anchors. RESULTS: For the study population, the mean postoperative arc of elbow motion was 115° (range, 75° to 140°), the average Disabilities of the Arm, Shoulder and Hand (DASH) score was 16 (range, 0 to 43), and the average Broberg-Morrey score was 90 (range, 64 to 100). For repair of the coronoid fracture, the suture lasso technique was more stable than the other techniques intraoperatively, both before (p < 0.05) and after (p < 0.05) LUCL repair, and at the final follow-up (p < 0.05). ORIF was associated with a higher prevalence of implant failure (p < 0.05), and suture anchors were associated with a higher prevalence of malunion and nonunion (p < 0.05). CONCLUSIONS: For terrible triad injuries, greater stability with fewer complications was achieved with use of the suture lasso technique for coronoid fracture fixation.

Long-term outcomes of fractures of both bones of the forearm.

BACKGROUND: Previous studies identified limited impairment and disability several years after diaphyseal fractures of both the radius and ulna, although the relationship between impairment and disability was inconsistent. This investigation studied skeletally mature and immature patients more than ten years after injury and addressed the hypotheses that (1) objective measurements of impairment correlate with disability, (2) depression and misinterpretation of nociception correlate with disability, and (3) patients injured when skeletally mature or immature have comparable impairment and disability. METHODS: Seventy-one patients with diaphyseal fractures of the radius and ulna were evaluated at an average of twenty-one years after injury. Twenty-five of the thirty-five patients who were skeletally immature at the time of injury were treated nonoperatively, and thirty-one of the thirty-six skeletally mature patients were treated operatively. Objective evaluation included radiographs, functional assessment, and grip strength. Validated questionnaires were used to measure arm-specific disability (the Disabilities of the Arm, Shoulder and Hand [DASH] score), misinterpretation of pain (Pain Catastrophizing Scale [PCS]), and depression (the validated Dutch form of the Center for Epidemiologic Studies-Depression scale [CES-D]). RESULTS: The average DASH score was 8 points (range, 0 to 54); 97% of patients had excellent or satisfactory results according to the criteria of Anderson et al., and 72% reported no pain. Both the forearm rotation and the wrist flexion/extension arc was 91% of that seen on the uninjured side; grip strength was 94%. There were small but significant differences in rotation (151° versus 169°, p = 0.004) and wrist flexion-extension (123° versus 142°, p = 0.002) compared with the results in the uninjured arm. There was no difference in disability between patients who were skeletally mature or immature at the time of injury. Pain, pain catastrophizing (misinterpretation of nociception), and grip strength were the most important predictors of disability. CONCLUSIONS: An average of twenty-one years after sustaining diaphyseal fractures of both the radius and the ulna, patients who were skeletally immature or mature at the time of fracture have comparable disability. Disability correlates better with subjective and psychosocial aspects of illness, such as pain and pain catastrophizing, than with objective measurements of impairment. LEVEL OF EVIDENCE: Therapeutic Level IV. See Instructions to Authors for a complete description of levels of evidence.

Health status after open elbow contracture release.

BACKGROUND: Operative contracture release may improve motion of a posttraumatic stiff elbow. In this study, we tested the hypothesis that improvement in ulnohumeral motion after elbow contracture release leads to improvement in general health status and decreases upper-extremity-specific disability. METHODS: Twenty-three patients with posttraumatic loss of ≥30° of elbow flexion or extension who elected to have an open elbow capsulectomy completed the Disabilities of the Arm, Shoulder and Hand questionnaire (DASH) and the Short Form-36 (SF-36) preoperatively and at least one year postoperatively. Pain was measured with use of the American Shoulder and Elbow Surgeons (ASES) Elbow Evaluation instrument. Four patients underwent additional, subsequent procedures to address residual elbow stiffness. RESULTS: One patient who needed several additional procedures, including a total elbow arthroplasty, was considered to have had a failure of the operative contracture release and was excluded from the analysis; this left twenty-two patients in the study. On the average, the arc of flexion and extension improved from 51° preoperatively to 106° postoperatively; the DASH score, from 38 points to 18 points; the SF-36 Physical Component Summary (PCS) score, from 39 points to 49 points (all p < 0.05); and the SF-36 Mental Component Summary (MCS) score, from 49 points to 54 points (p < 0.05). There was no significant correlation between the improvement in the arc of flexion and extension and the improvement in the DASH (p = 0.53), PCS (p = 0.73), or MCS (p = 0.41) score. There also was no correlation between the final arc of flexion and extension and the final DASH score (p = 0.39 for the total score, p = 0.52 for the PCS score, and p = 0.42 for the MCS score). CONCLUSIONS: Health status and disability scores improve after open elbow contracture release, but the improvements do not correlate with the improvement in elbow motion. Among multiple objective and subjective factors, pain was a strong predictor of the final general health status and arm-specific disability.

Resection of heterotopic ossification of the elbow: a comparison of ankylosis and partial restriction.

PURPOSE: This study tests the hypothesis that the results of release of elbow stiffness related to heterotopic ossification (HO) are comparable whether there is partial or complete restriction (ankylosis) of flexion and extension. METHODS: Eighteen patients who had surgical release of complete bony ankylosis between the humerus and ulna were retrospectively compared to 27 matched patients who had surgical release of partial restriction of elbow flexion and extension related to HO. Patients were evaluated a minimum of 10 months after surgery, using the Disabilities of the Arm, Shoulder, and Hand questionnaire and the Broberg and Morrey rating system. RESULTS: An average of 22 months after surgery (range, 10 to 62 mo), the arc of flexion and extension averaged 95 degrees in the ankylosis cohort and 93 degrees in the partial HO cohort. Forearm rotation averaged 131 degrees versus 134 degrees ; the mean Disabilities of the Arm, Shoulder, and Hand score was 28 versus 30 points; and the mean Broberg and Morrey score was 81 versus 84 points, respectively. CONCLUSIONS: After controlling for other factors, patients with elbow stiffness related to HO can recover comparable motion after surgical release at short-term follow-up whether they have complete ankylosis or only partial restriction of motion. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic III.

Agreement between Initial Classification and Subsequent Reclassification of Fractures of the Distal Radius in a Prospective Cohort Study.

We tested the hypothesis that the original surgeon-investigator classification of a fracture of the distal radius in a prospective cohort study would have moderate agreement with the final classification by the team performing final analysis of the data. The initial post-injury radiographs of 621 patients with distal radius fractures from a multicenter international prospective cohort study were classified according to the Comprehensive Classification of Fractures, first by the treating surgeon-investigator and then by a research team analyzing the data. Correspondence between original and revised classification was evaluated using the Kappa statistic at the type, group and subgroup levels. The agreement between initial and revised classifications decreased from Type (moderate; Κ(type) = 0.60), to Group (moderate; Κ(group) = 0.41), to Subgroup (fair; Κ(subgroup) = 0.33) classifications (all p < 0.05). There was only moderate agreement in the classification of fractures of the distal radius between surgeon-investigators and final evaluators in a prospective multicenter cohort study. Such variations might influence interpretation and comparability of the data. The lack of a reference standard for classification complicates efforts to lessen variability and improve consensus.

Correlation of DASH and QuickDASH with measures of psychological distress.

PURPOSE: In an attempt to shorten the questionnaires given to patients in both clinical and research settings, we studied whether the correlation of commonly used psychological measures was comparable for the standard Disabilities of the Arm, Shoulder, and Hand (DASH) and the shorter QuickDASH questionnaires. METHODS: A cohort of 839 patients with carpal tunnel syndrome, trigger finger, de Quervain's disease, trapeziometacarpal arthrosis, lateral epicondylosis, or a distal radius fracture 2 weeks after surgery, who completed the DASH and 1 or more measures of psychological distress, was created from 10 databases from previously implemented studies. Correlations of the DASH and the QuickDASH with several measures of psychological factors (Center for Epidemiologic Studies Depression Scale [CES-D], Pain Catastrophizing Scale [PCS], and Pain Anxiety Symptoms Scale [PASS-40]) were calculated in both univariate and multivariable analyses. RESULTS: There was a large correlation between the DASH and QuickDASH (r = 0.79; p < .001). QuickDASH scores were significantly higher than DASH scores (p < .001). Correlations of the CES-D, PCS, and PASS-40 with the DASH and QuickDASH ranged from small to medium (range, 0.21-0.31; p < .001). There were no significant differences between correlations of the DASH and the QuickDASH with the psychological factors in the cohort including all patients, nor in subgroups according to diagnosis, gender, and limb dominance. CONCLUSIONS: The correlations of the DASH and QuickDASH with the CES-D, PCS, and PASS-40 were comparable. Our analysis suggests that a shorter and therefore potentially more practical measure of arm-specific disability can be used in studies that evaluate psychosocial aspects of illness behavior. TYPE OF STUDY/LEVEL OF EVIDENCE: Prognostic III.

The long-term outcome of open reduction and internal fixation of stable displaced isolated partial articular fractures of the radial head.

BACKGROUND: Excellent long-term results have been reported for nonoperative treatment of stable isolated displaced partial articular (Mason 2) fractures of the radial head, suggesting that the role of operative treatment can be questioned. This investigation reports the long-term outcome of operatively treated Mason 2 radial head fractures. METHODS: Sixteen patients with stable displaced partial articular (Mason 2) fractures of the radial head not associated with fracture or dislocation of the proximal forearm were evaluated an average of 22 years (range, 14-30 years) after open reduction and internal fixation with screws (11 patients) or a plate and screws (5 patients). Complications included two infections (1 deep and 1 superficial), two patients with restriction of motion because of screws of excessive length, and one transient posterior interosseous nerve palsy. A second surgery for implant removal was routine (14 of 16 patients). RESULTS: The average flexion arc was 129 degrees (range, 110-145 degrees) and the average forearm rotation arc was 166 degrees (range, 120-180 degrees). According to the Mayo Elbow Performance Index, elbow function was excellent in nine patients, good in four, fair in two, and poor in one patient. According to the classification system of Steinberg et al., there were three good, eight fair, and five poor results. The average score on the Disabilities of the Arm, Shoulder, and Hand questionnaire was 12 points (range, 0-52). CONCLUSION: The long-term results of operative treatment of stable isolated displaced partial articular (Mason 2) fractures of the radial head demonstrate no appreciable advantage over the long-term results of nonoperative treatment of these fractures published in prior reports. Moreover, the appeal of operative treatment is diminished by the potential complications.

Differences in prescription of narcotic pain medication after operative treatment of hip and ankle fractures in the United States and The Netherlands.

BACKGROUND: Interactions between American and Dutch surgeons suggested differences in prescription habits for pain medication after fracture treatment. METHODS: The percentages of 190 American [100 after hip open reduction and internal fixation (ORIF) and 90 after ankle ORIF] and 116 Dutch patients (69 after hip ORIF and 47 after ankle ORIF) receiving inpatient and outpatient prescriptions for narcotics were retrospectively compared between countries, to test the hypothesis that narcotics are prescribed more frequently in the United States as compared with The Netherlands after operative fracture treatment. RESULTS: Among patients with hip fractures, 85% of American and 58% of Dutch patients were prescribed narcotics during hospitalization (p < 0.001). After discharge, 77% of American and none of the Dutch patients were prescribed narcotics (p < 0.001). The multivariate model including country accounted for 11% of the variation in inpatient narcotic prescription (p < 0.001), and the model including country and surgeon accounted for 55% of the variation in outpatient narcotic prescription (p < 0.001). Among patients with ankle fracture, 98% of American and 64% of Dutch patients were prescribed narcotics during hospitalization (p < 0.001). After discharge, 82% of American patients and 6% of Dutch patients were prescribed narcotics (p < 0.001). Predictors included country and surgeon and they accounted for 20% of the variation in inpatient narcotics prescription (p < 0.001) and 49% of the variation in outpatient narcotic prescription (p < 0.001). CONCLUSIONS: American patients are prescribed significantly more inpatient and outpatient narcotic pain medication than Dutch patients after operative treatment of hip and ankle fractures.

Loss of anterior translation of the distal humeral articular surface is associated with decreased elbow flexion.

PURPOSE: The normal anterior translation of the articular surface of the distal humerus with respect to the humeral diaphysis facilitates elbow flexion. We hypothesize that there is a correlation between anterior translation of the distal humeral articular surface and flexion after open reduction and internal fixation (ORIF) of a fracture of the distal humerus. METHODS: Two independent observers evaluated 141 lateral radiographs of patients more than 6 months after fracture of the distal humerus and 155 lateral radiographs of patients without injury of the distal humerus. The distance between the most anterior point of the distal humerus articular surface, perpendicular to the humeral shaft, from the anterior border of the distal part of the humeral diaphysis, was measured on lateral radiographs as a percentage of the width of the humeral shaft. RESULTS: The technique of measuring anterior translation of the distal humeral articular surface had good intra- and interobserver reliability. The most anterior point of the distal humeral articular surface lies an average of 11.7 mm (range, 6.8 to 17.0 mm) in front of the most anterior border of the humeral shaft in normal distal humeri, which represents 62% of the humeral shaft diameter (range, 33% to 91%). There was a limited but significant correlation between flexion and anterior translation as a percentage of the humeral shaft diameter in distal humeri after fracture that was maintained in multivariable statistical models. CONCLUSIONS: Using a reproducible technique for measuring anterior translation of the distal humerus, there was a correlation between anterior translation of the distal humeral articular surface and elbow flexion after ORIF. Although the weakness of the correlation emphasizes that limitation of elbow flexion after ORIF of a distal humerus fracture is multifactorial, reduced anterior translation of the distal humeral articular surface might be a contributing factor. TYPE OF STUDY/LEVEL OF EVIDENCE: Prognostic IV.

Open elbow contracture release: postoperative management with and without continuous passive motion.

PURPOSE: Surgical contracture release can restore motion to stiff elbows. Some authors suggest that use of continuous passive motion (CPM) in postoperative management can increase ultimate mobility. This study tests the null hypothesis that there is no difference in the arc of flexion and extension between patients who used CPM and those who did not use CPM after open elbow contracture release. METHODS: Sixteen patients who had an arc of flexion and extension of less than 80 degrees and used CPM after open contracture release were matched based on age, gender, diagnosis, preoperative arc of flexion and extension, and radiographic appearance (joint congruity, heterotopic bone, and arthritis) to 16 control patients who did not use CPM. Stiffness was of posttraumatic origin in 24 patients, related to primary osteoarthrosis in 4 patients, and related to heterotopic ossification after central nervous system injury or burns in 4 patients. The preoperative arc of flexion and extension averaged 38 degrees in the CPM cohort and 42 degrees in the no-CPM cohort. RESULTS: Subsequent surgeries included procedures to address residual stiffness in 1 patient in the CPM cohort and in 3 patients in the no-CPM cohort. At an average 6 months of follow-up, there was no difference in improvement in the arc of flexion and extension (58 degrees vs 61 degrees ) between the CPM and no-CPM cohorts. At the final evaluation, the improvement in arc of flexion and extension (59 degrees in both cohorts) and the final arc of flexion and extension (96 degrees vs 101 degrees ) were comparable between cohorts. CONCLUSIONS: These matched retrospective data do not demonstrate a benefit of CPM in the postoperative management of elbow contracture release.

Correspondence between perceived disability and objective physical impairment after elbow trauma.

BACKGROUND: Substantial differences between disability and impairment are commonplace and puzzling. Subjective (psychosocial) factors may be paramount given that pain is a more important determinant of perceived overall arm-specific disability than is objective elbow impairment. To further evaluate the relationship between impairment and disability, we tested the hypothesis that objective loss of elbow motion predicts perceived elbow-related task-specific disability better than does pain after elbow trauma. METHODS: One hundred and fifty-eight patients were evaluated at a median of twenty-six months after a traumatic elbow injury and completed the Disabilities of the Arm, Shoulder and Hand (DASH) questionnaire. Predictors of the total DASH score and of the scores for individual DASH items that were expected to be related to elbow function were evaluated with univariate and multivariate analyses. RESULTS: Motion accounted for 35% of the variability in the total DASH score, for 11% to 12% of the variability in the responses to questions specific to hand-based activities, and for 24% to 33% of the variability in the scores for tasks depending on elbow motion. Pain accounted for 41% of the variability in the total DASH score and was a better predictor than motion of disability associated with three tasks: opening a tight jar (with pain and motion accounting for 24% and 11% of the variability, respectively), pushing open a door (25% and 12%, respectively), and placing an object overhead (28% and 25%, respectively). None of the multivariate models explained more than 53% of the variability in the DASH scores. CONCLUSIONS: Objective physical elbow impairment correlated with self-reported disability with respect to specific tasks, but a large proportion of disability remains unexplained. Further research is needed to better understand the differences between objective impairment and perceived disability.

Comparison of acute versus subacute treatment of terrible triad injuries of the elbow.

PURPOSE: To test the null hypothesis that there is no difference in flexion arc or Broberg and Morrey rating between patients treated within 2 weeks of the injury (acute treatment) and those treated 3 weeks or more after injury with persistent or recurrent dislocation or subluxation (subacute treatment). METHODS: The acute cohort consisted of 18 patients treated an average 6 days after injury. The radial head was replaced in 17 patients and repaired with screw in 1, the coronoid was secured with suture in all patients and with an additional screw in 2, and the lateral collateral ligament was reattached in all patients. No external fixators were applied. Four of 14 patients in the subacute cohort had 5 operative procedures before presenting to us. All patients presented with instability and were treated an average 7 weeks after injury. Except for 1 patient who presented with an active infection, all patients were treated with radial head replacement and lateral collateral ligament repair, and fixation or reconstruction of the coronoid occurred in 9 patients. Stability was protected with a hinged external fixator for an average of 6 weeks. RESULTS: Five patients in the acute cohort and 1 in the subacute cohort had 8 subsequent surgeries (addressing stiffness in 3 patients). Prior to subsequent surgeries, the flexion arc averaged 116 degrees in the acute cohort and 93 degrees in the subacute cohort and improved to an average 119 degrees in the acute cohort and 100 degrees in the subacute cohort after all subsequent surgeries. Broberg and Morrey scores were comparable between cohorts (90 vs 87 points). CONCLUSIONS: Stability and strength were restored with both acute and subacute treatment, but earlier treatment is more straightforward and is associated with a better flexion arc. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic III.

Long-term outcome of operatively treated fracture-dislocations of the olecranon.

OBJECTIVES: To report the long-term results of operative treatment of anterior and posterior olecranon fracture-dislocations and compare them with the results recorded fewer than 2 years after surgery. DESIGN: Retrospective case series with long-term evaluation. SETTING: Level I trauma center. PATIENTS AND PARTICIPANTS: Ten patients with anterior olecranon fracture-dislocation and ten patients with posterior olecranon fracture-dislocation were evaluated after an average of 18 years (range, 11 to 28 years) after injury. Fifteen patients had an early follow-up available at an average 14 months (range, 6 to 24 months) after surgery. The average age at injury was 30 years (range, 14 to 53 years). INTERVENTION: Treatment included plate and screw fixation (11 patients), tension band wiring (8 patients), and radiocapitellar transfixation (1 patient). Six patients had additional elbow surgery before the final evaluation. MAIN OUTCOME MEASUREMENTS: Flexion arc, arthrosis, Mayo Elbow Performance Index (MEPI), Disability of Arm Shoulder and Hand questionnaire (DASH). RESULTS: The mean arc of elbow flexion was 105 degrees (range, 15 to 140 degrees) at 1 year and 122 degrees (range 10 to 145 degrees; P = 0.01) at final evaluation. Radiographic arthrosis was observed in 14 patients (70%): severe in 3, moderate in 2, and mild in 9 patients. Five patients (25%) had ulnar nerve dysfunction at the final evaluation. The MEPI was excellent in 13 patients, good in 4, fair in 2, and poor in 1. The mean DASH score was 9 points (range, 0 to 53 points). CONCLUSION: The initial results of operative treatment of fracture-dislocations of the olecranon are durable over time.

The posttraumatic stiff elbow: a review of the literature.

Loss of motion is a common complication of elbow trauma. Restoration of joint motion in the posttraumatic stiff elbow can be a difficult, time-consuming, and costly challenge. In this review of the literature, the biologic response to trauma and the possible etiologic events that may lead to fibrosis of the capsules and heterotopic ossification will be discussed, as well as nonsurgical and surgical management of stiffness and expected outcomes of treatment.