Locking plate fixation in comminuted coronoid fractures with partial loss of the articular cartilage - Of basal-1 type according to the O'Driscoll classification.

BACKGROUND: We have attempted to restore the arc of motion by considering trochlear-coronoid articulation as a complete circle during fixation of the coronoid, even for comminuted coronoid fractures with partial loss of articular cartilage (CCFPLAC), using various kinds of locking plates. Herein, we report the radiological and clinical outcomes after fixation of the basal-1 type of CCFPLAC (O'Driscoll classification) using our method. METHODS: Thirty-one patients diagnosed with CCFPLAC were admitted between January 2012 and December 2020. Sixteen of these patients met the inclusion/exclusion criteria and were enrolled in this study. Surgically, the lost area (defect of articular cartilage) was never compressed or minimized, but the original height and shape of the coronoid were preserved as is. Provisionally, a few K-wires were used to maintain the original shape and position of the CCFPLAC, and various kinds of locking plates/screws were used to fix the fragment anatomically and firmly. If needed, the plate was bent to ensure stable compression of the coronoid according to its size. In a few cases, locking plates were adjusted by cutting extra screw holes. RESULTS: Among the 16 patients, the mean age was 46.2 years, and the male:female ratio was 10:6. The mean follow-up period was 3.63 years. 8, 6, and 2 patients were designated as group 1 (isolated CCFPLAC), 2 [CCFPLAC in type 4 (terrible triad) injury), and 3 (CCFPLAC in type 5 posterior olecranon fracture-dislocations), respectively. Complete union was achieved after a mean of 8.94 weeks. The mean flexion-extension and pronation-supination arcs were 127.19 ± 4.46° and 135.31.59 ± 8.06°, respectively, which were significantly different from those on the contralateral (normal) side (p < 0.001); however, the arcs were within the functional ranges for ordinary daily living. Additionally, the functional status was satisfactory in all patients. However, Mayo Elbow Performance Score and the degree of arthritis were statistically poor in group 2. CONCLUSIONS: CCFPLAC of the basal-1 type (O'Driscoll classification) can be treated satisfactorily if already designed and widely distributed locking plates are properly manipulated to maintain the original geometry of the coronoid according to the individual joint characteristics. LEVEL OF EVIDENCE: Level IV, Retrospective case series.

Common Fractures of the Radius and Ulna.

Fractures of the radius and ulna are the most common fractures of the upper extremity, with distal fractures occurring more often than proximal fractures. A fall onto an outstretched hand is the most common mechanism of injury for fractures of the radius and ulna. Evaluation with radiography or ultrasonography usually can confirm the diagnosis. If initial imaging findings are negative and suspicion of fracture remains, splinting and repeat radiography in seven to 14 days should be performed. Incomplete compression fractures without cortical disruption, called buckle (torus) fractures, are common in children. Greenstick fractures, which have cortical disruption, are also common in children. Depending on the degree of angulation, buckle and greenstick fractures can be managed with immobilization. In adults, distal radius fractures are the most common forearm fractures and are typically caused by a fall onto an outstretched hand. A nondisplaced, or minimally displaced, distal radius fracture is initially treated with a sugar-tong splint, followed by a short-arm cast for a minimum of three weeks. It should be noted that these fractures may be complicated by a median nerve injury. Isolated midshaft ulna (nightstick) fractures are often caused by a direct blow to the forearm. These fractures are treated with immobilization or surgery, depending on the degree of displacement and angulation. Combined fractures involving both the ulna and radius generally require surgical correction. Radial head fractures may be difficult to visualize on initial imaging but should be suspected when there are limitations of elbow extension and supination following trauma. Treatment of radial head fractures depends on the specific characteristics of the fracture using the Mason classification.

Fracture-dislocations of the forearm joint: a systematic review of the literature and a comprehensive locker-based classification system.

BACKGROUND: Monteggia, Galeazzi, and Essex-Lopresti injuries are the most common types of fracture-dislocation of the forearm. Uncommon variants and rare traumatic patterns of forearm fracture-dislocations have sometimes been reported in literature. In this study we systematically review the literature to identify and classify all cases of forearm joint injury pattern according to the forearm joint and three-locker concepts. METHODS: A comprehensive search of the PubMed database was performed based on major pathological conditions involving fracture-dislocation of the forearm. Essex-Lopresti injury, Monteggia and Galeazzi fracture-dislocations, and proximal and/or distal radioulnar joint dislocations were sought. After article retrieval, the types of forearm lesion were classified using the following numerical algorithm: proximal forearm joint 1 [including proximal radioulnar joint (PRUJ) dislocation with or without radial head fractures], middle radioulnar joint 2, if concomitant radial fracture R, if concomitant interosseous membrane rupture I, if concomitant ulnar fracture U, and distal radioulnar joint 3 [including distal radioulnar joint (DRUJ) dislocation with or without distal radial fractures]. RESULTS: Eighty hundred eighty-four articles were identified through PubMed, and after bibliographic research, duplication removal, and study screening, 462 articles were selected. According to exclusion criteria, 44 full-text articles describing atypical forearm fracture-dislocation were included. Three historical reviews were added separately to the process. We detected rare patterns of two-locker injuries, sometimes referred to using improper terms of variant or equivalent types of Monteggia and Galeazzi injuries. Furthermore, we identified a group of three-locker injuries, other than Essex-Lopresti, associated with ulnar and/or radial shaft fracture causing longitudinal instability. In addition to fracture-dislocations commonly referred to using historical eponyms (Monteggia, Galeazzi, and Essex-Lopresti), our classification system, to the best of the authors' knowledge, allowed us to include all types of dislocation and fracture-dislocation of the forearm joint reported in literature. According to this classification, and similarly to that of the elbow, we could distinguish between simple dislocations and complex dislocations (fracture-dislocations) of the forearm joint. CONCLUSIONS: All injury patterns may be previously identified using an alphanumeric code. This might avoid confusion in forearm fracture-dislocations nomenclature and help surgeons with detection of lesions, guiding surgical treatment. LEVEL OF EVIDENCE: V.

Fracture energy threshold in parry injuries due to sharp and blunt force.

Blows with axes, machetes or blunt objects such as baseball bats, truncheons, etc. are often parried, resulting in typical parry injuries, or so-called nightstick fractures to the ulna. In this study, we sought to assess the impact energy required to break the ulna in such parry incidents in an experimental setting using semisynthetic and fully synthetic models. Twenty-seven sheep radii and 33 polyurethane synthetic bones were cast into gelatin prior to being fired at with missiles made of a section of an axe blade or steel rod at different firing velocities using a compressed-nitrogen cannon. Each model was then examined as to the presence of hair-line fractures or complete fractures. Sheep bones and synthetic bones displayed comparable results when struck by the axe missile; here, a clear fracture threshold was evident between 14.00 and 15.26 J. When struck by the rod missile, only the synthetic bones produced significant results, namely a fracture threshold between 20.15 and 23.59 J. In conclusion, our results show an ulnar fracture threshold of approximately 15 J when struck by an axe. The experiments regarding blows with a rod displayed a fracture threshold of around 22 J, but, as this could not be validated with biological bones, this result is questionable.

Analysis of radial head and coronoid process fractures in terrible triad of elbow.

PURPOSE: To describe the morphological characteristics of radial head and coronoid fractures and evaluate the relationship of two fracture patterns in terrible triad. METHODS: Distributions of all types of radial head and coronoid fractures according to the Mason, Regan-Morrey, and O'Driscoll classifications were firstly described by reviewing radiographs and computed tomography scans in 92 consecutive terrible triads. Then, distributions of all combinations of radial head and coronoid fractures were reported. Correlation analysis between severity of radial head and coronoid fractures was finally performed. RESULTS: In radial head fractures, Mason 2 accounted for 68%, Mason 3 accounted for 32%, and no Mason 1 was found. In coronoid fractures, there were 29 type 1, 44 type 2, and 19 type 3 in Regan-Morrey classification and 72 type 1, one type 2, and 19 type 3 in O'Driscoll classification. There were 28 M2R2, 23 M2R1, 16 M3R2, 12 M2R3, seven M3R3, and six M3R1 in combined Mason and Regan-Morrey type. There were 53 M2O1, 19 M3O1, 10 M3O3, nine M2O3, and one M2O2 in combined Mason and O'Driscoll type. A weak correlation was found between radial head and coronoid fractures. CONCLUSIONS: In terrible triad injuries, the most common type of radial head fracture is Mason 2, while the most common type of coronoid fracture is Regan-Morrey type 2 or O'Driscoll type 1. In combinations of two fracture patterns, M2R2 or M2O1 is the most common. Severity of radial head fractures is weakly correlated with coronoid fractures.

Fragmento dorso-ulnar en fracturas de radio distal: clasificación y manejo / Dorso-ulnar fragment in distal radius fractures: classification and treatment

INTRODUCCIÓN: El fragmento dorso-ulnar (FDU) en la fractura intraarticular de radio distal es de especial importancia puesto que implica una alteración en la articulación radio-carpiana así como también en la articulación radio-ulnar distal (RUD), donde la incongruencia articular permanente puede generar secuelas a largo plazo. OBJETIVO: Proponer una clasificación del FDU, definiendo cuándo realizar el procedimiento quirúrgico con asistencia artroscópica, basado en una serie consecutiva de casos operados de fractura del radio distal estudiados con tomografía computada (TC). MÉTODO: Estudio descriptivo de una serie de casos de pacientes operados por fractura del radio distal entre enero del 2015 y diciembre del 2016. En base a eso, se elabora una clasificación del FDU y se sugiere un esquema de manejo específico. Se describe el FDU como aquel fragmento específico ubicado en la esquina dorso-ulnar de la carilla articular del radio distal, con compromiso de más del 30% de la superficie articular RUD y más de 5mm desde el borde ulnar hacia radial de la cortical dorsal del radio observado en el corte axial de la TC preoperatoria. Se considera un fragmento mayor (FM) cuando el rasgo de fractura compromete hacia radial hasta el tubérculo de Lister y se considera fragmento menor (Fm) cuando el rasgo no alcanza a comprometer el tubérculo de Lister. Nuestra propuesta de clasificación reconoce 4 tipos: tipo I (FM sin desplazamiento, en fracturas tipo C de la AO); tipo II (FM con desplazamiento, en fracturas tipo C de la AO); tipo III (Fm independiente del desplazamiento, en fracturas tipo C de la AO) y tipo IV (FM/Fm con desplazamiento, en fracturas tipo B2 de la AO). Esquema de manejo: Tipo I síntesis con placa bloqueada por abordaje palmar, sin obligación de asistencia artroscópica. Tipo II síntesis con placa bloqueada por abordaje palmar, con asistencia artroscópica requerida. Tipo III síntesis percutánea dorsal contornillo canulado, bajo asistencia artroscópica. Tipo IV síntesis dorsal con placa o tornillo mediante abordaje dorsal bajo visión directa o con asistencia artroscópica, usando portales artroscópicos volares. RESULTADOS: Se operaron 488 fracturas de radio distal durante el período mencionado; 375 fracturas clasificadas como tipo C de la AO. Del total operadas, solo 392 fracturas contaban con TC peroperatoria, que permitía evaluar la presencia del FDU, el cual estuvo presente en 127/392 de los casos (32,4%). Analizados por grupo, 38 casos presentaban fragmentos tipo I, 22 tipo II, 69 tipo III y 7 tipo IV. DISCUSIÓN: El FDU se presentó en un 32,4% de los casos evaluables por TC en nuestra serie. El manejo dirigido de este fragmento con asistencia artroscópica permitió una reducción anatómica con fijación estable específica de éste. CONCLUSIÓN: Proponemos una nueva clasificación del FDU basada en la TC preoperatoria que permite realizar un adecuado plan prequirurgico y abordar este fragmento de manera específica sugiriendo cuando utilizar asistencia artroscópica.

INTRODUCTION: The dorsal-ulnar fragment (DUF) in the distal radius fracture is of special importance since it implies an alteration in the radio-carpal joint as well as in the distal radio-ulnar joint (DRUJ), where permanent joint incongruence can generate long-term sequelae. OBJECTIVE: To propose a classification of the DUF, advising when to perform arthroscopic assistance, based on a consecutive series of operated cases of distal radius fracture studied with computed tomography (CT). METHODS: Descriptive study of a series of cases of patients operated of distal radius fracture between January 2015 and December 2016. We describe a classification of the DUF and suggest a specific treatment scheme. The DUF is described as that specific fragment located in the dorso-ulnar corner of the articular surface of the distal radius, which involves more than 30% of the articular surface of the DRUJ and more than 5mm of the ulnar edge of the dorsal cortex of the radius observed in the axial section of the preoperative CT. It is considered a major fragment (FM) when the fracture compromises the Lister tubercle and is considered a minor fragment (Fm) when it does not. Our classification recognizes 4 types of DUF: type I (FM without displacement, in type C fractures of the AO); Type II (FM with displacement, in type C fractures of the AO); Type III (Fm independent of displacement, in fractures type C of the AO) and type IV (FM/Fm with displacement, in fractures type B2 of the AO). Treatment scheme: Type I: synthesis with a palmar locked plate without arthroscopic assistance required. Type II: synthesis with palmar locked plate with arthroscopic assistance. Type III dorsal percutaneous synthesis with cannulated screw with arthroscopic assistance. Type IV dorsal synthesis with plate or screw by dorsal approach under direct vision or with arthroscopic assistance using volar portals. RESULTS: A total of 488 distal radius fractures were operated during this period. Only 392 fractures had preoperative CT, which allowed to evaluate the presence of the DUF. It was present in 127/392 of the cases (32.4%). Analyzed by group, 38 cases presented fragments type I, 22 cases type II, 69 cases type III and 7 cases type IV. DISCUSSION: The DUF was presented in 32.4% of the cases in our series. The management of this fragment with arthroscopic assistance allowed an anatomical reduction with specific stable fixation of this fragment. CONCLUSION: We propose a novel classification of the DUF based on preoperative CT that allows a specific management of this fragment and suggest when to use arthroscopic assistance.

Diagnosis and treatment of acute Essex-Lopresti injury: focus on terminology and review of literature.

BACKGROUND: Acute Essex-Lopresti injury is a rare and disabling condition of longitudinal instability of the forearm. When early diagnosed, patients report better outcomes with higher functional recovery. Aim of this study is to focus on the different lesion patterns causing forearm instability, reviewing literature and the cases treated by the Authors and to propose a new terminology for their identification. METHODS: Five patients affected by acute Essex-Lopresti injury have been enrolled for this study. ELI was caused in two patients by bike fall, two cases by road traffic accident and one patient by fall while walking. A literature search was performed using Ovid Medline, Ovid Embase, Scopus and Cochrane Library and the Medical Subject Headings vocabulary. The search was limited to English language literature. 42 articles were evaluated, and finally four papers were considered for the review. RESULTS: All patients were operated in acute setting with radial head replacement and different combinations of interosseous membrane reconstruction and distal radio-ulnar joint stabilization. Patients were followed for a mean of 15 months: a consistent improvement of clinical results were observed, reporting a mean MEPS of 92 and a mean MMWS of 90.8. One case complained persistent wrist pain associated to DRUJ discrepancy of 3 mm and underwent ulnar shortening osteotomy nine months after surgery, with good results. DISCUSSION: The clinical studies present in literature reported similar results, highlighting as patients properly diagnosed and treated in acute setting report better results than patients operated after four weeks. In this study, the definitions of "Acute Engaged" and "Undetected at Imminent Evolution" Essex-Lopresti injury are proposed, in order to underline the necessity to carefully investigate the anatomical and radiological features in order to perform an early and proper surgical treatment. CONCLUSIONS: Following the observations, the definitions of "Acute Engaged" and "Undetected at Imminent Evolution" injuries are proposed to distinguish between evident cases and more insidious settings, with necessity of carefully investigate the anatomical and radiological features in order to address patients to an early and proper surgical treatment.

Nonoperative manipulative reduction with Chinese herbs for the treatment of a displaced olecranon fracture: A case report.

RATIONALE: Displaced olecranon fracture is a common injury following a fall or direct trauma to the elbow. There have been no reports of patients with a displaced olecranon fracture who have only received nonoperative manipulative reduction with Chinese herbs. PATIENT CONCERNS: The patient was a 64-year-old woman with a complex elbow injury that occurred in a traffic accident. The patient complained of severe, painful limitation of motion on straightening or bending. DIAGNOSES: The patient was diagnosed with a displaced fracture of the left olecranon (type IIA olecranon fracture according to the Mayo classification system). INTERVENTIONS: The patient underwent nonoperative manipulation with Chinese herbs. OUTCOMES: The fracture was successfully reduced. After 3 to 4 months of follow-up, severe pain and disability in the elbow were improved following reduction of the left olecranon fracture in which there was no longer a displacement. LESSONS: Nonoperative manipulative reduction performed by a well-trained physician with Chinese herbs may be a treatment option for displaced olecranon fractures.

The Correlation Between the OTA/AO Classification System and Compartment Syndrome in Both Bone Forearm Fractures.

OBJECTIVE: To evaluate the efficacy of using the Orthopaedic Trauma Association (OTA/AO) classification for both bone forearm fractures in predicting compartment syndrome. DESIGN: Retrospective cohort. SETTING: Level 1 Academic Trauma Center. PATIENTS/PARTICIPANTS: One hundred fifty-one patients 18 years of age and older, with both bone forearm fractures diagnosed from 2001 to 2016 were categorized based on the OTA/AO classification. Patients with both bone fractures caused by gunshot wounds were excluded. MAIN OUTCOME MEASUREMENTS: The endpoint for our study was whether forearm fasciotomies were performed based on the presence of compartment syndrome. RESULTS: Of a total of 151 both bone forearm fractures, 15% underwent fasciotomy. Six of 80 (7.5%) grouped 22-A3, 8 of 44 (18%) grouped 22-B3, and 9 of 27 (33%) grouped 22-C underwent fasciotomies for compartment syndrome (P = 0.004). The relative risks of developing compartment syndrome for group 22-B3 versus 22-A3 was 2.42 (P = 0.08), 22-C versus 22-B3 was 1.83 (P = 0.15), and 22-C versus 22-A3 was 4.44 (P = 0.002). CONCLUSIONS: There is a significant correlation between the OTA/AO classification and the need for fasciotomies, with group C fractures representing the highest risk. Clinicians can use this information to have a higher index of suspicion for compartment syndrome based on OTA/AO classification to help minimize the risk of a missed diagnosis. LEVEL OF EVIDENCE: Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

The AO Pediatric Comprehensive Classification of Long Bone Fractures (PCCF).

Background and purpose - To achieve a common understanding when dealing with long bone fractures in children, the AO Pediatric Comprehensive Classification of Long Bone Fractures (AO PCCF) was introduced in 2007. As part of its final validation, we present the most relevant fracture patterns in the upper extremities of a representative population of children classified according to the PCCF. Patients and methods - We included children and adolescents (0-17 years old) diagnosed with 1 or more long bone fractures between January 2009 and December 2011 at the university hospitals in Bern and Lausanne (Switzerland). Patient charts were retrospectively reviewed and fractures were classified from standard radiographs. Results - Of 2,292 upper extremity fractures in 2,203 children and adolescents, 26% involved the humerus and 74% involved the forearm. In the humerus, 61%, and in the forearm, 80% of single distal fractures involved the metaphysis. In adolescents, single humerus fractures were more often epiphyseal and diaphyseal fractures, and among adolescents radius fractures were more often epiphyseal fractures than in other age groups. 47% of combined forearm fractures were distal metaphyseal fractures. Only 0.7% of fractures could not be classified within 1 of the child-specific fracture patterns. Of the single epiphyseal fractures, 49% were Salter-Harris type-II (SH II) fractures; of these, 94% occurred in schoolchildren and adolescents. Of the metaphyseal fractures, 58% showed an incomplete fracture pattern. 89% of incomplete fractures affected the distal radius. Of the diaphyseal fractures, 32% were greenstick fractures. 24 Monteggia fractures occurred in pre-school children and schoolchildren, and 2 occurred in adolescents. Interpretation - The pattern of pediatric fractures in the upper extremity can be comprehensively described according to the PCCF. Prospective clinical studies are needed to determine its clinical relevance for treatment decisions and prognostication of outcome.

The AO Pediatric Comprehensive Classification of Long Bone Fractures (PCCF).

Background and purpose - The AO Pediatric Comprehensive Classification of Long Bone Fractures (PCCF) describes the localization and morphology of fractures, and considers severity in 2 categories: (1) simple, and (2) multifragmentary. We evaluated simple and multifragmentary fractures in a large consecutive cohort of children diagnosed with long bone fractures in Switzerland. Patients and methods - Children and adolescents treated for fractures between 2009 and 2011 at 2 tertiary pediatric surgery hospitals were retrospectively included. Fractures were classified according to the AO PCCF. Severity classes were described according to fracture location, patient age and sex, BMI, and cause of trauma. Results - Of all trauma events, 3% (84 of 2,730) were diagnosed with a multifragmentary fracture. This proportion was age-related: 2% of multifragmentary fractures occurred in school-children and 7% occurred in adolescents. In patients diagnosed with a single fracture only, the highest percentage of multifragmentation occurred in the femur (12%, 15 of 123). In fractured paired radius/ulna bones, multifragmentation occurred in 2% (11 of 687); in fractured paired tibia/fibula bones, it occurred in 21% (24 of 115), particularly in schoolchildren (5 of 18) and adolescents (16 of 40). In a multivariable regression model, age, cause of injury, and bone were found to be relevant prognostic factors of multifragmentation (odds ratio (OR) > 2). Interpretation - Overall, multifragmentation in long bone fractures in children was rare and was mostly observed in adolescents. The femur was mostly affected in single fractures and the lower leg was mostly affected in paired-bone fractures. The clinical relevance of multifragmentation regarding growth and long-term functional recovery remains to be determined.

Involvement of the lesser sigmoid notch in elbow fracture dislocations.

BACKGROUND: This study addressed the primary null hypothesis that there is no difference in the articular surface area of the lesser sigmoid notch involved among Mayo classes. Secondarily, we analyzed the fracture line location and the pattern of lesser sigmoid notch articular surface involvement among Mayo classes. METHODS: Using quantitative 3-dimensional computed tomography, we reconstructed and analyzed fractures involving the lesser sigmoid notch articular surface in 52 patients. Further, we assessed the surface area involved in the fracture, the number of fracture fragments, and the location and direction of the fracture lines. Coronoid fractures were classified according to Mayo types. RESULTS: There was no significant difference between Mayo types 1 and 2 in any characteristic of the involvement of the lesser sigmoid notch articular surface, whereas Mayo type 3 was significantly different from both Mayo types 1 and 2 in the area involved in the fracture (42% in Mayo type 3 vs. 9% in Mayo types 1 and 2), the number of articular fragments (>3 fragments in type 3 vs. 2 fragments in types 1 and 2), and the direction of fracture line (both horizontal and vertical lines in type 3 vs. only horizontal line in types 1 and 2). CONCLUSION: Mayo type III results in a more complex fracture, which might need to be addressed directly or indirectly during open reduction with internal fixation of olecranon fracture dislocations because changes in the geometry of lesser sigmoid notch may affect the radioulnar joint if it remains incongruent.

Joint capsule attachment to the coronoid process of the ulna: an anatomic study with implications regarding the type 1 fractures of the coronoid process of the O'Driscoll classification.

BACKGROUND: The attachment of the anterior joint capsule on the ulnar coronoid process is not yet completely understood. The purpose of this study was to clarify the anatomic relationship between the anterior capsule of the elbow joint and the tip of the coronoid process. METHODS: Seventeen embalmed elbows were used for this anatomic study. The anterior capsule of the elbow joint was reflected, and the attachment of the capsule on the coronoid process was exposed. The attachment of the joint capsule on the coronoid process was macroscopically and histologically observed, its relationship to the coronoid tip was assessed, and the length of the attachment of the joint capsule was measured. RESULTS: The length of the capsule attachment at the radial side of the coronoid (11.9 mm) was greater than that at the ulnar side (6.1 mm). The bone thickness on the coronoid tip from the proximal edge of the joint capsule attachment was 1.9 mm; together, the cartilage and bone thickness was 4.7 mm. At the radial side of the coronoid, the thickness of the joint capsule at the proximal aspect of the attachment of 2 samples was 0.6 mm and 0.3 mm, and that at the tip of the coronoid was 2.6 mm and 1.7 mm, respectively. CONCLUSIONS: The anterior capsule of the elbow joint had a substantial attachment on the radial side of the coronoid process. The subtype 2 tip fractures of the O'Driscoll classification included the joint capsule attachment, joint cartilage, and subchondral bone.

Segmental forearm bone injuries in children: classification and treatment.

BACKGROUND: Fractures of the forearm bones in children are a very frequent injury, while segmental injuries of the forearm bones are very rare and have not been sufficiently examined. In this retrospective study, segmental injuries involving the radius, the ulna or both in children are classified and treatment outcome is presented. MATERIALS AND METHODS: Bone injury included any type of fracture or dislocation; segmental bone injury indicated the occurrence of more than one traumatic injury throughout the whole extent of each forearm bone. A total of 17 patients with 22 segmental bone injuries were identified and classified. Of these injuries, 12 involved the radius and 10 the ulna. The mean age at the time of injury was 8.9 years (range 3-13). In all cases, conservative treatment was the first treatment option; in three cases, however, surgical treatment was necessary. RESULTS: All injuries were classified into five types using the new nomenclature. Patients were evaluated after an average follow-up of 10.4 years. Union was noted in all cases without any complications. The function results were rated as excellent in 15 cases and satisfactory in 2 cases. CONCLUSIONS: An inclusive classification system for segmental injuries of the forearm bones in children is presented. The proposed classification is a practical and utilitarian scheme that classified the patients of this report as well as all case reports previously published in the literature. It revealed that a wide variety of segmental injuries may be diagnosed following forearm injuries in children. This report also provided useful information that may influence the treatment of these complex injuries indicating that conservative treatment may be considered the first treatment option, and that primary surgical treatment is not justified. LEVEL OF EVIDENCE: Level V.

A classification and grading system for Barton fractures.

PURPOSE: We described a morphological classification and grading system for volar Barton fractures. METHODS: We divided these fractures into four types: typical Barton, ulna Barton, radial Barton, comminuted Barton. Moreover, we graded the fractures into two degrees: simple split and split-depression. We retrospectively reviewed all wrist radiographs showing Barton fractures in our hospital between January 2013 and January 2015. We identified 100 cases whose records and radiographs were reviewed and included 36 men and 64 women with a mean age of 50 years (15-78). The morphological classification was applied to the 100 cases by three reviewers on two occasions using the Kappa statistic. RESULTS: The inter- and intra-observer reliability of the morphological classification was 0.71-0.80 and 0.68-0.88, respectively. The distribution of typical, ulna, radial and comminuted Barton type fractures was 69 %, 7 %, 5 % and 19 %, respectively. Grade 2 fractures accounted for 49 % in our series. CONCLUSIONS: This classification and grading system of Barton fractures is likely to have implications in terms of pathophysiology and surgical technique.

Quantitative 3-dimensional computed tomography analysis of olecranon fractures.

HYPOTHESIS/BACKGROUND: Olecranon fractures have variable size of the proximal fragment, patterns of fragmentation, and subluxation of the ulnohumeral joint that might be better understood and categorized on the basis of quantitative 3-dimensional computed tomography analysis. Mayo type I fractures are undisplaced, Mayo type II are displaced and stable, and Mayo type III are displaced and unstable. The last is categorized into anterior and posterior dislocations. The purpose of this study was to further clarify fracture morphology between Mayo type I, II, and III fractures. METHODS: Three-dimensional models were created for a consecutive series of 78 patients with olecranon fractures that were evaluated with computed tomography. We determined the total number of fracture fragments, the volume and articular surface area of each fracture fragment, and the degree of displacement of the most proximal olecranon fracture fragment. RESULTS: Displaced olecranon fractures were more comminuted than nondisplaced fractures (P = .02). Displaced fractures without ulnohumeral subluxation were smallest in terms of both volume (P < .001) and articular surface involvement (P < .001) of the most proximal olecranon fracture fragment. There was no difference in average displacement of the proximal fragment between displaced fractures with and without ulnohumeral subluxation (P = .74). Anterior olecranon fracture-dislocations created more displaced (P = .04) and smaller proximal fragments than posterior fracture-dislocations (P = .005), with comparable fragmentation on average (P = .60). DISCUSSION/CONCLUSION: The ability to quantify volume, articular surface area, displacement, and fragmentation using quantitative 3-dimensional computed tomography should be considered when increased knowledge of fracture morphology and fracture patterns might be useful.

Adult Monteggia and Olecranon Fracture Dislocations of the Elbow.

Monteggia fractures and olecranon fracture dislocations represent complex injuries with distinct patterns of bony and soft tissue involvement. Fractures of the proximal ulna and olecranon process may lead to disruption of the proximal radioulnar joint and/or ulnohumeral joint. The keys to treatment are recognition of the pattern of injury and formation of an algorithmic surgical plan to address all components of the injury process. Complications are common and may be related to the injury spectrum itself and/or inadequate fracture alignment or fixation.