Injury complexity factors predict heterotopic ossification restricting motion after elbow trauma.

BACKGROUND: Heterotopic ossification (HO) is a common extrinsic cause of elbow stiffness after trauma. However, factors associated with the development of HO are incompletely understood. QUESTIONS/PURPOSES: We retrospectively identified (1) patient-related demographic factors, (2) injury-related factors, and (3) treatment-related factors associated with the development of HO severe enough to restrict motion after surgery for elbow trauma. We also determined what percentage of the variation in HO restricting motion was explained by the variables studied. METHODS: Between 2001 and 2007, we performed surgery on 417 adult patients for elbow fractures; of these, 284 (68%) were available for radiographs at a minimum of 4 months and clinical review at a minimum of 6 months after surgery (mean, 7.9 months; range, 6­31 months). HO was classified according to the Hastings and Graham system. Patients with HO restricting motion (defined as a Hastings and Graham Class II or III) were compared with patients without HO restricting motion in terms of demographics, fracture location, elbow dislocation, open wound, mechanism of injury, ipsilateral fracture, head trauma, time from injury to surgery, number of surgeries within 4 weeks, total number of surgeries, bone graft, and infection, using bivariate and multivariable analyses. A total of 96 patients had radiographic HO, and in 27 (10% of those available for followup), it restricted motion. RESULTS: There were no patient-related demographic factors that predicted the formation of symptomatic HO. Ulnohumeral dislocation in addition to fracture (odds ratio, 2.38; 95% CI, 1.01­5.64; p = 0.048) but not fracture location was associated with HO. Longer time from injury to definitive surgery and number of surgical procedures in the first 4 weeks were also independent predictors of HO (p = 0.01 and 0.004, respectively). These factors explained 20% of the variance in risk for HO restricting motion. CONCLUSIONS: HO restricting motion after operative elbow fracture treatment associates with factors that seem related to injury complexity, in particular, ulnohumeral dislocation, delay, and number of early surgeries; however, a substantial portion of the variation among patients with elbow fracture who develop restrictive HO remains unexplained. LEVEL OF EVIDENCE: Level III, therapeutic study. See Instructions for Authors for a complete description of levels of evidence.

A comparison of the long-term outcome of partial articular (AO Type B) and complete articular (AO Type C) distal radius fractures.

PURPOSE: A short-term comparison of AO type B (shearing) and type C (compression) articular fractures of the distal radius found no significant differences in functional outcome, but long-term studies would provide important information. We tested the null hypothesis that there is no difference in arm-specific disability between patients with type B and C fractures in long-term follow-up. METHODS: We evaluated 46 patients (17 with type B fractures and 29 patients with 31 type C fractures of the distal radius) with a mean age of 39 years at the time of injury at a mean of 20 years after operative treatment. We used the Disabilities of the Arm, Shoulder, and Hand questionnaire and 2 physician-based rating systems, the modified Mayo wrist score and the modified Gartland and Werley score. We performed bivariate and multivariable analyses to identify the factors that contributed most to the variation in these scores. RESULTS: There were no significant differences between patients with type B and C fractures on the Disabilities of the Arm, Shoulder, and Hand, modified Mayo wrist, or Gartland and Werley scores, or with respect to range of motion, grip strength, and arthrosis. The only statistical difference was in volar tilt of the articular surface on lateral radiographs. CONCLUSIONS: On average, patients undergoing operative treatment of type B and type C articular fractures of the distal radius have similar impairment, symptoms, and disability in the long-term. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic III.

Temporary joint-spanning external fixation before internal fixation of open intra-articular distal humeral fractures: a staged protocol.

INTRODUCTION: This study determined outcomes after temporary joint-spanning external fixation before internal fixation of open intra-articular distal humeral fractures. MATERIALS AND METHODS: A retrospective case analysis was done of all patients who were treated between 2000 and 2008 in 3 level I trauma centers with temporary joint-spanning external fixation before internal fixation of an open intra-articular distal humeral fracture. Healing rates, complications, Disabilities of Arm, Shoulder and Hand (DASH), and Smith and Cooney outcome scores were documented. RESULTS: The study included 16 patients. Mean follow-up was 35.2 months. Fractures united after an average of 5.2 months. No complications specifically related to the external fixation occurred. The DASH outcome score averaged 15.1. Although complications occurred in 12 patients (9 patients requiring surgery), 10 of 16 had an excellent/good outcome score. CONCLUSIONS: Temporary joint-spanning external fixation before internal fixation of open intra-articular distal humeral fractures is a safe adjunct.

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.

Predictors of diagnosis of ulnar neuropathy after surgically treated distal humerus fractures.

PURPOSE: Ulnar nerve dysfunction is a common sequela of surgical treatment of distal humerus fractures. This study addresses the null hypothesis that different types of distal humerus injuries have comparable rates of diagnosis of ulnar neuropathy. METHODS: We assessed diagnosis of ulnar neuropathy in 107 consecutive adults who had a surgically treated fracture of the distal humerus followed up at least 6 months after injury. Diagnosis of ulnar neuropathy was defined as documentation of sensory and motor dysfunction of the ulnar nerve in the medical record. Fractures were categorized as either columnar fractures or fractures of the capitellum and trochlea. The explanatory (independent) variables included age, sex, fracture type, AO type, associated wound, associated elbow dislocation, mechanism of trauma, ipsilateral skeletal injury, olecranon osteotomy, implant over or below the medial epicondyle, infection, time from injury to surgery, the number of surgeries within 4 weeks and 6 months of injury, the total number of surgeries, and whether the nerve was transposed. RESULTS: Postoperative ulnar neuropathy was diagnosed in 17 of 107 patients (16%), including 16 of 59 columnar fractures (21%). The only risk factor for ulnar neuropathy was columnar fracture. CONCLUSIONS: Patients with columnar fractures might be at higher risk for the development of postoperative ulnar neuropathy than patients with capitellum and trochlea fractures, regardless of whether the ulnar nerve was transposed. TYPE OF STUDY/LEVEL OF EVIDENCE: Prognostic IV.

Diagnostic accuracy of 2- and 3-dimensional imaging and modeling of distal humerus fractures.

PURPOSE: This investigation used prospectively recorded intraoperative evaluation as the reference standard for distal humerus fracture type and characteristics, in order to measure the diagnostic performance characteristics of computed tomography (CT) and physical models. In secondary analyses, we assessed the reliability of classification. METHODS: Thirty-five fractures were evaluated by the treating surgeon and first assistant on radiographs and 2-dimensional CT (2DCT) images first; a second time based on radiographs and 2- and 3-dimensional CT (3DCT) images; a third time based on 2- and 3DCT as well as 3D physical models; and a fourth time based on intraoperative visualization of the fracture characteristics. The intraoperative evaluation of the attending surgeon was used as the reference standard. RESULTS: The addition of 3DCT and the 3D models to 2DCT and radiographs led to significant improvements in sensitivity, but not specificity, in the diagnosis and proposed treatment, and improved the interobserver agreement with respect to specific fracture characteristics but not classification. CONCLUSION: Increasingly sophisticated imaging and modeling leads to slight but significant improvements in diagnostic performance characteristics and interobserver agreement on fracture characteristics.

Quantitative 3-dimensional computed tomography measurement of distal humerus fractures.

PURPOSE: To measure the average number, size, shape and articular surface area of articular fracture fragments of the distal humerus using quantitative analysis of 3-dimensional computed tomography (3DCT) images. MATERIALS AND METHODS: Forty-eight computed tomography scans of distal humerus fractures were analyzed with quantitative 3DCT (Q3DCT). Twenty-one patients had a capitellum and trochlea fracture, and 27 patients had bicolumnar fractures of the distal humerus. The volume and articular surface area of each articular fracture fragment were measured. A small fragment was defined of having a volume of less than 500 mm(3) or an articular surface of less than 500 mm(2). RESULTS: Bicolumnar fractures have a mean of 9.3 fragments, 5.4 small fragments, and 3.7 articular fragments per fracture. Trochlea and capitellum fractures have a mean of 3.6 fragments, 1.5 small fragments, and 2.3 articular fragments per fracture. For each fracture type, the number of small fragments correlated with the total number of fragments. CONCLUSION: Columnar fractures had more articular fragments and more small fragments than trochlea and capitellum fractures.

Nonunion of operatively treated capitellum and trochlear fractures.

PURPOSE: To test the hypothesis that comminuted fractures of the capitellum and trochlea with posterior comminution (Dubberley type 3B) have a greater risk of nonunion than other types of capitellum and trochlea fractures. METHODS: We observed 30 patients with operatively treated fractures of the capitellum and trochlea for an average of 34 months (range, 12-75 mo). We compared 18 fractures with comminution of the capitellum and trochlea and posterior comminution (type 3B according to Dubberley and colleagues) with 12 fractures consisting of single large anterior fracture fragments with (6 patients; Dubberley type 2B) or without (6 patients; Dubberley type 2A) posterior comminution. RESULTS: Of 18 patients, 8 with type 3B fractures were noted to have nonunion. No patients with type 2 fractures had a nonunion. CONCLUSIONS: Fractures of the capitellum and trochlea are prone to nonunion when they create multiple articular fragments and there is posterior comminution (Dubberley type 3B).

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.

Magnetic resonance imaging signal abnormalities in enthesopathy of the extensor carpi radialis longus origin.

PURPOSE: Some surgeons use magnetic resonance imaging (MRI) findings in patients with enthesopathy of the extensor carpi radialis brevis (ECRB) origin (commonly referred to as lateral epicondylitis) to plan and justify surgical treatment. Overinterpretation of defects of the origin of the ECRB or associated abnormalities of the lateral collateral ligament (LCL) could affect decision-making. We tested the hypothesis that patients with MRI signal abnormalities consistent with enthesopathy of the ECRB are equally likely to have findings consistent with an ECRB defect or LCL abnormality whether they are being evaluated as part of preoperative planning for lateral elbow pain or for an elbow condition that does not feature lateral elbow pain. METHODS: For each of 24 consecutive patients with enthesopathy of the ECRB who had MRI for preoperative evaluation, we selected 2 age- and gender-matched controls from a list of patients who had an elbow MRI to evaluate other elbow problems. The origin of the ECRB and the LCL were specifically evaluated. RESULTS: Patients diagnosed with enthesopathy of the ECRB were significantly more likely than control patients to have signal changes consistent with enthesopathy of the ECRB origin (24 of 24 vs 9 of 48; p < .001). The proportion of patients with a partial thickness defect of the ECRB origin (14 of 24 vs 4 of 9) was comparable between patients diagnosed with enthesopathy of the ECRB origin and controls. Signal changes in the LCL were comparable in patients diagnosed with enthesopathy of the ECRB origin and control patients (8 of 24 vs 2 of 9; p = .27), and no patient had clinical evidence of instability. CONCLUSIONS: Use of MRI in the management of patients with enthesopathy of the ECRB origin merits further study.

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.

Fractures of the medial column of the distal humerus in adults.

PURPOSE: Medial column fractures of the distal humerus are uncommon in adults. Among 26 patients identified in the English language literature, only 2 had articular fragmentation. We reviewed the experience of 2 trauma centers with isolated medial column fractures to evaluate our impression that these fractures often involve complex articular fragmentation. METHODS: There were 10 men and 4 women with an average age of 61 years (range, 44-86 years). The incidence was 3% of all distal humerus fractures at one institution with a prospective fracture database. The mechanism of injury was a fall from standing height in most patients. There was one B2.1 fracture, 3 B2.2 fractures, 9 B2.3 (multifragmentary), and 1 C3.2 fracture. All patients were treated surgically; 7 were treated with an olecranon osteotomy. Eight patients had 1 or more postoperative complications and 5 patients underwent subsequent surgeries. RESULTS: We observed 11 patients for an average of 8 years (range, 14 months to 21 years). The arc of ulnohumeral motion averaged 92 degrees, average flexion was 118 degrees, and average flexion contracture was 25 degrees. According to the Broberg and Morrey Functional Rating Index, the result was excellent in 4 patients, good in 6, and fair in 1. Six patients had arthrosis (3 grade 1 and 3 grade 2) according to the radiographic criteria of Broberg and Morrey. CONCLUSIONS: Surgeons should be aware that the relatively uncommon medial column adult distal humerus fracture usually features complex articular fragmentation, but that satisfactory results can be obtained after open reduction and internal fixation.

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.