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David Ring - One of the best experts on this subject based on the ideXlab platform.
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patient and surgeon factors associated with prosthetic replacement rather than with open reduction and internal fixation of a radial head Fracture
Hand, 2020Co-Authors: Casey M Oconnor, Lee M Reichel, Joost T P Kortlever, Gregg A Vagner, David RingAbstract:Background: The decision between radial head arthroplasty and open reduction internal fixation in the context of a terrible triad Elbow Fracture-dislocation is debated. This study investigated both...
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patient and surgeon factors associated with prosthetic replacement rather than with open reduction and internal fixation of a radial head Fracture
Hand, 2020Co-Authors: Casey M Oconnor, Lee M Reichel, Joost T P Kortlever, Gregg A Vagner, David RingAbstract:Background: The decision between radial head arthroplasty and open reduction internal fixation in the context of a terrible triad Elbow Fracture-dislocation is debated. This study investigated both surgeon and patient factors associated with surgeons' recommendations to use arthroplasty. Methods: One hundred fifty-two surgeon members of the Science of Variation Group participated. Surgeons were asked to complete an online survey that included surgeon demographics and 16 patient scenarios. The patient scenarios were randomized using 2 patient variables and 2 anatomical variables. Multilevel logistic mixed regression analysis was performed to identify surgeon and patient variables associated with recommendations for radial head arthroplasty. Results: We found that radial head replacement was recommended in 38% of the scenarios. Scenarios with older patients, with Fractures of the whole head, and those involving 3 Fracture fragments were independently associated with radial head replacement. Conclusion: We found that most surgeons recommended radial head Fracture fixation rather than arthroplasty. Surgeons were more likely to recommend fixation for younger patients with partial articular Fractures or with Fractures with 3 or fewer Fracture fragments. It seems that surgeons are uneasy about using a prosthesis in a young active patient.
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Terrible Triad Elbow Fracture-Dislocation
Surgical Techniques for Trauma and Sports Related Injuries of the Elbow, 2019Co-Authors: Job N. Doornberg, David Ring, Gregory I. BainAbstract:The coronoid process of the ulna is an important bony stabilizer of the Elbow forming an anterior buttress with the radial head to avoid posterior subluxation or dislocation of the Elbow (Fig. 38.1). Specific Fracture types are associated with distinct patterns of traumatic Elbow instability. Coronoid Fractures are classified using the O’Driscoll classification based on fragment morphology: type 1 are tip Fractures associated with terrible triad Elbow Fracture-dislocations, type 2 are anteromedial facet Fractures associated with posteromedial varus rotational-type injuries (PMVRI), and type 3 are large basal Fracture associated with olecranon Fracture-dislocations.
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multicenter trial of an internal joint stabilizer for the Elbow
Journal of Shoulder and Elbow Surgery, 2017Co-Authors: Jorge L Orbay, David Ring, Amir Reza Kachooei, Jose Santiagofigueroa, Luis Bolano, Miguel Pirelacruz, Michael R Hausman, Rick PapandreaAbstract:Background Our primary efficacy objective was to evaluate the effectiveness of the internal joint stabilizer of the Elbow (IJS-E) in maintaining concentric location of the Elbow during and after removal of the device in the treatment of persistent or recurrent instability after Elbow Fracture or dislocations, or both. The secondary study objectives were to assess range of motion, Broberg-Morrey functional score, Broberg-Morrey categorical rating, the Disabilities of the Arm, Shoulder and Hand score, and the rate of complications and adverse events after the use of IJS-E. Methods Twenty-four patients were studied in a multicenter, nonrandomized, prospective, single-arm study. The IJS-E was used to provide temporary stabilization of the Elbow joint and allow a functional range of motion while ligaments and Fractures healed. Results The Elbow remained concentrically aligned in 23 of 24 patients. One coronoid-deficient Elbow did not maintain concentric reduction. At the last evaluation a minimum of 6 months after device removal, the mean arc of Elbow flexion was 119° (range, 80°-150°; standard deviation [SD], 18°), and the mean arc of forearm rotation was 151° (range, 90°-190°; SD, 24°). The mean and median Broberg-Morrey scores were 93 and 97, respectively. Categorically the results were excellent in 14, good in 8, fair in 1, and poor in 1. The mean Disabilities of the Arm, Shoulder and Hand score was 16 (range, 0-68; SD, 18). Conclusion The IJS-E maintains concentric reduction, allows Elbow motion, and avoids the inconveniences and pin problems of percutaneous fixation.
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involvement of the lesser sigmoid notch in Elbow Fracture dislocations
Journal of Shoulder and Elbow Surgery, 2016Co-Authors: Neal C Chen, Amir Reza Kachooei, Jos J Mellema, Matthew Tarabochia, Niek C Van Dijk, David RingAbstract: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.
Amir Reza Kachooei - One of the best experts on this subject based on the ideXlab platform.
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multicenter trial of an internal joint stabilizer for the Elbow
Journal of Shoulder and Elbow Surgery, 2017Co-Authors: Jorge L Orbay, David Ring, Amir Reza Kachooei, Jose Santiagofigueroa, Luis Bolano, Miguel Pirelacruz, Michael R Hausman, Rick PapandreaAbstract:Background Our primary efficacy objective was to evaluate the effectiveness of the internal joint stabilizer of the Elbow (IJS-E) in maintaining concentric location of the Elbow during and after removal of the device in the treatment of persistent or recurrent instability after Elbow Fracture or dislocations, or both. The secondary study objectives were to assess range of motion, Broberg-Morrey functional score, Broberg-Morrey categorical rating, the Disabilities of the Arm, Shoulder and Hand score, and the rate of complications and adverse events after the use of IJS-E. Methods Twenty-four patients were studied in a multicenter, nonrandomized, prospective, single-arm study. The IJS-E was used to provide temporary stabilization of the Elbow joint and allow a functional range of motion while ligaments and Fractures healed. Results The Elbow remained concentrically aligned in 23 of 24 patients. One coronoid-deficient Elbow did not maintain concentric reduction. At the last evaluation a minimum of 6 months after device removal, the mean arc of Elbow flexion was 119° (range, 80°-150°; standard deviation [SD], 18°), and the mean arc of forearm rotation was 151° (range, 90°-190°; SD, 24°). The mean and median Broberg-Morrey scores were 93 and 97, respectively. Categorically the results were excellent in 14, good in 8, fair in 1, and poor in 1. The mean Disabilities of the Arm, Shoulder and Hand score was 16 (range, 0-68; SD, 18). Conclusion The IJS-E maintains concentric reduction, allows Elbow motion, and avoids the inconveniences and pin problems of percutaneous fixation.
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involvement of the lesser sigmoid notch in Elbow Fracture dislocations
Journal of Shoulder and Elbow Surgery, 2016Co-Authors: Neal C Chen, Amir Reza Kachooei, Jos J Mellema, Matthew Tarabochia, Niek C Van Dijk, David RingAbstract: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.
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intraoperative physical examination for diagnosis of interosseous ligament rupture cadaveric study
Journal of Hand Surgery (European Volume), 2015Co-Authors: Michael Rivlin, Amir Reza Kachooei, Aram Faghfouri, Kyle R Eberlin, David RingAbstract:Purpose To study the intraobserver and interobserver reliability of the diagnosis of interosseous ligament (IOL) rupture in a cadaver model. Methods On 12 fresh frozen cadavers, radial heads were cut using an identical incision and osteotomy. After randomization, the soft tissues of the limbs were divided into 4 groups: both IOL and triangular fibrocartilage (TFCC) intact; IOL disruption but TFCC intact; both IOL and TFCC divided; and IOL intact but TFCC divided. All incisions had identical suturing. After standard instruction and demonstration of radius pull-push and radius lateral pull tests, 10 physician evaluators with different levels of experience examined the cadaver limbs in a standardized way (Elbow at 90° with the forearm held in both supination and pronation) and were asked to classify them into one of the 4 groups. Next, the same examiners were asked to re-examine the limbs after randomly changing the order of examination. Results The interobserver reliability of agreement for the diagnosis of IOL injury (groups 2 and 3) was fair in both rounds of examination and the intraobserver reliability was moderate. The intra- and interobserver reliabilities of agreement for the 4 groups of injuries among the examiners were fair in both rounds of examination. The sensitivity, specificity, accuracy, positive, and negative predictive values were all around 70%. The likelihood of a positive test corresponding with the presence of IOL rupture (positive likelihood ratio) was 2.2. The likelihood of a negative test correctly diagnosing an intact IOL was 0.40. Conclusions In cadavers, intraoperative tests had fair reliability and 70% accuracy for the diagnosis of IOL rupture using the push-pull and lateral pull maneuvers. The level of experience did not have any effect on the correct diagnosis of intact versus disrupted IOL. Clinical relevance Although not common, some failure of surgeries for traumatic Elbow Fracture-dislocations is because of failure in timely diagnosis of IOL disruption.
Job N. Doornberg - One of the best experts on this subject based on the ideXlab platform.
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Terrible Triad Elbow Fracture-Dislocation
Surgical Techniques for Trauma and Sports Related Injuries of the Elbow, 2019Co-Authors: Job N. Doornberg, David Ring, Gregory I. BainAbstract:The coronoid process of the ulna is an important bony stabilizer of the Elbow forming an anterior buttress with the radial head to avoid posterior subluxation or dislocation of the Elbow (Fig. 38.1). Specific Fracture types are associated with distinct patterns of traumatic Elbow instability. Coronoid Fractures are classified using the O’Driscoll classification based on fragment morphology: type 1 are tip Fractures associated with terrible triad Elbow Fracture-dislocations, type 2 are anteromedial facet Fractures associated with posteromedial varus rotational-type injuries (PMVRI), and type 3 are large basal Fracture associated with olecranon Fracture-dislocations.
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temporary presence of myofibroblasts in human Elbow capsule after trauma
Journal of Bone and Joint Surgery-british Volume, 2014Co-Authors: Job N. Doornberg, Jesse B Jupiter, David Ring, Mark S Cohen, Tjalling Bosse, Peter KloenAbstract:Summary In contrast to the current literature, myofibroblasts are not present in chronic posttraumatic Elbow contractures. However, myofibroblasts are present in the acute phase after an Elbow Fracture and/or dislocation. This suggests a physiological role in normal capsule healing and a potential role in the early phase of posttraumatic contracture formation. Introduction Elbow stiffness is a common complication after Elbow trauma. The Elbow capsule is often thickened, fibrotic and contracted upon surgical release. The limited studies available suggest that the capsule is contracted because of fibroblast to myofibroblast differentiation. However, the timeline is controversial and data on human capsules are scarce. We hypothesise that myofibroblasts are absent in normal capsules and early after acute trauma and elevated in patients with posttraumatic Elbow contracture. Patients & Methods We obtained twenty-one human Elbow joint capsules within fourteen days after an Elbow Fracture and/or dislocation and thirty-four capsules from thirty-four patients who had operative release of posttraumatic contractures greater than five months after injury. Myofibroblasts in the joint capsules were quantified using immunohistochemistry. Alpha-smooth muscle actin (α-SMA) was used as a marker for myofibroblasts. Samples were characterised and scored by an independent pathologist blinded for clinical data. Results Eleven capsules were associated with the acute phase after trauma (hours to 7 days), and staining for α-SMA was negative in all eleven specimens. Ten specimens were associated with a later phase post trauma with myofibroblasts staining positive for α-SMA in all but two. All, but two, thirty-four long standing contractures showed a histological pattern consistent with chronic stages of fibrosis, characterised by increased fibroblast-like cell proliferation and higher cellular density of fibroblast-like cells with highly unstructured collagen. There was no staining of α-SMA in fibroblast-like cells in, all but two of these longstanding contractures suggesting absence of myofibroblasts. Conclusions This study present ‘negative results’ on the hypothesis that myofibroblast numbers are elevated in longstanding (> 5 months) human posttraumatic Elbow capsules. This is in contrast to all studies on human tissue in the literature to date. One recent animal study is in agreement withy our data. We did find some myofibroblasts in Elbow capsules in the late-phase posttrauma (between 7 and 14 days) suggesting a potential role in early phase of posttraumatic contracture formation.
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temporary presence of myofibroblasts in human Elbow capsule after trauma
Journal of Bone and Joint Surgery American Volume, 2014Co-Authors: Job N. Doornberg, Jesse B Jupiter, David Ring, Mark S Cohen, Tjalling Bosse, Peter KloenAbstract:Background: Elbow stiffness is a common complication after Elbow trauma. The Elbow capsule is often thickened, fibrotic, and contracted at the time of surgical release. The limited studies available suggest that the capsule is contracted because of fibroblast-to-myofibroblast differentiation. We hypothesize that myofibroblasts are absent in normal Elbow capsules and in acute trauma and that they are subsequently elevated in patients with posttraumatic Elbow contracture. Methods: We obtained twenty-one human Elbow joint capsules within fourteen days after an Elbow Fracture and/or dislocation and thirty-four Elbow joint capsules in thirty-four patients who had undergone operative release of posttraumatic contractures more than five months after injury. Myofibroblasts in the joint capsules were quantified with use of immunohistochemistry. Alpha-smooth muscle actin was used as a marker for myofibroblasts. Samples were characterized and were scored by an independent pathologist blinded for clinical data. Results: Eleven capsules were associated with the acute phase after trauma (hours to less than seven days), and staining for alpha-smooth muscle actin was negative in all but one capsule. Ten capsules were associated with a later posttraumatic phase with myofibroblasts staining positive for alpha-smooth muscle actin in all but two capsules. Thirty-two long-standing contractures showed a histological pattern consistent with chronic stages of fibrosis, characterized by increased fibroblast-like cell proliferation and higher cellular density of fibroblast-like cells with highly unstructured collagen. Two joint capsules showed an earlier phase of fibrosis. Only two of the long-standing contractures had staining of alpha-smooth muscle actin in fibroblast-like cells; the lack of staining in the other contractures suggested an absence of myofibroblasts. Conclusions: This study presents negative results on the hypothesis that myofibroblast numbers are elevated in long-standing (more than five months) human posttraumatic Elbow capsules. The absence of myofibroblasts in long-standing Elbow contracture capsules is in contrast to most other studies on human tissue in the literature to date.
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diagnosis of Elbow Fracture patterns on radiographs interobserver reliability and diagnostic accuracy
Clinical Orthopaedics and Related Research, 2013Co-Authors: Job N. Doornberg, Thierry G Guitton, David RingAbstract:Background Studies of traumatic Elbow instability suggest that recognition of a pattern in the combination and character of the Fractures and joint displacements helps predict soft tissue injury and guide the treatment of traumatic Elbow instability, but there is no evidence that patterns can be identified reliably.
Casey M Oconnor - One of the best experts on this subject based on the ideXlab platform.
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patient and surgeon factors associated with prosthetic replacement rather than with open reduction and internal fixation of a radial head Fracture
Hand, 2020Co-Authors: Casey M Oconnor, Lee M Reichel, Joost T P Kortlever, Gregg A Vagner, David RingAbstract:Background: The decision between radial head arthroplasty and open reduction internal fixation in the context of a terrible triad Elbow Fracture-dislocation is debated. This study investigated both...
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patient and surgeon factors associated with prosthetic replacement rather than with open reduction and internal fixation of a radial head Fracture
Hand, 2020Co-Authors: Casey M Oconnor, Lee M Reichel, Joost T P Kortlever, Gregg A Vagner, David RingAbstract:Background: The decision between radial head arthroplasty and open reduction internal fixation in the context of a terrible triad Elbow Fracture-dislocation is debated. This study investigated both surgeon and patient factors associated with surgeons' recommendations to use arthroplasty. Methods: One hundred fifty-two surgeon members of the Science of Variation Group participated. Surgeons were asked to complete an online survey that included surgeon demographics and 16 patient scenarios. The patient scenarios were randomized using 2 patient variables and 2 anatomical variables. Multilevel logistic mixed regression analysis was performed to identify surgeon and patient variables associated with recommendations for radial head arthroplasty. Results: We found that radial head replacement was recommended in 38% of the scenarios. Scenarios with older patients, with Fractures of the whole head, and those involving 3 Fracture fragments were independently associated with radial head replacement. Conclusion: We found that most surgeons recommended radial head Fracture fixation rather than arthroplasty. Surgeons were more likely to recommend fixation for younger patients with partial articular Fractures or with Fractures with 3 or fewer Fracture fragments. It seems that surgeons are uneasy about using a prosthesis in a young active patient.
Jesse B Jupiter - One of the best experts on this subject based on the ideXlab platform.
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nonacute treatment of Elbow Fracture with persistent ulnohumeral dislocation or subluxation
Journal of Bone and Joint Surgery American Volume, 2014Co-Authors: Neal C Chen, Jesse B Jupiter, Scott P Steinmann, David RingAbstract:➤ There are patterns of traumatic Elbow instability that help a surgeon to anticipate which structures are injured. ➤ Patients treated for persistent subluxation or dislocation of the Elbow more than two weeks after injury regain less motion and experience more adverse events. ➤ The primary goal of treatment is stable reduction of the ulnohumeral joint and functional Elbow motion. ➤ Motion and pain are affected by contracture and scarring of the soft tissues, malalignment of the joint, Fracture malunion, damage to the articular surface, and ulnar neuropathy. ➤ Biomechanical and clinical studies support treatment with radial head arthroplasty and/or coronoid reconstruction for patients who have osseous insufficiency.
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temporary presence of myofibroblasts in human Elbow capsule after trauma
Journal of Bone and Joint Surgery-british Volume, 2014Co-Authors: Job N. Doornberg, Jesse B Jupiter, David Ring, Mark S Cohen, Tjalling Bosse, Peter KloenAbstract:Summary In contrast to the current literature, myofibroblasts are not present in chronic posttraumatic Elbow contractures. However, myofibroblasts are present in the acute phase after an Elbow Fracture and/or dislocation. This suggests a physiological role in normal capsule healing and a potential role in the early phase of posttraumatic contracture formation. Introduction Elbow stiffness is a common complication after Elbow trauma. The Elbow capsule is often thickened, fibrotic and contracted upon surgical release. The limited studies available suggest that the capsule is contracted because of fibroblast to myofibroblast differentiation. However, the timeline is controversial and data on human capsules are scarce. We hypothesise that myofibroblasts are absent in normal capsules and early after acute trauma and elevated in patients with posttraumatic Elbow contracture. Patients & Methods We obtained twenty-one human Elbow joint capsules within fourteen days after an Elbow Fracture and/or dislocation and thirty-four capsules from thirty-four patients who had operative release of posttraumatic contractures greater than five months after injury. Myofibroblasts in the joint capsules were quantified using immunohistochemistry. Alpha-smooth muscle actin (α-SMA) was used as a marker for myofibroblasts. Samples were characterised and scored by an independent pathologist blinded for clinical data. Results Eleven capsules were associated with the acute phase after trauma (hours to 7 days), and staining for α-SMA was negative in all eleven specimens. Ten specimens were associated with a later phase post trauma with myofibroblasts staining positive for α-SMA in all but two. All, but two, thirty-four long standing contractures showed a histological pattern consistent with chronic stages of fibrosis, characterised by increased fibroblast-like cell proliferation and higher cellular density of fibroblast-like cells with highly unstructured collagen. There was no staining of α-SMA in fibroblast-like cells in, all but two of these longstanding contractures suggesting absence of myofibroblasts. Conclusions This study present ‘negative results’ on the hypothesis that myofibroblast numbers are elevated in longstanding (> 5 months) human posttraumatic Elbow capsules. This is in contrast to all studies on human tissue in the literature to date. One recent animal study is in agreement withy our data. We did find some myofibroblasts in Elbow capsules in the late-phase posttrauma (between 7 and 14 days) suggesting a potential role in early phase of posttraumatic contracture formation.
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temporary presence of myofibroblasts in human Elbow capsule after trauma
Journal of Bone and Joint Surgery American Volume, 2014Co-Authors: Job N. Doornberg, Jesse B Jupiter, David Ring, Mark S Cohen, Tjalling Bosse, Peter KloenAbstract:Background: Elbow stiffness is a common complication after Elbow trauma. The Elbow capsule is often thickened, fibrotic, and contracted at the time of surgical release. The limited studies available suggest that the capsule is contracted because of fibroblast-to-myofibroblast differentiation. We hypothesize that myofibroblasts are absent in normal Elbow capsules and in acute trauma and that they are subsequently elevated in patients with posttraumatic Elbow contracture. Methods: We obtained twenty-one human Elbow joint capsules within fourteen days after an Elbow Fracture and/or dislocation and thirty-four Elbow joint capsules in thirty-four patients who had undergone operative release of posttraumatic contractures more than five months after injury. Myofibroblasts in the joint capsules were quantified with use of immunohistochemistry. Alpha-smooth muscle actin was used as a marker for myofibroblasts. Samples were characterized and were scored by an independent pathologist blinded for clinical data. Results: Eleven capsules were associated with the acute phase after trauma (hours to less than seven days), and staining for alpha-smooth muscle actin was negative in all but one capsule. Ten capsules were associated with a later posttraumatic phase with myofibroblasts staining positive for alpha-smooth muscle actin in all but two capsules. Thirty-two long-standing contractures showed a histological pattern consistent with chronic stages of fibrosis, characterized by increased fibroblast-like cell proliferation and higher cellular density of fibroblast-like cells with highly unstructured collagen. Two joint capsules showed an earlier phase of fibrosis. Only two of the long-standing contractures had staining of alpha-smooth muscle actin in fibroblast-like cells; the lack of staining in the other contractures suggested an absence of myofibroblasts. Conclusions: This study presents negative results on the hypothesis that myofibroblast numbers are elevated in long-standing (more than five months) human posttraumatic Elbow capsules. The absence of myofibroblasts in long-standing Elbow contracture capsules is in contrast to most other studies on human tissue in the literature to date.
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Elbow dislocation and articular Fracture of the distal humerus
Chinese Journal of Orthopaedic Trauma, 2006Co-Authors: Andres Arizmendi, David Ring, Santiago A Lozanocalderon, Jesse B JupiterAbstract:Objective To describe dislocation of the Elbow with articular Fracture of the distal humerus, a type of Elbow Fracture-dislocation about which little has been written. Methods Four patients with a dislocation of the Elbow and Fracture of the distal humerus were identified. Three had dislocation and complex intraarticular Fracture of the capitellum, trochlea, and lateral epicondyle. Results Two patients （one treated with a second operation to address avaseular necrosis of the capitellum） achieved a functional arc of Elbow motion and one patient was lost after removal of the implants 3 months after Fracture with documented healing. The fourth patient had a complex open Fracture dislocation involving the entire articular surface. An attempt to salvage the articular surface resulted in deep infection. Extensive heterotnpic bone led to arthrodesis of the Elbow. Conclusions Dislocations of the Elbow with articular Fracture of the humerus are uncommon. Most injuries involve the capitellum, lateral trochlea, and lateral epicondyle. Open reduction and internal fixation of the distal humerus Fracture can restore stability without repairing the medial collateral ligament. Key words: Elbow ; Fracture ; Dislocation ; Distal humerus
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posterior dislocation of the Elbow with Fractures of the radial head and coronoid
Journal of Bone and Joint Surgery American Volume, 2002Co-Authors: David Ring, Jesse B Jupiter, Jeffrey L ZilberfarbAbstract:Background: Posterior dislocation of the Elbow with associated Fractures of the radial head and the coronoid process of the ulna has been referred to as the "terrible triad of the Elbow" because of the difficulties encountered in its management. However, there are few published reports on this injury. Methods: Eleven patients with this pattern of injury were evaluated after a minimum of two years. The radial head Fracture had been repaired in five patients, and the radial head had been resected in four. None of the coronoid Fractures had been repaired, and the lateral collateral ligament had been repaired in only three patients. All eleven patients returned for clinical examination, functional evaluation, and radiographs. Results: Seven Elbows redislocated in a splint after manipulative reduction. Five, including all four treated with resection of the radial head, redislocated after operative treatment. At the time of final follow-up, three patients were considered to have a failure of the initial treatment. One of them had recurrent instability, which was treated with a total Elbow arthroplasty after multiple unsuccessful operations; one had severe arthrosis and instability resembling neuropathic arthropathy; and one had an Elbow flexion contracture and proximal radioulnar synostosis requiring reconstructive surgery. The remaining eight patients, who were evaluated at an average of seven years after injury, had an average of 92° (range, 40° to 130°) of ulnohumeral motion and 126° (range, 40° to 170°) of forearm rotation. The average Broberg and Morrey functional score was 76 points (range, 34 to 98 points), with two results rated as excellent, two rated as good, three rated as fair, and one rated as poor. Overall, the result of treatment was rated as unsatisfactory for seven of the eleven patients. All four patients with a satisfactory result had retained the radial head, and two had undergone repair of the lateral collateral ligament. Seven of the ten patients who had retained the native Elbow had radiographic signs of advanced ulnohumeral arthrosis. Conclusions: Elbow Fracture-dislocations that involve a Fracture of the coronoid process in addition to a Fracture of the radial head are very unstable and prone to numerous complications. Identification of the coronoid Fracture is therefore important, and computed tomography should be used if there is uncertainty. With operative treatment, the surgeon should attempt to restore stability by providing radiocapitellar contact (preserving the radial head when possible and replacing it with a prosthesis otherwise), repairing the lateral collateral ligament, and perhaps performing internal fixation of the coronoid Fracture.