Epidemiological Evaluation of Pediatric Elbow Injuries: A Retrospective Observational Single Center

Introduction Elbow fractures are the commonest fractures in the pediatric age group. The aim of this study is to evaluate the epidemiology of fresh and neglected pediatric elbow fractures in a hilly state of India with a limited health care facility. Materials and Methods This was a retrospective observational single-center study conducted between January 2019 and January 2021. Results Supracondylar was the most common fracture in 58.7% of patients followed by lateral condyle and proximal radius fracture. The highest number of fractures were reported in the age group of 5 to 8 years. In addition, 19% of patients presented with associated complications, 8% of patients had combination injuries of the ipsilateral upper limb, 16% of patients presented to the hospital 1 week after the trauma, 48% of patients had the first contact with a bonesetter/native practitioner. Conclusion Supracondylar fracture was the most common elbow fracture followed by lateral condyle. The most common involved age group was 5 to 8 years. A significant number of elbow fractures are mismanaged by native practitioners in rural India.

Application of ultrasound in the closed reduction and percutaneous pinning in supracondylar humeral fractures

Background Ultrasound examination can be applied to the diagnosis of pediatric elbow fracture. This study aims to analyze the application value of ultrasound in the surgical treatment of supracondylar humeral fractures. Methods 64 children with supracondylar humeral fractures were treated with ultrasound-guided closed reduction and percutaneous pinning (CRPP), 31 patients were treated with CRPP under radiography guidence. The reduction effect of supracondylar humeral fractures was determined through the perioperative ultrasound images of the lateral, medial and posterior aspects of the elbow. Percutaneous pinning was performed after supracondylar humeral fractures were well reduced. A follow-up examination was performed and all the patients were evaluated according to Flynn’s criteria. Results The mean duration of surgery was 58.3 min (42–108 min) in the ultrasound group and 41.5 min (24-63 min) in the radiography group (P < 0.05). The mean carrying angle was 8.2° (0°–15°) in the ultrasound group and 9.4°(3°–16°) in the radiography group; The mean Baumann’s angle was 75.5°(60°–85°) in the ultrasound group and 73.4°(62°–82°) in the radiography group; The mean lateral humerocapitellar angle was 38.4° (26°–54°) in the ultrasound group and 41.6°(29°–52°) in the radiography group; No significant differences were observed between the two groups. According to the Flynn’s criteria, 49 (76.6%) patients had excellent, 10 (15.6%) patients achieved good, 3 (4.7%) patients showed fair results and 2 (3.1%) patients achieved poor results in the ultrasound group; 22 (70.9%) patients had excellent, 6 (19.4%) patients achieved good, 2 (6.5%) patients showed fair results and 1 (3.2%) patients achieved poor results in the radiography group; No statistically significant difference was noted between the results of these two groups (P > 0.05). After surgery, three patients had pin tract infection. One patient had ulnar nerve neurapraxia in the radiography group. No cases with Volkmann’s contracture were reported. Conclusion Ultrasound-guided CRPP is a safe and reliable surgical treatment of pediatric supracondylar humeral fractures. Trial registration Retrospectively registered.

Comparison of Functional Outcomes in the Management of Intercondylar Fractures by Olecranon Osteotomy Approach versus Triceps on and Triceps off Approach

Intercondylar fracture of the distal humerus is a relatively rare and challenging intra-articular elbow fracture, with available choice of surgical treatment includes open reduction and extensive internal fixation. This systematic review aims to evaluate the effectiveness of the surgical approach regarding the functional outcome following intercondylar fracture treatment. A systematic search on literature was performed online from the inception dates to November 2020. Main outcome of interest included functional outcomes, Mayo Elbow Performance Score (MEPS) and The Disabilities of the Arm, Shoulder and Hand (DASH) Score. Animal studies, case reports, review articles and non-English papers were excluded. Four articles were included in this review. The functional outcome was different among the olecranon osteotomy approach, triceps on with the triceps sparing approach and triceps off with the triceps lifting approach or the TRAP approach. Triceps on approach with triceps sparing had lower MEPS in patients above 60 years of age but satisfactory in younger patients, while olecranon osteotomy approach showed excellent MEPS rate in all age groups. Olecranon osteotomy approach gives better exposure for more accurate anatomical reduction of the intra articular fracture resulting in better functional outcome. Mean DASH score was significantly higher in Triceps Reflecting anconeus (TRAP) group. Olecranon osteotomy approach was found to be better than triceps on approach, with better functional outcome. However, other triceps off (TRAP) did not show any significant differences in terms of functional outcome in the management of intercondylar fractures. Keywords: intercondylar fractures, olecranon osteotomy, triceps on, triceps off, functional outcome.

Evaluation and Experience in the Treatment of Coronal Plane Elbow Fractures via the Anterior Approach

Background: The existing approaches to treating elbow fractures include anterior, external, internal, and posterior approaches. Of these, the anterior approach is often not chosen by surgeons to avoid damaging important nerves and blood vessels. In fact, the anterior approach has unique advantages. The purpose of this study was to report the outcomes in 38 patients with coronal plane elbow fractures treated through the anterior approach.Methods: We retrospectively analyzed 38 cases of coronal plane elbow fractures treated through an anterior approach at our institution between March 2015 and July 2019. The length of the surgical incision, operation time, intraoperative blood loss, and postoperative complications were recorded. The range of flexion, extension, and rotation of the affected elbow and the healthy elbow were collected at follow-up. Functional outcomes were evaluated using the Mayo Elbow Function Score (MEPS).Results: All 38 patients were followed up. At the final follow-up, solid osseous union was confirmed for all coronal plane elbow fractures. The mean elbow flexion arc was 129.26 ± 6.9 degrees, and the extension arc was 8.87 ± 6.13 degrees. The mean pronation arc was 83.45 ± 2.9 degrees, and the supination arc was 80.05 ± 2.92 degrees. The mean MEPS was 90.0±7.53 points, with 18 excellent cases and 20 good cases. There was no significant difference in elbow extension, flexion, and pronation between 31 cases of single fracture and the healthy elbow (P > 0.05); the arc of supination was slightly worse than that of the healthy elbow (P < 0.05). The VAS pain scores of the patients before the operation, three months after the operation, and during follow-up were compared. The pain of the patients was significantly reduced after treatment (P < 0.05). Two patients experienced transient postoperative median nerve paralysis, from which they recovered within three months. One patient had mild heterotopic ossification and was not treated because it did not affect the function of the elbow joint. All patients returned to work and were satisfied with the treatment.Conclusion: The anterior approach has the benefits of simplicity, safety, minimal invasion, excellent exposure, and satisfactory prognosis for coronal plane elbow fracture.

Medial Epicondyle Apophyseal Avulsion Fractures in Youth Throwers: A Severe Variant of Little League Elbow (132)

Objectives: Medial epicondyle apophyseal avulsion fractures sustained during throwing represent an understudied, severe variant of medial epicondyle apophysitis, or ‘Little League elbow’. The current study sought to characterize presenting features, treatment options, and clinical results of a large cohort of pre-adolescent and adolescent patients who presented with these fractures. Methods: Skeletally immature athletes with medial epicondyle apophyseal avulsion fractures sustained during throwing from 2003-2017 at a tertiary-care pediatric referral center were identified. Exclusion criteria were fractures sustained during non-throwing activity or prior elbow fracture. Medical records and radiographic images were reviewed for study variables. Treatment decisions were made independently by fellowship-trained pediatric orthopaedic surgeons or sports medicine physicians on a case-by-case basis. Patients treated with open reduction and internal fixation (ORIF) were compared to those treated non-operatively, and all fracture patients were compared to a larger control group of patients diagnosed with medial epicondyle apophysitis/Little League elbow with no fracture. Results: During the study period, a total of 317 patients were diagnosed with Little League elbow due to medial epicondyle apophyseal overuse injury, 50 of whom (16%) sustained a discreet, radiographically confirmed epicondyle fracture sustained during a single throw. Median age of the fracture cohort at presentation was 13.1 years (range 8 years – 16 years). Forty-nine fracture patients (98%) were male baseball pitchers and one (2%) was a male football quarterback. Fracture patients had significantly higher median BMI (21.3 kg/m2 vs. 19.2kg/m2, p=0.004) than the apophysitis control group, but there was no significant difference in age. Of the 37 patients with documentation regarding pre-injury symptoms, 31 patients (84%) described pre-existing medical elbow pain prior to their acute injury, while 6 (16%) denied pain prior to the inciting throw. Of the 12 patients (24%) with documented shoulder exams at presentation, 5 (42%) demonstrated glenohumeral internal rotation deficit (GIRD). Twenty-three patients (46%) were treated with ORIF (22 single screw fixation; 1 suture anchor fixation), while 27 (54%) were treated non-operatively. Median fracture displacement was significantly greater in operative patients than non-operative patients (5.0mm vs. 3.0mm, p=<.001), with all ‘minimally displaced’ (<4mm) fractures undergoing non-operative treatment (Figure 1). Multivariable analysis determined that for each additional mm of displacement, the odds of surgical intervention increased by 6.4 times (OR=6.36; 95% CI=1.83-22.07; p=.004), when controlling for age and BMI. All patients returned to their throwing sport (RTS) at a median of 12.8 weeks post-diagnosis, but 13 (26%) developed recurrent elbow pain, with no significant difference in in RTS time or recurrence rate between treatment cohorts. Nine of twenty-two (41%) screw ORIF patients underwent secondary implant removal, with no significant difference in this rate between those with or without a washer. Conclusions: Medial epicondyle apophyseal avulsion fractures in youth throwers represent a severe variant of Little League elbow, constituting approximately 16% of cases within the condition’s spectrum. These fractures may be effectively treated with either non-operative measures, particularly minimally displaced fractures <4mm, or ORIF, though >40% of operative patients may require implant removal. A large majority of patients reported medial elbow pain prior to fracture, suggesting this severe presentation of Little League elbow may be preventable.

Complex open elbow fracture-dislocation with severe proximal ulna bone loss: a case report of massive osteochondral allograft surgical treatment

We report a case of a 69-year-old right-dominant man who had an open Monteggia-like lesion of the right elbow (Gustilo-Andersen IIIA) with severe proximal ulna bone loss associated with an ipsilateral ulnar shaft fracture due to a motorcycle accident. The patient underwent two-stage surgery. Wound debridement and bridging external fixation were performed at first. Three months later, a frozen massive osteochondral ulnar allograft was implanted and fixed with a locking compression plate. A superficial wound infection appeared 5 weeks after the second surgery. Superficial wound debridement, negative pressure therapy, and antibiotics were administered for 3 months, achieving infection healing. At 3 years post-surgery, the elbow range of motion was satisfactory with a Disabilities of the Arm, Shoulder and Hand (DASH) score of 16.7. Radiographs and computed tomography scans showed good allograft-bone integration without allograft reabsorption or hardware loosening. Although not complication-free, massive ulna osteochondral allograft implantation can be considered a valid option in cases of open Monteggia-like lesions associated with ulnar shaft fracture and severe bone loss in active patients, whenever osteosynthesis or joint replacement is not a proper solution. This type of bone stock restoration allows for future surgery, like arthroplasty, if needed.

Long-Term Outcomes of Radial Head Arthroplasty in Complex Elbow Fracture Dislocation

The purpose of the current study was to investigate the long-term outcomes of radial head arthroplasty in complex elbow injuries through radiographic analysis and functional correlation. We evaluated 24 radial head arthroplasties in 24 consecutive patients with complex elbow fracture dislocation. All patients were treated with a single type of modular monopolar prosthesis containing smooth stem in press-fit implantation. Clinical survey using the Mayo Elbow Performance Score (MEPS), self-reported scales of shortened Disabilities of the Arm, Shoulder, and Hand (QuickDASH) and the visual analog scale (VAS) at more than 10-year follow-up were reported and compared to 2-year outcomes. Periprosthetic osteolysis was measured in the 10 zones of prosthesis-cortical interface with a modified radiolucency score, which was calibrated by each prosthesis size. Pearson correlation analysis was performed to detect the association between periprosthetic radiolucency and clinical assessment. At the final follow-up, MEPS, QuickDASH score and VAS score averaged 82.5 ± 15, 14.1 ± 14.3 and 1.6 ± 1.2 respectively. A decline in functional status was noted, with decreased mean MEPS and increased mean QuickDASH and VAS scores as compared to the 2-year results while the difference was insignificant. Periprosthetic osteolysis was more prevalent around stem tip of zone 3 and zone 8. The final and 2-year radiolucency scores averaged 7.4 ± 4.2 and 2.6 ± 2.3 respectively with significant difference. Pearson correlation analysis indicated that the difference between radiolucency scores and clinical outcomes in MEPS/QuickDASH/VAS was −0.836, 0.517 and 0.464. Progression of periprosthetic osteolysis after postoperative 10 years is more prevalent around the stem tip with moderate to high correlation to clinical outcomes. Sustained follow-up is warranted to justify subsequent surgery for revision or implant removal.