A New Pediatric Monteggia Fracture Type 4 Variant

Introduction: Monteggia fracture-dislocations are rare and complex injuries that usually involve a fracture of the proximal ulna associated with a proximal radioulnar and radiocapitellar joint dislocations. These injuries comprise <1% of all pediatric forearm fractures. We report on a pediatric Monteggia fracture-dislocation variant that included an irreducible divergent ulnohumeral joint dislocation, an irreducible anterior radial head dislocation, and a proximal and distal radius and ulna fracture. Case Report: A 6-year-old female came to our emergency room with a right elbow and forearm pain and deformity after a fall from a slide on the same day. X-rays revealed a divergent ulnohumeral joint dislocation, an anterior radiocapitellar joint dislocation, a proximal radioulnar joint dislocation, and a proximal and distal ulna and radius fracture. Closed reduction under sedation in the emergency room was not successful, with persistent ulnohumeral, ulnoradial, and radiocapitellar joint dislocations. The patient was taken to the operating room the next morning. She underwent open reduction and internal fixation of the proximal ulna fracture with a one-third tubular locking plate, and radial head dislocation open reduction. A stable reduction of the ulnohumeral joint was only possible after the fixation of the proximal ulna fracture. The most stable position for the radiocapitellar joint after its open reduction was at 70o of elbow extension and full forearm supination; the patient was casted in that position for 6 weeks. Conclusion: Pediatric Monteggia fracture-dislocations are rare and complex childhood fractures, and new variants of this injury can have even more complex presentations. Open reduction and stable internal fixation addressing all components of this injury will lead to an excellent outcome. Keywords: Pediatric monteggia fracture-dislocation, new type four variant, divergent ulnohumeral joint dislocation, irreducible dislocation.

A novel treatment for prevention of post-traumatic elbow stiffness using onaBotulinum toxin type A: a prospective placebo controlled randomized trial

Approximately 30% of all upper extremity fractures are elbow fractures which may result elbow stiffness. This study aimed to investigate the efficacy of onaBotulinum Toxin type A injection to prevent post-traumatic pain and elbow-stiffness. All patients were included who presented to a single surgeon with supracondylar/ intraarticular distal humerus fractures, proximal ulna and radius fractures. The study was developed in a randomized placebo controlled study between 2003-2007. The Disabilities of the Arm, Shoulder, and Hand (DASH) score as well as the arc-of-motion (AOM) were assessed after three, six, twelve-months and final follow up for evaluation. Of the 31-patients included, 15-patients (48.4%) received Botox injections. In all patients no complication was observed when injecting a dosage 100-units for the brachialis and biceps brachii muscles. Furthermore, it was an effective method to prevent post-traumatic elbow stiffness, lasting six- months. Significant differences in DASH, VAS-score and ROM after three-months between the Botox and control group (DASH 21.6±11.0 vs. 55.3±11.0 ; VAS 1.2±5.2 vs. 5.7±21.9 ; ROM 103±7.6 vs. 73±6.3 ; p>0.05) were identified in the prospective group. Botulinum toxin is a safe, reliable and effective treatment to prevent post-traumatic elbow stiffness. Our study demonstrates improved early range-of- motion (p<0.05), better extension after 6 weeks and improved functional outcome including VAS and DASH score (p<0.05).

Atypical Fracture of Proximal Ulna Associated with Prolonged Bisphosphonate Therapy Managed with Nonoperative Treatment: A Case Report and Literature Review

Prolonged bisphosphonate (BP) treatment is associated with some complications, such as atypical femoral fractures (AFFs). Recent studies showed that atypical fractures also occurred in other bones, especially in the atypical fracture of the proximal ulna (AFPU). Although, AFPUs frequently share the same characteristics of atypical fractures as AFFs, such as fracture configuration and high risk of non-union, there is still limited evidence of the role of non-operative treatment in AFPU. The aim of the present study was to present an interesting case involving an 80-year-old female presented with non-displaced AFPU after receiving long-term BP medication and had been treated with a conservative method for 2.5 years, and to review the literature regarding the available AFPU treatment options. To the best of the authors’ knowledge, the present case report introduced new insight of the outcome of non-operative treatment for AFPU. Keywords: Non-displaced fracture; Ulna fracture; Long-term bisphosphonates; Conservative treatment; Nonunion; Osteoporosis

Monteggia Fracture-Dislocation with Associated TFCC Injury and DRUJ Subluxation – A Very Rare Case Report

Introduction:Monteggia fracture-dislocation is defined as a proximal third ulna fracture with radiocapitellar joint dislocation. The term “Monteggia equivalent or variant” describes various injuries with similar radiographic patterns and injury biomechanics. Several isolated cases of unusual injuries associated with Monteggia fractures have been reported. However, an associated TFCC injury has not been described in the literature before. We present a rare report of a 24-year-old female with a Monteggia fracture and associated TFCC injury – a crisscross type of injury. Case Report:A 24-year-old female was involved in a road traffic accident and presented to our level I trauma center with pain and deformity in the left forearm. On evaluation, she was found to have type I Monteggia fracture-dislocation. Intraoperatively, once the proximal ulna was fixed, she had clicking in the wrist during rotations. Fluoroscopic images showed DRUJ subluxation, but it was stable in supination. Hence was splinted in a reduced position. The patient continued to have persistent symptoms in the wrist despite adequate conservative measures. Hence, she underwent arthroscopic TFCC repair and DRUJ pinning. At her last follow-up (3 months), the patient was clinically better with a good range of motion and no pain. Conclusion:In treating Monteggia fracture-dislocations, high index of suspicion is needed to diagnose radioulnar joint instability. If they are missed, they can result in long-term disability, so appropriate evaluation to diagnose TFCC and DRUJ injuries is required. DRUJ stabilization and TFCC repair can produce consistent results when treated adequately. Keywords:TFCC, monteggia, wrist, arthroscopy, proximal ulna.

Topographic and Histologic Analysis of the Collateral Ligament Complex around the Elbow

Purpose: The purpose of this study was to evaluate topographic anatomy of the footprints of key ligaments of the elbow and assess their relationships with bony parameters using micro-computed tomography (micro-CT). Additionally, the ratios of type I/III collagen at the medial collateral ligament (MCL) and lateral collateral ligament (LCL) of elbow were investigated.Methods: Eleven cadaveric elbows attached by both the MCL and LCL were scanned using micro-CT and reconstructed three-dimensionally. Additionally, the ligaments were examined under polarized light microscopy to determine the histological characteristics of collagen patterns. Results: Areas of footprints of the MCL and LCL attaching onto the humerus were 133.2±25.8 mm² and 128.3±23.2 mm², respectively. Footprint sizes of anterior and posterior bundles of the MCL in the proximal ulna and lateral ulnar collateral ligament (LUCL) attaching to the proximal ulna averaged to 109.9 mm², 89.2 mm², and 89.7 mm², respectively. There were a positive correlation between footprint size of the MCL and LUCL at the humeral side and a negative correlation between the footprint size of the MCL at humeral side and maximal diameter of the radial head. The collagen I/III ratio of the humeral attachment of the MCL was higher than distal attachment of the MCL. Conclusion: This study provides a better understanding of the pathologies of the MCL and LCL complex of the elbow and their relationships with osseous anatomy and may assist the clinician with an anatomic reconstruction of the ligaments.

A Unique Salvage Operation Strategy: Implantation of the Ulnar Total Elbow Component to the Radius to Overcome Large Ulnar Bone Defect Caused by Infection After Total Elbow Arthroplasty

ABSTRACT The elbow joints of patients with rheumatoid arthritis (RA) are often destroyed, and total elbow arthroplasty (TEA) is one treatment for these patients. However, patients with RA tend to develop surgical site infections due to immunosuppression. Once an implant is infected, reoperation may be difficult because of the risk of reinfection. In such patients, the infected site must be debrided thoroughly, although this might reduce the bone scaffold needed for re-TEA. We used a unique method to manage a large ulnar bone defect and an infected implant. The patient with RA had undergone TEA 15 years earlier. Etanercept was initiated to control disease activity; however, this treatment led to infection of the elbow prosthesis. Several surgical debridements were performed to eradicate the bacteria, which improved the symptoms of infection. However, most of the proximal ulna was lost, and it seemed impossible to fix the prosthesis using the remaining small ulna after debridement. Therefore, we planned to implant the ulnar component into the radius as a salvage technique. With this procedure, we provided the patient with elbow mobility and eradicated the infection. This is an alternative method for restoring function in an elbow with a massive bone defect in the ulna.

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.