Treatment Outcome of Tardy Ulnar Nerve Palsy Associated with Traumatic Cubitus Valgus by Supracondylar Shortening Wedge Rotary Osteotomy and Ulnar Nerve in Situ Tension Release

Background Tardy ulnar nerve palsy is a common late complication of traumatic cubitus valgus. At present, the treatment of tardy ulnar nerve palsy associated with traumatic cubitus valgus is still controversial, whether these two problems can be corrected safely and effectively in one operation is still unclear. To investigate the supracondylar shortening wedge rotary osteotomy combined with in situ tension release of the ulnar nerve in the treatment of tardy ulnar nerve palsy associated with traumatic cubitus valgus. Methods Between 2012 and 2019, 16 patients who had traumatic cubitus valgus deformities with tardy ulnar nerve palsy were treated with simultaneous supracondylar shortening wedge rotary osteotomy and ulnar nerve in situ tension release. we compared a series of indicators of preoperative and postoperative follow-up for at least 24 months, (1) elbow range of motion; (2) the radiographic correction of the preoperative and postoperative humerus-elbow-wrist angles; (3) the static two-point discrimination and grip strength; and (4) the preoperative and postoperative DASH scores of upper limb function. The minimum follow-up was 24 months postoperative (mean, 33 months; range, 24ཞ44 months). Results The mean ROM was improved from 107 ° preoperatively to 122 ° postoperatively (P = 0.001). The mean preoperative elbow wrist angle was 24.6 °, and the mean postoperative humerus-elbow wrist angle was 12.1 ° (P < 0.001). The average grip strength and static two-point discrimination improved from 28 kg force and 8 mm to 21 kg force and 4.0 mm (P < 0.001 and P < 0.001, respectively). The ulnar nerve symptoms were improved in all patients except one. The mean HASH score improved from 29 to 16 (P < 0.001). Conclusion Supracondylar shortening wedge rotary osteotomy combined with in situ tension release of ulnar nerve is an effective method for the treatment of traumatic cubitus valgus with tardy ulnar nerve palsy, which restored the normal biomechanical characteristics of the affected limb and improved the elbow joint function.

Rare Presentation of Ulnar Nerve Palsy in Closed Both Bone Forearm Fracture in Pediatric Population

Introduction:Ulnar nerve injury in closed both bone forearm fracture is rare. Most nerve injuries are neuropraxia and rarely the nerve is trapped or is transected. Most of the time recovery is spontaneous but sometimes requires surgical exploration. We are reporting a case of a 14-year-old boy with closed both bone forearm fracture with ulnar nerve palsy due to entrapment and laceration between ulnar bone fracture fragment. Case Report:A 14-year-old boy presented in emergency department elsewhere with a left forearm closed injury due to fall while playing where he was diagnosed with both bone forearm shaft fracture with ulnar nerve palsy and was given an above elbow slab. After 3 days, the patient presented to our outpatient department (OPD) with completely absent sensation over little finger, ulnar aspect of ring finger, and ulnar clawing. No signs of compartment syndrome in the form of tense swelling or stretch pain were seen. There was a suspected ulnar nerve injury for which patient was admitted and posted for fracture fixation and exploration of the nerve in emergency which showed lacerated ulnar nerve trapped in fracture fragment. Open reduction and internal fixation with ulnar plating and radius titanium elastic nailing was done by orthopedic surgeon while ulnar nerve neurolysis and micro repair was subsequently done by plastic surgeon. There was no neurological recovery immediately post-operatively. Patient was discharged after 48 h and called for regular follow-up in OPD to assess fracture union and neurological recovery. There was gradual neurological recovery over the period of time. Complete motor and sensory recovery took place in 4 months. Conclusion:Ulnar nerve injury associated with close both bone forearm fracture is uncommon. They are usually associated with a contusion for which the treatment is basically conservative. Immediate nerve exploration and fracture fixation should be reserved for suspicious nerve laceration or entrapment within displa

Management of lateral condyle fractures of the humerus in children

Lateral condyle fracture of the humerus is the second most common paediatric elbow fracture and is often missed, which can result in severe consequences including malunion, growth arrest and tardy ulnar nerve palsy. The difficulty in managing this fracture stems from a lack of awareness and the often subtle findings on radiographs. Patients can also present with quite vague symptoms; clinicians who do not have a high index of suspicion may not investigate beyond the initial clinical assessment and could miss vital cues. This article provides a guide to managing this common paediatric fracture, from initial presentation to definitive treatment, and discusses the complications that can ensue if managed incorrectly.

Functional outcome of surgical management of distal humeral fracture with precontoured anatomical locking plate

Background: Intra-articular distal humeral fractures are among the common fractures seen in adults. The cause of injury most commonly being road traffic accidents. These fractures require fixation methods which are technically difficult to achieve a good functional outcome and to minimize complications. This study was useful to analyse the above factors, to come to conclusion.Methods: This was a prospective study of 20 cases of supracondylar fracture humerus with intercondylar extension treated surgically and assessed for functional outcome, which were admitted to our hospital between 2015 to 2017. Precontoured distal humerus anatomical locking plates were used for fracture fixation with various standard approaches to elbow. Various clinical and functional outcome were analysed at the end using mayo elbow performance score.Results: Out of 23 patients, 20 patients were available for final follow up and outcome analysis. There were 15 males and 5 females with an average age of 34.4 year (21-50 years). Average time between admission and surgery was 4 days. Clinical and radiological consolidation of fracture was observed in all cases at an average of 12 weeks (9-14 week). The results obtained using mayo elbow performance score were graded as excellent 10 (50%) patients, fair in 6 (30%), poor in 4 (20%). One case had superficial wound infection and managed with IV and oral antibiotics. One patient had transient ulnar nerve palsy managed conservatively and recovered.Conclusions: Open reduction and internal fixation with anatomical precontoured locking plate is the treatment of choice in comminuted intercondylar distal humerus fractures. specially in young active adults. It provides stable fixation and thereby facilitating early postoperative rehabilitation. However, the outcome mainly depends on restoring the anatomic nature of articular surface along with minimal soft tissue destruction.

Retrospective comparison of conservative treatment and surgery for widely displaced olecranon fractures in low-demanding geriatric patients

Introduction The aim of this study was to evaluate the difference of the clinical outcome of elderly patients who were treated surgically or conservatively for a displaced olecranon fracture (Mayo type IIA or IIB). Patients and methods Patients above the age of 70 years who were treated surgically (n = 11) for a displaced Mayo type IIA and IIB olecranon fracture between July 2015 and February 2019 were retrospectively compared with patients who were treated conservatively (n = 6). The range of motion, elbow strength, grip strength, VAS, DASH, OES, MEPI and Broberg and Morrey scores were evaluated. Results The conservative group showed a non-union with a persistent fracture gap of 17 mm (SD 12 mm) at the articular rim and 31 mm (15 mm) at the dorsal rim while there was no case of non-union in the surgical group. The arch of motion was 120° in the conservative group and 136° in the surgical group. There was no obvious difference in elbow extension strength in comparison to the healthy contralateral side (p = 0.20; 88% group I/87% group II). There was no difference in the OES (p = 0.30; 42 (SD 7) vs. 45 (SD 5)) and MEPI score (p = 0.46; (SD 8) vs. 96 (SD 19)). The conservative group presented a slightly worse DASH [p = 0.10; 26 (SD 25) vs 7 (SD 14)] and a significantly worse Broberg and Morrey score (p = 0.02; 84(SD 9) vs. 95 (SD 7)). The conservative group presented one complication (ulnar nerve palsy), while the surgical group presented two cases (prolonged lymphedema; blocked forearm rotation due to screw length with consecutive revision surgery). Conclusion Widely displaced olecranon fractures can successfully be treated conservatively in low-demanding geriatric patients with a satisfactory outcome. Patient selection is essential as patients that are more active might benefit from surgical treatment. Yet, treatment risks and benefits need to be balanced carefully in regard to the patient`s demands and requests.

OPEN REDUCTION OF MEDIAL EPICONDYLE FRACTURES IN CHILDREN AND ADOLESCENTS: SUPINE VERSUS PRONE POSITION

Background: Operative treatment of medial epicondyle (ME) fractures can be performed in either supine or prone position. In the supine position, visualization and fixation of the fracture is difficult. However, the prone position requires extensive patient repositioning but may improve visualization. Purpose: The purpose of this study was to compare the results of ORIF of ME fractures between supine and prone positions. Methods: In a retrospective review, patients <18 who underwent open reduction of an acute ME fracture from 2011-2019 were identified. Results and complications were compared between the supine and prone positions. Results: 204 patients were included, with a mean age of 11.7 years. 133(65.1%) were sports injuries, and 67(32.8%) had concomitant dislocation, with 17(8.3%) having an incarcerated fracture. 122(60%) patients were in the supine group, and 82(40%) in prone. The mean wheels in-wheels out time was 113 minutes in the supine group, and 141 minutes in the prone group (P<0.001). Mean tourniquet time was 53.1 and 55 minutes in supine and prone positions (P=0.4). C-arm usage was 27.9 and 26.9 seconds in the supine and prone groups, respectively (P=0.7). Displacement of the fracture on the first post-operative x-rays was 2.06 and 1.1 millimeters for the supine and prone groups (P<0.001). A total of 39(19%) patients had some ROM limitation at follow-up, with the majority (33 patients) having <10° loss of ROM. Five patients (2.5%) underwent 7 reoperations due to stiffness, 2 patients due to tardy ulnar nerve palsy, 2 due to non-union, and 53(26%) had a surgical hardware removal. Surgical position was not predictive of complications/reoperation. All of the nine surgeons (out of 16) who have operated at least one patient in the prone position have changed their preferred surgical position to prone. Conclusion: With the largest study population in the literature, the results of our study show that surgical stabilization of medial epicondyle fractures is safe, with minimal complications. While the prone position requires additional time in the operating room, presumably for positioning, the surgical procedure takes the same time and the prone position allows for a more accurate reduction. While the clinical significance of a 1mm difference in reduction quality is unknown, the observation that no surgeon that has tried the prone position had ever gone back to the supine position suggests that the surgical procedure is technically easier in this position.

Localized Immunoglobulin Light-Chain Amyloidosis of the Ulnar Nerve

Amyloidosis is a disorder caused by extracellular tissue deposition of insoluble fibrils. Amyloidosis can be divided into systemic or localized disease. Primary systemic amyloidosis is a multisystem disease caused by the deposition of amyloid in various tissues. Localized amyloidosis has different characteristics than those of systemic amyloidosis. In this paper, we present the case of a middle-aged woman who presented with worsening ulnar nerve palsy. Electrophysiological examination and MRI indicated a tumor surrounding the ulnar nerve in the forearm. However, the operative findings revealed that ulnar nerve fascicles were replaced with a yellow tissue, which was diagnosed as amyloid light-chain λ amyloidosis, based on histopathological examination. Systemic amyloidosis was ruled out after the screening examinations. This paper is the first report of the ulnar nerve as the sole site of localized immunoglobulin light-chain amyloidosis manifestation.

Neglected Lateral condyle Humerus Fractures: Current Concepts and Practices

Neglected lateral condyle fractures present varied and difficult challenges to the treating orthopaedic surgeon. They have the potential to cause long term problems like deformities, stiffness, instability and tardy ulnar nerve palsy. The treatment of lateral condyle non-unions depend on the presence or absence of deformity, the duration of non-union, skeletal maturity of the child and the presence or absence of ulnar nerve palsy. Accordingly the treatment ranges from conservative management in neglected fractures with no deformity and no ulnar nerve palsy at one end, Open/mini-open or closed in-situ fixation for established non-unions with instability and corrective osteotomy with fixation of non-union and ulnar nerve transposition at the other end. In this article, the authors have endeavoured to go through the various aspects of clinical presentations and treatment modalities for this difficult fracture. Keywords: Neglected lateral condyle fractures, Cubitus valgus, Tardy ulnar nerve palsy, Instability.

Robert Wartenberg Syndrome and Sign: A Review Article

Background: Robert Wartenberg, a European-American neurologist, was born in 1887 and died in 1956. His description of radial sensory nerve compression at the forearm is memorialized as Wartenberg’s syndrome. He recognized that involuntary abduction of the little finger could be caused by ulnar nerve palsy - a finding often called Wartenberg’s sign Syndrome and signs are reviewed, and a brief biography is presented. Objective: To review Wartenberg’s sign and Wartenberg’s syndrome. Discussion: Compression of the superficial branch of the radial nerve, often called Wartenberg’s syndrome, is characterized by pain, paresthesia, and dysesthesia along the dorsoradial distal forearm. Non-operative treatment can include activity restriction and anti-inflammatory medication. If symptoms persist, surgical decompression of the radial nerve is an option. The abducted posture of the little finger - Wartenberg’s sign - can result from a low ulnar nerve palsy. Tendon transfer can be performed to correct this deformity. Conclusion: Compression of the superficial branch of the radial nerve and abducted posture of the little finger were described by Robert Wartenberg and carry his name as eponymous syndrome and sign, respectively.