Technical Note: Arthroscopic Resection of Snapping, Interponating Annular Ligament of the Elbow

The indication for surgical treatment of lateral snapping elbow syndrome is recurrent joint blockage in combination with pain of the affected elbow joint. Different parts of the lateral synovial capsule sleeve complex, including the annular ligament itself, a hypertrophic synovial fold, or meniscus-like soft tissue interposition can lead to painful entrapment. Surgical treatment options can include an arthroscopic or open procedure. The aim of this technical note is to provide a step-by-step illustration of the authorsʼ preferred arthroscopic approach with a comprehensive review of literature on clinical outcome.

Surgical stabilization of traumatic elbow joint luxation and proximal ulnar fracture in a silvery langur (Trachypithecus cristatus)

CASE DESCRIPTION A 3-year-old 5-kg sexually intact female silvery langur housed in a single-species group at a zoological institution was presented because of acute trauma to the left forelimb. CLINICAL FINDINGS Radiography of the left forelimb revealed a type II Monteggia fracture (proximal ulnar fracture with cranial displacement and caudal luxation of the radial head). During surgery, disruption of the annular ligament and rupture of the lateral collateral ligament were noted. TREATMENT AND OUTCOME The langur underwent open reduction and internal fixation of the ulnar fracture and placement of a radioulnar positional screw, a prosthetic lateral collateral ligament, and a temporary hinged type 1A external skeletal fixator. The langur was returned to group housing, underwent behavioral training, and was periodically anesthetized for physical therapy sessions to improve range of motion of the left elbow joint. The external skeletal fixator was removed 4 weeks after surgery, and the radioulnar positional screw was removed 6 weeks after surgery. Three months after surgery, the range of motion of the langur’s left elbow joint was considered normal, and the animal returned to normal activity. CLINICAL RELEVANCE For the captive silvery langur of the present report, surgical stabilization and postoperative management of a type II Monteggia fracture of the left forelimb were successful with recovery of elbow joint function. These techniques may be applied to other captive nonhuman primates, including those that brachiate or are members of social species that must be housed with conspecifics in the postoperative period to maintain group dynamics.

Osteotomia da ulna para correção cirúrgica de fratura de Monteggia negligenciada em criança com deformidade plástica da ulna. Relato de caso / Ulna osteotomy for surgical correction of neglected Monteggia fracture in a child with ulna bowing. Case report

Introdução: A luxação da cabeça do rádio com deformidade plástica da ulna, quando combinadas, configuram uma condição rara, e frequentemente não diagnosticada na urgência. Objetivo: Relatar um caso de fratura de Monteggia negligenciada em criança com defomidade plástica da ulna, tratada cirurgicamente com redução e fixação da cabeça dorádio, sem reconstrução do ligamento anular, e osteotomia da ulna. Relato do Caso: Paciente de 6 anos de idade, sexo masculino, vítima de queda ao solo com a mão espalmada, deu entrada em Unidade de Pronto Atendimento com queixa de dor no cotovelo direito. Paciente foi submetido à exames de imagem radiográficos do cotovelo interpretados peloexaminador como sem alterações. Duas semanas após, o paciente retornou mantendo dor, e foram solicitados exames de radiografia do antebraço, que evidenciaram presença de deformidade plástica da ulna associada à luxação da cabeça do rádio. Como tratamento, optou-se pela redução aberta e fixação da cabeça do rádio com fios metálicos, associado aosteotomia de flexão da ulna fixada com fio de Kirschnner. Evoluiu no pós operatório com consolidação da osteotomia, manutenção da redução da cabeça do rádio, e recuperação do arco de movimento total do cotovelo e antebraço. Conclusão: Pacientes pediátricos que se apresentam com dor no cotovelo, em decorrência de queda com a mão espalmada, devem ser minuciosamente avaliados quanto à possibilidade de deformidade plástica da ulna associada à luxação da cabeça do rádio. A osteotomia na ulna com fixação da cabeça do rádio, sem reconstrução do ligamento anular, trouxe bom resultado no tratamento de fratura de Monteggia negligenciada em criança com defomidade plástica da ulna. Palavras chave: Fratura de Monteggia, Ulna/deformidades, Fraturas da ulna, Osteotomia, Trauma, Criança, Pediatria Abstract Introduction: Dislocation of the radial head with ulna bowing, when combined, constitutes a rare condition, and often missed diagnosed. Objective: Report a case of neglected Monteggia fracture in a child with ulna bowing, treated surgically with reduction and fixation of the radial head, without reconstruction of the annular ligament, and osteotomy of the ulna. Case Report: A 6-year-old male patient, victim of falling to the ground, was admitted to the Emergency Department with complaints of pain in his right elbow. The patient was submitted to radiographic exams of the elbow, interpreted by the physician as normal. Two weeks later, the patient returned with pain, and radiographic exams of the forearm showed the presence of ulna bowing associated with dislocation of the radial head. As a treatment, we opted for open reduction and fixation of the radial head with metallic wires, associated with flexion osteotomy of the ulna. It evolved in the postoperative period with consolidation of the osteotomy, maintenance of the reduction of the radial head, and recovery of the total range of motion of the elbow and forearm. Conclusion: Pediatric patients who present with pain in the elbow, due to a fall, should be thoroughly evaluated for the possibility of ulna bowing associated with dislocation of the radial head. Ulna osteotomy with fixation of the radial head, without reconstruction of the annular ligament, brought good results in the treatment of neglected Monteggia fracture in a child with ulna bowing. Keywords: Monteggia fracture, Ulna/deformities, Ulna fractures, Osteotomy, Trauma, Child, Pediatrics

BIOMECHANICAL SIMULATION OF RADIAL HEAD SUBLUXATION IN CADAVERIC PEDIATRIC ELBOWS

Background: Radial head subluxation, known as pulled elbow or Nursemaid’s elbow, is a common pediatric condition that occurs when a longitudinal traction force is applied to an elbow that is pronated and extended. Although the stability of the proximal radioulnar joint has been previously examined in cadaveric models, there are no current studies quantifying the biomechanics of nursemaid’s elbow. The purpose of our study was to demonstrate and quantify the axial traction force required to produce a nursemaid’s elbow in a pediatric cadaver specimen. Methods: Two fresh-frozen cadaveric elbows from a single 3 year-old male donor were dissected by a fellowship-trained orthopedic surgeon. An Instron 5944 testing machine with a 2 kN load cell was used to perform uniaxial testing. The radius and humerus were mounted to the Instron machine, and loaded in the axial direction with the elbow in full extension. Loading occurred at a rate of 10 mm/sec for 4 seconds, during which the force and actuator displacement were continuously recorded. The local instantaneous load and extension displacement at the time of subluxation were recorded, and data was synced with high-frame-rate video footage used to confirm the annular ligament subluxation. Results: The load to failure required to produce the nursemaid’s elbow injury in the first elbow was 31N, with a failure displacement of 4.6mm. The second elbow demonstrated a load to failure of 26N, with a failure displacement of 4.6mm. After subluxation, we reduced the annular ligament from the first specimen. The elbow was then re-tested and demonstrated a load to failure of 20N, with a failure displacement of 2.6mm. Conclusion: Axial traction applied to a pediatric cadaver specimen results in subluxation of the annular ligament into the radiocapitellar joint. The mean load to failure is 28.5N, and a lower load to failure was required to produce a recurrent subluxation in a previously injured specimen. Lower load for a recurrent subluxation may be attributed to damage on the annular ligament due to the first subluxation. [Figure: see text]

Ulnar osteotomy is the only required procedure for chronic monteggia fracture in children.

Objective: To determine containment of radial head after ulnar osteotomy in chronic Monteggia fractures. Study Design: Retrospective study. Setting: Children Hospital and The Institute of Child Health, Lahore. Period: 2019 to January 2020. Material & Methods: Ten patients presented in outdoor patient department with a diagnosis of chronic Monteggia fracture. Four patients were labelled as missed Monteggia fractures, four with late presented Monteggia fractures and two with inadequately treated Monteggia fractures. Bado and Letts classifications were applied for patients. Mean age was 6 years and 8 months and ranged from 4 to 10 years. Mean time interval between injury and admission was 6.1 months. Open reduction of radial head and ulnar osteotomy was done through Boyed approach. Transcapitellar wire was inserted temporarily and then removed so it is not required permanently. The ulnar osteotomy was angulated opposite to the direction of radial head dislocation and fixed with plate and screws. Results: 10 patients were included in this study. The age range was between 4 and 10 years. The study period was six months and follow up was one year. Mean ulnar angulation at osteotomy site was 21.3° (16-25°). Mean ulnar lengthening at osteotomy site was 0.85 cm (0.5-1.8 cm).Improvement in flexion-extension was 20.3%, pronation was 5.1% and supination was 13.7%. Complications included were nounion in 1 case and cubitus valgus in 1 case. Conclusion: Containment of radial head is obtained by open reduction of radial head and with ulnar osteotomy in chronic Monteggia fractures. Annular ligament reconstruction and transcapitellar wire insertion are not required if proper angulation and fixation of ulnar osteotomy is performed. No age limit for this procedure but surgery should be performed before radial head deformation.

A novel technique of annular ligament reconstruction using extensor carpi radialis longus tendon fascia: a report of 3 cases

<p class="abstract">Annular ligament is an important stabiliser of radial head. In cases of chronic radial head dislocation, annular ligament reconstruction is warranted to maintain radial head reduction to improve elbow function. We have reported here a novel technique using the fascia overlying extensor carpi radialis longus tendon for annular ligament reconstruction. We reported an average flexion of 130º and full supination in all 3 cases. 2 patients achieved mid pronation and 1 achieved full pronation; comparable with other described techniques. Our novel technique through a single incision has excellent functional outcomes. Additionally, it is simple, cost effective, requires no hardware.</p>