The posttraumatic stiff elbow: a review of the literature

Loss of motion is a common complication of elbow trauma. Restoration of joint motion in the posttraumatic stiff elbow can be a difficult, time-consuming, and costly challenge. In this review of the literature, the biologic response to trauma and the possible etiologic events that may lead to fibrosis of the capsules and heterotopic ossification will be discussed, as well as nonsurgical and surgical management of stiffness and expected outcomes of treatment.

Radioscapholunate arthrodesis for advanced degenerative radiocarpal osteoarthritis

Degenerative joint disease affecting the radioscaphoid and radiolunate articulations while sparing the midcarpal joint may be best treated by a radioscapholunate arthrodesis. Limited wrist fusions have been shown to reliably improve pain and maintain some wrist motion. However, nonunion rates have been reported to be relatively high with traditional forms of fixation such as multiple Kirschner wires or cannulated screws. We report a technique of using two angled 2.4-mm distal radius plates to provide locking plate stabilization for radioscapholunate fusions. Our technique also features careful preparation of the planned fusion sites and the use of iliac crest bone graft. We have not had any instances of nonunion or delayed union with this technique thus far.

Distal radius osteotomy in the elderly patient using angular stable implants and Norian bone cement

PURPOSE

To report our results after testing the combination of two technologies--angular-stable locking screw implants and Norian SRS cement--in corrective osteotomies of the distal radius in the elderly. This technique eliminates donor site bone-graft morbidity and expands the indications of corrective osteotomies to older patients with osteoporotic bone.

METHODS

Our retrospective series include 6 patients (5 women and 1 man) with an average age of 60 years. Three patients had corrections through a dorsal approach, 1 through a volar approach, and 2 through a combined approach. Two corrections included an intraarticular osteotomy. We used 2.4-mm volar T plates in patients approached volarly and 2.4-mm L and T plates for those approached dorsally; the osseous defect was filled with bone cement (Norian SRS). Range of motion and grip strength were measured at 16 months average follow-up. Standard wrist radiographs were taken to evaluate alignment and determine improvement. At final follow-up, patients completed the Modified Mayo Wrist score, the Modified Gartland and Werley score, and the Disabilities of the Arm, Shoulder, and Hand (DASH) questionnaire.

RESULTS

There were no perioperative complications. All corrective osteotomies healed. One patient required a Darrach procedure at 6 months. The average wrist and forearm motion was 77% of the opposite side and grip strength 88% of the opposite side. The average total correction in the sagittal plane was 22 degrees with all patients returning to neutral or better alignment. The average ulnar variance improvement was 2 mm. Average postoperative DASH was 28 points; average Modified Mayo Wrist score was 68; and the Modified Gartland and Werley score averaged 9 points.

CONCLUSIONS

We believe that corrective osteotomy of the distal radius in the elderly using angular stable implants and Norian calcium phosphate cement is a safe and predictable surgical technique, even in patients with underlying osteoporosis. It eliminates donor site morbidity, and patient-rated outcome measures demonstrated acceptable daily living function return.

Current concepts in the management of distal radius fractures

The treatment of fractures at the distal end of the radius continues to challenge orthopaedic and upper extremity surgeons. As our understanding of the injury mechanism and local anatomy continues to improve, so too have our surgical techniques in helping patients regain functional use of the injured extremity. The purpose of this manuscript is to review the treatment methods available for distal radius fracture management.

Comparison of elbow contracture release in elbows with and without heterotopic ossification restricting motion

We compared 16 patients with post-traumatic heterotopic ossification (HO) restricting elbow motion (but not complete bony ankylosis) after elbow trauma with 21 patients with capsular contracture alone to test the hypothesis that HO is associated with diminished motion after release. Patients with burns or head injury were excluded. The preoperative flexion arc averaged 59 degrees in the HO cohort and 52 degrees in the capsular contracture cohort. The mean flexion arc after the index surgery improved by 54 degrees to a mean arc of 113 degrees in the HO cohort and by 35 degrees to a mean of 87 degrees in the capsular contracture cohort (P = .02). After all subsequent procedures (including procedures to address residual stiffness in 1 patient in the HO cohort and 4 patients in the capsular contracture cohort), the flexion arc averaged 116 degrees in the HO cohort and 98 degrees in the capsular contracture cohort (P = .19). Open release of post-traumatic elbow stiffness is more effective when HO hindering motion is removed than when there is capsular contracture alone.

A comparison of proximal radioulnar synostosis excision after trauma and distal biceps reattachment

We tested the hypothesis that the results of operative resection of a proximal radioulnar synostosis are better when the synostosis is due to a distal biceps reattachment (11 patients) than when it occurs after trauma (13 patients). Two patients in the trauma cohort had recurrence of the synostosis, and 1 had repeat resection. Two patients in the trauma cohort and 1 in the biceps cohort had substantial loss of forearm rotation due to regrowth of heterotopic ossification without synostosis, and 2 patients were addressed with subsequent surgeries. The arc of forearm rotation after the index surgery averaged 94 degrees in the trauma cohort and 131 degrees in the biceps cohort. This study confirms that operative resection of a proximal radioulnar synostosis can restore substantial motion in most patients. The results for excision of a synostosis after a distal biceps reattachment were better than those of excision of a synostosis after trauma.

Human Shaped Thumb Bone Tissue Engineered by Hydrogel-β-Tricalciumphosphate/Poly-ε-Caprolactone Scaffolds and Magnetically Sorted Stem Cells

Traumatic amputation of a thumb with bone loss leaves a patient in severe disability. Reconstructive procedures are restricted by limited shape and have the disadvantage of severe donor-site morbidity. To overcome these limitations, we used a tissue engineering approach to create a distal thumb bone phalanx, combining magnetically sorted 133+ human mesenchymal stem cells (hMSCs) suspended in successful tested hydrogels for bone formation and porous 3-dimensionally printed scaffolds (3DP) in the shape of a distal thumb bone phalanx. Collagen I and fibrin glue hydrogels with suspended hMSCs were first histologically evaluated in vitro for bone formation after 6 weeks. Then 3DP scaffolds, made from a mix of osteoinductive and -conductive beta-tricalciumphosphate (beta-TCP) and poly-epsilon-caprolactone (PCL), with hydrogels and suspended hMSCs, were implanted into nude mice subcutaneously for 15 weeks. Histologic evaluation, high-resolution volumetric CT (VCT) scanning, and biomechanical testing confirmed formation of bonelike tissue. Both hydrogels with CD 133+ hMSCs on 3DP scaffolds supported bone formation. Collagen I resulted in radiologically better bone formation. Bone tissue can be successfully tissue engineered with CD 133+ hMSCs, collagen I hydrogels, and porous 3DP beta-TCP/PCL scaffolds.

Flap advancement coverage after excision of large mucous cysts

Mucous cysts are common problems seen by hand surgeons. Surgical excision of symptomatic cysts is the most commonly accepted treatment. Removal of large mucous cysts often requires simultaneous flap coverage or skin grafting for the resulting defect. We present the use of a dorsal advancement flap to permit excellent skin coverage after cyst excision with a tension-free closure.

Monteggia fracture-dislocations

Monteggia fracture-dislocations remain a relatively uncommon injury. Prompt recognition of this injury is imperative. The character of the ulnar fracture is useful in determining optimal treatment. It is imperative to look for associated injuries of the radial head and coronoid, which alter the management and lead to altered outcomes.

Nonunion After Functional Brace Treatment of Diaphyseal Humerus Fractures

OBJECTIVE

To assess which fractures of the humeral diaphysis are prone to nonunion after functional bracing by analyzing patients that present for treatment of nonunion after brace treatment.

METHODS

Thirty-two patients treated operatively for a nonunion of the diaphyseal humerus after functional brace treatment were analyzed with respect to the location and the pattern of the original fracture. There were 21 women and 11 men with an average age of 53 years (range 23-84 years).

RESULTS

The fracture involved the proximal third of the diaphysis in 17 patients, the middle third in 14 patients, and the distal third in 1 patient. The pattern of the fracture was oblique or spiral in 27 patients with a butterfly fragment in 11 of those patients. Only four patients had a transverse fracture. Operative fixation ultimately achieved union in all 32 patients, but a second procedure was necessary for loosening of fixation or persistent nonunion in 3 older-aged patients. The functional results were good or excellent in all 32 patients.

CONCLUSIONS

Compared with the epidemiology of acute diaphyseal humerus fractures, nonunions after functional bracing are more likely to follow spiral/oblique fractures that involve the mid- or proximal-third of the diaphysis. Operative treatment can gain union and improve arm function.

[Distal radius fractures: new concepts as basis for surgical treatment]

New advances in the biomechanics and pathomechanics of distal radius fractures as well as new generations of plates and improved surgical approaches now make possible the stable management and early functional rehabilitation not only of simple but also of complicated distal radius fractures according to the principles for articular and juxta-articular fractures. Especially for complex articular fractures, the fracture patterns are so heterogeneous that an individual surgical treatment strategy must be developed for each case. The preoperative clarification of articular fractures with computed tomography is particularly useful for planning surgery. Mental exposition with the three-column model and pathomechanics is an important prerequisite for understanding this type of injury and the appropriate choice of operative technique. A decisive factor for success is the subtle surgical procedure in approaching and handling the fine plates.

Distal radius fractures--classification of treatment and indications for surgery

Distal radius fractures are common injuries. Multiple classification systems have highlighted the evolution of the understanding of distal radius fractures. Understanding the classifications of distal radius fractures is important in identifying the important aspects that affect their outcome. Surgical indications of distal radius fractures can be divided into the following categories: patient factors, fracture reduction, fracture stability, and the presence of associated injuries.

Perilunate fracture-dislocations of the wrist: comparison of temporary screw versus K-wire fixation

PURPOSE

Temporary intercarpal screw fixation has been suggested as an alternative to temporary K-wire fixation in the treatment of perilunate wrist dislocations. We compared the 2 treatment methods in 2 retrospective cohorts with a null hypothesis that there would be no difference in final wrist motion.

METHODS

Eighteen patients with surgically treated perilunate wrist dislocations (9 treated with intercarpal screws, 9 with intercarpal K-wires) were evaluated an average of 44 months after injury. The intercarpal screws were removed an average of 5 months and the K-wires an average of 3 months after the initial procedure. Complications included 3 pin track infections (1 with wrist sepsis), 2 scaphoid nonunions (screw fixation), and 2 patients with loss of reduction (K-wire fixation) treated with repeat surgery.

RESULTS

Four patients (2 in each cohort) had wrist arthrodesis with poor results. Among the 14 remaining patients the final flexion arc was 97 degrees for patients treated with screw fixation compared with 73 degrees for patients treated with K-wires. The mean grip strength was 74% (screw fixation) and 67% (K-wire) that of the uninjured arm. According to the Mayo Modified Wrist Score, the functional result was excellent in 1 patient (screw), good in 2 patients (1 each group), fair in 6 patients (3 in each group), and poor in 9 patients (4 screws, 5 K-wire). Seven patients (2 screws, 5 K-wires) had grade 2 or 3 midcarpal arthritis according to the criteria of Knirk and Jupiter, but none had more than mild radiocarpal arthritis.

CONCLUSIONS

The results of treatment with temporary screws are comparable to the results of treatment with temporary K-wires.

TYPE OF STUDY/LEVEL OF EVIDENCE

Therapeutic III.

Posttraumatic reconstruction in the hand

The complex anatomy of the hand means that injuries result in substantial loss of function. The damage must be repaired to regain the lost function. Fractures need to heal in anatomic position, and the soft tissues must be supple so that the fingers can move through a useful range of motion. Evaluation and management of malunion, nonunion, bone loss, and stiff fingers are important factors in posttraumatic reconstruction of the hand.

Elbow capsulectomy for posttraumatic elbow stiffness

PURPOSE

To determine factors associated with diminished elbow function and upper-extremity-specific health status after elbow capsulectomy for posttraumatic stiffness.

METHODS

Forty-six adult patients with posttraumatic elbow stiffness were evaluated an average of 48 months after open capsular excision. A second capsular excision was performed in 9 patients (29%). Stepwise multiple linear regression analysis was used to identify predictors of the American Shoulder and Elbow Surgeons Elbow Score, the Mayo Elbow Performance Index, and the Disabilities of the Arm, Shoulder, and Hand scores after all procedures.

RESULTS

The average improvement in ulnohumeral motion after the index surgery for capsular release was 53 degrees . (The average flexion was 98 degrees .) The 9 patients who had subsequent repeat elbow contracture release gained an additional 24 degrees , leading to a final average flexion arc for the entire cohort of 103 degrees . Multiple linear regression identified the American Shoulder and Elbow Surgeons pain score, persistent ulnar nerve dysfunction, and duration of follow-up evaluation after the initial capsular release as independent predictors of a higher Disabilities of the Arm, Shoulder, and Hand questionnaire score; flexion arc and pain score as independent predictors of the Mayo Elbow Performance Index; and flexion arc, forearm arc, pain score, and persistent ulnar neuropathy as independent predictors of the American Shoulder and Elbow Surgeons score.

CONCLUSIONS

Open elbow capsulectomy for posttraumatic elbow stiffness restores a near-100 degrees flexion arc on average. Second elbow releases provide limited additional motion in most patients. Final motion influences physician-based rating scales but not patient-specific health status (Disabilities of the Arm, Shoulder, and Hand questionnaire), which is dominated by pain and persistent ulnar neuropathy.

TYPE OF STUDY/LEVEL OF EVIDENCE

Therapeutic IV.