A meta-analysis on the diagnostic utility of ultrasound in pediatric distal forearm fractures

Pediatric distal forearm fractures, comprising 30% of musculoskeletal injuries in children, are conventionally diagnosed using radiography. Ultrasound has emerged as a safer diagnostic tool, eliminating ionizing radiation, enabling bedside examinations with real-time imaging, and proving effective in non-hospital settings. The objective of this study is to evaluate the diagnostic efficacy of ultrasound for detecting distal forearm fractures in the pediatric population. A systematic review and meta-analysis were conducted through a comprehensive literature search in PubMed, Scopus, Web of Science, and Embase databases until October 1, 2023, following established guidelines. Eligible studies, reporting diagnostic accuracy measures of ultrasound in pediatric patients with distal forearm fractures, were included. Relevant data elements were extracted, and data analysis was performed. The analysis included 14 studies with 1377 patients, revealing pooled sensitivity and specificity of 94.5 (95% CI 92.7-95.9) and 93.5 (95% CI 89.6-96.0), respectively. Considering pre-test probabilities of 25%, 50%, and 75% for pediatric distal forearm fractures, positive post-test probabilities were 83%, 44%, and 98%, while negative post-test probabilities were 2%, 6%, and 15%, respectively. The bivariate model indicated significantly higher diagnostic accuracy in the subgroup with trained ultrasound performers vs. untrained performers (p = 0.03). Furthermore, diagnostic accuracy was significantly higher in the subgroup examining radius fractures vs. ulna fractures (p < 0.001), while no significant differences were observed between 4-view and 6-view ultrasound subgroups or between radiologist ultrasound interpreters and non-radiologist interpreters. This study highlighted ultrasound's reliability in detecting pediatric distal forearm fractures, emphasizing the crucial role of expertise in precisely confirming fractures through ultrasound examinations.

MDCT evaluation of distal radius fractures and their association with carpal and distal ulnar fractures

PURPOSE

The purpose of this study was to evaluate the characteristics of distal radius fractures (DRFs) in patients undergoing multi-detector computed tomography (MDCT) and their association with carpal and distal ulnar fractures.

METHODS

This retrospective study analyzed 120 patients, who underwent MDCT for evaluation of DRFs. Two radiologists independently evaluated the data for various fracture characteristics and for associated carpal and distal ulnar fractures.

RESULTS

Out of 120 DRFs, 74 were complete articular, 40 were partial articular and only 6 were extra-articular. Displacement was present in 99 fractures and intra-articular step off was present in 73 fractures. A total of 81 carpal bone fractures were identified in 46 (38.3%) patients, with more than one carpal bone fracture in 21 patients. Distal ulnar fractures were detected in 79 patients (65.8%), out of which 67 involved the ulnar styloid. DRFs with intra-articular step off were more frequently associated with carpal bone fracture (p value: 0.021), while displaced DRFs were more frequently associated with distal ulnar fracture (p value <0.001). Interobserver agreement for detection of carpal bone fractures (κ = 0.807) and distal ulnar fractures (κ = 0.923) was excellent.

CONCLUSION

Majority of DRFs in patients referred for MDCT were complete articular with high incidence of displacement and intra-articular step off. Associated carpal bone and distal ulna fractures were not uncommon.

The With Or Without Olecranon K-wire (WOW OK) Trial of tension band wire fixation versus cerclage fixation without K-wires in displaced stable olecranon fractures: study protocol for a randomized controlled trial

BACKGROUND

Displaced olecranon fractures with a stable elbow joint are classified as Mayo type 2a or 2b and are commonly operated with tension band wiring, i.e. two K-wires and a cerclage. Retrospective studies have reported fewer reoperations and complications with cerclage fixation alone when compared to tension band wiring, though with similar long-term results. We decided to compare tension band wiring to cerclage fixation of displaced, stable olecranon fractures in adults in a randomized controlled trial.

METHODS

All patients ≥ 18 years old with Mayo type 2a and 2b fractures presenting at Skåne University hospital will be eligible for study inclusion, unless exclusion criteria are met. Two hundred participants will be included and randomized 1:1 to cerclage fixation or tension band wiring. Outpatient physiotherapist follow-up appointments will be scheduled at 2 and 6 weeks and at 3, 12, and 36 months at the Dept. of Orthopaedics. A lateral view radiograph of the elbow will be analysed at 6 months. The primary outcome of our study is the rate of reoperations. Secondary outcomes are complication rates, severity of complications, and patient-reported outcome measures (QuickDASH, Short Musculoskeletal Function Assessment, pain level, and patient satisfaction). The sample size was calculated to give 80% power for detecting a statistically significant difference in reoperation rates (with alpha-value 0.05), based on a previous retrospective study.

DISCUSSION

Reoperation and complication rates after tension band wiring of olecranon fractures are high. Treatment of these injuries is debated, and several ongoing trials compare tension band wiring with plate fixation, suture fixation, and non-operative treatment. As data from retrospective studies indicate that cerclage fixation may be superior to tension band wiring, we see a need for a randomized controlled trial comparing these methods. The WOW-OK Trial aims to obtain level-1 evidence that may influence treatment choice for this type of fracture.

TRIAL REGISTRATION

ClinicalTrials.gov NCT05657899 . Registered on 16 November 2022. The trial complies with SPIRIT and CONSORT guidelines. The SPIRIT figure is found in Table 2.

Intractable Fractures of the Bilateral Proximal Ulnae After 8 Years of Zoledronate Treatment for Breast Cancer Bone Metastasis

Long-term administration of bisphosphonates strongly suppresses osteoclastic bone resorption and rarely causes atypical fractures. This report presents a case of bilateral atypical ulnar fractures, following an 8-year course of zoledronate to treat breast cancer bone metastasis. Nonsurgical treatment for the left ulnar fracture failed, in spite of minimal displacement with callus formation at initial presentation. After failure of plate fixation with a pedicled vascularized bone graft, removal of osteosclerotic lesions and plate fixation with corticocancellous iliac bone graft resulted in bone healing, although the healing process took 1.5 years. Plate fixation for the contralateral fractured ulna was unsuccessful.

Serious games therapy associated with conventional physical therapy intervention accelerated hand muscles strengthening and hand functioning after complex fracture of the wrist: A case report

STUDY DESIGN

Case report.

INTRODUCTION

A severe wrist fracture can cause permanent physical disabilities and deformities, leading to limit patients in their occupation and social environment.

PURPOSE OF THE STUDY

We aim at presenting a treatment protocol and the functional outcome of a patient with severe clinical state after a rare wrist fracture.

METHODS

We provided physical therapy intervention associated with serious games for muscle strengthening.

RESULTS AND DISCUSSION

There was an increase in strengthening and a decrease in Disability of the Arm, Shoulder and Hand score and Patient Rated Wrist Evaluation scores. The International Classification of Functioning scores have changed from severe to light or to absent in many of the domains.

CONCLUSION

The use of serious games combined with a conventional physical therapy intervention played a fundamental role in recovery and return to work activities, and there was also an important recovery of general health condition.

Proximal ulna fractures in adults: A review of diagnosis and management

Proximal ulna fractures are relatively common upper limb injuries, which may represent fragility fractures or result from high-energy trauma. These include fractures of the olecranon, coronoid and associated radial head dislocations. A wide variety of treatment options are available for the management of these injuries that makes the selection of most appropriate treatment difficult. We aim to provide a brief overview of the treatment options for such injuries.

Ulnar shaft stress fractures in fast-pitch softball pitchers: a case series and proposed mechanism of injury

BACKGROUND

Stress fractures of the upper extremities in athletes are important injuries for radiologists to appreciate despite being far less common than stress fractures of the lower extremities. Among upper extremity stress fractures, those involving the olecranon have been well described in overhead pitching athletes. Isolated stress fractures of the ulnar shaft however are less commonly reported in the literature and considered to be rare. We have observed a correlation between young patients with ulnar shaft stress fractures and the activity of fast-pitch softball pitching.

CASE REPORTS

In this series, we present the imaging findings in four cases of ulnar shaft stress fractures in softball pitchers who presented with insidious onset forearm pain. Furthermore, a review of the literature focusing on softball pitching mechanics is provided to offer a potential underlying mechanism for the occurrence and location of these injuries.

CONCLUSION

An awareness of the imaging appearance of ulnar shaft stress fractures along with an understanding of its proposed mechanism will facilitate accurate and timely imaging diagnosis of this injury by the radiologist.

[Acumed intramedullary nail for the treatment of adult diaphyseal both-bone forearm fractures]

OBJECTIVE

To evaluate the results of Acumed intramedullary nail for the treatment of adult diaphyseal fractures of both-bone forearm fractures.

METHODS

From January 2009 to December 2016, 86 adult patients with both forearm fractures were treated by intramedullary nail including 54 males and 32 females with an average age of 36.8 years old ranging from 18 to 72 years old;There were 50 cases were on the right and 36 cases on the left. The operation time, blood loss and X-ray expose time intra-operation, time of fracture union, complications, DASH(Disabilities of the Arm, Shoulder and Hand questionnaire), Grace-Eversman criteria were recorded to evaluate the clinical outcomes of intramedullary nail for the treatment of forearm fractures.

RESULTS

All patients were followed up from 48 to 144 weeks with an average of 86.8 weeks; the blood loss intraoperation was 30 to 80 ml with an average of 52 ml; the the X-ray expose time was 1 to 6 min with an average of 2.5 min;the operation time was 31 to 55 min with an average of 46 min; Among them, 85 cases healed successfully, the union time was 10 to 16 weeks with an average of 13.3 weeks. There were 1 case of hypertrophic nonunion, 1 case of ulnar radial bone bridge formation, and 1 case of extensor hallucis longus tendon injury. The DASH score was 4 to 37(means 15.6); according to Grace-Eversman criteria, the results were excellent in 65 cases, good in 15, acceptable in 5, poor in 1.

CONCLUSIONS

Intramedullary fixation method in treating both-bone forearm fractures has advantages of closed application, short operation time, little complication, and clinical outcomes is satisfied.

Forearm diaphyseal fractures in children: intramedullary Kirschner's wire fixation treatment

INTRODUCTION

Diaphyseal fractures of the forearm comprise 6%-10% of all fractures in children. The treatment depends on the age and type of displacement, and conservative and surgical management with fixation of intramedullary nails, among other techniques, is valid. The aim is to show the radiological and functional outcomes, and complications of intramedullary fixation with Kirschner nails in children.

MATERIALS AND METHODS

A retrospective descriptive case series of patients treated with intramedullary fixation of forearm fractures. The radiological and functional results, and complications are correlated.

RESULTS

Of the 117 patients operated, 59 met the inclusion criteria. The average age was 10 years. Eighty-four point seven percent were males and the left side was the most affected (62.7%). In 88.1% both bones were fractured and 11 cases had open fractures. An open reduction was performed in 72.8% of the cases, the main indications for this being instability, failed reduction and refracture. There were 52 excellent outcomes, 2 good, and 4 regular and 1 bad. There were 13.5% minor complications.

DISCUSSION

This study shows that intramedullary fixation with Kirschner nails in radius and ulna diaphysis fractures in children is a safe, low-cost procedure and offers adequate short and medium term functional outcomes, with a low prevalence of serious complications with only 6 cases of non-consolidation and refracture. Larger preoperative angulations in the anteroposterior and lateral planes, and lateral postoperative angulations, could be considered predictors of less satisfactory functional results.

[Mini-locking plates for the treatment of Regan-Morrey type III fracture of ulnar coronoid process through anterior approach of elbow joint]

OBJECTIVE

To explore clinical effects of mini-locking plates for the treatment of Regan-Morrey type III fractures of ulnar coronoid process through an anterior approach of elbow joint.

METHODS

A retrospective analysis on 12 patients with Regan-Morrey type III fractures of the ulnar coronoid process was performed from January 2011 to June 2014, who were treated with unini-locking plates through the anterior approach of elbow joint. There were 7 males and 5 females, ranging in age from 23 to 65 years old, averaged 43 years old. Four patients had fractures on the left and 8 patients had fractures on the right. The X-ray films were taken to evaluate the location and healing of the fracture before and after operation. Clinical evaluation included analysis on surgical complications, range of motion and Mayo elbow function score. All the patients were treated with mini-locking plates, and the elbow joint was stable after operation.

RESULTS

All the patients were followed up, and the duration ranged from 14 to 36 months. All the fractures were healed, and the healing time ranged from 12 to 20 weeks. The average healing time was 15.6 weeks. There were no complications occurred such as heterotopic ossification, traumatic arthritis and others. At the latest follow-up, the average angle of elbow flexion was (127.0±5.6)°(120° to 135°); the average extension angle was(4.2±4.5)° (0° to 10°); the average pronation angle of forearm was (86.0±6.1)°(75° to 90°); the average supination angle of forearm was (87.0±6.9)°(80° to 100°). Mayo elbow function score was 80 to 96 points, with an average of 88 points, of which 2 cases got an excellent result, 10 good.

CONCLUSIONS

Elbow anterior approach can clearly expose the Regan-Morrey type III coronoid fractures, and mini-locking plate fixation has a satisfactory effect.

Arthroscopic reduction and fixation of coronoid fractures with an exchange rod-a new technique

BACKGROUND

The ulnar coronoid process plays a central role in maintaining elbow stability. Some of its fractures were often combined with injury of bone and ligament. Arthroscopy enables perfect visualization to allow anatomical repair.

METHODS

From January 2012 to December 2013, six patients (four males, two females) with a mean age of 26.6 years were treated. The left and right ulnas were involved in two and four patients, respectively. All patients suffered from ipsilateral subluxation of the elbow without associated radial fracture. According to the Regan and Morrey fracture classification and O'Driscoll's classification, two and four patients were classified as type I and type II and as having tip fracture (O'Driscoll type I) and anteromedial fracture (O'Driscoll type II), respectively. Exchange rod technology via the elbow front center approach was used for reduction and fixation of fractures of the coronoid process of the ulna.

RESULTS

Intra- and postoperative X-ray examination showed that the fractures were satisfactorily fixed and that the screw and fracture line were vertical to each other. Follow-ups showed that the fractures had healed well, and the average elbow extension was -2° while the average flexion was 140°. No problems related to pronation or supination, elbow instability, or complications of blood vessels or nerves were reported. The elbows showed excellent results according to the Mayo Elbow Performance Score.

CONCLUSIONS

Arthroscopy using an exchange rod can provide excellent visual exposure of the fractured joints, without the need for a large incision during the anatomical repair. Moreover, it protects the surrounding soft tissue, shows good stability of the components, and allows early rehabilitation exercises.

Functional evaluation of patients with surgically treated terrible triad of the elbow

OBJECTIVES

To evaluate the functional outcome of patients with surgically treated terrible triad of the elbow.

METHODS

A retrospective evaluation was performed using the MEPS score (Mayo Elbow Performance Score) of patients diagnosed with terrible triad of the elbow who underwent surgical treatment.

RESULTS

14 patients (nine men and five women) and 15 elbows (one bilateral case) were evaluated. A MEPS average score of 78 points and 86% good and excellent results was obtained. As complications, we had one case of infection and three of neuropraxia of the ulnar nerve.

CONCLUSION

The patients had stable elbow with good function, however with reduced range of motion. Level of Evidence IV, Case Series.

Proximal ulnar fractures in adults: a review of 163 cases

The aim of this study was to report the epidemiological characteristics and the experience of 5 departments of trauma, in France, in the management of fractures of the proximal ulna. 163 patients with fractures of the proximal ulna with a mean age of 49.9 years (range 16-97) were managed. The most common mode of injury was a motor vehicle collision (48%). 18% sustained associated injuries to the ipsilateral limb. Open fractures were present in 42 patients (25%). A total of 109 patients had a fracture of the olecranon, with the Mayo 2A and B types most frequently seen (66%). The patients were invited for clinical examination at a mean duration of 16 months, retrospectively. Validated patient-oriented assessment scores involving the Mayo Elbow Performance Index (MEPI) and the Broberg and Morrey score were evaluated. All patients had follow-up radiographs. The mean arc of elbow motion was 130° (70-150°). The mean MEPI was 91 (20-100) with good results in 23% and excellent results in 52% of the patients. The mean Broberg and Morrey score was 90 after isolated olecranon fracture, and decreased with the complexity of the lesion. 117 fractures (72%) healed with ulnohumeral congruity. 9 fracture non-unions occurred (6%). Although the fracture of the proximal ulna can be described in several classifications, none of them accommodate it satisfactorily, because of the complexity of the lesion. The coronoid process is the keystone for the stability of the elbow. It forms the anterior buttress with the radial head. Tension band wire fixation is by far the commonest technique of internal fixation used for the treatment of non-comminuted olecranon fractures. Dorsal plate fixation is a useful option by providing improved fixation of complex comminuted fractures and fracture-dislocations. The radiocapitellar joint has to be restored appropriately, preserving the radial head when possible and replacing it with a prosthesis otherwise. The lateral collateral ligament complex is commonly disrupted and usually can be reattached to its origin from the lateral epicondyle. In addition, a brief period of hinged external fixation should be considered.

Reproducibility of classifications for olecranon fractures

INTRODUCTION

Fractures of the olecranon are relatively common injuries in adults and are of great clinical importance. Classification systems have been developed as tools to assist surgeons in grouping different types of fractures, to facilitate communication and to standardise treatment, but none of the systems used today is universally accepted for olecranon fractures.

METHODS

Fifty-nine olecranon fractures were classified according to the Schatzker, Colton, Mayo and AO/ASIF systems by four observers with different levels of expertise. Intra- and inter-observer agreement was assessed. Each observer analysed the images at three different times; the images were randomised and presented in a different sequence at each assessment.

RESULTS

There was higher mean intra-observer agreement in the AO/ASIF (0.60) and Mayo (0.64) classifications compared with the Schatzker (0.49) and Colton (0.38) classifications. Inter-observer agreement was better with AO/ASIF and Mayo (0.35 and 0.32, respectively) than with Schatzker and Colton (0.29 and 0.12, respectively).

CONCLUSION

The results of this study indicate that the most commonly used classifications for olecranon fractures are associated with low reproducibility.