Introduction: Acute elbow trauma is commonly seen in the emergency department. The purpose of the present study was to evaluate in our emergency department the assessment of elbow trauma radiographs in children. Methods: 136 patients aged between 0 and 16 presented at our institution for an elbow trauma over a 6 months period. All the radiographs were digitalised and stored in a commercially available computerised X ray system. All the radiographs were reviewed at the daily clinical radiological conference by an orthopaedic surgeon and a radiologist. Results: There were 64 fractures, 2 dislocations, 37 radial head subluxations and 33 simple contusions. Of these, 15 (11 per cent) were considered to have been misinterpreted. There were 12 undisplaced fractures (5 supra-condylar fractures, 3 radial head fractures, one fracture of the lateral condyle, 3 fractures of the olecranon and 3 false-positive diagnoses of fractures. All patients were reviewed within a few days and were correctly reassessed and treated. Conclusions: Compared to other fractures, children’s elbow trauma are commonly misdiagnosed in the emergency department. In this short series, correct diagnosis was missed 15 times (11%) by various physicians working in the Emergency Department (trainees, emergency physicians). The senior specialists (orthopaedic surgeon and radiologist) used real time digital contrast enhancement, as well as magnification and soft tissue assessment with the digitizer to correctly analyse the missed diagnosis. X ray review by senior specialists at the daily clinical radiological conference is time consuming and sometimes difficult but appears to be clearly beneficial to patients ‘care

Purpose of Study. We report the outcome of five cases of chronic paediatric Monteggia lesion treated with a modified Bell-Tawse procedure. Methods. Five patients with a chronic Monteggia lesion were treated over an eight-year period (2004–2012) at our institution. All underwent a modified Bell-Tawse procedure. The patient medical records were retrospectively analysed. We report the outcome in five patients. Results. Four girls and one boy were treated for a chronic Monteggia lesion in the period studied. The mean age at time of surgery was 8 years old (range 4–14 years). The mechanism of injury was post-traumatic in four of the five cases, while in one case the mechanism was uncertain. All children underwent modified Bell-Tawse procedure. All children ultimately required ulnar osteotomy, while two also required radial osteotomy. At a mean follow-up of 22 months (range 16–38 months), four children had experienced complications. Symptomatic metalwork was removed in one case, two children re-dislocated the affected joint, and one child required revision Bell-Tawse procedure. No nerve palsies were noted on follow-up. Conclusion. Paediatric elbow trauma necessitates early, senior management. We report a series of five patients who underwent modified Bell-Tawse procedure for chronic Monteggia lesion. Four of the five children experienced complications. All required shortening osteotomies. The chronic Monteggia lesion is an unusual but troublesome presentation in the paediatric population. Further research in the area is necessary

The COVID-19 pandemic presented a significant impact on orthopaedic surgical operating. This multi-centre study aimed to ascertain what factors contributed to delays to theatre in patients with shoulder and elbow trauma. A retrospective cohort study of 621 upper limb (shoulder and elbow) trauma patients between 16/03/2020 and 16/09/2021 (18-months) was extracted from trauma lists in NHS Tayside, Highland and Grampian and Picture Archiving and Communication Systems (PACS). Median patient age =51 years (range 2-98), 298 (48%) were male and 323 (52%) female. The commonest operation was olecranon open reduction internal fixation (ORIF) 106/621 cases (17.1%), followed by distal humerus ORIF − 63/621 (10.1%). Median time to surgery was 2 days (range 0-263). 281/621 (45.2%) of patients underwent surgical intervention within 0-1 days and 555/621 patients (89.9%) had an operation within 14 days of sustaining their injury. 66/621 (10.6%) patients waited >14 days for surgery. There were 325/621 (52.3%) patients with documented evidence of delay to surgery; of these 55.6% (181/325) were due to amendable causes. 66/325 (20.3%) of these patients suffered complications; the most common being post-operative stiffness in 48.6% of cases (n=32/66). To our knowledge, this is the first study to specifically explore effect of COVID-19 pandemic on upper limb trauma patients. We suggest delays to theatre may have contributed to higher rates of post-operative stiffness and require more physiotherapy during the rehabilitation phase. In future pandemic planning, we propose dedicated upper-limb trauma lists to prevent delays to theatre and optimise patients’ post-operative outcomes

The April 2015 Shoulder & Elbow Roundup. 360 . looks at: Distal clavicular resection not indicated in cuff repair?; Platelet-rich plasma in rotator cuff repair; Radial head geometry: time to change?; Heterotopic ossification in elbow trauma; Another look at heterotopic ossification in the humerus; Triceps on for total elbow arthroplasty?; Predicting outcomes in rotator cuff repair; Deltoid fatty infiltration and reverse shoulder arthroplasty

Elbow contracture is a recognized sequel of elbow trauma. We aim at reviewing the clinical outcome of surgical capsulectomy and elbow debridement. The operative notes as well as pre and post-operative clinical records were reviewed for 15 patients who sustained an elbow trauma which resulted in elbow contracture and were managed with open capsulectomy and debridement. In addition two patients had anterior transfer of the ulnar nerve, twohad removal of loose bodies, two had excision of heterotopic bone, one patient had reconstruction of the medial collateral ligament and one patient had repair of the lateral collateral ligament . These patients were followed up for a mean of 21 months (6 to 37). Elbow flexion contracture improved from a mean of 37° (10° to 55°), to a mean of 10° (0° to 25°). Elbow flex-ion improved from a mean of 125° (95° to 140°) to a mean of 129° (90° to 140°). There were no major complications. Two patients underwent repeat debridement due to recurrence of contracture. One patient developed serious collection that settled gradually. We conclude that open capsulectomy and debridement is a satisfactory way of management of post-traumatic elbow contracture in the short and intermediate term

Aims

The aims of this study were to identify and evaluate the current literature examining the prognostic factors which are associated with failure of total elbow arthroplasty (TEA).

Summary. In contrast to the current literature, myofibroblasts are not present in chronic posttraumatic elbow contractures. However, myofibroblasts are present in the acute phase after an elbow fracture and/or dislocation. This suggests a physiological role in normal capsule healing and a potential role in the early phase of posttraumatic contracture formation. Introduction. Elbow stiffness is a common complication after elbow trauma. The elbow capsule is often thickened, fibrotic and contracted upon surgical release. The limited studies available suggest that the capsule is contracted because of fibroblast to myofibroblast differentiation. However, the timeline is controversial and data on human capsules are scarce. We hypothesise that myofibroblasts are absent in normal capsules and early after acute trauma and elevated in patients with posttraumatic elbow contracture. Patients & Methods. We obtained twenty-one human elbow joint capsules within fourteen days after an elbow fracture and/or dislocation and thirty-four capsules from thirty-four patients who had operative release of posttraumatic contractures greater than five months after injury. Myofibroblasts in the joint capsules were quantified using immunohistochemistry. Alpha-smooth muscle actin (α-SMA) was used as a marker for myofibroblasts. Samples were characterised and scored by an independent pathologist blinded for clinical data. Results. Eleven capsules were associated with the acute phase after trauma (hours to 7 days), and staining for α-SMA was negative in all eleven specimens. Ten specimens were associated with a later phase post trauma with myofibroblasts staining positive for α-SMA in all but two. All, but two, thirty-four long standing contractures showed a histological pattern consistent with chronic stages of fibrosis, characterised by increased fibroblast-like cell proliferation and higher cellular density of fibroblast-like cells with highly unstructured collagen. There was no staining of α-SMA in fibroblast-like cells in, all but two of these longstanding contractures suggesting absence of myofibroblasts. Conclusions. This study present ‘negative results’ on the hypothesis that myofibroblast numbers are elevated in longstanding (> 5 months) human posttraumatic elbow capsules. This is in contrast to all studies on human tissue in the literature to date. One recent animal study is in agreement withy our data. We did find some myofibroblasts in elbow capsules in the late-phase posttrauma (between 7 and 14 days) suggesting a potential role in early phase of posttraumatic contracture formation

Aim: Postraumatic elbow stiffness is a common condition after elbow trauma. Sometimes it is a quite disabling symptom not responding to conservative measures. We present the surgical treatment of such cases of posttraumatic elbow stiffness. Material: Twenty three patients, fourteen male and nine female with an average age of 34 yrs, underwent a surgical treatment of their stiff elbow. The average preoperative range of motion regarding elbow flexion-extension was 65° and the average rotational movement was 123°. All patients had received a resection of the anterior capsule, release or resection of posterior elements, removal of loose bodies and resection of osseous beaks if it was necessary. Two patients received a triceps lengthening. The results evaluated with the Mayo Elbow Performance Score. Results: The average follow up was twenty nine months. All the patients were available for clinical assessment. There was an improvement of the average ROM to 115°, regarding flexion extension and to 164° regarding supination pronn. Postoperatively a dynamic elbow splint was used in twenty patients and a hinged external fixator in the remaining patients. Revision elbow release was performed in three patients and in one patient the elbow stiffness was deteriorated. Sixteen patients had an excellent or good result, and seven had a fair or poor one. Conclusion: Elbow stiffness is an extremely disabling condition causing a functional impairment. Surgical elbow release is quite reliable, and relatively safe procedure given the fact that the patient follows strictly the rehabilitation protocol

Aim of the study: Mason type I radial head fractures are non-displaced fractures and are treated conservatively with early mobilization and excellent results. The aspiration of the accompanying haematoma is advocated by several authors in order to achieve an analgesic effect. The aim of this study was to investigate the effect of haematoma aspiration on intraarticular pressure and on pain relief after Mason I radial head fractures. Materials and Methods: 10 patients (6 men and 4 women, age 23–47 y), who presented in the emergency department after an elbow trauma. Following plain radiographs that showed a Mason I radial head fracture, the patients were subjected to haematoma paracentesis. Initially, the intraarticular pressure was measured by using the Stryker Intra-Compartmental Pressure Monitor System. Afterwards, aspiration of the haematoma was performed, followed by a new pressure measurement without moving the needle. Finally, a brachial-elbow-wrist back slab was placed and a questionnaire was completed, including among others pain evaluation before and after haematoma aspiration by using an analogue ten point pain scale. Results: The intraarticular elbow pressure prior to haematoma aspiration varied from 49 mmHg to 120 mmHg (mean 76.9 mmHg), while following aspiration it ranged from 9 mmHg to 25 mmHg (mean 16.7 mmHg). The mean quantity of the aspired blood was 3.45 ml (0.5 ml to 8.5 ml). Finally, the patients reported a pain decrease from 5.5 (4 to 8) before aspiration to 2.8 (1 to 4) after haematoma aspiration. Decrease for both pressure and pain was statistically significant (p< 0.001). Conclusion: The built of an intraarticular haematoma in the elbow joint following an undisplaced Mason I radial head fracture leads to a pronounced increase of the intraarticular pressure accompanied by intense pain for the patient. The aspiration of the haematoma results in an acute pressure decrease and an immediate patient relief

Purpose of the study: The articulated external fixator of the elbow joint is often useful for the treatment of trauma victims. It can neutralise dislocation forces and protect osteosynthesis assemblies and ligament repairs while authorising early mobilisation. This work reports our indications and application of this type of fixator, as well as the expected clinical and radiographic outcomes. Material and methods: From 1995 to 2008, 34 patients had an external fixator of the elbow in our unit, in combination with classical treatment. Two groups of patients were distinguished, those with a traumatic injury requiring emergency care (n=15, group 1: six dislocations, two fracture-dislocations, and seven complex fractures), and those treated outside an emergency context (n=10, group 2: ten chronic dislocations or subluxations, four stiff joints, one infection, four material disassemblies). Eighteen patient were reviewed retrospectively, clinically and radiographically. The DASH score and the Mayo Elbow Performance Score (MEPS) were noted. The Broberg and Morrey classification was used for osteoarthritis. Results: At mean 4.3 years follow-up, for groups 1 and 2, the DASH scores were 35 and 25 points and the MEPS scores 74 and 74 points respectively. In group 1, the range of motion was 63° for flexion-extension; the elbow was centred and stable in all cases except 2 (one posterior subluxation). Six elbows presented moderate to severe osteoarthritis. In group 2, the range of motion was 80° flexion-extension; the elbow was centred and stable in all cases except one (one posterior subluxation). Moderate to severe osteoarthritis was noted in five elbows. There were four complications: two cases of transient (ulnar and radial) paralysis, one fracture of the humerus on a pin track, and one superficial pin track infection. Discussion: This study demonstrates that the articulated external fixation can maintain the reduction during the healing process for complex elbow trauma where stability is compromised. The morbidity is low and functional outcomes favourable. Early mobilization of these injured elbows can limit secondary stiffness. The prognosis remains a function of the initial injury and the quality of the associated treatments

Post-traumatic synostosis of the forearm are challenging situations after elbow trauma, injuries of the forearm or the wrist. According to Vince or Hastings classification, therapeutic options are still controversial, due to an unpredictive outcome with recurrence of the synostosis or progressive loss of mobility from post-op to definitive situations. A retrospective study of 13 cases, including 3 Vince Type 1, 6 Vince Type 2 and 4 Vince type 3 with a minimum follow-up of 3 years was analyzed as well as a review of 47 worldwide publications for defining the optimal therapeutic options. All data files were reviewed including extensive analysis of the CT-scans, and detailed surgical procedures. For Vince 1 synostosis, in post-traumatic situations, Sauve-Kapandji procedure give excellent or good results when no recurrence of the synostosis is seen. Instability of the proximal ulna after segmental resection is the major complication to be described. In Vince 2 synostosis, an extensive resection of the synostosis is mandatory to obtain a potential good result. Knowledge of the entire anatomy of the forearm is needed for accurate neurolysis of radial nerve and branches. The ulnar approach to the synostosis must be completed with an anterior approach to the radius for a complete resection. In Vince 3 synostosis, resection is easy but recurrence is frequent, due to the associated lesions of the elbow. Based on the litterature review, no additive treatment is necessary for better results Therapeutic options in post-traumatic synostosis of the forearm is a rare complications of elbow lesions (Vince 3), forearm comminutive or complex fractures (Vince 2), or wrist injuries (Vince 1). The latter give the more predictable results after complete resection. Elbow lesions associated with radio-ulnar synostosis are easy to treat but with important recurrence rate, whatever treatment was done. Vince 2 post-traumatic radio-ulnar synostosis are the most challenging situation as bone resection must be extensive meanwhile neurolysis of forearm nerves must be done in the same time. No adjuvant treatment is indicated in either situation according to Vince classification

The causes of a stiff elbow are numerous including: post-traumatic elbow, burns, head injury, osteoarthritis, inflammatory joint disease and congenital. Types of stiffness include: loss of elbow flexion, loss of elbow extension and loss of forearm rotation. All three have different prognoses in terms of the timing of surgery and the likelihood of restoration of function. Contractures can be classified into extrinsic and intrinsic (all intrinsic develop some extrinsic component). Functional impairment can be assessed medicolegally; however, in clinical practice the patient puts an individual value on the arc of motion. Objectively most functions can be undertaken with an arc of 30 to 130 degrees. The commonest cause of a Post-traumatic Stiff elbow is a radial head fracture or a complex fracture dislocation. Risk factors for stiffness include length of immobilisation, associated fracture with dislocation, intra-articular derangement, delayed surgical treatment, associated head injury, heterotopic ossification. Early restoration of bony columns and joint stability to allow early mobilisation reduces incidence of joint stiffness. Heterotopic ossification (HO) is common in fracture dislocation of the elbow. Neural Axis trauma alone causes HO in elbows in 5%. However, combined neural trauma and elbow trauma the incidence is 89%. Stiffness due to thermal injury is usually related to the degree rather than the site. The majority of patients have greater than 20% total body area involved. Extrinsic contractures are usually managed with a sequential release of soft tissues commencing with a capsular excision (retaining LCL/MCL), posterior bundle of the MCL +/− ulna nerve decompression (if there is loss of flexion to 100 degrees). This reliably achieved via a posterior incision, a lateral column exposure +/− ulna nerve mobilisation. A medial column exposure is a viable alternative. Arthroscopic capsular release although associated with a quicker easier rehabilitation is associated with increased neural injury. Timing of release is specific to the type of contracture, i.e. flexion contractures after approx. six months, extension contractures ASAP but after four months, loss of forearm rotation less 6 to 24 months. The use of Hinged Elbow Fixators is increasing. The indications include reconstructions that require protection whilst allowing early movement, persistent instability or recurrent/late instability or interposition arthroplasty. Post-operative rehabilitation requires good analgesia, joint stability and early movement. The role of CPM is often helpful but still being evaluated

Post-traumatic elbow stiffness is a disabling condition that remains challenging for upper limb surgeons. Open elbow arthrolysis is commonly used for the treatment of stiff elbow when conservative therapy has failed. Multiple questions commonly arise from surgeons who deal with this disease. These include whether the patient has post-traumatic stiff elbow, how to evaluate the problem, when surgery is appropriate, how to perform an excellent arthrolysis, what the optimal postoperative rehabilitation is, and how to prevent or reduce the incidence of complications. Following these questions, this review provides an update and overview of post-traumatic elbow stiffness with respect to the diagnosis, preoperative evaluation, arthrolysis strategies, postoperative rehabilitation, and prevention of complications, aiming to provide a complete diagnosis and treatment path.

Cite this article: Bone Joint Open 2020;1-9:576–584.

The December 2014 Research Roundup³⁶⁰ looks at: demineralised bone matrix not as good as we thought?; trunk control following ACL reconstruction; subclinical thyroid dysfunction: not quite subclinical?; establishing musculoskeletal function in mucopolysaccharidosis; starting out: a first year in consultant practice under the spotlight; stroke and elective surgery; sepsis and clots; hip geometry and arthritis incidence; and theatre discipline and infection.

The October 2015 Children’s orthopaedics Roundup³⁶⁰ looks at: Radiographic follow-up of DDH; When the supracondylar goes wrong; Apophyseal avulsion fractures; The ‘pulled elbow’; Surgical treatment of active or aggressive aneurysmal bone cysts in children; Improving stability in supracondylar fractures; Biological reconstruction may be preferable in children’s osteosarcoma; The paediatric hip fracture