Olecranon plates used for the internal fixation of complex olecranon fractures are applied directly over the triceps tendon on the posterior aspect of the olecranon. The aim of the study is to describe the relationship of the plates and screws to the triceps tendon at the level of the olecranon. Eight cadaveric elbows were used. Dimensions of the triceps tendon at the insertion and 1cm proximal were measured. A long or a short olecranon plate was then applied over the olecranon and the most proximal screw applied. The length of the plate impinging on the tendon and the level of the screw tract on the tendon and bone were measured. The mean olecranon height was 24.3cm (22.4-26.9cm) with a tip-to-tendon distance of 14.5cm (11.9-16.2cm). The triceps tendon footprint averaged 13.3cm (11.7-14.9cm) and 8.8cm (7.6-10.2cm) in width and length, respectively. The mean width of the central tendon 1 cm proximal to the footprint was 6.8 cm. The long olecranon plate overlay over more movable tendon length than did the short plate and consequently the superior screw pierced the triceps tendon more proximally with the long plate. Using the Mann-Whitney U test, the differences were significant. The long olecranon plates encroach on more triceps tendon than short plates. This may be an important consideration for olecranon fractures with regards implant loosening or triceps tendon injury

Background. The pattern of appearance of secondary ossification centers in the elbow has been based on historical studies and is popularly referred to with the mnemonic CRITOL. However the six secondary ossification centers can be variable in their presentation and pose a challenge in assessment of children with elbow injuries. Furthermore limited studies available in the current literature have reported an aberration to the sequence of appearance especially with the ossification centers of trochlea and olecranon. Aims. The aim of the study was to evaluate the relative sequence of appearance of secondary ossification centers for the trochlea and olecranon. Methods. Children between 8 and 10 years of age who had radiographs of elbow following trivial trauma between July 2013 and Feb 2015 were identified using the hospital PACS database. Cases with radiographic markers of significant trauma ie. fat pad sign, displaced fracture were excluded. Anteroposterior and lateral views of elbow were reviewed for the presence of the six ossification centers. Results. A total of 114 radiographs were reviewed of which 51 were boys and 63 were girls with a mean age of 9.03 years (±0.59). 60 radiographs were of right elbow and 54 were of the left elbow. The capitulum, radial head and medial epicondyle ossification centers were present in all patients. Both trochlea and olecranon ossification centers were noted in 51/114 (44.7%) children. 12/114 (10.5%) of the children were noted to have trochlea ossification center with no olecranon ossification center. Of these 12 children 7 were boys and 5 were girls. On the other hand 19/114 (16.7%) of the children had an olecranon ossification center but without a trochlea ossification center. Amongst these 7 were boys and 12 were girls. Discussion and Conclusions. The results of this limited cross sectional study demonstrate that the CRITOL sequence may not followed in 16.7% of cases and more so in girls. Historical studies were based on conventional radiographs. However the current digital radiographs with image enhancement tools help in accurate identification of relatively small ossification centers which may not be apparent on conventional radiographs. The current study has helped to quantify the violators to CRITOL sequence. Level of Evidence. Level III (Cross-sectional study among non-consecutive patients)

Olecranon fractures account for 20% of elbow fractures. Displaced fractures can be treated by several methods – Tension Band Wiring (TBW), Open Reduction and Internal Fixation with a plate (ORIF) or conservative measures. Studies from UK specialist centres have demonstrated infection rates of up to 15% and metal ware removal rates of up to 80%. In addition studies have shown that conservative treatment provides a good function and pain relief in the elderly and infirm. We aimed to look at all displaced olecranon fractures within our unit over a 4 year period and analyse their case notes for patient features, age stratification, treatment methods, complications and outcomes. We also aimed to compare our results to outcomes in studies published by specialist centres. All olecranon fractures admitted to our unit in calendar years 2007–2010 were identified from our trauma database. Case sheets were analysed for patient's age, co-morbidities, treatment, complications and outcome. X-rays were analysed to classify the fractures and assess outcome of treatment. 71 patients were identified, Male: Female = 33:38. Age range was 7–93, mean was 62.8 years. Treatment used – TBW 42 (59.1%), ORIF 9 (12.7%), and Conservative 20 (28.2%). In the surgical group of 51 patients there were 4 infections (7.8%). There were no incidences of nerve palsy. Metalware was removed in 15 patients (29.4%) – for TBW this was 11/42 (26.25%) and ORIF 4/9 (44.4%) – however the difference was not significant (p=0.06). The conservative group had no complications. In our study group we have demonstrated a lower infection rate and a far lower rate of metal ware removal than published studies. We have a high rate of patients treated conservatively who do well. Further work is being performed into the functional outcome of the whole group

Olecranon fractures account for 20% of elbow fractures. Displaced fractures can be treated by several methods – Tension Band Wiring (TBW), Open Reduction and Internal Fixation with a plate (ORIF) or conservative measures. Studies from UK specialist centres have demonstrated infection rates of up to 15% and metalware removal rates of up to 80%. In addition studies have shown that conservative treatment provides good function and pain relief in the elderly and infirm. To look at all displaced olecranon fractures within our unit (the busiest district general hospital in Scotland) over a 4 year period and analyse for patient features, age stratification, identify treatment methods, complications and outcomes. To compare this to outcomes in studies published by specialist centres. All olecranon fractures admitted to our unit in calendar years 2007–2010 were identified from our trauma database. Case sheets were analysed for patient's age, co-morbidities, treatment, complications & outcome. Xrays were analysed to classify the fractures and assess outcome of treatment. 71 patients were identified, Male: Female = 33:38. Age range was 7–93. Mean 62.8. Treatment used – TBW 42 (59.1%), ORIF 9 (12.7%), Conservative 20 (28.2%). In the surgical group of 51 patients there were 4 infections (7.8%). There were no incidences of nerve palsy. Metalware was removed in 15 patients (29.4%) – for TBW this was 11/42 (26.25) and ORIF 4/9 (44.4%) – however the difference was not significant (p=0.06). The conservative group had no complications. In our study group we have demonstrated a lower infection rate and a far lower rate of metalware removal than published studies.?We have a high rate of patients treated conservatively who do well. Further work is being performed into the functional outcome of the whole group

Using an osteotomy of the olecranon as a model of a transverse fracture in 22 cadaver elbows we determined the ability of three different types of suture and stainless steel wire to maintain reduction when using a tension-band technique to stabilise the bone. Physiological cyclical loading simulating passive elbow movement (15 N) and using the arms to push up from a chair (450 N) were applied using an Instron materials testing machine whilst monitoring the osteotomy site with a video extensometer. Each osteotomy was repaired by one of four materials, namely, Stainless Steel Wire (7), No 2 Ethibond (3), No 5 Ethibond (5), or No 2 FiberWire (7). There were no failures (movement of > 2 mm) with stainless steel wire or FiberWire and no significant difference in the movements measured across the site of the osteotomy (p = 0.99). The No. 2 Ethibond failed at 450 N and two of the five of No. 5 Ethibond sutures had a separation of > 2 mm at 450 N. FiberWire as the tension band in this model held the reduction as effectively as stainless steel wire and may reduce the incidence of discomfort from the hardware. On the basis of our findings we suggest that a clinical trial should be undertaken

Introduction:. Mayo 2A Olecranon fractures are traditionally managed with a tension band wire device (TBW) but locking plates may also be used to treat these injuries. Objectives:. To compare clinical outcomes and treatment cost between TBW and locking plate fixation in Mayo 2A fractures. Methods:. All olecranon fractures admitted 2008–2013 were identified (n=129). Patient notes and radiographs were studied. Outcomes were recorded with the QuickDASH (Disabilies of Arm, Shoulder and Hand) score. Incidence of infection, hardware irritation, non-union, fixation failure and re-operation rate were recorded. Results:. 89 patients had Mayo 2A fractures (69%). Of these patients 64 underwent TBW (n=48) or locking plate fixation (n=16). The mean age for both groups were 57 (15–93) and 60 (22–80) respectively. In the TBW group, the final follow-up QuickDASH was 12.9, compared with 15.0 for the Locking plate group. There was no statistically significant difference between either group (p = 0.312). 19 of the 48 TBW patients had complications (48%). There was 1 infection (2%). 15 cases of metalwork irritation (31%). 1 non-union (2%). 2 fixation failures (4%). 14 of the 48 TBW patients had re-operations (29%). There were 13 removal of metalwork procedures (27%), 1 washout (2%) and 2 revision fixations (4%). There were 0 complications and 0 re-operations in the 16 patients who underwent locking plate fixation. This was statistically significant, (p = 0.003) and (p= 0.015) respectively. TBW costs £7.00 verses £244.10 for a locking plate. Theatre costs were equivalent. A 30 minute day surgery removal of metalwork or similar case costs £1420. In this cohort, when costs of re-operation were included, locking plates were on average £177 less per patient. Conclusions:. Locking plates are superior to TBW in terms of incidence of post-operative morbidity and re-operation rate. Financial savings may be made by choosing a more expensive initial implant

Background. The treatment of olecranon fractures frequently involves the use of tension band fixation. Although associated with high union rates, this method has a high incidence of morbidity associated with soft tissue compromise and limitation of range of movement requiring frequent re-operation for removal of metal. Objectives. We describe the use of a simple jig to ensure intramedullary placement of longitudinal K-wires and compare the accuracy of placement of wires using this device with the traditional free hand method. Methods & Materials. 10 orthopaedic surgical trainees passed 2 longitudinal k wires into synthetic ulnae. This was done using the free hand method and then plastic jig. The ulnae were then sectioned to identify the position of the wires relative to the intramedullary canal. Results. Of the free hand wires, only 11 of 20 were found to be intramedullary versus 20 of 20 in the group passed using the jig. (p<0.001). The mean distance from the center of the ulnar canal was 6.5 mm in the freehand group (range 1-18mm, SD 6.1mm) and 1.6 mm in the O-Jig group (range 1-2mm, SD 0.5mm). The difference in the mean distance from the centre was 4.9mm which was significant (p< 0.001). Conclusions. We found the distance from the centre of the medullary canal, the range and standard deviations of wire positions to be significantly more precise when the jig was used

Radial head fractures are among the most common fractures around the elbow. Radial head arthroplasty is one of the surgical treatment options after complex radial head fractures. This surgery is usually done under general anaesthesia. However, there is a recent anaesthetic technique - wide awake local anaesthesia no tourniquet (WALANT) - that has proven useful in different surgical settings, such as in distal radius or olecranon fractures. It allows a good haemostatic control without the use of a tourniquet and allows the patient to actively collaborate during the surgical procedure. Furthermore, there are no side effects or complications caused by the general anaesthesia and there's an earlier patient discharge. The authors present the case of a seventy-six-year-old woman who presented to the emergency department after a fall from standing height with direct trauma to the left elbow. The radiological examination revealed a complete intra-articular comminuted fracture of the radial head (Mason III). Clinical management: The patient was submitted to surgery with radial head arthroplasty, using WALANT. The surgery was successfully completed without pain. There were no intra or immediate post-operative complications and the patient was discharged on the same day. Six weeks after surgery, the patient had almost full range of motion and was very pleased with the functional outcome, with no limitations on her activities of daily living. The use of WALANT has been expanded beyond the hand and wrist surgery. It is a safe and simple option for patients at high risk of general anaesthesia, allowing similar surgical outcomes without the intraoperative and postoperative complications of general anaesthesia and permitting an earlier hospital discharge. Furthermore, it allows the patient to actively collaborate during the surgery, providing the surgeons the opportunity to evaluate active mobility and stability, permitting final corrections before closing the incision

Abstract. Background. Benign osteolytic lesions of bone represent a diverse group of pathological and clinical entities. The aim of this study is to highlight the importance of intraoperative endoscopic assessment of intramedullary osteolytic lesions in view of the rate of complications during the postoperative follow up period. Methods. 69 patients (median age 27 years) with benign osteolytic lesion had been prospectively followed up from December 2017 to December 2018 in a university hospital in Cairo, Egypt and in a level-1 trauma center in United Kingdom. All patients had been treated by curettage with the aid of endoscopy through a standard incision and 2 portals. Histological analysis was confirmed from intraoperative samples analysis. All patients had received bone allografts from different donor sites (iliac crest, fibula, olecranon, etc). None of them received chemo or radiotherapy. Results. Most of lesions were enchondroma (n=29), followed by Aneurysmal bone cyst (ABC) (n=16), Fibrodysplasia (n=13), Chondromyxoid fibroma (n=3), simple bone cyst (n= 3), non-ossifying fibroma (n= 3), giant cell tumour (n= 1) and chondromyxoid fibroma (n = 1). Site of lesion varied from metacarpals (n = 29), femur (n= 1), lower leg (n= 31), and upper limb (n=18). Complications happened only in 9 cases (pathological fractures (n=2), infection (n= 1), recurrence (n=3, all aneurysmal bone cyst), residual pain (n= 3, all in tibia). None of cases developed malignant transformation. Conclusion. Endoscopy is recommended in management of benign osteolytic bone lesions; as it aids in better visualization of the hidden lesions that are missed even after doing apparently satisfactory blind curettage. From our study the recurrence rate is 2% compared to the known 12–18% recurrence rate in the blind technique from literature

Introduction and Objective. Curative resection of proximal humerus tumours is now possible in this era of limb salvage with endoprosthetic replacement considered as the preferred reconstructive option. However, it has also been linked with mechanical and non-mechanical failures such as stem fracture and aseptic loosening. One of the challenges is to ensure that implants will endure the mechanical strain under physiological loading conditions, especially crucial in long surviving patients. The objective is to investigate the effect of varying prosthesis length on the bone and implant stresses in a reconstructed humerus-prosthesis assembly after tumour resection using finite element (FE) modelling. Methods. Computed tomography (CT) scans of 10 humeri were processed in Mimics 17 to create three-dimensional (3D) cortical and cancellous solid bone models. Endoprostheses of different lengths manufactured by Stryker were modelled using Solidworks 2020. The FE models were divided into four groups namely group A consisting of the intact humerus and groups B, C and D composed of humerus-prosthesis assemblies with a body length of 40, 100 and 120 mm respectively and were meshed using linear 4-noded tetrahedral elements in 3matic 13. The models were then imported into Abaqus CAE 6.14. Isotropic linear elastic behaviour with an elastic modulus of 13400, 2000 and 208 000 MPa were assigned to the cortical bone, cancellous bone and prosthesis respectively and a Poisson's ratio of 0.3 was assumed for each material. To represent the lifting of heavy objects and twisting motion, a tensile load of 200 N for axial loading and a 5 Nm torsional load for torsional loading was applied separately to the elbow joint surface with the glenohumeral joint fixed and with all contact interfaces defined as fully bonded. A comparative analysis against literature was performed to validate the intact model. Statistical analysis of the peak von Mises stress values collected from predicted stress contour plots was performed using a one-way repeated measure of analysis of variance (with a Bonferroni post hoc test) using SPSS Statistics 26. The average change in stress of the resected models from the intact state were then determined. Results. The validation of the intact humerus displayed a good agreement with literature values. The peak bone stress occurred distally above the coronoid and olecranon fossa closer to the load application region in the intact and resected bone models with a significant amount of loading borne by the cortical bone, while the peak implant stress occurred at the bone-prosthesis contact interface under both loading conditions. Based on the results obtained, a statistically significant difference (p =.013) in implant stress was only seen to occur between groups B and C under tension. Results illustrate initiation of stress shielding with the bone bearing lesser stress with increasing resection length which may eventually lead to implant failure by causing bone resorption according to Wolff's law. The peak implant stress under torsion was 3–5 times the stress under tension. The best biomechanical behaviour was exhibited in Group D, having the least average change in stress from the intact model, 5% and 3.8% under tension and torsion respectively. It can be deduced that the shorter the prosthesis length, the more pronounced the effect on cortical bone remodelling. With the maximum bone and implant stresses obtained being less than their yield strength, it can be concluded that the bone-implant construct is safe from failure. Conclusions. The developed FE models verified the influence of varying the prosthesis length on the bone and implant stresses and predicted signs of stress shielding in longer endoprostheses. By allowing for 2 cm shortening in the upper extremity and post-surgical scarring, it is beneficial to err towards a shorter endoprosthesis

Advancements in treating the unstable elbow. We will review and discuss the kinematics and biomechanics of the forearm, concentrating on the role of soft tissue structures and how they affect forearm and elbow function. During this session, we will review the latest techniques for treating the terrible triad, including solutions to complex injuries of the olecranon, coronoid, and radial head. Techniques presented will address fixation, reconstruction, and salvaging of complex unstable elbow injuries

Objectives

There are various pin-in-plaster methods for treating fractures of the distal radius. The purpose of this study is to introduce a modified technique of ‘pin in plaster’.

We undertook a study on eight arms from fresh cadavers to define the clinical usefulness of the lesser sigmoid notch as a landmark when reconstructing the length of the neck of the radius in replacement of the head with a prosthesis. The head was resected and its height measured, along with several control measurements. This was compared with in situ measurements from the stump of the neck to the proximal edge of the lesser sigmoid notch of the ulna. All the measurements were performed three times by three observers acting independently.

The results were highly reproducible with intra- and interclass correlations of > 0.99. The mean difference between the measurement on the excised head and the distance from the stump of the neck and the lesser sigmoid notch was −0.02 mm (−1.24 to +0.97). This difference was not statistically significant (p = 0.78).

The proximal edge of the lesser sigmoid notch provides a reliable landmark for positioning a replacement of the radial head and may have clinical application.

The effect of zoledronic acid on bone ingrowth was examined in an animal model in which porous tantalum implants were placed bilaterally within the ulnae of seven dogs. Zoledronic acid in saline was administered via a single post-operative intravenous injection at a dose of 0.1 mg/kg. The ulnae were harvested six weeks after surgery. Undecalcified transverse histological sections of the implant-bone interfaces were imaged with backscattered scanning electron microscopy and the percentage of available pore space that was filled with new bone was calculated. The mean extent of bone ingrowth was 6.6% for the control implants and 12.2% for the zoledronic acid-treated implants, an absolute difference of 5.6% (95% confidence interval, 1.2 to 10.1) and a relative difference of 85% which was statistically significant. Individual islands of new bone formation within the implant pores were similar in number in both groups but were 69% larger in the zoledronic acid-treated group. The bisphosphonate zoledronic acid should be further investigated for use in accelerating or enhancing the biological fixation of implants to bone.

The aim of this randomised, controlled in vivo study in an ovine model was to investigate the effect of cylic pneumatic pressure on fracture healing. We performed a transverse osteotomy of the right radius in 37 sheep. They were randomised to a control group or a treatment group where they received cyclic loading of the osteotomy by the application of a pressure cuff around the muscles of the proximal forelimb. Sheep from both groups were killed at four or six weeks. Radiography, ultrasonography, biomechanical testing and histomorphometry were used to assess the differences between the groups. The area of periosteal callus, peak torsional strength, fracture stiffness, energy absorbed over the first 10° of torsion and histomorphometric analysis all showed that the osteotomies treated with the cyclic pneumatic pressure at four weeks were not significantly different from the control osteotomies at six weeks.