Introduction. Adequate exposure is a prerequisite for treatment of distal humeral fractures. In this study, we compared the clinico-radiological and functional outcome of TRAP approach with that of olecranon osteotomy for distal humerus fractures. Material & Methods. 27 patients with distal humerus fractures were randomized into 2 groups: Group 1 (n=14, TRAP approach), Group 2 (n=13, Olecranon osteotomy). All patients were operated with bi-columnar fixation. All patients were mobilized from day 2. Follow-up evaluation was done at 1, 3, 6 and 12 months. Results. All patients achieved union. The mean surgical time was higher in group 1 (120 min) as compared to group 2 (100 min). The final ROM was higher in group 1 (1160) as compared to group 2 (850). Two patients in group 2 needed posterior release. 5 patients in group 2 had hardware complications related to olecranon osteotomy and needed removal. Two patients in Group 1 had transient ulnar nerve paraesthesias. There was no difference in triceps power in both groups. Conclusion. Our results demonstrate that TRAP approach is extensile and safe enough in treating these complex fractures with better final ROM and fewer complications

Compression and absolute stability are important in the management of intra-articular fractures. We compared tension band wiring with plate fixation for the treatment of fractures of the olecranon by measuring compression within the fracture. Identical transverse fractures were created in models of the ulna. Tension band wires were applied to ten fractures and ten were fixed with Acumed plates. Compression was measured using a Tekscan force transducer within the fracture gap. Dynamic testing was carried out by reproducing cyclical contraction of the triceps of 20 N and of the brachialis of 10 N. Both methods were tested on each sample. Paired t-tests compared overall compression and compression at the articular side of the fracture. The mean compression for plating was 819 N (. sd. 602, 95% confidence interval (CI)) and for tension band wiring was 77 N (. sd. 19, 95% CI) (p = 0.039). The mean compression on the articular side of the fracture for plating was 343 N (. sd. 276, 95% CI) and for tension band wiring was 1 N (. sd. 2, 95% CI) (p = 0.038). During simulated movements, the mean compression was reduced in both groups, with tension band wiring at −14 N (. sd. 7) and for plating −173 N (. sd. 32). No increase in compression on the articular side was detected in the tension band wiring group. Pre-contoured plates provide significantly greater compression than tension bands in the treatment of transverse fractures of the olecranon, both over the whole fracture and specifically at the articular side of the fracture. In tension band wiring the overall compression was reduced and articular compression remained negligible during simulated contraction of the triceps, challenging the tension band principle

Non-operative management of displaced olecranon fractures in elderly low demand patients is reported to result in a satisfactory outcome despite routinely producing a nonunion. The aim of this study was to assess whether there is evidence of dynamic movement of the fracture fragment during the elbow arc of movement. Five consecutive patients (≥70 years of age) with a displaced olecranon fracture (Mayo 2A) that were managed with non-operative intervention were recruited. All underwent ultrasound evaluation at six weeks and follow-up questionnaires at six months including the DASH and Oxford Elbow Score (OES). There were three women and two men with a mean age of 79yrs (range 70–88). All injuries were sustained following a fall from standing height. The mean fracture gap in extension was 22.5mm (95% CI 13.0–31.9), midflexion 21.8mm (11.6–32.0) and in deep flexion 21.8mm (10.9–32.8). Although the amount of fracture displacement varied between patients, it remained static in each patient with no significant differences observed throughout the arc of motion (ANOVA p=0.99). The six-month median DASH score was 7.5 (IQR range, 4.2–39.3) and the OES was 44.0 (29.0–47.5). Four out of the five patients were satisfied with their function. Ultrasound evaluation of displaced olecranon fractures following non-operative management suggests the proximal fragment may function as a sesamoid type bone within the triceps sleeve. This could explain how a functional arc of movement with a minimum level of discomfort can usually be expected with non-operative management in select patients

In order to achieve satisfactory reduction of complex distal humeral fractures, adequate exposure of the fracture fragments and the joint surface is required. Several surgical exposures have been described for distal humeral fractures. We report our experience using the anconeus pedicle olecranon flip osteotomy approach. This involves detachment of the triceps along with a sliver of olecranon, which retains the anconeus pedicle. We report the use of this approach in ten patients (six male, four female) with a mean age of 38.4 years (28 to 51). The mean follow-up was 15 months (12 to 18) with no loss to follow-up. Elbow function was graded using the Mayo Score. The results were excellent in four patients, good in five and fair in one patient. The mean time to both fracture and osteotomy union was 10.6 weeks (8 to 12) and 7.1 weeks (6 to 8), respectively. We found this approach gave reliably good exposure for these difficult fractures enabling anatomical reduction and bicondylar plating without complications. . Cite this article: Bone Joint J 2014;96-B:1252–7

Myotome values for the upper limb appear to have been established in the early twentieth century based on historical work. Supraclavicular brachial plexus injuries present with a pattern of neurological loss consistent to the nerve roots affected. Recent advances in radiological imaging and intraoperative nerve stimulation have allowed confirmation of the affected nerve roots. The records of 43 patients with partial injuries to the supraclavicular brachial plexus were reviewed. The injuries covered the full range of injury patterns including those affecting C5, C5-6, C5-7, C5-8, C7-T1 and C8-T1 roots. All cases with upper plexus injuries had surgical exploration of the brachial plexus with the injury pattern being classified on the basis of whether the roots were in continuity, ruptured, or avulsed, and, if seen in continuity, the presence or absence of a response to stimulation. For lower plexus injuries the classification relied on identification of avulsed roots on Magnetic Resonance Imaging. Muscle powers recorded on clinical examination using the MRC grading system. In upper plexus injuries paralysis of flexor carpi radialis indicated involvement of C7 in addition to C5-6, and paralysis of triceps and pectoralis major suggested loss of C8 function. A major input from T1 was confirmed for flexor digitorum superficialis, flexor digitorum profundus (FDP) to the radial digits, and extensor pollicis longus. C8 was the predominant innervation to the ulnar side of FDP and intrinsic muscles innervated by the ulnar nerve with some contribution from C7. A revised myotome chart for the upper limb is proposed

We reviewed 26 patients who had had internal fixation of an open intra-articular supracondylar fracture of the humerus. All operations were performed using a posterior approach, 13 with a triceps split and 13 with an olecranon osteotomy. The outcome was assessed by means of the Mayo Elbow score, the Disability of the Arm, Shoulder and Hand (DASH) score and the SF-36 Physical Function score. Patients with an olecranon osteotomy had less good results

AIM. Chronic osteomyelitis still remains challenging and expensive to treat inspite of advances in antibiotics and operative techniques. We present our experience with free muscle flap after radical debridement of chronic osteomyelitis, performed as a single stage procedure. METHODS. We retrospectively identified eight patients (5 Females) with mean age of 63 yrs (Range40–71 yrs) Case notes were reviewed for co morbidities, Pre and post treatment inflammatory markers (plasma viscosity and CRP) and clinical staging. Mean follow up was 3 yrs (Range 1–6 yrs) All the patients were jointly operated by orthopaedic and plastic surgeons and underwent thorough debridement and muscle flap (Seven free flaps and one rotational flap) in the same sitting. All the patients were reviewed regularly by plastic and orthopaedic surgeons. Seven patients had free Gracilis flap and one had Triceps flap. Clinical assessment of reinfection was made on presence of erythema, wound discharge, pain and swelling. Primary outcome measure was resolution of infection. RESULTS. Seven patients had full resolution of osteomyelitis as evident by clinical examination and inflammatory markers. Three patients had graft problems to start with, but theses settled within six months One patient had minor wound discharge at three years which settled with conservative management. One further patient developed eczematous dermatitis around the flap which was managed successfully by the dermatologist. CONCLUSIONS. We believe this to be the only study in which both the procedures (debridement and muscle flap) are performed in one sitting. This technique is a successful and useful addition to the armamentarium of surgeons in the management of chronic osteomyelitis. Though our study is small but our results are encouraging

Injuries to the ankle are common in children. We investigated whether decreased dorsiflexion predisposes to such fractures and sprains. Passive dorsiflexion in children with ankle injuries was compared with that in a control group of patients with a normal ankle. The uninjured side was examined to determine flexibility in those patients with ankle injuries. In 82, the mean dorsiflexion was 5.7° with the knee extended and 11.2° with the knee flexed. In 85 controls, the mean dorsiflexion was 12.8° with the knee extended and 21.5° with the knee flexed (p < 0.001, Student’s t-test). There was a strong association between decreased ankle dorsiflexion and injury in children. A flexible triceps surae appeared to absorb energy and protect the bone and ligaments, while stiffness predisposed to injury. We suggest that children with tight calf muscles should undergo a regimen of stretching exercises to improve their flexibility

Aims

The aim of this prospective randomised controlled trial was to compare non-operative and operative management for acute isolated displaced fractures of the olecranon in patients aged ≥ 75 years.

The outcomes of 261 nerve injuries in 100 patients were graded good in 173 cases (66%), fair in 70 (26.8%) and poor in 18 (6.9%) at the final review (median 28.4 months (1.3 to 64.2)). The initial grades for the 42 sutures and graft were 11 good, 14 fair and 17 poor. After subsequent revision repairs in seven, neurolyses in 11 and free vascularised fasciocutaneous flaps in 11, the final grades were 15 good, 18 fair and nine poor. Pain was relieved in 30 of 36 patients by nerve repair, revision of repair or neurolysis, and flaps when indicated. The difference in outcome between penetrating missile wounds and those caused by explosions was not statistically significant; in the latter group the onset of recovery from focal conduction block was delayed (mean 4.7 months (2.5 to 10.2) vs 3.8 months (0.6 to 6); p = 0.0001). A total of 42 patients (47 lower limbs) presented with an insensate foot. By final review (mean 27.4 months (20 to 36)) plantar sensation was good in 26 limbs (55%), fair in 16 (34%) and poor in five (11%). Nine patients returned to full military duties, 18 to restricted duties, 30 to sedentary work, and 43 were discharged from military service. Effective rehabilitation must be early, integrated and vigorous. The responsible surgeons must be firmly embedded in the process, at times exerting leadership.

Heterotopic ossification occurring after the use of commercially available bone morphogenetic proteins has not been widely reported. We describe four cases of heterotopic ossification in patients treated with either recombinant bone morphogenetic protein 2 or recombinant bone morphogenetic protein 7. We found that while some patients were asymptomatic, heterotopic ossification which had occurred around a joint often required operative excision with good results.

A total of 11 patients with combined traumatic injuries of the brachial plexus and spinal cord were reviewed retrospectively. Brachial plexus paralysis in such dual injuries tends to be diagnosed and treated late and the prognosis is usually poor. The associated injuries, which were all on the same side as the plexus lesion, were to the head (nine cases), shoulder girdle (five), thorax (nine) and upper limb (seven). These other injuries were responsible for the delayed diagnosis of brachial plexus paralysis and the poor prognosis was probably because of the delay in starting treatment and the severity of the associated injuries. When such injuries are detected in patients with spinal cord trauma, it is important to consider the possibility of involvement of the brachial plexus.