29 cases of complex elbow injuries were reviewed at a mean period of 15 months. Outcome measures included MEPS and DASH score. Patients who had defined early surgery were significantly better than those in whom surgery was delayed. We concluded that Management of complex elbow injuries can be improved by early definitive surgery. The magnitude and type of soft tissue injuries should be identified. MRI scans should be liberally used for this purpose. We believe that early, adequate and appropriate management of soft tissue injuries including use of articulated external fixator for early mobilisation improves the outcome of complex elbow injuries.
Contoured locking plates are commonly used to fix the proximal humerus fractures. Their long-term results are unknown. We present long-term radiological and functional outcome of three and four part fractures of the proximal humerus treated with PHILOS plate. We prospectively analysed 53 consecutive three and four part proximal humerus fractures treated with PHILOS plate between 2002 and 2007. Patients were assessed using Oxford Shoulder Score and DASH score. 44 fractures (21 three part and 23 four part) were available at the final follow up. At a mean follow-up of 8.5 years (6.4 years–10.8 years) the average Oxford Shoulder Score was 43.9 (range 23–48) and the average DASH score was 7.7 (range 0–36.7). 30% of patients required re-operation (five for hemiarthroplasty, three for impingement syndrome, five for removal of implant). Avascular necrosis (AVN) developed in 10 patients, of which only three required hemiarthroplasty. All except one patient were satisfied with the result of their operation. Our study supports the use of locking plates for the treatment of three and four part proximal humeral fractures. In spite of some patients requiring secondary surgical intervention in the first few years, the function of the shoulder continues to improve and in the long term patients were satisfied with the outcome. An important finding of our study is that the post-traumatic AVN of humeral head does not necessarily need major surgical intervention. We believe that the possibility of avascular necrosis should not be a major determinant in the choice of surgical treatment of proximal humeral fractures.
Lunate or perilunate dislocations are common carpal injuries. Current treatment of these injuries by repair or reconstruction of intra-carpal ligaments is largely based on Mayfield's description of sequential failure of these ligaments. We do treat significant number of these injuries. We have observed that dorsal wrist capsule is attached to dorsal aspect of proximal carpal row and its interosseous ligaments by vertically oriented identifiable fibres. This can be seen as carpal bones suspended from dorsal capsule, akin to cloths suspended from a washing line. We have also observed that in lunate or perilunate dislocations, dorsal capsule is peeled off from the dorsal aspect of lunate and distal radius, similar to a Bankart lesion in the shoulder. We believe that dorsal capsule plays a bigger role in the stabilising mechanism of carpal bone than the intercarpal ligaments. It has not been described before. We dissected three cadaveric wrists and found vertical fibres running from dorsal wrist capsule/ligaments to the dorsal components of the scapholunate and lunotriquetralinterosseous ligaments. We have modified the Mayo approach to dorsal wrist capsule and use suture anchors to attach dorsal capsule/ligaments to scaphoid, lunate and triquetrum rather than repairing intra-carpal ligament. We have used this technique in 26 patients so far. Follow up for more than 4 years have shown satisfactory results and no significant recurrence of instability. We present a novel, so far unreported, method of repairing the intracarpal injuries, using the dorsal capsule/ligaments, based on anatomic and intra-operative observations.
