Aims. Medial humeral epicondyle fractures (MHEFs) are common elbow fractures in children. Open reduction should be performed in patients with MHEF who have entrapped intra-articular fragments as well as displacement. However, following open reduction, transposition of the ulnar nerve is disputed. The aim of this study is to evaluate the need for ulnar nerve exploration and transposition. Methods. This was a retrospective cohort study. The clinical data of patients who underwent surgical treatment of MHEF in our hospital from January 2015 to January 2022 were collected. The patients were allocated to either transposition or non-transposition groups. Data for sex, age, cause of fracture, duration of follow-up, Papavasiliou and Crawford classification, injury-to-surgery time, preoperative ulnar nerve symptoms, intraoperative exploration of ulnar nerve injury, surgical incision length, intraoperative blood loss, postoperative ulnar nerve symptoms, complications, persistent ulnar neuropathy, and elbow joint function were analyzed. Binary logistic regression analysis was used for statistical analysis. Results. A total of 124 patients were followed up, 50 in the ulnar nerve transposition group and 74 in the non-transposition group. There were significant differences in ulnar nerve injury (p = 0.009), incision length (p < 0.001), and blood loss (p = 0.003) between the two groups. Binary logistic regression analysis revealed that preoperative ulnar nerve symptoms (p = 0.012) were risk factors for postoperative ulnar nerve symptoms. In addition, ulnar nerve transposition did not affect the occurrence of postoperative ulnar nerve symptoms (p = 0.468). Conclusion. Ulnar nerve transposition did not improve clinical outcomes. It is recommended that the ulnar nerve should not be transposed when treating MHEF operatively. Cite this article: Bone Joint J 2024;106-B(2):212–218

We evaluated the morphological changes to the ulnar nerve of both elbows in the cubital tunnel by sonography in a total of 237 children, of whom 117 were aged between six and seven years, 66 between eight and nine years, and 54 between ten and 11 years. We first scanned longitudinally in the extended elbow and then transversely at the medial epicondyle with the elbow extended to 0°. We repeated the scans with the elbow flexed at 45°, 90°, and 120°. There were no significant differences in the area of the ulnar nerve, but the diameter increased as the elbow moved from extension to flexion in all groups. More importantly, the ulnar nerve was subluxated anteriorly on to the medial epicondyle by 1.5% to 1.9% in extended elbows, by 5.9% to 7.9% in those flexed to 45°, by 40.0% to 44% in those flexed to 90°, and by 57.4% to 58.1% in those flexed to 120°, depending on the age group. Sonography clearly and accurately showed the ulnar nerve and was useful for localising the nerve before placing a medial pin. Because the ulnar nerve may translate anteriorly onto the medial epicondyle when the elbow is flexed to 90° or more, it should never be overlooked during percutaneous medial pinning

We conducted an anatomical study to determine the best technique for transfer of the anterior interosseous nerve (AIN) for the treatment of proximal ulnar nerve injuries. The AIN, ulnar nerve, and associated branches were dissected in 24 cadaver arms. The number of branches of the AIN and length available for transfer were measured. The nerve was divided just proximal to its termination in pronator quadratus and transferred to the ulnar nerve through the shortest available route. Separation of the deep and superficial branches of the ulnar nerve by blunt dissection alone, was also assessed. The mean number of AIN branches was 4.8 (3 to 8) and the mean length of the nerve available for transfer was 72 mm (41 to 106). The transferred nerve reached the ulnar nerve most distally when placed dorsal to flexor digitorum profundus (FDP). We therefore conclude that the AIN should be passed dorsal to FDP, and that the deep and superficial branches of the ulnar nerve require approximately 30 mm of blunt dissection and 20 mm of sharp dissection from the point of bifurcation to the site of the anastomosis. The use of this technique for transfer of the AIN should improve the outcome for patients with proximal ulnar nerve injuries. Cite this article: Bone Joint J 2014;96-B:789–94

The transfer of part of the ulnar nerve to the musculocutaneous nerve, first described by Oberlin, can restore flexion of the elbow following brachial plexus injury. In this study we evaluated the additional benefits and effectiveness of quantitative electrodiagnosis to select a donor fascicle. Eight patients who had undergone transfer of a simple fascicle of the ulnar nerve to the motor branch of the musculocutaneous nerve were evaluated. In two early patients electrodiagnosis had not been used. In the remaining six patients, however, all fascicles of the ulnar nerve were separated and electrodiagnosis was performed after stimulation with a commercially available electromyographic system. In these procedures, recording electrodes were placed in flexor carpi ulnaris and the first dorsal interosseous. A single fascicle in the flexor carpi ulnaris in which a high amplitude had been recorded was selected as a donor and transferred to the musculocutaneous nerve. In the two patients who had not undergone electrodiagnosis, the recovery of biceps proved insufficient for normal use. Conversely, in the six patients in whom quantitative electrodiagnosis was used, elbow flexion recovered to an M4 level. Quantitative intra-operative electrodiagnosis is an effective method of selecting a favourable donor fascicle during the Oberlin procedure. Moreover, fascicles showing a high-amplitude in reading flexor carpi ulnaris are donor nerves that can restore normal elbow flexion without intrinsic loss

1. A case of compression of the deep branch of the ulnar nerve is described. 2. Anatomical evidence is presented that the reason for the special liability of the deep branch to be compressed by ganglia in this region is its relationship to a ligamentous band which passes from the pisiform bone to the hamate superficial to the deep branch of the ulnar nerve. 3. This band, though constant, has not been well recognised

1. Three cases of Colles's fracture complicated by ulnar nerve paralysis are described. 2. Observation at operation in two cases and studies in a cadaver demonstrated a close relationship of the ulnar nerve to a fracture line at the lower end of the radius when the distal fragment is displaced dorsally and radially. It is surprising that this injury has not been observed and commented on previously

Twenty-two patients with ulnar nerve palsy at the elbow, confirmed by electromyography, were treated by a night splint which prevented flexion of the elbow beyond 60 degrees. The splint was worn all night regularly for at least six months. At a mean follow-up of 11.3 months, 17 patients had clinical and electromyographic assessment and five were contacted by telephone. There was improvement in the symptoms in every patient, including three who had failed to respond to surgical decompression. There was electromyographic improvement in 16 of the 17 patients re-examined at follow-up. The mean improvement in motor nerve conduction velocity was 6.5 m/s and in sensory nerve conduction velocity 9.5 m/s. The efficacy of this treatment suggests that nocturnal elbow flexion is an important cause of ulnar nerve lesions at the elbow

1. A case of compression of the deep palmar branch of the ulnar nerve by an accessory abductor minimi digiti muscle is described. 2. The morphology of abnormal muscles in the hypothenar region is discussed. 3. Five previously reported cases of ulnar nerve compression at the wrist by an anomalous muscle are reviewed. 4. When symptoms are produced by an anomalous hypothenar muscle, they seem to be related to the anatomical site of the muscle and the presence of muscle hypertrophy. Occupational factors may be important in producing this hypertrophy

Outcome studies of revision surgical treatment for recurrent or persistent neuropathy of the ulnar nerve at the elbow are relatively rare and none involves patient self-assessment. In this study of 40 patients (41 elbows), a clear discrepancy is shown between clinical assessment and the patient’s own view. From clinical assessment, 20% of patients had an excellent result, whereas only one (2.5%) patient self-reported a complete cure. More reports using patient self-assessment and validated scores are required

1. A case of ulnar nerve compression at the wrist caused by rheumatoid arthritis producing motor and sensory changes is presented. 2. The diagnosis from compression at the elbow can be determined by electromyography. 3. It may be that lesions of the deep branch leading to motor changes only occur in rheumatoid arthritis more often than is suspected, their effects being hidden by the concomitant disease and its associated muscle wasting

1. Sixty-one cases of compression of the ulnar nerve are reported, forty at the elbow and twenty-one at the wrist. Although contributory factors may include deformity, osteoarthritis, injury, ganglia and other tumours, the narrow anatomical confines of the nerve at these two levels are noteworthy and alone may produce nerve compression. 2. Careful clinical examination will usually determine the level of involvement if not the exact pathology. Surgical exploration is indicated both as a diagnostic and therapeutic procedure in most cases. 3. Following removal of the compressing agent rapid recovery occurred in most cases

Ulnar nerve function, during and after open reduction and internal fixation of fractures of the distal humerus with subperiosteal elevation of the nerve, was assessed by intra-operative neurophysiological monitoring. Intermittent recording of the compound muscle action potentials was taken from the hypothenar muscles in 18 neurologically asymptomatic patients. The mean amplitude of the compound muscle action potential after surgery was 98.1% (. sd. 17.6; −37% to +25%). The amplitude improved in six patients following surgery. Despite unremarkable recordings one patient had progressive paresis. Motor impairment is unlikely if the compound muscle action potential is continuously preserved and not reduced by more than 40% at the end of surgery. Temporary decreases in amplitude by up to 70% were tolerated without clinical consequences. However, repeated clinical examination is obligatory to recognise and treat early post-operative palsy

Traumatic neuritis of the deep branch of the ulnar nerve may be caused by compression of the nerve by a ganglion originating in a carpal joint, and removal of the protrusion is followed by a prompt recovery. This lesion was found in four out of five explorations

1. The progress of recovery after transposition of the ulnar nerve has been studied in forty-six patients with ulnar neuritis of traumatic or mechanical origin. 2. In assessing the results, the lesions were divided into three grades according to the severity of the neurological signs: Grade I, minimal lesions with no detectable motor weakness; Grade II, intermediate lesions; Grade III, severe lesions with paralysis of one or more of the ulnar intrinsic muscles. 3. The earliest and most constant result after operation was the relief of discomfort and ulnar paraesthesiae. 4. The degree of motor recovery varied according to the severity of the lesion at the time of the operation. In Grades I and II cases, all the muscles (with one exception) were acting against gravity and resistance at the final examination. In Grade III cases, the recovery was usually far from complete. Recovery of sensibility was uniformly good. 5. In a further six patients with persistent symptoms after transposition, relief was obtained by free mobilisation and placing the nerve deep to the flexor origin

The June 2024 Children’s orthopaedics Roundup. 360. looks at: Proximal femoral unicameral bone cysts: is ESIN the answer?; Hybrid-mesh casts in the conservative management of paediatric supracondylar humeral fractures: a randomized controlled trial; Rate and risk factors for contralateral slippage in adolescents treated for slipped capital femoral epiphysis; CRP predicts the need to escalate care after initial debridement for musculoskeletal infection; Genu valgum in paediatric patients presenting with patellofemoral instability; Nusinersen therapy changed the natural course of spinal muscular atrophy type 1: what about spine and hip?; The necessity of ulnar nerve exploration and translocation in open reduction of medial humeral epicondyle fractures in children

Ulnar neuropathy presents as a complication in 5% to 10% of total elbow replacements, but subsequent ulnar neurolysis is rarely performed. Little information is available on the surgical management of persistent ulnar neuropathy after elbow replacement. We describe our experience with the surgical management of this problem.

Of 1607 total elbow replacements performed at our institution between January 1969 and December 2004, eight patients (0.5%) had a further operation for persistent or progressive ulnar neuropathy. At a mean follow-up of 9.2 years (3.1 to 21.7) six were clinically improved and satisfied with their outcome, although, only four had complete recovery. When transposition was performed on a previously untransposed nerve the rate of recovery was 75%, but this was reduced to 25% if the nerve had been transposed at the time of the replacement.

Aims. Reconstruction after osteoarticular resection of the proximal ulna for tumours is technically difficult and little has been written about the options that are available. We report a series of four patients who underwent radial neck to humeral trochlea transposition arthroplasty following proximal ulnar osteoarticular resection. Methods. Between July 2020 and July 2022, four patients with primary bone tumours of the ulna underwent radial neck to humeral trochlea transposition arthroplasty. Their mean age was 28 years (12 to 41). The functional outcome was assessed using the range of motion (ROM) of the elbow, rotation of the forearm and stability of the elbow, the Musculoskeletal Tumor Society score (MSTS), and the nine-item abbreviated version of the Disabilities of the Arm, Shoulder and Hand questionnaire (QuickDASH-9) score. Results. All patients were available for follow-up at a mean of 33 months (25 to 43) and were disease-free. The mean flexion arc was 0° to 105°. Three patients had complications. One had neuropraxia of the ulnar nerve. The symptoms resolved after three months. In one patient, the screw used for fixation of the triceps tendon became exposed and was removed, six months postoperatively. One patient with wound dehiscence required a local flap for soft-tissue cover, four months postoperatively. At a mean follow-up of 33 months (25 to 43), the mean flexion arc was 0° to 105°. All patients had full supination (85°) but none had any pronation. The mean MSTS score was 23.5 (23 to 24) and mean QuickDASH-9 score was 26.13 (16.5 to 35.75). Three patients had varus-valgus instability on examination, although only one had a sense of instability while working. Conclusion. Radial neck to humeral trochlea transposition offers a satisfactory and cost-effective biological reconstructive option after osteoarticular resection of the proximal ulna, in the short term. It provides good elbow function and, being a biological reconstruction option using native bone, is likely to provide long-term stability and durability. Cite this article: Bone Joint J 2024;106-B(11):1301–1305

The outcome of surgery in patients with medial epicondylitis of the elbow is less favourable in those with co-existent symptoms from the ulnar nerve. We wanted to know whether we could successfully treat such patients by using musculofascial lengthening of the flexor-pronator origin with simultaneous deep transposition of the ulnar nerve. We retrospectively reviewed 19 patients who were treated in this way. Seven had grade I and 12 had grade IIa ulnar neuropathy. At a mean follow-up of 38 months (24 to 48), the mean visual analogue scale pain scores improved from 3.7 to 0.3 at rest, from 6.6 to 2.1 with activities of daily living, and from 7.9 to 2.3 at work or sports, and the mean disabilities of the arm, shoulder and hand scores improved from 42.2 to 23.5. These results suggest that this technique can be effective in treating patients with medial epicondylitis and coexistent ulnar nerve symptoms

We report our experience of performing an elbow hemiarthroplasty in the treatment of comminuted distal humeral fractures in the elderly patients. A cohort of 42 patients (three men and 39 women, mean age 72; 56 to 84) were reviewed at a mean of 34.3 months (24 to 61) after surgery. Functional outcome was measured with the Mayo Elbow Performance Score (MEPS) and range of movement. The disabilities of the arm, shoulder and hand questionnaire (DASH) was used as a patient rated evaluation. Complications and ulnar nerve function were recorded. Plain radiographs were obtained to assess prosthetic loosening, olecranon wear and heterotopic bone formation. The mean extension deficit was 23.5° (0° to 60°) and mean flexion was 126.8° (90° to 145°) giving a mean arc of 105.5° (60° to 145°). The mean MEPS was 90 (50 to 100) and a mean DASH score of 20 (0 to 63). Four patients had additional surgery for limited range of movement and one for partial instability. One elbow was revised due to loosening, two patients had sensory ulnar nerve symptoms, and radiographic signs of mild olecranon wear was noted in five patients. Elbow hemiarthroplasty for comminuted intra-articular distal humeral fractures produces reliable medium-term results with functional outcome and complication rates, comparable with open reduction and internal fixation and total elbow arthroplasty. Cite this article: Bone Joint J 2015;97-B:1377–84

Abstract. Nerve transfer has become a common and often effective reconstructive strategy for proximal and complex peripheral nerve injuries of the upper limb. This case-based discussion explores the principles and potential benefits of nerve transfer surgery and offers in-depth discussion of several established and valuable techniques including: motor transfer for elbow flexion after musculocutaneous nerve injury, deltoid reanimation for axillary nerve palsy, intrinsic re-innervation following proximal ulnar nerve repair, and critical sensory recovery despite non-reconstructable median nerve lesions

We assessed the long-term results of 58 Souter-Strathclyde total elbow replacements in 49 patients with rheumatoid arthritis. The mean length of follow-up was 9.5 years (0.7 to 16.7). The mean pre-operative Mayo Elbow Performance Score was 30 (15 to 80) and at final follow-up was 82 (60 to 95). A total of 13 elbows (22.4%) were revised, ten (17.2%) for aseptic loosening, one (1.7%) for instability, one (1.7%) for secondary loosening after fracture, and one elbow (1.7%) was removed because of deep infection. The Kaplan-Meier survival rate was 70% and 53% at ten and 16 years, respectively. Failure of the ulnar component was found to be the main problem in relation to the loosening. Anterior transposition of the ulnar nerve had no influence on ulnar nerve paresthaesiae in these patients

Contracture of the collateral ligaments is considered to be an important factor in post-traumatic stiffness of the elbow. We reviewed the results of isolated release of the medial collateral ligament in a series of 14 patients with post-traumatic loss of elbow flexion treated between 1998 and 2002. There were nine women and five men with a mean age of 45 years (17 to 76). They were reviewed at a mean follow-up of 25 months (9 to 48). The operation was performed through a longitudinal posteromedial incision centred over the ulnar nerve. After decompression of the ulnar nerve, release of the medial collateral ligament was done sequentially starting with the posterior bundle and the transverse component of the ligament, with measurement of the arc of movement after each step. If full flexion was not achieved the posterior half of the anterior bundle of the medial collateral ligament was released. At the latest follow-up, the mean flexion of the elbow improved significantly from 96° (85° to 115°) pre-operatively to 130° (110° to 150°) at final follow-up (p = 0.001). The mean extension improved significantly from 43° (5° to 90°) pre-operatively to 22° (5° to 40°) at final follow-up (p = 0.003). There was a significant improvement in the functional outcome. The mean Broberg and Morrey score increased from a mean of 54 points (29.5 to 85) pre-operatively to 87 points (57 to 99) at final follow-up (p < 0.001). All the patients had normal elbow stability. Our results indicate that partial surgical release of the medial collateral ligament is associated with improved range of movement of the elbow in patients with post-traumatic stiffness, but was less effective in controlling pain

Locognosia, the ability to localise touch, is one aspect of tactile spatial discrimination which relies on the integrity of peripheral end-organs as well as the somatosensory representation of the surface of the body in the brain. The test presented here is a standardised assessment which uses a protocol for testing locognosia in the zones of the hand supplied by the median and/or ulnar nerves. The test-retest reliability and discriminant validity were investigated in 39 patients with injuries to the median or ulnar nerve. Intraclass correlation coefficients were used to calculate the test-retest reliability. Discriminant validity was assessed by comparing the injured with the unaffected hand. Excellent test-retest reliability was demonstrated for the injuries to the median (intraclass correlation coefficient 0.924, 95% confidence interval 0.848 to 1.00) and the ulnar nerves (intraclass correlation coefficient 0.859, 95% confidence interval 0.693 to 1.00). The magnitude of the difference in scores between affected and unaffected hands showed good discriminant validity. For injuries to the median nerve the mean difference was 11.1 points (1 to 33; . sd. 7.4), which was statistically significant (p < 0.0001, paired t-test) and for those of the ulnar nerve it was 4.75 points (1 to 13.5; . sd. 3.16), which was also statistically significant (paired t-test, p < 0.0001). The locognosia test has excellent test-retest reliability, is a valid test of tactile spatial discrimination and should be included in the evaluation of outcome after injury to peripheral nerves

The anatomy of the cubital tunnel and its relationship to ulnar nerve compression is not well documented. In 27 cadaver elbows the proximal edge of the roof of the cubital tunnel was formed by a fibrous band that we call the cubital tunnel retinaculum (CTR). The band is about 4 mm wide, extending from the medial epicondyle to the olecranon, and perpendicular to the flexor carpi ulnaris aponeurosis. Variations in the CTR were classified into four types. In type 0 (n = 1) the CTR was absent. In type Ia (n = 17), the retinaculum was lax in extension and taut in full flexion. In type Ib (n = 6) it was tight in positions short of full flexion (90 degrees to 120 degrees). In type II (n = 3) it was replaced by a muscle, the anconeus epitrochlearis. The CTR appears to be a remnant of the anconeus epitrochlearis muscle and its function is to hold the ulnar nerve in position. Variations in the anatomy of the CTR may explain certain types of ulnar neuropathy. Its absence (type 0 CTR) permits ulnar nerve displacement. Type Ia is normal and does not cause ulnar neuropathy. Type Ib can cause dynamic nerve compression with elbow flexion. Type II may be associated with static compression due to the bulk of the anconeus epitrochlearis muscle

Aims. We present the clinical and radiographic outcome of 81 children with Gartland type I to III supracondylar humeral fractures at a minimum follow-up of ten years (mean 12.1 years; 10.3 to 16.1) following injury. Patients and Methods. The clinical and functional outcomes are compared with normal age- and gender-matched individuals. The population-based study setting was first identified from the institutional registries; the rate of participation was 76%. Controls were randomly selected from Finnish National Population Registry. Results. According to Flynn's criteria, most fractures (75.3%) resulted in a satisfactory (“good or excellent”) outcome. Satisfactory recovery was achieved in 75.0% of type I fractures treated by closed splinting (p = 0.013). Type II fractures were associated with both satisfactory (57.7%) and unsatisfactory (42.3%) results, regardless of the type of treatment, although the numbers were small in the sub groups. Most type III fractures were treated operatively, and most (76%) had a satisfactory outcome according to Flynn’s criteria (p = 0.015). Compared with none among the normal subjects, flexion of the elbow was reduced by >  10° at long-term follow-up in 20 cases (24.7%, p < 0.001) and 9 (11.1%) had a reduced flexion of > 15° (p = 0.004). In patients who had sustained a type III fracture, the carrying angle was decreased by 35.7% (from 9.8° to 6.3°; p = 0.048). All patients achieved an excellent Mayo Elbow Performance Score (mean 96.4 points). Conclusion. The long-term outcome of extension-type supracondylar humeral fractures is generally good, but not exclusively benign, with the potential for long-term pain and ulnar nerve sensitivity, and a decrease in grip strength and range of movement in type II and type III fractures. Bony remodelling cannot be relied upon to correct any residual deformity. In particular, type II fractures have impaired long-term recovery and justify individual consideration in their treatment. Cite this article: Bone Joint J 2016;98-B:1410–17

Between 1998 and 2002, 37 neuropathies in 32 patients with a displaced supracondylar fracture of the humerus who were referred to a nerve injury unit were identified. There were 19 boys and 13 girls with a mean age of 7.9 years (3.6 to 11.3). A retrospective review of these injuries was performed. The ulnar nerve was injured in 19, the median nerve in ten and the radial nerve in eight cases. Fourteen neuropathies were noted at the initial presentation and 23 were diagnosed after treatment of the fracture. After referral, exploration of the nerve was planned for 13 patients. Surgery was later cancelled in three because of clinical recovery. Six patients underwent neurolysis alone. Excision of neuroma and nerve grafting were performed in four. At follow-up, 26 patients had an excellent, five a good and one a fair outcome

Aims. We aimed to identify the pattern of nerve injury associated with paediatric supracondylar fractures of the humerus. Patients and Methods. Over a 17 year period, between 1996 and 2012, 166 children were referred to our specialist peripheral nerve injury unit. From examination of the medical records and radiographs were recorded the nature of the fracture, associated vascular and neurological injury, treatment provided and clinical course. Results. Of the 166 patients (111 male, 55 female; mean age at time of injury was seven years (standard deviation 2.2)), 26 (15.7%) had neurological dysfunction in two or more nerves. The injury pattern in the 196 affected nerves showed that the most commonly affected nerve was the ulnar nerve (43.4%), followed by the median (36.7%) and radial (19.9%) nerves. A non-degenerative injury was seen in 27.5%, whilst 67.9% were degenerative in nature. Surgical exploration of the nerves was undertaken in 94 (56.6%) children. The mean follow-up time was 12.8 months and 156 (94%) patients had an excellent or good clinical outcome according to the grading of Birch, Bonney and Parry. Conclusion. Following paediatric supracondylar fractures we recommend prompt referral to a specialist unit in the presence of complete nerve palsy, a positive Tinel’s sign, neuropathic pain or vascular compromise, for consideration of nerve exploration. . Take home message: When managed appropriately, nerve recovery and clinical outcomes for this paediatric population are extremely favourable. Cite this article: Bone Joint J 2016;98-B:851–6

In children cubitus varus is common after malunion of a supracondylar fracture of the humerus. Later problems such as tardy ulnar nerve palsy, snapping of the lateral triceps tendon or ulnar nerve and posterolateral rotatory instability are well documented. We present a case of anteromedial dislocation of the entire triceps tendon with loss of extensor power and describe the method of treatment

We reviewed 101 patients with injuries of the terminal branches of the infraclavicular brachial plexus sustained between 1997 and 2009. Four patterns of injury were identified: 1) anterior glenohumeral dislocation (n = 55), in which the axillary and ulnar nerves were most commonly injured, but the axillary nerve was ruptured in only two patients (3.6%); 2) axillary nerve injury, with or without injury to other nerves, in the absence of dislocation of the shoulder (n = 20): these had a similar pattern of nerve involvement to those with a known dislocation, but the axillary nerve was ruptured in 14 patients (70%); 3) displaced proximal humeral fracture (n = 15), in which nerve injury resulted from medial displacement of the humeral shaft: the fracture was surgically reduced in 13 patients; and 4) hyperextension of the arm (n = 11): these were characterised by disruption of the musculocutaneous nerve. There was variable involvement of the median and radial nerves with the ulnar nerve being least affected. Surgical intervention is not needed in most cases of infraclavicular injury associated with dislocation of the shoulder. Early exploration of the nerves should be considered in patients with an axillary nerve palsy without dislocation of the shoulder and for musculocutaneous nerve palsy with median and/or radial nerve palsy. Urgent operation is needed in cases of nerve injury resulting from fracture of the humeral neck to relieve pressure on nerves

We analysed the outcome of the Coonrad-Morrey total elbow replacement used for fracture of the distal humerus in elderly patients with no evidence of inflammatory arthritis and compared the results for early versus delayed treatment. We studied a total of 32 patients with 15 in the early treatment group and 17 in the delayed treatment group. The mean follow-up was 56.1 months (18 to 88). The percentage of excellent to good results based on the Mayo elbow performance score was not significantly different, 84% in the early group and 79% in the delayed group. Subjective satisfaction was 92% in both the groups. One patient in the early group developed chronic regional pain syndrome and another type 4 aseptic loosening. Two elbows in the early group also showed type 1 radiological loosening. Two patients in the delayed group had an infection, two an ulnar nerve palsy, one developed heterotopic ossification and one type 4 aseptic loosening. Two elbows in this group also showed type 1 radiological loosening. The Kaplan-Meier survivorship analysis for the early and delayed treatment groups was 93% at 88 months and 76% at 84 months, respectively. No significant difference was found between the two groups

Cubitus varus and valgus are the most common complications of supracondylar and lateral condylar fractures. Various combinations of osteotomy and fixation have been described to correct these deformities but each is associated with significant complications. In this study, we used distraction osteogenesis and Ilizarov frame fixation to treat 24 elbows in 23 patients with cubitus varus or valgus. Their clinical outcome was evaluated using the protocol of Bellemore et al. The mean time to follow-up was 18.3 months (10 to 36) and the mean time to frame removal was 13.5 weeks (8 to 20). The mean carrying angle was corrected from −18.7° (−10° to −30°) to 6.1° (2° to 10°) in patients with cubitus varus and from 36.5° (25° to 45°) to 9.4° (4° to 15°) in patients with cubitus valgus. There were 18 excellent and six good results. The Ilizarov method with gradual distraction is a safe, stable, adjustable and versatile method of treating deformities at the elbow without the problems of an unsightly scar or limited range of movement, and gives a good clinical and radiological outcome. Tardy ulnar nerve palsy should be treated first by anterior transposition

Between 1993 and 2002, 58 GSB III total elbow replacements were implanted in 45 patients with rheumatoid arthritis by the same surgeon. At the most recent follow-up, five patients had died (five elbows) and six (nine elbows) had been lost to follow-up, leaving 44 total elbow replacements in 34 patients available for clinical and radiological review at a mean follow-up of 74 months (25 to 143). There were 26 women and eight men with a mean age at operation of 55.7 years (24 to 77). At the latest follow-up, 31 excellent (70%), six good (14%), three fair (7%) and four poor (9%) results were noted according to the Mayo elbow performance score. Five humeral (11%) and one ulnar (2%) component were loose according to radiological criteria (type III or type IV). Of the 44 prostheses, two (5%) had been revised, one for type-IV humeral loosening after follow-up for ten years and one for fracture of the ulnar component. Seven elbows had post-operative dysfunction of the ulnar nerve, which was transient in five and permanent in two. Despite an increased incidence of loosening with time, the GSB III prosthesis has given favourable mid-term results in patients with rheumatoid arthritis

Six children with entrapment of the medial epicondyle in the elbow after closed reduction of a posterior dislocation were seen an average of 14 weeks after injury. The elbows were painful and the average range of flexion was 22 degrees. Two children had ulnar nerve involvement which recovered after operation. The epicondyle was removed from the joint and either reattached to the humerus or excised, and the muscles reattached. Two children had anterior transposition of the ulnar nerve, one for pre-operative hyperaesthesia, and the other to relieve tension on the nerve. At follow-up, at an average of 15 months after operation, flexion had increased fivefold, none of the children had pain and all were leading normal lives

We operated on 16 patients for ulnar neuropathy associated with osteoarthritis of the elbow. They were all male manual workers, with an average age of 51 years at the time of surgery. The severity of the symptoms was McGowan grade 1 in five patients, grade 2 in nine and grade 3 in two. The mean follow-up was 36 months. The operation consists of resecting the osteophytes around the postcondylar groove. The shallow and narrow cubital tunnel is made deep and wide and the ulnar nerve is replaced with its surrounding soft tissues in the enlarged groove. All patients were relieved of discomfort and all showed some improvement or full recovery of motor and sensory function. The ulnar nerve showed no evidence of irritation or adhesion. This procedure also allows early movement of the elbow after operation, because the subcutaneous tissues and muscles have not been detached

We performed ulnar nerve neurolysis and transposition during reconstructive operations on 20 consecutive patients (21 elbows) with neuropathy after the failure of primary treatment of elbow fractures. There were 11 men and nine women with a mean age of 48.3 years. Preoperatively, four elbows were in McGowan stage I, seven in stage II and ten in stage III and the mean Gabel and Amadio ulnar nerve score was 3.2. At a mean follow-up of 32.1 months (24 to 67) we performed comprehensive neurological, functional, electrophysiological and outcome assessments. Patient satisfaction was high with good pain relief and restoration of hand strength and dexterity. The mean Gabel and Amadio score had improved to 6.5, an improvement of 3.3. There were one excellent, 16 good, 2 fair and 2 poor results; both of the last were due to failure of the underlying elbow reconstruction. Even for advanced stage-II and stage-III lesions we achieved good function, return of intrinsic power, and a high rate of patient satisfaction

We describe a method for stabilising the distal radioulnar joint using a double breasted slip of extensor retinaculum. This is a retrospective series of 30 patients with a painful wrist secondary to instability of the distal radioulnar joint. The results were assessed by a modified Mayo Score. The mean follow-up was for 38.1 months (13 months to 8 years). Twelve patients had excellent, 16 good and 2 fair outcomes. One patient had experienced temporary numbness in the distribution of the dorsal branch of the ulnar nerve. The modified Mayo wrist score increased from a pre-operative mean of 23.89 (10 to 50) to a final mean of 94.4 (85 to 100). Stabilisation of the distal radioulnar joint by the method of using a double breasted slip of the extensor retinaculum gives satisfactory results. The procedure is simple and reproducible

Although supracondylar fracture is a very common elbow injury in childhood, there is no consensus on the timing of surgery, approach for open reduction and positioning of fixation wires. We report our ten-year experience between 1993 and 2003 in 291 children. Most fractures (285; 98%) were extension injuries, mainly Gartland types II (73; 25%) and III (163; 56%). Six (2%) were open fractures and a neurovascular deficit was seen in 12 (4%) patients. Of the 236 children (81%) who required an operation, 181 (77%) were taken to theatre on the day of admission. Most (177; 75%) of the operations were performed by specialist registrars. Fixation was by crossed Kirschner wires in 158 of 186 (85%) patients and open reduction was necessary in 52 (22%). A post-operative neurological deficit was seen in nine patients (4%) and three (1%) required exploration of the ulnar nerve. Only 22 (4%) patients had a long-term deformity, nine (3%) from malreduction and three (1%) because of growth arrest, but corrective surgery for functional limitation was required in only three (1%) patients

Between September 1993 and September 1996, we performed 34 Kudo 5 total elbow replacements in 31 rheumatoid patients. All 22 surviving patients were reviewed at a mean of 11.9 years (10 to 14). Their mean age was 56 years (37 to 78) at the time of operation. All had Larsen grade IV or V rheumatoid changes on X-ray. Nine (three bilateral replacements and six unilateral) had died from unrelated causes. One who had died before ten years underwent revision for dislocation. Of the 22 total elbow replacements reviewed six had required revision, four for aseptic loosening (one humeral and three ulnar) and two for infection. Post-operatively, one patient had neuropraxia of the ulnar nerve and one of the radial nerve. Two patients had valgus tilting of the ulnar component. With revision as the endpoint, the mean survival time for the prosthesis was 11.3 years (95% confidence interval (10 to 13) and the estimated survival of the prosthesis at 12 years according to Kaplan-Meier survival analysis was 74% (95% confidence interval 0.53 to 0.91). Of the 16 surviving implants, ten were free from pain, four had mild pain and two moderate. The mean arc of flexion/extension of the elbow was 106° (65° to 130°) with pronation/supination of 90° (30° to 150°) with the joint at 90° of flexion. The mean Mayo elbow performance score was 82 (60 to 100) with five excellent, ten good and one fair result. Good long-term results can be expected using the Kudo 5 total elbow replacement in patients with rheumatoid disease, with a low incidence of loosening of the components

Displaced extension supracondylar fractures of the elbow 1. One hundred and ten children were treated by reduction and stabilisation by two pins inserted laterally at an angle of 30 degrees to one another. 2. The complications before and after treatment included fifteen nerve lesions in thirteen patients. The ulnar nerve was involved on one occasion only. Solitary radial nerve injuries occurred with postero-medial displacement of the distal fragment, while median nerve and brachial artery injuries were associated with postero-lateral displacement. All the lesions recovered spontaneously. 3. There were no ischaemic complications after treatment, despite the ligation of one ruptured brachial artery. 4. The average stay in hospital was four days, compared with twenty days for thirty-two other patients treated in traction because of gross oedema. 5. Of eighty patients seen six months to five years after the fracture, seventy (or 87·5 per cent) had excellent or good results, seven patients with marked varus deformities had fair results, and two patients had poor results with very stiff elbows. Displaced flexion fractures 1. The clinical features, complications and treatment of seventeen cases are described. 2. There were no complications involving the median or radial nerves or the brachial artery, but three patients had a lesion of the ulnar nerve. 3. Nine children had closed reduction and fixation by two lateral percutaneous pins. 4. Reduction was difficult and the results poor compared with extension fractures. Closed reduction failed in one-third of the children, and the functional and cosmetic results were unsatisfactory in over half the patients reviewed

A total of 14 women and seven men with a mean age of 43 years (18 to 68) who sustained a Mason type IV fracture of the elbow, without an additional type II or III coronoid fracture, were evaluated after a mean of 21 years (14 to 46). Primary treatment included closed elbow reduction followed by immobilisation in a plaster in all cases, with an additional excision of the radial head in 11, partial resection in two and suturing of the annular ligament in two. Delayed radial head excision was performed in two patients and an ulnar nerve transposition in one. The uninjured elbows served as controls. Nine patients had no symptoms, 11 reported slight impairment, and one severe impairment of the elbow. Elbow flexion was impaired by a mean of 3° (. sd. 4) and extension by a mean of 9° (. sd. 4) (p < 0.01). None experienced chronic elbow instability or recurrent dislocation. There were more degenerative changes in the formerly injured elbows, but none had developed a reduction in joint space. We conclude that most patients with a Mason type IV fracture of the elbow report a good long-term outcome

Aims. Displaced distal radius fractures were investigated at a level 1 major trauma centre during the COVID-19 2020 lockdown due to the implementation of temporary changes in practice. The primary aim was to establish if follow-up at one week in place of the 72-hour British Orthopaedic Association Standards for Trauma & Orthopaedics (BOAST) guidance was safe following manipulation under anaesthetic. A parallel adaptation during lockdown was the non-expectation of Bier’s block. The secondary aim was to compare clinical outcomes with respect to block type. Methods. Overall, 90 patients were assessed in a cross-sectional cohort study using a mixed, retrospective-prospective approach. Consecutive sampling of 30 patients pre-lockdown (P1), 30 during lockdown (P2), and 30 during post-lockdown (P3) was applied. Type of block, operative status, follow-up, and complications were extracted. Primary endpoints were early complications (≤ one week). Secondary endpoints were later complications including malunion, delayed union or osteotomy. Results. In P1, 86.6% of patients were seen between days one to three, 26.7% in P2, and 56.7% in P3. There were no documented complications from days one to three. Operative rate was 35.5%, which did not vary significantly (p= 0.712). Primary endpoints occurred between day four to seven, and included one patient each period treated for plaster cast pain. Secondary endpoints in P1 included delayed union (one patient). During P2, this included malunion (one patient), a pressure sore (one patient) and ulnar cutaneous nerve symptoms (two patients). In P3, malunion was identified in one patient. Mean follow-up was six months (4 to 9) with union rate 96%. Change in block practice varied significantly (p =＜0.05). The risk ratio of complications using regional block (Bier’s) over haematoma block was 0.65. Conclusion. Follow-up adaptations during lockdown did not adversely affect patient outcomes. Regional anaesthesia is gold standard for manipulation of displaced distal radial fractures. Cite this article: Bone Jt Open 2021;2(5):338–343

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There are concerns regarding complications and longevity of total elbow arthroplasty (TEA) in young patients, and the few previous publications are mainly limited to reports on linked elbow devices. We investigated the clinical outcome of unlinked TEA for patients aged less than 50 years with rheumatoid arthritis (RA).

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The aim of this study is to report the implant survival and factors associated with revision of total elbow arthroplasty (TEA) using data from the Dutch national registry.

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In patients with a failed radial head arthroplasty (RHA), simple removal of the implant is an option. However, there is little information in the literature about the outcome of this procedure. The aim of this study was to review the mid-term clinical and radiological results, and the rate of complications and removal of the implant, in patients whose initial RHA was undertaken acutely for trauma involving the elbow.

Aims

The sensitivity and specificity of electrodiagnostic parameters in diagnosing carpal tunnel syndrome (CTS) have been reported differently, and this study aims to address this gap.

Periprosthetic joint infection represents a devastating complication after total elbow arthroplasty. Several measures can be implemented before, during, and after surgery to decrease infection rates, which exceed 5%. Debridement with antibiotics and implant retention has been reported to be successful in less than one-third of acute infections, but still plays a role. For elbows with well-fixed implants, staged retention seems to be equally successful as the more commonly performed two-stage reimplantation, both with a success rate of 70% to 80%. Permanent resection or even amputation are occasionally considered. Not uncommonly, a second-stage reimplantation requires complex reconstruction of the skeleton with allografts, and the extensor mechanism may also be deficient. Further developments are needed to improve our management of infection after elbow arthroplasty.

Cite this article: Bone Joint J 2024;106-B(11):1321–1326.

The December 2023 Wrist & Hand Roundup³⁶⁰ looks at: Volar locking plate for distal radius fractures with patient-reported outcomes in older adults; Total joint replacement or trapeziectomy?; Replantation better than revision amputation in traumatic amputation?; What factors are associated with revision cubital tunnel release within three years?; Use of nerve conduction studies in carpal tunnel syndrome; Surgical site infection following surgery for hand trauma: a systematic review and meta-analysis; Association between radiological and clinical outcomes following distal radial fractures; Reducing the carbon footprint in carpal tunnel surgery inside the operating room with a lean and green model: a comparative study.

Aims

The study aimed to assess the clinical outcomes of arthroscopic debridement and partial excision in patients with traumatic central tears of the triangular fibrocartilage complex (TFCC), and to identify prognostic factors associated with unfavourable clinical outcomes.

We report two cases of vertebral osteochondroma. In one patient a solitary cervical lesion presented as entrapment neuropathy of the ulnar nerve and in the other as a thoracic tumour associated with hereditary multiple exostoses producing paraplegia. We highlight the importance of an adequate preoperative evaluation in such patients

Aims

Multiple secondary surgical procedures of the shoulder, such as soft-tissue releases, tendon transfers, and osteotomies, are described in brachial plexus birth palsy (BPBP) patients. The long-term functional outcomes of these procedures described in the literature are inconclusive. We aimed to analyze the literature looking for a consensus on treatment options.

We describe a posterior approach to the elbow which combines the advantages of both splitting and reflecting the triceps. It gives protection to the ulnar nerve and its blood supply during the operation while providing excellent exposure of the distal humerus. During closure, the triceps muscle can be tensioned, thereby improving stability of the elbow. This approach has particular relevance to unlinked total elbow arthroplasty allowing early rehabilitation of the joint

1. Two cases of fracture-dislocation of the trochlea are described. One case was complicated by complete ulnar nerve palsy. 2. The injury is caused by direct force applied to the point of the elbow, or it may be associated with posterior dislocation of the joint. 3. Open reduction is recommended, the fragment being held in position by soft-tissue sutures alone. 4. Four other cases mentioned in the literature are reviewed

One pattern of injury to the brachial plexus shows recovery of the fifth and sixth cervical nerves but little else. These patients have useful shoulders and functional elbow flexion, but elbow and wrist extension is weak or absent. Their hand function is negligible. We restored hand function in three such patients using free functioning muscle transfer for finger flexion and transfer of the sensory rami of the intercostal nerve to the ulnar nerve for sensation. Supplementary operations to restore elbow and wrist extension were necessary in one patient

We carried out a prospective randomised study comparing medial epicondylectomy with anterior transposition for the treatment of ulnar neuropathy at the elbow. The mean follow-up period was 4.5 years and we assessed the patients neurologically and orthopaedically. Neither procedure appeared to have a significant effect on elbow function. Our study showed better results after medial epicondylectomy; in particular patient satisfaction was higher than after ulnar nerve transposition. There were no significant differences in motor power or nerve-conduction rates and sensory fibres appeared to be more vulnerable to devascularisation

1. Synovectomy of the elbow affected by rheumatoid arthritis is a worthwhile procedure even in the presence of advanced radiological changes. 2. Relief of pain is good (93 per cent) and movement is retained (87 per cent). 3. Although the follow-up in this series was short, averaging nineteen months, the results seem to be maintained. 4. Good access to the joint may be had through medial and lateral incisions, and division of the olecranon is unnecessary. A lateral incision alone is not recommended. 5. The ulnar nerve should be preserved during dissection. Anterior transposition is needed only if there are neurological symptoms before operation

Symptoms due to a supracondylar spur of the humerus, although rare, are common enough to make it the subject of routine examination of a patient with pain and disturbance of sensibility of the hand. It can mimic the carpal tunnel syndrome; it may produce ulnar nerve symptoms. Irritation or compression of either the brachial artery or, if there is a high division of it, the ulnar artery, may cause episodes of ischaemic pain in the forearm. The clinical features of a supracondylar spur causing symptoms are: symptoms of median nerve compression; forearm claudication; a palpable spur about two inches above the medial epicondyle; and disappearance of the radial or ulnar pulse on full extension and supination of the forearm

A total of 33 children were treated for acute traumatic dislocation of the elbow between 1994 and 2002; 30 dislocations were posterior and three anterior. Eight children had a pure dislocation and 25 had an associated fracture of the elbow. Two had compound injuries. Two children had injury to the ulnar nerve, one to the radial nerve and one to the median nerve together with injury to the brachial artery. Twenty required open reduction. Complications included pseudarthrosis of the medial epicondyle in one child and loss of flexion and rotation of between 10° and 30° in ten others. Meticulous clinical and radiological assessment is mandatory in children with dislocation of the elbow to exclude associated injuries. The results were excellent to good in 22 patients, fair in ten and poor in one

We have carried out a retrospective review of 11 Souter-Strathclyde primary total elbow arthroplasties in ten patients with osteoarthritis, over a period of nine years. The diagnosis was primary osteoarthritis in nine elbows and post-traumatic arthritis in two. The mean follow-up was 68 months (15 to 117). Although no patient was symptomatic, radiological review revealed evidence of loosening affecting three humeral and two ulnar components, one of which subsequently failed and was revised at 97 months. There were no dislocations, deep infections or mechanical failures. Complications included two superficial wound infections and two neurapraxias of the ulnar nerve which resolved. This study shows that the unlinked Souter-Strathclyde total elbow arthroplasty can be considered for patients with osteoarthritis and gives good symptomatic relief and improvement in function

We treated 49 patients at an average age of 80 years (75 to 90) with distal mostly intraarticular humeral fractures by open reduction. There were 8 class A, 13 class B and 28 class C fractures on Muller's classification. The patients were reviewed at a postoperative average of 18 months. The patients' assessment of the result was very good in 31%, good in 49%, fair in 15% and poor in 5%. The flexion-extension range was very good in 41%, good in 44% and fair in 15%. The incidence of implant failure, pseudarthrosis of the olecranon osteotomy and ulnar nerve lesion was no higher in these elderly patients than in younger patients. Old age is not a contraindication to open reduction and internal fixation; it is important to restore full function

Two cases of unusual snapping at the elbow are described. In both, the medial head of the triceps was found to be separated from the main muscle belly. During flexion of the elbow, the medial head dislocated over the medial epicondyle, producing a characteristic snapping phenomenon. Both cases were of long standing and had been asymptomatic for years. The first clinical symptoms were those of an ulnar neuropathy. In order to restore the normal position of the medial head of the triceps, its tendon was detached from the olecranon, passed under the central tendon and interlaced to it. The ulnar nerve was left in the epicondylar groove in one case and transposed anteriorly in the other. At the end of the procedure flexion of the elbow was unobstructed and the snapping phenomenon had disappeared

From an anatomical study and clinical review of fractures of the lateral humeral condyle in children, the following conclusions are drawn. The mechanism of injury is a violent varus force with the elbow in extension, the condyle being avulsed. by the lateral ligament and the extensor muscles. If the fracture is incomplete, with an intact hinge of pre-osseous cartilage medially, the fragment will not be displaced. If the fracture is complete the fragment may be displaced, and open reduction with internal fixation is mandatory. The results of open reduction more than three weeks after the fracture are no better than those of no treatment at all, and may kill the lateral condylar fragment by damaging its blood supply. The major problem of a neglected fracture is tardy ulnar nerve palsy; to avoid this, immediate anterior transposition of the nerve is recommended, operation for the fracture itself being of no benefit

1. Evidence is given of successful direct implantation of a motor branch of the ulnar nerve to the denervated flexor carpi radialis muscle in the dog with the formation of new motor end-plates. 2. A method is described of measuring four muscle parameters-volume, myoneural delay, rate of contraction and greatest developed tension-which allows a quantitative comparison of the muscle in its original state with that after it has been changed experimentally. 3. By use of this method it was found that the direct implantation of a new motor nerve restored the denervated muscle volume in twenty weeks and that at least 50 per cent of its original strength was recovered. 4. The success of motor nerve transplantation is likely to be influenced by the length of time lapsing between denervation and implantation, by the number of functioning motor fibres in the transplanted nerve, and by the amount of recovery achieved in the afferent and spindle efferent systems

1 . Voluntary activity of any given muscle in the hand is not an absolute indication of the state of the nerve which usually supplies it. 2. Significant variations in the standard pattern of innervation have been found in 20 per cent of 226 cases studied. 3. The pattern of innervation described in standard text-books occurred in only 33 per cent. of cases. 4. A striking variation is the supply of every thenar muscle by the ulnar nerve. In other cases the first dorsal interosseous muscle may be supplied by the median nerve. 5. In order to arrive at an accurate diagnosis when anomalous innervation is suspected, nerve blocks at appropriate levels are required. 6. Great care must be taken during operations to avoid damage to connections between the ulnar and the median nerves, especially in patients with anomalous innervation of the hand muscles

A mucoid pseudocyst of a peripheral nerve is a rare and benign tumour of controversial origin. We have reviewed ten patients with a mean follow-up of 3.2 years. The tumour affected the common peroneal nerve in eight and the ulnar nerve in two. The mean time between the onset of symptoms and diagnosis was 7.4 months (1.2 months to 2 years). On examination, there was pain in eight patients and swelling in seven. Motor deficit in the corresponding nerve territory was found in all. The diagnosis was usually confirmed by MRI. Treatment was always surgical. All the patients recovered, with a mean time to neurological recovery of 10.75 months. Recurrence was seen in only one patient and was treated successfully by further surgery. Our results are similar to those reported by other authors. A successful surgical outcome depends on early diagnosis before neurological damage has occurred

The August 2023 Wrist & Hand Roundup360 looks at: Complications and patient-reported outcomes after trapeziectomy with a Weilby sling: a cohort study; Swelling, stiffness, and dysfunction following proximal interphalangeal joint sprains; Utility of preoperative MRI for assessing proximal fragment vascularity in scaphoid nonunion; Complications and outcomes of operative treatment for acute perilunate injuries: a systematic review; The position of the median nerve in relation to the palmaris longus tendon at the wrist: a study of 784 MR images; Basal fractures of the ulnar styloid? A randomized controlled trial; Proximal row carpectomy versus four-corner arthrodesis in SLAC and SNAC wrist; Managing cold intolerance after hand injury: a systematic review.

After dislocation of the elbow with avulsion of the medial epicondyle, the management of the latter is controversial. Of 28 children followed up after initial closed reduction of the elbow, 19 had a satisfactory closed reduction of the epicondyle and were treated in plaster. At follow-up, 11 children had a normal elbow and eight had lost an average of 15 degrees of flexion. Nine children had had open reduction and internal fixation of the fragment, one for an open injury, three for displacement of the epicondyle and six for intra-articular entrapment of the fragment. Five of these children had ulnar nerve contusion or compression, four requiring anterior transposition of the nerve. At review, only three had normal elbows and six had lost an average of 37 degrees of flexion. We agree with other authors that surgery is indicated only for children in whom the epicondyle is trapped in the joint or is significantly displaced after closed reduction

Aims

The ulna is an extremely rare location for primary bone tumours of the elbow in paediatrics. Although several reconstruction options are available, the optimal reconstruction method is still unknown due to the rarity of proximal ulna tumours. In this study, we report the outcomes of osteoarticular ulna allograft for the reconstruction of proximal ulna tumours.

Aims

Acute and chronic injuries of the interosseus membrane can result in longitudinal instability of the forearm. Reconstruction of the central band of the interosseus membrane can help to restore biomechanical stability. Different methods have been used to reconstruct the central band, including tendon grafts, bone-ligament-bone grafts, and synthetic grafts. This Idea, Development, Exploration, Assessment, and Long-term (IDEAL) phase 1 study aims to review the clinical results of reconstruction using a synthetic braided cross-linked graft secured at either end with an Endobutton to restore the force balance between the bones of the forearm.

This is a retrospective study of primary repairs of flexor pollicis longus in 16 children under 15 years of age. Patients with injuries to the median or ulnar nerve at the wrist, crush injuries, skin loss or fracture were excluded. Repairs were carried out within 24 hours using a modified Kessler technique. The mean follow-up was for two years. The final results were evaluated using the criteria of Buck-Gramko and Tubiana. They were good or excellent in all except one patient who had a secondary tendon rupture. When compared with the non-injured thumb, however, there was a significant decrease in active interphalangeal flexion (> 30°) in one-third of cases. A new method of assessment is proposed for the recovery of function of the flexor pollicis tendon which is more suitable for children. Postoperative immobilisation using a short splint had a negative effect on outcome. The zone of injury, an early mobilisation programme or concurrent injury to the digital nerve had no significant effect on the final result

Aims

The aim of this study was to investigate the outcome of periprosthetic fractures of the humerus and to assess the uniformity of the classifications used for these fractures (including those around elbow and/or shoulder arthroplasties) by performing a systematic review of the literature.

We reviewed the results of 13 adults of secondary reconstruction of malunited and ununited intraarticular distal humeral fractures. Their average age was 39.7 years, and preoperatively all had pain, loss of motion and functional disability; the average arc of motion was only 43 degrees and the average flexion contracture was 45 degrees. Nine patients had ulnar neuropathy. Elbow reconstruction, at an average of 13.4 months after the original injury, included osteotomy for malunion or debridement for nonunion, realignment with stable fixation and autogenous bone grafts, anterior and posterior capsulectomy and ulnar neurolysis. The elbows were mobilised 24 hours postoperatively. There were no early complications and all nonunions and intra-articular osteotomies healed. After a mean follow-up of 25 months, the average arc of motion was 97 degrees with no progressive radiographic degeneration. Ulnar nerve function improved in all cases and clinical assessment using the Morrey score showed two excellent, eight good and three fair results. Reconstruction of intra-articular malunion and nonunion of the distal humerus in young active adults is technically challenging, but can improve function by restoring the intrinsic anatomy of the elbow

Between 1986 and 1994, 13 patients with mobile painful arthritic elbows were treated by distraction interposition arthroplasty using fascia lata. The mean period of follow-up was 63 months. An elbow distractor/fixator was applied for three to four weeks to separate the articular surfaces and to protect the fascial graft. Nine of the 13 patients (69%) had satisfactory relief from pain; eight (62%) had an excellent or good result by the objective criteria of the Mayo Elbow Performance score. Four have required revision to total elbow arthroplasty at a mean of 30 months with good results to date. Instability of the elbow, both before and after surgery, was found to be associated with unsatisfactory results. The rate of success when the procedure was performed for inflammatory arthritis was similar to that for post-traumatic arthritis, about 67%. Eight complications occurred in six patients, all in the group with post-traumatic arthritis. Two of these required further surgical procedures such as transposition of the ulnar nerve or repair of hernia of the fascia lata. Although less reliable than prosthetic replacement, distraction interposition arthroplasty is a useful option in the treatment of young, high-demand patients with arthritis of the elbow. It is rarely indicated in the presence of generalised inflammatory arthritis, but may be of value in those patients in whom the disease is limited primarily to the elbow

Between 1993 and 1996, we undertook 35 Kudo 5 total elbow replacements in a consecutive series of 31 rheumatoid patients. A total of 25 patients (29 procedures) was evaluated at a mean follow-up of six years (5 to 7.5) using the Mayo Clinic performance index. In addition, all patients were assessed for loosening using standard anteroposterior and lateral radiographs. At review, 19 elbows (65%) had either no pain or mild pain, ten (35%) had moderate pain and none had severe pain. The mean arc of flexion/extension was 94° (35 to 130) and supination/pronation was 128° (30 to 165). A fracture of the medial epicondyle occurred during surgery in one patient. This was successfully treated with a single AO screw and a standard Kudo 5 implant was inserted. Postoperatively, there were no infections. One patient had a dislocation which was treated by closed reduction and five had neurapraxia of the ulnar nerve. Radiologically, there was no evidence of loosening of the humeral component, but two ulnar components had progressive radiolucent lines suggestive of loosening. Two other ulnar components had incomplete and non-progressive radiolucent lines. With definite radiological loosening as the endpoint, the probability of survival of the Kudo 5 prosthesis at five years using the Kaplan-Meier method was 89%

Aims

Arthroplasties of the elbow, including total elbow arthroplasty, radial head arthroplasty, distal humeral hemiarthroplasty, and radiocapitellar arthroplasty, are rarely undertaken. This scoping review aims to outline the current research in this area to inform the development of future research.

1 . In the common type of Volkmann's ischaemic contracture affecting the forearm flexors, the infarct takes the form of an ellipsoid with its axis in the line of the anterior interosseous artery and with its central point a little above the middle of the forearm. The greatest damage is at the centre and usually falls most heavily on flexor digitorum profundus and flexor pollicis longus, which are often necrotic. Those muscles more superficially placed, and sometimes the deep extensors, are more likely to exhibit fibrosis. 2. The median nerve runs near the centre of the ellipsoid and may exhibit profound ischaemia. The ulnar nerve, lying at the edge of the ischaemic zone, tends to be less severely affected. 3. The treatment for this condition is excision of all tissues irreparably damaged by ischaemia. If this operation is performed within twelve months from the time of injury, correction of the contracture should be almost complete. The tendons of shortened but active muscles are lengthened or transplanted. 4. After such excision it is possible to carry out reconstructive procedures commonly used in the surgery of lower motor neurone disorders and of trauma. A wide variety of tendon transplantations is available. The median nerve may be repaired either by a free graft or, in cases where both nerves have been extensively damaged by ischaemia, by an ulnar to median nerve-pedicle graft

We studied a consecutive series of 58 patients with penetrating missile injuries of the brachial plexus to establish the indications for exploration and review the results of operation. At a mean of 17 weeks after the initial injury, 51 patients were operated on for known or suspected vascular injury (16), severe persistent pain (35) or complete loss of function in the distribution of one or more elements of the brachial plexus (51). Repair of the nerve and vascular lesions abolished, or significantly relieved, severe pain in 33 patients (94%). Of the 36 patients who underwent nerve graft of one or more elements of the plexus, good or useful results were obtained in 26 (72%). Poor results were observed after repairs of the medial cord and ulnar nerve, and in patients with associated injury of the spinal cord. Neurolysis of lesions in continuity produced good or useful results in 21 of 23 patients (91%). We consider that a vigorous approach is justified in the treatment of penetrating missile injury of the brachial plexus. Primary intervention is mandatory when there is evidence of a vascular lesion. Worthwhile results can be achieved with early secondary intervention in patients with debilitating pain, failure to progress and progression of the lesion while under observation. There is cause for optimism in nerve repair, particularly of the roots C5, C6 and C7 and of the lateral and posterior cords, but the prognosis for complete lesions of the plexus associated with damage to the cervical spinal cord is particularly poor

We report the results of a series of 59 unconstrained total arthroplasties of the elbow after a mean follow-up of 6.5 years (4 to 10). All the patients had rheumatoid arthritis. The indication for surgery was pain in all but one. Outcome was assessed by the Mayo Elbow Performance Index (MEPI). Of the 59 arthroplasties, two were lost to follow-up. Ten patients died, but as two of their arthroplasties were failures we included them in the results. The outcome in the remaining 49 was excellent in 26 (53%), good in 15 (31%), fair in one (2%) and poor or a failure in seven (14%). There was an improvement in the pain score (p < 0.001), movement (p < 0.001) and function (p < 0.001). Two patients developed instability, but neither required further surgery. There was a mean increase of 21° in flexion and of 7° in extension. The overall rate of complications was 33.9%. Lesions of the ulnar nerve, one of which did not recover, occurred in four patients, deep infection in two and stiffness in five. The rates of complications were similar to those in recent reports of other elbow arthroplasties. We carried out a radiological analysis of 39 arthroplasties which showed radiolucent lines around the humeral component in 22 and the ulnar component in 15. There were lower scores on the MEPI for those with radiolucent lines around the humeral component

Aims

The aim of this study was to develop and internally validate a prognostic nomogram to predict the probability of gaining a functional range of motion (ROM ≥ 120°) after open arthrolysis of the elbow in patients with post-traumatic stiffness of the elbow.

Aims

The aim of this study was to report the incidence of implant-related complications, further operations, and their influence on the outcome in a series of patients who underwent primary reverse total shoulder arthroplasty (RTSA).

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.

Upper limb amputations, ranging from transhumeral to partial hand, can be devastating for patients, their families, and society. Modern paradigm shifts have focused on reconstructive options after upper extremity limb loss, rather than considering the amputation an ablative procedure. Surgical advancements such as targeted muscle reinnervation and regenerative peripheral nerve interface, in combination with technological development of modern prosthetics, have expanded options for patients after amputation. In the near future, advances such as osseointegration, implantable myoelectric sensors, and implantable nerve cuffs may become more widely used and may expand the options for prosthetic integration, myoelectric signal detection, and restoration of sensation. This review summarizes the current advancements in surgical techniques and prosthetics for upper limb amputees.

Cite this article: Bone Joint J 2021;103-B(3):430–439.

1. The amount of orthopaedic surgery which is possible in patients with leprosy is immense. It is likely to decline with improved medical care as deformity rarely begins after the start of medical treatment. In spite of prolonged chemotherapy, skin smears often remain positive for more than five years and lifelong treatment may be necessary. 2. In Hong Kong the disease affects mainly those in the best working years of their lives and at an age when they should be best able to understand the benefits that treatment confers. Education of the public must be one of the main points of disease control. This education should extend to enable patients with anaesthetic extremities to learn the limitations that the disease places upon their activities. Thus they will be less liable to injure themselves and better able to prevent minor injuries from becoming serious. Ulceration only occurs in areas lacking protective sensation but, although bilateral anaesthesia is common, bilateral ulceration is not often seen. 3. In patients with diminished sensation or with paralysed muscle groups there is usually enlargement of the nerves but this may be difficult to detect. 4. Clawing of the fingers is best treated by standard surgical procedures but opposition transplant in the combined median and ulnar nerve paralysis of leprosy is less satisfactory. Any transplant must prevent hyperextension at the metacarpo-phalangeal joint and this is best done by providing a double insertion for the transplant. If the soft tissues between the first and second metacarpals are contracted it is better to perform osteotomy of the base of the first metacarpal bone rather than to perform the standard operation of soft-tissue release and skin grafting. 5. The value of tibialis posterior transplantation in drop-foot has been confirmed. 6. The problem of fitting an artificial limb to an anaesthetic stump has not been solved. It was often found that ulcers of the stump occurred even with well-fitting sockets and cooperative patients. If amputation above the foot is necessary it is usually wiser to try a through-knee amputation. 7. Return of power or sensation after the start of medical treatment is unusual but it is also unusual for these symptoms to be noted for the first time when the patient is taking sulphones. It would be worth while investigating the effects of decompression of the median nerve at the level of the wrist by dividing the carpal ligament in those patients developing symptoms and signs of impaired median nerve function. Nerve decompression should also be performed in patients showing tender, swollen nerves in acute lepromatous reactions where steroid therapy fails to bring improved function within six hours. 8. It is essential that surgical methods of limiting disability such as incision, decapsulation or transposition of nerves, which have received favourable comment in the past, should be repeated in a controlled series. Series, so far, have lacked reference to the natural history of the condition under medical treatment alone and have often lacked adequate follow-up. 9. Acute lepromatous reactions in the foot often subside with little bone destruction if the patient is rested in bed with the foot immobilised in plaster. If deformity occurs it may be corrected by triple arthrodesis or pantalar arthrodesis. Shortening of the limb may be necessary to prevent stretching the posterior tibial artery. The use of staples at operation greatly eases the task of maintaining the position. Surgery is not always contra-indicated in the presence of long-standing ulceration

Aims

Studies on long-term patient-reported outcomes after open surgery for triangular fibrocartilage complex (TFCC) are scarce. Surgeons and patients would benefit from self-reported outcome data on pain, function, complications, and satisfaction after this surgery to enhance shared decision-making. The aim of this study is to determine the long-term outcome of adults who had open surgery for the TFCC.

Aims

The aim of this study was to assess and compare active rotation of the forearm in normal subjects after the application of a short-arm cast (SAC) in the semisupination position and a long-arm cast (LAC) in the neutral position. A clinical study was also conducted to compare the functional outcomes of using a SAC in the semisupination position with those of using a LAC in the neutral position in patients who underwent arthroscopic triangular fibrocartilage complex (TFCC) foveal repair.

Aims

Patients with a triangular fibrocartilage complex (TFCC) injury report ulnar-sided wrist pain and impaired function. The surgical procedure of TFCC reinsertion aims to improve function in patients with this injury in whom conservative treatment has failed. The purpose of this study was to investigate the outcomes of open TFCC reinsertion.

Introduction

In response to the COVID-19 pandemic, there was a rapidly implemented restructuring of UK healthcare services. The The Royal National Orthopaedic Hospital, Stanmore, became a central hub for the provision of trauma services for North Central/East London (NCEL) while providing a musculoskeletal tumour service for the south of England, the Midlands, and Wales and an urgent spinal service for London. This study reviews our paediatric practice over this period in order to share our experience and lessons learned. Our hospital admission pathways are described and the safety of surgical and interventional radiological procedures performed under general anaesthesia (GA) with regards to COVID-19 in a paediatric population are evaluated.