The posttraumatic stiff elbow: an update.

Posttraumatic elbow stiffness is a disabling condition that remains challenging to treat despite improvement of our understanding of the pathogenesis of posttraumatic contractures and new treatment regimens. This review provides an update and overview of the etiology of posttraumatic elbow stiffness, its classification, evaluation, nonoperative and operative treatment, and postoperative management.

Improvements in elbow motion after resection of heterotopic bone: a systematic review.

Complex elbow trauma, severe burn, or a closed head injury render patients at risk for developing heterotopic ossification around the elbow. When heterotopic ossification restricts elbow motion, some patients request surgical resection. We performed a systematic review of the literature to analyze improvement in elbow motion after resection of heterotopic ossification around the elbow.

A randomized controlled trial of nonoperative treatment versus open reduction and internal fixation for stable, displaced, partial articular fractures of the radial head: the RAMBO trial.

Background: The choice between operative or nonoperative treatment is questioned for partial articular fractures of the radial head that have at least 2 millimeters of articular step-off on at least one radiograph (defined as displaced), but less than 2 millimeter of gap between the fragments (defined as stable) and that are not associated with an elbow dislocation, interosseous ligament injury, or other fractures. These kinds of fractures are often classified as Mason type-2 fractures. Retrospective comparative studies suggest that operative treatment might be better than nonoperative treatment, but the long-term results of nonoperative treatment are very good.

Diagnostic accuracy of two-dimensional and three-dimensional imaging and modeling of radial head fractures.

Unlabelled: To tests the hypothesis that classification and characterization of fractures of the radial head is more accurate with 3D than 2D computed tomography images and radiographs, using a prospective study design with intraoperative inspection as the reference standard. Treating surgeons and first assistants completed a questionnaire assigning a fracture type according to the Broberg and Morrey modification of Mason's classification, evaluating selected fracture characteristics, and electing preferred management based upon radiographs and 2D images alone; then adding 3D-CT; then 3D printed physical models; and finally intra-operative visualization. The addition of the 3D CT and physical models improved the sensitivity for fracture line separating the entire head from the neck, comminution of the radial neck, fracture involving the articular surface, articular fracture gap greater than 2 mm, impacted fracture fragments, greater than 3 articular fragments, and articular fragments judged too small to repair.

Satisfaction with pain relief after operative treatment of an ankle fracture.

Background: American patients are prescribed more opioid pain medication than Dutch patients after operative treatment of an ankle fracture, but it is possible that pain is undertreated in Dutch patients. This study tests if there is a difference in pain and satisfaction with pain relief between Dutch and American patients after operative treatment of ankle fractures.

Methods: Thirty American and 30 Dutch patients were enrolled in a prospective comparative study prior to operative treatment of ankle fractures.

A prospective randomized controlled trial of dynamic versus static progressive elbow splinting for posttraumatic elbow stiffness.

Background: Both dynamic and static progressive (turnbuckle) splints are used to help stretch a contracted elbow capsule to regain motion after elbow trauma. There are advocates of each method, but no comparative data. This prospective randomized controlled trial tested the null hypothesis that there is no difference in improvement of motion and Disabilities of the Arm, Shoulder and Hand (DASH) scores between static progressive and dynamic splinting.

Fixation of the coronoid process in elbow fracture-dislocations.

Background: Terrible triad injuries consist of a posterior dislocation of the elbow, a coronoid fracture, and a radial head fracture. The coronoid plays a pivotal role as an anterior buttress, yet the optimal management of the coronoid fracture remains unknown. We hypothesize that suture lasso fixation of the coronoid fracture leads to fewer complications and improved outcomes compared with screw or suture anchor fixation techniques.

Long-term outcomes of fractures of both bones of the forearm.

Background: Previous studies identified limited impairment and disability several years after diaphyseal fractures of both the radius and ulna, although the relationship between impairment and disability was inconsistent. This investigation studied skeletally mature and immature patients more than ten years after injury and addressed the hypotheses that (1) objective measurements of impairment correlate with disability, (2) depression and misinterpretation of nociception correlate with disability, and (3) patients injured when skeletally mature or immature have comparable impairment and disability.

Methods: Seventy-one patients with diaphyseal fractures of the radius and ulna were evaluated at an average of twenty-one years after injury.

Health status after open elbow contracture release.

Background: Operative contracture release may improve motion of a posttraumatic stiff elbow. In this study, we tested the hypothesis that improvement in ulnohumeral motion after elbow contracture release leads to improvement in general health status and decreases upper-extremity-specific disability.

Methods: Twenty-three patients with posttraumatic loss of ≥30° of elbow flexion or extension who elected to have an open elbow capsulectomy completed the Disabilities of the Arm, Shoulder and Hand questionnaire (DASH) and the Short Form-36 (SF-36) preoperatively and at least one year postoperatively.

Resection of heterotopic ossification of the elbow: a comparison of ankylosis and partial restriction.

Purpose: This study tests the hypothesis that the results of release of elbow stiffness related to heterotopic ossification (HO) are comparable whether there is partial or complete restriction (ankylosis) of flexion and extension.

Methods: Eighteen patients who had surgical release of complete bony ankylosis between the humerus and ulna were retrospectively compared to 27 matched patients who had surgical release of partial restriction of elbow flexion and extension related to HO. Patients were evaluated a minimum of 10 months after surgery, using the Disabilities of the Arm, Shoulder, and Hand questionnaire and the Broberg and Morrey rating system.

Correlation of DASH and QuickDASH with measures of psychological distress.

Purpose: In an attempt to shorten the questionnaires given to patients in both clinical and research settings, we studied whether the correlation of commonly used psychological measures was comparable for the standard Disabilities of the Arm, Shoulder, and Hand (DASH) and the shorter QuickDASH questionnaires.

Methods: A cohort of 839 patients with carpal tunnel syndrome, trigger finger, de Quervain's disease, trapeziometacarpal arthrosis, lateral epicondylosis, or a distal radius fracture 2 weeks after surgery, who completed the DASH and 1 or more measures of psychological distress, was created from 10 databases from previously implemented studies. Correlations of the DASH and the QuickDASH with several measures of psychological factors (Center for Epidemiologic Studies Depression Scale [CES-D], Pain Catastrophizing Scale [PCS], and Pain Anxiety Symptoms Scale [PASS-40]) were calculated in both univariate and multivariable analyses.

Differences in prescription of narcotic pain medication after operative treatment of hip and ankle fractures in the United States and The Netherlands.

Background: Interactions between American and Dutch surgeons suggested differences in prescription habits for pain medication after fracture treatment.

Methods: The percentages of 190 American [100 after hip open reduction and internal fixation (ORIF) and 90 after ankle ORIF] and 116 Dutch patients (69 after hip ORIF and 47 after ankle ORIF) receiving inpatient and outpatient prescriptions for narcotics were retrospectively compared between countries, to test the hypothesis that narcotics are prescribed more frequently in the United States as compared with The Netherlands after operative fracture treatment.

Results: Among patients with hip fractures, 85% of American and 58% of Dutch patients were prescribed narcotics during hospitalization (p < 0.

The long-term outcome of open reduction and internal fixation of stable displaced isolated partial articular fractures of the radial head.

Background: Excellent long-term results have been reported for nonoperative treatment of stable isolated displaced partial articular (Mason 2) fractures of the radial head, suggesting that the role of operative treatment can be questioned. This investigation reports the long-term outcome of operatively treated Mason 2 radial head fractures.

Methods: Sixteen patients with stable displaced partial articular (Mason 2) fractures of the radial head not associated with fracture or dislocation of the proximal forearm were evaluated an average of 22 years (range, 14-30 years) after open reduction and internal fixation with screws (11 patients) or a plate and screws (5 patients).

Agreement between Initial Classification and Subsequent Reclassification of Fractures of the Distal Radius in a Prospective Cohort Study.

We tested the hypothesis that the original surgeon-investigator classification of a fracture of the distal radius in a prospective cohort study would have moderate agreement with the final classification by the team performing final analysis of the data. The initial post-injury radiographs of 621 patients with distal radius fractures from a multicenter international prospective cohort study were classified according to the Comprehensive Classification of Fractures, first by the treating surgeon-investigator and then by a research team analyzing the data. Correspondence between original and revised classification was evaluated using the Kappa statistic at the type, group and subgroup levels.

Loss of anterior translation of the distal humeral articular surface is associated with decreased elbow flexion.

Purpose: The normal anterior translation of the articular surface of the distal humerus with respect to the humeral diaphysis facilitates elbow flexion. We hypothesize that there is a correlation between anterior translation of the distal humeral articular surface and flexion after open reduction and internal fixation (ORIF) of a fracture of the distal humerus.

Methods: Two independent observers evaluated 141 lateral radiographs of patients more than 6 months after fracture of the distal humerus and 155 lateral radiographs of patients without injury of the distal humerus.

Open elbow contracture release: postoperative management with and without continuous passive motion.

Purpose: Surgical contracture release can restore motion to stiff elbows. Some authors suggest that use of continuous passive motion (CPM) in postoperative management can increase ultimate mobility. This study tests the null hypothesis that there is no difference in the arc of flexion and extension between patients who used CPM and those who did not use CPM after open elbow contracture release.

Correspondence between perceived disability and objective physical impairment after elbow trauma.

Background: Substantial differences between disability and impairment are commonplace and puzzling. Subjective (psychosocial) factors may be paramount given that pain is a more important determinant of perceived overall arm-specific disability than is objective elbow impairment. To further evaluate the relationship between impairment and disability, we tested the hypothesis that objective loss of elbow motion predicts perceived elbow-related task-specific disability better than does pain after elbow trauma.

Comparison of acute versus subacute treatment of terrible triad injuries of the elbow.

Purpose: To test the null hypothesis that there is no difference in flexion arc or Broberg and Morrey rating between patients treated within 2 weeks of the injury (acute treatment) and those treated 3 weeks or more after injury with persistent or recurrent dislocation or subluxation (subacute treatment).

Methods: The acute cohort consisted of 18 patients treated an average 6 days after injury. The radial head was replaced in 17 patients and repaired with screw in 1, the coronoid was secured with suture in all patients and with an additional screw in 2, and the lateral collateral ligament was reattached in all patients.

Long-term outcome of operatively treated fracture-dislocations of the olecranon.

Objectives: To report the long-term results of operative treatment of anterior and posterior olecranon fracture-dislocations and compare them with the results recorded fewer than 2 years after surgery.

Design: Retrospective case series with long-term evaluation.

Setting: Level I trauma center.

The posttraumatic stiff elbow: a review of the literature.

Loss of motion is a common complication of elbow trauma. Restoration of joint motion in the posttraumatic stiff elbow can be a difficult, time-consuming, and costly challenge. In this review of the literature, the biologic response to trauma and the possible etiologic events that may lead to fibrosis of the capsules and heterotopic ossification will be discussed, as well as nonsurgical and surgical management of stiffness and expected outcomes of treatment.

Comparison of elbow contracture release in elbows with and without heterotopic ossification restricting motion.

We compared 16 patients with post-traumatic heterotopic ossification (HO) restricting elbow motion (but not complete bony ankylosis) after elbow trauma with 21 patients with capsular contracture alone to test the hypothesis that HO is associated with diminished motion after release. Patients with burns or head injury were excluded. The preoperative flexion arc averaged 59 degrees in the HO cohort and 52 degrees in the capsular contracture cohort.

The anteromedial facet of the coronoid process of the ulna.

Fracture of the anteromedial facet of the coronoid process has been recognized as an important type of coronoid fracture. We performed a quantitative analysis of 21 3-dimensional computed tomography scans to evaluate the degree to which the anteromedial facet protrudes as a distinct process separate from the proximal ulnar metaphysis. The distance between the center axis of the trochlear notch and the most medial edge of the anteromedial facet averaged 12.

Open reduction and internal fixation compared with excision for unstable displaced fractures of the radial head.

Purpose: To determine if excision of the radial head for treatment of an unstable, displaced fracture is associated with a higher rate of early complications or late arthrosis as compared with open reduction and internal fixation (ORIF).

Methods: Unstable, displaced fractures of the radial head treated with either excision (15 patients) or ORIF (13 patients) were compared. Implants were removed routinely during the study period.