Anneluuk L.C. Lindenhovius

Two and three-dimensional computed tomography for the classification and management of distal humeral fractures. Evaluation of reliability and diagnostic accuracy.

BACKGROUND Complex fractures of the distal part of the humerus can be difficult to characterize on plain radiographs and two-dimensional computed tomography scans. We tested the hypothesis that three-dimensional reconstructions of computed tomography scans improve the reliability and accuracy of fracture characterization, classification, and treatment decisions. METHODS Five independent observers evaluated thirty consecutive intra-articular fractures of the distal part of the humerus for the presence of five fracture characteristics: a fracture line in the coronal plane; articular comminution; metaphyseal comminution; the presence of separate, entirely articular fragments; and impaction of the articular surface. Fractures were also classified according to the AO/ASIF Comprehensive Classification of Fractures and the classification system of Mehne and Matta. Two rounds of evaluation were performed and then compared. Initially, a combination of plain radiographs and two-dimensional computed tomography scans (2D) were evaluated, and then, two weeks later, a combination of radiographs, two-dimensional computed tomography scans, and three-dimensional reconstructions of computed tomography scans (3D) were assessed. RESULTS Three-dimensional computed tomography improved both the intraobserver and the interobserver reliability of the AO classification system and the Mehne and Matta classification system. Three-dimensional computed tomography reconstructions also improved the intraobserver agreement for all fracture characteristics, from moderate (average kappa [kappa2D] = 0.554) to substantial agreement (kappa3D = 0.793). The addition of three-dimensional images had limited influence on the interobserver reliability and diagnostic characteristics (sensitivity, specificity, and accuracy) for the recognition of specific fracture characteristics. Three-dimensional computed tomography images improved intraobserver agreement (kappa2D = 0.62 compared with kappa3D = 0.75) but not interobserver agreement (kappa2D = 0.24 compared with kappa3D = 0.28) for treatment decisions. CONCLUSIONS Three-dimensional reconstructions improve the reliability, but not the accuracy, of fracture classification and characterization. The influence of three-dimensional computed tomography was much more notable for intraobserver comparisons than for interobserver comparisons, suggesting that different observers see different things in the scans-most likely a reflection of the training, knowledge, and experience of the observer with regard to these relatively uncommon and complex injuries.

Injection of Dexamethasone Versus Placebo for Lateral Elbow Pain: A Prospective, Double-Blind, Randomized Clinical Trial

PURPOSE We tested the hypothesis that there is no difference in disability, pain, and grip strength 1 and 6 months after corticosteroid and lidocaine injection compared with lidocaine injection alone (placebo). METHODS Sixty-four patients were randomly assigned to dexamethasone (n = 31) or placebo (n = 33) injection. At enrollment, disability (Disabilities of the Arm, Shoulder, and Hand [DASH] questionnaire), pain on a visual analog scale, grip strength, depression (the Center for Epidemiologic Studies Depression Scale; CESD), and ineffective coping skills (the Pain Catastrophizing Scale; PCS) were comparable between treatment groups. At 1 and 6 months, DASH, pain, and grip strength measures were repeated. Univariate and multivariate analyses were used to determine predictors of disability. Analysis was by intention to treat. RESULTS One month after injection, DASH scores averaged 24 versus 27 points (dexamethasone vs placebo), pain 3.7 versus 4.3 cm, and grip strength 83% versus 87%. At 6 months, DASH scores averaged 18 versus 13 points, pain 2.4 versus 1.7 cm, and grip strength 98% versus 97%. CESD and PCS scores correlated with disability as measured by the DASH questionnaire. The best multivariate models included CESD at 1 month and PCS scores at 6 months and explained the majority of variability in DASH scores. CONCLUSIONS Corticosteroid injection did not affect the apparently self-limited course of lateral elbow pain. In secondary analyses in a subset of patients, perceived disability associated with lateral elbow pain correlated with depression and ineffective coping skills. TYPE OF STUDY/LEVEL OF EVIDENCE Therapeutic I.

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. No external fixators were applied. Four of 14 patients in the subacute cohort had 5 operative procedures before presenting to us. All patients presented with instability and were treated an average 7 weeks after injury. Except for 1 patient who presented with an active infection, all patients were treated with radial head replacement and lateral collateral ligament repair, and fixation or reconstruction of the coronoid occurred in 9 patients. Stability was protected with a hinged external fixator for an average of 6 weeks. RESULTS Five patients in the acute cohort and 1 in the subacute cohort had 8 subsequent surgeries (addressing stiffness in 3 patients). Prior to subsequent surgeries, the flexion arc averaged 116 degrees in the acute cohort and 93 degrees in the subacute cohort and improved to an average 119 degrees in the acute cohort and 100 degrees in the subacute cohort after all subsequent surgeries. Broberg and Morrey scores were comparable between cohorts (90 vs 87 points). CONCLUSIONS Stability and strength were restored with both acute and subacute treatment, but earlier treatment is more straightforward and is associated with a better flexion arc. TYPE OF STUDY/LEVEL OF EVIDENCE Therapeutic III.

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. METHODS One hundred and fifty-eight patients were evaluated at a median of twenty-six months after a traumatic elbow injury and completed the Disabilities of the Arm, Shoulder and Hand (DASH) questionnaire. Predictors of the total DASH score and of the scores for individual DASH items that were expected to be related to elbow function were evaluated with univariate and multivariate analyses. RESULTS Motion accounted for 35% of the variability in the total DASH score, for 11% to 12% of the variability in the responses to questions specific to hand-based activities, and for 24% to 33% of the variability in the scores for tasks depending on elbow motion. Pain accounted for 41% of the variability in the total DASH score and was a better predictor than motion of disability associated with three tasks: opening a tight jar (with pain and motion accounting for 24% and 11% of the variability, respectively), pushing open a door (25% and 12%, respectively), and placing an object overhead (28% and 25%, respectively). None of the multivariate models explained more than 53% of the variability in the DASH scores. CONCLUSIONS Objective physical elbow impairment correlated with self-reported disability with respect to specific tasks, but a large proportion of disability remains unexplained. Further research is needed to better understand the differences between objective impairment and perceived disability.

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. Patients and Participants: Ten patients with anterior olecranon fracture-dislocation and ten patients with posterior olecranon fracture-dislocation were evaluated after an average of 18 years (range, 11 to 28 years) after injury. Fifteen patients had an early follow-up available at an average 14 months (range, 6 to 24 months) after surgery. The average age at injury was 30 years (range, 14 to 53 years). Intervention: Treatment included plate and screw fixation (11 patients), tension band wiring (8 patients), and radiocapitellar transfixation (1 patient). Six patients had additional elbow surgery before the final evaluation. Main Outcome Measurements: Flexion arc, arthrosis, Mayo Elbow Performance Index (MEPI), Disability of Arm Shoulder and Hand questionnaire (DASH). Results: The mean arc of elbow flexion was 105 degrees (range, 15 to 140 degrees) at 1 year and 122 degrees (range 10 to 145 degrees; P = 0.01) at final evaluation. Radiographic arthrosis was observed in 14 patients (70%): severe in 3, moderate in 2, and mild in 9 patients. Five patients (25%) had ulnar nerve dysfunction at the final evaluation. The MEPI was excellent in 13 patients, good in 4, fair in 2, and poor in 1. The mean DASH score was 9 points (range, 0 to 53 points). Conclusion: The initial results of operative treatment of fracture-dislocations of the olecranon are durable over time.

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). Complications included two infections (1 deep and 1 superficial), two patients with restriction of motion because of screws of excessive length, and one transient posterior interosseous nerve palsy. A second surgery for implant removal was routine (14 of 16 patients). RESULTS The average flexion arc was 129 degrees (range, 110-145 degrees) and the average forearm rotation arc was 166 degrees (range, 120-180 degrees). According to the Mayo Elbow Performance Index, elbow function was excellent in nine patients, good in four, fair in two, and poor in one patient. According to the classification system of Steinberg et al., there were three good, eight fair, and five poor results. The average score on the Disabilities of the Arm, Shoulder, and Hand questionnaire was 12 points (range, 0-52). CONCLUSION The long-term results of operative treatment of stable isolated displaced partial articular (Mason 2) fractures of the radial head demonstrate no appreciable advantage over the long-term results of nonoperative treatment of these fractures published in prior reports. Moreover, the appeal of operative treatment is diminished by the potential complications.

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. Pain was measured with use of the American Shoulder and Elbow Surgeons (ASES) Elbow Evaluation instrument. Four patients underwent additional, subsequent procedures to address residual elbow stiffness. RESULTS One patient who needed several additional procedures, including a total elbow arthroplasty, was considered to have had a failure of the operative contracture release and was excluded from the analysis; this left twenty-two patients in the study. On the average, the arc of flexion and extension improved from 51° preoperatively to 106° postoperatively; the DASH score, from 38 points to 18 points; the SF-36 Physical Component Summary (PCS) score, from 39 points to 49 points (all p < 0.05); and the SF-36 Mental Component Summary (MCS) score, from 49 points to 54 points (p < 0.05). There was no significant correlation between the improvement in the arc of flexion and extension and the improvement in the DASH (p = 0.53), PCS (p = 0.73), or MCS (p = 0.41) score. There also was no correlation between the final arc of flexion and extension and the final DASH score (p = 0.39 for the total score, p = 0.52 for the PCS score, and p = 0.42 for the MCS score). CONCLUSIONS Health status and disability scores improve after open elbow contracture release, but the improvements do not correlate with the improvement in elbow motion. Among multiple objective and subjective factors, pain was a strong predictor of the final general health status and arm-specific disability.

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. METHODS Sixty-six patients with posttraumatic elbow stiffness were enrolled in a prospective randomized trial: thirty-five in the static progressive and thirty-one in the dynamic cohort. Elbow function was measured at enrollment and at three, six, and twelve months later. Patients completed the DASH questionnaire at enrollment and at the six and twelve-month evaluation. Three patients asked to be switched to static progressive splinting. The analysis was done according to intention-to-treat principles and with use of mean imputation for missing data. RESULTS There were no significant differences in flexion arc at any time point. Improvement in the arc of flexion (dynamic versus static) averaged 29° versus 28° at three months (p = 0.87), 40° versus 39° at six months (p = 0.72), and 47° versus 49° at twelve months after splinting was initiated (p = 0.71). The average DASH score (dynamic versus static) was 50 versus 45 points at enrollment (p = 0.52), 32 versus 25 points at six months (p < 0.05), and 28 versus 26 points at twelve months after enrollment (p = 0.61). CONCLUSIONS Posttraumatic elbow stiffness can improve with exercises and dynamic or static splinting over a period of six to twelve months, and patience is warranted. There were no significant differences in improvement in motion between static progressive and dynamic splinting protocols, and the choice of splinting method can be determined by the patients and their physicians.

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. METHODS Sixteen patients who had an arc of flexion and extension of less than 80 degrees and used CPM after open contracture release were matched based on age, gender, diagnosis, preoperative arc of flexion and extension, and radiographic appearance (joint congruity, heterotopic bone, and arthritis) to 16 control patients who did not use CPM. Stiffness was of posttraumatic origin in 24 patients, related to primary osteoarthrosis in 4 patients, and related to heterotopic ossification after central nervous system injury or burns in 4 patients. The preoperative arc of flexion and extension averaged 38 degrees in the CPM cohort and 42 degrees in the no-CPM cohort. RESULTS Subsequent surgeries included procedures to address residual stiffness in 1 patient in the CPM cohort and in 3 patients in the no-CPM cohort. At an average 6 months of follow-up, there was no difference in improvement in the arc of flexion and extension (58 degrees vs 61 degrees ) between the CPM and no-CPM cohorts. At the final evaluation, the improvement in arc of flexion and extension (59 degrees in both cohorts) and the final arc of flexion and extension (96 degrees vs 101 degrees ) were comparable between cohorts. CONCLUSIONS These matched retrospective data do not demonstrate a benefit of CPM in the postoperative management of elbow contracture release.

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. Twenty-five of the thirty-five patients who were skeletally immature at the time of injury were treated nonoperatively, and thirty-one of the thirty-six skeletally mature patients were treated operatively. Objective evaluation included radiographs, functional assessment, and grip strength. Validated questionnaires were used to measure arm-specific disability (the Disabilities of the Arm, Shoulder and Hand [DASH] score), misinterpretation of pain (Pain Catastrophizing Scale [PCS]), and depression (the validated Dutch form of the Center for Epidemiologic Studies-Depression scale [CES-D]). RESULTS The average DASH score was 8 points (range, 0 to 54); 97% of patients had excellent or satisfactory results according to the criteria of Anderson et al., and 72% reported no pain. Both the forearm rotation and the wrist flexion/extension arc was 91% of that seen on the uninjured side; grip strength was 94%. There were small but significant differences in rotation (151° versus 169°, p = 0.004) and wrist flexion-extension (123° versus 142°, p = 0.002) compared with the results in the uninjured arm. There was no difference in disability between patients who were skeletally mature or immature at the time of injury. Pain, pain catastrophizing (misinterpretation of nociception), and grip strength were the most important predictors of disability. CONCLUSIONS An average of twenty-one years after sustaining diaphyseal fractures of both the radius and the ulna, patients who were skeletally immature or mature at the time of fracture have comparable disability. Disability correlates better with subjective and psychosocial aspects of illness, such as pain and pain catastrophizing, than with objective measurements of impairment. LEVEL OF EVIDENCE Therapeutic Level IV. See Instructions to Authors for a complete description of levels of evidence.