Jos J. Mellema

Posterior Malleolar Fracture Patterns.

Objective: To characterize posterior malleolar fracture morphology using Cole fracture mapping and to study reliability of quantification of 3-dimensional computed tomography (CT)–modeling for posterior malleolar fractures with respect to quantification of fragment size (in cubic millimeter) and true articular involvement (in square millimeter). Methods: CT scans of a consecutive series of 45 patients with an ankle fracture involving the posterior malleolus were reconstructed to calculate (1) fracture maps, (2) fragment volume, (3) articular surface of the posterior malleolar fragment, (4) articular surface of intact tibia, and (5) articular surface of the medial malleolus by 3 independent observers. Three-dimensional animation of this technique is shown on www.traumaplatform.org. Results: Fracture mapping revealed (1) a continuous spectrum of posterolateral oriented fracture lines and (2) fragments with posterolateral to posteromedial oriented fracture lines extending into the medial malleolus. Reliability of measurements of the volume and articular surface of posterior malleolar fracture fragments was defined as almost perfect according to the categorical system of Landis (interclass coefficient, range, 0.978–1.000). Conclusions: Mapping of posterior malleolar fractures revealed a continuous spectrum of Haraguchi III to I fractures and identified Haraguchi type II as a separate pattern. Quantification of 3-dimensional CT–modeling is reliable to assess fracture characteristics of posterior malleolar fracture fragments. Morphology might be more important than posterior malleolar fracture size alone for clinical decision making.

Tibial Plateau Fracture Characteristics: Computed Tomography Mapping of Lateral, Medial, and Bicondylar Fractures

BACKGROUND Computed tomography (CT) is seen as a useful diagnostic modality in preoperative planning for tibial plateau fractures. The purpose of this study was to characterize patterns of tibial plateau fractures with use of CT mapping. We hypothesized that CT mapping of fractures of the tibial plateau would reveal recurrent patterns of fragments and fracture lines, including patterns that do not fit into Schatzkers original classification. METHODS One hundred and twenty-seven tibial plateau fractures were retrospectively included in this study. Fracture lines and zones of comminution were graphically superimposed onto an axial template of an intact subarticular tibial plateau to identify major patterns of fracture and comminution. This fracture map of the tibial plateau was subsequently divided into lateral (Schatzker types I, II, and III), medial (Schatzker type IV), and bicondylar (Schatzker types V and VI) fracture maps. RESULTS This study included seventy-three female and fifty-four male patients (average age, forty-seven years [range, seventeen to ninety-one years]) with a tibial plateau fracture. Sixty-four of the fractures were Schatzker type I, II, or III; fifteen were Schatzker type IV; and forty-eight were Schatzker type V or VI. Analysis of the fracture maps suggested patterns in the Schatzker type-IV, V, and VI fractures beyond those described in Schatzkers original classification. The maps of the 127 fractures revealed four recurrent major fracture features: the lateral split fragment (A), found in 75%; the posteromedial fragment (B), seen in 43%; the tibial tubercle fragment (C), seen in 16%; and a zone of comminution that included the tibial spine and frequently extended to the lateral condyle (D), seen in 28%. CONCLUSIONS Tibial plateau fracture maps show recurrent patterns of fracture lines, revealing four major fracture characteristics. An understanding of these recurrent features of tibial plateau fractures can aid surgeons during diagnosis, preoperative planning, and execution of surgical strategies.

Distribution of Coronoid Fracture Lines by Specific Patterns of Traumatic Elbow Instability

PURPOSE To determine if specific coronoid fractures relate to specific overall traumatic elbow instability injury patterns and to depict any relationship on fracture maps and heat maps. METHODS We collected 110 computed tomography (CT) studies from patients with coronoid fractures. Fracture types and pattern of injury were characterized based on anteroposterior and lateral radiographs, 2- and 3-dimensional CT scans, and intraoperative findings as described in operative reports. Using quantitative 3-dimensional CT techniques we were able to reconstruct the coronoid and reduce fracture fragments. Based on these reconstructions, fracture lines were identified and graphically superimposed onto a standard template in order to create 2-dimensional fracture maps. To further emphasize the fracture maps, the initial diagrams were converted into fracture heat maps following arbitrary units of measure. The Fisher exact test was used to evaluate the association between coronoid fracture types and elbow fracture-dislocation patterns. RESULTS Forty-seven coronoid fractures were associated with a terrible triad fracture dislocation, 30 with a varus posteromedial rotational injury, 1 with a anterior olecranon fracture dislocation, 22 with a posterior olecranon fracture dislocation, and 7 with a posterior Monteggia injury associated with terrible triad fracture dislocation of the elbow. The association between coronoid fracture types and elbow fracture-dislocation patterns, as shown on 2-dimensional fracture and heat maps, was strongly significant. CONCLUSIONS Our fracture maps and heat maps support the observation that specific patterns of traumatic elbow instability have correspondingly specific coronoid fracture patterns. Knowledge of these patterns is useful for planning management because it directs exposure and fixation and helps identify associated ligament injuries and fractures that might benefit from treatment. CLINICAL RELEVANCE Two-dimensional fracture and heat mapping techniques may help surgeons to predict the distribution of coronoid fracture lines associated with specific injury patterns.

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.

Fracture mapping of displaced partial articular fractures of the radial head

BACKGROUND Recognition of patterns of traumatic elbow instability helps anticipate specific fracture characteristics and associated injuries. The objective of this study was to assess the association of fracture line distribution and location of displaced partial articular radial head fractures with specific patterns of traumatic elbow instability using fracture mapping techniques. METHODS Fracture line distribution and location of 66 acute displaced partial articular radial head fractures were identified using quantitative 3-dimensional computed tomography reconstructions that allowed reduction of fracture fragments and a standardized method to divide the radial head into quadrants with forearm in neutral position. Based on qualitative and quantitative assessment of fracture maps, the association between fracture characteristics of displaced partial articular radial head fractures and specific elbow fracture patterns was determined. RESULTS In partial articular radial head fractures, the highest fracture line intensity was located in the anterolateral quadrant near the center of the radial head. Fracture location corresponded with fracture line distribution; most fractures involved the anterolateral quadrant (n = 65; 98%), whereas parts of the posteromedial quadrant were involved in a minority of the fractures (n = 10; 15%). The association of fracture line distribution and location with overall fracture patterns of the elbow, as depicted on fracture maps, was not statistically significant. CONCLUSION Fracture maps demonstrated no association between fracture line distribution and location of displaced partial articular fractures of the radial head and overall specific patterns of traumatic elbow instability, suggesting a common fracture mechanism that involves the anterolateral part of the radial head in most patients.

Prevalence of and Factors Associated With Major Depression in Patients With Upper Extremity Conditions

PURPOSE To determine the prevalence of an estimated diagnosis of major depression in patients with upper extremity conditions and factors that help identify patients who might benefit from psychological treatment. METHODS In this observational cross-sectional study, 190 patients completed questionnaires measuring symptoms of depression with the Patient Health Questionnaire, upper extremity disability with the Patient-Reported Outcomes Measurement Information System Upper Extremity, pain interference with the Patient-Reported Outcomes Measurement Information System Pain Interference, and health anxiety with the Short Health Anxiety Inventory. RESULTS The estimated prevalence of an estimated diagnosis of major depression (Patient Health Questionnaire 9 ≥ 10) among this group of patients was 12%. Having multiple pain conditions, a history of depression, and greater limitation from pain for daily activities were independently associated with an estimated diagnosis of major depression. CONCLUSIONS The finding that 1 in 8 patients presenting to a hand surgeon have untreated or undertreated symptoms of depression sufficient to qualify for an estimated diagnosis of major depression emphasizes the importance of assessing for depression at all levels of care.

The Relationship Between Catastrophic Thinking and Hand Diagram Areas

PURPOSE To evaluate the relationship between the total area marked on pain and numbness diagrams and psychosocial factors (depression, pain catastrophic thinking, and health anxiety). METHODS A total of 155 patients marked painful and numb areas on separate hand diagrams. Patients also completed demographic, condition-related, and psychosocial (Pain Catastrophizing Scale, Patient-Reported Outcomes Measurement Information System Depression Computer Adaptive Test, and Short Health Anxiety Inventory) questionnaires. Bivariate and multivariable analyses were used to determine factors associated with total area marked on the pain and numbness diagrams. RESULTS The total area marked on the pain diagram correlated with catastrophic thinking, symptoms of depression, and health anxiety. In multivariable analysis, catastrophic thinking was the sole predictor of marked pain area, accounting for 10% of variance in the hand pain diagram. The total area marked on the numbness diagram correlated with the interval between onset and visit, diagnosis, catastrophic thinking, and symptoms of depression. In multivariable analysis, the interval between onset and visit, a diagnosis of carpal tunnel syndrome, and catastrophic thinking were independently associated with total area marked on the hand numbness diagram. CONCLUSIONS Catastrophic thinking was independently associated with larger pain and numbness areas on a hand diagram. This suggests that larger symptom markings on hand diagrams may indicate less effective coping strategies. Hand diagrams might be used as a basis for discussion of coping strategies and illness behavior in patients with upper extremity conditions. TYPE OF STUDY/LEVEL OF EVIDENCE Diagnostic III.

Influence of Priming on Patient-Reported Outcome Measures: A Randomized Controlled Trial

BACKGROUND Patient-reported outcome measures (PROMs) are influenced by psychosocial factors, but it is unknown whether we can influence PROM scores by modifying the mindset of the patient. PURPOSE We assessed whether priming affects scores on PROMs. METHODS In all, 168 patients with musculoskeletal illness participated in this double-blinded, randomized, controlled, parallel study between July 2014 and October 2014 in a level I trauma center. Inclusion criteria were patients aged 18 years or older with English fluency and literacy and the ability to provide informed consent. Priming was performed by means of the Pain Catastrophizing Scale (PCS). The patients were randomized (1:1:1) into 3 groups: intervention group I was negatively primed with the original PCS; intervention group II was positively primed with a positively phrased PCS group; and control group III was not primed. Assessments were performed using PROMs on the domain of physical function, depression, and pain. Bivariate and multivariable regression analyses were conducted. RESULTS The intervention and control groups were well balanced in demographic and condition-specific characteristics. The positive PCS was independently associated with higher PROM scores in the physical function domain (Patient-Reported Outcome Measurement Information System Upper Extremity Function: coefficient = 4.7, partial R(2) = 0.042; CI: 1.2-8.2; p < 0.010). CONCLUSIONS Patients primed with a positively phrased version of the PCS reported less functional disability as compared with patients who were either negatively primed or not primed at all. This suggests that by influencing the mindset, PROMs can be influenced, resulting in better outcome if positively primed. LEVEL OF EVIDENCE Level 1 therapeutic study. TRIAL REGISTRATION NCT02209259.

The yield of subsequent radiographs during nonoperative treatment of radial head and neck fractures

OBJECTIVES After diagnosis of an isolated radial head or neck fracture and selection of nonoperative treatment, the value of subsequent radiographs is uncertain. This study tested the null hypothesis that there are no patient, surgeon, or injury factors associated with alteration in patient management based on subsequent radiographs. Secondarily, we tested the null hypothesis that the use of subsequent radiographs is not associated with patient, surgeon, and fracture characteristics. METHODS We identified 415 adult patients with nonoperative treatment for isolated Broberg and Morrey modified Mason type 1 or 2 fractures at a large urban hospital system during years 2013 and 2014. Patient demographics, fracture characteristics, provider characteristics, and treatment details were obtained from a hospital database. Bivariate analysis and multivariable logistic regression modeling were performed. RESULTS One of 255 patients with 262 fractures that had subsequent radiographs (0.4%) was offered surgery but declined. In multivariable analysis, displaced fractures were more likely to have subsequent radiographs, but surgeon-to-surgeon variation was a far more influential factor. CONCLUSIONS Radiographs subsequent to diagnosis do not alter treatment of radial head fractures with no associated ligament injuries or fractures. The substantial surgeon-to-surgeon variation in the use of subsequent radiographs suggests that this may be a good focus for quality improvement initiatives.

Quantitative 3-dimensional computed tomography analysis of olecranon fractures

HYPOTHESIS/BACKGROUND Olecranon fractures have variable size of the proximal fragment, patterns of fragmentation, and subluxation of the ulnohumeral joint that might be better understood and categorized on the basis of quantitative 3-dimensional computed tomography analysis. Mayo type I fractures are undisplaced, Mayo type II are displaced and stable, and Mayo type III are displaced and unstable. The last is categorized into anterior and posterior dislocations. The purpose of this study was to further clarify fracture morphology between Mayo type I, II, and III fractures. METHODS Three-dimensional models were created for a consecutive series of 78 patients with olecranon fractures that were evaluated with computed tomography. We determined the total number of fracture fragments, the volume and articular surface area of each fracture fragment, and the degree of displacement of the most proximal olecranon fracture fragment. RESULTS Displaced olecranon fractures were more comminuted than nondisplaced fractures (P = .02). Displaced fractures without ulnohumeral subluxation were smallest in terms of both volume (P < .001) and articular surface involvement (P < .001) of the most proximal olecranon fracture fragment. There was no difference in average displacement of the proximal fragment between displaced fractures with and without ulnohumeral subluxation (P = .74). Anterior olecranon fracture-dislocations created more displaced (P = .04) and smaller proximal fragments than posterior fracture-dislocations (P = .005), with comparable fragmentation on average (P = .60). DISCUSSION/CONCLUSION The ability to quantify volume, articular surface area, displacement, and fragmentation using quantitative 3-dimensional computed tomography should be considered when increased knowledge of fracture morphology and fracture patterns might be useful.