Lee M. Reichel

Elbow lateral collateral ligament injuries

The lateral collateral ligament (LCL) of the elbow is a complex capsuloligamentous structure critical in stabilizing the ulnohumeral and radiocapitellar articulations. LCL injury can result in elbow instability, allowing the proximal radius and ulna to externally rotate away from the humerus as a supination stress is applied to the forearm. Elbow dislocation is the most common cause of LCL injury, followed by iatrogenic injury. LCL pathology resulting in late recurrent instability is rare but disabling. The diagnosis requires a high index of suspicion, detailed history, and focused physical examination maneuvers. Stress radiographs are often the most useful imaging modality. Despite controversy over the anatomy of the LCL complex and the relative importance of its component structures, treatment of late instability is focused on lateral ligament reconstruction from the humerus to the ulna using tendon grafts with reasonably good outcomes.

Molecular mechanisms of heterotopic ossification.

First described in the early 1800s, heterotopic ossification (HO) refers to the formation of extraskeletal bone.1 In the upper extremity, HO most frequently occurs after injury to the elbow, and can result in severe functional impairment (Fig. 1). A variety of factors have been implicated, including elbow dislocation, open injury, severe chest injury, longer wait time to surgery, and prolonged immobilization.2,3 “Terrible triad” complex elbow fracture dislocations and distal humeral fractures have the highest rates of HO.3 A spectrum of HO formation exists after elbow injury, with more severe HO being associated with greater functional loss. Although associated injuries, radiographic findings, and clinical implications have been well documented, the molecular mechanisms have not pervaded the surgical literature. In the past several years, important advancements in our understanding of molecular mechanisms behind HO have been made. FIGURE 1 High-energy elbow injury resulting in ankylosed elbow joint secondary to HO. A injury. B Intraoperative reduction and stabilization. C Early HO. D Mature bridging HO resulting in ankylosed joint.

Radiotherapy to bone has utility in multifocal metastatic renal carcinoma.

Renal cell carcinoma metastases to bone are classically considered radioresistant. We reviewed 28 patients who underwent irradiation for metastatic renal cell carcinomas to bone to test the hypothesis that irradiation of renal metastases to bone provides adequate palliation in carefully selected patients. Metastases were multifocal in all patients. All patients were followed until death. Overall, 36 index radiotherapy treatments were given as palliative initial treatment for 36 osseous metastatic sites. Twenty-five of 36 sites (69.5%) had no subsequent radiotherapy. Eight sites (22.2%) underwent repeat radiotherapy at a mean 28.9 weeks after treatment. Two (5.6%) additional sites underwent surgery at the site at an average 74 weeks later, and a pathologic fracture occurred at one (2.8%) site 3 weeks after irradiation. Overall, 33 of 36 (91.7%) sites had only radiotherapy as their source of palliation. Median times to return to pretreatment pain and functional levels, however, were 2 months and 1 month, respectively. Radiotherapy to osseous sites appears to control pain for the short term and generally prevents fractures and avoids the need for surgery in renal cell carcinoma patients with multiple bone metastases.Level of Evidence: Level IV, therapeutic study. See the Guidelines for Authors for a complete description of levels of evidence.

Measurement of ulnar variance from the lateral radiograph: A comparison of techniques

PURPOSE To determine the reliability of measuring ulnar variance on lateral wrist radiographs and to compare this technique with previously described methods. METHODS Ulnar variance was measured in 100 normal wrist radiographs using the methods of perpendiculars, central reference point, and the lateral radiograph by 3 surgeons on 2 occasions. Intraobserver repeatability and agreement between raters and methods were assessed and compared. RESULTS Intra- and interobserver reliability and agreement were both excellent using all 3 methods within a ± 1.0-mm cutoff. However, there was substantial pairwise disagreement in measures of ulnar variance between all 3 methods. CONCLUSIONS This study demonstrates that, for measurement of ulnar variance, the methods of perpendiculars, central reference point, and lateral radiographic measurement each have clinically acceptable intraobserver repeatability and interobserver agreement. Despite their independent reliability, each method of radiographic determination of ulnar variance had considerable disagreement with the other methods, indicative of inherent inaccuracies in the techniques. The lateral radiograph uniquely allows for visualization of the amount of ulnar head protruding proximal or distal to the concave lunate facet and allows for a rapid estimation of pronosupination, which is known to affect ulnar variance. CLINICAL RELEVANCE Determination of ulnar variance can be an important component of surgical decision making in various pathological conditions of the hand and wrist. Traditionally, it has been measured through methods using the posteroanterior wrist radiograph, but there are potential shortcomings with these methods, and use of the lateral radiograph may provide a more clinically relevant picture of ulnar variance. This study shows that measurement from the lateral radiograph provides similar reliability to previously accepted techniques.

Gross Anatomy of the Elbow Capsule: A Cadaveric Study

PURPOSE The elbow is an inherently stable joint because of its bony articulation and surrounding capsuloligamentous structures. Anatomic and biomechanical studies have focused on the medial and lateral collateral ligamentous contributions to stability. In 1918, Gray provided a qualitative description of the elbow capsule and its fibers. Our study was performed to detail the gross anatomy of the elbow capsule. METHODS We evaluated the elbow capsule of 6 paired, fresh-frozen cadaveric specimens to detail gross capsular anatomy. RESULTS We identified 3 distinct bands within the anterior capsule and 3 distinct bands within the posterior capsule. CONCLUSIONS Further study is needed to delineate the functional meaning of these anatomic findings. CLINICAL RELEVANCE Greater understanding of elbow capsule gross anatomy may lead to improved understanding of acute and chronic elbow pathoanatomy and treatment modalities.

Osteology of the coronoid process with clinical correlation to coronoid fractures in terrible triad injuries

BACKGROUND Terrible triad complex elbow fracture-dislocations are represented by elbow dislocations associated with fractures of the coronoid and radial head. Published literature has focused on classifying coronoid fractures by their radiographic morphology on plain x-ray images and computed tomography imaging. No study has specifically related native coronoid osteology to in situ fracture morphology. We identified 3 distinct bony regions of the coronoid, (medial, intermediate, and lateral ridges) with correlation to common fracture patterns associated with terrible triad injuries. METHODS Coronoid osteology in 8 fresh frozen cadaveric elbows was examined, and three distinct ridges were identified and dimensions measured. RESULTS The measurements were compared with retrospective intraoperative measurements taken of coronoid fracture fragments being stabilized during terrible triad injury repair. CONCLUSION Classification of native coronoid process anatomy into functional ridges (medial, intermediate, lateral) may improve our understanding of coronoid fracture patterns in unstable terrible triad injuries. LEVEL OF EVIDENCE Basic Science, Anatomic Study, Cadaver and In Vivo.

Radial styloid fractures

Radial styloid fractures can occur in isolation or in association with other injuries, including complex intra-articular distal radius fractures, carpal fractures, carpal dislocations, and radiocarpal dislocations. The anatomy surrounding the radial styloid is complex, and complications related to surgical approach, treatments, and symptomatic hardware can occur. Operative treatments vary according to the injury pattern present, and pattern recognition is the key to optimizing treatment of these injuries. Outcomes are related to the precision of the reconstruction as well as the magnitude of the injury; better results are associated with lower-energy patterns.

Arthrodesis of the Elbow

Elbow arthrodesis (EA) is a procedure reserved for the salvage of failed elbow reconstruction or elbow injuries that defy reconstruction of a useful joint. Although arthrodesis of some joints is often straightforward and predictable, EA is technically difficult and associated with a high rate of complications. Furthermore, a successful EA does not translate to a gratifying clinical success. The functional limitations to activities of daily living and personal care are significant.

Management of distal humeral coronal shear fractures

Coronal shear fractures of the distal humerus are rare, complex fractures that can be technically challenging to manage. They usually result from a low-energy fall and direct compression of the distal humerus by the radial head in a hyper-extended or semi-flexed elbow or from spontaneous reduction of a posterolateral subluxation or dislocation. Due to the small number of soft tissue attachments at this site, almost all of these fractures are displaced. The incidence of distal humeral coronal shear fractures is higher among women because of the higher rate of osteoporosis in women and the difference in carrying angle between men and women. Distal humeral coronal shear fractures may occur in isolation, may be part of a complex elbow injury, or may be associated with injuries proximal or distal to the elbow. An associated lateral collateral ligament injury is seen in up to 40% and an associated radial head fracture is seen in up to 30% of these fractures. Given the complex nature of distal humeral coronal shear fractures, there is preference for operative management. Operative fixation leads to stable anatomic reduction, restores articular congruity, and allows initiation of early range-of-motion movements in the majority of cases. Several surgical exposure and fixation techniques are available to reconstruct the articular surface following distal humeral coronal shear fractures. The lateral extensile approach and fixation with countersunk headless compression screws placed in an anterior-to-posterior fashion are commonly used. We have found a two-incision approach (direct anterior and lateral) that results in less soft tissue dissection and better outcomes than the lateral extensile approach in our experience. Stiffness, pain, articular incongruity, arthritis, and ulnohumeral instability may result if reduction is non-anatomic or if fixation fails.

Heterotopic Ossification Following Distal Radius Fractures in a Patient With Parkinson Disease Treated With Levodopa-Carbidopa

a V-Y flap. The histological picture was consistent with the diagnosis of a schwannoma. Postoperative follow-up of 12 months was uneventful, with nearly normal appearance (Fig. 1C). Radiographs showed good healing of the distal phalanx with resolution of previous erosive changes (Fig. 1B). Schwannomas, also known as neurilemmomas, are solitary, slow-growing, encapsulated tumors most commonly reported in the head and neck followed by the trunk, and upper and lower extremities. Approximately 1% of reported cases have been in the hand, and it rarely occurs distal to the proximal interphalangeal joints. Cutaneous involvement is uncommon and subungual location is also rare. Clinical diagnosis is difficult and can be easily confused with solid tumors including neurofibromas, lipomas, and giant cell tumors as well as with ganglions. Treatment of schwannomas consists of resection of tumor with emphasis on identifying the nerve fascicles. Recurrence is rare, even when the excision is incomplete. Bony erosion from a benign schwannoma is rare and has been reported to occur in the spinal canal, proximal phaFIGURE 1: A Mass on ring fingertip. B Lateral x-ray showin