Per Olof Josefsson

Surgical versus non-surgical treatment of ligamentous injuries following dislocation of the elbow joint. A prospective randomized study.

Thirty consecutive patients who had dislocation of the elbow without concomitant fracture and who were sixteen years old or more were examined under general anesthesia for stability of the joint at an average of four days after the injury. All of the elbows showed medial and sixteen showed both medial and lateral instability. The patients were then randomly assigned to undergo either non-surgical or surgical treatment of the ligamentous injuries. All of the surgically treated elbows showed complete rupture or avulsion of both the medial and lateral collateral ligaments, and in about half of these patients the muscle origins were found to be torn from the humeral epicondyles. At follow-up, both groups showed generally good results; the differences were not statistically significant. There was no evidence that the results of surgical repair of the ligaments were any better than those of non-surgical treatment.

Dislocations of the elbow and intraarticular fractures.

Of 23 patients with an elbow dislocation associated with at least one displaced fracture of the radial head, 19 patients had the radial head extirpated two days range, 0-16 days) after injury. In four elbows, redislocation occurred. All four redislocations were associated with a displaced fracture of the coronoid process. A follow-up examination was performed in 19 patients between three and 34 years after the injury. Severe osteoarthritis with reduced joint space developed in 12 elbows. Reduced range of motion was the most common complaint, and reduced extension was the most common finding. To lower the risk and prevent severe instability, the radial head should be preserved if possible. If the radial head must be resected, suturing of torn ligaments and muscles at the epicondyles is essential.

Long-term sequelae of simple dislocation of the elbow.

Fifty-two patients with a radiographically verified dislocation of the elbow were re-examined at an average of twenty-four years after injury. Half of the patients had no residual symptoms or signs whatsoever and more than one-third had a slight or moderate decrease in the range of extension, which was associated with slight degenerative change in the joint or with periarticular calcification. No reduction in joint space was evident. Even when the examination revealed some instability in a few patients they did not register complaints. Among the patients who had sustained the injury when they were less than sixteen years old, there were few with residual symptoms, signs, or radiographic changes.

Fractures of the Radial Head and Neck Treated with Radial Head Excision

BACKGROUND The reported long-term outcomes of the treatment of radial head and neck fractures with excision of the radial head have been mixed. The purpose of the present study was to evaluate the long-term outcomes of primary or delayed radial head excision for the treatment of these fractures. METHODS Sixty-one individuals (mean age, forty-four years) with thirty-nine Mason type-II, ten Mason type-III, and twelve Mason type-IV fractures were evaluated subjectively, objectively, and radiographically at a mean of eighteen years (range, eleven to thirty-three years) after treatment. Forty-three fractures were treated with primary radial head excision, and the remaining eighteen were treated with delayed radial head excision at a median of five months (range, one to 238 months) after the injury. RESULTS At the time of follow-up, twenty-eight individuals had no symptoms, twenty-seven had occasional elbow pain, and six had daily pain. Four individuals with daily pain had had a Mason type-IV fracture. The range of motion of the formerly injured upper extremities was slightly less than that of the uninjured upper extremities in terms of flexion (139 degrees +/- 11 degrees compared with 142 degrees +/- 8 degrees ), extension (-7 degrees +/- 12 degrees compared with -1 degrees +/- 6 degrees ), and supination (77 degrees +/- 20 degrees compared with 85 degrees +/- 10 degrees ) (all p < 0.01). A higher percentage of formerly injured elbows than uninjured elbows had cysts, sclerosis, and osteophytes (73% compared with 7%; p < 0.001), but none had a reduced joint space. No differences were found between the outcomes for individuals treated with a primary radial head excision and those for individuals treated with a delayed excision. CONCLUSIONS Following a displaced radial head or neck fracture, excision of the radial head often leads to a good or fair result. We found no differences in outcome between primary and delayed radial head excisions following a Mason type-II, III, or IV fracture. The outcomes are associated with the type of fracture, with Mason type-IV fractures having the worst results, rather than with the timing of the radial head excision (primary or delayed).

Incidence of elbow dislocation

Totally, 178 elbow dislocations--with and without concomitant fracture--that had occurred in the city of Malmö in the course of 12 years were studied. There was some preponderance of left-sided injury, but no significant sex difference. The dislocations were most frequent in the very young and occurred most often in conjunction with sports activities.

Pin-tract complications in external fixation of fractures of the distal radius

We analyzed retrospectively the rate and outcome of pin-tract complications in 314 unstable fractures of the distal radius, treated with the Hoffmann small-frame external fixator. The overall rate of complications was 27%. The commonest complication (21%) was pin-tract infection, which was treated with oral antibiotics. There were no cases of osteitis. Complications led to premature removal of the fixator in 17 of the cases. Women over the age of 75 years had a significantly higher rate of pin loosening (17%), but not a higher rate of premature removal of the fixator due to complications. 4% of the cases had a pin-site fracture, all women. The rate of pin-tract complications was high, but severe complications were rare, even in old women.

Epicondylar elbow fracture in children: 35-year follow-up of 56 unreduced cases

Fifty-six conservatively treated children (7-17 years) with a displaced (1-15 mm) fracture of the medial humeral epicondyle were examined 35 (21-48) years after the injury. In 31 cases a pseudarthrosis had developed of which 3 had mild ulnar nerve symptoms. The function and range of motion of the elbow was good in all cases.

Jones fracture. Surgical versus nonsurgical treatment

Sixty-three patients with 66 transverse and short oblique fractures of the proximal shaft of the fifth metatarsal bone (Jones fracture) were evaluated an average of five years (range, one to ten years) after the injury. There were 27 acute fractures and 39 chronic, or stress, fractures. The primary treatment was surgical for one third of the injuries and nonsurgical for the others. Surgical treatment consisted of the insertion of medullary screws. Nonsurgical treatment consisted of the application of either a plaster cast or an elastic bandage. Almost one fourth of the fractures treated nonsurgically later had to be treated surgically because of delayed unions or refractures. Late surgery was required in 12% of acute fractures and in 50% of chronic fractures with sclerosis narrowing the medullary canal. Irrespective of the primary treatment, all the patients had full function at the time of the follow-up evaluation, and no nonunions were diagnosed.

Closed treatment of jones fracture: Good results in 40 cases after 11-26 years

40 patients with transversal or short oblique fractures of the proximal shaft of the fifth metatarsal bone (Jones fracture) were treated with full weight bearing with or without elastic bandage in 39 cases and plaster cast immobilization in one. 24 cases were acute traumatic fractures, 14 stress fractures and 2 refractures. After 17 (11-26) years, 33 of the fractures had healed primarily, evidence of refracture or delayed union was found in 7 and there were no non-unions. All but one of the patients were free of symptoms.

Fracture-induced changes in bone turnover: a potential confounder in the use of biochemical markers in osteoporosis

To examine the short- and long-term bone metabolic effects of fracture assessed by biochemical markers, we utilized a clinical fracture model—proximal tibial osteotomy—and prospectively followed 14 patients. This model of an induced fracture of a major bone gives the advantage of assessing baseline levels prior to fracture. Follow-up occurred at 6–9 weeks, 4–7 months, 9–13 months, and 14–17 months after fracture. Serum was assayed for type 1 procollagen peptide (PICP), total alkaline phosphatase (ALP), and carboxy-terminal-telopeptide of type I collagen (ICTP), while deoxypyridinoline (Dpyr) was measured in urine. Serum osteocalcin (OC) was measured using two recently developed two-site immunofluorometric assays, which both measure full-length and fragmented forms of OC (OCtot), with one of the assays specifically detecting only the carboxylated form of OC (OCcxy). In addition, OC was measured in urine using the same assays as those used for serum. Serum OCtot increased to a peak at 4–7 months after fracture (P < 0.001) and a similar increase was seen for OCcxy (P < 0.05) and ALP (P < 0.01). Bone formation had returned to baseline after a year. Dpyr increased significantly, with a doubling at 6 weeks, while serum (S)-ICTP increased by 73% (P < 0.01 and P < 0.001). Urine OC increased to a maximum of 84% at 6 weeks. The initial percentage increase of bone resorption was greater than that of bone formation. We conclude that: (1) bone turnover as measured by biochemical markers is altered soon after fracture, (2) the major changes occur within 6 weeks to 6 months, but may persist for up to a year. (3) The initial increase in bone resorption exceeds the increase in bone formation, which may contribute to the enhanced bone loss after fracture. (4) The two novel urine OC assays show a similar pattern of change as established marks of bone resorption, which may indicate that they measure bone resorption. (5) Fracture-induced effects on bone turnover are significant and, thus, are potential confounders in the assessment of osteoporosis.