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23rd European Congress of Trauma & Emergency Surgery

Prof.

Posterior elbow dislocation with displaced fracture of the lateral epicondyle in a pediatric patient

Skeletal trauma and sports medicine

Trauma and Emergency surgery | Miscellaneous

CASE HISTORY 9-year-old male patient with pain, deformity and functional impotence of the right elbow after trauma. CLINICAL FINDINGS He presented elbow deformity without preservation of Nelaton's triangle, prominence of the external epicondyle with pain and limitation for active elbow mobilization, and preserved distal neurovascular status. INVESTIGATION/RESULTS AP and lateral x-rays of the elbow showed posterior dislocation of the elbow with fracture of the lateral epicondyle with displacement . Closed reduction is performed under sedation in the Emergency Department and immobilization is performed with a brachioantebrachial splint. CT scan reported a fracture of the lateral epicondyle with intra-articular extension (Salter Harris type IV). DIAGNOSIS Elbow dislocation with lateral epicondyle fracture. THERAPY AND PROGRESSIONS Surgical intervention is performed through a lateral approach to the elbow, with reduction of the fracture and fixation with two 4.0 partial thread cannulated screws. The capsular lesion is sutured and postsurgical splinting is performed. The splint is removed after two weeks, beginning the rehabilitation protocol. One year after surgery the patient has a full range of mobility and has returned to playing sports. COMMENTS The fracture most commonly associated with pediatric elbow dislocations is the fracture of the medial epicondyle, with the association of dislocation and fracture of the lateral epicondyle being uncommon. In these cases, closed reduction can be performed, which usually solves the dislocation. However a good result is not always obtained with the fragment of the epicondyle in a closed manner, requiring surgery with open reduction and fixation of the fracture in case of displacement greater than 2mm and joint involvement. REFERENCES van Haaren ER, van Vugt AB, Bode PJ. Posterolateral dislocation of the elbow with concomitant fracture of the lateral humeral condyle: case report. J Trauma. 1994;36:288–290.No.

Poster

Arm wrestling aftermath: A distal humerus fracture with a butterfly fragment – A case report

Arm wrestling has surged in popularity among young adults. It involves a unique biomechanical pattern characterized by axial pressure loading on the humerus, with a stabilized glenohumeral joint and a flexed and fixed elbow. This interplay of forces creates a focal stress point in the humeral shaft, potentially leading to humeral shaft fractures. The most common fracture subtype is a spiral fracture. We report a rare case of an oblique distal humerus fracture, featuring a butterfly fragment, in a 21-year-old healthy male who sustained the injury during an arm-wrestling match. Upon presentation to the emergency department, he exhibited a swollen and tender right elbow and arm, with no compromise to the neurovascular structures, following the arm-wrestling contest with a colleague. The x-ray revealed a displaced oblique fracture with a butterfly fragment of the distal humerus. Due to the unusual mechanism of injury, a computed tomography scan was done, confirming an oblique fracture with a single large butterfly fragment (Fig 1). The fracture was treated by open reduction and internal fixation, using a posterior arm approach with the patient in lateral decubitus. The reduction was achieved through the use of 2 lag screws and a LCP posterior plate. During the approach, the radial and the posterior interosseous nerve were identified (Fig 2), showing the immediate proximity of the radial nerve to the typical fracture site. Distal humerus fracture, specially those with a butterfly fragment, associated with arm wrestling are a very rare entity. At 6 months after surgery, the patient revealed frature healing, almost complete range of motion with no impairment and full arm and forearm sthrengh. Between 8% to 12% of patients experience radial nerve palsy with these types of fractures. All patients who present with histories of sudden arm pain after arm wrestling should receive appropriate radiologic studies and a careful neurologic examination. No

Effectiveness of lateral paraolecranon approach for simple intra-articular distal humerus fractures

Introduction： When intra-articular fixation of distal humerus fractures is performed by direct visualization, internal fixation of intra-articular fractures using the lateral paraolecranon approach has been reported recently. We report good results with this approach at our own institution. Material ＆ Methods： Of 12 patients who underwent internal fixation for intra-articular fractures of the distal humerus at our hospital between April 2020 and October 2023, 6 patients who used the lateral paraolecranon approach were included. Age, gender, preoperative AO/ASIF classification, intra-articular step off, surgical complications, and final range of motion were investigated in patients who could be followed for more than six months after surgery. Intra-articular step off was measured using AP X-ray immediately recorded after surgery. Results： The mean age at injury was 54 (18-73) years, 1 male and 5 females. Preoperative AO/ASIF classification was B1 in 1 case and C2 in 5 cases. The average intra-articular step-off was 0.75mm (0-2mm). No surgical complications were noted, and postoperative loss of extensor strength was not a problem in any of the patients. Final range of motion averaged 136 (135-140) in flexion and -4 (-10-0) in extension. All followed fractures got union. Conclusions： The para olecranon approach is useful for simple intra-articular fractures except AO/OTA classification 13C2.3 and C3, with good clinical results. It is considered to be a useful option. Reference： Iwamoto T, Suzuki T, Matsumura N, Nakamura M, Matsumoto M, Sato K. Lateral Para-Olecranon Approach for the Treatment of Distal Humeral Fracture. J Hand Surg Am. 2017 May;42(5):344-350. doi: 10.1016/j.jhsa.2017.02.004. Epub 2017 Mar 27. PMID: 28359639.No

Prof. Dr. med. univ.

Outcome of distal AO type C humerus fractures – Case series over 50 years

Introduction Distal humerus C-type fractures in adults are in majority complicated injuries. In most cases surgical treatment with complex reconstruction and osteosynthesis is necessary. The age structure in Austria is changing and more and more elderly patients have higher demands concerning functional outcome even with worse bone quality. Objectives The aim of this study is to examine the subjective and objective outcome of patients after osteosynthesis of distal humerus C-type fractures to evaluate whether the currently used methods are still acceptable as state of the art. Patients &amp; methods In 4 case series (A-D) over 40 years (1968-2008) we retrospectively reviewed 189 patients with distal humerus fractures (AO13-C1-3), treated operatively with osteosynthesis at Medical University of Graz, Dept. of Orthopedics and Traumatology. Data of 59 patients is currently being collected as part of a retrospective cohort study in the period 2009-2018 (series E). Preliminary data of the results of series E are presented in this abstract. Results The mean age raised from series A to E from 43.3 to 71.8 years. Falls occurred more often over time. There is a small surplus of female patients in each series. Type C3 injuries increased in series E. Osteosynthesis with two plates and screws was the most common procedure at all. According to Cassebaum score 88.(A), 89.6 (B), 91.7(C), 86.4(D) and 80.0%(E) were evaluated with good to excellent. Personal opinion was good to excellent in 86.0(A), 93.1(B), 89.6(C), 90.9(D) and 81.8%(E). Based on Jupiter Score over 72.4% of the patients were graded as good to excellent in the first 4 series, in series E it decreases to 29.4%. Conclusion There seems to be a tendency of worsening of the clinical results in the recent series. The cause of this could be the increased demand of the patients on everyday functionality as well as the rise of C3 injuries. Due to increased average age of the patients, also bone quality can be assumed as worse.No.

Complex fracture dislocation of the elbow on polytrauma patient, in relation to a clinical case and literature review

Case History: Elbow fractures happen mostly in young people with high-energy. Distal fractures of the humerus represent up to 7% of all fractures. There are many of Surgical treatments, although several techniques have been developed for a better surgical outcome.We present a case of 21-year-old male, who attended to the emergency after a motorcycle accident. He sustained multiple injuries: of the sacred vertebrae, femoral shaft fracture, open book pelvic fracture, fracture of the left scapula and open fracture of elbow GA III with distal fracture of Humerus Milch II and Mason III of radial head, and fracture of the base of the metacarpal. Results:Due to his hemodynamic instability, he was initially admitted to splenectomy, osteotaxis of the pelvis and femur and reduction of the exposed fracture and closure of the elbow slough. On week later he was submitted, in second time, to pubic symphysis osteosynthesis closed anterograde femoral nailing. Therapy:Was admitted the following week, the posterior approach of the elbow with osteotomy of the olecranon and obtained open reduction and osteosynthesis with Herbert screws and posterolateral platting of the distal humerus and arthroplasty of the radial head and reinsertion of the lateral collateral ligament. After 3 months, the K wires were extracted from the olecranon andarthrolysis was also performed.After a year, the patient underwent 1º of flexion and -20º of extension and pronosupination without deficits. Comments:The pre-op planning in these cases is crucial and these procedures are planned. The surgical gestures are performed based on the type of the fractures. Many times, some of the decision making process is developed during the surgery. As this case is an articular fracture, anatomical reduction is essential, with a fixation that is stable enough for a good progression of the rehabilitation program, that is fundamental for a good outcome.References:Midtgaardk.;etall;ElbowFrcaturesClinSportsMed39(2020)623–636 NO

Total elbow arthroplasty as a treatment option for complex elbow fracture – Clinical report

Polytrauma

The treatment of multifragmentary fractures of the distal humerus in elderly is challenging. The poor bone quality is a factor to take into account when deciding on the best treatment option. Osteoporosis is the enemy of internal fixation, especially when dealing with comminution of the artificial surface while in young patients the indication of prosthesis is restricted to those cases when there is no other option for treatment1. The clinical case about a 77-year-old woman presented to the emergency department with a chief complaint of right elbow pain after a fall from standing. She had pain and was unable to active move the elbow, and the passive movements triggered pain. The neurovascular status was intact. Plain radiography revealed a complete and multifragmentary articular fracture of distal humerus (figure 1). This fracture type is classified by the AO/OTA as 13C3.3. The pre-operative planning was completed with CT scan with 3D reconstruction. Our selected treatment consisted of total elbow arthroplasty (Discovery - Lima Corporate®). We performed a posterior approach of the elbow and the ulnar nerve was identified and protected (figure 2).As there is no clear scientific evidence regarding when to start physical rehabilitation, we used a splint for up to 14 days with the elbow in semiextension in order to protect the soft tissues, after that she started de rehabilition program.At 3 months follow-up we report a result consisting of great pain control, range of motion (ROM) 90º for flexion and 10º for extension with absence of signs of instability or implant loosening. 1.Gallucci, G., W. Larrondo Calderón, Boretto, J. G., J.A. Castellaro Lantermo, J. Terán, &amp; Pablo De Carli. (2016). Total elbow arthroplasty for the treatment of distal humeral fractures. Revista Española de Cirugía Ortopédica Y Traumatología. https://doi.org/10.1016/j.recote.2016.03.00No

Reconstruction of chronic distal biceps tendon rupture with autologous semitendinosus tendon graft

Research

INTRODUCTION: Rupture of the distal biceps brachii tendon (DBT) is a rare injury seen predominantly in middle-aged men. Primary surgical repair is usually preferred in both acute and chronic cases, but in cases of tendon insufficiency, a tendon autograft or allograft can be used to bridge the defect and reattach the biceps to the bicipital tuberosity, with predictably good results. OBJECTIVES: Analysis of clinical outcomes of surgical reconstruction of chronic DBT ruptures using a semitendinosus autograft through an extended anterior approach and bicortical button fixation at least 18 months after surgery. PATIENTS &amp; METHODS: We studied 8 patients with chronic rupture who underwent tendon reconstruction with autologous semitendinosus graft and bicortical button fixation. The time after surgery ranged from 18 months to 11 years. The range of motion (ROM) of the elbow on the injured and non-injured side was compared, as were the patient-related outcomes. RESULTS: All 8 patients showed excellent results. ROM was complete in all patients. Mean satisfaction with surgery on a VAS of 1-10 was 9.6 (±0.5). All would choose surgical treatment again. Patient-reported outcomes, given as mean and range of values, were: Oxford Elbow Score = 3.1 (0-17); Mayo Elbow Performance Index = 97 (85-100); The Disabilities of the Arm, Shoulder, and Hand (DASH) = 5.6 (0-28); QuickDASH = 5.4 (0-27). CONCLUSION: DBT ruptures are rare injuries that require surgical treatment to restore elbow function. In chronic ruptures, when the tendon is retracted, scarred, and shortened, direct repair is not always possible. In such cases, reconstruction of the tendon with a semitendinosus autograft and bicortical button fixation can achieve a good functional result. REFERENCES: 1. Dillon MT, King JC. Treatment of chronic biceps tendon ruptures. Hand. 2013;8(4):401–9.No

Anterior approach for open reduction and internal fixation of coronoid process fractures in terrible triad injury of the elbow: Surgical technique and clinical experience

Introduction.Fixation of the coronoid process is the main challenge in terrible triad injury of the elbow. Currently, there is no consensus on the most appropriate approach and fixation methods, although the anterior approach has recently been proposed as a safe and reproducible alternative. The aim of this study is to analyze the functional and radiological outcomes obtained by performing this approach for fixation of the coronoid process. Material and methods.We performed a retrospective analysis of 7 patients who presented with a terrible elbow triad between January 2019 and August 2022. The surgical technique consisted on a sequential process by combining a posterior approach for radial head and collateral ligaments repair and anterior approach for coronoid process repair. Demographic data, type of coronoid process fracture (Regan-Morrey, O'Driscoll classifications), surgical protocol, functional outcomes, complications and radiological parameters (consolidation, heterotopic calcifications and degenerative signs) were analysed. Results.The sample was 57% female with a mean age of 56.5+/-9.2SD years and 43% male with a mean age of 48+/-8.3SD years. Mean follow-up was 11.4 months. Consolidation was observed in all cases. In 5 patients (71%) it was necessary to repair the LCL and in 2 patients (28%) radial head arthroplasty was performed. The range of motion achieved was 140º/-6º±8.9/8.3 for flexion-extension and 90º/85º±0/8.3 for prono-supination. Heterotopic calcifications were observed in 3 patients (42%) without interfering with range of motion, and degenerative signs were visualised in 2 patients (28%). Conclusions.The anterior elbow approach, in combination with the posterior approach, could be a therapeutic option for the treatment of coronoid process fractures in the context of terrible elbow triads. This approach allows better anatomical exposure of the fracture facilitating proper osteosynthesis without increasing the risk of neurovascular injury. No

Bilateral Galeazzi-equivalent fracture on paediatric population: A case report and literature review

Classically, in adults, a Galeazzi fracture is described as a radial shaft fracture with na associated injury of the distal radioulnar joint (DRUJ). In children and adolescents it is a even more rare entity than in adults. In this young population it is described a variant of Galeazzi fracture, the so called Galeazzi-equivalent fracture, which consists of a distal radius fracture, at the distal metaphyseal-diaphyseal junction, with a concomitant fracture trough the distal growth plate of the ulna, usually a Salter-Harris type II injury. A 13-year-old boy, fell from his bicycle and sustained a bilateral Galeazzi-equivalent fracture with dorsal angulation (Walsh type I). Closed reduction and casting were attempted but without a satisfactory result for nonoperative treatment. Thus ORIF was performed. On the left wrist, we performed closed reduction and percutaneous crossed pinning with K-wire of radial fracture and ORIF of ulnar epiphysis with K-wire. On the right wrist, we performed ORIF of radial fracture with a volar locking plate and screws and ORIF of ulnar epiphysis with a K-wire. After both bone osteossynthesis, DRUJ was assessed and presented unstable. Radioulnar pinning was then performed with a K-wire. An above-elbow splint was applied on both wrists. The main concern regarding these specific type of fracture is the high prevalence of ulnar physeal growth arrest occuring in approximately 55% of the cases.It is advisable a follow up period of at least 2 years with periodic appointments, to assess a possible premature ulnar physis closure, length discrepancies or DRUJ instability. At 2 year postoperatively, our patient had no clinical complaints, with normal range of motion, performing daily activities and sport activities without any limitation. Radiographs showed complete bone union and no signs of ulnar growth arrest. Mayo score was 100 and DASH score was 5. No complications were found at this time of follow-up.No

Radial malunion following both bone forearm fracture – When plate is needed in the pediatric patient

In pediatric age, both bone forearm fractures correspond to 40% of all fractures, and mainly affect the distal metaphysis. Treatment in most cases involves closed reduction and immobilization with a cast, but fixation criteria, are useful in clinical decision. The most accepted fixation method in diaphyseal fractures is nailing with elastic rods, and there are also described cases of hybrid fixation, where delayed union or malunion are rare. An 8-year-old patient with a diaphyseal fracture of radiusand ulna with significant angulation was admitted in the emergency department. Non operative treatment was the initial choice, with brachypalmar cast. The 1 week follow-up resulted in loss of acceptable reduction and operative treatment was determined. Percutaneous intramedullary nailing of both forearm bones was the initial surgery and 2 month follow-up was carried out with no complications. Nail extraction was decided after 10 weeks. At 3 month post-op we observed complete union of the ulna but minimal angulation with delayed union of the radius. At this point, functional bracing was settled, and the patient presented no pain. Close follow-ups every 4 weeks showed progressive angulation and significant and palpable deformity was noted. At 6 months follow up, radial deformity was dorsal 30º angulation, resulting in the decision to reoperate, with radial osteotomy and deformity correction with plate and screws fixation. There were no operative and post operative complications and the patient had complete union of the fracture and no functional impairment. Complete mobility of elbow and wrist was accomplished and plate and screws were removed after 1 year. This case presents an infrequent complication that we must avoid. Di Gennaro described risk fractures for fracture malunion in children and we might notice that early nail extraction was determinant to treatment failure. Successfull recovery and full range of motion was achieved, with optimal radiographic result.No

Plastic deformity – "A strange radius"

Case history Plastic deformity is a type of incomplete diaphyseal fracture that does not affect the growth plate. It occurs in children and young adolescents and is most common in the forearm bones. In this type of fracture, the cortical bone is subjected to traction forces on the convex side and compression forces on the concave side. If these forces exceed the elastic limit, deformity will occur without radiological evidence of fracture. CNG, 4 years old, admitted to the ED due to pain and deformity of the left forearm. According to the mother, these complaints lasted 2 days, starting after falling on the same level. Clinical findings On clinical examination, the child assumed an antalgic position of the left upper limb, with the arm close to the trunk, elbow flexed at 90º and pronation of the forearm. He had pain on palpation at the level of the middle third of the radius. Also presented pain and functional incapacity when asked to supinate the left forearm, with the elbow in flexion. Investigation/Results Radiography of the forearm in 2 views demonstrated a plastic deformity of the radius with 15º of dorsal angulation, without other fractures. Diagnosis Plastic deformity of left radius. Therapy and Progressions A closed reduction of the deformity was performed under sedation with Nitrogen Protoxide and a closed brachypalmar plaster cast was placed, with the elbow flexed at 90º and the wrist in a neutral position. Results The control x-ray verified the closed reduction and the patient was discharged with an appointment scheduled at 4 weeks. Comments Plastic deformity of a long bone is often underdiagnosed. This is particularly relevant in the case of the radius, due to its natural arc. Hence, early diagnosis of injuries that cause functional disability and/or unacceptable angular deformity and their timely treatment are the key to clinical success. References Scweich, Paula. "Midshaft forearm fractures in children." Uptodate, 20/10/2023.No.

Ass. Prof. Dr.

Comparison of the percutaneous volar versus dorsal limited approach for the treatment of minimally and non-displaced scaphoid waist fractures: A prospective, randomised study with 10-year follow up

Introduction: minimally and non-displaced scaphpoid waist fractures can be treated with Herbert screw using palmar percutaneous (PPA) or dorsal limited (DLA) approaches. Comparative studies of the treatemnt results are relatively frequent in the literature, but long term follow up and prospective randomised design of the studies are missing. Material and method: Between July 2008 and December 2010 a total number of 76 patients met entry criterion. The submission of the patient into group 1 -PPA and group 2- DLA was performed on the basis of systematic sampling which provided systém homogeneity in age, sex and hand dominance. Two patients were lost during 1st year follow up and total loss during a ten year follow-up was 13 patients (17 %). We evaluate CT examination, ROM, grip strengh, teh presence of pain and DASH questionaire. Results: There was one symptomatic scaphoid nonunion in the group PPA. This was noit statistically significant as were the results of ROM, grip strengh, the presence of pain and results of DASH questionaire. We found three patients ing group PPA with degenerative change of STT joint, but only one was clinically significant. Conclusion: Base on our data from this prospective randomized 10-year follow up, we did not find the PPA for the treatment of min imally or non-displaced scaphoid waist farcture o be superior to DLA. References: 1) Saedén B, Törnkvist H, Ponzer S, Hoglund M. Fracture of the carpal scaphoid. A prospective, randomised 12-year follow-up comparing operative and conservative teratment. J bOne Joint Surg 2002;83B: 230-234. 2) Nicholl JE, Buckland-Wright JC. Degenerative changes at the scaphotrapezial joint following Herbert screw insertion: A radiologic study comparing patients with scaphoid fracture and primary hand arthritis. J Hand Surg 2000;25B: 422-426. No

Routine 6-weeks outpatient visit in patients treated surgically for upper extremity fractures: Is it truly necessary?

Objectives: To investigate the usefulness of the routinely planned six week outpatient visit and X-ray in patients treated surgically for the most common upper extremity fractures including clavicula, proximal humerus, humerus shaft, olecranon, radial shaft and distal radius. Method: This was a retrospective snapshot study of all patients treated surgically for the most common upper extremity fractures between 2019 and 2022 in a level 1 trauma center. The first outcome of interest was the incidence of abnormalities found on the X-ray made at the 6-weeks outpatient visitIn case an abnormality was detected, the hospital records were screened to determine its clinical consequence. The clinical consequences were categorized into requiring either additional diagnostics, additional interventions, change of standard postoperative immobilization, weightbearing or allowed range of motion (ROM). The second outcome of interest was the incidence of deviations from the local standard post operative treatment and follow-up protocol based on the 6-weeks outpatient visit as a whole. Deviations were also categorized in the same manner. Results A total of 267 patients were included. Abnormalities on X-ray at 6-weeks were found in only 10 (3.7%) patients of which only 4 (1.5%) had clinical implications (in three patients extra imaging was required and in one patient it was necessary to deviate from standard weightbearing/ROM limitation regime). The clinical/radiological findings during the 6-weeks outpatient visit led to a deviation from standard in only 8 (3.0%) patients. Notably, the majority of these patients experienced symptoms suggestive for complications. Conclusion The routine 6-weeks outpatient visit and X-ray, after surgery for common upper extremity fractures, rarely has clinical consequences. It should be questioned whether these routine visits are necessary and whether a more selective approach should be considered.none

Poster session 2
Session 2: Upper extremity: Elbow, forearm and hand

Appointment

Chairs

Topic

Programme

Poster session 2Session 2: Upper extremity: Elbow, forearm and hand

Appointment

Chairs

Topic

Programme

Poster session 2
Session 2: Upper extremity: Elbow, forearm and hand