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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.

Background: Terrible triad injuries consist of a posterior dislocation of the elbow, a coronoid fracture, and a radial head fracture. The coronoid plays a pivotal role as an anterior buttress, yet the optimal management of the coronoid fracture remains unknown. We hypothesize that suture lasso fixation of the coronoid fracture leads to fewer complications and improved outcomes compared with screw or suture anchor fixation techniques., Methods: A retrospective chart review performed at three tertiary care centers identified forty consecutive patients treated for terrible triad injuries of the elbow with a minimum follow-up of eighteen months (mean, twenty-four months; range, eighteen to fifty-three months). All patients were managed with a standard approach consisting of: (1) repair or replacement of the radial head; (2) repair of the lateral ulnar collateral ligament (LUCL) of the elbow; and (3) repair of the coronoid fracture with one of two techniques: Group I (n = 28) consisted of the "lasso" technique and Group II (n = 12) consisted of open reduction and internal fixation (ORIF) with screws or suture anchors., Results: For the study population, the mean postoperative arc of elbow motion was 115° (range, 75° to 140°), the average Disabilities of the Arm, Shoulder and Hand (DASH) score was 16 (range, 0 to 43), and the average Broberg-Morrey score was 90 (range, 64 to 100). For repair of the coronoid fracture, the suture lasso technique was more stable than the other techniques intraoperatively, both before (p < 0.05) and after (p < 0.05) LUCL repair, and at the final follow-up (p < 0.05). ORIF was associated with a higher prevalence of implant failure (p < 0.05), and suture anchors were associated with a higher prevalence of malunion and nonunion (p < 0.05)., Conclusions: For terrible triad injuries, greater stability with fewer complications was achieved with use of the suture lasso technique for coronoid fracture fixation.

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.

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.

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.

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.