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Background: Intramedullary fixation in distal biceps tendon repair may be a solution to address specific shortcomings of current fixation techniques. Most investigations are limited to biomechanical evaluation. The purpose of this study was to report the short-term outcomes of an intramedullary fixation device. Methods: We evaluated functional and radiographic outcomes at up to 6 months of follow-up. Patients with an acute distal biceps tendon nipture eligible for surgical repair were invited to take part in the study. Ten patients were included in the final analysis. All patients were evaluated both clinically and radiographically at 2 weeks, 6 weeks, 3 months, and 6 months. Outcomes were recorded using a visual analog scale score for pain, the Mayo Elbow Performance Score, and the Disabilities of the Arm, Shoulder and Hand score. Radiographic evaluation comprised radiographic and computed tomography evaluation. Results: There were no failures of fixation in the patient group examined. Elbow mobility was symmetrical for all patients from 3 months onward. Supination strength was 86% of the uninjured side at final follow-up. The mean Disabilities of the Arm, Shoulder and Hand score and Mayo Elbow Performance Score at final follow-up were 0 and 100, respectively. Computed tomography images showed no signs of button migration, cortical thinning due to button pressure, or button breakout. The tendon could be followed to the button in all cases. Conclusions: The intramedullary fixation button technique to repair the distal biceps tendon has excellent functional outcomes at 6 months. No adverse reactions of the button on the bone were seen. As this technique minimizes the risk of posterior interosseous nerve injury and has a sufficient bone tunnel to avoid gap formation, this may be a promising new technique for distal biceps tendon rupture refixation. (C) 2021 Journal of Shoulder and Elbow Surgery Board of Trustees. All rights reserved.

Background: The clinical diagnosis of partial distal biceps tendon ruptures or tendinosis can be challenging. Three clinical tests have been described to aid in an accurate and timely diagnosis: biceps provocation test, tilt sign, and resisted hook test. However, not much is known about the sensitivity, specificity, and inter-rater reliability as the available evaluations are based on small groups or are case based. Furthermore, these tests have not been compared together in the same patient group. Methods: Two dedicated elbow surgeons each included 20 consecutive patients in whom distal biceps tendon pathology was suspected. Patients with a complete distal biceps tendon tear were excluded. As a control, the same number of consecutive patients with various elbow pathologies other than distal biceps tendon problems was included. All 3 tests were performed both in control patients and in patients with suspected biceps tendon pathology. Magnetic resonance imaging (MRI) in the flexion-abduction-supination view and/or surgical exploration was performed in both groups. The findings of the clinical tests were determined before the results of MRI and other technical investigations were analyzed. The values of sensitivity, specificity, and accuracy were calculated. Results: The combined sensitivity, specificity, and accuracy values for the biceps provocation test were 95%, 97%, and 96%, respectively. For the resisted hook test, the combined values were 78%, 76%, and 77%, respectively. The combined values for the tilt sign were 58%, 55%, and 56%, respectively. When the biceps provocation test and the resisted hook test were combined in a parallel testing setup, the sensitivity increased to 98% whereas the specificity was 73%. The sensitivity and specificity of the biceps provocation test and the tilt sign in a parallel testing setup were 97% and 53%, respectively. Finally, the sensitivity and specificity of the tilt sign and the resisted hook test in a parallel testing setup were 90% and 41%, respectively. Conclusions: The biceps provocation test yielded higher accuracy than the resisted hook test and the tilt sign. When the biceps provocation test and the resisted hook test were combined, the sensitivity increased to 98%. We advise integration of these tests in daily practice to minimize delays in the diagnosis of partial distal biceps tendon ruptures, distal biceps tendon bursitis, or tendinosis. MRI in the flexion-abduction-supination view is still advised to distinguish between a partial biceps tendon rupture and tendinosis or bursitis at the distal biceps tendon insertion as this may influence further treatment. (C) 2021 Journal of Shoulder and Elbow Surgery Board of Trustees. All rights reserved.

Coronoid fractures are often a part of extensive elbow trauma and persistent elbow instability can occur after a coronoid fracture. The decision to perform surgery is based less on fragment size and more on the impact on elbow joint stability. To lessen the impact on the elbow joint and to accelerate rehabilitation, arthroscopic repair is gaining popularity. Repair can be performed as an arthroscopic reduction and internal fixation (ARIF) or, when the fragment is too small, as an anterior capsulodesis. Good functional outcome has been reported with the arthroscopic fixation technique.

Posterolateral rotatory instability (PLRI) involves an avulsion of the lateral collateral ligament complex, including the lateral ulnar collateral ligament. It is usually caused by a traumatic simple dislocation but can also be iatrogenic after surgery on the lateral elbow. If conservative treatment fails, surgery may be indicated. The ligament is classically reinserted or reconstructed with an open procedure, but arthroscopic treatment is gaining popularity. In this chapter we present our arthroscopic imbrication technique to treat posterolateral rotatory instability. Results are generally excellent with low complication rates or recurrence of instability.

Primary radial head arthroplasty (RHA) produces good or excellent results in approximately 85% of patients. However, complications are not uncommon and have been described in up to 23% of cases. The number of RHA is increasing, and consequently the absolute number of complications is expected to rise as well. The decision on whether to revise or remove the prosthesis seems more likely to depend on the preference of the surgeon or the hospital, rather than on objectifying problems with the prosthesis. The current article presents an algorithm for the work-up and treatment of most complications that can occur following RHA. Five subgroups of problems were identified: osteoarthritis, stiffness, instability, infection and implant-related issues. In short, the preferred treatment depends mainly on the chondral condition and stability of the elbow joint.Cite this article: EFORT Open Rev 2020;5:398-407. DOI: 10.1302/2058-5241.5.190055

In malunion cases, restoration of anatomy is a key factor in obtaining a good functional outcome, but this can be technically very challenging. Three-dimensional printed bone models can further improve understanding of the malunion pattern. The use of three-dimensional (3D) computer planning, and the assembly of patient-specific instruments and implants, especially in complex deformities of the upper limb, allow accurate correction while reducing operation time, blood loss volume and radiation exposure during surgery. One of the major disadvantages of the 3D technique is the additional cost because it requires specific computer software, a dedicated clinical engineer, and a 3D printer. Further technical developments and clinical investigations are necessary to better define the added value and cost/benefit relationship of 3D in the treatment of complex fractures, non-unions, and malunions. Cite this article: EFORT Open Rev 2019;4 DOI: 10.1302/2058-5241.4.180074

Background Although revision arthroplasty surgery is a frequently used treatment for failed total elbow arthroplasty (TEA), published results are conflicting. The aim of this systematic review was to provide an overview of the outcomes of revision TEA surgery. Methods A systematic literature search was performed in major databases to find articles relating to outcomes after revision of TEA. Two reviewers independently screened the articles for inclusion, and a third reviewer screened them before final inclusion. Results Twenty-one articles containing 532 cases were included. The mean age at revision was 61 years. The mean interval between primary and revision arthroplasty was 77 months, and the average follow-up period was 65 months. Different types of prostheses were included, with 69% of the revision prostheses having linked designs and 31% having unlinked designs. The visual analog scale score, Mayo Elbow Performance Score, Oxford Elbow Score, and range of motion improved significantly after revision surgery. Complications were reported in 232 of 532 cases (44%), leading to reoperations in 22%. After revision with linked prostheses, the Mayo Elbow Performance Score, range of flexion-extension, and pronation improved significantly more than with unlinked designs. Conclusion Improved functional outcomes can be expected after revision TEA, but the complication rate remains high. Revision TEA should still be considered a salvage procedure for failed TEA. Linked designs for revision TEA result in better outcomes than unlinked designs in the midterm follow-up.

Elbow injuries in the throwing athlete have distinct injury patterns. They commonly develop medial elbow problems due to the tensile forces applied to the medial stabilising structures, combined with lateral compartment compression and posterior shear forces. Repetitive valgus stresses may lead to a selection of chronic overuse problems, but athletes can also present with acute and acute-on-chronic injuries. The spectrum of throwing injuries encompasses ulnar collateral ligament tears, flexor-pronator tendinopathy, medial epicondyle apophysitis, and valgus extension overload syndrome. Non-operative treatment begins with a period of rest from throwing, followed a rehabilitation programme promoting elbow range of motion, flexor-pronator strengthening, ultimately leading to retraining in throwing mechanics at approximately 3 months. Acute surgical repair of ulnar collateral ligament tears is indicated in cases of acute avulsion from the humeral origin or the coronoid insertion. Chronic insufficiency may warrant ulnar collateral ligament reconstructive surgery involving a free tendon graft, usually placed in bone tunnels in the humerus and ulna.

Background: The aim of this study was to analyze indications, outcomes, and complications in patients treated with radiocapitellar arthroplasty. Methods: This prospective analysis of clinical and radiographic results included 16 elbows in 15 patients. Results: This study included 4 men and 11 women (mean age, 51.9 years; age range, 32-65 years). The mean follow-up period was 3.4 years (range, 2-6 years). The indications were post-traumatic (n = 10) and primary radiohumeral osteoarthritis (n = 6). A mean of 2 surgical procedures (range, 0-4) had been performed before radiocapitellar arthroplasty. The mean Mayo Elbow Performance Score significantly improved from 46 points to 85 points (P < .01). The arc of motion improved from 106 degrees to 117 degrees (P = .27). Radiographic ulnohumeral degeneration progressed in 40% of cases but was not symptomatic in any. Subsequent surgery was required in 5 elbows (31%). Revision of the radial head component was necessary in 4 patients (25%). In 3 patients this was a result of loosening of the stem. The radial component was subsequently removed because of persistent pain in 1. Radiographic loosening not requiring revision was found in 2 patients. Conclusion: The overall Mayo Elbow Performance Score was good to excellent after radiocapitellar arthroplasty. Both the revision and reoperation rates were high, and one should consider this before performing this procedure. Loosening of the radial head component was a problem. An improved fixation technique or an adaptation of the design is needed before this type of surgery can be recommended as a standard procedure. (C) 2018 Published by Elsevier Inc. on behalf of Journal of Shoulder and Elbow Surgery Board of Trustees.

There has been an increase in thrower-specific elbow injuries in recent years. High valgus stresses during the late cocking and acceleration phases of throwing need to be compensated by the flexor pronator muscles as these can exceed the tensile strength of the medial collateral ligament complex. Prevention of injuries is the priority, with a focus on strengthening, reducing throwing frequency, decreasing force, and promoting a technique. The spectrum of thrower injuries ranges from a simple sprain to complete failure of the valgus stabilizing factors. The medial collateral ligament can stretch, leading to posteromedial impingement and radiocapitellar compression forces. This in turn can result in arthrosis and the formation of osteophytes. Ligament failure may eventually occur, making it impossible for the athlete to continue their throwing activities. The outcome of conservative treatment with strengthening, improvement of technique, and relative rest is often disappointing. Direct repair may no longer be possible in these acute-on-chronic injuries and a reconstruction with a tendon graft may be necessary.In den letzten Jahren gab es einen Anstieg wurfspezifischer Ellenbogenläsionen. Eine hohe Valgusbelastung während der späten Anspannungs- und Beschleunigungsphasen des Werfens muss durch die Flexoren und Pronatoren ausgeglichen werden, da diese die Zugkraft des medialen kollateralen Bandkomplexes übersteigen können. Der Prävention von Verletzungen wird der Vorzug gegeben, dabei liegt ein Fokus auf der Stärkung, der Verminderung der Wurfhäufigkeit, der Verminderung des Krafteinsatzes und einer ausgefeilten Technik. Werferverletzungen umfassen ein Spektrum von Verletzungen von einer einfachen Zerrung bis zum vollständigen Ausfall der valgusstabilisierenden Faktoren. Das mediale kollaterale Band kann gedehnt werden, was zu einem posteromedialen Impingement und Kompressionskräften zwischen dem Radius und dem Capitulum humeri führt. Dies kann in einer Arthrose und der Bildung von Osteophyten enden. Das Ligament kann schließlich reißen, was es für den Sportler unmöglich macht, seine Wurfsportart weiter auszuführen. Das Ergebnis der konservativen Therapie mit Stärkung, Verbesserung der Technik und relativer Ruhe ist oftmals enttäuschend. Eine direkte Rekonstruktion ist bei diesen chronischen Verletzungen mit akuter Phase ggf. nicht mehr möglich, und u. U. bedarf es einer Rekonstruktion mit einem Sehnenimplantat.

For those patients with instability of the medial and lateral sided of the elbow, there is a place for a circumferential graft. This has the main advantage of simplifying the bone tunnel creation and graft fixation, compared to having both medial- and lateral-sided reconstructions.

Postoperative rehabilitation plays a crucial role in the treatment of elbow pathology. Depending on the type of surgery, the elbow may need to be protected. As a general rule, the elbow should not be immobilized for a prolonged period after surgery. A removable splint can be used to protect the soft-tissues immediately postoperative and the patient is encouraged to remove the splint several times daily to mobilize the elbow. Dynamic articulated braces can be used to encourage movement while ligament or tendon repairs are being protected. Literature on postoperative elbow rehab is scarce. In this paper we provide practical guidelines for specific surgical procedures.

Background Medial epicondylitis is a common orthopedic condition that typically results from overuse or previous microtrauma of the flexor-pronator mass. Repetitive eccentric loading of the muscles leads to subsequent degeneration of the flexor tendons. Diagnosis Patients present with a painful elbow. In the case of concomitant elbow pathologies, including ulnar neuritis and ulnar collateral ligament injury, there should be a detailed examination. Generally, the diagnosis is based on the clinical examination. T2-weighted magnetic resonance imaging can be useful for chronic courses, over 6 months. Treatment Nonsurgical management is the mainstay of treatment. Hence, surgical treatment may be indicated for patients with persistent symptoms after conservative treatment. In the case of a surgical treatment, arthroscopy can be useful to capture concomitant elbow pathologies.

Instability is stratified between acute and chronic and according to the direction of the instability. Acute elbow dislocations are treated by closed reduction. Further treatment is determined by clinical exam following the reduction. Chronic instability is classified as lateral, medial, or multidirectional. Advanced imaging is often helpful next to taking a thorough history and performing a clinical exam with specific testing of the direction and mechanism of instability.

Triceps injuries, including triceps tendon ruptures, are relatively rare. Recently, the knowledge of tendon lesions has increased, and it seems to be related to more precise diagnostic and clinical assessments. The most common mechanism of injury remains a forceful eccentric contraction of the muscle. Several other risk factors have been studied, such as chronic renal failure, endocrine disorders, metabolic bone diseases, and steroid use. Olecranon bursitis and local corticosteroid injections may also play a role. The most common site of rupture is at the tendon’s insertion into the olecranon and rarely at the myotendinous junction or intramuscularly. Surgical intervention is recommended in acute complete ruptures; non-operative treatment is reserved for patients with major comorbidities, as well as for partial ruptures with little functional disability and in low demand patients. Various techniques and approaches have been proposed for the management of these challenging injuries. The goal of surgical management should be an anatomical repair of the injured tendon by selection of a procedure with a low complication rate and one that allows early mobilization.

Snapping and pain at the medial elbow can be caused by a snapping of the triceps tendon and muscle belly. It can be accompanied by a shooting pain in the distribution of the ulnar nerve. Eccentric loading of the triceps tendon is the most specific test to confirm a snapping triceps syndrome. Two snaps may be experienced during clinical exam. A first snap occurs at around 90°. This is the ulnar nerve subluxating out of its groove. A second snap usually occurs at around 115° when the triceps dislocates over the medial epicondyle. Surgical treatment consists of an anterior transposition of the ulnar nerve and removal of the medial part of the triceps.

The indication for surgery in a patient with an acute simple elbow dislocation remains debatable. The decision to perform surgery depends on the patient and the severity of the instability. Surgery can be performed with an open or an arthroscopic technique. Arthroscopic evaluation of the unstable elbow is helpful in both acute and chronic cases. Medial and lateral laxity can be evaluated under direct view of the ulnohumeral and radiohumeral joint spaces. Varus and valgus testing can show opening of the joint space. Arthroscopic repair is possible, as well as open repair. We prefer to use a bone anchor. Postoperatively the patient is protected in a brace that allows for progressive extension.

In some patients, a primary repair of the ruptured triceps tendon may not be possible. A tendon augmentation will be necessary. This can be done in multiple ways. We prefer to use an Achilles tendon allograft technique to reconstruct the distal triceps tendon and to obtain a firm fixation to the proximal ulna. It is imperative to debride scar tissue from the triceps tendon stump up to healthy tendon. The native tendon is released to mobilize it as far as possible toward the proximal ulna, with the elbow extended. The proximal part of the Achilles tendon is draped over at least 10 cm of the triceps tendon stump. It is fixed with multiple rows of suture to obtain a strong fixation and to decrease the risk of a seroma between the native and allograft tendons. The distal part of the allograft Achilles tendon is fixed to the bone with bone tunnels and a bone anchor. The calcaneum can be used to achieve a bone-to-bone fixation, but as it is bulky, we prefer not to use this if the bone stock of the patient is sufficient. Postoperatively, the elbow is protected with a dynamic brace that allows for progressive flexion over a period of 6 weeks.

Isolated arthritis of the lateral compartment of the elbow is rare. Arthroscopic debridement and removal of loose bodies and osteophytes usually lead to good results, when conservative measures fail. The indications for radiocapitellar replacements therefore remain limited. Patients who suffer from post-traumatic or primary radiocapitellar osteoarthritis, who have failed other treatment options, may be considered candidates for a radiocapitellar arthroplasty. Other treatment modalities that could be considered include radial head resection or interposition of tissue. This could also be considered as salvage when a radiocapitellar replacement fails. Placement of a radiocapitellar arthroplasty is technically more challenging, but the incidence of complications should be decreased with a correct surgical technique. Special attention should be paid to perfect alignment and solid placement of the components. Current literature is scarce on outcome data. With the right selection of patients and without postoperative complications, patients’ satisfaction rate is high, with excellent pain relief and functional results.

Background: Contact stresses of radial head prostheses remain a concern, potentially leading to early capitellar cartilage wear and erosion. In particular, point contact or edge loading could have a detrimental effect. The purpose of this study was to compare 3 different types of radial head prostheses in terms of joint contact areas with each other and with the native situation. The hypothesis was that the joint contact areas would be lower after monopolar arthroplasty. Methods: Seven fresh-frozen cadaveric upper limbs were used. Radiocapitellar contact areas of a monopolar design, a straight-neck bipolar design, and an angled-neck bipolar design were compared with each other and with the native joint. After standardized preparation, polysiloxane was injected into the loaded radiocapitellar joint to create a cast from which the joint contact area was measured. Measurements were performed at 3 angles of elbow flexion and in 3 different forearm positions. Results: In the native elbow, contact areas were highest in supination. Elbow flexion had no significant effect on native and prosthetic joint contact areas. Contact areas were decreased for all types of arthroplasties compared with the native joint (from 11% to 53%). No significant contact area difference was found between the 3 designs. However, bipolar prostheses showed lateral subluxation in neutral forearm rotation, resulting in a significant decrease in the contact areas from pronation to the neutral position. Conclusions: All types of radial head prostheses tested showed a significant decrease in radiocapitellar contact area compared with the native joint. Bipolar designs led to subluxation of the radial head, further decreasing radiocapitellar contact., SCOPUS: ar.j, info:eu-repo/semantics/published

Simple elbow dislocations are usually treated conservatively. Radiographs are negative in simple dislocations. Results are generally good, although a small percentage of patients may develop chronic instability. Ligamentous repair can be indicated in high demand patients or if the elbow remains unstable following a closed reduction. Chronic instability is classified per their direction. Surgery is often indicated in the chronically unstable elbow.

Purpose We evaluated clinical and radiographic outcome of percutaneous transtrapezial fixation of the scaphoid delayed union or nonunion using a headless bone screw without bone grafting. Methods Sixteen patients with delayed union or nonunion of the scaphoid were included in this retrospective study between 2006 and 2011. All patients had a delayed presentation of scaphoid fracture, and none of them was treated conservatively elsewhere. Patients with bone graft, sclerotic bone debridement, or displacement of the fragment at the nonunion site were excluded. A percutaneous transtrapezial fixation technique was used in all cases. Patients were reviewed until clinical and radiographic union was observed. At the final follow-up, DASH (Disabilities of the Arm, Shoulder and Hand) and PRWHE (Patient-Rated Wrist and Hand Evaluation) outcome scores were completed. Results Radiographic union was obtained in 15 out of 16 patients (94%) at an average follow-up of 36 months (range: 12–98 months). No complications from the percutaneous technique were noted. The average DASH score was 6 (range: 0–39) and the average PRWHE score was 10 (range: 0–56). No statistical significant difference in range of motion and grip strength was found between the operated side and the contralateral side. Conclusion Percutaneous transtrapezial screw fixation for delayed or nonunion of selected scaphoid fractures without bone grafting is promising. At a mean of 4 months, 94% union was obtained with good functional results when there was no sclerosis, minimal osteolysis, and no displacement at the scaphoid nonunion site. Type of Study Therapeutic study. Level of Evidence IV.

Purpose One of the options to repair a ruptured distal biceps tendon to the radial tuberosity is by means of a transosseous cortical button. Although excellent functional outcomes have been reported, no studies have been performed to quantify the effect of the transosseous fixation technique on the radius. Our study evaluated the clinical outcome and radiological outcome of this technique. The main goal of this study was to evaluate the radiographic evolution of the bone tunnel in the radius. Methods Patients with an acute distal biceps tendon rupture treated with a transosseous cortical button were invited to take part in the study. Fourteen patients were included in the final analysis. All patients were evaluated both clinically and by computed tomography scanning of the proximal radius after a minimum follow-up of 2 years. Outcomes were recorded using the visual analog scale score for pain, the Mayo Elbow Performance Score, and Disabilities of the Arm, Shoulder, and Hand scores. Bone tunnel volume was measured with semiautomated computed tomography segmentation using image-processing software. Results There were no failures of fixation in the patient group examined. Elbow mobility, arm, and forearm circumference were symmetric for all patients. Average visual analog scale for pain was less than 2. Mean Disabilities of the Arm, Shoulder, and Hand score and Mayo Elbow Performance Score were 2.3 and 97.6, respectively. Computed tomography images showed an average closure of the radial bony tunnel of 64% of the initial volume. Conclusions Biceps tendon repair with cortical button fixation only shows partial tunnel closure. This could reduce the risk of potential complications due to osteolysis, such as radius fracture or hardware failure. Functional results were excellent and comparable to other fixation methods. The role of interference screws in transosseous cortical button techniques to strengthen the repair and to avoid osteolysis may therefore be questioned. Type of study/level of evidence Therapeutic IV.

Background The transverse carpal ligament is well known for its involvement in carpal tunnel syndrome, and sectioning of this ligament remains the definite treatment for this pathology. Some authors believe that the transverse carpal ligament is an important stabilizer of the carpal arch, whereas others do not consider it to be significant. Several studies have been performed, both in vivo and in in vitro. Sectioning of the transverse carpal ligament does not seem to have any effect on the width of the carpal arch in the unloaded condition. However, patients will load the arch during their activities of daily living. Materials and Methods A cadaveric study was done with distraction of the carpal bones before and after sectioning the transverse carpal ligament. Results With the transverse carpal ligament intact, the carpal arch is mobile, with distraction leading up to 50% widening of the arch. Sectioning of the transverse carpal ligament resulted in a significant widening of the carpal arch by a further 30%. Conclusions Loading of the carpal arch after sectioning of the transeverse carapal ligament leads to a significant increase in intracarpal mobility. This will inevitably influence carpal kinematics in the patient and might be responsible for some complications after simple carpal tunnel releases, such as pillar pain, palmar tenderness, and loss of grip strength.

The ulnar collateral ligament is the primary static constraints of the elbow to valgus stress. Injuries to this ligament may lead to significant functional impairment and potential secondary intra-articular damage to the elbow. A diverse group of patients can present with symptoms related to ulnar collateral ligament insufficiency, ranging from children with acute elbow dislocations to professional athletes with chronic overload injuries. The current review will discuss, anatomy, biomechanics and clinical findings regarding ulnar collateral ligament injuries. An overview of treatment options will also be presented.

Purpose Double plating has been promoted, in recent years, as an alternative treatment method for proximal ulna fractures. This study aimed to compare the biomechanical properties of double-plate osteosynthesis with posterior plate fixation using a novel investigational design utilizing a 3-dimensional camera system to analyze fracture micromotion. Methods Fourteen fresh-frozen specimens were available for this study. Mayo type IIA fractures of the olecranon were created and internal fixation was performed with either an angular stable posterior plate or angular stable double plates. Fracture micromotion was evaluated by means of digital image correlation with a 3-dimensional camera system before and after dynamic cyclic loading from 15° to 90° of elbow flexion with a pulling force of 25 N to 80 N. Results Micromotion of fragments was less pronounced in double-plate osteosynthesis when compared with single plates before and after cyclic loading. However, overall results were similar. Two of the single plates failed during cyclic loading but there were no failures in the double plates. Conclusions This biomechanical analysis shows that single and double plating results in comparable stability of fixation. Although the double-plating technique tends to provide more stable fixation, relevant differences were not observed. Clinical relevance Double plating potentially represents an efficient option for fixation of proximal ulna fractures. It could decrease the risk of soft tissue complications owing to their low profile and the superior soft tissue coverage.

Background and purpose Radial head fractures are common, and may be associated with other injuries of clinical importance. We present the results of a standard additional MRI scan for patients with a radial head fracture. Patients and methods 44 patients (mean age 47 years) with 46 radial head fractures underwent MRI. 17 elbows had a Mason type-I fracture, 23 a Mason type-II fracture, and 6 elbows had a Mason type-III fracture. Results Associated injuries were found in 35 elbows: 28 elbows had a lateral collateral ligament lesion, 18 had capitellar injury, 1 had a coronoid fracture, and 1 elbow had medial collateral ligament injury. Interpretation The incidence of associated injuries with radial head fractures found with MRI was high. The clinical relevance should be investigated.

Although triceps tendon ruptures can result from a traumatic incident, chronic overuse causing degenerative changes to the insertion and leading to a complete or partial rupture is more common. In our practice, we have found that anabolic steroid abuse by weightlifters is the most common predisposing factor. The initial diagnosis is often missed. A thorough clinical examination is imperative to avoid missing a partial or complete rupture. Ultrasound or magnetic resonance imaging can confirm the diagnosis. Early diagnosis increases the chance of a direct repair. Operative treatment with direct repair is usually indicated for full-thickness or large partial-thickness tears. Direct repair may be possible for selected chronic tears. Triceps tendon repair is performed with the following steps.Step 1: The patient is placed in lateral decubitus.Step 2: The stump is debrided, and retraction of the tendon is evaluated.Step 3: Two crossed bone tunnels are drilled, and an anchor is placed centrally in the olecranon.Step 4: The elbow is extended, and the tendon is reduced and sutured centrally to the anchor and medially and laterally with use of the sutures from the bone tunnels.Step 5: The elbow is flexed to evaluate tension. If gapping occurs, the repair should be reinforced with extra sutures. Tension-free range of motion will guide postoperative rehabilitation.Step 6: A posterior splint is applied in the operating room with the elbow extended.Step 7: A dynamic brace is applied on the first postoperative day. Extension is free but flexion is blocked at the tension-free range; 30° of extra flexion is permitted every 2 weeks. Full flexion is always allowed after 6 weeks. Strengthening starts at 3 months. Pitfalls of the procedure include difficulty in differentiating between tendon and scar in subacute and chronic ruptures. It may not be possible to directly repair the triceps back to bone, and a graft may be needed to reconstruct the tendon. It is important to know where the ulnar nerve is and to release it if needed. It is important not to debride past the cortical surface of the olecranon if an anchor is used because, if this is done, fixation may be insufficient. The anchor should be predrilled as the cortical bone of the tip of the olecranon is very dense. Reruptures occur in up to 21% of cases. A functional range of motion is usually achieved with an average loss of extension of 10° and average flexion to 136°. At 1 year, one can expect a peak strength of approximately 80% of that on the uninjured side and endurance strength of 99%1.

Snapping triceps syndrome is a rare and therefore often unknown cause of medial elbow pain. It is a condition in which the distal portion of the triceps dislocates over the medial epicondyle during flexion and extension of the elbow. It can occur, with or without ulnar neuropathy symptoms. The available literature on this subject is scarce and consists mainly of case reports. This report reviews the current literature and will provide guidance in diagnosis and treatment of this uncommon condition.

The goal of this study was to look at the pattern of osteophyte distribution on a 3-dimensional computed tomography scan of patients with symptomatic osteoarthritis in the elbow. We recruited 22 consecutive patients with symptomatic osteoarthritis of the elbow for the study. Three-dimensional reconstructed anterior, posterior, medial, and lateral views of the elbow were reviewed. Ulnohumeral osteophytes were found in 21 patients (95%), and radiohumeral osteophytes were found in 13 (59%). Cadaveric and biomechanical studies suggest that the radiohumeral joint appears to be more prone to wear and stress than the ulnohumeral joint. Our study showed that the percentage of patients with ulnohumeral joint osteophytes (95%) was higher than that of radiohumeral joint (59%). Therefore, this study challenges the conventional belief that osteoarthritis starts from the radiohumeral joint and progress toward the ulnohumeral joint.

Radial head fractures are common injuries. In American publications, one-third of the patients with these fractures have been shown to have associated injuries. The aim of this retrospective study is to describe the epidemiology of radial head fractures and associated fractures of the ipsilateral upper extremity in a European population. This study describes the epidemiology of radial head and associated fractures of the upper extremity in a Dutch population by a retrospective radiographic review of all patients with a radial head fracture between 1 January 2006 and 1 July 2007. A total of 147 radial head fractures were diagnosed in 145 patients. The incidence in the general population was 2.5 per 10.000 per year. The average age was 45.9 (SD 17.3) years and male–female ratio was 2:3. The mean age of males was significantly lower (37.1, SD 14.2 years) than of women (53.9, SD 16.4 years). Associated fracture of the upper extremity was found in 10.2%. Coronoid fractures were most common (4.1%). Associated upper limb fractures in patients with a radial head fracture are common in the European population. It is of clinical importance to suspect associated lesions and to perform a thorough physical examination and additional radiological examination on demand.

Elbow instability is usually the result of an acute major or minor traumatic event, resulting in injury to the ulnar collateral ligament (UCL) or lateral ulnar collateral ligamentous complex (LUCL). This manuscript will focus on the specific salient features of the evaluation and surgical decision-making for injuries to the elbow resulting in medial and lateral (posterolateral) instability.

Elbow arthroscopy is becoming more and more popular. Compared to open elbow procedure, this surgical technique has several advantages: able to see better, improved access, magnification (a microscope of the elbow), minimal “collateral damage,” less scarring, decreased risk of infection, and less postoperative pain. But it also includes some risks that are more common compared to an open procedure like compartment syndrome and transient or permanent nerve injuries.

Acromioclavicular joint (ACJ) dislocation is a common injury often affecting young adults. Its sequalae range from an asymptomatic shoulder to one that is painful with significant loss of strength in the affected upper limb. The management of ACJ dislocation has revolved around expert neglec

Reconstructing elbow instability remains a challenging problem. Techniques described have included techniques for the lateral ligamentous complex, including the lateral ulnar collateral ligament, and techniques to reconstruct the medial collateral ligament. We describe a new circumferential technique to reconstruct both the lateral and medial ligament complexes, using 1 circular graft. A hole is drilled through the center of rotation of the distal humerus and through the insertion sites of the medial and lateral ligament complexes. A hamstring tendon graft is passed through the humerus twice to reconstruct the anterior and posterior bands of the medial collateral ligament and sutured onto itself. Endobutton fixation is used to fix the graft on either side of the ulna. The graft is tightened on the lateral and medial sides and fixed into the humerus using interference fit screws. Advantages of the technique described include stabilization of both the medial and lateral ligament complexes with 1 graft. The strength of fixation allows for individual tensioning in all limbs of the reconstruction and the multiple passes of the graft through a single humeral tunnel increasing the strength of the reconstruction. Potential complications could include ulnar nerve damage, recurrent instability, elbow stiffness, and wound breakdown. Complications related to the potential use of a hinged external fixator are not specific to this procedure but can be associated. Early active mobilization can be initiated because of the strong stability provided by the circumferential graft and good fixation.

A patient presented with chronic shoulder pain from a rare plasmocytoma in the distal humerus that resolved following a pathologic fracture. Staged reconstruction of the elbow after resection of the tumor in the distal humerus resulted in resolution of the patient's elbow and shoulder symptoms.

Treatment of radial head fractures may be complicated because of the presence of associated lesions. However, little is known about the frequency or relevance of associated lesions in different types of radial head fractures. We studied the demographics of radial head fractures focusing on associated lesions in 333 adults from 1997 to 2002. The mean age of the patients was 45 years (range, 18-82 years). Two hundred twenty-three (67%) patients had Mason Type 1 fractures, 46 patients had Mason Type 2 (14%) fractures, and 64 patients had Mason Type 3 (19%) fractures. One hundred eighteen of 333 patients (39%) had associated fractures or soft tissue injury. Fifty-three (16%) patients had coronoid fractures, and 45 patients (14%) had elbow dislocations. Two hundred thirty-five (71%) patients had nonoperative treatment, which failed in six (3%) patients. Sixty-six (20%) patients had open reduction and internal fixation, which failed in six (9%) patients. Resection was used in 20 (6%) patients, and radial head replacement was used in 31 (9%) patients, one of which was revised. The ligamentous injury required surgical repair or reconstruction in 44 patients. A concurrent coronoid fracture was the most common associated injury prompting referral to this tertiary medical center.Diagnostic study, Level IV (case-control study). See the Guidelines for Authors for a complete description of levels of evidence.

Results of the treatment of the deficient coronoid and chronic elbow instability have not been reported. The purpose of this study was to analyze the results of structural bone graft for reconstruction of the coronoid process. Structural bone graft was used to reconstruct the coronoid process of 6 patients. All injuries were of the terrible triad: fracture of the coronoid, radial head fracture, and collateral ligament disruption. All cases had persistent posterior subluxation averaging 6 months (range, 1-13 months before reconstruction. Patient charts, surgical records, and radiographs were reviewed. All patients were contacted at a mean of 64 months after treatment to answer a specific set of questions to determine the Mayo Elbow Performance score. In 1 patient, radiographs showed complete resorption of the graft and severe osteoarthritis of the elbow at 54 months after surgery (case 4). The Mayo Elbow Performance score showed 1 excellent, 2 good, 1 fair, and 2 poor results. Structural bone graft may be a useful option for a deficient coronoid process and an unstable elbow, but the outcome is unpredictable.

Purpose The purpose of this study was to define the shape of the radial head by identifying the relationship between precisely defined axes of the radial head. Methods An anatomic study was done to define the shape of the radial head and specifically the relationship between the long and the short axis. Twenty-seven cadaveric upper extremities were used. The x and y axes of the radial head were defined in relationship to the radial notch of the ulna, with the forearm in neutral position. Outer diameters of the x and y axis were measured. These were compared with the actual maximum and minimum diameters of the radial head. X and y diameters of the articulating surface of the radial head also were measured. Paired 1-tailed Student's t -tests were used to compare the x and y diameters of the radial head. Regression analysis of x and y diameters of the radial head was done to identify a correlation between these parameters. Results Paired 1-tailed Student's t -tests showed a significant difference between X and Y diameters of the radial head. Regression analysis of x and y diameters of the radial head showed a strong correlation between these 2 axes. Conclusions The radial head is not round. A strong correlation exists between the x and y diameters of the radial head. The orientation of the long axis is perpendicular to the radial notch with the forearm in neutral rotation. This finding will make it possible to approach the anatomy of the radial head more closely when designing radial head prostheses. The definition of the axes can be used as a guide when implanting the radial head prosthesis.

The arthroscopic management of the arthritic elbow is technically challenging. Disastrous complications, such as permanent nerve damage, have been described. However, the frequency of complications is low and the results are usually very good. There are several pearls to achieve success. Firstly, the surgeons should know their limitations. Not all arthritic elbows may be treatable with an arthroscopic technique. Once the correct indication has been made, complications can usually be avoided. The elbow is thoroughly examined once anesthesia has been administered. A capsulectomy is, for example, not indicated if the patient has a full range of motion. The surface anatomy is marked on the skin and the elbow is insufflated to increase the space between the trocar and the neurovascular structures. A perfect knowledge of the anatomy is not only necessary for the correct placement of the portals, but also during the procedure when a shaver and other instruments are introduced into the joint. The tip of the shaver should be visible at all times and suction should not be used when the shaver is active. Patients can expect a significant improvement in pain and function and as a general rule, a 30° increase in arc of motion is realistic. When compared to open techniques, arthroscopy offers an excellent view of all intra-articular structures and decreases damage to extra-articular soft tissues. Arthroscopy of the elbow has evolved to a standard technique in the treatment of elbow pathology and every surgeon involved in the treatment of these patients should train themselves to face the technical challenges it brings.

Background: When a surgeon uses a percutaneous volar approach to treat scaphoid waist fractures, central screw placement is complicated by the shape of the scaphoid and by obstruction by the trapezium. In this study, we used radiographs and biomechanical tests to compare the standard volar percutaneous approach with the transtrapezial approach, with regard to central screw placement at the distal pole of the scaphoid. Methods: Fourteen matched pairs of cadaveric wrists were randomly assigned to two treatment groups. Under fluoroscopic control, a guidewire was drilled into the scaphoid, either through a transtrapezial approach or through a standard volar approach that avoided the trapezium. Guidewire position was measured in the coronal and sagittal planes. A transverse osteotomy was performed along the scaphoid waist, and this was followed by the insertion of the longest possible cannulated headless bone screw. Each specimen was placed into a fixture with a pneumatically driven plunger resting on the surface of the distal pole. Load was applied by using a load-controlled test protocol in a hydraulic testing machine. Results: All guidewires were inside the central one-third of the proximal pole. The guidewire positions at the distal pole differed significantly between the transtrapezial and standard volar approach groups (p < 0.001). The load to 2 mm of displacement and the load to failure averaged, respectively, 324.4 N (standard error of the mean [SEM] = 73.5 N) and 386.4 N (SEM = 65.6 N) for the transtrapezial approach group compared with 125.7 N (SEM = 22.6 N) (p = 0.002) and 191.4 N (SEM = 36.30 N) (p = 0.005) for the standard volar approach group. Conclusions: The data suggest that, in a cadaveric osteotomy-simulated scaphoid waist fracture model, the transtrapezial approach reliably achieves central positioning of a screw in the proximal and distal poles. This position offers a biomechanical advantage compared with central placement in only the proximal pole.