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Purpose: Stable fixation of distal humerus fracture fragments is necessary for adequate healing and maintenance of reduction. The purpose of this study was to measure the reliability and accuracy of interpretation of postoperative radiographs to predict which implants will loosen or break after operative treatment of bicolumnar distal humerus fractures. We also addressed agreement among surgeons regarding which fracture fixation will loosen or break and the influence of years in independent practice, location of practice, and so forth., Methods: A total of 232 orthopedic residents and surgeons from around the world evaluated 24 anteroposterior and lateral radiographs of distal humerus fractures on a Web-based platform to predict which implants would loosen or break. Agreement among observers was measured using the multi-rater kappa measure., Results: The sensitivity of prediction of failure of fixation of distal humerus fracture on radiographs was 63%, specificity was 53%, positive predictive value was 36%, the negative predictive value was 78%, and accuracy was 56%. There was fair interobserver agreement (κ = 0.27) regarding predictions of failure of fixation of distal humerus fracture on radiographs. Interobserver variability did not change when assessed for the various subgroups., Conclusions: When experienced and skilled surgeons perform fixation of type C distal humerus fracture, the immediate postoperative radiograph is not predictive of fixation failure. Reoperation based on the probability of failure might not be advisable., Type of Study/level of Evidence: Diagnostic III., (Copyright © 2016 American Society for Surgery of the Hand. Published by Elsevier Inc. All rights reserved.)

The purpose of this study was to evaluate surgeon, patient, and radiographic factors influencing the recommendation for operative treatment in distal radius fractures. In a web-based study 252 orthopaedic surgeons from a variety of countries reviewed 30 consecutive sets of radiographs of patients that presented to our emergency department with a fracture of the distal radius. Surgeons were randomly assigned to receive either 'Radiographs only' or 'Radiographs and clinical information'. Surgery was recommended on average 52% of the time whether or not surgeons received clinical information. Female surgeons, surgeons with less than 21 years of experience, and hand surgeons were more likely to recommend operative treatment, but these factors explained only 1% of the variation. Radiographic criteria (intra-articular fractures, ulnar styloid fractures, dorsal comminution, dorsal tilt, and ulnar variance) explained 49% of the variation. The overall agreement on treatment was moderate and slightly higher among surgeons that received radiographs alone. Level of evidence: Level II, therapeutic; not a clinical study., (© The Author(s) 2014.)

Purpose: To identify risk factors for complications after volar locking plate fixation of distal radius fractures., Methods: We assessed early postoperative complications in 594 patients with fracture of the distal radius repaired with a volar locking plate and a minimum 1-month evaluation in the medical record. Later complications were assessed among 321 patients as a subset of the original cohort with a minimum 6 months' evaluation. We compared patient demographics, fracture characteristics, and aspects of management between patients with and without complications in bivariate analysis. Multivariable logistic regression analysis was applied to identify the factors independently associated with complications., Results: A total of 47 complications were documented in the medical record. Early complications occurred in 24 of 594, including 8 intra-articular screws and 7 patients with loss of fixation. Late complications occurred in 23 of 321, including 14 patients diagnosed with tendon irritation (one rupture of the flexor pollicis longus tendon) and 5 patients who had subsequent surgery to address dysfunction of the distal radioulnar joint (malunion, synostosis, and arthrofibrosis). Of the 47 complications, 26 were attributed to the plate, of which 9 were considered major (intra-articular screws and tendon rupture; 1.3% (8 out of 594) and less than 1% (1 out of 321) of the early and late groups, respectively). In the logistic regression models, fall from a height and an ipsilateral elbow injury were positive independent predictors of early complications, whereas high-volume surgeons and plates other than the most commonly used plate were positive independent predictors of later complications., Conclusions: Volar locking plate fixation of distal radius fractures was associated with relatively few plate-related complications in our institutions. Factors indicating higher energy or complexity predicted early complications. The most common late complication was tendon irritation, which is less discrete and perhaps variably diagnosed. Further study is warranted regarding plate design and familiarity, which may help reduce complications., Type of Study/level of Evidence: Prognostic IV., (Copyright © 2011. Published by Elsevier Inc.)

Ulnohumeral subluxation or dislocation is rare after open reduction and internal fixation of a bicolumnar fracture of the distal humerus. We report 3 patients in whom detachment of the origins of the lateral collateral ligament and common extensor muscle origins from the lateral epicondyle contributed to postoperative instability after open reduction and internal fixation of a fracture of the distal humerus. This may be due to either unrecognized ligament injury or iatrogenic injury during surgical dissection., (Copyright 2010. Published by Elsevier Inc.)

Purpose: The purpose of this retrospective study was to evaluate the functional and radiological long-term outcome of open reduction and internal fixation of skeletally mature patients with a Bado type 1 Monteggia fracture., Methods: We identified 11 consecutive skeletally mature patients who had surgical treatment of an anterior (Bado type 1) Monteggia fracture. Long-term evaluation at a median of 20 years after injury (range, 7-34 years) was compared with an early evaluation at a median of 13 months after injury (range, 11-32 months). The early and long-term results were evaluated radiographically and according to the system of Broberg and Morrey. The long-term result was also evaluated according to the Mayo Elbow Performance Index, the American Shoulder and Elbow Surgeons, and the Disabilities of the Arm Should and Hand scores., Results: Two patients had subsequent surgery to address a nonunion and 3 elbows had radiographic signs of arthrosis. The mean arc of elbow flexion increased from 110 degrees (range, 35 degrees to 140 degrees) at early follow-up to 120 degrees (range, 40 degrees to 150 degrees) at late follow-up. The mean arc of forearm rotation increased from 145 degrees (range, 90 degrees to 180 degrees) to 149 degrees (range, 90 degrees to 180 degrees). The mean Broberg and Morrey score increased from 89 points (range, 62-100 points) to 94 points (range, 76-100 points). The median DASH score was 7 points (range, 0-34 points) at long-term follow-up. There was no statistical difference between early and late range of motion or Broberg and Morrey score., Conclusions: The results of open reduction and internal fixation of anterior Monteggia fractures in skeletally mature patients are maintained over long-term follow-up., Type of Study/level of Evidence: Therapeutic IV.

Background: Recent work has established that apparently isolated fractures of the capitellum are often more complex and involve the lateral epicondyle, trochlea, and posterior aspect of the distal part of the humerus. We assessed the experience with operative stabilization of fractures of the capitellum and trochlea at one level-I trauma center over a twenty-eight-year period., Methods: Thirty classifiable partial articular fractures involving the capitellum and trochlea were included in the study. Twenty-seven patients were followed for a minimum of twelve months, and fourteen patients returned for long-term follow-up at a median of seventeen years. The early and long-term results were evaluated according to the Broberg and Morrey Functional Rating Index. The long-term results were also evaluated according to the Mayo Elbow Performance Index (MEPI), the American Shoulder and Elbow Surgeons (ASES) score, and the Disabilities of the Arm, Shoulder and Hand (DASH) questionnaire., Results: Eighteen patients (67%) had one or more subsequent surgical procedures, and eight of these patients had the procedure to address surgical complications. Five of the eight patients with complications and ten additional patients underwent routine removal of implants; these fifteen patients included twelve of the fourteen patients in the long-term cohort. In addition to the fracture of the distal part of the humerus, four patients had a dislocation of the elbow; three, a fracture of the olecranon or the proximal part of the ulna; and two, a fracture of the radial head. The median arc of flexion improved from 106 degrees at the time of early follow-up to 119 degrees at the time of long-term follow-up (p < 0.05). In the group of fourteen patients with long-term follow-up, the median Broberg and Morrey score was 93 points at the time of early follow-up and 95 points at the time of late follow-up. The functional results were worse for patients with a Type-3 fracture, as classified with the system of Dubberley et al., than they were for those with a Type-1 fracture. The fourteen patients with long-term follow-up had a median MEPI of 98 points, a median ASES score of 88 points, and a median DASH score of 8 points; nine of the fourteen patients had radiographic signs of arthrosis., Conclusions: The vast majority of what appear to be capitellar fractures are actually complex fractures of the articular surface involving both the capitellum and the trochlea. More complex fractures have worse functional results; however, the functional results of operative treatment seem to be durable over time.