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The treatment of elbow injuries can be challenging because of the complexity of both anatomy and pathology. We present a rare traumatic avulsion fracture of the supinator crest of the ulna in a 37-year-old patient. Conservative treatment in a long arm cast for four weeks led to satisfactory results. Reproduction of the fracture on a cadaveric elbow clarified that the avulsed fragment holds the insertion of the lateral ulnar collateral ligament (LUCL). The mechanism of trauma that causes this fracture is a posterolateral (sub) luxation of the elbow, which usually causes the LUCL to rupture, but in rare cases the insertion of this ligament can be avulsed. A posterolateral (sub) luxation of the elbow can lead to chronic posterolateral rotational instability and therefore the stability of the elbow should be taken into account in the treatment of patients with such a fracture. A review of the literature concluded that this fracture often is associated with other injuries to the elbow and that it is easily missed on conventional AP and lateral radiographs. CT or MRI imaging and a radial head-capitellum view radiograph can be beneficial. Both conservative and operative treatments have been described with good clinical results., (Copyright © 2016 Elsevier Masson SAS. All rights reserved.)

A 26-year-old male complained of painful clavicles. His medical history included multiple fractures of both clavicles, all treated conservatively. Conventional radiographs revealed a typical shape of both clavicles, suggesting non-union. His extraordinary medical history and non-union of both clavicles led to the diagnosis: 'congenital pseudarthrosis of both clavicles'.

Background: Treatment of displaced paediatric distal forearm fractures is not always successful. Re-occurrence of angular deformity is a frequent complication. No consensus exists when to perform secondary manipulations. The purpose of this study was to analyse the long-term outcome of re-angulated paediatric forearm fractures to determine if re-manipulations can be avoided., Methods: Children who underwent closed reduction for distal forearm fractures and presented with re-angulation at follow-up were included in this retrospective cohort study. We compared those that were re-manipulated to those managed conservatively. Re-angulation was defined as ≥15° of angulation on either the AP or lateral view. Children were reviewed after 1-8 years post injury. Outcome measures were residual angulation on radiographs, active range of motion, grip strength, Visual Analogue Scales (satisfaction, cosmetics and pain) and the ABILHANDS-kids questionnaire., Results: Sixty-six children (mean age of 9.6 years) were included. Twenty-four fractures were re-manipulated and 42 fractures had been left to heal in angulated position. At time of re-angulation, children <12 years in the conservative group had similar angulations to those re-manipulated. Children ≥12 years in the re-manipulation group had significantly greater angulations than children in the conservative group. At final follow-up, after a mean of 4.0 years, near anatomical alignment was seen on radiographs in all patients. Functional outcome was predominantly excellent. There was no significant difference in functional, subjective or radiological outcomes between treatment groups., Conclusion: Re-manipulation of distal forearm fractures in children <12 years did not improve outcomes, deeming re-manipulations unnecessary. Children ≥12 years in the conservative group achieved satisfactory outcomes despite re-angulations exceeding current guidelines. Based on observed remodelling, we now accept up to 30° angulation in children <9 years; 25° angulation in children aged 9-<12; 20° angulation in children ≥12 years, when re-angulation occurs. We conclude that clinicians should be more reluctant to perform re-manipulations.

Introduction: Both-bone forearm fractures in children frequently result in a limitation of pronation/supination, which hinders daily activities. The purpose of this prospective multicentre study was to investigate which clinical factors are related to the limitation of pronation/supination in children with a both-bone forearm fracture., Methods: In four Dutch hospitals, consecutive children (<16 years) who sustained a both-bone forearm fracture were included. Children were followed up for 6-9 months and data from questionnaires, physical examination and X-rays were collected. Univariate and multivariate logistic regression analyses were used to assess the relationship between limitation of pronation/supination (≥20°) and several clinical factors., Results: A group of 410 children with both-bone forearm fractures were included, of which 10 children missed the final examination (follow-up rate of 97.6%). We found that a re-fracture (odds ratio (OR) 11.7, 95% confidence interval (CI) 1.2; 118.5), a fracture in the diaphysis (OR 3.3, 95% CI 1.4; 7.9) and less physiotherapy during follow-up (OR 0.90, 95% CI 0.82; 0.98) were independently associated with a limitation of pronation/supination of 20° or more., Conclusions: These findings imply that a re-fracture and a diaphyseal located fracture were associated independently of each other with a limitation of pronation/supination in children with a both-bone forearm fracture. Furthermore, in children with severe limitation extensive physiotherapy is associated with better functional outcome., (Copyright © 2013 Elsevier Ltd. All rights reserved.)

Introduction: Although both-bone forearm fractures in children may result in severe limitation of forearm rotation, finding the cause remains a diagnostic challenge. This study tries to evaluate the role of rotational malunion, bony impingement and contractures of the interosseous membrane., Patients and Methods: Children (5-16 years) who suffered from a both-bone forearm fracture in diaphysis or distal metaphysis with a limitation of pronation/supination ≥40° at ≥6 months after trauma were included for analysis with conventional radiographs, computed tomography (CT) and magnetic resonance imaging (MRI)., Results: A total of 410 children with a both-bone forearm fracture were prospectively followed in four Dutch hospitals. At a median of 205 days, 7.3 % suffered from a limitation of pronation/supination ≥40°. 14 children were included (median limitation of 40°) and the radiographs revealed a median maximum angular malunion of 16°. CT analysis showed rotational malunion of both radius (median 19°) and ulna (median 9°). MRI analysis revealed neither bony impingement nor contractures of the interosseous membrane., Conclusions: Three-dimensional imaging of children with a severe limitation of pronation/supination after a both-bone forearm fracture revealed rotational malunions of both radius and ulna without bony impingement or soft tissue contractures., Level of Evidence: Prospective multicenter study, Level 2.

Background: It is unclear whether it is safe to convert above-elbow cast (AEC) to below-elbow cast (BEC) in a child who has sustained a displaced diaphyseal both-bone forearm fracture that is stable after reduction. In this multicenter study, we wanted to answer the question: does early conversion to BEC cause similar forearm rotation to that after treatment with AEC alone?, Children and Methods: Children were randomly allocated to 6 weeks of AEC, or 3 weeks of AEC followed by 3 weeks of BEC. The primary outcome was limitation of pronation/supination after 6 months. The secondary outcomes were re-displacement of the fracture, limitation of flexion/extension of the wrist and elbow, complication rate, cast comfort, complaints in daily life, and cosmetics of the fractured arm., Results: 62 children were treated with 6 weeks of AEC, and 65 children were treated with 3 weeks of AEC plus 3 weeks of BEC. The follow-up rate was 60/62 and 64/65, respectively with a mean time of 6.9 (4.7-13) months. The limitation of pronation/supination was similar in both groups (18 degrees for the AEC group and 11 degrees for the AEC/BEC group). The secondary outcomes were similar in both groups, with the exception of cast comfort, which was in favor of the AEC/BEC group., Interpretation: Early conversion to BEC cast is safe and results in greater cast comfort.

Introduction: This multicentre randomised controlled trial was designed to explore whether 6 weeks above-elbow cast (AEC) or 3 weeks AEC followed by 3 weeks below-elbow cast (BEC) cause similar limitation of pronation and supination in non-reduced diaphyseal both-bone forearm fractures in children., Materials and Methods: Children were randomly allocated to 6 weeks AEC or to 3 weeks AEC followed by 3 weeks BEC. The primary outcome was limitation of pronation and supination after 6 months. The secondary outcomes were re-displacement of the fracture, complication rate, limitation of flexion and extension of wrist and elbow, cast comfort, cosmetics, complaints in daily life and assessment of radiographs., Results: A group of 23 children was treated with 6 weeks AEC and 24 children with 3 weeks AEC and 3 weeks BEC. The follow-up rate was 98 % with a mean follow-up of 7.0 months. The mean limitation of pronation and supination was 23.3 ± 22.0 for children treated with AEC and 18.0 ± 16.9 for children treated with AEC and BEC. The other study outcomes were similar in both groups., Conclusions: Early conversion to BEC is safe in the treatment of non-reduced diaphyseal both-bone forearm fractures in children., Level of Evidence: Multicentre randomised controlled trial, Level II.

Forearm fractures in children have a tendency to displace in a cast leading to malunion with reduced functional and cosmetic results. In order to identify risk factors for displacement, a total of 247 conservatively treated fractures of the forearm in 246 children with a mean age of 7.3 years (sd 3.2; 0.9 to 14.9) were included in a prospective multicentre study. Multivariate logistic regression analyses were performed to assess risk factors for displacement of reduced or non-reduced fractures in the cast. Displacement occurred in 73 patients (29.6%), of which 65 (89.0%) were in above-elbow casts. The mean time between the injury and displacement was 22.7 days (0 to 59). The independent factors found to significantly increase the risk of displacement were a fracture of the non-dominant arm (p = 0.024), a complete fracture (p = 0.040), a fracture with translation of the ulna on lateral radiographs (p = 0.014) and shortening of the fracture (p = 0.019). Fractures of both forearm bones in children have a strong tendency to displace even in an above-elbow cast. Severe fractures of the non-dominant arm are at highest risk for displacement. Radiographs at set times during treatment might identify early displacement, which should be treated before malunion occurs, especially in older children with less potential for remodelling.

Introduction: Displaced metaphyseal both-bone fractures of the distal forearm are generally reduced and stabilised by an above-elbow cast (AEC) with or without additional pinning. The purpose of this study was to find out if re-displacement of a reduced stable metaphyseal both-bone fracture of the distal forearm in a child could be prevented by stabilisation with Kirschner wires., Methods: Consecutive children aged <16 years with a displaced metaphyseal both-bone fracture of the distal forearm (n = 128) that was stable after reduction were randomised to AEC with or without percutaneous fixation with Kirschner wires. The primary outcome was re-displacement of the fracture., Results: A total of 67 children were allocated to fracture reduction and AEC and 61 to reduction of the fracture, fixation with Kirschner wires and AEC. The follow-up rate was 96% with a mean follow-up of 7.1 months. Fractures treated with additional pinning showed less re-displacement (8% vs. 45%), less limitation of pronation and supination (mean limitation 6.9 (± 9.4)° vs. 14.3 (± 13.6)°) but more complications (14 vs. 1)., Conclusions: Pinning of apparent stable both-bone fractures of the distal forearm in children might reduce fracture re-displacement. The frequently seen complications of pinning might be reduced by a proper surgical technique., (Copyright © 2012 Elsevier Ltd. All rights reserved.)

A 24-year-old woman with Ehlers-Danlos syndrome visited the emergency department because of a post-traumatic painful and swollen left elbow with impaired function. A plain radiograph showed chronic luxation of the radial head with impression in the humeral capitellum. The clinical presentation of chronic luxation of the radial head is easily confused with that of an acute dislocation of the radial head, which may wrongly result in subsequent reduction.

Purpose: Platelet rich plasma (PRP) is derived from the patient's own blood. The activated blood platelets release a cocktail of growth factors, some of which are thought to initiate and stimulate repair. We compared two groups to investigate whether the use of PRP mixed with bone chips improves bone healing in patients with a skeletal defect., Methods: In total, 41 patients were observed. One group underwent a high tibial osteotomy with the addition of PRP and bone chips in the open wedge. The other group underwent the same procedure without the addition of PRP. Six patients had to be excluded because of insufficient data or they were lost to follow-up. Bone healing was studied using computed tomography scanning. The blood was sequestered and PRP was produced using a blood cell separator with a PRP software program (Electa, Sorin Group, Mirandola, Italy)., Results: Analysis focused on the remaining 35 patients. At baseline, there were no differences between the two groups for age, sex and side of operation. At one week postoperatively, the bone density under (p = 0.02) and above the wedge was significantly lower in the PRP group than the control group (p = 0.24). At six weeks postoperatively, no significant differences between the treatment groups were found. At 12 weeks, the PRP group had significantly lower bone density under the wedge compared to the control group (p = 0.01)., Conclusions: We found that patients with a skeletal defect did not benefit from the application of PRP mixed with an allograft regarding bone healing.

Introduction: Minimally displaced metaphyseal both-bone fractures of the distal forearm in children are often treated with an above-elbow cast (AEC). Treatment with a below-elbow cast (BEC) could give more comfort, but might lead to fracture displacement reducing pronation and supination. Because this has not been systematically investigated, we set up a randomised multicentre study. The purpose of this study was to find out whether BEC causes equal limitation of pronation and supination but with higher comfort level, compared with AEC., Patients and Methods: In four hospitals, consecutive children aged<16 (mean 7.1) years with a minimally displaced metaphyseal both-bone fracture of the distal forearm were randomised to 4 weeks BEC (n=35) or 4 weeks AEC (n=31). Primary outcome was limitation of pronation and supination 6 months after initial trauma. The secondary outcomes were cast comfort, limitation of flexion/extension of wrist/elbow, complications, cosmetics, complaints, and radiological assessment., Results: A group of 35 children received BEC and 31 children received AEC. All children attended for the final examination at a mean follow-up of 7.0 months (range 5.0-11.6 months). Limitation of pronation and supination 6 months after initial trauma showed no significant difference between the two groups [4.4° (± 5.8) for BEC and 5.8° (± 9.8) for AEC]. Children treated with BEC had significantly higher cast comfort on a visual analogue scale [5.6 (± 2.7) vs. 8.4 (± 1.4)] and needed significantly less help with dressing (8.2 days vs. 15.1 days). Six complications occurred in the BEC group and 14 in the AEC group. Other secondary outcomes were similar between the two groups., Conclusions: Children with minimally displaced metaphyseal both-bone fractures of the distal forearm should be treated with a below-elbow cast., (Copyright © 2012 Elsevier Ltd. All rights reserved.)

We present a case of symptomatic, incomplete bony carpal coalition between capitate and trapezoid. We describe previous case reports and possible therapeutic options., (Copyright © 2011 American Society for Surgery of the Hand. Published by Elsevier Inc. All rights reserved.)

An 18-year-old man presented with the inability of pro- and supination of the right forearm. Radiographic examination of the elbow showed a radioulnar synostosis. The degree of fixation of pronation of the forearm determines the functional complaints. In this case, the patient had a favourable pronation of 5 degrees, which allowed for conservative treatment.

Displaced supracondylar fractures of the humerus in children may be managed with or without Kirschner-wire fixation. The results of treatment of displaced supracondylar fractures of the humerus in children were analyzed, comparing the period before and after an audit of our results in 1997. From 1998 onward a more active policy regarding the use of percutaneous Kirschner-wire fixation was adopted. We treated 33 children between 1991 and 1997 (Period 1) and 49 children between 1998 and 2004 (Period 2). In Period 1, closed reduction and plaster immobilisation was performed in 29 patients. Four received initial Kirschner-wire fixation with plaster immobilisation. Secondary dislocation necessitating re-reduction occurred in 14 patients. In Period 2 initial Kirschner-wire fixation was performed in 41 patients, of whom 23 had open reduction. The other eight had conservative treatment consisting of closed reduction and plaster immobilization, two of them needing re-reduction. This evaluation indicates that a more active policy with regard to (open) reduction with Kirschner-wire fixation in displaced supracondylar humeral fractures in children, results in less need for secondary intervention with comparable functional and cosmetic outcome.