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Monteggia fracture is a relatively uncommon injury in pediatric patients, accounting for less than 2% of forearm fractures, characterized by a combination of ulna fracture and radial head dislocation. Neglected Monteggia fractures define as those that have not received treatment within 3 weeks. In children, ulna fractures are easily diagnosed while radial head dislocation may be overlooked, necessitating open reduction after neglecting the Monteggia fracture and potentially causing additional trauma to the child. This study aims to review the pathological characteristics of neglected Monteggia fractures based on the length ratio of the ulna and radius, relative positions between the proximal ends of the ulna and radius, the integrality of annular ligament and the pathological change of proximal radioulnar joint. The findings will provide valuable insights and guidance for managing neglected Monteggia fractures.
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PURPOSE: A comprehensive analysis of the morphology of fractures of the coronoid process (CP) can aid diagnosis and guide treatment. The involvement of the radial notch of the ulna (RN)-e.g., in anterolateral facet fractures and transverse fractures of the CP-may influence the biomechanical conditions of the proximal radioulnar joint. However, the morphometric relation between the CP and the RN and the extent to what the proximal radioulnar joint can be affected in these types of fractures is unknown. METHODS: A total of 113 embalmed, cadaveric ulnae were dissected. All soft tissue was removed. Strictly lateral, high-resolution photographs were taken and digitally analyzed. The height of the CP and its relation to the RN was measured. Sex differences and correlations between measured parameters were calculated. RESULTS: Mean height of the CP was 16 mm (range: 12-23 mm; SD: 2). Mean height of the RN was 16 mm (11-25 mm; 2.2). The 50% mark of the CP corresponded to 18% (0-56%; 11.2) of the height of the RN. No significant differences were found between male and female specimens. CONCLUSION: The RN of the ulna extends only to a small part to the CP. Transverse or anterolateral fractures of less than 50% of the coronoid process may involve only a small portion of the proximal radioulnar joint.
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Articulación del Codo , Fracturas del Radio , Fracturas del Cúbito , Humanos , Masculino , Femenino , Cúbito/anatomía & histología , Articulación del Codo/anatomía & histología , Extremidad SuperiorRESUMEN
OBJECTIVE: In order to reduce surgical scars and the risk of neurovascular injury for the treatment of terrible triad injuries of the elbow (TTI), minimally invasive and better therapeutic effect approaches are being explored to replace the conventional combined lateral and medial approach (CLMA). This study was performed to compare the clinical effect and security of the modified posterior approach (MPA) through the space of the proximal radioulnar joint vs the CLMA for treatment of TTI. METHODS: This study retrospectively analyzed 76 patients treated for TTI from January 2009 to December 2020 (MPA: n = 44; CLMA: n = 32). Treatment involved plate and screw fixation or Steinmann pin fixation for the radial head and ulnar coronoid process fractures. Surgeons only sutured the lateral ligament because the medial collateral ligament was usually integrated in the TTI. The continuous variables were compared by the independent Student t-test and the categorical variables by the χ2 -test or Fisher's exact test. RESULTS: Both groups of patients attained a satisfactory MEPS after the operation. The MEPS (MPA: 96.82 ± 6.04 vs CLMA: 96.56 ± 5.51) was not significantly different between the two groups (p > 0.05). However, the MPA resulted in better elbow flexion and extension (MPA: 123.98 ± 10.09 vs CLMA: 117.66 ± 8.29), better forearm rotation function (MPA: 173.41 ± 6.81 vs CLMA: 120.00 ± 12.18), and less intraoperative hemoglobin (MPA: 9.34 ± 5.64 vs CLMA: 16.5 ± 8.75) and red cell volume loss (MPA: 3.09 ± 2.20 vs CLMA: 6.70 ± 2.97) (All p < 0.05). Although the CLMA had a shorter surgery time (MPA: 171.73 ± 80.68 vs CLMA: 130.16 ± 71.50) (p < 0.05), it had a higher risk of neurologic damage (MPA: 0 vs CLMA: 4) (p < 0.05). Four patients developed forearm or hand numbness after the CLMA, but no patients developed numbness after the MPA. All 76 patients were followed up for 15 months postoperatively. CONCLUSION: The MPA through the space of the proximal radioulnar joint has more prominent advantages than the CLMA for TTI, including single scar, clear exposure, good fixation, lower risk of neurovascular injury, and better elbow joint motion. It is a safe and effective surgical approach that is worthy of clinical promotion.
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Lesiones de Codo , Articulación del Codo , Luxaciones Articulares , Fracturas del Radio , Fracturas del Cúbito , Articulación del Codo/cirugía , Antebrazo , Fijación Interna de Fracturas/métodos , Humanos , Hipoestesia/etiología , Luxaciones Articulares/cirugía , Fracturas del Radio/etiología , Fracturas del Radio/cirugía , Rango del Movimiento Articular , Estudios Retrospectivos , Resultado del Tratamiento , Fracturas del Cúbito/etiología , Fracturas del Cúbito/cirugíaRESUMEN
PURPOSE: The proximal radioulnar joint (PRUJ) and the radiocapitellar joint may be destabilized after trauma. Different techniques for stabilization of PRUJ have been proposed, but none of them can stabilize the radiocapitellar joint at the same time. We propose a ligamentoplasty to stabilize the radial head at these two joints by reconstructing the radial head annular ligament and the lateral collateral ulnar ligament (LCUL) with a single graft (palmaris longus or gracilis tendon of the knee). METHODS: Fifteen cadaveric upper limbs were used to compare the stabilization obtained by performing our ligamentoplasty with the palmaris longus or the gracilis tendon. For each technique, the stabilization obtained was evaluated by measuring the displacement of the radial head in the anterior, lateral and posterior directions when a force of 1 N was applied in maximum supination, neutral rotation and maximum pronation. We also evaluated whether this technique could damage the ulnar nerve or the posterior interosseous nerve by dissecting them and whether it could limit the range of rotation of the forearm. RESULTS: Our ligamentoplasty enables to restore PRUJ stability equivalent to the intact ligament condition. The palmaris longus was inconstant (13/15) and too short to allow concomitant reconstruction of the LCUL (except in one case). No nerve damage was found during the dissection, and the range of rotation of the forearm was not limited by the ligamentoplasty. We also report a clinical case with an excellent result and without complications. CONCLUSION: This ligamentoplasty we have described makes it possible to stabilize the radial head with respect to the radial notch of the ulna and with respect to the capitellum of the humerus. The gracilis tendon is more suitable than the palmaris longus because of its constant presence and length. A clinical series is now necessary to better evaluate this technique.
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Articulación del Codo , Antebrazo , Fenómenos Biomecánicos , Cadáver , Articulación del Codo/cirugía , Estudios de Factibilidad , Antebrazo/cirugía , Humanos , Radio (Anatomía)/diagnóstico por imagen , Radio (Anatomía)/cirugía , Tendones/cirugíaRESUMEN
OBJECTIVE: To evaluate the effect of the proximal and central bundles of the interosseous membrane on the stability of proximal radioulnar joint. METHODS: Twenty fresh samples of human forearm provided by the anatomy room of the Department of Human Anatomy of Nanjing Medical University were included in this study. They were used to explore the effect of proximal interosseous membrane bundle on the stability of proximal radioulnar joint. The proximal bundle was reconstructed along the original attachment point. The reconstructions of central bundle were divided into the reconstruction of original attachment point on radius-midpoint of the ulnar original attachment point (reconstruction A) and original attachment point reconstruction (reconstruction B). The loads of the proximal radioulnar joint in different positions were measured. The load of the proximal radioulnar joint was analyzed in neutral, pronation, and supination positions. RESULTS: After resection of proximal and central fascicles, the loads of proximal radioulnar joint in neutral, pronation, and supination positions were significantly lower than those before resection (P < 0.05). After reconstruction, the loads of proximal radioulnar joint in neutral and supination positions were higher than those after resection (P < 0.05). After reconstruction, the loads of proximal radioulnar joint in neutral and supination positions were higher than those after resection (P < 0.05), and that after reconstruction B in pronation position was higher than that after resection (P < 0.05), while there was no significant difference between reconstruction A and after resection (P > 0.05). In supination position, the load of reconstruction B was higher than that of reconstruction A (P < 0.05). After reconstruction of the proximal and central bundles, the proximal radioulnar joint could not reached the same load as it could before resection (P < 0.05). CONCLUSION: The stability of proximal radioulnar joint is affected by central bundle and proximal bundle. Reconstruction can increase the stability of proximal radioulnar joint.
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Membrana Interósea/lesiones , Membrana Interósea/cirugía , Procedimientos de Cirugía Plástica/métodos , Traumatismos de la Muñeca/cirugía , Adulto , Anciano , Fenómenos Biomecánicos , Cadáver , Femenino , Humanos , Masculino , Persona de Mediana EdadRESUMEN
The one bone forearm is a salvage procedure for treatment of painful, instability of the forearm that results from trauma, congenital deformity, tumor, infection, and failed reconstructive efforts. By creating a stable osseous bridge between the ulnohumeral and radiocarpal joints, one bone forearm addresses defects in the bony architecture of the radius and ulna, their articulations, and their associated ligamentous complexes. Global instability of the forearm is a complex clinical pathology with few other answers. Choice of technique should be dictated by adjacent bone loss. This article presents experience with creating a one bone forearm in patients using synostosis procedures.
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Antebrazo/cirugía , Inestabilidad de la Articulación/cirugía , Procedimientos Ortopédicos/métodos , Terapia Recuperativa/métodos , Adolescente , Adulto , Anciano , Niño , Articulación del Codo/fisiopatología , Femenino , Antebrazo/fisiopatología , Humanos , Inestabilidad de la Articulación/fisiopatología , Masculino , Persona de Mediana Edad , Articulación de la Muñeca/fisiopatología , Adulto JovenRESUMEN
INTRODUCTION: The radial head has an ellipsoid shape so that a longest and a shortest axis can be defined. The aim of this study is to evaluate the position of the longest axis of the radial head (LARH) in relation to proximal radioulnar joint (PRUJ) and to the forearm in neutral position using 3D computed tomography (CT). MATERIALS AND METHODS: 3D CT reconstructions of the distal humerus, the radius and the ulna of 27 healthy volunteers (average age 27.65 ± 9.25; 24 males, 3 females) were created. First an evaluation of the elliptic form of the radial head and the location of its longest axis was performed. Next, three planes were defined: the PRUJ plane, the forearm plane and a neutral plane. Based on the angle between the forearm plane and the neutral plane, the rotation of the scanned forearm was measured. Taking this rotation into account, the position of the LARH compared to PRUJ plane and forearm plane in neutral position is recalculated. RESULTS: The shape of the radial head is determined to be non-circular based on this study population (p < .001). In neutral position, the angle between the LARH and the forearm plane is 5.28° (SD: 15.09) and between the LARH and the PRUJ is 33.46° (SD: 13.91). CONCLUSIONS: The position of the LARH is found to be approximately perpendicular to the forearm plane when the forearm is in neutral position and perpendicular to the PRUJ plane when the forearm is on average in 30° of pronation.
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BACKGROUND: A Monteggia fracture is defined as a fracture of the proximal ulna combined with a luxation of the radial head. The aim of the present work is to evaluate the extent of instability of the radius head in the proximal radioulnar joint (PRUJ) as a function of the severity of elbow fracture and ligamentous injury in an experimental biomechanical approach. METHODS: Eight fresh-frozen cadaver arms were used. All soft tissues were removed except for the ligamentous structures of the PRUJ and forearm. A tensile force of 40 N was exerted laterally, anteriorly or posteriorly onto the proximal radius. The dislocation in the PRUJ was photometrically recorded and measured by two independent examiners. After manual dissection of the ligamentous structures up to the interosseous membrane, the instability was documented and subsequently measured. The following dissection levels were differentiated: intact ligamentous structures, dissection of annular ligament, oblique cord and proximal third of interosseous membrane. RESULTS: An anterior instability remains relatively constant until the proximal third of the interosseous membrane is dissected. The radial head already dislocates relevantly in the posterior direction after dissection of the annular ligament with an additional considerable stability anteriorly and laterally. Subsequently, the posterior instability increases less pronouncedly in regard of distal resected structures. The lateral instability increases constantly during the progressing resection of the ligamentous structures. CONCLUSION: On the one hand, a complete healing of the ligament injury after functional treatment is hardly conceivable with ligamentary damage up to the level of the proximal interosseous membrane. A remaining instability of the proximal radius could therefore be a possible cause for the unsatisfactory clinical results after certain Monteggia fractures. On the other hand, the present study may give a possible explanation (i.e. early dorsal radius head dislocation after dissection of annular ligament) why the Bado II injury is the most frequent type of Monteggia fractures.
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Inestabilidad de la Articulación/fisiopatología , Fractura de Monteggia/fisiopatología , Anciano , Anciano de 80 o más Años , Articulación del Codo/fisiopatología , Femenino , Humanos , Inestabilidad de la Articulación/etiología , Ligamentos/lesiones , Ligamentos/fisiopatología , Masculino , Persona de Mediana Edad , Fractura de Monteggia/diagnóstico por imagen , Radiografía , Radio (Anatomía)/lesiones , Radio (Anatomía)/fisiopatología , Resistencia a la Tracción , Fracturas del Cúbito/fisiopatología , Lesiones de CodoRESUMEN
Transposition of the proximal radioulnar joint, so-called convergent elbow dislocation, is an extremely rare injury whereby the proximal radius crosses over the proximal ulnar and converges medially. This injury can occur in isolation or even less frequently in association with a posterior humeroulnar dislocation. Open reduction is almost always necessary. The diagnosis is frequently delayed as the injury is easily overlooked. In the literature, 13 cases in children and 2 in adults have so far been described. This is the first report of a combined elbow dislocation (posterior and convergent) with an initially diagnosed and definitively treated comminuted radial head fracture in adults.
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Articulación del Codo , Fracturas Conminutas , Luxaciones Articulares , Fracturas del Radio , Adulto , Niño , Codo , HumanosRESUMEN
BACKGROUND: Chronic posterior subluxation or dislocation of the radial head is uncommon and difficult to treat. To restore radiocapitellar alignment, procedures such as deepening of the notch using a high-speed burr have been described, but they can result in cartilage damage. We hypothesized that a radial notch labralization using soft tissue could improve radiocapitellar tracking without violating the joint surface. METHODS: A radial notch labralization was performed in 3 patients with chronic posterior subluxation of the radial head and developmental dysplasia of the radial notch in the setting of complex recurrent instability of the elbow. A soft tissue graft (typically a portion of an allograft hamstring tendon) was used to create a meniscus-like bumper posteriorly, thereby deepening the radial notch and reducing its radius of curvature. A corrective anterior opening wedge ulnar osteotomy was also performed to realign the radial head with the capitellum. RESULTS: At a mean follow-up of 32 months, all 3 patients were pain free and had maintained a stable joint, with a functional range of motion. Each patient gave a rating of either "Greatly Improved" or "Almost Normal" on the Summary Outcome Determination scale. Radiographs performed during the last follow-up showed improved radiocapitellar alignment. CONCLUSION: Chronic posterior subluxation or dislocation of the radial head can occur subsequent to developmental joint changes. The radial notch labralization using a soft tissue graft associated with a corrective ulnar osteotomy was successful in restoring radial head stability and avoiding cartilage damage.
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Articulación del Codo/cirugía , Luxaciones Articulares/cirugía , Inestabilidad de la Articulación/cirugía , Radio (Anatomía)/cirugía , Tendones/trasplante , Adolescente , Adulto , Articulación del Codo/diagnóstico por imagen , Articulación del Codo/fisiopatología , Epífisis/cirugía , Femenino , Humanos , Luxaciones Articulares/complicaciones , Inestabilidad de la Articulación/etiología , Masculino , Osteotomía , Radiografía , Radio (Anatomía)/anomalías , Radio (Anatomía)/diagnóstico por imagen , Rango del Movimiento Articular , Resultado del Tratamiento , Cúbito/diagnóstico por imagen , Adulto JovenRESUMEN
Proper functioning of the hand relies on its capacity to rotate and point the palm upward (i.e. supination) or downward (i.e. pronation) when standing up with the elbow in 90° flexion. Hand rotation is possible because of forearm rotation and also rotation of the whole upper limb at the shoulder. Two distinct mechanisms contribute to hand rotation: one in which the ulna is immobile and another in which the ulna is mobile. In this review, we first summarize how evolution of the human species has led to the progressive development of specific forearm anatomy that allows for pronation and supination. Then we analyze how the three joints of the forearm (i.e. proximal, middle and distal radioulnar joints), in association with the characteristic shape of both forearm bones, allow the forearm to rotate around a single axis. Lastly, we describe the neuromuscular anatomy that controls these complex rotational movements. The anatomical and biomechanical points developed in this paper are analyzed while considering clinical applications.
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Antebrazo , Mano , Pronación/fisiología , Supinación/fisiología , Huesos del Brazo/anatomía & histología , Huesos del Brazo/fisiología , Evolución Biológica , Fenómenos Biomecánicos/fisiología , Epífisis/anatomía & histología , Epífisis/fisiología , Antebrazo/anatomía & histología , Antebrazo/fisiología , Mano/anatomía & histología , Mano/fisiología , Humanos , Articulación de la Muñeca/anatomía & histología , Articulación de la Muñeca/fisiologíaRESUMEN
PURPOSE: To compare the joint contact area and peak contact stress of different radial head (RH) hemiarthroplasty articular profiles for the proximal radioulnar joint (PRUJ) to the native radial head with the hypothesis that the side radius and side angle closest to the native mating ulnar articular profile would provide the best contact mechanics. METHODS: Finite element models generated from the computed tomography geometry of 14 native elbows (73 ± 17.5 years) were subjected to 12 different RH profiles having varying side radii (flat [r = ∞ mm], 16.25, 8.12, and 4.50 mm) and side angles (0°, 5°, and 10°) under a constant compressive 20-N medial load. Contact areas and peak contact stresses were computed and compared with the native joint. RESULTS: On average, RH implants significantly reduced PRUJ contact area by 55% ± 16% and increased peak contact stress by 337% ± 241% compared with the native RH. The prosthesis side radius had significant effects on both contact area and stress, but side angle did not. The 16.25-mm radii produced the largest contact areas, and the 4.50-mm radius model generated the smallest contact areas. As the side radius was decreased, peak contact stress was reduced as the contact migrated toward the center of the native ulnar articulation, although the 8.12-mm radius achieved the lowest peak contact stress. CONCLUSIONS: Whereas RH hemiarthroplasty side radius can affect both contact area and peak contact stress, the magnitude of the effect on contact area is relatively small compared with that of the peak contact stress. Furthermore, although a flat RH side profile with a side angle of 5° more closely matched the side profile of the native ulnas used in the present study, the optimal profile was found to be a smaller radius of 8.12 mm. CLINICAL RELEVANCE: Optimizing PRUJ contact mechanics after metallic RH hemiarthroplasty may contribute to better clinical outcomes by reducing the potential for native cartilage degeneration.
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Fenómenos Biomecánicos/fisiología , Hemiartroplastia , Radio (Anatomía)/cirugía , Articulación de la Muñeca/fisiopatología , Articulación de la Muñeca/cirugía , Anciano , Cadáver , Cartílago Articular/fisiología , Simulación por Computador , Análisis de Elementos Finitos , Humanos , Prótesis Articulares , Estrés MecánicoRESUMEN
This biomechanical study assessed integrated function of the proximal radioulnar joint (PRUJ), interosseous ligament (IOL), and distal radioulnar joint (DRUJ). Tekscan™ pressure sensors were inserted into the DRUJ and PRUJ of 15 cadaveric specimens. MicroStrain(®) sensors were mounted onto the IOL on nine of these specimens. A customized biomechanical jig was used to apply axial loads and take measurements through pronosupination. The PRUJ, IOL, and DRUJ were shown to function as an integrated osseoligamentous system distributing applied load. The PRUJ has transmitted pressure profiles similar to those of the DRUJ. Different IOL components support loading at different stages of pronosupination. The IOL is lax during pronation. Mid-IOL tension peaks in the midrange of forearm rotation; distal-IOL tension peaks in supination. Axial loading consistently increases IOL strain in a non-linear fashion. There are clinical implications of this work: disease or surgical modification of any of these structures may compromise normal biomechanics and function.
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Ligamentos Articulares/fisiología , Articulación de la Muñeca/fisiología , Adolescente , Adulto , Anciano , Fenómenos Biomecánicos/fisiología , Femenino , Antebrazo/fisiología , Humanos , Masculino , Persona de Mediana Edad , Pronación/fisiología , Supinación/fisiología , Adulto JovenRESUMEN
BACKGROUND: Proximal radioulnar synostosis is a complication after elbow injuries. Various treatment methods have been reported and are associated with unpredictable outcomes. In a prospective study, we evaluated the medium-term effects of proximal radial resection on wrist and elbow function and forearm rotation in 15 cases. METHODS: We treated 15 patients with posttraumatic proximal radioulnar synostosis by resection of 1 cm of the proximal radial diaphysis. On the preoperative examination and last follow-up, the Mayo Elbow Performance Score, grip force, visual analog scale for elbow and wrist score, radiographic ulnar variance changes, and elbow range of motion were measured. The Disabilities of the Arm, Shoulder, and Hand (QuickDASH) score and the general satisfaction of the patients were assessed at the final follow-up. RESULTS: The mean duration of follow-up was 31 ± 13 months. The mean active postoperative supination/pronation arc was 101° ± 45°. The mean increase measured in the ulnar variance at the final follow-up was 3.3 ± 1.5 mm (P = .02). The mean final QuickDASH score was 13.3 ± 12.1. The preoperative and final Mayo scores were 57 ± 10 and 91 ± 7, respectively (P = .01). The general satisfaction with the results of the operation was 86.6%. CONCLUSIONS: We suggest that proximal radial resection for the treatment of posttraumatic proximal radioulnar synostosis shows acceptable results in adults regarding the recovery of range of motion and patient satisfaction. This technique might be considered as a salvage procedure, particularly in cases with previous failed heterotopic resection at the proximal radioulnar joint, resulting in disturbed anatomy. LEVEL OF EVIDENCE: Level IV, case series, treatment study.
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Traumatismos del Brazo/cirugía , Radio (Anatomía)/anomalías , Radio (Anatomía)/cirugía , Sinostosis/cirugía , Cúbito/anomalías , Adolescente , Adulto , Traumatismos del Brazo/complicaciones , Traumatismos del Brazo/fisiopatología , Niño , Diáfisis , Codo/fisiopatología , Codo/cirugía , Femenino , Antebrazo/fisiopatología , Humanos , Masculino , Persona de Mediana Edad , Osteotomía , Satisfacción del Paciente , Estudios Prospectivos , Radio (Anatomía)/fisiopatología , Rango del Movimiento Articular , Recuperación de la Función , Sinostosis/etiología , Sinostosis/fisiopatología , Resultado del Tratamiento , Cúbito/fisiopatología , Cúbito/cirugía , Muñeca/fisiopatología , Adulto JovenRESUMEN
The elbow, forearm and wrist act as a unified structure to provide a stable, strong and highly mobile strut for positioning the hand in space and for conducting load-bearing tasks. An understanding of the relevant anatomy and biomechanics is important for the surgeon assessing and treating disorders of forearm function. This paper is concerned with illuminating the principles and concepts governing forearm rotation and load-bearing functions.
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Objective To investigate the mechanism of radioulnar dissociation, an uncommon special injury, and its clinical diagnosis and treatment. Methods From 1990 to 1998, 4 patients with concurrent injuries of the proximal and distal radio ulnar joints were treated in my department. Of the 3 cases diagnosed early, 2 were treated with open reduction and internal fixation and 1 with closed reduction. The remaining one patient, whose radio ulnar dissociation was diagnosed 2 months later, had to be treated by secondary operation. Results The 4 patients were followed up for 16 months to 8 years (averaging 46 months). All had excellent results. Conclusion The early accurate diagnosis and early treatment of concurrent injuries of the elbow and the distal radio ulnar joint produce satisfactory results.