Reconstruction of the Shoulder and Humerus in Metastatic Bone Disease.
Instr Course Lect. 2019;68:577-584
Authors: Cheng EY, Ogilvie CM
Metastatic disease involving the skeleton most often affects the spine, pelvis, and proximal long bones of the extremities. In the upper extremity, the proximal humerus is frequently affected. Although many of the principles of managing metastatic bone disease are similar, regardless of the metastatic site, the upper extremity has some unique anatomic and functional traits that warrant consideration when making management decisions. The main anatomic differences from the lower extremity pertain to the smaller bone size, rotator cuff function, and proximity to major neurologic structures, and the important functional differences that relate to activities of daily living have a greater dependence on the upper, rather than lower, extremity; greater range of motion of the shoulder; side dominance; limited weight-bearing function; and marked propensity of the elbow to develop stiffness. Clinicians should consider aspects of the shoulder and humerus as they relate to the overall management of metastatic bone disease, either monostotic or polyostotic, when evaluating and managing metastatic lesions at this site.
PMID: 32032059 [PubMed - indexed for MEDLINE]
New Paradigms in the Throwing Shoulder: Labral Injury, Surgery, and Rehabilitation.
Instr Course Lect. 2019;68:499-512
Authors: Kibler WB, Sciascia A
Knowledge regarding the importance of the superior labrum in shoulder function is evolving as biomechanical and clinical studies define the roles of the labrum in shoulder function and dysfunction. The diagnosis of the clinically significant labral injury, the alteration in labral anatomy that is associated with the production of clinical symptoms and dysfunction and requires management, is based on specific history and clinical examination findings that point to the loss of labral roles. Surgical management should address all aspects of the altered labral anatomy and repair the labral structure to allow normal labral roles without excessive biceps tension. It may be that the superior labral injury may be a normal variant in throwers, allowing the thrower to achieve optimum cocking in external rotation. Specific guidelines for intraoperative assessment of the labral injury and criteria for determining the adequacy of the repair may be followed. Emerging data suggest that approximately 50% of patients with a clinically significant labral injury can become asymptomatic with guided rehabilitation. Rehabilitation has specific goals to restore the demonstrated deficits, should be organized into specific phases based on the patient's injury and functional capability, and should have specific criteria to allow return to play.
PMID: 32032054 [PubMed - indexed for MEDLINE]
Monteggia Fracture-Dislocations in Children: History and Current Concepts and Management Schemes.
Instr Course Lect. 2019;68:407-414
Authors: Baldwin KD, Hosseinzadeh P, Milbrandt TA, Abzug JM
Since pediatric Monteggia fracture-dislocations were first described in 1814, they have been a complicated injury for orthopaedic surgeons to manage. These injuries typically consist of a fracture of the ulna with dislocation of the radial head. Unlike most pediatric injuries, Monteggia fracture-dislocations remodel very poorly, and the relationship between the radial head and the capitellum does not improve with time. As such, a more attentive approach is necessary. It is important for orthopaedic surgeons to be knowledgeable about the history of Monteggia fractures, common pathologic mechanisms, closed reduction techniques, surgical indications and methods, and outcomes, in addition to preferred management principles.
PMID: 32032047 [PubMed - indexed for MEDLINE]
Lateral Condyle Fractures in Children.
Instr Course Lect. 2019;68:367-374
Authors: Huser AJ, Baldwin KD, Milbrandt TA, Abzug JM, Hosseinzadeh P
Lateral condyle fractures are the second most common fracture sustained in the pediatric elbow. Several classification systems are used to describe these fractures. The more recently described classifications help guide management, which is based on the degree of displacement and stability of the fracture. The goal of management is to obtain reduction of the articular surface and fracture union using closed or open reduction and fixation with Kirschner wires or screws. Motion should improve after the surgery. Complications, such as osteonecrosis and nonunion, are rare, but the treating surgeon should watch for these conditions.
PMID: 32032044 [PubMed - indexed for MEDLINE]
Elbow Trauma Sequelae: Instability, Stiffness, Non-arthroplasty, and Arthroplasty Options.
Instr Course Lect. 2019;68:117-140
Authors: Cheung E, Nathani A, Tashjian R, Armstrong A, Morrey M
Sequelae of elbow trauma are complicated to manage. Undiagnosed instability patterns are important to recognize to get the elbow into concentric alignment for further reconstructive efforts. Stiffness is also common after elbow trauma. Surgeons should be familiar with the different approaches to the elbow to safely address stiffness. Non-arthroplasty and arthroplasty salvage options are also important to understand because the indications are expanding and outcomes for these procedures are being better understood.
PMID: 32032041 [PubMed - indexed for MEDLINE]
Sports Injuries of the Hand, Wrist, and Elbow.
Instr Course Lect. 2019;68:153-166
Authors: Goldfarb C, Dy C, Brogan D, Osei D
Sports injuries of the upper extremity are a common problem seen by those who care for athletes and those who manage upper extremity injuries. The term "high-level athlete" may include adolescents and high school students, collegiate athletes, and of course, the professional athlete. However, the "weekend warrior" can sustain similar injuries and can have a similar desire to return to play as quickly as possible. The challenge in management of these injuries to the elbow, wrist, and hand is identifying those injuries that will benefit from early surgery compared with those that may be safely treated nonsurgically. A rapid return to play may be possible with some injuries with cast or splint immobilization based on the sport and position played. Management of common sports injuries of the hand, wrist, and medial elbow should be reviewed with consideration of return to play.
PMID: 32032034 [PubMed - indexed for MEDLINE]
Perioperative Risks Are Similar for Normal versus Selected High-Body Mass Index Patients Undergoing Outpatient Hand and Elbow Surgery.
Plast Reconstr Surg. 2019 11;144(5):836e-840e
Authors: Warrender W, Jones C, Selverian S, Lutsky K, Banner L, Beredjiklian PK
BACKGROUND: Many ambulatory surgery centers use body mass index as a screening tool to make admissions decisions because of complication risks associated with high-body mass index patients. The objective of this investigation was to evaluate perioperative complications in a cohort of high-body mass index patients undergoing hand and elbow surgery at an ambulatory surgery center. The authors' hypothesis was that anesthesia-related complications for this cohort would be similar to those of a normal-body mass index group.
METHODS: The authors retrospectively reviewed data from all hand and elbow procedures performed on patients with a high body mass index (>40 kg/m). One hundred eighty-nine high-body mass index patients and 189 normal-body mass index patients were included in the analysis.
RESULTS: The average weight-based dosage of propofol was similar in both groups but was lower in the high-body mass index group for midazolam and fentanyl. Two high-body mass index patients had oxygen desaturations in the postanesthesia care unit. No patients developed complications related to anesthesia. In the high-body mass index group, one patient developed hypotension in the postanesthesia care unit, was admitted to the emergency room for monitoring, but was discharged the following morning.
CONCLUSIONS: Outpatient hand surgical care of high-body mass index patients can be performed safely. Body mass index alone should not be considered as an absolute contraindication for surgery. Careful patient selection, evaluation of comorbidities, and close involvement of the anesthesia and medical teams are critical.
CLINICAL QUESTION/LEVEL OF EVIDENCE: Risk, II.
PMID: 31688759 [PubMed - indexed for MEDLINE]
Washers do not affect the rate of implant removal or elbow motion in medial epicondyle fractures.
J Pediatr Orthop B. 2019 Nov;28(6):526-529
Authors: Patel NM, Gajewski CR, Ascoli AM, Lawrence JTR
The use of a washer to supplement screw fixation can prevent fragmentation and penetration during the surgical treatment of pediatric medial epicondyle fractures. However, concerns may arise regarding screw prominence and the need for subsequent implant removal. The purpose of this study is to evaluate the impact of washer utilization on the need for hardware removal and elbow range of motion (ROM). All pediatric medial epicondyle fractures treated with a single screw over a 7-year period were queried for this retrospective case-control study. Hardware removal was performed only if the patient experienced a complication or implant-related symptoms that were refractory to non-operative management. Of the 137 patients included in the study, a washer was utilized in 90 (66%). Thirty-one patients (23%) ultimately underwent hardware removal. There was not an increased need for implant removal in those with a washer (P = 0.11). When analyzing a subgroup of 102 athletes only, there was similarly no difference in the rate of implant removal if a washer was used (P = 0.64). Overall, 107 (78%) patients regained full ROM at a mean of 13.9 ± 9.7 weeks after surgery with no significant difference along the lines of washer use. Use of a washer did not affect the need for subsequent implant removal or elbow ROM after fixation of medial epicondyle fractures, even in athletes. If there is concern for fracture fragmentation or penetration, a washer can be included without concern that future unplanned surgeries may be required.
PMID: 31356502 [PubMed - indexed for MEDLINE]
A physical profile of novice and experienced professional motorcycle speedway riders.
J Sports Med Phys Fitness. 2019 Nov;59(11):1791-1797
Authors: Martin S, Doggart L, Bloxham S
BACKGROUND: There is a paucity of data relating to Professional Motorcycle Speedway riders physical characteristics despite its growing popularity.
METHODS: The participants were divided into two categories depending on their Calculated Match Average (CMA); high performers (CMA>5.0, N.=16) and low performers (CMA<4.9, N.=16). Anthropometric data, isometric hand grip strength, isometric knee extension strength, dynamic stability of the upper and lower limbs and functional movement scores were measured to establish differences between high and low performing professional speedway riders.
RESULTS: High performing riders had significantly better functional movement screen composite scores than low performers (P=0.003) and hurdle step (P=0.002) and shoulder mobility movements (P=0.032). Significant hand grip and leg strength was observed in riders right limbs compared to their left (P=0.004 and P=0.000 respectively) and greater dynamic stability in their right leg than left (P=0.011). High performing riders had greater grip strength (right hand P=0.016 and left hand P=0.034) and knee extension strength in the right (P=0.036) legs than their low performing counterparts.
CONCLUSIONS: The findings of this study provide a benchmark of physical characteristics of high and low performing riders, highlighting mobility, functional movement, dynamic stability and isometric strength as essential attributes of an elite rider.
PMID: 31111721 [PubMed - indexed for MEDLINE]
A novel transverse ultrasonography technique for minimally displaced lateral humeral condyle fractures in children.
Orthop Traumatol Surg Res. 2019 05;105(3):557-562
Authors: Li XT, Shen XT, Wu X, Chen XL
INTRODUCTION: Management of minimally displaced lateral humeral condyle fractures in pediatric patients is controversial. This is primarily because with current imaging modalities it is difficult to accurately and conveniently determine the stability of the fractures by detecting the integrity of the cartilage hinge. Nevertheless, transverse ultrasonography has not been intensively reported in previous studies.
HYPOTHESIS: Transverse ultrasonography can determine the integrity of the cartilage hinge in minimally displaced lateral condyle fractures.
MATERIALS AND METHODS: We retrospectively reviewed the medical records of 39 pediatric patients with minimally displaced fractures of the lateral humeral condyle who underwent transverse ultrasonography between 2014 and 2017. Conservative treatment was given to pediatric patients with intact cartilage hinges that had been confirmed by transverse ultrasound images. Surgical treatment was recommended for pediatric patients with disrupted cartilage hinges. Data regarding healing of the lateral humeral condyle fractures were recorded and analyzed.
RESULTS: According to transverse ultrasonography, there were 14 children with intact cartilage hinges and 25 children with disrupted cartilage hinges. Fourteen children with intact cartilage hinges of the fracture were treated conservatively, and none of them showed secondary displacement. There were 16 children in whom there was surgical intervention, and 9 other children decided to have conservative treatment among the 25 children with disruption of the cartilage hinge. Five of these 9 children who underwent conservative treatment were found to have further displacement during an average of 12.6 days after the fracture event, and no other patient was found to have further displacement.
CONCLUSION: Transverse ultrasonography can simply and accurately determine the stability of minimally displaced lateral condyle fractures without sedation, ionizing radiation or invasive techniques. We recommend routine use of transverse ultrasonography to detect stability of the fractures, which can effectively avoid inadequate treatment and unnecessary surgery in pediatric patients with minimally displaced fractures of the lateral humeral condyle.
LEVEL OF EVIDENCE: IV, retrospective cohort study.
PMID: 30935813 [PubMed - indexed for MEDLINE]
No difference in outcomes in a matched cohort of operative versus nonoperatively treated displaced medial epicondyle fractures.
J Pediatr Orthop B. 2019 Nov;28(6):520-525
Authors: Axibal DP, Ketterman B, Skelton A, Carry P, Georgopoulos G, Miller N, Mayer SW
The purpose of our study was to compare the treatment outcomes and complications between operatively and nonoperatively treated displaced medial epicondyle fractures. Pediatric patients treated for an acute, displaced medial epicondyle fracture between 2005 and 2015 were retrospectively reviewed. A total of 22 operative participants were matched to 22 nonoperative participants, with an average displacement of 9.7 mm in both groups. There was no statistical difference in average length of immobilization, median time to full pronation/supination and flexion/extension, proportion of patients needing physical therapy, and complications. There were no statistical differences in outcomes between operative and nonoperatively treated, moderately displaced, pediatric medial epicondyle fractures. This suggests that operative and nonoperative interventions show equivalent outcomes for these injuries.
PMID: 30540624 [PubMed - indexed for MEDLINE]
Sensitivity of Shoulder Musculoskeletal Model Predictions to Muscle-Tendon Properties.
IEEE Trans Biomed Eng. 2019 05;66(5):1309-1317
Authors: Blache Y, Michaud B, Rogowski I, Monteil K, Begon M
OBJECTIVE: While the sensitivity of estimated muscle forces to muscle-tendon properties is well documented for the lower limbs, little is known about the shoulder and upper limbs. The purpose of this study was to assess the sensitivity of estimated shoulder muscle forces and scapulohumeral joint force to muscle-tendon properties.
METHODS: One healthy male participant performed arm flexions and simulated throwing maneuvers. Kinematics were recorded using intra-cortical pins. Muscle forces were estimated using static optimization with the generic delft shoulder and elbow in OpenSim, and scapulohumeral joint forces were calculated from the estimated forces. Then, variations from -25% to +25% of the nominal values of the tendon slack length, the optimal fiber length, the maximal isometric force, and the pennation angle were applied to the musculoskeletal model to compute affected muscle forces and scapulohumeral joint force.
RESULTS: The variations in muscle-tendon properties led to changes up to 9.6 N or 174% in the muscle nominal forces. The more sensitive muscles were those that produced the greatest force: the rotator cuff muscles and the prime movers specific to the task. Among the four muscle-tendon properties, the maximal isometric force and the optimal fiber length had the greatest influence on the muscle force variability. Glenohumeral force was slightly influenced by muscle-tendon properties (<8%).
CONCLUSION: Generic models (i.e., those without personalization of muscle-tendon properties) can lead to misinterpretations of muscle force. Efforts should focus on the maximal isometric force and the optimal fiber length of the rotator cuff muscles and prime movers.
PMID: 30281425 [PubMed - indexed for MEDLINE]