Elbow fracture-dislocations destabilize the elbow, preventing functional rehabilitation. If left untreated, they commonly result in functional compromise and poor outcomes. The "terrible triad" injury is classically described as a combination of a coronoid process and radial head fractures, as well as a posterolateral elbow dislocation. Surgical treatment to restore stable elbow range of motion has evolved in the past few decades based on increased understanding of elbow biomechanics and the anatomy of these injuries. This article highlights current concepts in the treatment of these complicated injuries.

Even with no detectable intrahepatic tumor, bile duct HCC thrombus should be considered in patients predisposed to HCC, and some imaging signs are indicative of its diagnosis.

BackgroundVolar locking plates provide significant structural stability to the distal radius. Failure of a volar locked plating is a rarely reported complication in the literature.Case PresentationA 40 year-old, obese female patient who presented with a displaced extraarticular distal radius fracture, underwent open reduction and internal fixation of the fracture using a volar locking plate. Radiographs taken at 10 weeks postoperatively showed failure of fixation with breakage of the four distal locking screws. A hardware removal was performed at 6 months, and the patient was then lost to follow-up. She presented again at 18 months after the first surgery, with significant pain, and radiographic signs of a radial collapse and a fracture-nonunion. A total wrist fusion was performed as the method of choice at that point in time.ConclusionVolar locked plating represents the new "gold standard" of distal radius fracture fixation. However, despite the stability provided by locking plates, hardware failure may occur and lead to a cascade of complications which will ultimately require a wrist fusion, as outlined in this case report. Additional structural support by bone grafting may be needed in selected cases of volar locked plating, particularly in patients with a high risk of developing a fracture-nonunion.

Background: Controversy exists with regard to the amount of fracture displacement that warrants surgical fixation of medial epicondyle fractures. Inaccurate determination of degree of displacement on plain radiographs may account for the disputed management. Recently, a novel distal humerus axial radiograph technique has been developed to improve the accuracy of radiographs. The purposes of the study are 2-fold; to identify the anatomic orientation of the medial elbow epicondyle physis in children and to compare the accuracy of determining fracture displacement between axial radiographs and standard anterior-posterior (AP) radiographs in a cadaveric medial epicondyle fracture model. Methods: Twelve pediatric elbow computed tomographic scans and 19 pediatric elbow magnetic resonance imaging scans were analyzed for the orientation of the medial elbow physis. After determining the correct orientation, 15 adult cadaveric medial epicondyle fracture models were created at displacements of 2, 5, 10 mm, and maximum displacement with elbow at 90 degrees of flexion. A linear mixed model regression analysis was used to compare displacement based on the axial versus the AP radiographic methods. Results: The medial epicondyle physis was found to be a posterior structure angled distally at ~36 degrees (range, 10.7 to 49.6) and angled posteriorly at 45 degrees (range, 32.2 to 59). The AP radiograph significantly underestimated displacement relative to the axial radiograph at 5 mm [mean difference, −1.6; 95% confidence interval (CI), −2.9 to −0.3], at 10 mm (mean difference, −4.5; 95% CI, −5.8 to −3.2 mm), and at maximal displacement (mean, 15 mm; range, 13 to 20 mm) (mean difference, −7.1; 95% CI, −8.3 to −5.8). Conclusions: The medial epicondyle physis of the distal humerus is a posterior structure angled distally and posteriorly. When displacement was >5 mm, the distal humerus axial radiograph technique was significantly more accurate than the AP radiograph technique at determining actual fracture displacement in our adult cadaveric fracture models. Therefore, we recommend clinicians to include the axial radiograph view during the evaluation of patients with medial epicondyle fractures. Clinical Relevance: This study provides further insight into the location and orientation of the medial humeral epicondyle physis, and further supports the improved accuracy of the distal humerus axial radiograph at detecting displacement in medial epicondyle fractures.

Background:Optimization of the electronic medical record (EMR) is essential to support the clinician and to improve the quality and efficiency of patient care. The present report describes the development and implementation of a standardized template that is embedded in the EMR and is focused on a comprehensive physical examination during the evaluation of pediatric supracondylar humeral fractures. We compared the completeness of physical examinations as well as the timing of detection and documentation of neurovascular injuries before and after implementation of the template. We hypothesized that the use of a template would increase the completeness of examinations and would lead to earlier documentation of neurovascular injuries.Methods:A multidisciplinary quality-improvement task force was created to address neurovascular documentation practices for patients who underwent operative treatment of supracondylar humeral fractures. Following a series of formative and process evaluations, a standardized EMR template was implemented. Neurovascular examination documentation practices that were in use before (pre-template group, n = 224) and after (template group, n = 300) the implementation of the template were compared. Logistic regression analyses of the 2 groups were used to compare the likelihood of a complete neurovascular examination and the timing of neurovascular injury identification.Results:There was significant improvement in the documentation of the vascular (odds ratio [OR], 70.7; 95% confidence interval [CI], 39.5 to 126.6; p < 0.0001), motor (OR, 17.6; 95% CI, 9.5 to 32.7; p < 0.0001), and sensory (OR, 23.9; 95% CI, 12.9 to 44.4; p < 0.0001) examinations in the template group. Neurological injuries were more likely to be identified preoperatively in the template group compared with the pre-template group (OR, 6.8; 95% CI, 1.7 to 27.1; p = 0.0067).Conclusions:The incorporation of a standardized template in the EMR improved the completeness and timing of documentation of neurological injury. Standardized EMR templates developed by a clinically driven multidisciplinary task force have the potential to improve the quality of clinical documentation and to ease communication among providers.Level of Evidence:Level III. See Instructions for Authors for a complete description of levels of evidence.