Monteggia fracture associated with ipsilateral intercondylar distal humeral fracture with posterior interosseous nerve palsy: case report, medico-legal implications, and methodological assessment analysis

BACKGROUND: The Monteggia fracture, defined as a fracture of the proximal third of the ulnar shaft associated with an anterior or posterior dislocation of the proximal radial epiphysis, is a serious injury accounting for 0.7% of all elbow fractures and dislocations in adults. For adult patients, good results can only be obtained through early diagnosis and adequate surgical treatment. Monteggia fracture-dislocations associated with distal humeral fracture are extremely rare injuries in adults and there are few cases described in the literature. Medico-legal implications arising from such conditions have a host of complexities that cannot be discounted.CASE REPORT: This case report revolves around a patient affected by a type I Monteggia fracture-dislocation, according to the Bado classification, associated with an ipsilateral intercondylar distal humeral fracture. To our knowledge, this combination of lesions has never been reported before in adult patients. A positive result was obtained due to early diagnosis, achievement of anatomical reduction, and optimal stabilization with internal fixation which made it possible to achieve early functional recovery.CONCLUSIONS: Monteggia fracture -dislocations associated with ipsilateral intercondylar distal humeral fracture are extremely rare in adults. In the case herein reported, a favorable outcome was obtained due to early diagnosis, achievement of anatomical reduction and management with internal fixation with plate and screws, as well as early functional training. Misdiagnosis makes such lesions risky in terms of potentially delayed treatment, increasing the need for surgical interventions and the possibility of high-risk complications and disabling sequelae, with possible medico -legal implications. In the case of unrecognized injuries under urgent circumstances, the injuries may become chronic, making the treatment more complex. The ultimate outcomes of a misdiagnosed Monteggia lesion can lead to very serious functional and aesthetic damage

Lumbar spinal stenosis treatment with aperius perclid interspinous system

The purpose of this study is to report clinical outcome and imaging changes of percutaneous Aperius stand-alone implant in patients with degenerative lumbar spinal stenosis and neurogenic intermittent claudication, which did not respond to conservative treatment.Between January 2008 and July 2010, 37 patients (20 males and 17 females) with mean age of 64.3 years underwent surgery for the onset of claudicatio spinalis with Aperius PercLID interspinous device (Medtronic). In all patients, the diagnosis was: foraminal stenosis, in one case (2.7 \%) it was associated to a degenerative anterior listhesis (I grade), in three cases (8.1 \%) it was associated to an intraforaminal disc herniation. The mean follow-up was of 18 months (range 2-35 months). The patients were evaluated through the Oswestry disability index, Zurich Claudication Questionnaire (ZCQ), VAS scales. In all cases were obtained preoperative and in postoperative radiographs and magnetic resonance imaging.The VAS score decreased significantly after surgery: the patients presented a mean VAS of seven preoperatively and two postoperatively (p < 0.001). The ZCQ score significantly decreased postoperatively, with an average reduction of 21.89 \% (p < 0.001). The ODI score as well showed a significant reduction postoperatively of an average 26.09 \% (p < 0.001).Despite of the brief follow up, the preliminary results are encouraging, showing a significantly decrease of the disability parameters, a marked improvement of the function with the vanishing of the claudicatio spinalis and the following increase of the free interval during the walk. Aperius PercLID system seems to offer an alternative to the traditional decompression surgery

Radial head prosthesis disassembly: case report and medico-legal implications

Background: The aim of the treatment of radial head comminuted fractures is the restoration of anatomical normalcy to avoid the risk of several complications such as joint instability. Among the options for the treatment of such fractures, it is worth mentioning osteosynthesis, resection of the radial head or prosthetic replacement. In the presence of comminution or severe dislocation of the fracture's fragments, as in our patient's type III Mason fracture, prosthesis implantation is the treatment of choice. Case report: This clinical case reports a 22-year-old volleyball player, who during training suffered a comminuted fracture of the radial head, type III according to Mason's classification. A prosthesis was implanted. The post-operative course took place regularly. However, approximately three months after surgery, the patient experienced sudden pain and functional limitation following a normal elbow extension movement, so much so that he required medical attention in our emergency room. Following all the appropriate clinical-instrumental tests, a complete dissociation of the bipolar prosthesis of the radial head was found. Conclusions: Our clinical case shows the disassembly of a bipolar radial head prosthesis, a rather rare complication. From a medicolegal perspective, the patients should be aware of the increased risk of requiring further surgery after radial head replacement. When patients are thoroughly informed, they can cooperate and comply with indications more effectively, thus taking an active role in recovery management

Surgical treatment of the “terrible triad” of the elbow: long-term outcomes at 5 years’ follow-up

BACKGROUND: Terrible triad (TT) is one of the most challenging pattern of elbow injuries to treat and it often yields to severe complications. The aim of this study was to evaluate clinical and functional outcomes in 28 patients treated at our center from January 2011 to april 2019. METHODS: Fracture patterns, surgical technique and residual elbow instability, range of motion (ROM), grip and pinch strength were evaluated in all patients. Functional outcomes were assessed by Mayo elbow performance score (MEPS), disability of arm and shoulder and hand score (DASH) and visual analogue scale (VAS). Radiographic follow-up (FU) was possible in 18 patients to check heterotopic bone formation and arthritic changes. the mean FU was 60 months (range, 12-108). RESULTS: At the last FU a decreased ROM was observed in all patients compared to the contralateral elbow (an average of 7° in flexion, 15° in extension, 7.2° in supination, 5.2° in pronation), however only four of them (14%) had a functional limitation. also reduction of mean grip strength was observed (mean 5.11 kg, p=0.011). No elbow instability was detected at the last FU. After treatment, six minor and seven major complications were found; the major ones required second surgery. However mean Meps, dash and Vas were still satisfying. CONCLUSIONS: The surgical treatment of the tt of the elbow provides overall satisfactory results, although a considerable number of complications still persist and need to be addressed in the future

Simple posterior elbow dislocations: Conservative management and role of ulnar-bone coverage angle

BACKGROUND: In simple posterior elbow dislocations, not associated with fracture, conservative treatment consists of a closed reduction with the restoration of joint relationships and a subsequent immobilization in a cast in the absence of any postreduction instability. The functional outcome is usually satisfactory, but several complications are possible. The aim of this study was to determine the outcomes of simple elbow dislocation treated conservatively and the possible role of an open ulnar bone converge angle (UBCA) as a risk factor. METHODS: A retrospective case series study with a follow-up of 60.96 months (range, 24-95) was performed, analyzing simple elbow dislocation cases, treated at Unit of Orthopedics and Trauma, Varese, Italy, from October 2012 to September 2018. The population consisted of 28 patients, 17 men and 11 women, with an average age of 53 (range, 26-90). A conservative treatment, consisting in closed reduction and immobilization in plaster cast, was applied if there was no instability after reduction. The Disability of the Arm, Shoulder and Hand (DASH), the Mayo Elbow Performance Score (MEPS) questionnaires were used. CT-scan were analyzed to calculate the UBCA. RESULTS: At the last follow-up there was a reduction of the affected elbow ROM compared to the contralateral: 52.6% of patients had an extension deficit, 15.9% of flexion, 10.6% of prone supination. Under no circumstances was post-traumatic residual instability. A statistically significant reduction was found for extension of the affected elbow (-3.05\ub0 vs. 3.26\ub0) and for the entire flexion-extension motion (134.05\ub0 vs. 142.27\ub0) compared to the healthy one. The average DASH score is 6.029 and the MAYO average score is 94.286, values considered excellent. The average UBCA was 171.59\ub0 (range, 147.50\ub0-191.50\ub0). In 3 patients (15.8%) prone-supination pain was reported, and of these 2 also to flexion-extension (10.5%). CONCLUSIONS: The outcome of posterior elbow simple dislocations, conservatively treated, was satisfactory. A UBCA, narrower than 180\ub0, may represent a risk factor for dislocation

TRP channels expression in Chronic Low Back Pain

Chronic Low Back Pain (CLBP) is an inflammatory condition that may originate from an injury, disease or stress on tendons, ligaments and discus of the spinal structure. It is known that neuroinflammatory processes are pathologichallmarks of CLBP that lead to the release of proinflammatory molecules that increase nociceptors sensitization, pain hypersensitivity or hyperalgesia. Transient Receptor Potential (TRP) channels are known to act as receptors of various stimuli in peripheral sensory neurons and in other somatic structure. Numerous studies highlighted the activation and/or sensitization of these channels during inflammation as the major mechanism underlying neuropathic and inflammatory pain. In order to investigate the roleplayed and to classify TRPs channels in samples from 6 patients affected by CLBP, the TRPs expression was measured and morphological, ultrastructural and immunohistochemical alterations were analyzed. Immunofluorescence and expression analyses showed a significant increase in the levels of TRPs (A1, V1, V2, V4 and M8) in the pathological capsule compared to control tissues. Interesting, in each patient analyzed, we found an over-expression of TRPV4, independently by the location and number of affected sites. Moreover, using silver impregnation, it was shown that in CLBP patients the capsular connective tissue appeared degraded and infiltrated by sensitive unmyelinated nervous fibers. The findings confirm the involvement of TRP channels, in particularly of the TRPV4 and TRPM8 in CLBP pathological condition suggesting that these channels could represent a target for new therapeutic approaches