Objective:To introduce the surgical techniques and treating results of the old “terrible triad”of the elbow.Methods:A retrospective analysis of 1 1 cases of old “terrible triad”of the elbow treated by the author from March 2009 to February 2014 were performed,with 9 males and 2 females;mean age was (31.82 ±8.66)years (17-45 years).The average time after injury was (6.36 ±2.50) weeks (4-12 weeks),with 7 cases on the left and 4 right.The combined injury included 2 cases with distal radius fractures,1 with ankle fractures,fractures of the distal radius and the head injury (minor epidural hematoma,no surgery),and 1 with Pilon fractures and L4 fractures (fixed at local hospital). All the patients had elbow stiffness and joint dislocation,and 2 patients had symptoms of ulnar nerve. Mason classification of radial head fractures:2 cases were type Ⅰ,5 were type Ⅱ,4 were type Ⅲ. Classification of the coronoid process:Regan &Morrey:1 was type Ⅰ,10 were type Ⅱ;according to O’Driscoll classification,all the fractures were tip fracture,one was the first subtype,10 were the second subtype.The elbow were released,the coronoid process were fixed by lasso suture combined with Kirschner wires.Radial head fractures were resected in 1 case,and replaced in 1 case,3 cases with no
treatment,6 cases with osteotomy and 3.0 mm headless compression screw (HCS)fixation.The lateral collateral ligament complex and the common extensor tendon were repaired to the humeral lateral epicon-dyles,No.2 Ethibon was used in 2 cases through bone holes,and suture anchorsin the other 9 cases.All the patients were fixed by Stryker DJDⅡhinged external fixator to protect the bone and soft tissue.Re-sults:The average follow-up time was (38.36 ±21.92)months (19-77 months).All the patients had no obvious pain,instability and ulnar nerve symptoms in the last follow-up.The average elbow flexion was 134.09°±12.41°(100°-140°),average extension was -15.91°±14.46°(-40°-0°),range of flexion and extension was 118.18°±23.80°(70°-140°).Average pronation was 70.91°±26.63° (20°-90°),supination was 70.91°±26.63°(20°-100°).The range of motion (ROM)of forearm rotation was 150.91°±43.00°(40°-180°).Average Mayo elbow performance score (MEPS)was 96.36 ±5.04 (85 -100).X-ray showed that no degenerative changes.Five patients had heterotopic os-sifications,according to Hastings and Graham grading:1 case was grade Ⅰ,3 cases were grade ⅡA, 1 case was ⅡB.Conclusion:The old “terrible triad”of elbow with no operative history is difficult to treat.The elbow’s functions and stabilization can be recovered by thorough elbow release,repair of coro-noid process and anterior capsule,radial head fractures,lateral collateral ligament and the common ex-tensor tendon insertion,combined with hinged external fixator.Joint stiffness and heterotopic ossification are common complications.

Objective:To discuss the diagnosis,differential diagnosis,classification methods and treat-ment of the capitellar fractures of the distal humerus.Methods:In the study,28 adult patients with the capitellar fractures were treated in Beijing Jishuitan Hospital from Sep.2008 to Jan.2014.There were 10 females and 18 males with an average age of 34 years (range:14-66 years).According to Dubber-ley classification:ⅠA type in 6 cases,ⅠB type in 2 cases,ⅡA type in 8 cases,ⅡB type in 4 cases,ⅢA type in 4 cases,and ⅢB type in 4 cases.Sixteen patients were treated with a single Kochr approach,1 with a lateral approach combined with a medial approach,2 combined with anterior elbow approach and 9 combined with posterior median approach.All of the fractures were fixed with Herbert screws,7 cases with support plates,and 4 cases with the hinged elbow external fixator.All of the pa-tients were followed up for clinical examination and radiograph check.They were evaluated with Broberg-Morrey score system.Results:The average follow-up time was 28.5 months (range 12 -72 months). The average bone union time was 8 weeks.The average ulnohumeral motion was 1 12°(60°-150°)and forearm rotation was 145°(100°-170°).The average Broberg-Morrey score was 92.5 points (range:62-100 points).The excellent and good rate was 91.8%.The complications of traumatic arthritis was in 2 cases and elbow stiffness was in 2 cases.Conclusion:Attention should be paid to the diagnosis and differential diagnosis of capitellar fractures without missing the combined injury.According to Dubberley classification,appropriate surgical approach and the internal and external fixed methods could be chosen. Early postoperative,reasonable and effective exercise is helpful to the recovery of elbow joint function.

0.05). Conclusion Although it is expensive, CT scan should serve as a routine examination before operation because it has significant effects on treatment plan and classification of tibial plateau fractures.

Although chronic lateral instability of the ankle is a common disorder, there are not many reports and researches on it in China. This is because most patients with the condition do not seek a thorough cure of it and consequently surgeons pay little attention to it. In this article, we discuss some of the problems about its diagnosis, describe and compare several surgical procedures for reconstruction of the lateral ligament. We hope this paper can help surgeons know more about how to make an accurate diagnosis of the chronic lateral instability of the ankle and how to deal with it.

Objective To introduce the diagnosis and treatment of the missed adolescent humeral capitellar fracture malunion.Methods Retrospectively analyzed 6 cases with missed adolescent capitellar fracture malunion treated by the author from Jul.2010 to Mar.2015 and their follow-up results.Among them, 5 were male and 1 was female.The average age is (14.33 ± 1.86) years, 4 were left-side and 2 were right.Results The average time from injury to the operation is (8.67 ± 3.88) months.Before operation, the average elbow flexion was (91.67° ±7.53°), the average elbow extension was (40.0° ± 8.94°), the average range of flexion and extension activities was (51.67° ±11.69°).Forearm rotation was not limited.Average M EPS score was (80.83 ± 4.92).Released the elbow in 3 cases with additional medial incision.The fragment was fixed by HCS.The lateral collateral ligament was repaired by suture anchors (2 cases) or by trans-os suture(4 cases).Three cases were fixed by DJDⅡ Stryker hinged external fixatorswhich were removed after 8 weeks.The average postoperative follow-up time was (39.33 ± 20.42) months.Postoperatively, the average elbow flexion was (138.33° ±7.528°), the average elbow extension was (5.0° ± 4.472°), the average range of flexion and extension activities was (133.33° ±9.832°).Forearm rotation is not limited.The average MEPS score was 100.Conclusions The adolescent capitellar fracture is prone to be missed and cause malunion, elbow stiffness or other complications which is very difficult to deal with.By complete elbow release, osteotomy and internal fixation, the lateral collateral ligament repair, and hinged external fixator if necessary, the final elbow function can be improved.

Objective:To investigate the clinical efficacy and outcomes of two separate vertical wiring combined with tension band and Kirschner-wire plus cerclage wire in the treatment of displaced inferior pole fractures of the patella.Methods:From January 201 3 to January 201 5,1 5 consecutive patients (mean age 54.5 years)with inferior pole fractures of the patella were retrospectively included in this study.All the patients underwent open reduction and internal fixation by separate vertical wiring com-bined with tension band and Kirschner-wire plus cerclage wire through longitudinal incision,4.5 d (range:3.1 -5.9 d)after initial injury.A safety check for early knee range of motion was performed before wound closure.The complications including infection,nonunion,loss of fixation and any wire breakage or irritation from implant were recorded.Anteroposterior and lateral views of the knee joint ob-tained during the follow-up were used to assess bony union based on the time when the fracture line disap-peared.At the time of the final outpatient follow up,functional evaluation of the knee joint was conduc-ted by B?stman system.Results:The follow-up time was 1 3.1 months (range:1 2 -1 9 months)after surgery on average,immediate motion without immobilization in all the cases was allowed and there was no case of reduction loss of the fracture and wire breakage.There was no case of irritation from the im-plant.At the final follow-up,the average range of motion (ROM)arc was 1 26.7°(range:1 1 5°-1 40°),the average ROMlag versus contralateral healthy leg was 1 0.3°(range:0°-35°).The mean B?stman score at the last follow-up was 28.9 (range:27 -30),and graded excellent in most cases. Conclusion:Two separate vertical wiring is an easy and effective method to reduce the displaced inferior pole fracture of patella.Augmentation of separate vertical wiring with tension band and Kirschner-wire plus cerclage wire in these patients provides enough strength to protected the early exercise of the knee joint and uneventful healing.By this surgical treatment,excellent results in knee function can be expec-ted for cases of displaced inferior pole fractures of the patella.

Objective To explore the clinical efficacy of radial head replacement with titanic prosthesis for comminuted fractures of the radial head associated with elbow instability. Methods From 2000 to 2003, a total of 18 patients, 13 men and 8 women (mean age, 34.8 years, range, 24-47 years) underwent radial head replacement with titanic prosthesis for comminuted fractures associated with elbow instability. All were the close fractures, left elbow in 8 and right elbow in 10 cases. 3 patients suffered multiple fractures in ipsilateral elbow, including proximal comminuted fracture of radius in 1, fracture of coronoid process in 2. 4 patients suffered simultaneous fracture in ipsilateral upper extremity, including distal fracture of radius in 3, fracture of surgical neck of humerus in 1. According to Mason classification, 10 fractures were of type Ⅲ, 7 of type Ⅳ, and 1 with Essex-Lopresti injury. 4 cases were old fractures and dislocations, the other 14 were of fresh injuries within 2 weeks. Operations were undertaken averagely in 9 days after injury (range, 4-26 days). Results Patients were followed from 12 to 44 months (average, 29 months). According to Broberg and Morrey scoring system, 8 patients (44.4%) were rated as excellent, 8 (44.4%) as good, 1 (5.6%) as fair, and 1 (5.6%) as poor. The rate of excellent and good results was 88.9%. No cases of infection, neural injury, foreign body reaction, exacerbation of cubitus valgus or deformity of wrist was found. On X-ray films, all of the titanic radial head prosthesis were stable, no shortening or proximal migration of radius, or subluxation of distal radioulnar joint was found. No sign of inflammatory reaction was noted. Mild heterotopic ossification was found in 6 elbows, but no distinct resulted limitation of locomotion. Conclusion The radial head replacement with titanic prosthesis provides an effective method for the treatment of comminuted fractures of the radial head associated with elbow instability.

Objective To study the relationship between the Bado's classification of the Monteggia fracture in adult and their prognosis. Methods Studying the 60 patients in our hospital suffering from Monteggia fracture-dislocation during 10 years between 1994 to 2004, and their clinical data of the follow-up is analysised with statistics. There were 26 cases with Bado type Ⅰ fracture-dislocations, 14 cases with Bado type Ⅱ fracture-dislocations, 19 cases with Bado type Ⅲ and 1 case with Bado type Ⅳ fracture-dislocations. The fractures of the shaft of the ulna were treated operatively with open reduction and internal fixation using plates and screws. The fractures of the radial head were operated with open reduction and internal fixation, or are treated with the resection of the partial or total radial head. For the cases of the dislocation of the radial head without fracture, the most commonly used treatment method was to reduce the dislocation closely and stable the position with external fixation by a plaster cast. For the injury of the radial nerve associated with the Monteggia fracture dislocation, no operation had been done to make an exploration. Rank Sun Test of NoSA system was adopted to analysis the clinical data gained above. Results The average duration of the follow-up was 24 months (12-72 months). The results were graded according to the score system of Broberg and Morrey. In Bado type Ⅰ, 24 cases were considered satisfactory and 2 cases unsatisfactory, satisfactory ratio is 92%; In Bado type Ⅱ, 10 cases satisfactory and 4 cases unsatisfactory, satisfactory ratio was 71%; In Bado type Ⅲ and type Ⅳ, all the cases gained satisfactory results, satisfactory ratio was 100%. Rank Sun Test showed there was no obvious difference on prognosis between every group of the Bado's classification system. But statistical obvious difference could be found between the group with the fractures of the radial head and the group without. Conclusion The classification system of Bado has no prediction prognosis. In adult Monteggia fracture, the final result largely depends on whether there is a fracture of the radial head.

Objective To compare the clinical outcomes of open reduction and internal fixation (ORIF) with total elbow arthroplasty (TEA) for type C inter-condylar fractures of the distal humerus in the elderly. Methods Twenty-two patients who were treated with ORIF or TEA from April 2003 to September 2009 were included in the study. All fractures were OTA classification 13C. Among them, 10 patients who were treated with ORIF were follow up for 8-56 months, while 12 patients who were treated with TEA were followed up for 15-54 months. The Mayo elbow performance score (MEPS) and the complications were compared. Results Using the MEPS, there were 2 in excellent, 4 in good, 4 in fair in the patients treated with ORIF. Complications included heterotopic ossifications (2 cases) and ulnar nerve dysfunction (2 cases).There were 6 in excellent, 4 in good, 2 in fair in the patients treated with TEA. Complications included 1heterotopic ossification (1 case), ulnar nerve dysfunction (1 case), the weakness of musculus triceps brachii (1 case). The patients treated with TEA had significantly better range of motion (107.5° vs 84.5°, P=0.007),also had better MEPS (87.9 vs 75.5, P=0.047) than those with ORIF had ones. Conclusion TEA is a liable option for type C inter-condylar fractures of the distal humerus in the elderly.

Objective To discuss the characteristics, treatment method and prognosis of tibial tuberosity avulsion fracture in children. Methods From January 1995 to December 2007, there were 25 cases (23 boys and 2 girls). The age at injury ranged from 12 to 16 years(average 13.5 years). All cases were unilateral involved (10 of left, 15 of right). All of the injuries resulted from participation in athletic activities, 10 in basketball, 7 while jumping, and 8 in football game. According to the classification of Ogden, there were 1 type 1A, 4 type 1B, 5 type 2A, 7 type 2B, 4 type 3A, and 4 type 3B fractures. One type 1A fracture was treated nonoperatively with east immobilization, and other 24 fractures with open reduction and internal fixation. Results All of 25 cases were followed from 14 months to 7 years (average 43 months). The range of motion of knee joint was 0°-140° 3 months after operation, and all of them recovered to pre-injury levels of activity by 6 months after operation. According to Mosier clinical assessment system, the final outcome was evaluated as excellent in all. Wound healed primary, no compartment syndrome was found. The time of bony union ranged from 2 to 5 months, with the mean time of 3 months. No complications of infection, ex-tremities deformity and inner fixation failure were found. Conclusion The tuberosity avulsion fracture in children is an uncommon and special type of epiphyseal injury. These fractures occur in the narrow range of 13 to 16 years of age. The majority of patients are males, and most of them are unilateral involved. This in-jury has an excellent outcome without deformity or functional loss, once adequate reduction and fixation of fracture fragments have been achieved.