ABSTRACT
Background: Proximal ulna fracture-dislocations are challenging injuries with a myriad of existing classification systems. The Coronoid, proximal Ulna, Radius, and Ligaments classification (CURL) is a simple framework designed to focus attention on the key components affecting outcome and guide surgical management. This study evaluates interobserver and intraobserver reliability of this new classification. Methods: Four observers independently reviewed plain radiographs and computed tomography (CT) scans of patients with proximal ulna fracture-dislocations. Each observer scored the Coronoid (C), proximal Ulna (U), and Radius (R) components for each fracture on 2 occasions. The osseous components were subclassified as 'intact', 'simple', or 'complex'. The Ligament component (L) was not rated as this requires intraoperative classification. Interobserver and intraobserver reliability was calculated using Cohen's weighted kappa coefficients. X-ray and CT were compared for patients with both imaging modalities. The Landis and Koch criteria were used to interpret the strength of the kappa statistics. Results: One hundred seventy seven patients had plain X-rays; 58 patients had both X-ray and CT scans. Overall, in the X-ray only cohort, there was 'almost perfect' interobserver reliability for the radial head (k = 0.94) and coronoid (k = 0.83), and 'substantial' reliability (k = 0.68) for the proximal ulna. For the X-ray and CT cohort, interobserver reliability was 'almost perfect' across both modalities for the radial head (k = 0.88 and k = 0.93, respectively) and 'moderate' for the proximal ulna (k = 0.48 and k = 0.52, respectively). For the coronoid, interobserver reliability for X-ray interpretation was 'substantial' (k = 0.74) and for CT was 'almost perfect' (k = 0.89). Intraobserver reliability was 'almost perfect' for all components, other than CT assessment of the proximal ulna which demonstrated 'substantial' reliability (k = 0.74). Conclusion: The Coronoid, proximal Ulna, Radius, and Ligaments classification demonstrates strong interobserver and intraobserver reliability, supporting use of the classification for proximal ulna fracture-dislocations. CT is recommended for improved characterization of any fracture with a coronoid component.
ABSTRACT
Background: Intra-articular distal humerus fractures in the older population remain a challenge to fix, due to the comminution of fragments and poor bone stock. Recently Elbow Hemiarthroplasty (EHA) has gained popularity to treat these fractures, however no studies exist comparing EHA to Open Reduction Internal Fixation (ORIF). Objectives: To compare the clinical outcomes of patients over the age of 60 years treated with ORIF or EHA for multi-fragmentary distal humerus fractures. Methods: Thirty-six patients (mean age 73 years) treated surgically for a multi-fragmentary intra-articular distal humeral fracture were followed up for a mean duration of thirty-four months (12-73 months). Eighteen patients were treated with ORIF and eighteen with EHA. The groups were matched for fracture type, demographic characteristics and follow up time. Outcome measures collected included Oxford Elbow Score (OES), Visual Analogue pain Score (VAS), range of motion (ROM), complications, re-operations and radiographic outcomes. The quality of ORIF was judged against set radiographic criteria in order to understand the effect of sub-optimal ORIF technique. Results: No significant clinical difference was found between EHA and ORIF in mean OES (42.5 vs 39.6, p = 0.28), mean VAS (0.5 vs 1.7, p = 0.08) or mean flexion-extension arc (123° vs 112°, p = 0.12). There were significantly more complications associated with ORIF compared to EHA (39% vs 6%, p = 0.04). ORIF executed with satisfactory fixation technique had a comparable complication rate compared to EHA (17% vs 6%, p = 0.6). Two ORIF patients required revision to Total Elbow Arthroplasty (TEA). None of the EHA patients required revision surgery. Conclusion: This study demonstrated similar short-term functional outcomes between EHA and ORIF for the treatment of multi-fragmentary intra-articular distal humeral fractures in patients >60 years of age. Early complications and re-operations were higher in the ORIF group, although this could be related to improper ORIF technique and patient selection.
