Surgical treatment and outcomes of trans-ulnar basal coronoid fracture-dislocations.

BACKGROUND: Trans-ulnar fracture-dislocations of the elbow are complex injuries that can be difficult to classify and treat. Trans-ulnar basal coronoid injuries, in which the coronoid is not attached to either the olecranon or the metaphysis, present substantial challenges to achieve anatomic reduction and stable internal fixation. The purpose of this study was to analyze the outcome of surgical treatment of trans-ulnar basal coronoid fracture-dislocations. MATERIALS AND METHODS: Between 2002 and 2019, 32 consecutive trans-ulnar basal coronoid fracture-dislocations underwent open reduction and internal fixation at our institution. Four elbows were lost to follow-up within the first 6 months after surgery and were excluded. Among the 28 elbows remaining, there were 13 females and 15 males with a mean age of 56 (range 28-78) years at the time of injury. The mean clinical and radiographic follow-up times were 37 months and 29 months, respectively. Radiographs were reviewed to determine rates of union, Hastings and Graham heterotopic ossification (HO) grade, and Broberg and Morrey arthritis grade. RESULTS: Union occurred in 25 elbows. Union could not be determined for 1 elbow at most recent follow-up and the remaining 2 elbows developed nonunion of the coronoid. Complications occurred in 10 elbows (36%): deep infection (4), ulnar neuropathy (2), elbow contracture (2), and nonunion (2). There were reoperations in 11 elbows (39%): irrigation and débridement with hardware removal (4), hardware removal (2), ulnar nerve transposition (2), contracture release with HO removal (2), and revision with iliac crest autograft (1). At most recent follow-up, the mean flexion-extension arc was 106° (range 10°-150°), and the mean pronation-supination arc was 137° (range 0°-170°). The mean Quick Disabilities of Arm, Shoulder, and Hand score was 11 (range 0-39) points with a mean Single Assessment Numeric Evaluation-Elbow score of 81 (range 55-100) points. At final radiographic follow-up, 16 elbows (57%) had HO (8 class I and 8 class II), and 20 elbows (71%) had arthritis (8 grade 1, 6 grade 2, and 6 grade 3). DISCUSSION: Trans-ulnar basal coronoid fracture-dislocations are severe injuries associated with high rates of reoperation, HO, and post-traumatic arthritis. However, the majority of elbows achieve union, a functional range of motion, and reasonable patient reported outcome measures. Over the study period, surgeons were more likely to utilize multiple deep approaches and separate fixation of the coronoid (either with lag screws or anteromedial plates) to ensure anatomic reduction.

A coronoid-centric classification system of proximal trans-ulnar fracture-dislocations has almost perfect intraobserver and interobserver agreement.

BACKGROUND: Fracture-dislocations of the elbow, particularly those that involve a fracture through the proximal ulna, are complex and can be difficult to manage. Moreover, current classification systems often cannot discriminate between Monteggia-variant injury patterns and trans-olecranon fracture-dislocations, particularly when the fracture involves the coronoid. The Mayo classification of proximal trans-ulnar fracture-dislocations categorizes these fractures into 3 types according to what the coronoid is still attached to: trans-olecranon fracture-dislocations (the coronoid is still attached to the ulnar metaphysis); Monteggia-variant fracture-dislocations (the coronoid is still attached to the olecranon); and ulnar basal coronoid fracture-dislocations (the coronoid is not attached to either the olecranon or the ulnar metaphysis). The purpose of this study was to evaluate the intraobserver and interobserver agreement of the Mayo classification system when assessing elbow fracture-dislocations involving the proximal ulna based on radiographs and computed tomography scans. METHODS: Three fellowship-trained shoulder and elbow surgeons and 2 fellowship-trained orthopedic trauma surgeons blindly and independently evaluated the radiographs and computed tomography scans of 90 consecutive proximal trans-ulnar fracture-dislocations treated at a level I trauma center. The inclusion criteria included subluxation or dislocation of the elbow and/or radioulnar joint with a complete fracture through the proximal ulna. Each surgeon classified all fractures according to the Mayo classification, which is based on what the coronoid remains attached to (ulnar metaphysis, olecranon, or neither). Intraobserver reliability was determined by scrambling the order of the fractures and having each observer classify all the fractures again after a washout period ≥ 6 weeks. Interobserver reliability was obtained to assess the overall agreement between observers. κ Values were calculated for both intraobserver reliability and interobserver reliability. RESULTS: The average intraobserver agreement was 0.87 (almost perfect agreement; range, 0.76-0.91). Interobserver agreement was 0.80 (substantial agreement; range, 0.70-0.90) for the first reading session and 0.89 (almost perfect agreement; range, 0.85-0.93) for the second reading session. The overall average interobserver agreement was 0.85 (almost perfect agreement; range, 0.79-0.91). CONCLUSION: Classifying proximal trans-ulnar fracture-dislocations based on what the coronoid remains attached to (olecranon, ulnar metaphysis, or neither) was associated with almost perfect intraobserver and interobserver agreement, regardless of trauma vs. shoulder and elbow fellowship training. Further research is needed to determine whether the use of this classification system leads to the application of principles specific to the management of these injuries and translates into better outcomes.

The radiological findings in complex elbow fracture-dislocation injuries.

Elbow fracture-dislocation is a complex injury which can lead to significant bony and soft tissue damage. Surgical intervention is guided towards restoring joint stability, allowing early mobilization and preventing long-term joint stiffness. The most common types are posterolateral, posteromedial, Monteggia type (and variants), and anterior trans-olecranon fracture-dislocations. Posterolateral fracture-dislocation is characterized by a radial head fracture (± anterolateral coronoid fracture) and typically capsuloligamentous disruption (lateral collateral ligaments injury is the most common). A posterolateral fracture-dislocation with radial head and coronoid anterolateral facet fractures is termed a terrible triad injury. In posteromedial fracture-dislocation, there is a fracture of the anteromedial facet of the coronoid, typically with proximal avulsion of the lateral collateral ligaments (± injury to the posterior bundle of the ulnar collateral ligament). Monteggia fracture-dislocation injuries demonstrate proximal ulnar fracture (with possible involvement of the olecranon and the coronoid) and radial head dislocation. These can be divided into apex anterior or apex posterior variants. The latter are commonly associated with radial head fractures and lateral ligamentous injury, and have a worse prognosis. In trans-olecranon fracture-dislocation, there is significant disruption of the greater sigmoid notch and the olecranon, with various involvement of the coronoid and the proximal ulna. The article describes the radiological findings and outlines the management principles in complex elbow fracture-dislocation injuries.

Trans-olecranon fracture-dislocation of the elbow in children.

OBJECTIVES: Trans-olecranon fracture-dislocations are rare in children. To our knowledge, only 12 cases have been described in children till now and the treatment strategy for this injury in children remains unclear. To provide a clear clinical description and more accurate treatment options, we retrospectively reviewed cases with this kind of injury in our institution. METHODS: From 2002 to 2019, eleven cases diagnosed with trans-olecranon fracture-dislocation of the elbow were identified, and their medical charts and radiographs were obtained. All patients underwent open reduction and internal fixation through a posterior approach. At the most recent follow-up visit, all patients were evaluated clinically using the Mayo Elbow Performance Score (MEPS). RESULTS: The mean follow-up was 22 months (range, 6-42 months). All injuries were unilateral, and there were nine males and two females. The mean age at injury was nine years (range, 4-13 years), and the mean time from injury to surgery was 16.6 days (range, 2-60 days). According to Tiemdjo classification, there was one case with type I injury, one case with type II, six cases with type III, and three cases with type IV. According to the MEPS criteria, the outcomes were excellent in five cases, good in two cases, fair in one case, and poor in three cases. Four patients were delayed cases, who underwent surgery two weeks after injury. The average operation time was significantly longer in four children sustaining delayed surgery (140 ± 43 min, vs. 50 ± 12 min, p < 0.001). CONCLUSION: To our knowledge, this is the largest sample size reported to date. We recommend open reduction and internal fixation, using either plates or tension-band techniques, depending on the injury pattern. In addition, we emphasize that early operation could achieve good clinical outcomes.

Coronoid fractures and complex elbow instability: current concepts.

Fractures of the coronoid process typically occur as part of more complex injury patterns, such as terrible triads, trans-olecranon fracture-dislocations, posteromedial rotatory injuries or Monteggia-like lesions. Each pattern is associated with a specific type of coronoid fracture with regard to shape and size and specific soft-tissue lesions. O' Driscoll classification incorporates those associations identifying three major types of fractures: tip, anteromedial facet, and basal fractures. The objective of this study is to review the most common types of complex elbow instability, identify the indications for coronoid fixation and guide the appropriate management. Tip fractures as those seen in terrible triads can conditionally left untreated provided that elbow stability has been restored after radial head fixation and ligaments repair. Anteromedial facet fractures benefit from a buttress plate, while large basilar fractures can be effectively secured with posteroanterior screws. Coronoid reconstruction with a graft should be considered in post-traumatic cases of chronic coronoid deficiency.

Usability of Minimal Invasive Surgery for Elbow Dislocation with Coronoid Process Fracture: A Protocol Development Study.

OBJECTIVE: The study aims to explain whether or not minimal invasive surgery (MIS) would be feasible in elbow fracture-dislocation with coronoid process fracture. METHODS: At Taipei Veterans General Hospital, patients who had elbow dislocations with coronoid process fractures underwent a single surgeon's MIS techniques which included the fluoroscopy-guided ulnar anteromedial (FGUAM) approach in the stage of reducing the coronoid process. When there is a proximal ulnar fracture, the posterior incision should be necessary, followed by the incision over the lateral or medial elbow for treating radial fractures or ligament injuries. RESULTS: The Flow Diagram for approach recommendation was established on the basis of defining MIS as that which does not include cross-plane dissection. The importance of anterior rigid fixation for the coronoid process was also emphasized. CONCLUSIONS: MIS can be achieved by multiple limited surgical incisions. Although the posterior extensile approach is necessary in situations of ulnar metaphysis or ligament avulsion fracture, the FGUAM approach decreases the cross-plane dissection.

Outcomes of Posterior Monteggia Variant Fractures Repaired Through a Trans-Olecranon Approach.

Purpose: To evaluate the clinical and radiographic outcomes and complications following surgical treatment of adult posterior Monteggia fracture variants in which coexisting radial head and coronoid fractures were addressed through a single extensile posterior trans-olecranon approach. Methods: We performed a retrospective review from January 1, 2010, to January 1, 2021, of all adult patients who underwent fixation of posterior Monteggia variant fractures with coexisting radial head and/or coronoid fractures through a trans-olecranon approach by a single surgeon. Patient records were reviewed for postoperative complications and radiographic outcomes. All patients were contacted to participate in a repeat clinical examination and functional assessment. Results: Thirteen patients met the inclusion criteria, of which 7 agreed to participate. Final follow-up was conducted at an average of 49 months postoperatively. Six patients had a coexisting radial head fracture, 1 had a radial neck fracture, and all 7 patients had a coronoid fracture. All 7 coronoid fractures were repaired, 2 patients had internal fixation of the radial head, and 5 had radial head replacement. Four patients underwent reoperation. There were no cases of infection or heterotopic ossification, and all patients achieved radiographic bony union. The average final range of motion was 13°-133° flexion-extension (range: 0°-30° extension to 125°-145° flexion), 76° pronation (range: 70°-90°) and 72° supination (range: 60°-90°). The average Mayo Elbow Performance Score was 86 (range: 70-100), average Visual Analog Scale score was 1.4 (range: 0-3), and average Disabilities of the Arm, Shoulder, and Hand score was 9.8 (range: 0.83-35.83). Conclusions: Use of a single extensile trans-olecranon exposure offers reliable visualization and access to all bony structures requiring repair while minimizing soft tissue disruption. Patients treated with this trans-olecranon surgical approach demonstrate satisfactory clinical and radiographic outcomes with low rates of heterotopic ossification, nonunion, and infection. Level of Evidence: Therapeutic IV.

Trans-olecranon fracture dislocations: How should we treat them?

BACKGROUND: Trans-olecranon fracture dislocations are the least frequent complex elbow instability. Proper surgical treatment should be performed to avoid postoperative complications. METHODS: A retrospective design study was performed. Patients that suffered from this injury, treated at our center from 2010 to 2016 were included. Fifteen patients were analyzed. Functional results were measured using DASH, MEPS and VAS scores. Average time from injury to first surgical treatment was 4.87 days. Radial head fracture was present in seven cases and coronoid process in three patients. Most frequent complication was hardware disturbances in five patients. Mean follow up was 3.65 years. RESULTS: Mean range of motion (ROM) was evaluated 1 year postoperatively: 129° flexion, 6° flexion contracture, and less than 5° deficit of pronation/supination. Clinical and functional results are encouraging, DASH 36.38, MEPS 100 and VAS 0.46. CONCLUSION: Trans-olecranon fracture dislocations could obtain functional range of movement, pain relief and good functional outcomes with a standardized protocol of surgical fixation. It is important to achieve proper ulnar fixation, focusing in reestablishing dorsal angulation, and also to treat radial head and coronoid injuries properly, if present.

Pediatric trans-olecranon fracture dislocation of the elbow associated with fracture of the radial head and with medial collateral ligament lesion: A case report and review of the literature.

INTRODUCTION: We report what is, to the best of our knowledge, the first case of pediatric trans-olecranon fracture dislocation of the elbow associated with a radial head fracture and with a medial collateral ligament disruption. CASE PRESENTATION: A 7-year-old girl presented to the emergency department after a fell on his right elbow while playful activity at home. The elbow X-ray showed acute trans-olecranon fracture dislocation of the elbow associated with a radial head fracture. A pre-operative 3D TC scans confirmed and clarified the injury pattern. However, stress radiographs performed in the operating room under anesthesia revealed an associated severe valgus instability caused by medial collateral ligament disruption. The olecranon fracture was fixed with two crossing 1.5 mm K-wires and the angulated radial neck fracture was fixed with a retrograde 1.5 mm K-wire by S.E.R.I. technique. CONCLUSION: Although trans-olecranon fracture dislocation of the elbow is well recognized and clearly described in adults, it is uncommon in children. A pre-operative 3D TC scans are recommended to enable a more accurate diagnosis and surgical planning. Medial collateral ligament has a central role in elbow stability and is very important to repair it during surgery.

Treatment of complex elbow fracture-dislocations.

Successful management of complex elbow fracture-dislocations requires, in part, recognition of the overall injury pattern, which can aid in the identification of concomitant bony and soft tissue injuries. Trans-olecranon fracture-dislocations are best treated surgically with stable anatomic restoration of the trochlear notch. Terrible triad elbow injuries are believed to be caused by a valgus posterolateral force. Although select terrible triad injuries can be managed non-operatively, the majority of injuries are treated with stable surgical repair to allow early elbow motion. Unlike terrible triads, varus posteromedial forces are theorized to cause anteromedial coronoid fractures. These are usually associated with LCL disruptions, but do not have concomitant MCL or radial head injuries. A subset of anteromedial coronoid fractures can also be managed non-operatively. Internal fixation is recommended for injuries associated with large fracture fragments or elbow instability preventing early motion.

Effect analysis of different surgical approaches in improving elbow joint function of patients with humeral intercondylar fractures / 中国现代医生

Objective To analyze the surgical effects of trans-olecranon osteotomy approach and trans-triceps bilateral approach in improving the elbow joint function of patients with humeral intercondylar fractures. Methods Eighty-five patients with humeral intercondylar fractures were randomly divided into two groups. The olecranon group received trans-olecranon osteotomy approach surgery and the triceps group received trans-triceps bilateral approach surgery. The surgery and elbow joint function recovery situation of the two groups were observed. Results The triceps group had longer operative time and intraoperative blood loss higher than the olecranon group (P<0.01). The triceps group had better Mayo elbow joint function score and joint range of motion than the olecranon group (P<0.01). The excellent and good rate of the triceps group was 81.40%, which was higher than the 59.52% of the olecranon group (P<0.05). The C3 excellent and good rate of the olecranon group was 26.19%, which was significantly better than the 9.30%of the triceps group (P<0.05). Conclusion Trans-olecranon osteotomy approach and trans-triceps bilateral approach each has advan-tages in improving the elbow joint function of patients with humeral intercondylar fractures. The former is suitable for patients with C3 humeral intercondylar fractures and the latter C1 or C2 humeral intercondylar fractures.