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Meyer MA, Leversedge FJ, Catalano LW, Lauder A. Complex Elbow Fracture-Dislocations: An Algorithmic Approach to Treatment. J Am Acad Orthop Surg 2024; 32:669-680. [PMID: 38709855 DOI: 10.5435/jaaos-d-23-00460] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/17/2023] [Accepted: 02/20/2024] [Indexed: 05/08/2024] Open
Abstract
Elbow stability arises from a combination of bony congruity, static ligamentous and capsular restraints, and dynamic muscular activation. Elbow trauma can disrupt these static and dynamic stabilizers leading to predictable patterns of instability; these patterns are dependent on the mechanism of injury and a progressive failure of anatomic structures. An algorithmic approach to the diagnosis and treatment of complex elbow fracture-dislocation injuries can improve the diagnostic assessment and reconstruction of the bony and ligamentous restraints to restore a stable and functional elbow. Achieving optimal outcomes requires a comprehensive understanding of pertinent local and regional anatomy, the altered mechanics associated with elbow injury, versatility in surgical approaches and fixation methods, and a strategic rehabilitation plan.
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Affiliation(s)
- Maximilian A Meyer
- From the Department of Orthopedic Surgery, University of Colorado School of Medicine, Aurora, CO(Dr. Meyer, Dr. Leversedge, Dr. Catalano, and Dr. Lauder), Department of Orthopedic Surgery, Denver Health Medical Center, Denver, CO (Dr. Lauder)
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Nieboer MJ, Cancio-Bello A, Mallett KE, Velasquez Garcia AR, Hidden KA, Yuan BJ, Morrey ME, Sanchez-Sotelo J, O'Driscoll SW, Barlow JD. Trans-ulnar fracture dislocations of the elbow: a systematic review and clarification of classification systems. J Shoulder Elbow Surg 2024; 33:975-983. [PMID: 38036255 DOI: 10.1016/j.jse.2023.10.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/11/2023] [Revised: 09/24/2023] [Accepted: 10/18/2023] [Indexed: 12/02/2023]
Abstract
BACKGROUND Complex elbow dislocations in which the dorsal cortex of the ulna is fractured can be difficult to classify and therefore treat. These have variably been described as either Monteggia variant injuries or trans-olecranon fracture dislocations. Additionally, O'Driscoll et al classified coronoid fractures that exit the dorsal cortex of the ulna as "basal coronoid, subtype 2" fractures. The Mayo classification of trans-ulnar fracture dislocations categorizes these injuries in 3 types according to what the coronoid remains attached to: trans-olecranon fracture dislocations, Monteggia variant fracture dislocations, and trans-ulnar basal coronoid fracture dislocations. The purpose of this study was to evaluate the outcomes of these injury patterns as reported in the literature. Our hypothesis was that trans-ulnar basal coronoid fracture dislocations would have a worse prognosis. MATERIALS AND METHODS We conducted a systematic review to identify studies with trans-ulnar fracture dislocations that had documentation of associated coronoid injuries. A literature search identified 16 qualifying studies with 296 fractures. Elbows presenting with basal subtype 2 or Regan/Morrey III coronoid fractures and Jupiter IIA and IID injuries were classified as trans-ulnar basal coronoid fractures. Patients with trans-olecranon or Monteggia fractures were classified as such if the coronoid was not fractured or an associated coronoid fracture had been classified as O'Driscoll tip, anteromedial facet, basal subtype I, or Regan Morrey I/II. RESULTS The 296 fractures reviewed were classified as trans-olecranon in 44 elbows, Monteggia variant in 82 elbows, and trans-ulnar basal coronoid fracture dislocations in 170 elbows. Higher rates of complications and reoperations were reported for trans-ulnar basal coronoid injuries (40%, 25%) compared to trans-olecranon (11%, 18%) and Monteggia variant injuries (25%, 13%). The mean flexion-extension arc for basal coronoid fractures was 106° compared to 117° for Monteggia (P < .01) and 121° for trans-olecranon injuries (P = .02). The mean Mayo Elbow Performance Score was 84 points for trans-ulnar basal coronoid, 91 for Monteggia (P < .01), and 93 for trans-olecranon fracture dislocations (P < .05). Disabilities of the Arm, Shoulder and Hand and American Shoulder and Elbow Surgeons scores were 22 and 80 for trans-ulnar basal coronoid, respectively, compared to 23 and 89 for trans-olecranon fractures. American Shoulder and Elbow Surgeons was not available for any Monteggia injuries, but the mean Disabilities of the Arm, Shoulder and Hand was 13. DISCUSSION Trans-ulnar basal coronoid fracture dislocations are associated with inferior patient reported outcome measures, decreased range of motion, and increased complication rates compared to trans-olecranon or Monteggia variant fracture dislocations. Further research is needed to determine the most appropriate treatment for this difficult injury pattern.
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Affiliation(s)
- Micah J Nieboer
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, MN, USA
| | | | | | - Ausberto R Velasquez Garcia
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, MN, USA; Department of Orthopedic Surgery, Clinica Universidad de los Andes, Santiago, Chile
| | - Krystin A Hidden
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, MN, USA
| | - Brandon J Yuan
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, MN, USA
| | - Mark E Morrey
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, MN, USA
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da Mota J, da Cruz SA, De Simoni LF, Zimmermmann DSR, Andrade-Silva FB, Mendes AF. TRANSOLECRANON FRACTURE-DISLOCATION: CONCEPTS AND FUNCTIONAL RESULTS OF SURGICAL TREATMENT. ACTA ORTOPEDICA BRASILEIRA 2023; 31:e255572. [PMID: 37082161 PMCID: PMC10112355 DOI: 10.1590/1413-785220233101e255572] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/25/2021] [Accepted: 02/10/2022] [Indexed: 04/22/2023]
Abstract
Objectives This study aimed to evaluate the functional results of the treatment protocol for the treatment of transolecranon fracture-dislocation, by surgical reduction and osteosynthesis with plate and screws, in patients attended at a referral hospital for orthopedic trauma, with a minimum follow-up period of six months. Methods Twenty-five individuals treated surgically from January 2014 to November 2018 were selected for a primary observational longitudinal study using questionnaires to assess upper limb and elbow function (DASH and MEPS), quality of life (SF-12), pain (visual analog scale - VAS), and radiographic evaluation in anteroposterior and lateral views of the elbow. Results Fifteen patients were male, and the mean age was 46.8 years. All participants had their fractures consolidated, with no radiolgraphic signs of implant failure, or degenerative arthritis. Mean range of motion was reduced relative to the contralateral limb: 102.6º for flexion-extension and 132.8º for pronation-supination. The mean MEPS and DASH scores were 89.6 and 16.5 respectively. There was no residual pain in 84% of the cases according to the VAS. Conclusion The surgical treatment proposed for transolecranon fracture-dislocations showed satisfactory results according to MEPS, DASH scores and quality of life measures. Evidence Level IV; Retrospective observational study.
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Affiliation(s)
- José da Mota
- Universidade Federal de Juiz de Fora, Hospital Universitário, Serviço de Ortopedia e Traumatologia, Juiz de Fora, MG, Brazil
| | - Sebastião Alves da Cruz
- Universidade Federal de Juiz de Fora, Hospital Universitário, Serviço de Ortopedia e Traumatologia, Juiz de Fora, MG, Brazil
| | - Leandro Furtado De Simoni
- Hospital Maternidade Therezinha de Jesus, Serviço de Ortopedia e Traumatologia, Juiz de Fora, MG, Brazil
| | | | - Fernando Brandão Andrade-Silva
- Universidade de São Paulo, Faculdade de Medicina, Instituto de Ortopedia e Traumatologia (IOT-FMUSP), São Paulo, SP, Brazil
| | - Adriano Fernando Mendes
- Universidade Federal de Juiz de Fora, Hospital Universitário, Serviço de Ortopedia e Traumatologia, Juiz de Fora, MG, Brazil
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Su F, Sun C, Wang B, Li M, Qu JN, Yang YT, Wu YT, Jie Q. The characteristics and treatment strategy for transolecranon fracture-dislocation of the elbow in children: a retrospective study. BMC Musculoskelet Disord 2022; 23:298. [PMID: 35351082 PMCID: PMC8962554 DOI: 10.1186/s12891-022-05249-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/14/2021] [Accepted: 03/17/2022] [Indexed: 11/10/2022] Open
Abstract
Abstract
Background
Transolecranon fracture-dislocation of the elbow is rarely seen in children. The purpose of this retrospective study was to discuss the pathological characteristics and treatment strategy for this injury in children.
Methods
From October 2016 to March 2019, 15 patients seen and treated at our institutions for transolecranon fracture-dislocation of the elbow were identified, and their medical records and radiographs were reviewed retrospectively. There were 11 boys and 4 girls, with an average age of 8.3 years (from 5 to 14 years). The left arm was involved in 10 cases, and the right arm was involved in 5 cases. Type I (simple fracture) was found in 11 cases, and type II (comminuted fracture) was found in 4 cases, 3 of which with coronoid process involved. Closed reduction was successful under local anaesthesia in 14 cases but failed in 1 case. In 11 patients with type I fractures, 10 received fixation of Kirschner wire and tension band, and one patient underwent bone plate fixation. In 4 patients with comminuted fractures (type II), internal fixation was performed with Kirschner wires combined with reconstruction plates.
Results
The 15 patients were followed up for 24 to 48 months (average, 30.2 months). The final evaluation showed fine anatomical relationship of the elbow in all with no complications observed. Failure of internal fixation did not occur in any patient. The fractures acquired bony union in all patients after 8 to 12 weeks (average, 9.6 weeks). The therapeutic efficacy was evaluated at the final follow-up by the Mayo elbow performance score (MEPS) as excellent in 11 cases, good in 3 cases and fair in one case.
Conclusions
As a type of complicated fracture-dislocation of the elbow, the transolecranon fracture-dislocation is rare in children. The fracture is mainly simple type. Treatment options depend on the type of fracture-dislocation. Only anatomical reduction of the olecranon fracture and restoration of a normal trochlear notch can lead to a stable humeroradial joint and good clinical efficacy.
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Reichert ILH, Ganeshamoorthy S, Aggarwal S, Arya A, Sinha J. Dislocations of the elbow - An instructional review. J Clin Orthop Trauma 2021; 21:101484. [PMID: 34367909 PMCID: PMC8321949 DOI: 10.1016/j.jcot.2021.101484] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/23/2021] [Accepted: 06/20/2021] [Indexed: 11/27/2022] Open
Abstract
Dislocations of the elbow require recognition of the injury pattern followed by adequate treatment to allow early mobilisation. Not every injury requires surgery but if surgery is undertaken all structures providing stability should be addressed, including fractures, medial and lateral ligament insertion and the radial head. The current concepts of biomechanical modelling are addressed and surgical implications discussed.
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Affiliation(s)
- Ines LH. Reichert
- King's College Hospital, Denmark Hill, King's College Hospital NHS Foundation Trust, London, UK
| | | | - Saurabh Aggarwal
- Princess Royal University Hospital, King's College Hospital NHS Foundation Trust, London, UK
| | - Anand Arya
- King's College Hospital, Denmark Hill, King's College Hospital NHS Foundation Trust, London, UK
| | - Joydeep Sinha
- King's College Hospital, Denmark Hill, King's College Hospital NHS Foundation Trust, London, UK
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Trans-olecranon fracture dislocations: How should we treat them? Injury 2021; 52 Suppl 4:S131-S136. [PMID: 33642078 DOI: 10.1016/j.injury.2021.02.058] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/29/2020] [Accepted: 02/16/2021] [Indexed: 02/02/2023]
Abstract
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.
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Midtgaard KS, Nolte PC, Miles JW, Tanghe KK, Peebles LA, Provencher MT, Adolfsson L. Biomechanical significance of the collateral ligaments in transolecranon fracture-dislocations. J Shoulder Elbow Surg 2021; 30:1245-1250. [PMID: 33010439 DOI: 10.1016/j.jse.2020.09.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/11/2020] [Revised: 08/29/2020] [Accepted: 09/08/2020] [Indexed: 02/01/2023]
Abstract
BACKGROUND It is widely accepted that transolecranon fracture-dislocations are not associated with collateral ligament disruption. The aim of the present study was to investigate the significance of the collateral ligaments in transolecranon fractures. METHODS Twenty cadaveric elbows with a mean age of 46.3 years were used. All soft tissue was dissected to the level of the capsule, leaving the anterior band of the medial collateral ligament (MCL) and lateral collateral ligament (LCL) intact. A standardized, oblique osteotomy starting from the distal margin of the cartilage bare area of the ulna was made. The elbows were loaded with an inferiorly directed force of 5 and 10 N in the intact, MCL cut, LCL cut, and both ligaments cut states. All measurements were recorded on lateral calibrated radiographs. RESULTS The mean inferior translation with intact ligaments (n = 20) when the humerus was loaded with 5 and 10 N was 1.52 mm (95% confidence interval [CI], 1.02-2.02) and 2.23 mm (95% CI, 1.61-2.85), respectively. When the LCL was cut first (n = 10), the inferior translation with 5 and 10 N load was 4.11 mm (95% CI, 0.95-7.26) and 4.82 mm (95% CI, 1.91-7.72), respectively. When the MCL was cut first (n = 10), the inferior translation when loaded with 5 and 10 N was 3.94 mm (95% CI, 0.796-7.08) and 5.68 mm (95% CI, 3.03-8.33), respectively. The inferior translation when loaded with 5 and 10 N and both ligaments cut was 15.65 mm (95% CI, 12.59-18.79) and 17.50 mm (95% CI, 14.86-20.13), respectively. There was a statistical difference between the intact and MCL cut first at 10 N and when both ligaments were cut at 5 and 10 N. CONCLUSIONS The findings suggest that collateral ligament disruption is a prerequisite for a transolecranon fracture-dislocation. An inferior translation of more than 3 mm suggests that at least one of the collateral ligaments is disrupted, and more than 7.5 mm indicates that both collateral ligaments are disrupted.
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Affiliation(s)
- Kaare S Midtgaard
- Institute of Military Medicine and Epidemiology, Norwegian Armed Forces Joint Medical Services, Oslo, Norway; Division of Orthopaedic Surgery, Oslo University Hospital, Oslo, Norway; Department of Biomedical Engineering, The Steadman Philippon Research Institute, Vail, CO, USA.
| | - Philip-Christian Nolte
- Department of Biomedical Engineering, The Steadman Philippon Research Institute, Vail, CO, USA; Department of Trauma and Orthopedic Surgery, BG Trauma Center Ludwigshafen, Ludwigshafen, Germany
| | - Jon W Miles
- Department of Biomedical Engineering, The Steadman Philippon Research Institute, Vail, CO, USA
| | - Kira K Tanghe
- Department of Biomedical Engineering, The Steadman Philippon Research Institute, Vail, CO, USA
| | - Liam A Peebles
- Department of Biomedical Engineering, The Steadman Philippon Research Institute, Vail, CO, USA
| | - Matthew T Provencher
- Department of Biomedical Engineering, The Steadman Philippon Research Institute, Vail, CO, USA; The Steadman Clinic, Vail, CO, USA
| | - Lars Adolfsson
- Department of Clinical and Experimental Medicine, University of Linköping, Linköping, Sweden
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Results of standardized treatment of elbow fracture dislocations as per their injury pattern: a retrospective cohort of 89 patients. JSES Int 2021; 5:588-596. [PMID: 34136875 PMCID: PMC8178606 DOI: 10.1016/j.jseint.2020.12.004] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
Background Elbow fracture dislocations represent difficult injuries to treat, with a high percentage of complications. Classically, they are divided into posterolateral, posteromedial and transulnar pattern. It is essential to distinguish them to guide intraoperative treatment to achieve an anatomic and stable reduction that allows early mobility. Methods A retrospective study of 89 adult patients diagnosed with elbow fracture dislocations who underwent a standardized surgery between 2013 and 2018 with a minimum follow-up of 12 months. Demographic data, characteristics of the injury, and associated procedures were collected. Patients were evaluated with functional scores (Mayo elbow performance score/Broberg and Morrey score) and ranges of movement at the end of the follow-up. Results The mean age was 41 ± 12 years, mostly men (82%), with an average follow-up of 29 months. We present 42 patients with posterolateral fracture dislocation (47%), 21 posteromedial (24%) and 26 transulnar (29%). The average range of motion at the end of follow-up was −12 ± 11° extension, 124 ± 20° flexion, 76 ± 16° pronation, and 73 ± 20° supination, with a Mayo elbow performance score of 88.7 ± 12 points and 87.2 ± 12 points in the Broberg and Morrey scale. Reoperation rate was 23%, with no infection or heterotopic ossification cases. Transulnar fracture dislocations have significantly worse extension and supination. As per the functional result (Mayo elbow performance score/Broberg and Morrey scale), there are no significant differences between the different patterns. Conclusion Proper injury pattern recognition and a standardized surgical management lead to a stable joint and good results in range of motion. Functional results are encouraging at least at short term, despite the high reoperations rate.
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Patient Outcomes After Transolecranon Fracture-Dislocation. J Am Acad Orthop Surg 2021; 29:109-115. [PMID: 32433427 DOI: 10.5435/jaaos-d-20-00254] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/24/2020] [Accepted: 04/13/2020] [Indexed: 02/01/2023] Open
Abstract
INTRODUCTION There are few small case series that discuss patient outcomes after a transolecranon fracture-dislocation, and they suggest that patients have reasonable function after injury. The purpose of this study was to describe the injury pattern and clinical outcomes of transolecranon fracture-dislocations. METHODS After Institutional Review Board approval, transolecranon fracture-dislocations treated at two academic level 1 trauma centers between 2005 and 2018 were retrospectively reviewed. Fracture characteristics and postsurgical complications were recorded. Radiographs were reviewed for arthrosis, and Quick Disabilities of Arm, Shoulder, and Hand (QuickDASH) scores were obtained at a minimum of 12 months after injury. RESULTS Thirty-five patients with a mean follow-up of 28 months (range, 12 to 117 months) were included. Nine patients had associated radial head fracture, 23 patients had associated coronoid fracture, four patients had ligamentous injury, and two patients had capitellum fracture. Four patients (11%) developed infection and required irrigation and débridement with intravenous antibiotics. Thirteen patients (13 of 35, 37%) developed radiographic arthrosis with most (11 of 13) having grade 2 or three changes. Patients who had associated radial head fracture, coronoid fracture, capitellum fracture, and/or ligamentous injury had significant arthrosis (10 of 24, 42%) more commonly than patients with olecranon fracture alone (1 of 11, 9%) (P = 0.05). Twenty-eight patients completed patient outcomes instrument and achieved a mean QuickDASH score of 9 (range, 0 to 59). Patients with isolated transolecranon fracture had a significantly better QuickDASH score (0.93, 0 to 4) than patients with transolecranon fracture variant with associated coronoid fracture, radial head fracture, distal humeral fracture, or ligamentous injury (11.74, 0 to 59) (P = 0.04). DISCUSSION Patients with transolecranon fracture-dislocation had excellent return to function based on the QuickDASH outcome assessment. Patients with transolecranon fracture with associated radial head fracture, coronoid fracture, humeral condyle fracture, and/or ligamentous injury tend to have worse functional outcome than patients with simple transolecranon fracture. LEVEL OF EVIDENCE Level IV-case series.
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Cho CH, Kim DH, Na SS, Choi BC, Kim BS. Trans-Olecranon Fracture-Dislocations of the Elbow: A Systematic Review. Diagnostics (Basel) 2020; 10:diagnostics10121058. [PMID: 33291269 PMCID: PMC7762091 DOI: 10.3390/diagnostics10121058] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2020] [Revised: 12/03/2020] [Accepted: 12/04/2020] [Indexed: 01/06/2023] Open
Abstract
The purpose of this study is to provide a systematic review of the definition, ideal surgical method, complications, and prognosis of trans-olecranon fracture dislocations. An electronic search was performed in the PubMed, EMBASE, Scopus, and MEDLINE databases. The eligibility criteria included retrospective clinical study and review article in subjects older than 18 years with trans-olecranon fracture dislocations. Trans-olecranon fracture dislocations are defined as fractures in which the stability of the ulnohumeral joint is lost due to the intra-articular fracture of the olecranon without disruption of the proximal radioulnar joint. The seven papers were included that met the eligibility criteria for the quantitative synthesis. Findings indicate that a pre-contoured plate was used in 88.3% of cases (68 of 77 reports), with no reports of complications, suggesting that the pre-contoured 3.5 mm plate is the first choice of treatment. Postoperative mean elbow range of motion for the flexion–extension arc was 121.1° and 146.5° for the pronation-supination arc. Methods for postoperative clinical scores included the Broberg/Morrey rating with a result of excellent or good in 82.9% of cases, the ASES score with a mean of 88.7, and the DASH score with a mean of 11.75. Complications included heterotopic ossification in 21.9% (23/105) of cases, arthrosis in 25.7% (27/105) of cases, nerve damage in 18.1% (19/105) of cases, and osteoarthritis in 14.3% (15/105). With better understanding of the mechanism of injury and proper diagnosis and treatment, findings of the current review suggest a positive outcome. PROSPERO registration No.: CRD42019126568.
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Luchetti TJ, Abbott EE, Baratz ME. Elbow Fracture-Dislocations: Determining Treatment Strategies. Hand Clin 2020; 36:495-510. [PMID: 33040962 DOI: 10.1016/j.hcl.2020.07.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
Elbow dislocations represent common injuries. A quarter of these injuries involve at least 1 fracture. The sequel of elbow fracture-dislocations can be fraught with complications, including recurrent instability, posttraumatic arthritis, elbow contracture, and poor functional results. The 3 main patterns of injury are valgus posterolateral rotatory instability, varus posteromedial rotatory instability, and transolecranon fracture-dislocation. This article discusses each pattern individually, including the anatomy, the typical injury pattern, and treatment strategies. It also discusses common complications that can occur.
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Lee SH, Nam DJ, Yu HK, Kim JW. The lateral ligament is injured preferentially in posterolateral dislocation of the elbow joint. Bone Joint J 2020; 102-B:227-231. [PMID: 32009431 DOI: 10.1302/0301-620x.102b2.bjj-2019-0966.r1] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
Abstract
AIMS The purpose of this study was to evaluate the relationships between the degree of injury to the medial and lateral collateral ligaments (MCL and LCL) and associated fractures in patients with a posterolateral dislocation of the elbow, using CT and MRI. METHODS We retrospectively reviewed 64 patients who presented between March 2009 and March 2018 with a posterolateral dislocation of the elbow and who underwent CT and MRI. CT revealed fractures of the radial head, coronoid process, and medial and lateral humeral epicondyles. MRI was used to identify contusion of the bone and collateral ligament injuries by tear, partial or complete tear. RESULTS A total of 54 patients had a fracture; some had more than one. Radial head fractures were found in 25 patients and coronoid fractures in 42. Lateral and medial humeral epicondylar fractures were found in eight and six patients, respectively. Contusion of the capitellum was found in 43 patients and rupture of the LCL was seen in all patients (partial in eight and complete in 56), there was complete rupture of the MCL in 37 patients, partial rupture in 19 and eight had no evidence of rupture. The LCL tear did not significantly correlate with the presence of fracture, but the MCL rupture was complete in patients with a radial head fracture (p = 0.047) and there was significantly increased association in those without a coronoid fracture (p = 0.015). CONCLUSION In posterolateral dislocation of the elbow, LCL ruptures are mostly complete, while the MCL exhibits various degrees of injury, which are significantly associated with the associated fractures. Cite this article: Bone Joint J 2020;102-B(2):227-231.
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Affiliation(s)
- Sung H Lee
- Department of Orthopaedic Surgery, School of Medicine, Wonkwang University Hospital, Iksan, South Korea
| | - Dae J Nam
- Department of Orthopaedic Surgery, School of Medicine, Wonkwang University Hospital, Iksan, South Korea
| | - Hyun K Yu
- Department of Orthopaedic Surgery, School of Medicine, Wonkwang University Hospital, Iksan, South Korea
| | - Jeong W Kim
- Department of Orthopaedic Surgery, School of Medicine, Wonkwang University Hospital, Iksan, South Korea
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Clinical and radiological evaluation of surgical management in olecranon fracture-dislocations. Musculoskelet Surg 2019; 104:321-328. [PMID: 31583519 DOI: 10.1007/s12306-019-00623-0] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2018] [Accepted: 09/27/2019] [Indexed: 10/25/2022]
Abstract
PURPOSE The treatment of olecranon fracture-dislocations (OFDs) remains challenging. OFDs are often misdiagnosed as Monteggia lesions, and the real frequency is actually higher. However, studies on OFDs are limited. This study aimed to report on the surgical management of OFDs and to highlight the importance of three-dimensional computed tomography (3D CT) evaluation in the treatment of OFDs. MATERIALS AND METHODS The study participants included 18 patients (11 men, 7 women, mean age 44 years (range 24-78) with OFDs. Each patient's medical records, radiographs, and 3D CT scans were reviewed for demographics, injury details, operative findings, and information about radiological and functional outcomes. The patients were divided into 2 groups according to the direction of the dislocation: the posterior dislocation group (group 1, 7 patients) and anterior dislocation group (group 2, 11 patients). The clinical evaluation was performed according to Broberg-Morrey and the American Shoulder and Elbow Surgeons-Elbow (ASES-E) scoring systems. RESULTS The mean follow-up period was 39 months (range 25-62 months). The Broberg-Morrey results were excellent in 4, good in 9, fair in 3, and poor in 2 patients. The mean ASES-E score was 84.83 (range 48-100) points. There were signs of ulna-humeral arthrosis in 5 elbows. Arthrosis was graded as grade 1, grade 2, and grade 3 in 3, 1, and 1 elbows, respectively. Partial sensory recovery was observed in one patient with postoperative ulnar neuropathy at the last follow-up visit. CONCLUSIONS OFDs are complex injuries of the proximal ulna and may involve the radial head, coronoid process, and lateral collateral ligament. The effective treatment of OFDs begins with the proper identification of the injury with 3D CT. A secure fixation including the coronoid process is mandatory for the elbow joint stability. Insufficient restoration of the trochlear notch may lead to problems with loss of motion and arthrosis. Although an application of a pre-contoured locking anatomical olecranon plate can simplify the fixation procedure in most cases, the surgeons' equipment should also include radial head implant, coronoid plates, headless screws, small cannulated screw system, suture anchors, fluoroscopy, and articulated external fixator.
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Klug A, Gramlich Y, Buckup J, Wincheringer D, Hoffmann R, Schmidt-Horlohé K. Excellent results and low complication rate for anatomic polyaxial locking plates in comminuted proximal ulna fractures. J Shoulder Elbow Surg 2018; 27:2198-2206. [PMID: 30006238 DOI: 10.1016/j.jse.2018.05.032] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/13/2018] [Revised: 05/14/2018] [Accepted: 05/21/2018] [Indexed: 02/01/2023]
Abstract
BACKGROUND Comminuted fractures of the proximal ulna remain a great challenge in orthopedic surgery. The purpose of this study was to report the outcomes of comminuted proximal ulna fractures treated with a new construct type-anatomically preformed polyaxial locking compression plates. METHODS Between 2013 and 2016, 46 patients with isolated comminuted fractures were treated with a 2.7-/3.5-mm VA-LCP Olecranon Plate (Synthes, Umkirch, Germany). Of these, 44 were available for an assessment after a mean follow-up period of 2.5 years (range, 12-50 months). We evaluated range of motion, time to recovery, revision rate, and indications, as well as functional scores. Radiographs were analyzed. RESULTS The study included 8 Mayo IB, 29 Mayo IIB, and 7 Mayo IIIB fractures. All fractures showed bony union, and only 2 revision surgical procedures were performed because of a new trauma. No other complications occurred. Mean range of motion was 139° (range, 105°-150°), and the mean pain level was less than 1 on a visual analog scale. Regarding elbow function, we found a mean Mayo Elbow Performance Score of 98; a mean Oxford Elbow Score of 44; and a mean Disabilities of the Arm, Shoulder and Hand score of 6. Of the plates, 41% were removed after an average time of 16 months, whereby a significant improvement in extension deficit was detected (P < .01). Ninety-five percent of all patients returned to their pretrauma sports level. CONCLUSION The 2.7-/3.5-mm VA-LCP Olecranon Plate represents an effective option with excellent fracture reduction, sufficient stability for early postoperative functional rehabilitation, and a minimum of complications.
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Affiliation(s)
- Alexander Klug
- Berufsgenossenschaftliche Unfallklinik Frankfurt am Main, Zentrum für Unfallchirurgie und Orthopädische Chirurgie, Frankfurt am Main, Germany.
| | - Yves Gramlich
- Berufsgenossenschaftliche Unfallklinik Frankfurt am Main, Zentrum für Unfallchirurgie und Orthopädische Chirurgie, Frankfurt am Main, Germany
| | - Johannes Buckup
- Berufsgenossenschaftliche Unfallklinik Frankfurt am Main, Zentrum für Unfallchirurgie und Orthopädische Chirurgie, Frankfurt am Main, Germany
| | - Dennis Wincheringer
- Berufsgenossenschaftliche Unfallklinik Frankfurt am Main, Zentrum für Unfallchirurgie und Orthopädische Chirurgie, Frankfurt am Main, Germany
| | - Reinhard Hoffmann
- Berufsgenossenschaftliche Unfallklinik Frankfurt am Main, Zentrum für Unfallchirurgie und Orthopädische Chirurgie, Frankfurt am Main, Germany
| | - Kay Schmidt-Horlohé
- Orthopaedicum Wiesbaden-Praxis für Orthopädie, Unfallchirurgie und Sportmedizin, Zentrum für Ellenbogenchirurgie, Wiesbaden, Germany
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15
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Jones ADR, Jordan RW. Complex Elbow Dislocations and the "Terrible Triad" Injury. Open Orthop J 2017; 11:1394-1404. [PMID: 29290879 PMCID: PMC5721343 DOI: 10.2174/1874325001711011394] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/06/2017] [Revised: 07/12/2017] [Accepted: 07/18/2017] [Indexed: 02/08/2023] Open
Abstract
Background: The elbow is the second most commonly dislocated joint in adults and up to 20% of dislocations are associated with a fracture. These injuries can be categorised into groups according to their mechanism and the structures injured. Methods: This review includes a literature search of the current evidence and personal experiences of the authors in managing these injuries. Results: All injuries are initially managed with closed reduction of the ulno-humeral joint and splinting before clinical examination and radiological evaluation. Dislocations with radial head fractures should be treated by restoring stability, with treatment choice depending on the type and size of radial head fracture. Terrible triad injuries necessitate operative treatment in almost all cases. Traditionally the LCL, MCL, coronoid and radial head were reconstructed, but there is recent evidence to support repairing of the coronoid and MCL only if the elbow is unstable after reconstruction of lateral structures. Surgical treatment of terrible triad injuries carries a high risk of complications with an average reoperation rate of 22%. Varus posteromedial rotational instability fracture-dislocations have only recently been described as having the potential to cause severe long-term problems. Cadaveric studies have reinforced the need to obtain post-reduction CT scans as the size of the coronoid fragment influences the long-term stability of the elbow. Anterior dislocation with olecranon fracture has the same treatment aims as other complex dislocations with the added need to restore the extensor mechanism. Conclusion: Complex elbow dislocations are injuries with significant risk of long-term disability. There are several case-series in the literature but few studies with sufficient patient numbers to provide evidence over level IV.
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Affiliation(s)
- Alistair D R Jones
- Department of Trauma and Orthopaedics, Worcestershire Royal Hospital, Charles Hastings Way, WR5, Worcester, 1DD, UK
| | - Robert W Jordan
- Coventry and Warwickshire Shoulder and Elbow Unit, University Hospitals Coventry & Warwickshire NHS Trust, Clifford Bridge Road, Coventry, CV2 2DX, UK
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16
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Tarassoli P, McCann P, Amirfeyz R. Complex instability of the elbow. Injury 2017; 48:568-577. [PMID: 24161720 DOI: 10.1016/j.injury.2013.09.032] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/10/2013] [Revised: 09/02/2013] [Accepted: 09/19/2013] [Indexed: 02/02/2023]
Abstract
Injuries to the elbow are commonly encountered in orthopaedic practice. They range from low energy, simple isolated fractures, to high energy complex fracture dislocations with severe ligamentous disruption. Recognising the precise pattern of injury is critical in restoring elbow function and preventing chronic instability, pain and weakness. This article discusses the important osseous and ligamentous stabilisers of the elbow joint and provides management protocols for the common patterns of complex injury encountered by the practising surgeon.
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Affiliation(s)
- Payam Tarassoli
- Department of Trauma and Orthopaedics, University Hospitals Bristol NHS Trust, Level 5, Queens Building, Upper Maudlin Street, Bristol BS2 8HW, United Kingdom.
| | - Philip McCann
- Department of Trauma and Orthopaedics, University Hospitals Bristol NHS Trust, Level 5, Queens Building, Upper Maudlin Street, Bristol BS2 8HW, United Kingdom
| | - Rouin Amirfeyz
- Department of Trauma and Orthopaedics, University Hospitals Bristol NHS Trust, Level 5, Queens Building, Upper Maudlin Street, Bristol BS2 8HW, United Kingdom
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17
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Complex coronoid and proximal ulna fractures are we getting better at fixing these? Injury 2016; 47:2053-2059. [PMID: 27527379 DOI: 10.1016/j.injury.2016.07.060] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/20/2016] [Revised: 07/25/2016] [Accepted: 07/29/2016] [Indexed: 02/02/2023]
Abstract
Technological advances and improved understanding of functional anatomy about the elbow have lead an evolution regarding operative reconstruction of complex proximal ulnar and coronoid fractures. When treating these complex and challenging fractures, goals of anatomic articular restoration along with balanced soft tissue stability can lead to early range of motion and thus, desired functional outcome. The purpose of this review is to outline and provide tips and pearls to achieve desired results, with a comprehensive update on the most recent literature to support the latest fixation methods and techniques.
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18
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Abstract
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.
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19
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Ozel O, Demircay E. Review of management of unstable elbow fractures. World J Orthop 2016; 7:50-54. [PMID: 26807356 PMCID: PMC4716571 DOI: 10.5312/wjo.v7.i1.50] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/04/2015] [Revised: 08/12/2015] [Accepted: 11/04/2015] [Indexed: 02/06/2023] Open
Abstract
Stable and painless elbow motion is essential for activities of daily living. The elbow joint is the second most commonly dislocated joint in adults. The goals of treatment are to perform a stable fixation of all fractures, to achieve concentric and stable reduction of the elbow and to provide early motion. The treatment modality for complex elbow instability is almost always surgical. The treatment objectives are anatomic reduction, stable fixation, and early rehabilitation of the elbow. The common complications of these unstable fractures include recurrent instability, stiffness, myositis ossifications, heterotopic calcification, and neurovascular dysfunction. We analyzed the management of complex elbow fractures and instabilities on the basis of recent literature and suggested possible guidelines for the treatment in this paper. In conclusion, recognition of the injury pattern and restoration of the joint stability are the prerequisites for any successful treatment of an unstable elbow injury.
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20
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Fahsi M, Benameur H, El Andaloussi Y, Bennouna D, Fadili M, Nechad M. [Transolecranon fracture dislocations]. Pan Afr Med J 2015; 22:52. [PMID: 26664553 PMCID: PMC4662526 DOI: 10.11604/pamj.2015.22.52.7744] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2015] [Accepted: 09/02/2015] [Indexed: 11/11/2022] Open
Abstract
Les fracture-luxations transolécraniennes sont une entité rare des fracture-luxations du coude. Il s'agit d'une lésion complexe qui peut compromettre le pronostic fonctionnel du coude. Dix patients étaient diagnostiqués dans notre service entre janvier 2005 et novembre 2012. Tous nos patients étaient de sexe masculin, l’âge moyen était de 29 ans. Les fractures de l'olécrane étaient complexes et comminutives dans sept cas et simples chez trois patients. Deux cas étaient associés à des fractures de la tête radiale (Mason III) et deux autres à des fractures de l'apophyse coronoïde. Les résultats étaient évalués après un recul moyen de trois ans et demi par le score de BROBERG et MORREY: trois cas étaient excellents, quatre bons, deux moyens et un mauvais. Cette lésion complexe nécessite une bonne reconstruction de la surface articulaire et une réparation des lésions associées pour permettre une rééducation précoce, seul garant d'une bonne récupération fonctionnelle.
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Affiliation(s)
- Mohamed Fahsi
- Service de Chirurgie Orthopédique et Traumatologique (Aile IV), CHU Ibn Rochd, Casablanca, Maroc
| | - Hamza Benameur
- Service de Chirurgie Orthopédique et Traumatologique (Aile IV), CHU Ibn Rochd, Casablanca, Maroc
| | - Yassir El Andaloussi
- Service de Chirurgie Orthopédique et Traumatologique (Aile IV), CHU Ibn Rochd, Casablanca, Maroc
| | - Driss Bennouna
- Service de Chirurgie Orthopédique et Traumatologique (Aile IV), CHU Ibn Rochd, Casablanca, Maroc
| | - Mustapha Fadili
- Service de Chirurgie Orthopédique et Traumatologique (Aile IV), CHU Ibn Rochd, Casablanca, Maroc
| | - Mohamed Nechad
- Service de Chirurgie Orthopédique et Traumatologique (Aile IV), CHU Ibn Rochd, Casablanca, Maroc
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21
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Abstract
Monteggia fractures and olecranon fracture dislocations represent complex injuries with distinct patterns of bony and soft tissue involvement. Fractures of the proximal ulna and olecranon process may lead to disruption of the proximal radioulnar joint and/or ulnohumeral joint. The keys to treatment are recognition of the pattern of injury and formation of an algorithmic surgical plan to address all components of the injury process. Complications are common and may be related to the injury spectrum itself and/or inadequate fracture alignment or fixation.
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Affiliation(s)
- Justin C Wong
- Department of Orthopaedic Surgery, Thomas Jefferson University Hospital, 1020 Walnut Street, College Building Room 516, Philadelphia, PA 19107, USA.
| | - Charles L Getz
- Department of Orthopaedic Surgery, The Rothman Institute, Thomas Jefferson University Hospital, 925 Chestnut Street, 5th Floor, Philadelphia, PA 19107, USA
| | - Joseph A Abboud
- Department of Orthopaedic Surgery, The Rothman Institute, Thomas Jefferson University Hospital, 925 Chestnut Street, 5th Floor, Philadelphia, PA 19107, USA
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22
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Abstract
Complex elbow dislocations (ie, fracture-dislocations) are challenging injuries to treat and may result in significant patient morbidity. Chronic instability, posttraumatic arthrosis, and poor functional outcomes are frequent. Orthopaedic surgeons should strive to optimize elbow function through restoration of articular congruity and stability coupled with early rehabilitation. Although most of these injuries require surgical management, not all complex elbow dislocations are equivalent. Understanding elbow biomechanics and the injury mechanism provides valuable insight into the variations of pathology that may be observed. Identifying the particular fracture pattern, such as an axial loading, valgus posterolateral rotatory, or varus posteromedial rotatory injury mechanism, helps guide appropriate treatment.
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23
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Niglis L, Bonnomet F, Schenck B, Brinkert D, Di Marco A, Adam P, Ehlinger M. Critical analysis of olecranon fracture management by pre-contoured locking plates. Orthop Traumatol Surg Res 2015; 101:201-7. [PMID: 25736196 DOI: 10.1016/j.otsr.2014.09.025] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/19/2014] [Revised: 08/19/2014] [Accepted: 09/29/2014] [Indexed: 02/02/2023]
Abstract
BACKGROUND Fractures of the proximal ulna are rare and usually managed surgically. Strong fixation of the harware is essential to obtain good outcomes. We report our experience with pre-contoured locking plate fixation of complex olecranon fractures and present a critical appraisal of the outcomes. HYPOTHESIS Pre-contoured locking plates provide good outcomes, but their clinical tolerance may be limited in some instances. MATERIALS AND METHODS From September 2009 to December 2011, 28 patients were managed using a pre-contoured locking compression plate (LCP(®)). Among them, 6 were excluded because of missing data, which left 22 patients (11 males and 11 females) with a mean age of 55.7 years, including 12 who were employed. The fracture was on the dominant side in 11 patients. According to the Mayo Clinic classification, 15 fractures were type II and 7 type III. In addition to the ulnar fracture, a radial head fracture was present in 9 patients and a coronoid process fracture in 5 patients. Functional recovery was assessed using the Broberg-Morrey score and Mayo Elbow Performance Score (MEPS). Radiographs were obtained to evaluate the quality of fracture reduction and fracture healing, as well as to look for ossifications and osteoarthritis. RESULTS Mean follow-up was 20 months. Flexion was 131°, extension loss was 9.5°, pronation was 79°, and supination was 80.5°. The mean Broberg-Morrey score was 96.7 and the mean MEPS score 96.6. Fracture healing occurred in all patients, within a mean of 10.6 weeks. Evidence of early osteoarthritis was found in 6 patients, ossifications in 3 patients, and synostosis in 1 patient. An infection was successfully treated with lavage and antibiotic therapy in 1 patient. The fixation hardware was removed in 6 patients. No prognostic factors were identified. DISCUSSION-CONCLUSION Our hypothesis was confirmed. The outcomes are encouraging and comparable to those reported in the literature. The critical issue is the limited clinical tolerance of the plate with a high rate of posterior impingement requiring plate removal (27%). Rigorous technique is essential during plate implantation. LEVEL OF EVIDENCE Level IV, retrospective study.
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Affiliation(s)
- L Niglis
- Service de chirurgie orthopédique et de traumatologie, CHU Hautepierre, hôpitaux universitaires de Strasbourg, 1, avenue Molière, 67098 Strasbourg cedex, France
| | - F Bonnomet
- Service de chirurgie orthopédique et de traumatologie, CHU Hautepierre, hôpitaux universitaires de Strasbourg, 1, avenue Molière, 67098 Strasbourg cedex, France
| | - B Schenck
- Service de chirurgie orthopédique et de traumatologie, CHU Hautepierre, hôpitaux universitaires de Strasbourg, 1, avenue Molière, 67098 Strasbourg cedex, France
| | - D Brinkert
- Service de chirurgie orthopédique et de traumatologie, CHU Hautepierre, hôpitaux universitaires de Strasbourg, 1, avenue Molière, 67098 Strasbourg cedex, France
| | - A Di Marco
- Service de chirurgie orthopédique et de traumatologie, CHU Hautepierre, hôpitaux universitaires de Strasbourg, 1, avenue Molière, 67098 Strasbourg cedex, France
| | - P Adam
- Service de chirurgie orthopédique et de traumatologie, CHU Hautepierre, hôpitaux universitaires de Strasbourg, 1, avenue Molière, 67098 Strasbourg cedex, France
| | - M Ehlinger
- Service de chirurgie orthopédique et de traumatologie, CHU Hautepierre, hôpitaux universitaires de Strasbourg, 1, avenue Molière, 67098 Strasbourg cedex, France.
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24
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Niéto H, Billaud A, Rochet S, Lavoinne N, Loubignac F, Pietu G, Baroan C, Espie A, Bonnevialle P, Fabre T. Proximal ulnar fractures in adults: a review of 163 cases. Injury 2015; 46 Suppl 1:S18-23. [PMID: 26528935 DOI: 10.1016/s0020-1383(15)70006-9] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
The aim of this study was to report the epidemiological characteristics and the experience of 5 departments of trauma, in France, in the management of fractures of the proximal ulna. 163 patients with fractures of the proximal ulna with a mean age of 49.9 years (range 16-97) were managed. The most common mode of injury was a motor vehicle collision (48%). 18% sustained associated injuries to the ipsilateral limb. Open fractures were present in 42 patients (25%). A total of 109 patients had a fracture of the olecranon, with the Mayo 2A and B types most frequently seen (66%). The patients were invited for clinical examination at a mean duration of 16 months, retrospectively. Validated patient-oriented assessment scores involving the Mayo Elbow Performance Index (MEPI) and the Broberg and Morrey score were evaluated. All patients had follow-up radiographs. The mean arc of elbow motion was 130° (70-150°). The mean MEPI was 91 (20-100) with good results in 23% and excellent results in 52% of the patients. The mean Broberg and Morrey score was 90 after isolated olecranon fracture, and decreased with the complexity of the lesion. 117 fractures (72%) healed with ulnohumeral congruity. 9 fracture non-unions occurred (6%). Although the fracture of the proximal ulna can be described in several classifications, none of them accommodate it satisfactorily, because of the complexity of the lesion. The coronoid process is the keystone for the stability of the elbow. It forms the anterior buttress with the radial head. Tension band wire fixation is by far the commonest technique of internal fixation used for the treatment of non-comminuted olecranon fractures. Dorsal plate fixation is a useful option by providing improved fixation of complex comminuted fractures and fracture-dislocations. The radiocapitellar joint has to be restored appropriately, preserving the radial head when possible and replacing it with a prosthesis otherwise. The lateral collateral ligament complex is commonly disrupted and usually can be reattached to its origin from the lateral epicondyle. In addition, a brief period of hinged external fixation should be considered.
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Affiliation(s)
- H Niéto
- Department of Trauma and Orthopaedics, Niort, France
| | - A Billaud
- Department of Trauma and Orthopaedics, Pau, France
| | - S Rochet
- University Hospital of Besançon, France
| | - N Lavoinne
- Department of Trauma and Orthopaedics, Saint Jean de Luz, France
| | - F Loubignac
- Department of Trauma and Orthopaedics, Toulon, France
| | - G Pietu
- University Hospital of Nantes, France
| | - C Baroan
- Department of Trauma and Orthopaedics, Niort, France
| | - A Espie
- Department of Trauma and Orthopaedics, Albi, France
| | | | - T Fabre
- University Hospital of Bordeaux, France
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25
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Scolaro JA, Beingessner D. Treatment of Monteggia and Transolecranon Fracture-Dislocations of the Elbow. JBJS Rev 2014; 2:01874474-201401000-00002. [DOI: 10.2106/jbjs.rvw.m.00049] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/14/2023]
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26
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Manidakis N, Sperelakis I, Hackney R, Kontakis G. Fractures of the ulnar coronoid process. Injury 2012; 43:989-98. [PMID: 21963158 DOI: 10.1016/j.injury.2011.08.030] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/19/2011] [Accepted: 08/18/2011] [Indexed: 02/02/2023]
Abstract
The ulnar coronoid process plays a central role in elbow stability due to its unique anatomic characteristics. A fracture of the coronoid, although uncommon, represents a serious injury that can adversely affect functional outcome if not treated appropriately. Several surgical interventions addressing different fracture patterns are being increasingly recognised as effective treatment options even for smaller fragments. A review of the literature was performed in order to evaluate different treatment strategies applied to clearly defined fracture configurations. 14 articles reporting data for the management of 236 coronoid fractures met our inclusion criteria and were subjected to critical analysis. The data suggest that recognition of specific coronoid fracture patterns, use of appropriate classification systems and application of staged surgical protocols can stabilise the elbow effectively and lead to favourable outcomes.
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27
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Butler MA, Martus JE, Schoenecker JG. Pediatric variants of the transolecranon fracture dislocation: recognition and tension band fixation: report of 3 cases. J Hand Surg Am 2012; 37:999-1002. [PMID: 22541155 DOI: 10.1016/j.jhsa.2012.02.037] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/29/2011] [Revised: 02/16/2012] [Accepted: 02/22/2012] [Indexed: 02/02/2023]
Abstract
Anterior transolecranon fracture dislocation of the elbow is relatively uncommon in children. We reviewed the experience over the past 5 years at our institution in treating this injury to identify pediatric variants and outline a rational treatment strategy. We found 2 pediatric variants to the injury pattern and determined that tension band constructs can successfully be used to treat certain pediatric transolecranon fracture dislocations. The pediatric variants identified in this report are fracture dislocations with associated medial epicondyle fracture and radial neck fracture. We recommend a heightened vigilance in looking for a fracture through the ulna when an anterior dislocation is present, as physeal injuries can be challenging to see on plain radiographs.
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28
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Giannicola G, Greco A, Sacchetti FM, Cinotti G, Nofroni I, Postacchini F. Complex fracture-dislocations of the proximal ulna and radius in adults: a comprehensive classification. J Shoulder Elbow Surg 2011; 20:1289-99. [PMID: 21885302 DOI: 10.1016/j.jse.2011.06.003] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/18/2010] [Revised: 05/26/2011] [Accepted: 06/05/2011] [Indexed: 02/01/2023]
Abstract
BACKGROUND Complex fracture-dislocations of the proximal ulna and radius include multiple anatomic lesions, the management of which is known to be demanding. Although several classifications have been proposed, none appear to be exhaustive, and most of them have neither therapeutic nor prognostic value. The purpose of this study was to design a comprehensive classification that may provide a guide for the operative management of these injuries. MATERIALS AND METHODS The classification is aimed at identifying definite anatomic lesions, called the "main lesions," the presence of which can affect the prognosis and require peculiar treatments. The main lesions include (1) ulnar fracture (including its location with respect to the insertion of collateral ligaments and coronoid fracture), (2) radiohumeral dislocation, (3) proximal radioulnar dislocation, (4) radial fracture, (5) distal radioulnar joint and interosseous membrane lesion, and (6) humeral-ulnar dislocation. Intraobserver and interobserver reliability was assessed in 25 complex fracture-dislocations. Standard radiographs and computed tomography scans were analyzed by 3 independent observers. RESULTS The main lesions were labeled by an alphanumeric system. Numbers 1 through 6 identified the type of ulnar fracture, and letters A through E indicated the dislocated joint or presence of a radial fracture. The direction of dislocation and the type of radial fracture were identified by Roman numerals, from I to III, placed after the letter. A κ value of 0.873 or greater resulted from intraobserver and interobserver evaluation. CONCLUSION We created a comprehensive classification of complex fracture-dislocations of the elbow. The classification appeared to be reproducible and may represent a useful tool for the management of such difficult injuries.
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Affiliation(s)
- Giuseppe Giannicola
- Department of Orthopaedic Surgery, University of Rome La Sapienza, Rome, Italy.
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29
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Wang YH, Tao R, Xu H, Cao Y, Zhou ZY, Xu SZ. Mid-term outcomes of contoured plating for comminuted fractures of the olecranon. Orthop Surg 2011; 3:176-80. [PMID: 22009648 PMCID: PMC6583130 DOI: 10.1111/j.1757-7861.2011.00139.x] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/23/2011] [Accepted: 03/20/2011] [Indexed: 12/30/2022] Open
Abstract
OBJECTIVE To evaluate the mid-term outcomes of contoured plating for comminuted fractures of the olecranon. METHODS Twenty eight patients were available for analysis. Their mean age was 41 years (range, 25 to 61 years). Associated fractures were of the coronoid process in three, radial head in four, and both in three patients. A plate and screw system was used to stabilize comminuted fractures of the olecranon in all cases. Coronoid fractures were stabilized according to the fracture patterns. Displaced radial head fractures were treated with either mini-screw fixation or radial head replacement. Because of the severity of their fractures, 12 patients underwent primary bone grafting. RESULTS Primary stability was achieved in 25 of 28 cases. There were no cases of non-union. The mean time to union was 15 weeks (range, 12-22 weeks). The mean range of flexion of the elbow was from 14° to 125°, with 65° of pronation and 74° of supination. The end results were 6 excellent, 16 good, 4 fair and 2 poor, based on the Broberg and Morrey scale. The excellent plus good rate was 78.6%. CONCLUSION Favorable mid-term outcomes can be achieved by contoured plating of complex, comminuted fractures of the olecranon.
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Affiliation(s)
- You-hua Wang
- Department of Orthopaedics, Affiliated Hospital of Nantong University, Nantong, China.
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30
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Comminuted fractures of the proximal ulna--Preliminary results with an anatomically preshaped locking compression plate (LCP) system. Injury 2010; 41:1306-11. [PMID: 20828689 DOI: 10.1016/j.injury.2010.08.008] [Citation(s) in RCA: 37] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/23/2010] [Revised: 07/26/2010] [Accepted: 08/04/2010] [Indexed: 02/02/2023]
Abstract
INTRODUCTION The purpose of this investigation was to review the preliminary results and patients outcome following treatment with an anatomically preshaped LCP in patients with comminuted fractures of the proximal ulna. We hypothesized that this fixation system provides equal or superior results in fracture care when compared with other available plating devices, but results in better patient's comfort due to its low-profile design. PATIENTS AND METHODS Between 2007 and 2009, 15 patients with comminuted fractures of the proximal ulna including three posterior Monteggia fractures were managed with the preshaped LCP olecranon plate. The patients were invited for clinical examination at a mean duration of 16 months, retrospectively. Validated patient-oriented assessment scores involving the Mayo Elbow Performance Index (MEPI) and the shortened Disability of the Arm, Shoulder and Hand (Quick-DASH) score, postoperative range of motion, objective muscle-strengths testing and patient's satisfaction were evaluated. All patients had follow-up radiographs. RESULTS Fourteen patients were available for evaluation. The mean arc of elbow motion was 129°. The mean MEPI was 97 with good results in two patients and excellent results in 12 patients. The mean Quick-DASH was 13. Thirteen of fourteen patients documented satisfaction with their elbow outcome. There was one patient with symptomatic hardware and one patient complained about deficit of motion. In four patients the hardware was removed including two patients with elective removal. Fourteen fractures healed with ulnohumeral congruity after a mean time to union of 11 weeks. One fracture non-union occurred without mechanical failure or loss of reduction. CONCLUSION Anatomically preshaped LCP olecranon plating is an effective fixation method for comminuted fractures of the proximal ulna allowing reliable stability for early elbow motion. The functional results are comparable with formerly described plating systems. A low rate of symptomatic hardware removal suggests better patient's compatibility.
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Rochet S, Obert L, Lepage D, Lemaire B, Leclerc G, Garbuio P. Proximal ulna comminuted fractures: fixation using a double-plating technique. Orthop Traumatol Surg Res 2010; 96:734-40. [PMID: 20801732 DOI: 10.1016/j.otsr.2010.06.003] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/29/2009] [Revised: 03/29/2010] [Accepted: 06/14/2010] [Indexed: 02/02/2023]
Abstract
INTRODUCTION Comminuted fractures of the proximal ulna are severe injuries often associated with bone and ligament injuries of the elbow joint (Monteggia lesion, radial head fractures, dislocation of the elbow). The treatment of these fractures is very demanding and the functional results often fairly mediocre due to associated injuries. Based on a single-center retrospective study, we report the results of the treatment of these fractures fixed using a double-plate technique. The aim was to evaluate the feasibility and reliability of this fixation mode and to compare it with other fractures series using a single plate fixation (in terms of bone union, elbow joint function, and complications stemming from the plates). PATIENTS AND METHODS Eighteen patients sustained a comminuted proximal ulna fracture between 2002 and 2006. The fractures were associated in five cases with a Monteggia type lesion, in two cases with elbow dislocation, and in four cases with a Mason 3 radial head fracture. Four patients had an open fracture. These comminuted ulna fractures included nine Mayo Clinic IIIB fractures. Bone fixation was performed with two third-cylinder tubular plates, one plate on each side of the proximal ulna. This allows more versatile solutions for screw insertion. Functional assessment (according to Broberg and Morrey) and radiological evaluation (bone healing) were provided at 6 months and at the longest follow-up by an independent surgeon. RESULTS Sixteen of 18 patients achieved bone union. No septic complications occurred and no hardware removal was required on patient request. In 67% of the cases, the Morrey score indicated excellent or good results with a mean score of 82. DISCUSSION There are no reports in the literature on the technical point of fixation concerning complex fractures of the ulna. Two plates mean the possibility of twice the number of screw insertions for epiphyseal reconstruction . This fixation remains easy to perform and provides stable anatomic reconstruction of the ulna. LEVEL OF EVIDENCE Level IV. Retrospective study.
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Affiliation(s)
- S Rochet
- Orthopaedics, Traumatology, plastic and reconstructive surgery and Hand salvage Department, EA 4268 Innovation, Imaging, Engineering and Healthcare policy Division, IFR 133 Inserm, Innovation and Surgical Technique sub-unit, Jean Minjoz Teaching hospital Center, Franche Comté University, Besançon, France.
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Comminuted proximal Ulna fractures: injury pattern surgical techniques and outcome. EUROPEAN JOURNAL OF ORTHOPAEDIC SURGERY AND TRAUMATOLOGY 2010. [DOI: 10.1007/s00590-010-0614-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
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Abstract
Complex instability of the elbow, also known as fracture dislocation of the elbow, is one of the most challenging injuries of the musculoskeletal system. A clear understanding of the biomechanics of the joint with special focus on the relative contributions of the articular components and the ligamentous constraints is critical to the proper management of these injuries. The accurate recognition and implications of associated injuries offers a rationale for approaching these difficult problems by appropriately addressing the elements of the trauma. Further, doing so in a timely fashion enhances the outcome. Currently, even the most devastating of injuries are felt to have a more favourable prognosis than was present in the past if the principles contained herein are followed.
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Affiliation(s)
- B F Morrey
- Orthopedic Manuscript Office, Mayo Clinic, 200 First Street SW, Rochester, MN 55905, USA.
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Abstract
OBJECTIVES To report the long-term results of operative treatment of anterior and posterior olecranon fracture-dislocations and compare them with the results recorded fewer than 2 years after surgery. DESIGN Retrospective case series with long-term evaluation. SETTING Level I trauma center. PATIENTS AND PARTICIPANTS Ten patients with anterior olecranon fracture-dislocation and ten patients with posterior olecranon fracture-dislocation were evaluated after an average of 18 years (range, 11 to 28 years) after injury. Fifteen patients had an early follow-up available at an average 14 months (range, 6 to 24 months) after surgery. The average age at injury was 30 years (range, 14 to 53 years). INTERVENTION Treatment included plate and screw fixation (11 patients), tension band wiring (8 patients), and radiocapitellar transfixation (1 patient). Six patients had additional elbow surgery before the final evaluation. MAIN OUTCOME MEASUREMENTS Flexion arc, arthrosis, Mayo Elbow Performance Index (MEPI), Disability of Arm Shoulder and Hand questionnaire (DASH). RESULTS The mean arc of elbow flexion was 105 degrees (range, 15 to 140 degrees) at 1 year and 122 degrees (range 10 to 145 degrees; P = 0.01) at final evaluation. Radiographic arthrosis was observed in 14 patients (70%): severe in 3, moderate in 2, and mild in 9 patients. Five patients (25%) had ulnar nerve dysfunction at the final evaluation. The MEPI was excellent in 13 patients, good in 4, fair in 2, and poor in 1. The mean DASH score was 9 points (range, 0 to 53 points). CONCLUSION The initial results of operative treatment of fracture-dislocations of the olecranon are durable over time.
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