Clinical usefulness of proximal ulnar and radial fracture-dislocation comprehensive classification system (PURCCS): prospective study of 39 cases

Trans-ulnar fracture dislocations of the elbow: a systematic review and clarification of classification systems

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.

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.

Monteggia fractures and Monteggia-like-lesions: a systematic review

Monteggia injuries are rare, but severe injuries of the elbow including various injury patterns. Treatment of these injuries is still topic of debate and strategies differ widely. In this systematic review on Monteggia injuries in adults, we aimed to clarify the incidence of different injury patterns within Monteggia injuries, investigate the main reasons leading to revision surgery and explore which surgical treatments should be favored to achieve satisfactory clinical results.We initially identified 182 publications and ultimately included 17 retrospective studies comprising 651 cases. All patients were classified using the Bado classification, leading to 30.5% Bado type I fractures, 60.4% type II fractures, 5.1% type III and 3.1% type IV fractures. Mean revision rate was 23%. Ulna non-union (28%) and limited range-of-motion (22%) are the main reasons for revision surgery. Meta-analysis shows a trend toward the use of locking plates for ulna fixation which may lead to less revision surgery and fewer ulna non-unions. Further biomechanical and clinical research is necessary to clarify the role of radial head surgery.

Olecranon With Concomitant Radial Head Fracture: A Case Series of Fifteen Patients

Introduction

Simultaneous olecranon and radial head fractures are rare injuries and due to this factor, the outcome of the selected therapy is not widely studied. The aim of this study is to report and evaluate the functional outcome of the surgical treatment of simultaneous olecranon and radial head fractures.

Materials and Methods

This is a retrospective study of fifteen patients with concomitant olecranon and radial head fractures presenting to our orthopedic department between 2015 and 2020. Olecranon fractures were classified by Mayo classification and radial head fractures by Mason classification and were managed appropriately. Main outcome measures include range of elbow extension-flexion, pronation-supination, Broberg and Morrey rating system score, and quickDASH score.

Results

Our study included 6 females and 9 males with a mean age of 50 (r, 25-73). The mean of follow-up was 31 months (r, 3-51). Olecranon fractures were fixed with tension band with K-Wires or intramedullary compression screw or locking plate. Radial head fractures were fixed with headless compression screws or mini plate or replaced (radial head arthroplasty). Postoperatively, an average 115° extension-flexion arc and 135° pronation-supination arc was noted. The mean Broberg and Morrey rating system score was 78 and the mean quick DASH score was 25, indicating a good result. Two cases of heterotopic ossification were present and no nonunion was noted.

Conclusion

Surgical management of concomitant olecranon and radial head fractures with appropriate technique can result in the restoration of a functional movement arc and a satisfactory outcome.

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.

Clinical and radiological evaluation of surgical management in olecranon fracture-dislocations

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.

Fixation of the Various Coronal Plane Fracture Fragments, Including the Entire Coronoid Process, in Patients with Mayo Type IIB Olecranon Fractures - Four Methods for Fixation

BACKGROUND

We introduce several methods for fixation of unique Mayo type II olecranon fractures with the coronal plane fragment (CPF) including the entire coronoid process and report the radiological and clinical results through a case series.

MATERIALS AND METHODS

12 patients were operated using this method with a mean age of 44 years. CPFs were fixed with concurrent fixation by a locking plate screw for the olecranon in three patients (method 1), cerclage wiring in six patients (method 2), a mini plate in two patients (method 3), and a double-locking plate (method 4) in one patient. We accessed the fragment through an additional medial coronoid approach after identifying the olecranon fragment through a dorsal approach (methods 1-3). In method 4, the CPF was fixed through a dorsal approach between the comminuted metaphyseal fragments.

RESULTS

With the exception of one patient with delayed union, all patients had achieved union at 3-month followup. The mean flexion extension arc was 125°. The mean pronation/supination was 72.5°/71.7° (range, 60-80°/60-80°). The mean visual analog scale score for elbow pain was 0.92 (range, 0-2), and the mean Mayo Elbow Performance Score was 86.7 (range, 80-90). The mean Disabilities of the Arm, Shoulder, and Hand score was 10.2 (range, 4-14). There were no major complications.

CONCLUSION

A thorough preoperative understanding of the fragment patterns and preparation of tools for adequate reduction and fixation are necessary for satisfactory clinical and radiological outcomes. However, further comparative trials of conservative management versus surgery for CPF fixation, and any differences in outcomes according to the CPF fixation options, are required.

How to approach Monteggia-like lesions in adults: A review

Monteggia-like lesions encompass a wide spectrum of fractures of the forearm and elbow associated with dislocations, subluxations and ligamentous lesions. Many attempts have been made to classify these injuries, not only to understand their pathology but also to develop optimal treatments. Unfortunately, although some of these classifications are complete, they are either complex, not immediately usable, or not exhaustive. An orthopedic surgeon who aims to rapidly treat this kind of injury needs a visual classification, and knowledge of the best surgical approach. Monteggia like lesions do not allow for mistakes during surgery, as even a minor error could be prove detrimental to performing and completing all surgical steps. In this paper, based on our extensive experience in treating these rare lesions, we suggest a practical guide to the best surgical approach for various types of Monteggia like lesions. Some technical tips and pitfalls are also described.