Complications of type I coronoid fractures in competitive athletes: report of two cases and review of the literature

Complex instability of the elbow

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.

The posttraumatic stiff elbow: an update

Posttraumatic elbow stiffness is a disabling condition that remains challenging to treat despite improvement of our understanding of the pathogenesis of posttraumatic contractures and new treatment regimens. This review provides an update and overview of the etiology of posttraumatic elbow stiffness, its classification, evaluation, nonoperative and operative treatment, and postoperative management.

Arthroscopic Management of Elbow Fractures

Several types of elbow fractures are amenable to arthroscopic or arthroscopic-assisted fracture fixation, including fractures of the coronoid, radial head, lateral condyle, and capitellum. Other posttraumatic conditions may be treated arthroscopically, such as arthrofibrosis or delayed radial head excision. Arthroscopy can be used for assessment of stability or intra-articular fracture displacement. The safest portals are the midlateral (soft spot portal), proximal anteromedial, and proximal anterolateral. Although circumstances may vary according to the injury pattern, a proximal anteromedial portal is usually established first. Arthroscopy enables a less invasive surgical exposure that facilitates visualization of the fracture fragments in select scenarios.

Evidence-based indications for elbow arthroscopy

PURPOSE

The purpose was to review the literature on the outcomes of elbow arthroscopy and to make evidence-based recommendations for or against elbow arthroscopy for the treatment of various conditions. Our hypothesis was that the evidence would support the use of elbow arthroscopy in the management of common elbow conditions.

METHODS

A literature search was performed by use of the PubMed database in October 2010. All therapeutic studies investigating the results of treatment with elbow arthroscopy were analyzed for outcomes and complications. The literature specific to common elbow arthroscopy indications was summarized and was assigned a grade of recommendation based on the available evidence.

RESULTS

There is fair-quality evidence for elbow arthroscopy in the treatment of rheumatoid arthritis of the elbow and lateral epicondylitis (grade B recommendation). There is poor-quality evidence for, rather than against, the arthroscopic treatment of degenerative arthritis, osteochondritis dissecans, radial head resection, loose bodies, post-traumatic arthrofibrosis, posteromedial impingement, excision of a plica, and fractures of the capitellum, coronoid process, and radial head (grade C(f) recommendation). There is insufficient evidence to give a recommendation for or against the arthroscopic treatment of posterolateral rotatory instability and septic arthritis (grade I recommendation).

CONCLUSIONS

The available evidence supports the use of elbow arthroscopy in the management of the majority of conditions where it is currently used. The quality of the evidence, however, is generally fair to poor.

LEVEL OF EVIDENCE

Level IV, systematic review of Level II-IV studies.

Current concepts in the management of complex elbow trauma

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.

Arthroscopic-assisted treatment of coronoid fractures

PURPOSE

Little information exists regarding arthroscopic treatment of coronoid fractures; this study reports outcomes in a series of patients.

METHODS

Forty-one coronoid fractures were identified by retrospective chart review; 7 were treated arthroscopically; 6 with >12 months of available follow-up. Regan-Morrey fracture types were II (n = 4) and III (n = 3). The age of the patients averaged 37 years; the mechanism of injury was a fall in 6 patients and a motocross accident in 1 patient. Fracture fixation included: plate-and-screws following arthroscopic reduction (1); screws (2) and threaded Steinmann pins (2); 2 fractures were debrided. Three patients had immediate (2) or delayed (1) lateral ulnar collateral ligament repair.

RESULTS

Follow-up averaged 31.8 months. The range of motion averaged 9 degrees to 133 degrees in flexion-extension and 87 degrees/79 degrees in prono-supination. Mayo Elbow Performance scores were 100 in 5 of 6 patients and unavailable in 1 patient. Complications included asymptomatic heterotopic ossification (1) and delayed ulnar neuropathy (1).

CONCLUSIONS

In our series of coronoid fractures treated with arthroscopic means, all patients had a functional, pain-free result. All patients returned to preoperative avocations and occupations.

LEVEL OF EVIDENCE

Level IV, therapeutic case series.

Major international sport profiles

Sports are part of the sociocultural fabric of all countries. Although different sports have their origins in different countries, many sports are now played worldwide. International sporting events bring athletes of many cultures together and provide the opportunity not only for athletic competition but also for sociocultural exchange and understanding among people. This article reviews five major sports with international appeal and participation: cricket, martial arts, field hockey, soccer, and tennis. For each sport, the major aspects of physiological and biomechanical demands, injuries, and prevention strategies are reviewed.

Fractures of the proximal ulna olecranon and coronoid fractures

Fractures of the proximal ulna present unique challenges to the surgeon because of the complexity of the elbow joint. It is important not to underestimate the potential difficulty of these cases and to give each one thorough preoperative consideration before embarking on a surgical course. The primary principles of treatment are to restore joint congruity and stability while permitting early range of motion. A logical and consistent approach, based on the fracture characteristics and concomitant injuries, should produce predictable results.

Operative treatment of nonunions about the elbow

Nonunions about the elbow present a great challenge to the orthopaedic surgeon. Recent advances have enabled the surgeon to achieve much improved results. The current study outlines the treatment of nonunions of the distal humerus, proximal ulna (including olecranon, Monteggia, and coronoid nonunions), and radial head and neck nonunions. The historic problems of treating these nonunions included the use of inadequate fixation, the poor understanding of the role of soft tissue surgery in the treatment of the stiff elbow, and the failure of previous postoperative rehabilitation protocols. Advances made in the techniques of soft tissue treatment, modern methods of stable internal fixation, and early postoperative rehabilitation all have made an exceptional difference in the surgeon's ability to treat these most complex problems. The current study will provide the reader with a greater understanding of nonunions about the elbow, clinical and technical details for their treatment, and the expected results after treatment.