The challenge of Monteggia-like lesions of the elbow

Coronoid Fragment Size in Monteggia Fractures Predicts Ultimate Function

We sought to determine what effect the size of a displaced coronoid fracture fragment in Monteggia injuries has on clinical outcome. Sixty-seven patients presented to an academic medical center for operative fixation of a Monteggia fracture. Radiographs were assessed for length and height of the displaced coronoid fragment using measuring tools in our center's imaging archive system. Data were analyzed using binary logistic or linear regression, as appropriate, controlling for sex, age, and Charlson Comorbidity Index. Outcome measurements included radiographic healing, range of motion, postoperative complications, and reoperation. The cohort had a mean follow-up of 16.7 months. Mean coronoid fragment area was 362.4±155.9 mm2. Elbow range of motion decreased by 3.8° of elbow flexion (P<.001), 3.3° of elbow extension (P<.001), and 3.8° of forearm supination (P=.007) for every 1-cm2 increase in coronoid fragment area. Complications (P=.012) and reoperation (P=.036) were associated with increasing coronoid fragment area. Nonunion rate, nerve injury, and pronation range of motion were not correlated to increasing coronoid fracture fragment area (P=.777, P=.123, and P=.351, respectively). As displaced coronoid fragment size increases in Monteggia fracture patterns, elbow range of motion decreases linearly. Coronoid displacement was also associated with increased rates of postoperative complication and need for reoperation. [Orthopedics. 2024;47(1):15-21.].

[Clinical results of total elbow arthroplasty after treatment failure for Monteggia-like injuries]

BACKGROUND

Monteggia-like fractures (MLF) are complex injuries with high complication rates and frequently unsatisfying clinical results. Total elbow arthroplasty (TEA) represents the only option to salvage the functional requirements in some patients with pronounced posttraumatic arthropathy. This case series provides clinical results of TEA following failed treatment of MLF.

METHODS

All patients who underwent TEA from 2017 to 2022 for failed treatment of MLF were retrospectively included in this study. Complications and revisions before and after TEA and functional results, measured by the Broberg/Morrey score, were evaluated.

RESULTS

In this study 9 patients with a mean age of 68 (±7; 54-79) years were included. The mean follow-up was 12 (±9; 2-27) months. The main reasons leading to posttraumatic arthropathy were chronic infections (44.4%), bony instability due to coronoid deficiency (33.3%) or a combined coronoid and radial head deficiency (22.2%) and non-union of the proximal ulna with radial head necrosis (11.1%). The mean number of surgical revisions between primary fixation and TEA was 2.7 (±1.8; 0-6). The revision rate following TEA was 44%. The mean Broberg/Morrey score at the time of the latest follow-up was 83 (±10; 71-97) points.

CONCLUSION

Chronic infection and coronoid deficiency are the main reasons for posttraumatic arthropathy after MLF leading to TEA. While the overall clinical results are satisfying, the indications should be reserved for selected cases due to high revision rates.

[Monteggia-like injuries : Pitfalls of surgical treatment]

The term Monteggia-like lesions or Monteggia equivalent injuries includes fractures of the proximal ulna with dislocation and dislocation fractures of the radial head from the proximal radio-ulnar joint. The complexity of the injury requires a dedicated understanding of the anatomical structures and their biomechanical properties. Particularly due to the rarity, the complication and revision rates are high. A conservative treatment is not usually effective. Three-dimensional imaging by computed tomography is part of the surgical preparation. The goal of surgical treatment is osteosynthetic reconstruction of the fractures and restoration of joint congruency. In cases of nonreconstructable radial head fractures, radial head arthroplasty may be necessary. In addition to reconstruction of the bony stabilizers, refixation of the ligamentous structures is essential for treatment success. The combination of complex fracture patterns and possible dislocation positions in the ulnohumeral, radiohumeral and proximal radio-ulnar joints poses a great challenge to the surgeon. The most frequent complications are peri-implant infections, implant failure, loss of reduction, stiffness or instability. Especially the anatomical configuration of the proximal ulna is complex and requires accurate reconstruction. Therefore, reconstruction of the proximal ulna in length and rotation, including the coronoid process, is considered to be a key factor in the surgical treatment of Monteggia-like injuries.

Surgical Treatment of Monteggia-Like Lesions With a Modified Boyd Approach

Introduction

Monteggia-like lesions are rare injuries in adults that include a wide spectrum of complex fracture-dislocations of the proximal ulna and radius. In this retrospective study, we performed a modified Boyd approach and a standard surgical protocol for the treatment of these lesions. Our aim was to evaluate the results of the operative treatment for patients with Monteggia-like lesions, using a modified Boyd approach.

Materials and Methods

We present a retrospective study of 14 patients who underwent surgical treatment for Monteggia-like lesions. Preoperative clinical and radiological evaluation was performed. In 5 cases radial head prosthesis was placed, and in 3 cases the radial fracture was stabilized with the use of interfragmental screws. Regarding the proximal ulnar fracture, ORIF-anatomical plate and ORIF-straight plate was used in 12 and 2 cases, respectively.

Results

Average clinical follow up was 16.9 months. Postoperatively, the mean Mayo Elbow Performance score was 83.4 points (range 70-100) and the mean visual analog scale was 1.7 (range 0-14). Mean flexion and loss of extension were 122.1° (range 80°-140°) and 21.4° (range 5°-40°), respectively. Mean supination of the forearm was 66.8° (range 50°-80°) and the mean pronation was 67.5° (range 60°-75°). Heterotopic ossification was observed in 3 patients (21.4%) and 1 patient developed stiffness (7.1%). The patient who developed stiffness underwent reoperation for plate removal and arthrolysis, with satisfactory results.

Conclusions

The surgical treatment of Monteggia-like lesions in adults remains a challenge. In the present study, the use of a standard surgical protocol, with a modified Boyd approach, successfully restores the movement and stability of the elbow, with a low complication rate.

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.

Monteggia fractures: analysis of patient-reported outcome measurements in correlation with ulnar fracture localization

BACKGROUND

Monteggia fractures and Monteggia-like lesions result after severe trauma and have high complication rates. Preliminary biomechanical studies suggested a correlation between ulnar fracture localization and clinical result.

OBJECTIVES

Key objective was to evaluate whether the site of the ulnar fracture can be correlated to clinical outcome after open reduction and internal stabilization.

METHODS

In a retrospective, monocentric study 35 patients who underwent surgical treatment after suffering a Monteggia injury or Monteggia-like lesion were included. Fractures were classified according to Bado and Jupiter, the site of the fracture location at the proximal ulna and regarding the potential accompanying ligamentary injury. In a follow-up examination validated patient-reported outcome measures and functional parameters were evaluated. Furthermore, treatment strategy and complications were analysed.

RESULTS

Mean patient age was 51.9 years (± 18.0). 69% were females (n = 24). Follow-up took place after 50.5 months (± 22.1). Fractures were classified according to Bado (I:2, II:27, III:4, IV:2). Bado II-fractures were further classified according to Jupiter (A:7, B:16, C:3, D:1). Cases were divided into subgroups depending upon the distance of the ulnar fracture site in respect to its distal endpoint (A: < 7 cm and B: > 7 cm). Average overall MEPS was 84.1 (± 19.0). Oxford elbow score and DASH were 37.2 (± 10.5) and 20.4 (± 20.5). Average extension capability reached - 7° (± 7.5). Mean flexion was 134.8° (± 19.7). Average pain according to visual analogue scale was 1.6 (± 1.9). We found no differences between the subgroups regarding the PROMs. Subgroup A displayed a worse extension capability (p = 0.027) and patients were significantly older (p < 0.01). Comparing patients with and without fracture of the radial head, we observed no differences. Patients with an accompanying injury of the coronoid process displayed higher pain levels (p = 0.011), a worse functionality (p = 0.027) and overall lower scoring in PROM.

CONCLUSION

The presented results suggest that in Monteggia fractures and Monteggia-like lesions, the localization of the ulna fracture can give a hint for its postoperative outcome. However, we could not confirm the hypothesis of an increasing instability in ulnar fractures located further distally (high severity of the potential ligamentous injury). Intraarticular fractures or injuries with a close relation to the joint have a worse prognosis, especially if the coronoid process is injured. Trial registration Registration was done with ClinicalTrials.gov under NCT05325268.

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.

Surgical Management of Complex Adult Monteggia Fractures

Monteggia fractures classically involve a proximal ulna fracture with an associated radial head dislocation. The presence of radial head/neck fracture and comminution of the proximal ulna with coronoid involvement elevates the complexity of surgical reconstruction considerably. The Jupiter classification captures this injury pattern as a subgroup of Bado posterior Monteggia lesions. Access to the critical coronoid fragment can be problematic from the posterior approach and may result in tenuous reduction and fixation, directly affecting the functional outcome. Multiple operative techniques have been described to address the broad spectrum of injuries seen in Monteggia fractures. This article will cover commonly used fixation techniques for Monteggia fractures with a comprehensive literature review, including technical tips, outcomes, and complications.

Current concepts in elbow fracture dislocation

BACKGROUND

Elbow fracture dislocations are complex injuries that can provide a challenge for experienced surgeons. Current classifications fail to provide a comprehensive system that encompasses all of the elements and patterns seen in elbow fracture dislocations.

METHODS

The commonly used elbow fracture dislocation classifications are reviewed and the three-column concept of elbow fracture dislocation is described. This concept is applied to the currently recognised injury patterns and the literature on management algorithms.

RESULTS

Current elbow fracture dislocation classification systems only describe one element of the injury, or only include one pattern of elbow fracture dislocation. A new comprehensive classification system based on the three-column concept of elbow fracture dislocation is presented with a suggested algorithm for managing each injury pattern.

DISCUSSION

The three-column concept may improve understanding of injury patterns and treatment and leads to a comprehensive classification of elbow fracture dislocations with algorithms to guide treatment.

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

BACKGROUND

Trans-olecranon fracture dislocations are the least frequent complex elbow instability. Proper surgical treatment should be performed to avoid postoperative complications.

METHODS

A retrospective design study was performed. Patients that suffered from this injury, treated at our center from 2010 to 2016 were included. Fifteen patients were analyzed. Functional results were measured using DASH, MEPS and VAS scores. Average time from injury to first surgical treatment was 4.87 days. Radial head fracture was present in seven cases and coronoid process in three patients. Most frequent complication was hardware disturbances in five patients. Mean follow up was 3.65 years.

RESULTS

Mean range of motion (ROM) was evaluated 1 year postoperatively: 129° flexion, 6° flexion contracture, and less than 5° deficit of pronation/supination. Clinical and functional results are encouraging, DASH 36.38, MEPS 100 and VAS 0.46.

CONCLUSION

Trans-olecranon fracture dislocations could obtain functional range of movement, pain relief and good functional outcomes with a standardized protocol of surgical fixation. It is important to achieve proper ulnar fixation, focusing in reestablishing dorsal angulation, and also to treat radial head and coronoid injuries properly, if present.

Fracture-dislocations of the forearm joint: a systematic review of the literature and a comprehensive locker-based classification system

BACKGROUND

Monteggia, Galeazzi, and Essex-Lopresti injuries are the most common types of fracture-dislocation of the forearm. Uncommon variants and rare traumatic patterns of forearm fracture-dislocations have sometimes been reported in literature. In this study we systematically review the literature to identify and classify all cases of forearm joint injury pattern according to the forearm joint and three-locker concepts.

METHODS

A comprehensive search of the PubMed database was performed based on major pathological conditions involving fracture-dislocation of the forearm. Essex-Lopresti injury, Monteggia and Galeazzi fracture-dislocations, and proximal and/or distal radioulnar joint dislocations were sought. After article retrieval, the types of forearm lesion were classified using the following numerical algorithm: proximal forearm joint 1 [including proximal radioulnar joint (PRUJ) dislocation with or without radial head fractures], middle radioulnar joint 2, if concomitant radial fracture R, if concomitant interosseous membrane rupture I, if concomitant ulnar fracture U, and distal radioulnar joint 3 [including distal radioulnar joint (DRUJ) dislocation with or without distal radial fractures].

RESULTS

Eighty hundred eighty-four articles were identified through PubMed, and after bibliographic research, duplication removal, and study screening, 462 articles were selected. According to exclusion criteria, 44 full-text articles describing atypical forearm fracture-dislocation were included. Three historical reviews were added separately to the process. We detected rare patterns of two-locker injuries, sometimes referred to using improper terms of variant or equivalent types of Monteggia and Galeazzi injuries. Furthermore, we identified a group of three-locker injuries, other than Essex-Lopresti, associated with ulnar and/or radial shaft fracture causing longitudinal instability. In addition to fracture-dislocations commonly referred to using historical eponyms (Monteggia, Galeazzi, and Essex-Lopresti), our classification system, to the best of the authors' knowledge, allowed us to include all types of dislocation and fracture-dislocation of the forearm joint reported in literature. According to this classification, and similarly to that of the elbow, we could distinguish between simple dislocations and complex dislocations (fracture-dislocations) of the forearm joint.

CONCLUSIONS

All injury patterns may be previously identified using an alphanumeric code. This might avoid confusion in forearm fracture-dislocations nomenclature and help surgeons with detection of lesions, guiding surgical treatment.

LEVEL OF EVIDENCE

V.

Monteggia-like lesions: preliminary reports and mid-term results of a single center

Background and aim of the work:

Monteggia-like lesions are complex and rare elbow injuries. A detailed classification and a proper surgical treatment can provide quite good functional and radiological outcomes. The aim of this retrospective study was to evaluate the mid-term results of Monteggia-like lesions surgical treatment. The other purpose was to investigate whether the complexity of ulna and radius fractures could be prognostic factors of insufficient functional results.

Methods:

Seven women and five men, with a mean age of 59,25 years who had sustained a Monteggia-like lesion were followed up clinically and radiologically after surgical treatment. The Mayo Elbow Performance Score (MEPS) and the Quick Disabilities of the Arm, Shoulder and Hand (QUICK-DASH) score were used for evaluation at a mean of 17,5 months postoperatively (12-26). The range of movement (ROM), patients’ satisfaction and neurological symptoms were also investigated. Osteolysis, implant loosening and heterotopic ossification were graded. Pearson’s test was used to correlate the different classification systems used (AO/OTA, Bado and Jupiter, PURCCS, Mason) with MEPS and QUICK-DASH score.

Results:

The mean MEPS was 84,92 (65 to 100). The mean QUICK-DASH score was 18,75 (0 to 34,1). The mean active pronation and supination was 72,5° and 59,17°, respectively. The mean active ROM of the elbow was 101,43°. Heterotopic ossifications were absent in six cases but were found in six. No statistically significant correlation was found between the analyzed variables.

Conclusions:

Quite good functional results can be obtained in Monteggia-like lesions if injury pattern is recognized and each component of the injury is addressed. Further studies are needed to determine any prognostic factors. (www.actabiomedica.it)

Complex Monteggia Fractures in the Adult Cohort: Injury and Management

Monteggia fractures involve proximal ulna fracture associated with a radiocapitellar joint dislocation. The Bado classification is primarily based on the direction of the radial head dislocation. The Jupiter subtype classification of Bado II fractures further characterizes the severity of proximal ulna comminution and the involvement of the coronoid fragment. This latter classification can better prognosticate the challenges of surgical reconstruction and clinical outcomes. Surgery for all adult Monteggia fractures is required to restore the anatomic alignment of the ulna, which indirectly reduces the radiocapitellar joint. The complexity of the injury is considerably increased by comminution of the proximal ulna, the degree of radial head fragmentation, the reduction of the radial head, and ulnohumeral instability. Anatomic reduction is considered critical to achieving a favorable outcome.

[Monteggia-fractures and Monteggia-like Lesions]

Monteggia lesions and Monteggia-like lesions involve ulna and radius injuries, which can not be successfully treated using the surgical principles of isolated fractures. Proximal ulnar fracture, radio-humeral dislocation, and additional dislocation in the proximal radioulnar joint result in the disintegration of the functional unit, and there is a complex injury across the elbow to the forearm, resulting in poor clinical outcomes. Thus, addressing all osteo-ligamentous injuries is essential for the long-term course.

Reliability and validity of the Wrightington classification of elbow fracture-dislocation

Aims

The Wrightington classification system of fracture-dislocations of the elbow divides these injuries into six subtypes depending on the involvement of the coronoid and the radial head. The aim of this study was to assess the reliability and reproducibility of this classification system.

Methods

This was a blinded study using radiographs and CT scans of 48 consecutive patients managed according to the Wrightington classification system between 2010 and 2018. Four trauma and orthopaedic consultants, two post CCT fellows, and one speciality registrar based in the UK classified the injuries. The seven observers reviewed preoperative radiographs and CT scans twice, with a minimum four-week interval. Radiographs and CT scans were reviewed separately. Inter- and intraobserver reliability were calculated using Fleiss and Cohen kappa coefficients. The Landis and Koch criteria were used to interpret the strength of the kappa values. Validity was assessed by calculating the percentage agreement against intraoperative findings.

Results

Of the 48 patients, three (6%) had type A injury, 11 (23%) type B, 16 (33%) type B+, 16 (33%) Type C, two (4%) type D+, and none had a type D injury. All 48 patients had anteroposterior (AP) and lateral radiographs, 44 had 2D CT scans, and 39 had 3D reconstructions. The interobserver reliability kappa value was 0.52 for radiographs, 0.71 for 2D CT scans, and 0.73 for a combination of 2D and 3D reconstruction CT scans. The median intraobserver reliability was 0.75 (interquartile range (IQR) 0.62 to 0.79) for radiographs, 0.77 (IQR 0.73 to 0.94) for 2D CT scans, and 0.89 (IQR 0.77 to 0.93) for the combination of 2D and 3D reconstruction. Validity analysis showed that accuracy significantly improved when using CT scans (p = 0.018 and p = 0.028 respectively).

Conclusion

The Wrightington classification system is a reliable and valid method of classifying fracture-dislocations of the elbow. CT scans are significantly more accurate than radiographs when identifying the pattern of injury, with good intra- and interobserver reproducibility. Cite this article: Bone Joint J 2020;102-B(8):1041–1047.

Monteggia-like lesions in adults treated with radial head arthroplasty-mid-term follow-up of 27 cases

Background

The aim of the study was to analyze the functional and radiological outcome of Monteggia-like lesions in adults with unreconstructible fracture of the radial head and treatment with radial head arthroplasty.

Methods

Twenty-seven patients (mean age 56 years; range 36 to 79 years) with a Monteggia-like lesion and treatment with radial head replacement were included in this retrospective study. Minimum follow-up was 2 years. Clinical assessment included the pain level with the visual analog scale in rest (VAS_R) and under pressure (VAS_P), range of motion, Mayo Elbow Performance Score (MEPS), and Disability of the Arm, Shoulder, and Hand score (DASH). A detailed radiological evaluation was performed. Complications and revisions were also analyzed.

Results

After a mean follow-up period of 69 months (range, 24 to 170) the mean DASH score was 30 ± 24, the MEPS averaged 77 ± 20 points, the mean VAS_R was 2.1 ± 2.4, and VAS_P was 4.5 ± 3.5. Mean loss of extension was 24° ± 18 and flexion was 124° ± 20. Heterotopic ossifications were noted in 12 patients (44%). A total of 17 complications were noted in 11 patients (41%), leading to 15 revision surgeries in 9 patients (33%). Patients with a complicated postoperative course showed a worse clinical outcome compared with patients without complications measured by MEPS (68 ± 22 vs. 84 ± 16), DASH (49 ± 16 vs. 20 ± 22) and ulnohumeral motion (77° ± 31 vs. 117° ± 23).

Conclusions

Monteggia-like lesions with unreconstructible radial head fracture and treatment with radial head replacement are prone to complications and revisions.

Surgical treatment of the radial head is critical to the outcome of Monteggia-like lesions

Aims

The aim of this study was to evaluate the outcome of Monteggia-like lesions at midterm follow-up and to determine whether the surgical treatment of the radial head influences the clinical and radiological results.

Patients and Methods

A total of 78 patients with a Monteggia-like lesion, including 44 women and 34 men with a mean age of 54.7 years (19 to 80), were available for assessment after a mean 4.6 years (2 to 9.2). The outcome was assessed using the Mayo Elbow Performance Score (MEPS), Oxford Elbow Score (OES), Mayo Modified Wrist Score (MMWS), and The Disabilities of the Arm, Shoulder and Hand (DASH) score. Radiographs were analyzed for all patients. A total of 12 Mason type I, 16 type II, and 36 type III fractures were included. Surgical treatment consisted of screw fixation for all type II and reconstructable type III fractures, while radial head arthroplasty (RHA) or excision was performed if reconstruction was not possible.

Results

The mean MEPS was 88.9 (40 to 100), mean OES was 40.1 (25 to 48), mean MMWS was 88.1 (50 to 100), mean DASH score was 14.7 (0 to 60.2), and mean movement was 114° (sd 27) in extension/flexion and 155° (sd 37) in pronation/supination. Mason III fractures, particularly those with an associated coronoid fracture treated with RHA, had a significantly poorer outcome. Suboptimal results were also identified in patients who had degenerative changes or heterotopic ossification on their latest radiograph. In contrast, all patients with successful radial head reconstruction or excision had a good outcome.

Conclusion

Good outcomes can be achieved in Monteggia-like lesions with Mason II and III fractures, when reconstruction is possible. Otherwise, RHA is a reliable option with satisfactory outcomes, especially in patients with ligamenteous instability. Whether the radial head should be excised remains debatable, although good results were achieved in patients with ligamentous stability and in those with complications after RHA. Cite this article: Bone Joint J 2019;101-B:1512–1519

Anatomically shaped locking plates for radial head and olecranon fracture fixation in Monteggia-like lesions

BACKGROUND

Monteggia-like lesions are rare injuries. We retrospectively reviewed 40 consecutive patients with Monteggia-like lesions treated at a level I trauma center from 2009 to 2016. Clinical results were evaluated with a focus on the use of modern locking plates.

OBJECTIVE AND METHODS

Twenty-eight patients had Bado type II fractures, 11 had Bado type I, and 1 had Bado type III. All patients were treated by plate fixation of the ulna with a locking compression plate or double mini-plates. Fixation or replacement was performed for radial head fractures. We characterized all fractures and recorded the range of motion (ROM); 100-point visual analog scale (VAS) scores for pain and function; Disabilities of the Arm, Shoulder and Hand (DASH) score; and Mayo Elbow Performance Score (MEPS). A follow-up rate of 78% was reached at an average of 36 months (range, 12-95 months).

RESULTS

Stable fixation without recurrent instability was accomplished. The average ROM for flexion reached 130∘ with an extension deficit of 13∘. The sum of supination and pronation was 136∘. The VAS scores for pain and function were 20 and 75, respectively. The average MEPS and DASH scores were 84 and 28, respectively. Bado type I fractures had better outcomes for all variables, especially forearm rotation (p< 0.05). The complication rate was 22.5% and revision rate was 17.5%.

CONCLUSION

This fracture repair technique can safely achieve good and excellent outcomes in most cases and is partly superior to previously published techniques. However, Bado type II fractures still have a risk of poor results.

Complex radial head and neck fractures treated with modern locking plate fixation

BACKGROUND

Internal fixation of complex radial head and neck (CRHN) fractures is difficult, and postoperative complications are common. This study evaluated elbow function and patient clinical status after internal fixation of CRHN fractures with modern locking plates.

METHODS

We included 40 patients with 41 fractures (1 bilateral lesion). In 25 patients (61%), a concomitant injury was found. Patients were an average age of 46 years (range, 22-70 years). The mean follow-up time was 36 months (range, 2-70 months). Postoperative assessments included evaluation of range of motion, functional scores, and radiologic findings. We assessed fracture healing, surgical complications, revision surgery, and the need for metal removal.

RESULTS

Of the 34 fractures available for follow-up, 33 (97%) healed well. The mean extension deficit was 6° (range, 0°-30°). The average elbow flexion was 134° (range, 90°-160°), pronation was 70° (range, 30°-90°), and supination was 64° (range, 20°-90°). The Mayo Elbow Performance Score showed a mean of 90 points (range, 65-100 points). We observed no "poor" results. The mean Disability of Arm, Shoulder and Hand score was 16.5 (range, 2.5-58.3; n = 29). All patients continued activity without daily analgesics. There were 12 (34%) complications. In 11 (32%) patients, the plate was removed.

CONCLUSIONS

CRHN fractures fixed with modern locking plates and treated as an osseoligamentous lesion exhibited promising midterm results. The new fixation devices represent an improvement in the treatment of this difficult and common fracture while reducing the need for joint replacement or radial head resection. Diagnosis and treatment of concomitant injuries should be emphasized.