Fractures of the proximal ulna: current concepts in surgical management

Prognostic value of the CURL classification system for proximal ulna fracture dislocations of the elbow

BACKGROUND

Proximal ulna fracture dislocations comprise a wide spectrum of injury. The Coronoid, proximal Ulna, Radius and Ligaments (CURL) classification is a simple framework designed to aid surgical decision-making by focusing attention on the key components of the injury and their relative severity. It has been demonstrated to have a high interobserver and intraobserver reliability. The aim of this study was to analyze the prognostic value of the CURL classification with respect to patient outcome.

METHODS

The CURL framework was applied retrospectively to 182 patients treated surgically for a proximal ulna fracture dislocation in a level 1 trauma center. Patient outcomes collected included complication rate, reoperations, patient satisfaction, and Oxford Elbow Score (OES). The CURL score overall and each individual component were assessed for the effect on outcome. Appropriateness of surgical fixation was also assessed and correlated with outcome.

RESULTS

Of 182 patients, 69 (37.9%) had at least 1 major or minor complication and the overall CURL score was associated with a higher rate of complications (r = 0.85, P = .02). The presence of a coronoid fracture as well as the radial head and ligament components was associated with increased complications (coronoid: r = 0.26, P < .01; radial head: r = 0.36, P < .01; ligament: r = 0.38, P < .01). The complication rate was higher as the CURL value increased for both coronoid and radial head components (coronoid score 0 = 30.9%, coronoid score 1 = 54.6%, coronoid score 2 = 69.2% and radial head score 0 = 26.1%, radial head score 1 = 50.0%, radial head score 2 = 73.3%). The median OES was 43, and the total CURL score was correlated with inferior OES (r = -0.89, P = .01) as were the coronoid, radial head, and ligament components (coronoid: r = -0.43, P < .01; radial head: r = -0.38, P < .01; ligament: r = -0.42, P < .01). The proximal ulna fracture severity was not correlated with increased complication rate or OES. Patients deemed to have inappropriate fixation (20.8%) had a significantly higher complication rate (65.8% vs. 30.5%, P ≤ .001), with the 9 patients with inadequate coronoid fixation demonstrating a 100.0% complication rate.

CONCLUSION

Proximal ulna fracture dislocations have a high complication rate and are intolerant to inadequate fixation. The CURL system demonstrates prognostic value with the coronoid component most influential on outcome.

Monteggia Equivalent Variant Type 1 in an Adult, its Management and Functional Outcome with Literature Review

Introduction

In 1814, Giovanni Battista Monteggia first described the fracture pattern which was further characterized by Luis Bado in 1967. Bado also coined the term Monteggia equivalent which includes a spectrum of complex fracture patterns and dislocations of the proximal ulna and radius. Monteggia equivalent lesions in adults are rare with different injury mechanisms compared to children, and thus having different management procedures.

Case Report

We report a Type 1 Monteggia equivalent variant in a 31-year-old female who presented with a proximal ulnar fracture along with an ipsilateral radial neck fracture extending into the radial head. A fracture pattern that has not been reported much in literature as per our observations and we suggest should be considered a Monteggia equivalent Type 1b. Osteosynthesis of the ulna and proximal radius was done and at 1-year follow-up, complete radiological union with near-native function was achieved.

Conclusion

Early recognition of such complex fracture patterns and a reconstruction of the proximal radius wherever possible gives a better outcome than arthroplasty or excision as per literature.

Intra-osteal fixation of comminuted coronoid process fracture with mini plate for the treatment of complex elbow fracture

Complex elbow fractures featuring a comminuted coronoid process are infrequent and pose considerable treatment challenges. The optimal strategy for maximizing recovery of elbow function through osteosynthesis remains a subject of ongoing debate among surgeons. We applied the principle of internal fixation by implementing intra-osteal fixation with a mini plate, which facilitated the successful restoration of exceptional elbow function in the patient. This approach adeptly managed the complexity of the coronoid process fracture, encompassing its fragmentation and associated injuries, thereby demonstrating its feasibility and efficacy in achieving favorable clinical outcomes. This article investigates the viability of this surgical technique for managing such complex fractures.

Monteggia Fracture Dislocation

SUMMARY

Monteggia fracture is a complex fracture consisting of a proximal ulna fracture with a dislocation of the radial head. This review article highlights the relevant anatomy, clinical evaluation, classification, surgical management, recent innovation, and advancements with treating these injuries. A thorough understanding of these fractures allows for detailed operative plans and reconstitution of normal anatomy.

Orthogonal plating for complex olecranon fractures: retrospective case series with patient-reported outcomes

INTRODUCTION

Treatment for complex olecranon fractures with metaphyseal comminution can be challenging. To improve reduction maneuvers and augment stability, we apply a small medial and/or lateral locking compression plate (LCP) prior to placing a posterior contoured 3.5 mm-2.7 mm LCP. The aim is to describe our technique and outcomes of this "orthogonal" plating technique.

MATERIAL AND METHODS

26 patients were treated with orthogonal plating. Clinical outcome variables were available for all patients at a median of 27 months (IQR 6-54), and patient-reported outcomes (Q-DASH and MEPS) for 23 patients at 38 months (IQR 18-71).

RESULTS

All fractures healed at a median of 2.0 months (IQR 1.5-3.8). The median elbow flexion was 120°, extension-deficit 15°, pronation 88°, and supination 85°. The median Q-DASH was 9 (IQR 0-22) and the median MEPS was 90 (IQR 80-100). Hardware was electively removed in seven patients. One patient had a late superficial infection that resolved with hardware removal and antibiotics, and one patient had two consecutive re-fractures after two hardware removals; and healed after the second revision surgery.

CONCLUSION

Orthogonal plating with a posterior LCP and a small medial and/or lateral LCP is a safe technique that leads to excellent healing rates, and good clinical and patient-reported outcomes.

Fixation of Olecranon Fractures Using a Hybrid Intramedullary Screw and Tension Band Construct

Introduction

Olecranon fractures are common injuries that require surgical intervention for optimal outcomes. Various fixation methods have been described in the literature, including the use of intramedullary proximal ulna screws in combination with tension band augmentation. Limited research has compared this hybrid technique to other established methods of fixation. This study compared complication and reoperation rates between multiple groups.

Methods

A retrospective review was conducted on patients with olecranon fractures who underwent internal fixation at a level 1 trauma center between January 1st, 2013, and April 22nd, 2023. Data was collected using CPT codes, and patients were categorized into five groups based on the method of fixation received: no implant, tension band only, locking olecranon plate, intramedullary screw and tension band hybrid, and others. Variables such as patient demographics, Mayo fracture classification, open vs. closed injury, implant type, reoperation rates, and postoperative complications were recorded.

Results

A total of 217 patients were included in the study. No difference was found with implant choice and reoperation rate (p = 0.461). There was a significant difference found with reoperation and fracture type (p = 0.027) and open fracture (p = 0.002).

Conclusion

The primary findings of this study indicate no significant difference in implant choice and reoperation rates among the various fixation methods used for olecranon fractures. These findings suggest that the hybrid fixation technique, utilizing intramedullary proximal ulna screws in combination with tension band augmentation, is a viable and comparable treatment option when evaluated against other well-documented methods of fixation. This study also reiterates that severity of initial injury is often the most important factor related to poorer outcomes. Further discussion and analysis of the data will provide a comprehensive understanding of implications and recommendations for olecranon fracture fixation.

Uncommon type 3 Monteggia equivalent lesion due to an ulnar shaft nonunion in adults: A case report

It is uncommon to observe a nonunion of an isolated ulnar shaft fracture after surgical treatment; therefore, complications due to this nonunion are very rare. Adults are more likely to develop nonunions compared to children. We report the case of a 34-year-old man, who had a left ulnar shaft fracture, treated with a screwed plate. Four months later, a septic nonunion occurred causing a type 3 Monteggia equivalent lesion with a lateral dislocation of the radial head. We describe the consecutive methods of treatment that resulted in complete bone consolidation. The case report aims to underline the diagnostic particularities and the therapeutic challenges of this rare complication.

Triple suture fixation for displaced comminuted olecranon fracture with a stable ulnohumeral joint

PURPOSE

To report the outcome of a novel fixation technique using three high-strength sutures which is including articular buttress suture, cerclage suture, and tension band with off-loading triceps suture (triple suture fixation) in the treatment of displaced comminuted olecranon fracture with a stable ulnohumeral joint (Mayo type IIB). The rationale of using this technique is that the sutures have been used to stabilize multiple fracture fragments in all sides of the olecranon.

MATERIAL AND METHODS

Between July 2018 and July 2021, 10 patients (7 women, 3 men; mean age, 49.9 years; mean follow-up duration, 27.8 months) with Mayo type IIB olecranon fractures who underwent triple suture fixation were included in the study. The elbow was immobilized in a splint for 2 weeks postoperatively. Range-of-motion exercises were initiated after splint removal and weight bearing was allowed at 6 weeks postoperatively.

RESULTS

Average active range of motion of the elbow was 145° of flexion (range, 135°-150°), 6.5° of extension (range, 0°-30°), 83° of supination (range, 70°-85°), and 77.5° of pronation (range, 70°-80°). Mean MEPS was 98.3 (range, 85-100) and DASH score was 3.1 (range, 0-10) at the final follow-up. Radiographic data at the final follow-up analyzed by paired t test demonstrated that there was no statistically significant difference of proximal olecranon height (OH), trochlear notch width (TW), and OH/TW ratio between postoperative treatment and normal side (p-value >.05). No complication of implant prominence, fixation failure, nonunion, infection or heterotopic ossification was found postoperatively. Breakage of drill bit occurred during drilling a distal oblique hole for articular buttress suture in one patient.

CONCLUSION

The triple suture fixation is an effective treatment with low incidence of complications in treatment of Mayo type IIB olecranon fractures. Larger comparative studies are needed to confirm the value of such technique.

[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.

Plating of Proximal Ulna Fractures Using Posterolateral Distal Humerus Plates: Surgical Technique and Case Series

Precontoured olecranon plates are frequently used in the management of proximal ulna fractures. Occasionally, in comminuted proximal ulna fractures or segmental ulna fractures, available precontoured olecranon plates are too short for the management of these fractures. The authors have utilized posterolateral distal humerus plates in these instances. The coronal bend in some posterolateral distal humerus plates anecdotally fits well to the proximal ulna, despite being designed for the distal humerus. We sought to measure the coronal angulation of precontoured posterolateral distal humerus plates from various companies and compare these to established proximal ulna angles. Case examples are also provided.

Morphological Characteristics of Proximal Ulna Fractures: A Proposal for a New Classification and Agreement for Validation

Historically, proximal ulna fractures have been simplistically diagnosed and treated as simple olecranon fractures, leading to an unacceptable number of complications. Our hypothesis was that the recognition of lateral, intermediate, and medial stabilizers of the proximal ulna and ulnohumeral and proximal radioulnar joints would facilitate decision-making, including the choice of approach and type of fixation. The primary aim was to propose a new classification for complex fractures of the proximal ulna based on morphological characteristics seen on three-dimensional computed tomography (3D CT). The secondary aim was to validate the proposed classification regarding its intra- and inter-rater agreement. Three raters with different levels of experience analyzed 39 cases of complex fractures of the proximal ulna using radiographs and 3D CT scans. We presented the proposed classification (divided into four types with subtypes) to the raters. In this classification, the medial column of the ulna involves the sublime tubercle and is where the anterior medial collateral ligament is inserted, the lateral column contains the supinator crest and is where the lateral ulnar collateral ligament is inserted, and the intermediate column involves the coronoid process of the ulna, olecranon, and anterior capsule of the elbow. Intra- and inter-rater agreement was analyzed for two different rounds, and the results were evaluated according to Fleiss kappa, Cohen kappa, and Kendall coefficient. Intra- and inter-rater agreement values were very good (0.82 and 0.77, respectively). Good intra- and inter-rater agreement attested to the stability of the proposed classification among the raters, regardless of the level of experience of each one. The new classification proved to be easy to understand and had very good intra- and inter-rater agreement, regardless of the level of experience of each rater.

Fractures of the Proximal Ulna: A Spectrum of Injuries and Outcomes

Introduction

The purpose of this study is to assess the effect of radial head/ neck injury in association with proximal ulna fractures.

Methods

Between 2006 and 2020, 107 patients presented to our academic medical center for treatment of a proximal ulna fracture and were enrolled into an IRB-approved database. Radiographs, injury details, and surgical interventions were retrospectively reviewed. Patients were classified as having an isolated proximal ulna fracture (PU), a PU fracture with an associated radial head dislocation (M-D), or a Monteggia fracture with an associated radial head fracture (M-V). Clinical and functional outcomes were assessed at follow-up to determine what differences exist between fracture patterns. Statistics were generated using Chi-squared tests for categorical variables and one-way ANOVA tests for numerical variables.

Results

While all patients ultimately healed, time to radiographic healing in the PU cohort was shorter at 3.57 ± 1.7 months when compared to the M-V cohort (5.67 ± 3.8 months) (p < 0.05). At follow-up, patients in the M-V cohort had poorer elbow pronation and supination when compared to the PU and M-D cohorts (p < 0.05). Patients within the PU cohort had fewer complications than those in the M-D and M-V cohorts (p < 0.05). No differences were found between the three cohorts in regard to rates of reoperation, non-union, wound infection, and nerve compression (p > 0.05).

Conclusion

The Monteggia fracture with a concomitant radial head/neck fracture is a more disabling injury pattern when compared to an isolated proximal ulna fracture and Monteggia fracture without an associated radial head/neck fracture.

TRANSOLECRANON FRACTURE-DISLOCATION: CONCEPTS AND FUNCTIONAL RESULTS OF SURGICAL TREATMENT

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.

Olecranon Fractures: A Critical Analysis Review

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Olecranon fractures account for 10% of all elbow fractures and are more likely to result from a low-energy injury. A displaced fracture with a stable ulnohumeral joint (Mayo type 2) is the most common type of injury.

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The management of an isolated olecranon fracture is based on patient factors (age, functional demand, and if medically fit to undergo surgery) and fracture characteristics including displacement, fragmentation, and elbow stability.

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Nonoperative management can be successfully used in undisplaced fractures (Mayo type 1) and in displaced fractures (Mayo type 2) in frail patients with lower functional demands.

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Patients with displaced olecranon fractures with a stable ulnohumeral joint without significant articular surface fragmentation (Mayo type 2A) can be managed with tension band wiring, plate osteosynthesis (PO), intramedullary fixation, or suture repair.

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PO is advocated for multifragmentary fractures and fractures that are associated with ulnohumeral instability. It is essential to consider the variable anatomy of the proximal ulna during surgery.

[Monteggia fractures-dislocations in children: retrospective study of 40 cases in the Department of Orthopedics, Habib Bourguiba University Hospital in Sfax, Tunisia]

Monteggia's fracture-dislocation is rare in pediatric traumatology and pose a problem of elapsed time before management and of prognosis. The purpose of this study was to describe the epidemiological features of this fracture and to assess functional and anatomical results. We report a series of 40 cases of Monteggia fracture in children whose data were collected and treated at the Habib Bourguiba University Hospital Center in Sfax over a period of 17 years, from January 1998 to January 2015. We listed the epidemiological data of our population as well as the types of fracture dislocations according to the Bado radiological classifications. For functional assessment, the choice of treatment was based on the type of fracture. P. Rigault's score and Kim's score were used. The average age of our study population was 8 years; 20 cases of fractures were classified as Bado I and 12 cases as Bado III. The time elapsed before treatment was less than 24 hours in 82% of cases. Surgical treatment was performed in 28 cases, and functional results were judged to be good in 30 cases. Our results were satisfactory due to the short time elapsed before patient management compared to literature data.

Reduction of olecranon fractures with no or minimal dorsal cortex comminution based on the contour of the posterior ulnar cortex: does it restore the greater sigmoid notch?

INTRODUCTION

When treating olecranon fractures surgically, surgeons rely on the contour of the posterior cortex of the proximal ulna. However, it is unclear whether the greater sigmoid notch (GSN) is restored anatomically by this method. We analyzed whether reduction of fractures based on the posterior ulnar cortex contour is reliable for restoration of the GSN contour in displaced olecranon fractures with no or minimal dorsal cortex comminution.

MATERIALS AND METHODS

We performed a retrospective review of 23 patients with Mayo type 2 olecranon fractures with no or minimal dorsal cortex comminution who were treated surgically. We analyzed pre- and postoperative elbow CT images and measured the interfragmentary distance (IFD), articular step-off, articular gap, contour defect and GSN angle to evaluate the restoration of the GSN contour.

RESULTS

The mean preoperative IFD and contour defect were 16.5 mm (range 4.3-35.6 mm) and 4.3 mm (range 0.7-13.3 mm), respectively. Postoperatively, there was no residual IFD, and the mean contour defect decreased significantly to 1.4 mm (range 0-3.7 mm). The residual articular step-off and gap were 0.2 mm (range 0-3.8 mm) and 1.0 mm (range 0-5.9 mm), respectively. Acceptable GSN restoration was achieved in 14 of 23 patients (60.9%). Sixteen patients had > 2 mm of preoperative contour defect, and 7 (43.8%) achieved acceptable GSN restoration; the remaining 7 patients (100%) who had < 2 mm of the contour defect achieved acceptable GSN restoration. Patients whose preoperative contour defect was > 2 mm had a higher risk of unacceptable GSN restoration, with an odds ratio of 2.29 (p = 0.019).

CONCLUSIONS

In displaced olecranon fractures without significant dorsal cortex comminution, reduction based on the posterior ulnar cortex could be reliable for fractures with under 2 mm of preoperative contour defect, but not for those with > 2 mm of contour defect.

LEVEL OF EVIDENCE

IV.

Distal Radius Fracture with Ipsilateral Elbow Dislocation: A Rare but Challenging Injury

Distal radius fractures are common and account for approximately 14% to 18% of all adult extremity injuries. On rare occasions, ipsilateral elbow dislocation can be observed additionally. However, this can be missed without careful examination, especially in patients experiencing altered mental status. The aim of this study was to analyze the mechanism, level of injury, demographics, and associated injuries in distal radius fracture with ipsilateral elbow dislocation. Between 2012 and 2019, we searched our trauma database for distal radius fracture with ipsilateral elbow dislocation. All patients older than 18 years old were included. Data on demographics, mechanism of injury, level of energy, and subsequent treatment were collected. A total of seven patients were identified. The mean age in this cohort was 68.7 ± 13.3 years old, and the left side was involved in 71.4% of the patients. Females were affected in 85.7% (n = 6/7) of cases, all of whom suffered from low-energy monotrauma at a mean age of 71.5 ± 12.3 years old. One male patient suffered from high-energy trauma (52 years old). Mainly, posterior elbow dislocations were observed (66.7%; n = 4/6). Distal radius fracture patterns, in accordance with the AO classification, included two C2-, two C3-, one C1-, and one B1-type fractures. In the patient suffering from high-energy trauma, the closed distal radius fracture was classified as type C3. Associated injures included open elbow dislocation, ulnar artery rupture, and damage to the flexor digitorum superficialis. Although distal radius fracture with ipsilateral elbow dislocation is thought to be from high-energy trauma, this study shows that most patients were elderly females suffering from low-energy mechanisms. It is important for clinicians to maintain a high level of suspicion for any concomitant injury in this population.

Repair Versus Non-Repair of Lateral Ulnar Collateral Ligament in Elbow Varus Posteromedial Rotatory Instability Treatment: A Comparative Study

OBJECTIVE

To compare the effects of repairing and not repairing the lateral ulnar collateral ligament (LUCL) when surgically treating elbow varus posteromedial rotatory instability (PMRI).

METHODS

In this retrospective study spanning June 2014 to February 2019, 24 patients with elbow PMRI who were treated surgically were assigned to group RL (Repair LUCL) or group NL (Non-repair LUCL) depending on whether the LUCL was repaired. Hospitalization time, operation time, intraoperative blood loss, and related complications were reviewed. The elbow range of motion (ROM), the visual analog scale (VAS), the Mayo elbow performance score (MEPS), and the disabilities of the arm, shoulder, and hand (DASH) score were used for functional assessment.

RESULTS

Among the 24 patients with PMRI, 15 were assigned to group RL and nine were assigned to group NL. The mean blood loss (184.66 ± 20.3 vs 207.33 ± 19.447, P < 0.001), the operation time (98.88 ± 12.693 min vs 184.66 ± 20.3 min, P < 0.001) were significantly lower in group RL compared to group NL. There were no significant differences between the two groups in time until surgery and follow-up time (6.66 ± 1.838 vs 6.11 ± 1.900 days, 25.53 ± 2.099 vs 26.11 ± 2.891 months, P = 0.577, P = 0.486). All of the patients achieved bone union. The elbow flexion-extension ROM (122.00° ± 3.162°vs 121.11° ± 3.333° at 12 months, P = 0.520) and pronation-supination ROM (154.53° ± 3.335° vs 155.55° ± 4.639° at 12 months, P = 0.537). Both groups achieved similar results in MEPS score (90.53 ± 2.695 vs 89.77 ± 3.865, P = 0.578) and DASH (9.77 ± 1.897 vs 9.99 ± 1.550, P = 0.772) score at the final follow-up. And the MEPS score revealed excellent results (87% in group RL, 89% in group NL).The VAS scores decreased significantly in group RL (from 6.13 ± 0.990 to 1.93 ± 0.593) and group NL (from 5.77 ± 1.481 to 1.88 ± 0.781), and no significant differences in preoperative or final follow-up were observed between the two groups (P = 0.487, P = 0.876). Complications observed in group NL with one patient occurred cubital tunnel syndrome 3 months after the operation, the patient underwent ulnar nerve simple neurolysis and the symptoms were relieved after 3 weeks.

CONCLUSION

For patients with elbow PMRI, satisfactory functional outcomes can be yielded with non-repair of the LUCL as long as the stable elbow joint is performed during operation.

Bilateral Traumatic Nightstick Fracture of the Ulna - A Rare Case Report and Review of the Literature

Introduction:

Unilateral isolated ulna fracture secondary to trauma are common but the bilateral nightstick fractures are quite rare in the clinical scenario. These are managed conservatively or surgically depending upon the degree of displacement, location of the fracture, fracture pattern and associated injury to other bones. Proper management of these fractures helps in getting a better outcome. The purpose of the study was to present a case of bilateral traumatic isolated ulna fracture and its management.

Case Report:

A 33-year-old male presented to the emergency department with complaints of pain and swelling over the dorsum of both forearms with a history of assault with a bamboo stick. The mechanism of the injury was, the patient placed his both the forearms in front of the face as a defense during the assault and sustained injury to both forearms. On examination, the patient had bilateral forearm swelling with tenderness. Bony crepitus was present over both the ulna on palpation. X-ray of both forearms (radius and ulna) revealed the fracture of both right and left ulna without any associated fractures/injuries. The patient was managed surgically with open reduction and internal fixation using a 3.5 mm locking compression plate. At present, 1-year follow-up, the patient is having complete wrist, elbow ROM and supination, pronation without any pain.

Conclusion:

Bilateral traumatic Nightstick fractures of the ulna are rare and this is the first reported case of traumatic bilateral isolated ulna fracture according to author’s best knowledge and literature review. Open reduction and stable internal fixation using the principles of fracture fixation along with early mobilization helps in getting better functional outcome and prevents further complications and secondary procedures. This case is unique as it helps in identifying the mode of trauma in medico legal cases like assault in cases of bilateral ulna fracture. The mode and the mechanism of injury are different in this case.

Management of Geriatric Elbow Injury

Approximately 4.1% of all fractures in the elderly involve the elbow. Most elbow injuries in geriatric patients occur as the result of low-energy mechanisms such as falls from standing height. Elbow injuries in elderly patients present complex challenges because of insufficient bone quality, comminution, articular fragmentation, and preexisting conditions, such as arthritis. Medical comorbidities and baseline level of function must be heavily considered in surgical decision making.

Proximal ulna fractures in adults: A review of diagnosis and management

Proximal ulna fractures are relatively common upper limb injuries, which may represent fragility fractures or result from high-energy trauma. These include fractures of the olecranon, coronoid and associated radial head dislocations. A wide variety of treatment options are available for the management of these injuries that makes the selection of most appropriate treatment difficult. We aim to provide a brief overview of the treatment options for such injuries.

Postoperative rehabilitation in elbow surgery

Postoperative rehabilitation plays a crucial role in the treatment of elbow pathology. Depending on the type of surgery, the elbow may need to be protected. As a general rule, the elbow should not be immobilized for a prolonged period after surgery. A removable splint can be used to protect the soft-tissues immediately postoperative and the patient is encouraged to remove the splint several times daily to mobilize the elbow. Dynamic articulated braces can be used to encourage movement while ligament or tendon repairs are being protected. Literature on postoperative elbow rehab is scarce. In this paper we provide practical guidelines for specific surgical procedures.

Treatment of Monteggia-like-lesion in a young patient: A case report

INTRODUCTION

A Monteggia fracture was described initially as a fracture of the proximal third ulna and anterior dislocation of the proximal epiphysis radius.[1] In 1967, Bado discovered "true Monteggia lesions" and classified them into 4 groups.[2] He also used the term "equivalents" or "Monteggia-like-lesions" to describe specific injuries with similar radiographic patterns.[3] This type of fracture is rare and frequently associated with complications, poor functional results, and further operations.[4].

PATIENT CONCERNS

A 16-year-old girl was admitted to our emergency department after a single motorcycle accident. Her main complaint was the pain and swollen of her left elbow. She was reluctant to move her arm due to pain.

DIAGNOSIS

Radiograph examination showed a displaced fracture of the left proximal third ulna accompanied by displacement of the left proximal radius. This fracture was similar to the Monteggia type III fracture except for proximal radial disruption that occurred laterally through a Salter-Harris type II fracture.

INTERVENTIONS

The patient underwent surgical debridement, and the forearm was immobilized using a backslap in a supine position and elbow flexion 90o. Open reduction and internal fixation were performed 5 days later. The ulna was reduced and stabilized first using a 3.5 mm one-third tubular plate (ORMED), and internal fixation of the radial epiphysis was done using a 1.6 mm miniplate (Prohealth).

OUTCOMES

After 3 months, the patient showed improvement with the Mayo Elbow Performance Score (MEPS) of 85. She did not complain of any pain and decreased strength. The patient regained 0 to 125o of elbow flexion and 0 to 165o of supination and pronation.

CONCLUSION

Monteggia-like-lesion has many variations in physical and radiograph appearance. Careful evaluation of fracture pattern, identification of injury mechanism, and appropriate treatment planning based on Monteggia fracture treatment principles are mandatory to achieve the patient's best outcome.

Treatment of olecranon fractures using an intramedullary cancellous screw and suture tension band: minimum 2-year follow-up

Background

Tension band wiring and plates are the most widely used treatments for transverse displaced fractures of olecranon despite high rates of hardware complications, subsequent implant removal, and associated costs. The purpose of this study was to report the outcomes of displaced transverse olecranon fractures treated with intramedullary screw and suture tension band.

Methods

We performed an observational, retrospective, consecutive, monocentric, continuous multioperator study. We reviewed 31 Mayo type IIA displaced olecranon fractures treated in our institution with intramedullary 6.5 mm AO cancellous screw and high-strength suture tension band (No. 2 FiberWire®) from 2016 to 2018. Inclusion was limited to functionally independent patients with Mayo type IIA fractures and minimum 24-month follow-up for implant removal. We assessed clinical outcomes including range of motion; QuickDASH score; and Mayo Elbow Performance Score. Categorical data were analyzed with Fisher's exact test when appropriate. Continuous data were analyzed with the Student t-test or Mann-Whitney U test after assessment for normality. Statistical analysis was performed with STATA 16 software.

Results

Twenty-seven patients with a mean follow-up period of 38.4 ± 6.2 months (range, 24.1-50 months) were included in the study. The average flexion was 134.5° ± 14.8° (range, 70°-140°) and the mean extension was -5.9° ± 7.0° (range, -20°-0°). Mean pronation and supination were 85.8° ± 11.9° (range, 45°-90°) and 86.9° ± 14.3° (range, 20°-90°), respectively. The mean Mayo Elbow Performance Score was 90.8 ± 9.6 (range, 70-100) with 92.3% good and excellent results. The mean QuickDASH score was 17.1 ± 16 (range, 0-54.5). There were 3 hardware-related removals (11.1%). The overall removal rate was 18.5%. Univariate analysis of the factors associated with implant removal were pain in relation to the implant (60% vs. 11%, P = 0.0482), proximal screw migration (3.7 mm vs. 1.7 mm, P = 0.05), articular angle (22.5° vs. 27.7°, P = 0.0353), and olecranon width (22.2 mm vs. 24.4 mm, P = 0.0166). In total, 26.1% of the cases presented some degree of proximal migration of the implant (2.7 ± 1.8 mm of migration; range, 1.5-6.2 mm). Univariate analysis of the factors associated with implant proximal migration were proximal ulnar dorsal angulation (1.7° vs. 6.4°, P = 0.0179), anteroposterior endomedullary canal (7.3 mm vs. 6.0 mm, P = 0.0369), and lateral endomedullary canal (7.2 mm vs. 5.0 mm, P = 0.0219).

Conclusion

The functional outcomes of simple transverse olecranon fractures treated with an intramedullary cancellous screw and a suture tension band are excellent, associated with a low rate of complications and material removal.

Management of Monteggia Injuries in the Adult

Monteggia fracture-dislocation of the elbow is a fracture of the proximal ulna with associated dislocation of the radial head or radial neck fracture. In adults, this injury is managed with open reduction and internal fixation of the ulna fracture. Care should be taken to ensure anatomic reduction of the proximal ulna. If radial head dislocation or subluxation persists, reduction of the ulna should be reassessed. Rarely, interposed soft tissue may block radial head reduction, and requires removal. Complications include hardware prominence, stiffness, infection, heterotopic ossification, nerve injury, malunion or nonunion of the ulna, radioulnar synostosis, and persistent radial head instability.

[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.

Nailing vs. plating in comminuted proximal ulna fractures - a biomechanical analysis

Background

Comminuted proximal ulna fractures are severe injuries with a high degree of instability. These injuries require surgical treatment, usually angular stable plating or double plating is performed. Nailing of proximal ulna fracture is described but not performed regularly. The aim of this study was to compare a newly developed, locked proximal ulna nail with an angular stable plate in an unstable fracture of the proximal ulna. We hypothesize, that locked nailing of the proximal ulna will provide non-inferior stability compared to locked plating.

Methods

A defect fracture distal to the coronoid was simulated in 20 sawbones. After nailing or plate osteosynthesis the constructs were tested in a servo-pneumatic testing machine under physiological joint motion (0°-90°) and cyclic loading (30 N – 300 N). Intercyclic osteotomy gap motion and plastic deformation of the constructs were analyzed using micromotion video-analysis.

Results

The locked nail showed lower osteotomy gap motion (0.50 ± 0.15 mm) compared to the angular stable plate (1.57 ± 0.37 mm, p < 0.001). At the anterior cortex the plastic deformation of the constructs was significantly lower for the locked nail (0.09 ± 0.17 mm vs. 0.39 ± 0.27 mm, p = 0.003). No statistically significant differences were observed at the posterior cortex for both parameters.

Conclusions

Nail osteosynthesis in comminuted proximal ulna fractures shows lower osteotomy gap motion and lower amount of plastic deformation compared to locking plate osteosynthesis under laboratory conditions.

Olecranon fractures: do they lead to osteoarthritis? Long-term outcomes and complications

PURPOSE

To report radiologic, functional outcomes, and complications with a long-term follow-up in acute olecranon fractures treated with osteosynthesis and, secondly, to determine the predisposing factors to arthritis.

METHODS

Forty-two patients treated with osteosynthesis for acute olecranon fractures were reviewed, with a minimum follow-up of 24 months. Radiological and clinical evaluations including DASH, MEPS, active range of motion, pain, arthritis, associated lesions, and complications were recorded. Arthritis was classified according to Broberg-Morrey scale. A logistic regression model was estimated to determine risk factors to develop ulnohumeral arthritis. The association between the types of fractures according to Mayo classification and MEPS, and the association between the type of fracture and the presence of pain were analyzed.

RESULTS

The average follow-up was of 43.64 months. The flexion-extension average range was 135.6°, and the mean MEPS was 89.45; the DASH was 25.26. Eighteen cases (42.86%) were fixed with pre-contoured locking plates, 21 with tension band wiring (50%), and 3 with cannulated screws of 7 mm (7.14%). Six cases (14.29%) needed hardware removal. All fractures healed. Ulnohumeral osteoarthritis was observed in 14 cases (33.3%). We did not find a significant association among the MEPS, pain, and the fracture type, according to Mayo (p > 0.1 for both values). A significant association was found (p < 0.05) between fracture type and the osteoarthritis.

CONCLUSIONS

In olecranon fractures, good functional and radiological results with low complications are predictable. The osteoarthritis is possible in more complex fractures and with other associated fractures.

Non-hip/non-vertebral fractures - How to treat best?

Fractures of the extremities in the elderly constitute more than two-thirds of all fragility fractures befalling frail, osteoporotic and sarcopenic patients. Although treatment controversies abound, consensus exists. Upper extremity fractures hinder activities of daily living and are debilitating. Open fractures or displaced fractures will need surgical intervention. Wrist fractures treated operatively allow early use of the hand. Most pelvic fractures are treated conservatively. In the lower extremities, fractures of the long bones, tibia and femur need surgical intervention. Non-displaced fractures around the foot may be treated with immobilisation and avoidance of full weight-bearing. As a rule, fractures take four months for consolidation. Individually tailored solutions are needed for frail patients with comorbidities. Maintaining joint mobility and muscle strength preserves mobility and autonomy. Caring for extremities trauma is team work, involving family and health care providers. Prevention efforts are mandatory.