Treatment of complex elbow fracture-dislocations

Reported outcome measures in complex fracture elbow dislocations: a systematic review

BACKGROUND

Complex elbow fracture dislocations, dislocation with fracture of one or several surrounding bony stabilizers, are difficult to manage and associated with poor outcomes. While many studies have explored treatment strategies but a lack of standardization of patient-reported outcome measures (PROMs) makes cross-study comparison difficult. In this systematic review, we aim to describe what injury patterns, measured outcomes, and associated complications are reported in the complex elbow fracture dislocation literature to provide outcome reporting recommendations that will facilitate improved future cross-study comparison.

METHODS

A systematic review was performed per Preferred Reporting Items for Systematic reviews and Meta-Analyses guidelines. We queried PubMed/MEDLINE, Embase, Web of Science, and Cochrane databases to identify articles published between 2010 and 2022 reporting on adult patients who had a complex elbow fracture dislocation. Pathologic fractures were excluded. A bias assessment using the methodological index for nonrandomized studies criteria was conducted. For each article, patient demographics, injury pattern, outcome measures, and complications were recorded.

RESULTS

Ninety-one studies reporting on 3664 elbows (3654 patients) with an elbow fracture and dislocation (weighted mean age 44 years, follow-up of 30 months, 41% female) were evaluated. Of these, the injury pattern was described in 3378 elbows and included 2951 (87%) terrible triad injuries and 72 (2%) transolecranon fracture-dislocations. The three most commonly reported classification systems were: Mason classification for radial head fractures, Regan and Morrey coronoid classification for coronoid fractures, and O'Driscoll classification for coronoid fractures. Range of motion was reported in 87 (96%) studies with most reporting flexion (n = 70), extension (n = 62), pronation (n = 68), or supination (n = 67). Strength was reported in 11 (12%) studies. PROMs were reported in 83 (91%) studies with an average of 2.6 outcomes per study. There were 14 outcome scores including the Mayo Elbow Performance Score (n = 69 [83%]), the Disabilities of Arm, Shoulder and Hand (DASH) score (n = 28 [34%]), the visual analog scale for pain (n = 27 [33%]), QuickDASH score (n = 13 [15.7%]), and Oxford Elbow score (n = 5 [6.0%]). No significance was found between the number of PROMs used per article and the year of publication (P = .313), study type (P = .689), complex fracture pattern (P = .211), or number of elbows included (P = .152).

CONCLUSION

There is great heterogeneity in reported PROMs in the complex elbow fracture dislocation literature. Although there is no gold standard PROM for assessing complex elbow fracture dislocations, we recommend the use of at least the Mayo Elbow Performance Score and DASH outcomes measures as well as visual analog scale pain rating scale in future studies to facilitate cross-study comparisons.

Complex elbow fracture-dislocations- what factors are associated with a poor post-operative outcome?

PURPOSE

Despite standardized treatment algorithms, patients with complex elbow fracture-dislocation frequently suffer from poor post-operative elbow function leading to reduced quality of life. Up to now, there is no valuable data regarding risk factors that lead to poor post-operative outcome after surgical reconstruction of complex elbow fracture-dislocations.

METHODS

From 06/2010 to 12/2020 134 patients (51.3 ± 15.1 years, 44% women) undergoing surgical treatment of complex elbow fracture-dislocations could be included in this study. Follow-up period was 4.4 years (SD 2.5). All patients were clinically evaluated for elbow movement, elbow stability and common elbow scores (MEPS, OES, DASH-Score). Potential risk factors for poor post-operative outcome were identified using bi- and multivariate analyses.

RESULTS

Overall good post-operative outcome has been achieved, mean MEPS was 88.8 ± 17.6. Post-operative complications occurred in 31.3% of the cases, while 25.4% required surgical revision. Patients with transolecranon dislocation fractures showed the significantly worst functional outcomes (p = 0.01). In addition, it has been shown that a patient's age of more than 70 years (OR = 10, p = 0.003) and a BMI of more than 35 kg/m2 (OR = 7.6, p = 0.004) are independent risk factors for a poor post-operative outcome. In contrast, gender and time to surgery showed no significant influence on post-operative outcome.

CONCLUSION

In most cases, good post-operative functional results can be achieved using standardized treatment protocols. However, complication and revision rates remain high. Patients older than 70 years of age or with a BMI over 35 kg/m2 are at risk for an inferior outcome and require close follow-up monitoring.

Influence of Coronoid fixation on the functional outcome and rate of complications in surgically treated acute complex elbow instability

INTRODUCTION

Fractures of the coronoid commonly present in elbow fracture-dislocations. Despite the evidence that the coronoid plays an important role in elbow stability, there is still controversy on which fractures should be surgically fixed. The aim of this study is to compare the clinical outcomes and rate of complications of patients with elbow fracture-dislocations in which the coronoid was fixed or left untreated.

MATERIALS AND METHODS

Thirty-nine patients with an elbow fracture-dislocation involving a coronoid fracture were prospectively followed for an average of 90 months (range 24-190). According to Morrey´s classification there were 22 type II and 8 type III. Nine patients had an anteromedial fracture of the coronoid. In 24 patients the coronoid was repaired (suture fixation in 9, screws fixation in 10 and plate fixation in 5) and in 15 patients the coronoid was not fixed. In 18 patients the radial head was replaced and in 8 patients it was fixed. All patients underwent repair of the lateral ligament complex. Clinical evaluation was performed with the MEPS. Radiographically, the rate of coronoid nonunion was specifically analyzed. Postoperative neurological complications were recorded.

RESULTS

At the most recent follow up, the average arc of flexion-extension was 120° (range 70°-140°) with a mean MEPS of 90 (range 25-100). No statistically significant differences were found in the MEPS and flexion-extension arc between the patients in whom synthesis was performed (117° ROM, and 89 MEPS) and those in whom it was not (122° ROM, 94 MEPS) (p = 0.42; p = 0.34). Coronoid fracture healing could be assessed in 36 patients: in 19 patients the coronoid was radiographically healed, and in 17 a nonunion was present, with no difference in the final clinical outcome between both groups. Nine patients, 6 of whom had undergone coronoid fixation, had a neurological complication related to the ulnar nerve.

CONCLUSIONS

Coronoid fractures affecting around 50% of its height can be treated without internal fixation as long as the rest of the osteo-ligamentous structures are adequately repaired. Osteosynthesis of the coronoid through a medial approach may carry a non-negligible risk of associated neurological injury.

Chronic Complex elbow fracture dislocation: Restoration of elbow function with ORIF and radial head replacement, a case report with long term follow up

INTRODUCTION

The dislocation of the elbow joint to the posterior or postero-lateral region accompanied by fractures in the radial head or neck and coronoid process of the Ulna is known as a terrible triad injury of the elbow (TTI).

IMPORTANCE

This injury presents as unique challenge for orthopedic surgeons due to elbow instability and stiffness, making the surgical intervention more difficult than usual.

CASE PRESENTATION

A 47-year-old man suffered from polytrauma, including a pelvis fracture, a left humerus shaft fracture, and left ulna shaft fracture. An open reduction and internal fixation were administered as a treatment option. However, during a follow-up examination four months later, a missed fracture dislocation of the right elbow was discovered.

CLINICAL DISCUSSION

The complex surgery required open reduction of the chronic dislocated joint, release of the triceps, resection of the radial head, replacement, bone grafting of the coronoid, reconstruction of the coronoid, and application of a spanning external fixation. The injury was complex, consisting of coronoid fractures, olecranon, a proximal third of the Ulna, and radial head malunion with heterotrophic ossification around the elbow joint.

CONCLUSION

After seven years, our patient had a full range of motion in elbow flexion with 20-25 lags in extension. The Mayo Elbow Performance Score (MEPS) was 100 and Disabilities of Arm, Shoulder and Hand (DASH) score was 0.

"How the Wrightington classification of traumatic elbow instability can simplify the algorithm for treatment"

There are numerous injury patterns of elbow-fracture dislocation that can lead to confusion about the best surgical management. The Wrightington classification aims to provide a simple categorization based on the injury to the coronoid process and the three column concept of the elbow osseous stability that describes a medial column consisting of the anteromedial coronoid facet and sublime tubercle, the middlecolumn is the anterolateral coronoid facet, and the lateral column is the radial head and lateral ligament complex with a fulcrum for varus/valgus stability between the two coronoid facets. Injuries are classified as type A (anteromedial facet/medial-column), B (bifacet/ medial and middle-columns), B+ (bifacet with radial head/all three columns), C (combined radial head and anterolateral facet/middle and lateral-columns), D (distal to coronoid where coronoid is in continuity with olecranon process), and D+ (distal to coronoid with radial head fracture). With each bony injury pattern, we can anticipate which soft tissue constraints are likely to be involved and the importance of their repair to restore stability, and thereby develop algorithms for management. The Wrightington classification has been shown to be reliable and valid. A consecutive series of 60 patients with elbow-fracture dislocation managed according to the surgical algorithms of the Wrightington classification have been reported to have excellent outcomes with a median Mayo Elbow Performance Score of 100 (interquartile 85-100) and flexion/extension arc of movement of 123° (interquartile 101°-130°). In conclusion, the Wrightington classification of elbow-fracture dislocation is a comprehensive, reliable, and valid classification with treatment algorithms that are associated with good functional outcomes.

Trans-olecranon fracture posterior dislocation: a novel type of elbow injury

BACKGROUND

Based on our experiences, we found that a kind of elbow injury is characterized by an olecranon fracture accompanied by elbow joint posterior dislocation with the proximal radioulnar joint intact. The aim of this study was to better define this kind of severe elbow instability, which has not been previously reported.

METHODS

We retrospectively analyzed all patients with olecranon fractures who were treated at our institution from January 2013 to April 2021. Data on these patient demographics, injury characteristics, preoperative and postoperative imaging, surgical management, and outcomes were recorded and analyzed. We also made the inclusion criteria and exclusion criteria.

RESULTS

A total of 309 patients were diagnosed olecranon fractures in our institution, and ten patients met the inclusion criteria, 9 males and 1 female, with an average age of 40.6 ± 12.7 years (26-68 years). Eight patients (80%) were comminuted, and two were oblique olecranon fracture. Nine patients (90%) suffered coronoid process fractures, eight fractures were type III, and one was type II. Eight patients (80%) suffered radial head fractures, seven fractures were type II, and one was type III. All patients suffered lateral collateral ligament complex injury. All patients underwent surgical management and were followed up on average for 15.8 ± 3.2 months (12-20 months). The motion of the elbow and functional outcome were evaluated with several methods. The mean arc of the elbow movement was 131.6° ± 6.0° (124°-140°), and the mean arc of the forearm rotation was 158.5° ± 17.8° (128°-180°). Nine patients' functional results according to the Mayo Elbow Performance Score (MEPS) were excellent with a mean score of 96.5 ± 5.3 points (85-100 points), and another was good. The mean score according to the Broberg and Morrey functional rating index was 98.8 ± 2.5 points (92-100 points), nine patients were excellent, and another was good. The mean Disabilities of the Arm, Shoulder, and Hand (DASH) score was 0.75 ± 1.2 points (0-3.3 points).

CONCLUSIONS

Trans-olecranon fracture posterior dislocation is a rare injury and has unique characteristics, and it is a kind of complex elbow instability involving the coronoid process and radial head fractures. After bony structure is restored, the repairment of lateral collateral ligament complex is also important to the stability of the elbow joint. Correct understanding of this kind of injury and reasonable treatment plan can achieve good function.

Functional outcomes of elbow injuries managed according to the Wrightington classification of elbow fracture-dislocations

Background

This study aims to review the functional outcomes of patients managed by the application of the Wrightington elbow fracture-dislocation classification system and its corresponding management algorithms.

Methods

This is a retrospective consecutive case series of patients over the age of 16 with an elbow fracture-dislocation managed according to the Wrightington classification. The primary outcome was the Mayo Elbow Performance Score (MEPS) at the last follow-up. Range of movement (ROM) and complications were collected as a secondary outcome.

Results

Sixty patients qualified for inclusion (32 female, 28 male) with a mean age of 48 years (19-84). Fifty-eight (97%) patients completed a minimum of three months follow-up. Mean follow-up was six months (3-18). The median MEPS at the final follow-up was 100 (interquartile range [IQR] 85-100) and median ROM of 123° (IQR 101-130) degrees. Four patients underwent secondary surgery and had improved outcomes with the average MEPS score improving from 65 to 94 following the second surgery.

Conclusions

The results of this study show that good outcomes can be achieved for complex elbow fracture-dislocations through pattern recognition and management with an anatomically based reconstruction algorithm as described by the Wrightington classification system.

[Winter sports injuries to the elbow joint]

BACKGROUND

Elbow injuries occur quite often when practicing winter sports. Due to the high sports dynamics and risk of fall the elbow joint is prone to injuries. Hereby, the most common injury is the dislocation of the elbow.

TREATMENT

Isolated ligamentous instabilities can usually be treated non-operatively when the joint is centered on post-reduction imaging. In the case of persistent symptomatic instability, secondary ligament reconstruction surgery is associated with reliable and good results. Most fractures of the elbow involve the radial head in terms of postero-lateral rotation instability, whereas distal humerus and olecranon fractures are more likely to occur in high-energy or direct trauma. Indication for surgical treatment is given according to common guidelines, including involvement of the joint line, fragment dislocation and instability with risk of secondary fracture dislocation. Minimally invasive techniques for the radial head as well as anatomic preformed locking plate systems seem to have reached a wide acceptance.

Biomechanical comparison of elbow stability constructs

BACKGROUND

Despite surgical stabilization of complex elbow trauma, additional fixation to maintain joint congruity and stability may be required. Multiple biomechanical constructs include a static external fixator (SEF), a hinged external fixator (HEF), an internal joint stabilizer (IJS), and a hinged elbow orthosis (HEO). The optimal adjunct fixation to surgical reduction is yet to be determined.

METHODS

Eight matched cadaveric upper extremities were tested in a biomechanical model. Anteroposterior stress radiographs were obtained of the elbow in full supination at 0° and 45° of elbow flexion with the weight of the hand serving as a varus load as the baseline. A 360° capsuloligamentous soft-tissue release was performed around the elbow. The biomechanical constructs were applied in the same sequential order: SEF, HEF, IJS, and HEO. For each construct, 0 kg (0-lb) and 2.3 kg (5-lb) of weight were applied to the distal arm. At both weights, radiographs were obtained with the elbow at 0° and 45° of flexion, with subsequent measurement of displacement, congruence at the ulnohumeral joint, and the ulnohumeral opening angle. Statistical analysis was performed to quantify the strength and stability of each construct.

RESULTS

Compared with the control group at 0° with and without 2.3 kg (5-lb) of varus force and at 45° with and without 2.3 kg (5-lb) of varus force, no difference was noted in the medial ulnohumeral joint space, lateral ulnohumeral joint space, or ulnohumeral opening angle between the SEF, HEF, and IJS. The gap change after exertion of a 2.3-kg (5-lb) force between the control condition and application of each construct demonstrated no difference between the SEF, HEF, and IJS. Comparison among destabilized elbows showed no significant difference between the SEF, HEF, and IJS. The HEO catastrophically failed in each position at 0 kg (0-lb) of weight.

CONCLUSION

The SEF, HEF, and IJS are neither superior nor inferior at maintaining elbow congruity with the weight of the arm and 2.3 kg (5-lb) of varus stress. The HEO did not provide additional stability to the unstable elbow.

The radiological findings in complex elbow fracture-dislocation injuries

Elbow fracture-dislocation is a complex injury which can lead to significant bony and soft tissue damage. Surgical intervention is guided towards restoring joint stability, allowing early mobilization and preventing long-term joint stiffness. The most common types are posterolateral, posteromedial, Monteggia type (and variants), and anterior trans-olecranon fracture-dislocations. Posterolateral fracture-dislocation is characterized by a radial head fracture (± anterolateral coronoid fracture) and typically capsuloligamentous disruption (lateral collateral ligaments injury is the most common). A posterolateral fracture-dislocation with radial head and coronoid anterolateral facet fractures is termed a terrible triad injury. In posteromedial fracture-dislocation, there is a fracture of the anteromedial facet of the coronoid, typically with proximal avulsion of the lateral collateral ligaments (± injury to the posterior bundle of the ulnar collateral ligament). Monteggia fracture-dislocation injuries demonstrate proximal ulnar fracture (with possible involvement of the olecranon and the coronoid) and radial head dislocation. These can be divided into apex anterior or apex posterior variants. The latter are commonly associated with radial head fractures and lateral ligamentous injury, and have a worse prognosis. In trans-olecranon fracture-dislocation, there is significant disruption of the greater sigmoid notch and the olecranon, with various involvement of the coronoid and the proximal ulna. The article describes the radiological findings and outlines the management principles in complex elbow fracture-dislocation injuries.

Dislocations of the elbow - An instructional review

Dislocations of the elbow require recognition of the injury pattern followed by adequate treatment to allow early mobilisation. Not every injury requires surgery but if surgery is undertaken all structures providing stability should be addressed, including fractures, medial and lateral ligament insertion and the radial head. The current concepts of biomechanical modelling are addressed and surgical implications discussed.

The three-column concept of elbow joint stability and the Wrightington elbow fracture-dislocation classification, emphasizing the role of cross-sectional imaging

Elbow fracture-dislocation is a complex injury with a combination of osseous and soft tissue disruption. Different classification systems have been used to describe the injury pattern and help guide the management. The article describes the important cross-sectional findings in complex elbow fracture-dislocation injuries based on the relatively new Wrightington classification. This includes the various elements and patterns seen in elbow fracture-dislocations providing a simple and comprehensive system to classify these injuries and help guide the surgical management. The article also describes the three-column concept of elbow joint stability, dividing the elbow joint osseous structures into lateral, middle and medial columns. Detailed radiological assessment of the fractures pattern is vital to understand the mechanism of injury, allowing clinicians to predict the associated capsuloligamentous injury and help guide the management decisions. The Wrightington elbow fracture-dislocation classification categorizes the injuries according to the ulnar coronoid process and radial head fractures. Type A is an anteromedial coronoid fracture. Type B is a bifacet or basal coronoid fracture, with B + indicating associated radial head fracture. Type C is a combined anterolateral facet and radial head or comminuted radial head fractures. Type D is a diaphyseal ulnar fracture, with D + indicating associated radial head fracture.

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.

Complications and functional outcomes after transolecranon distal humerus fracture

BACKGROUND

Transolecranon distal humerus fractures are uncommon injuries. This is the first multipatient case series to describe outcomes and complications following transolecranon distal humerus fractures in the adult population.

METHOD

Design: retrospective; setting: single level 1 trauma center; patients/participants: 16 patients; intervention: surgical management of transolecranon distal humerus fracture; main outcome measurement: Disabilities of the Arm, Shoulder, and Hand (DASH) questionnaire after a minimum of 12 months.

RESULTS

A total of 16 patients with open (n = 12) or closed (n = 4) transolecranon distal humerus fractures were identified. Nine female and 7 male patients with a mean age of 47 years were included. Mechanisms of injury included motor vehicle collisions (n = 3), motorcycle crashes (n = 4), ground-level falls (n = 3), falls from height (n = 4), train collision (n = 1), and an industrial accident (n = 1). Seven patients (44%) presented with nerve injury. Patients underwent open reduction with internal fixation (n = 15), external fixation (n = 6), or both (n = 5). Additional surgeries were ultimately required in 11 patients (69%), with a mean of 3 surgeries to manage each patient's elbow injuries. All patients returned for at least 3 clinical follow-up visits; mean clinical follow-up was 15.8 months and mean radiographic follow-up was 12.3 months. Complications were observed in 15 patients (94%). Eleven patients (69%) had limited range of motion with a flexion arc of less than 100° at their last clinic visit. Seven patients (44%) developed deep wound infections requiring repeat débridement and intravenous antibiotics. Implant removal was performed in 10 patients (62.5%) because of infection (n = 5), symptomatic hardware (n = 4), or device failure (n = 1). Heterotopic ossification was seen in 8 patients (50%) and post-traumatic arthrosis in 4 (25%). Two patients (12.5%) required flap reconstruction for soft tissue defects. Nonunion occurred in 7 patients (44%). DASH scores were obtained for 10 patients (62.5%) at a mean of 3.8 years after injury. The mean DASH score was 40.2, ranging from 4.2 to 76.5. Among respondents, 7 (70%) were able to resume working, with an average DASH work module score of 25.

CONCLUSION

Management of transolecranon distal humerus fractures remain a challenge for orthopedic surgeons. Complication rates, including deep infection and nonunion, are high, with frequent long-term functional limitations posed to the patient, as evidenced by DASH scores.

Surgical management of medial and lateral elbow instability secondary to acute atypical complex elbow dislocation: Case report and literature review

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The patient presented with an atypical complex elbow dislocation with fracture.

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The patient underwent lateral collateral ligament repair.

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The patient also underwent medial collateral ligament reconstruction.

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Elbow stability improved and the patient experienced improved functionality.

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Care is needed to identify and manage the underlying injury in this type of case.

Introduction and importance

Elbow dislocation is common in adults, and complex elbow dislocations are generally associated with bone fractures. Anteromedial coronoid fracture, in association with lateral collateral ligament (LCL) disruption, often results from varus posteromedial forces. “Terrible triad” injuries are more likely to result from valgus posterolateral forces. However, our case presentation has combined medial and lateral elbow instability in addition to “terrible triad” injury of the elbow with no radial head injury.

Case presentation

The patient was a 38-year-old man with an atypical complex elbow dislocation. He was successfully treated by stabilizing the medial epicondyle and coronoid anterolateral facet fractures, in addition to LCL repair and medial collateral ligament (MCL) reconstruction. A radial head fracture was unnoted. The procedure yielded satisfactory functional outcome, with a stable and painless full elbow range of motion.

Clinical discussion

Multi-ligament injuries with coronoid fractures result in highly unstable elbow joints, forming a variant of the “terrible triad” injury. Surgical options vary according to the surgeon’s experience and equipment availability. In this case, direct LCL repair and MCL reconstruction were performed and were well tolerated. Elbow stability improved and the patient experienced improved functionality with minimal pain. However, it may be premature to report a definite outcome in this case because of short follow-up time postoperatively.

Conclusion

The injury described in this case has a unique presentation as a multi-ligamentous injury will make the elbow very unstable. Thus, careful clinical judgment, knowledge, and experience are needed to identify the underlying injury and for optimal management.

Treatment of elbow instability: state of the art

The elbow is a congruent joint with a high degree of inherent stability, provided by osseous and soft-tissue constraints; however, when substantial lesions of these stabilising structures happen, instability of the elbow occurs. Significant improvements in surgical elbow instability diagnosis and treatment have been recently introduced both for acute and chronic cases. Specific stress tests, recently introduced in the clinical practice, and different imaging techniques, both static and dynamic, allow assessment of the elbow stabilisers and detection of the instability direction and mechanism even in subtle forms. Many surgical techniques have been standardised and surgical instruments and devices, specifically dedicated to elbow instability treatment, have been developed. Specific rehabilitation protocols have been designed to protect the healing of the elbow stabilisers while minimising elbow stiffness. However, despite the progress, surgical treatments can be challenging even for expert surgeons and the rate of persistent instability, post-traumatic arthritis, stiffness and pain can be still high especially in most demanding cases. The biology of the soft-tissue healing remains one of the most important aspects for future investigation. If future research will help to understand, correct or modulate the biological response of soft-tissue healing, our confidence in elbow instability management and the reproducibility of our treatment will tremendously improve. In this paper, the state of the art of the current knowledge of elbow instability is presented, specifically focusing on modern surgical techniques used to solve instability, with repair or reconstruction of the damaged elbow stabilisers.

Trans-Olecranon Fracture-Dislocations of the Elbow: A Systematic Review

The purpose of this study is to provide a systematic review of the definition, ideal surgical method, complications, and prognosis of trans-olecranon fracture dislocations. An electronic search was performed in the PubMed, EMBASE, Scopus, and MEDLINE databases. The eligibility criteria included retrospective clinical study and review article in subjects older than 18 years with trans-olecranon fracture dislocations. Trans-olecranon fracture dislocations are defined as fractures in which the stability of the ulnohumeral joint is lost due to the intra-articular fracture of the olecranon without disruption of the proximal radioulnar joint. The seven papers were included that met the eligibility criteria for the quantitative synthesis. Findings indicate that a pre-contoured plate was used in 88.3% of cases (68 of 77 reports), with no reports of complications, suggesting that the pre-contoured 3.5 mm plate is the first choice of treatment. Postoperative mean elbow range of motion for the flexion–extension arc was 121.1° and 146.5° for the pronation-supination arc. Methods for postoperative clinical scores included the Broberg/Morrey rating with a result of excellent or good in 82.9% of cases, the ASES score with a mean of 88.7, and the DASH score with a mean of 11.75. Complications included heterotopic ossification in 21.9% (23/105) of cases, arthrosis in 25.7% (27/105) of cases, nerve damage in 18.1% (19/105) of cases, and osteoarthritis in 14.3% (15/105). With better understanding of the mechanism of injury and proper diagnosis and treatment, findings of the current review suggest a positive outcome. PROSPERO registration No.: CRD42019126568.

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.

Radial Head Arthroplasty, Excision and Osteosynthesis in Complex Elbow Fracture-Dislocations in Young Adults: What is Preferred?

OBJECTIVE

Complex elbow fractures are common injuries in young adults. Results in recent studies with various operative treatment protocols are equivocal. We compared the results of radial head arthroplasty, excision with osteosynthesis in such injuries at two follow-ups 1 year apart.

METHODS

Thirty-five patients of complex elbow fracture-dislocations including, posterior/anterior olecranon dislocation of elbow, terrible triad injury, anteromedial facet of coronoid fracture, Type IV Monteggia fracture-dislocation and unclassified elbow dislocation were enrolled. They were managed operatively by standardized protocol similar to McKee et al. radial head reconstruction with miniplates, lag screws or non-operative treatment for undisplaced fractures. Arthroplasty of radial head with cemented prosthesis + LCL repair with suture anchor/transosseous tunnel was done. Coronoid and olecranon fixation was always performed. Patients were evaluated as follows: Q-DASH score, MEPI, pain according to VAS, range of motion, complications and radiographic findings and fracture union, and elbow instability.

RESULTS

The mean length of follow-up among the patients was 18 months. There were statistically significant differences between the DASH score/MEPS between radial head excision and replacement/reconstruction. Instability was significantly reduced in those with LCL reconstruction. Excising the comminuted radial head without replacement had the worst outcome. Best PROM was reported in patients with osteosynthesis.

CONCLUSION

Provided a standard protocol is applied, radial head osteosynthesis has preferable outcomes in terms of patient-related outcomes as compared to arthroplasty, although not statistically significant. Radial head excision though has acceptable outcomes but there is a restriction of movements especially flexion-extension. Acceptable rate of complications major or minor warrants need of secondary surgical procedures or a staged treatment.

Editorial Commentary: Do We Need to Treat All Lesions Operatively in Elbow Terrible Triad?

Arthroscopic reduction and fixation techniques in elbow surgery are evolving, and more and more literature is describing good outcomes of new arthroscopic fixation methods for coronoid fractures, lateral collateral ligament tears, radial head fractures, or capsular avulsions. The possible next step could be to use all these different techniques in cases in which all the described lesions can be seen. However, the question is if this approach is too aggressive. Although it is technically feasible to perform, this approach may not be necessary.

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.

Protocolised surgical treatment of terrible triad of elbow. Results and complications

BACKGROUND

Terrible triad of elbow is a complex lesion with a high rate of complications. Our goal is to analyse both clinical results and complications after performing protocolised surgery.

MATERIAL AND METHODS

The database of our hospital was used during 2005-2015, collecting characteristics of the patient, the fracture, the surgery and the associated complications, as well as functional results and range of mobility.

RESULTS

A total of 62 triads were obtained, of which 27 (43%) were women and 35 (56%) were men. All had a Kaplan lateral approach and those who needed it were complemented with a medial approach to repair the LCM. The radial head was synthesized in 14 (22%) cases, a prosthesis was placed in 45 (74%) cases and other actions in 3 (5%) cases. Osteosynthesis of the choroid process was performed by transosseous harpoon±suture in 41 (62%) patients and by synthesis in 12 (19%) cases. In 9 (14%) cases, no action was taken. In 100% of the cases the LCL was repaired and in 9 (14%) the LCM also had to be repaired. Twenty-two percent of the patients required ESA due to instability after the surgical technique. With respect to results, a range of mobility was obtained between 120°/-20° of flexoextension and 98°/85° of pronosupination. In terms of complications, we obtained a total of 17 (27%).

CONCLUSIONS

Elbow triads are complex lesions where protocolised surgery is necessary, nevertheless the complication rate was 27% in our series.

Reasons for surgical revision after conservatively treated radial head fractures-retrospective study of 70 patients

Background

An inadequate clinical outcome after conservatively treated radial head fractures is not uncommon. We analyzed the subjective limitations, objective complaints, and surgical procedures for radial head fractures initially treated conservatively.

Patients and method

Between 2007 and 2016, 70 patients (42 men, 28 women) who suffered from fracture sequelae after conservatively treated radial head fractures were examined. Demographic (age, 41.8 years, range, 16–75 years) and clinical data (pain, range of motion, instability) were retrospectively evaluated.

Results

The average time to surgery after trauma was 50 months (range, 5–360 months). In 38 cases, radial head fractures were initially treated with immobilization for 3.4 weeks (range, 1–8 weeks). Physiotherapeutic treatment was performed in 39 cases. In only half of the cases was retrospective Mason classification possible: 20 type I, 8 type II, 5 type III, and 2 type IV. Of the 70 patients, 53 had posttraumatic elbow stiffness; 34 had isolated lateral and four patients isolated medial ligament instability. There were eight cases with a combination of lateral and medial ligament instability and 27 cases of elbow stiffness combined with instability. An average of 1.2 (range, 1–4) surgical procedures per patient were performed. In all, 64 patients underwent elbow arthroscopy with arthrolysis and additional treatment depending on other injuries. The range of motion improved on average from preoperative flexion/extension of 131–15–0° to postoperative flexion/extension of 135–5–0° (gain in flexion: 4.2° and extension: 10.6°).

Conclusion

Conservative treatment of radial head fractures does not always yield good results. Reasons for a poor outcome include chronic instability, cartilage damage, stiffness, or a combination thereof. Improved outcomes can be achieved via arthroscopic arthrolysis.

Treatment of Radial Head Fractures with a Modular Metallic Radial Head Replacement

Introduction

Radial head arthroplasty with a smooth-stemmed metallic modular implant is a reliable treatment option for patients with acute unreconstructible radial head fractures, and good clinical outcomes may be expected beyond 5 years of follow-up (Video 1).

Indications & Contraindications

Step 1 Preoperative Planning

Obtain a careful history and perform a physical examination along with appropriate imaging to facilitate appropriate treatment decisions.

Step 2 Operating Room Setup and Patient Positioning

Perform proper operating room setup and patient positioning, as they are required to gain access to all affected structures around the elbow in a safe and efficient manner.

Step 3 Approach

Make a midline posterior skin incision with development of a full-thickness lateral fasciocutaneous flap or use a direct lateral incision; the deep interval is determined on the basis of the integrity of the LCL.

Step 4 Radial Head Excision

Remove and preserve all fragments of the radial head for implant sizing.

Step 5 Implant Sizing

Implant a prosthesis that closely replicates the dimensions of the native radial head, which is the primary goal of the procedure.

Step 6 Stem Broaching

Sequentially broach the canal until good cortical contact is achieved and undersize the definitive stem by 1 mm to allow implant movement within the canal and appropriate articulation with the capitellum.

Step 7 Insertion of Trial Components and Final Radial Head Implant

With the selected trial in place, assess the radial head diameter, height, and articular congruency.

Step 8 Closure and Repair of the LCL

Ensure proper repair of the LCL as it is essential to maintaining or restoring elbow stability.

Step 9 Postoperative Protocol

Postoperative rehabilitation depends on the status of the collateral ligaments.

Results

In a review of the cases of 55 patients at a mean follow-up of 8 years after radial head arthroplasty with a smooth-stemmed modular metallic prosthesis, Marsh et al.⁹.

Pitfalls & Challenges

Elbow instability: Are we able to classify it? Review of the literature and proposal of an all-inclusive classification system

BACKGROUND

In the recent years, considerable improvements have come in biomechanical knowledge about the role of elbow stabilizers. In particular, the complex interactions among the different stabilizers when injured at the same time have been better understood. Anyway, uncertainties about both nomenclature and classification still exist in the definition of the different patterns of instability.

MATERIAL AND METHODS

The authors examine the literature of the last 130 years about elbow instability classification, analyzing the intuitions and the value of each of them. However, because of the lack of a satisfactory classification, in 2015 a working group has been created inside SICSeG (Italian Society of Shoulder and Elbow Surgery) with the aim of defining an exhaustive classification as simple, complete and reproducible as possible.

RESULTS

A new all-inclusive elbow instability classification is proposed. This classification considers two main parameters: timing (acute and chronic forms) and involved stabilizers (simple and complex forms), and four secondary parameters: etiology (traumatic, rheumatic, congenital…), the involved joint (radius and ulna as a single unit articulating with the humerus or the proximal radio-ulnar joint), the degree of displacement (dislocation or subluxation) and the mechanism of instability or dislocation (PLRI, PMRI, direct axial loading, pure varus or valgus stress).

CONCLUSIONS

This classification is at the same time complete enough to include all the instability patterns and practical enough to be effectively used in the clinical practice. This classification can help in defining a shared language, can improve our understanding of the disorder, reduce misunderstanding of diagnosis and improve comparison among different case series.