Complex coronoid and proximal ulna fractures are we getting better at fixing these?

Highly extensile approach for comminuted ulna coronoid process fractures with mini-plate fixation: a case series of 31 patients

BACKGROUND

For the treatment of coronoid process fractures, medial, lateral, anterior, anteromedial, and posterior approaches have been increasingly reported; however, there is no general consensus on the method of fixation of coronal fractures. Here, we present a highly-extensile minimally invasive approach to treat coronoid process fractures using a mini-plate that can achieve anatomic reduction, stable fixation, and anterior capsular repair. Further, the study aimed to determine the complication rate of the anterior minimally invasive approach and to evaluate functional and clinical patient-reported outcomes during follow-up.

METHODS

Thirty-one patients diagnosed with coronoid fractures accompanied with a "terrible triad" or posteromedial rotational instability between April 2012 and October 2018 were included in the analysis. Anatomical reduction and mini-plate fixation of coronoid fractures were performed using an anterior minimally invasive approach. Patient-reported outcomes were evaluated using the Mayo Elbow Performance Index (MEPI) score, range of motion (ROM), and the visual analog score (VAS). The time of fracture healing and complications were recorded.

RESULTS

The mean follow-up time was 26.7 months (range, 14-60 months). The average time to radiological union was 3.6 ± 1.3 months. During the follow-up period, the average elbow extension was 6.8 ± 2.9° while the average flexion was 129.6 ± 4.6°. According to Morrey's criteria, 26 (81%) elbows achieved a normal desired ROM. At the last follow-up, the mean MEPI score was 98 ± 3.3 points. There were no instances of elbow instability, elbow joint stiffness, subluxation or dislocation, infection, blood vessel complications, or nerve palsy. Overall, 10 elbows (31%) experienced heterotopic ossification.

CONCLUSION

An anterior minimally invasive approach allows satisfactory fixation of coronoid fractures while reducing incision complications due to over-dissection of soft tissue injuries. In addition, this incision does not compromise the soft tissue stability of the elbow joint and allows the patient a more rapid return to rehabilitation exercises.

Proximal ulna morphology in various pediatric population age groups: proximal ulna dorsal angulation (PUDA) and olecranon tip-to-apex (TTA) distance

PURPOSE

To measure proximal ulna dorsal angulation (PUDA) and olecranon tip-to-apex distance (TTA) in pediatric population to aid surgeons with data for proximal ulna fractures fixation.

METHODS

Retrospective review of the hospital radiographic database. All elbow radiographs were identified and after implementing exclusion criteria, included were 95 patients aged 0-10; 53 patients aged 11-14; and 53 patients aged 15-18. PUDA was defined as the angle between lines placed on the "flat spot" of the olecranon and the dorsal edge of the ulnar shaft and TTA as the distance between the tip of the olecranon to the apex of angulation. Two evaluators performed measurements independently.

RESULTS

In age group 0-10, mean PUDA was 7.53°, range 3.8-13.7, 95% CI 7.16-7.91, while mean TTA was 22.04 mm, range 8.8-50.5, 95% CI 19.92-24.17. In age group 11-14, mean PUDA was 4.99°, range 2.5-9.3, 95% CI (4.61-5.37), while mean TTA was 37.41 mm, range 16.5-66.6, 95% CI (34.91-39.90). In age group 15-18, mean PUDA was 5.18°, range 2.9-8.1, 95% CI (4.75-5.61), while mean TTA was 43.79 mm, range 24.5-79.4, 95% CI (41.38-46.19). PUDA was negatively correlated with age (r = - 0.56, p < 0.001), while TTA was positively correlated with age (r = 0.77, p < 0.001). Reliability levels of 0.81-1 or 0.61-0.80 were achieved for most of intra- and inter-rater reliabilities besides two levels of 0.41-60 and one of 0.21-0.40.

CONCLUSION

The main study finding is that in most cases mean age-group values may serve as a template for proximal ulna fixation. There are some cases in which X-ray of contralateral elbow may provide surgeon with a better template.

LEVEL OF EVIDENCE

II.

A Novel Suture-Preset Spring Plate System (SSPS) for Comminuted Coronoid Process Fracture in the Elbow

OBJECTIVE

This study is aimed to investigate the clinical outcomes of a novel SSPS for fixation of the comminuted coronoid fracture.

METHODS

A retrospective study was carried out in the patients with comminuted fractures of the coronoid treated by SPSS fixation between January 2014 and December 2018. A total of 17 patients (17 sides) was included in our study, including 11 male and six female, with a mean age range from 18 to 60. All cases started to functional rehabilitation immediately after the operation. Clinical outcomes were evaluated both radiographically and functionally at the follow-up visit, including the elbow instability, range of motion and Mayo elbow performance score (MEPS).

RESULTS

According to the O'Driscoll classification system, there was two side of type 1.2, two of type 2.1, four of type 2.2, three of type 2.3, two of 3.1 and four of type 3.2. The surgery was carried out by Kocher and anteromedial approach in 12 patients, posterior and anteromedial approach in four, anterior approach in one. The average operation time and intraoperative blood loss was 129.41±43.87 min and 115.29±104.65 ml. The median follow-up time was 9 months (range, 6 to 15 months). The mean flexion, extension, pronation and supination motion was 138.76±8.67 degrees, 20.00±13.58, 82.94±5.32and 74.12±14.39 respectively at final follow up. The mean MEPS score was 89.76±8.46, including 11 excellent, 3 good and 3 fair result. The mean VAS score was 1.94±0.97. The mean union time of coronoid fractures was 2.77±0.31 months according to the established standard of healing. There were no significant differences in clinical outcomes among groups according to the O'Driscoll classification (P > .05) and ligament repair strategy (P > .05). No patient underwent instability or dislocation of the elbow during follow up. There were two cases with mild ulnar nerve symptoms which recovered totally at follow up. Meanwhile, there were three cases with heterotopic ossification of the elbow.

CONCLUSION

Our findings demonstrated that the SSPS can provide a reliable fixation for the comminuted coronoid fracture with satisfactory clinical outcomes.

Functional outcomes after treatments for different types of isolated ulnar coronoid fracture: A protocol for systematic review

BACKGROUND

Optimal treatments for ulnar coronoid fracture have yet to be determined. We aimed to systematically review treatment efficacy assessed by functional outcomes of patients with isolated ulnar coronoid fracture.

METHODS

Medline, Cochrane Library, EMBASE, and Google Scholar were searched for studies reporting quantitative outcomes data after surgical treatment for isolated ulnar coronoid fractures up to July 16, 2019. Functional outcomes determined using disabilities of the arm, shoulder and hand score; Mayo elbow performance score (MEPS); and range of motion were systematically reviewed.

RESULTS

Six studies with a total of 65 patients with isolated coronoid fracture who had received surgical treatment were included. All studies were of good quality according to a modified Delphi checklist. Most patients had Type II fractures based on Regan-Morrey or O'Driscoll classification. Disabilities of the arm, shoulder and hand scores were reported by 2 studies (mean range 5-17). Four studies reported MEPS (mean range 89-98). One study reported Broberg-Morrey scores, in which 93% patients achieved excellent or good outcomes. Five studies reported range of motion, with mean flexion ranging from 122 to 137 and mean extension ranging from 4.0 to 21 degrees. Quantitative analyses revealed that lateral, medial, or posterior approaches in treating Type II fractures are associated with higher postoperative MEPS and flexion scores than the anteromedial approach.

CONCLUSIONS

Treatment efficacy assessed by functional outcomes for isolated ulnar coronoid fractures is overall satisfactory. Whether lateral, medial, or posterior approaches lead to more favorable outcomes than the anteromedial approach is inconclusive. Further prospective studies are warranted.

Direct anterior approach for mini plate fixation of Regan-Morrey type II comminuted ulnar coronoid process fracture

BACKGROUND

The goal of this study was to evaluate the clinical effect of Regan-Morrey type II comminuted coronoid process fracture treated with mini plate through the direct anterior approach (DAA).

METHODS

Ten patients who underwent open reduction and internal fixation (ORIF) with mini plate through the DAA between February 2013 and August 2016 was included. There were three women and seven men, with an average age of 34.4 ± 7.5 years. At the final follow-up, the Mayo Elbow Performance Index (MEPS), Visual Analogue Scale (VAS) score, Disability of the Arm, Shoulder, and Hand (DASH) score, and the elbow range of motion were noted.

RESULTS

The mean follow-up was 26.3 ± 2.2 (range 24-31) months. The mean elbow arc of motion was 118.5° with a mean arc of extension of 4° ± 5.2° and flexion of 122.5° ± 7.2°.The mean forearm pronation was 72° ± 7.2°, and the mean supination was 68° ± 6.3° with a mean forearm rotation arc of 140°. The average postoperative score according to the MEPS was 91 ± 5.7 points (range 80-100 points), and all patients achieved satisfactory scores (8 excellent and 2 good). The final average VAS score was 0.6 ± 1 (range 0-3). The final average DASH score was 4.0 ± 1.6 (range 2.3-7.4). None of the patients complained about elbow instability that required secondary surgery. No complications of infection, joint incongruency, fracture nonunion, median nerve palsy, or implant failure were reported.

CONCLUSIONS

ORIF with mini plate through the DAA for the treatment of the type II comminuted coronoid process fractures can achieve satisfactory outcomes.

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

PURPOSE

The treatment of olecranon fracture-dislocations (OFDs) remains challenging. OFDs are often misdiagnosed as Monteggia lesions, and the real frequency is actually higher. However, studies on OFDs are limited. This study aimed to report on the surgical management of OFDs and to highlight the importance of three-dimensional computed tomography (3D CT) evaluation in the treatment of OFDs.

MATERIALS AND METHODS

The study participants included 18 patients (11 men, 7 women, mean age 44 years (range 24-78) with OFDs. Each patient's medical records, radiographs, and 3D CT scans were reviewed for demographics, injury details, operative findings, and information about radiological and functional outcomes. The patients were divided into 2 groups according to the direction of the dislocation: the posterior dislocation group (group 1, 7 patients) and anterior dislocation group (group 2, 11 patients). The clinical evaluation was performed according to Broberg-Morrey and the American Shoulder and Elbow Surgeons-Elbow (ASES-E) scoring systems.

RESULTS

The mean follow-up period was 39 months (range 25-62 months). The Broberg-Morrey results were excellent in 4, good in 9, fair in 3, and poor in 2 patients. The mean ASES-E score was 84.83 (range 48-100) points. There were signs of ulna-humeral arthrosis in 5 elbows. Arthrosis was graded as grade 1, grade 2, and grade 3 in 3, 1, and 1 elbows, respectively. Partial sensory recovery was observed in one patient with postoperative ulnar neuropathy at the last follow-up visit.

CONCLUSIONS

OFDs are complex injuries of the proximal ulna and may involve the radial head, coronoid process, and lateral collateral ligament. The effective treatment of OFDs begins with the proper identification of the injury with 3D CT. A secure fixation including the coronoid process is mandatory for the elbow joint stability. Insufficient restoration of the trochlear notch may lead to problems with loss of motion and arthrosis. Although an application of a pre-contoured locking anatomical olecranon plate can simplify the fixation procedure in most cases, the surgeons' equipment should also include radial head implant, coronoid plates, headless screws, small cannulated screw system, suture anchors, fluoroscopy, and articulated external fixator.

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

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