Management of anteromedial coronoid fractures according to a protocol focused on instability assessment provides good outcomes with infrequent need for coronoid fixation

A Feasibility Study on Using Hanging Arm Test to Assess Elbow Stability During Surgical Treatment for Varus Posteromedial Rotatory Instability

Objectives

The aim of this study to investigate the safety and effectiveness of performing the hanging arm test during surgical treatment for elbow varus posteromedial rotatory instability (VPMRI) to assess elbow stability and determine whether to repair the lateral ulnar collateral ligament (LUCL).

Methods

In a retrospective study from August 2014 to March 2019, 27 patients with VPMRI who had a negative result in the hanging arm test after fixation of coronoid fracture were selected. Intraoperative bleeding, operative time, elbow range of motion (ROM), and complications were recorded. Elbow function was evaluated with the Mayo elbow performance score (MEPS) and the disabilities of the arm, shoulder, and hand (DASH) score.

Results

The operation time was 85.9 ± 11.06 min (range 65-110). The intraoperative blood loss was 70.7 ± 9.31 ml (range 60-100). At the last follow-up, the elbow joint averaged 73.8° ± 2.931° in pronation, 78.9° ± 2.941° in supination, 7.2° ± 3.207° in extension, and 123.3° ± 6.651° in flexion. The MEPS score was 90.7 ± 4.36 (range 74-95), and the DASH score was 9.8 ± 2.58 (range 6.67-13.3). One patient presented with symptoms of ulnar nerve entrapment 2 months after operation and was treated with ulnar nerve release. The symptom of numbness went away completely 1 week after operation. No complications such as wound infection, arthritis, or chronic instability of the elbow were found in the other patients.

Conclusion

Our findings suggest that not all VPMRI patients need the LUCL to be repaired, and the hanging arm test is a safe and reliable method to assess whether to repair the LUCL in the treatment of elbow VPMRI.

Level of evidence

Level IV; Retrospective studies.

Considerable variation in current coronoid height and fracture measurement techniques: a systematic review

BACKGROUND

Coronoid fractures usually occur in the presence of a significant osseoligamentous injury to the elbow. Fracture size and location correlate with degree of instability and many authors have attempted to analyze the effect of fracture variation on decision making and outcome. There remains no standardized technique for measuring coronoid height or fracture size. The aim of this study was to appraise the literature regarding techniques for coronoid height measurement in order to understand variation.

METHODS

Preferred Reporting Items of Systematic Reviews and Meta-Analyses guidelines were followed. A search was performed to identify studies with either a description of coronoid height, fracture size, or bone loss using the terms (Coronoid) AND (Measurement) OR (Size) OR (Height). Articles were shortlisted by screening for topic relevance based on title, abstract and, if required, full-text review. Exclusion criteria were non-English articles, those on nonhuman species or parts other than the ulna coronoid process, and studies that included patients with pre-existing elbow pathology. Shortlisted articles were grouped based on study type, imaging modality, measurement technique, and measurement parameter as well as its location along the coronoid.

RESULTS

Thirty out of the initially identified 494 articles met the inclusion criteria. Twenty-one articles were clinical studies, 8 were cadaveric studies, and 1 combined patients as well as cadavers. A variety of imaging modalities (plain radiographs, 2-dimensional computed tomography [CT], 3-dimensional CT, magnetic resonance imaging or a combination of these) were used with CT scan (either 2-dimensional images or 3-dimensional reconstructions or both) being the most common modality used by 21 studies. Measurement technique also varied from uniplanar linear measurements in 15 studies to multiplanar area and volumetric measurements in 6 studies to techniques describing various angles and indices as an indirect measure of coronoid height in 8 studies. Across the 30 shortlisted studies, 19 different measurement techniques were identified. Fifteen studies measured normal coronoid height while the other 15 measured intact coronoid and/or fracture fragment height. The location of this measurement was also variable between studies with measurements at the apex of the coronoid in 24/30 (80%) of studies. Measurement accuracy was assessed by only 1 study. A total of 12/30 (40%) studies reported on the interobserver and intraobserver reliability of their measurement technique.

CONCLUSION

The systemic review demonstrated considerable variability between studies that report coronoid height or fracture size measurements. This variability makes comparison of coronoid height or fracture measurements and recommendations based on these between studies unreliable. There is need for development of a consistent, easy to use, and reproducible technique for coronoid height and bone loss.

Acute and chronic coronoid reconstruction using the olecranon Tip

Post-traumatic coronoid deficiency in the elbow can lead to chronic pain, instability and arthritis. A variety of osteochondral grafts have been used to reconstruct the coronoid, and restore elbow stability. The radial head and iliac crest grafts are the most common in the literature but have limitations. The olecranon tip is a promising alternative, with both cadaveric and computer models demonstrating superior congruency, without compromising elbow stability or disrupting the extensor mechanism. We present a small, case series demonstrating the technique for contralateral and ipsilateral grafts in both the acute and chronic setting.

Outcomes and complications after treatment for anteromedial facet fracture of the coronoid process: A systematic review

BACKGROUND

Fracture of the anteromedial facet (AMF) of the coronoid process is associated with varus posteromedial rotatory instability (VPMRI). However, there is still controversy regarding the optimal treatment for AMF fracture. The purpose of this study is to report on a systematic review of the outcomes and complications after treatment for AMF fracture.

METHODS

This study was conducted using electronic databases, PubMed, EMBASE and Scopus. Studies reporting outcome scores and complications were included. Studies that did not utilize O'Driscoll classification for AMF fractures were excluded. Through conduct of a thorough review of included studies, definite VPMRI were identified and cases involving other injury mechanisms were excluded.

RESULTS

Fifteen articles reporting on 246 patients were included. According to O'Driscoll classification, 6.2% of cases were anteromedial subtype I, 73.7% were subtype II, and 20.1% were subtype III. Two-hundred sixteen patients (87.8%) were treated surgically and 30 patients (12.2%) were treated conservatively. Lateral collateral ligament (LCL) injuries were 76.2% (157/206) and medial collateral ligament injuries were 16.9% (33/195). Among 216 cases who underwent surgical treatment, depending on the fragment size, displacement, and instability, coronoid fixation was performed in 189 cases and LCL repair alone was performed in 27 cases. The mean final Mayo Elbow Performance Score was 92.1 and the Broberg & Morrey score was 89.5. The overall complication and reoperation rates were 17.7% (41/232) and 12.9% (26/202).

CONCLUSIONS

Both surgical and conservative treatment for AMF fractures resulted in satisfactory final clinical outcomes. However, high complication and reoperation rates were observed.

Coronoid fractures and traumatic elbow instability

The coronoid process is key to concentric elbow alignment. Malalignment can contribute to post-traumatic osteoarthritis. The aim of treatment is to keep the joint aligned while the collateral ligaments and fractures heal. The injury pattern is apparent in the shape and size of the coronoid fracture fragments: (1) coronoid tip fractures associated with terrible triad (TT) injuries; (2) anteromedial facet fractures with posteromedial varus rotational type injuries; and (3) large coronoid base fractures with anterior (trans-) or posterior olecranon fracture dislocations. Each injury pattern is associated with specific ligamentous injuries and fracture characteristics useful in planning treatment. The tip fractures associated with TT injuries are repaired with suture fixation or screw fixation in addition to repair or replacement of the radial head fracture and reattachment of the lateral collateral ligament origin. Anteromedial facet fractures are usually repaired with a medial buttress plate. If the elbow is concentrically located on computed tomography and the patient can avoid varus stress for a month, TT and anteromedial facet injuries can be treated nonoperatively. Base fractures are associated with olecranon fractures and can usually be fixed with screws through the posterior plate or with an additional medial plate. If the surgery makes elbow subluxation or dislocation unlikely, and the fracture fixation is secure, elbow motion and stretching can commence within a week when the patient is comfortable.

Comparison of buttress plate and cannulated screw in the treatment of anteromedial coronoid fracture with elbow posteromedial rotatory instability

PURPOSE

The purpose of this study is to compare the effect of buttress plate and cannulated screw in the treatment of anteromedial coronoid fracture with posteromedial rotatory instability (PMRI).

METHODS

We retrospectively evaluated patients who were diagnosed with O'Driscoll type 2 fractures combined with elbow posteromedial rotatory instability and underwent surgery for anteromedial coronoid fracture between August 2014 and March 2019. They were divided into buttress plate (n=16) and cannulated screw (n=11) groups. The elbow range of motion, visual analog scale (VAS), Mayo elbow performance score (MEPS), and disabilities of the arm, shoulder, and hand score (DASH) were used for clinical outcome assessment.

RESULT

There were no significant differences in clinical outcomes. However, the surgical time was significantly shorter in cannulated screw group (85.45±4.156) compared to the buttress plate group (93.81±8.863, P=0.008), and the surgical time was associated with internal fixation (P=0.008).

CONCLUSION

Although there was selection of cases in that small fragments were treated with buttress plate and large fragments with cannulated screw, the buttress plate and cannulated screw have comparable functional outcomes on fixation of the anteromedial coronoid fracture with elbow PMRI. The fixation of the anteromedial coronoid fracture with large fragments using the cannulated screw has a shorter operation time.

Anteromedial coronoid facet fractures and associated ligament lesions: A case series

INTRODUCTION

Varus posteromedial rotational injury mechanisms lead to fractures of the coronoids process' anteromedial facet. As these fractures are often unstable, rapid fracture treatment is vital to prevent progressive osteoarthritis.

MATERIALS AND METHODS

Twelve patients with a fracture of the anteromedial facet treated surgically were enrolled in the study. Computed tomography images were used to classify the fractures according to the system by O'Driscoll et al. Clinical follow-up included each patient's medical record, surgical treatment algorithm, all complications encountered during the follow-up period, Disabilities of the arm, shoulder, and hand score, subjective elbow value, and pain.

RESULTS

A total of 8 men (66.7%) and 4 women (33.3%) were treated surgically and followed-up after a mean period of 45 ± 23 months. The mean DASH score was 11.9 ± 12.9 points. One patient complained of transient neuropathy in the innervation area of the ulnar nerve, however, this existed already pre-operatively and resolved after less than three months.

CONCLUSIONS

The presented patient cohort shows that AMF fracture of the coronoid process are unstable lesions according to the bony instability and the frequently ruptured collateral ligament complexes which need to be addressed. The MCL seems to be affected more frequently than previously appreciated.

LEVEL OF EVIDENCE

Level IV; Case Series; Treatment Study.

Results of arthroscopically assisted reduction and fixation of anteromedial facet coronoid fractures at short-term follow-up

BACKGROUND

Varus posteromedial rotatory instability is a typical pattern of elbow injury that involves fracture of the anteromedial facet (AMF) of the coronoid, as well as injuries to the lateral ligament complex and the posterior bundle of the medial collateral ligament. Some authors support the idea that subtype II AMF coronoid fractures require fixation to restore elbow stability, but this topic is still an issue in the literature. The purpose of this study was to assess the clinical and radiologic outcomes of arthroscopically assisted reduction and internal fixation (ARIF) of AMF fractures.

METHODS

This retrospective single-center trial evaluated consecutive patients who underwent ARIF of isolated subtype II AMF coronoid fractures between 2014 and 2020. At the final follow-up, the patients were examined for elbow range of motion, stability, and pain. Injury and post-treatment radiographs were reviewed to assess fracture healing and heterotopic ossification.

RESULTS

A total of 32 patients (21 male and 11 female patients) with a median age of 47 ± 16 years were included. The average follow-up period was 28 ± 12.4 months. Coronoid process fractures were fixed by cannulated screws in 26 cases (81.25%); in 2 of these cases, additional Kirschner wires were used. Two Kirschner wires were used in 1 case (3.12%), and in the remaining 5 cases (15.62%), osteosuture was used. The lateral ulnar collateral ligament was injured in 27 cases (84.4%) and was always repaired. Other associated lesions were medial collateral ligament injury, osteochondral lesion, and radial head fracture. There were no surgical complications. At the final follow-up, the average Mayo Elbow Performance Score was 98.4 ± 2.7 and the mean Oxford Elbow Score was 47.3 ± 1.4. No cases of nonunion were detected on radiographic assessment.

CONCLUSIONS

Although technically demanding, ARIF has several potential advantages in comparison to open surgery: less scarring, a decreased risk of infection, and less postoperative pain.

Radiographic Evaluation of Elbow Fractures

Fractures and dislocations of the elbow are a common cause of emergency department visits each year. Radiography remains the bedrock of an initial injury assessment, and recognition of distinctive injury patterns based on fracture location, morphology, and severity, guides optimal clinical decision-making. This article reviews basic elbow anatomy, frequently seen fractures and injury patterns, and highlights how these findings influence surgical planning and patient management.