A fragment-specific approach to Type IID Monteggia 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: An Algorithmic Approach to Treatment

Elbow stability arises from a combination of bony congruity, static ligamentous and capsular restraints, and dynamic muscular activation. Elbow trauma can disrupt these static and dynamic stabilizers leading to predictable patterns of instability; these patterns are dependent on the mechanism of injury and a progressive failure of anatomic structures. An algorithmic approach to the diagnosis and treatment of complex elbow fracture-dislocation injuries can improve the diagnostic assessment and reconstruction of the bony and ligamentous restraints to restore a stable and functional elbow. Achieving optimal outcomes requires a comprehensive understanding of pertinent local and regional anatomy, the altered mechanics associated with elbow injury, versatility in surgical approaches and fixation methods, and a strategic rehabilitation plan.

Usability of Minimal Invasive Surgery for Elbow Dislocation with Coronoid Process Fracture: A Protocol Development Study

OBJECTIVE

The study aims to explain whether or not minimal invasive surgery (MIS) would be feasible in elbow fracture-dislocation with coronoid process fracture.

METHODS

At Taipei Veterans General Hospital, patients who had elbow dislocations with coronoid process fractures underwent a single surgeon's MIS techniques which included the fluoroscopy-guided ulnar anteromedial (FGUAM) approach in the stage of reducing the coronoid process. When there is a proximal ulnar fracture, the posterior incision should be necessary, followed by the incision over the lateral or medial elbow for treating radial fractures or ligament injuries.

RESULTS

The Flow Diagram for approach recommendation was established on the basis of defining MIS as that which does not include cross-plane dissection. The importance of anterior rigid fixation for the coronoid process was also emphasized.

CONCLUSIONS

MIS can be achieved by multiple limited surgical incisions. Although the posterior extensile approach is necessary in situations of ulnar metaphysis or ligament avulsion fracture, the FGUAM approach decreases the cross-plane dissection.

Trans-ulnar fracture dislocations of the elbow: a systematic review and clarification of classification systems

BACKGROUND

Complex elbow dislocations in which the dorsal cortex of the ulna is fractured can be difficult to classify and therefore treat. These have variably been described as either Monteggia variant injuries or trans-olecranon fracture dislocations. Additionally, O'Driscoll et al classified coronoid fractures that exit the dorsal cortex of the ulna as "basal coronoid, subtype 2" fractures. The Mayo classification of trans-ulnar fracture dislocations categorizes these injuries in 3 types according to what the coronoid remains attached to: trans-olecranon fracture dislocations, Monteggia variant fracture dislocations, and trans-ulnar basal coronoid fracture dislocations. The purpose of this study was to evaluate the outcomes of these injury patterns as reported in the literature. Our hypothesis was that trans-ulnar basal coronoid fracture dislocations would have a worse prognosis.

MATERIALS AND METHODS

We conducted a systematic review to identify studies with trans-ulnar fracture dislocations that had documentation of associated coronoid injuries. A literature search identified 16 qualifying studies with 296 fractures. Elbows presenting with basal subtype 2 or Regan/Morrey III coronoid fractures and Jupiter IIA and IID injuries were classified as trans-ulnar basal coronoid fractures. Patients with trans-olecranon or Monteggia fractures were classified as such if the coronoid was not fractured or an associated coronoid fracture had been classified as O'Driscoll tip, anteromedial facet, basal subtype I, or Regan Morrey I/II.

RESULTS

The 296 fractures reviewed were classified as trans-olecranon in 44 elbows, Monteggia variant in 82 elbows, and trans-ulnar basal coronoid fracture dislocations in 170 elbows. Higher rates of complications and reoperations were reported for trans-ulnar basal coronoid injuries (40%, 25%) compared to trans-olecranon (11%, 18%) and Monteggia variant injuries (25%, 13%). The mean flexion-extension arc for basal coronoid fractures was 106° compared to 117° for Monteggia (P < .01) and 121° for trans-olecranon injuries (P = .02). The mean Mayo Elbow Performance Score was 84 points for trans-ulnar basal coronoid, 91 for Monteggia (P < .01), and 93 for trans-olecranon fracture dislocations (P < .05). Disabilities of the Arm, Shoulder and Hand and American Shoulder and Elbow Surgeons scores were 22 and 80 for trans-ulnar basal coronoid, respectively, compared to 23 and 89 for trans-olecranon fractures. American Shoulder and Elbow Surgeons was not available for any Monteggia injuries, but the mean Disabilities of the Arm, Shoulder and Hand was 13.

DISCUSSION

Trans-ulnar basal coronoid fracture dislocations are associated with inferior patient reported outcome measures, decreased range of motion, and increased complication rates compared to trans-olecranon or Monteggia variant fracture dislocations. Further research is needed to determine the most appropriate treatment for this difficult injury pattern.

Posterior Olecranon Fracture Dislocations in Adults: A Systematic Review

Posterior olecranon fracture dislocations (POFDs) were considered posterior Monteggia lesions, which were less described in the literature. The purpose of this study was to provide a systematic review of the diagnosis, treatment, prognosis, and complications of POFDs in adults. A systematic review was performed to identify all relevant studies on the POFDs in the PubMed, Web of Science, Embase, and MEDLINE databases. The methodological quality of the studies was scored using the Methodological Index for Non-Randomized Studies (MINORS). A total of 117 patients were identified in the nine studies selected. The high-energy injuries accounted for 42.7% of the included studies. The rates of concomitant coronoid process, radial head fractures, and lateral collateral ligament injury were 84.6% (99/117), 87.2% (102/117), and 5% (6/117), respectively. The procedure was performed with a dorsal mid longitudinal approach to reconstruct all injury components. The postoperative clinical scores included the Broberg/Morrey rating, with a mean rating of excellent or good at 66%, the mean DASH score was 20.6, and the mean ASES score was 83. The flexion and extension arc and forearm rotation arcs were 100° and 134°, respectively. Complications included arthrosis in 28.2% (33/117) of cases, fracture nonunion or delayed union in 9.4% (11/117) of cases, heterotopic ossification in 7% (8/117) of cases, and the re-operation rate was 16% (19/117). There was nearly no postoperative ulnohumeral instability. The main characteristics of POFDs were disruptions of the trochlear notch, including the olecranon and coronoid processes, and severe radial head fractures, while the lateral collateral ligament was spared. Although the POFDs had a low frequency of instability, the prognosis was relatively poor. The POFDs should be considered independently.

Complex Monteggia Fractures in the Adult Cohort: Injury and Management

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

Anthropometric Study of the Radiocapitellar Joint

PURPOSE

There is scant knowledge about the relationship between the size of the radial head and the size of the capitellum. Also, no data exist comparing the size of the capitellum between the left and the right elbow.

METHODS

Eight pairs of elbows and 12 single elbows from fresh-frozen cadavers were obtained for this study. The vertical height and anterior width of the capitellum were measured with digital calipers. Four different measurements were performed at the radial head: longest outer diameter, shortest outer diameter, the long dish diameter, and short dish diameter. The Pearson intrarater intraclass correlation coefficients were obtained for all measurements.

RESULTS

For the paired elbows, the correlations ranged between 0.95 and 0.96 for the capitellar dimensions and 0.77 and 0.98 for the radial head dimensions. The correlations between the long outer diameter of the radial head with the vertical height and the anterior width of the capitellum were 0.8 and 0.9, respectively.

CONCLUSIONS

There is a high correlation between the long outer diameter of the radial head and the vertical height of the capitellum as well its anterior width. There is also a high correlation between the left and the right elbow.

CLINICAL RELEVANCE

These findings are relevant to radiocapitellar arthroplasty and may be useful for radiocapitellar prosthetic design as well as in the preoperative planning of cases in which the radial head and/or the capitellum is destroyed.

Why and how do locking plates fail?

Locking plates have led to important changes in bone fracture management, allowing flexible biological fracture fixation based on the principle of an internal fixator. The technique has its indications and limitations. Most of the typical failure patterns arise from basic technical errors. Types of locking plates, material properties and the general principles of locking plate applications are reviewed together with their misapplication.

Comminuted olecranon fractures: biomechanical testing of locked versus minifragment non-locked plate fixation

INTRODUCTION

Open reduction and internal fixation has long been accepted as optimal treatment for displaced olecranon fractures based on poor results seen with conservative management. With the presence of comminution, tension-band wiring constructs are contraindicated due to tendency to compress through fragments, thereby shortening the articular segment. Therefore, plate fixation is typically employed. Our hypothesis was that in a comminuted fracture model, 2.7 mm reconstruction plating without locking screws will perform equally to 3.5 mm locked plating in terms of fracture displacement and rotation (shear).

MATERIALS AND METHODS

A three-part comminuted olecranon fracture pattern was created in nine matched pairs of cadaveric specimen using an oscillating saw in standardized, reproducible fashion. Each matched pair was then randomized to receive either 2.7 mm reconstruction plating or 3.5 mm proximal ulna locked plating. Random allocation software was used to assign the 2.7 mm plate construct to either the right or left side of each pair with the contralateral receiving the 3.5 mm plate construct. Specimens were cyclically loaded simulating passive range of motion exercises commonly performed during rehabilitation. Displacement and rotation in relation to the long axis of the ulna were measured through motion capture. Fragment gapping and rotation was quantified following 100 cycles at 10 N and again following 100 cycles at 500 N.

RESULTS

No significant differences were detected between the 2.7 and 3.5 mm plates in fracture rotation or gapping following loads at 10 N (0.5° and 0.7°; 0.6 and 1.2 mm; respectively; p > 0.05) or 500 N (2.3° and 1.6°; 3.8 and 3.1 mm; respectively; p > 0.05) loading. Fragment rotation and gapping were positively correlated within each plate construct (R ² > 0.445; p < 0.05).

CONCLUSIONS

2.7 mm plating is an alternative to 3.5 mm locked plating with decreased plate prominence without significantly sacrificing displacement and rotational control. This is beneficial in fracture patterns where the traditional dorsal plating does not offer optimal screw trajectory.

Type IIA Monteggia Fracture Dislocation with Ipsilateral Distal Radius Fracture in Adult - A Rare Association

Monteggia fracture constitutes about 5-10% of the forearm fractures. Monteggia fracture by definition is proximal ulnar fracture with disruption of proximal radioulnar joint. Bado classified Monteggia fracture dislocation into four types and Jupiter subclassified type II Bado's fractures into four types. The associated injury in the form of distal radial fractures and distal humerus fractures are rare though many cases of distal radial physeal injuries have been reported in paediatric population. Hereby we report a rare association of type IIA Monteggia fracture dislocation with ipsilateral distal radius fracture in an adult patient. This case report also highlights on proper examination and full length radiographs of forearm to avoid missing injury at wrist in cases of elbow injuries. Management of such complex injuries included open reduction and internal fixation of olecronon fracture, distal radius fracture and radial head resection. Functional outcome at six months was good at wrist whereas at elbow, stiffness was a major concern with elbow range of movement from 40°-110°.

Adult Monteggia and Olecranon Fracture Dislocations of the Elbow

Monteggia fractures and olecranon fracture dislocations represent complex injuries with distinct patterns of bony and soft tissue involvement. Fractures of the proximal ulna and olecranon process may lead to disruption of the proximal radioulnar joint and/or ulnohumeral joint. The keys to treatment are recognition of the pattern of injury and formation of an algorithmic surgical plan to address all components of the injury process. Complications are common and may be related to the injury spectrum itself and/or inadequate fracture alignment or fixation.

Proximal forearm fractures

Unfortunately, the literature has little guidance for revision elbow surgery. This article attempts to supplement what is known in the literature with the author's anecdotal experience. With this article, it is the author's hope that the reader may learn from his or her successes and his or her failures without having to discover them first hand. There is good reason for angst to overcome surgeons looking at radiographs depicting a traumatized proximal ulna or radius. Surgeons know that there is a good chance they will be seeing these patients for a long time.

Risk factors for development of heterotopic ossification of the elbow after fracture fixation

BACKGROUND

Postoperative heterotopic ossification (HO) about the elbow may occur after surgical fixation of fractures and can contribute to dysfunction. Factors associated with HO formation after surgical fixation of elbow trauma are not well understood.

METHODS

All patients who underwent surgery for elbow trauma at our institution from October 2001 through August 2010 were retrospectively reviewed. Patients with prior injury or deformity to the involved elbow were excluded. Demographic data; fracture type; surgical treatment; and presence, location, and size of HO were recorded. The Fisher exact test, χ(2) test, and multivariate logistic regression were used with an α value of .05 used for significance.

RESULTS

A total of 159 patients were identified, with 89 (37 men and 52 women) meeting inclusion and exclusion criteria. The mean age was 54.4 years (range, 18-90 years), and the mean follow-up time was 180 days. Age, male gender, lateral collateral ligament repair, and dual-incision approach were not associated with increased ectopic bone formation. Distal humeral fractures were a significant predictor of heterotopic bone. In patients in whom HO ultimately developed, it was visible on radiographs obtained 2 weeks postoperatively in 86% of cases.

CONCLUSION

This investigation found predictors for the development of HO after surgical fixation of intra-articular elbow fractures. Furthermore, HO went on to develop at the time of final follow-up in only 14% of patients without HO on radiographs obtained 2 weeks postoperatively. This may suggest that absence of HO on radiographs obtained 2 weeks postoperatively may predict a more favorable outcome.