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Chapleau J, Joly-Chevrier M, Tohmé P, El-Kayem E, Petit Y, Rouleau DM. A novel fragment specific classification of complex olecranon fractures: 3-dimensional model design, radiological validation, and proposed surgical algorithm. J Shoulder Elbow Surg 2024; 33:1084-1091. [PMID: 38365170 DOI: 10.1016/j.jse.2023.12.021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/01/2023] [Revised: 12/04/2023] [Accepted: 12/25/2023] [Indexed: 02/18/2024]
Abstract
BACKGROUND Current classifications for proximal ulna fracture patterns rely on qualitative data and cannot inform surgical planning. We propose a new classification system based on a biological and anatomical stress analysis. Our hypothesis is that fragment types in complex fractures can be predicted by the tendon and ligament attachments on the proximal ulna. METHODS First, we completed a literature review to identify quantitative data on proximal ulna soft tissue attachments. On this basis, we created a 3-dimensional model of ulnar anatomy with SliceOMatic and Catia V5R20 software and determined likely locations for fragments and fracture lines. The second part of the study was a retrospective radiological study. A level-1 trauma radiological database was used to identify computed tomography scans of multifragmentary olecranon fractures from 2009 to 2021. These were reviewed and classified according to the "fragment specific" classification and compared to the Mayo and the Schatzker classifications. RESULTS Twelve articles (134 elbows) met the inclusion criteria and 7 potential fracture fragments were identified. The radiological study included 67 preoperative computed tomography scans (mean 55 years). The fragments identified were the following: posterior (40%), intermediate (42%), tricipital (100%), supinator crest (25%), coronoid (18%), sublime tubercle (12%), and anteromedial facet (18%). Eighteen cases (27%) were classified as Schatzker D (comminutive) and 21 (31%) Mayo 2B (stable comminutive). Inter-rater correlation coefficient was 0.71 among 3 observers. CONCLUSION This proposed classification system is anatomically based and considers the deforming forces from ligaments and tendons. Having a more comprehensive understanding of complex proximal ulna fractures would lead to more accurate fracture evaluation and surgical planning.
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Affiliation(s)
- Julien Chapleau
- Department of Orthopedic Surgery, CIUSSS du Nord-de-l'île-de-Montréal, Hôpital du Sacré-Cœur de Montréal, Montreal, QC, Canada; Faculty of Medicine, Université de Montréal, Montreal, QC, Canada
| | | | - Patrick Tohmé
- Department of Orthopedic Surgery, CIUSSS du Nord-de-l'île-de-Montréal, Hôpital du Sacré-Cœur de Montréal, Montreal, QC, Canada; Faculty of Medicine, Université de Montréal, Montreal, QC, Canada
| | - Elie El-Kayem
- Department of Orthopedic Surgery, CIUSSS du Nord-de-l'île-de-Montréal, Hôpital du Sacré-Cœur de Montréal, Montreal, QC, Canada; Faculty of Medicine, Université de Montréal, Montreal, QC, Canada
| | - Yvan Petit
- Research Center, CIUSSS du Nord-de-l'île-de-Montréal, Hôpital du Sacré-Cœur de Montréal, Montreal, QC, Canada
| | - Dominique M Rouleau
- Department of Orthopedic Surgery, CIUSSS du Nord-de-l'île-de-Montréal, Hôpital du Sacré-Cœur de Montréal, Montreal, QC, Canada; Faculty of Medicine, Université de Montréal, Montreal, QC, Canada.
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Morphological Characteristics of Proximal Ulna Fractures: A Proposal for a New Classification and Agreement for Validation. Healthcare (Basel) 2023; 11:healthcare11050693. [PMID: 36900697 PMCID: PMC10000609 DOI: 10.3390/healthcare11050693] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2022] [Revised: 02/16/2023] [Accepted: 02/23/2023] [Indexed: 03/02/2023] Open
Abstract
Historically, proximal ulna fractures have been simplistically diagnosed and treated as simple olecranon fractures, leading to an unacceptable number of complications. Our hypothesis was that the recognition of lateral, intermediate, and medial stabilizers of the proximal ulna and ulnohumeral and proximal radioulnar joints would facilitate decision-making, including the choice of approach and type of fixation. The primary aim was to propose a new classification for complex fractures of the proximal ulna based on morphological characteristics seen on three-dimensional computed tomography (3D CT). The secondary aim was to validate the proposed classification regarding its intra- and inter-rater agreement. Three raters with different levels of experience analyzed 39 cases of complex fractures of the proximal ulna using radiographs and 3D CT scans. We presented the proposed classification (divided into four types with subtypes) to the raters. In this classification, the medial column of the ulna involves the sublime tubercle and is where the anterior medial collateral ligament is inserted, the lateral column contains the supinator crest and is where the lateral ulnar collateral ligament is inserted, and the intermediate column involves the coronoid process of the ulna, olecranon, and anterior capsule of the elbow. Intra- and inter-rater agreement was analyzed for two different rounds, and the results were evaluated according to Fleiss kappa, Cohen kappa, and Kendall coefficient. Intra- and inter-rater agreement values were very good (0.82 and 0.77, respectively). Good intra- and inter-rater agreement attested to the stability of the proposed classification among the raters, regardless of the level of experience of each one. The new classification proved to be easy to understand and had very good intra- and inter-rater agreement, regardless of the level of experience of each rater.
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KIM MB, LEE SH, LEE JH, YANG H. Arc Centre Distance Change after Treatment of Complex Transverse Olecranon Fractures with a Large Impacted Articular Fragment Treated with Tension Band Wiring and Bone Graft. J Hand Surg Asian Pac Vol 2022; 27:623-635. [DOI: 10.1142/s242483552250059x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
Background: The treatment of complex transverse olecranon fractures (CTOFs), also known as olecranon fractures with the impacted articular fragments (IAF), was reported recently. We fix IAFs with absorbable pins supported by autologous bone graft followed by olecranon fracture fixation. We have used the arc centre distance (ACD) method to evaluate the congruency of this concentric hinge joint. The aim of this study is to present the outcomes of this fixation technique and evaluate the value of the ACD method. Methods: We reviewed 26 cases of CTOF treated at our hospital from 2014 to 2020. The functional outcome and range of motion of the elbow joint was measured by MEPS (Mayo Elbow Performance Score). We measured the ACD of each fragment of the ulnotrochlear joint [coronoid process (CP), IAF and olecranon process (OP)] with the CT image taken at 15 months postoperatively on average. Results: The mean arc of elbow motion was 3º to 132º. The mean MEPS at 1 year postoperatively was 94, and 25 of 26 cases (96%) achieved a good or excellent outcome. Twelve patients, who took the elbow CT at least more than 3 months post-operatively, were included for ACD measurement. The postoperative joint incongruency of each fragment was as follows, 0.39 ± 0.70, 0.40 ± 0.69 and 0.29 ± 0.72 mm (CP, IAF and OP, respectively) according to the ACD method. The ACD value for each fragment was significantly different before and after the surgery (p < 0.05). Conclusions: Accurate reduction of IAF with absorbable pins completed by tension band wiring with autogenous bone grafting can be an effective technique for CTOF with a large IAF. The restoration of the joint improved ACD. Level of Evidence: Level IV (Therapeutic)
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Affiliation(s)
- Min B. KIM
- Seoul National University Hospital, Seoul, Republic of Korea
| | - Seung H. LEE
- Chungnam National University Sejong Hospital, Sejong, Republic of Korea
| | - Jeong H. LEE
- Seoul National University Hospital, Seoul, Republic of Korea
| | - Hanbual YANG
- Seoul National University Hospital, Seoul, Republic of Korea
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Brüggemann A, Mukka S, Wolf O. Epidemiology, classification and treatment of olecranon fractures in adults: an observational study on 2462 fractures from the Swedish Fracture Register. Eur J Trauma Emerg Surg 2021; 48:2255-2263. [PMID: 34345928 PMCID: PMC9192377 DOI: 10.1007/s00068-021-01765-2] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2021] [Accepted: 07/29/2021] [Indexed: 01/03/2023]
Abstract
Purpose This nationwide study aims to describe the epidemiology, fracture classification and current treatment regimens of olecranon fractures in adults. Methods We performed a descriptive study based on registered data from the Swedish Fracture Register (SFR). All non-pathological olecranon fractures reported between 1 January 2014 and 31 December 2018 in patients aged ≥ 18 years were included. Data on age, sex, injury mechanism, fracture classification (according to the modified Mayo classification system), primary treatment and seasonal variation were analyzed. We compared patients < 65 with those > 65 years regarding injury mechanism, distribution of fracture types and subsequent treatment. Results In total, 2462 olecranon fractures were identified in the SFR. Median age was 66 years and 65% were women. Of all fractures, 303 (12%) were proximal avulsion, 1044 (42%) simple central, 717 (29%) comminuted central and 398 (16%) distal olecranon fractures. Nonoperative treatment was performed in 21% of the patients < 65 and 35% of the patients > 65 years. Tension band wiring was used for most simple central fractures. Plate fixation was used in almost half of the operatively treated fractures classified as unstable comminuted central and distal olecranon fractures. Men show a higher proportion of high-energy trauma than women in both age groups. Conclusion Isolated fractures of the olecranon occur after a low-energy trauma, especially in older women (> 65 years). Non-operative treatment is common in uncomplicated fractures and operative treatment in more complex fractures nationwide. A shift to plate fixation in the more unstable fracture patterns is observed. These results may help health care providers and clinicians gain a better understanding of isolated olecranon fractures.
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Affiliation(s)
- Anders Brüggemann
- Department of Surgical Sciences, Orthopaedics, Uppsala University, Uppsala, Sweden
| | - Sebastian Mukka
- Department of Surgical and Perioperative Sciences, Orthopaedics, Umeå University, Umeå, Sweden
| | - Olof Wolf
- Department of Surgical Sciences, Orthopaedics, Uppsala University, Uppsala, Sweden.
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Okamoto M, Namba J, Kuriyama K, Miyamura S, Yokoi H, Yamamoto K. Surgical technique in tension band wiring method for selected comminuted olecranon fractures. EUROPEAN JOURNAL OF ORTHOPAEDIC SURGERY AND TRAUMATOLOGY 2019; 30:237-242. [PMID: 31538271 DOI: 10.1007/s00590-019-02551-y] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/29/2019] [Accepted: 09/10/2019] [Indexed: 10/26/2022]
Abstract
BACKGROUND The use of tension band wiring (TBW) for comminuted olecranon fractures is less recommendable these days. However, some experts preferentially apply TBW to comminuted fractures resulting in favorable outcomes. We here present the surgical technique using TBW with eyelet and absorbable pins for selected comminuted olecranon fractures and review the clinical and radiographic outcomes. METHODS Twenty-four surgically treated patients with Colton Group 2C or 2D olecranon fractures in focus on the intermediate fragment (IMF) were enrolled. IMFs were primarily fixed with buried bioabsorbable poly-L-lactic acid pins followed by definitive fixation of the olecranon process with TBW with eyelet. The adequacy of the reconstructed notch was especially estimated by parameters on radiographs using digital imaging software. RESULTS The average follow-up was 30 months (10 to 86 months). All 24 fractures achieved union, and the maintenance of the articular curvature was confirmed according to statistical analysis on radiographs. The average elbow flexion was 135.1° (range 100° to 145°), and the average elbow extension was - 4.8° (range - 20° to 10°). The mean Mayo Elbow Performance score was 97.3 points (range 80 to 100 points). No cases of pin migration, infection, nerve problem, heterotrophic ossification, or secondary osteoarthritis were observed. CONCLUSIONS For selected comminuted olecranon fractures, TBW with the eyelet pins and biodegradable pins could yield satisfactory clinical and radiographic outcomes.
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Affiliation(s)
- Michio Okamoto
- Department of Orthopaedic Surgery, Yao Municipal Hospital, 1-3-1 Ryugecho, Yao, Osaka, 581-0069, Japan.
| | - Jiro Namba
- Department of Orthopaedic Surgery, Hoshigaoka Medical Center, 4-8-1 Hoshigaoka, Hirakata, Osaka, 573-8511, Japan
| | - Kohji Kuriyama
- Department of Orthopaedic Surgery, Toyonaka Municipal Hospital, 4-14-1 Shibahara, Toyonaka, Osaka, 560-0055, Japan
| | - Satoshi Miyamura
- Department of Orthopaedic Surgery, Osaka University Graduate School of Medicine, 2-2 Yamadaoka, Suita, Osaka, 565-0871, Japan
| | - Hiroyuki Yokoi
- Department of Orthopaedic Surgery, Yukioka Hospital, 2-2-3, Ukita, Kita-ku, Osaka, Osaka, 565-0871, Japan
| | - Koji Yamamoto
- Yamamoto Orthopaedic Clinic, 2-16-3 Yuhigaoka, Toyonaka, Osaka, 561-0864, Japan
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Koziarz A, Woolnough T, Oitment C, Nath S, Johal H. Surgical Management for Olecranon Fractures in Adults: A Systematic Review and Meta-analysis. Orthopedics 2019; 42:75-82. [PMID: 30810755 DOI: 10.3928/01477447-20190221-03] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/28/2018] [Accepted: 02/12/2019] [Indexed: 02/03/2023]
Abstract
Olecranon fractures are common upper-extremity fractures amenable to various surgical techniques. The authors conducted a systematic review and meta-analysis to evaluate surgical management strategies for olecranon fractures in adult patients. Two investigators independently screened articles from records obtained from MEDLINE, Embase, SPORTDiscus, CINAHL, and the Cochrane Library databases. The authors compared tension-band wiring (TBW) with plate fixation (PF) for the outcomes of complications and hardware removal. Subgroup analyses were conducted comparing randomized controlled trials with observational studies for each outcome. In addition, the authors evaluated novel fixation techniques other than TBW and PF. Twenty-four studies were included in the systematic review and 10 studies were included in the meta-analysis of TBW vs PF. Compared with TBW (n=270), patients who underwent PF (n=369) had a significantly lower complication rate (relative risk, 0.48; 95% confidence interval, 0.36-0.64; P<.01; I2=16%). Plate fixation (41 of 332) also had less hardware removal compared with TBW (79 of 236; relative risk, 0.36; 95% confidence interval, 0.25-0.50; P<.01; I2=0%). Subgroup analyses showed no difference when comparing randomized controlled trials with observational studies for the outcomes of complication rate (P=.45) and hardware removal (P=.54). Qualitative analysis revealed novel methods of olecranon fixation: a modified cable pin system, tension banding through 2 cannulated screws, olecranon memory connector fixation, and cancellous screw TBW. This meta-analysis revealed significantly lower complication and hardware removal rates for PF compared with TBW. Several novel methods of olecranon fixation may represent viable alternatives. [Orthopedics. 2019; 42(2):75-82.].
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Complex coronoid and proximal ulna fractures are we getting better at fixing these? Injury 2016; 47:2053-2059. [PMID: 27527379 DOI: 10.1016/j.injury.2016.07.060] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/20/2016] [Revised: 07/25/2016] [Accepted: 07/29/2016] [Indexed: 02/02/2023]
Abstract
Technological advances and improved understanding of functional anatomy about the elbow have lead an evolution regarding operative reconstruction of complex proximal ulnar and coronoid fractures. When treating these complex and challenging fractures, goals of anatomic articular restoration along with balanced soft tissue stability can lead to early range of motion and thus, desired functional outcome. The purpose of this review is to outline and provide tips and pearls to achieve desired results, with a comprehensive update on the most recent literature to support the latest fixation methods and techniques.
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Abstract
Olecranon fractures are common upper extremity injuries, with all but nondisplaced fractures treated surgically. There has been a recent shift in the surgical management of these fractures from tension band wiring to locking plate fixation and intramedullary nailing; however, this comes with increased implant cost. Although most patients can expect good outcomes after these various techniques, there is little information to guide a surgeon's treatment plan. This article reviews the epidemiology, classification, treatment, and outcomes of olecranon fractures.
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Affiliation(s)
- Tyler J Brolin
- Department of Orthopaedic Surgery & Biomedical Engineering, University of Tennessee-Campbell Clinic, 1211 Union Avenue, Suite 510, Memphis, TN 38104, USA
| | - Thomas Throckmorton
- Department of Orthopaedic Surgery & Biomedical Engineering, University of Tennessee-Campbell Clinic, 1211 Union Avenue, Suite 510, Memphis, TN 38104, USA.
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