Patient Outcomes After Transolecranon Fracture-Dislocation

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.

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.

A coronoid-centric classification system of proximal trans-ulnar fracture-dislocations has almost perfect intraobserver and interobserver agreement

BACKGROUND

Fracture-dislocations of the elbow, particularly those that involve a fracture through the proximal ulna, are complex and can be difficult to manage. Moreover, current classification systems often cannot discriminate between Monteggia-variant injury patterns and trans-olecranon fracture-dislocations, particularly when the fracture involves the coronoid. The Mayo classification of proximal trans-ulnar fracture-dislocations categorizes these fractures into 3 types according to what the coronoid is still attached to: trans-olecranon fracture-dislocations (the coronoid is still attached to the ulnar metaphysis); Monteggia-variant fracture-dislocations (the coronoid is still attached to the olecranon); and ulnar basal coronoid fracture-dislocations (the coronoid is not attached to either the olecranon or the ulnar metaphysis). The purpose of this study was to evaluate the intraobserver and interobserver agreement of the Mayo classification system when assessing elbow fracture-dislocations involving the proximal ulna based on radiographs and computed tomography scans.

METHODS

Three fellowship-trained shoulder and elbow surgeons and 2 fellowship-trained orthopedic trauma surgeons blindly and independently evaluated the radiographs and computed tomography scans of 90 consecutive proximal trans-ulnar fracture-dislocations treated at a level I trauma center. The inclusion criteria included subluxation or dislocation of the elbow and/or radioulnar joint with a complete fracture through the proximal ulna. Each surgeon classified all fractures according to the Mayo classification, which is based on what the coronoid remains attached to (ulnar metaphysis, olecranon, or neither). Intraobserver reliability was determined by scrambling the order of the fractures and having each observer classify all the fractures again after a washout period ≥ 6 weeks. Interobserver reliability was obtained to assess the overall agreement between observers. κ Values were calculated for both intraobserver reliability and interobserver reliability.

RESULTS

The average intraobserver agreement was 0.87 (almost perfect agreement; range, 0.76-0.91). Interobserver agreement was 0.80 (substantial agreement; range, 0.70-0.90) for the first reading session and 0.89 (almost perfect agreement; range, 0.85-0.93) for the second reading session. The overall average interobserver agreement was 0.85 (almost perfect agreement; range, 0.79-0.91).

CONCLUSION

Classifying proximal trans-ulnar fracture-dislocations based on what the coronoid remains attached to (olecranon, ulnar metaphysis, or neither) was associated with almost perfect intraobserver and interobserver agreement, regardless of trauma vs. shoulder and elbow fellowship training. Further research is needed to determine whether the use of this classification system leads to the application of principles specific to the management of these injuries and translates into better outcomes.

Predicting the need for collateral ligament repair in transolecranon fractures of the elbow: a traffic light model

BACKGROUND

Biomechanical studies have shown that translation of the proximal radius relative to the capitellum in the sagittal plane can predict integrity of the collateral ligaments in a transolecranon fracture model; no studies have examined this in clinical practice.

METHODS AND MATERIALS

Nineteen consecutive transolecranon fracture dislocations were retrospectively reviewed. Data collection included patient demographics, fracture classifications, surgical management, and failure with instability. Distance between the center of the radial head and the center of the capitellum was measured on initial radiographs by 2 independent raters on 3 separate occasions. Statistical analysis was used to compare the median displacement between patients who required collateral ligament repair for stability and those who did not.

RESULTS

Sixteen cases with a mean age of 57 years (range 32-85) were analyzed with an inter-rater Pearson coefficient of 0.89 for displacement measurement. Median displacement where collateral ligament repair was needed and performed was 17.13 mm (interquartile range [IQR] = 10.43-23.88) compared with 4.63 mm (IQR = 2.68-6.58) where collateral ligament repair was not performed and not required (P = .002). In 4 cases, ligament repair was not performed initially but deemed necessary based on clinical outcome and postoperative and intraoperative images. Of these, the median displacement was 15.59 mm (IQR = 10.09-21.20), and 2 of these required revision fixation.

DISCUSSION

Where displacement on initial radiographs exceeded 10 mm, lateral ulnar collateral ligament (LUCL) repair was required in all cases (red group). If less than 5 mm, ligament repair was not required in any case (green group). Between 5 and 10 mm, following fracture fixation, the elbow must be screened carefully to assess for any instability and a low threshold set for LUCL repair to prevent posterolateral rotatory instability (amber group). Using these findings, we propose a traffic light model to predict the need for collateral ligament repair in transolecranon fractures and dislocation.

Improved Understanding of Traumatic Complex Elbow Instability

Recent advancements in surgical treatment have improved clinical results in complex traumatic elbow injury. There is increasing recognition that conservative treatment and inadequate surgical fixation carry high risk of substantial morbidity in many of these cases. Recent literature displays improved outcomes in complex elbow instability, in part, because of a more complete comprehension of the injury patterns and fixation methods. Prompt surgical management with stable internal fixation, which permits immediate postoperative mobilization, has been a consistent variable across the reports leading to more satisfactory outcomes. This applies to both acute and chronic cases.

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.

Trans-olecranon fracture-dislocation of the elbow in children

OBJECTIVES

Trans-olecranon fracture-dislocations are rare in children. To our knowledge, only 12 cases have been described in children till now and the treatment strategy for this injury in children remains unclear. To provide a clear clinical description and more accurate treatment options, we retrospectively reviewed cases with this kind of injury in our institution.

METHODS

From 2002 to 2019, eleven cases diagnosed with trans-olecranon fracture-dislocation of the elbow were identified, and their medical charts and radiographs were obtained. All patients underwent open reduction and internal fixation through a posterior approach. At the most recent follow-up visit, all patients were evaluated clinically using the Mayo Elbow Performance Score (MEPS).

RESULTS

The mean follow-up was 22 months (range, 6-42 months). All injuries were unilateral, and there were nine males and two females. The mean age at injury was nine years (range, 4-13 years), and the mean time from injury to surgery was 16.6 days (range, 2-60 days). According to Tiemdjo classification, there was one case with type I injury, one case with type II, six cases with type III, and three cases with type IV. According to the MEPS criteria, the outcomes were excellent in five cases, good in two cases, fair in one case, and poor in three cases. Four patients were delayed cases, who underwent surgery two weeks after injury. The average operation time was significantly longer in four children sustaining delayed surgery (140 ± 43 min, vs. 50 ± 12 min, p < 0.001).

CONCLUSION

To our knowledge, this is the largest sample size reported to date. We recommend open reduction and internal fixation, using either plates or tension-band techniques, depending on the injury pattern. In addition, we emphasize that early operation could achieve good clinical outcomes.

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.