Complex Elbow Fracture-dislocations Research Articles

Complex elbow fracture-dislocations- what factors are associated with a poor post-operative outcome?

Despite standardized treatment algorithms, patients with complex elbow fracture-dislocation frequently suffer from poor post-operative elbow function leading to reduced quality of life. Up to now, there is no valuable data regarding risk factors that lead to poor post-operative outcome after surgical reconstruction of complex elbow fracture-dislocations. From 06/2010 to 12/2020 134 patients (51.3 ± 15.1 years, 44% women) undergoing surgical treatment of complex elbow fracture-dislocations could be included in this study. Follow-up period was 4.4 years (SD 2.5). All patients were clinically evaluated for elbow movement, elbow stability and common elbow scores (MEPS, OES, DASH-Score). Potential risk factors for poor post-operative outcome were identified using bi- and multivariate analyses. Overall good post-operative outcome has been achieved, mean MEPS was 88.8 ± 17.6. Post-operative complications occurred in 31.3% of the cases, while 25.4% required surgical revision. Patients with transolecranon dislocation fractures showed the significantly worst functional outcomes (p = 0.01). In addition, it has been shown that a patient's age of more than 70 years (OR = 10, p = 0.003) and a BMI of more than 35kg/m2 (OR = 7.6, p = 0.004) are independent risk factors for a poor post-operative outcome. In contrast, gender and time to surgery showed no significant influence on post-operative outcome. In most cases, good post-operative functional results can be achieved using standardized treatment protocols. However, complication and revision rates remain high. Patients older than 70 years of age or with a BMI over 35kg/m2 are at risk for an inferior outcome and require close follow-up monitoring.

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.

Primary Hinged External Fixator for Complex Fracture Dislocations of the Elbow (Systematic Review/Meta-Analysis)

Background High-energy and fracture dislocations with compromise of the medial and lateral ligamentous complex, the joint capsule, and potentially the tertiary stabilizers (i.e., the flexor pronator, extensor supinator masses, and brachialis) often demonstrate residual instability after osseous and ligamentous stabilization. The optimal management of a complex elbow injury should results in restoring joint stability and its full range of motion. However, this is often difficult to achieve by surgical means and a marked restriction of movement remains a frequent con- sequence of severe elbow injury. Aim of the Study The aim of this study is to discuss the results of using a lateral hinged external fixator as an adjunct stabilizer in the treatment of a variety of acute destabilizing elbow injuries as a primary method of fixation not only in chronic or complicated cases. Patients and Methods Types of studies: Randomized controlled trials, including cluster RCTs, controlled (non-randomized) clinical trials or cluster trials, prospective and retrospective comparative cohort studies, and case-control or nested case-control studies. Types of participants: Only studies on human subjects with acute complex elbow fracture dislocation treated by hinged elbow external fixator. Types of interventions: Surgical treatment of acute complex elbow fracture dislocation with hinged external fixation of elbow. Types of outcome measures: Operative details, intra and postoperative complications and final clinical outcome. Literature searches will be conducted using the following databases:” PubMed, Ovid, Web of Science, ScienceDirect, Scopus, Cochrane Library, Google Scholar, Medline” using the following Keywords: acute complex elbow fracture dislocation, hinged external fixator, unstable elbow, terrible triad and long term for published studies from 2010-2021. Results Regarding studies done on the use of a lateral hinged external fixator on the elbow for complex fracture dislocation which are numerous in the last 11 years, we have reviewed the most applicable studies in our review. Regarding the mean flexion-extension arc and pronation-supination arc, the results were 121.5 º and 81 º respectively. Regarding the complications, wound infection was found in 10 patients out of 69 cases (14.4%) including pin tract infection and ORIF wound infection. Secondary humeral and ulnar shaft fractures were found in 3 patients out of 69 cases (4.3%) as a recognized complication of the shanz screws application in both humerus and ulna. Another complication founded was elbow joint incongruity in 5 patients among 69 cases (7.2%) which leads to series consequences like arthritis, progressive pain and instability. Instability as a postoperative complication was found in 1 patient out of 69 cases (1.4%) which shows the huge effect of adding a hinged external fixator to the ORIF construct. In fact, this was the only reason to add a hinged external fixator in the past where it was used in cases of recurrent and chronic instability. Non union was found in 2 patients out of 69 patients (2.8%) while heterotrophic calcification was found in 8 patients out of 69 cases (11.5%). Iordens et al in 2015 was the only paper to calculate the quick-dash score where among 27 patients the score were 30 at 6 weeks and 7 at 1 year. Regarding the mayo elbow performance score (MEPS), among the 69 patients 21 patients (30.4%) were not affiliated while the score was poor in 1 patient (1.4%), fair in 7 patients (10.1%), good in 18 patients (26%) and excellent in 22 patients (31.8%) which shows that above 50% of cases where good to excellent showing the effect of early protected range of motion gained by the addition of a hinged external fixator. Conclusion The best management for complex elbow fracture dislocations is still controversy but the additional use of a hinged external fixator to the ORIF repair shows better outcomes as described.

Mid-term functional outcome assessment of early surgical intervention in complex elbow fracture dislocation in adults

Aim: The aim of the present study was to study mid-term functional outcome assessment of early surgical intervention in complex elbow fracture dislocation in adults.Methods: The study was conducted in the Department of Orthopaedics, trauma centre, Institute of Medical Science, Banaras Hindu University, Varanasi, after getting clearance from the ethics committee. Patients with a complex elbow injury (instability or dislocation associated with fracture), age 18 years to 60 years, who were treated surgically between May 2016 and May 2021, who agreed to participate in the study and signed the free and informed consent with a minimum follow-up of 6 months.Results: 34 cases made up the study group. There were 23 male and 11 female patients, aged between 18 years and 60 years, who were followed up for an average of 38.56 months (range 6 months to 5 years) and were clinically and radiologically, retro prospectively, and prospectively evaluated. The dominant side was involved in 24 patients and the non-dominant in the other 10 patients. According to Mason's classification, 44.1% were type 3 followed by type 2 (32.4%) and type 1 (14.7%). According to Regan- Moore's classification, 23.5% were in type 1 and 3. Mean flexion-extension arc and mean supination-pronation arc in excised were 115.63 degrees and 101.25 degrees in radical group and mean flexion-extension arc and mean supination-pronation arc in excised were 132.75 degrees and 121.2 degrees in coronoid group. Mean flexion-extension arc and mean supination-pronation arc in 26-35 age group were 116.5 degrees and 97.5 degrees and mean flexion-extension arc and mean supination-pronation arc in dominant were 120.42 degrees and 107.92 degrees in coronoid group. There were no malunion, infection, ulnar neuropathy and neural deficit were observed. Mild pain was present in 47.1% cases.Conclusion: Although our number of patients and mean duration of follow-up are less than many other studies, we have achieved comparable results in view of both subjective and objective parameters of follow-up such as the mean arc of flexion-extension, supination-pronation, mean Q-DASH score, MEPI score.

Functional outcomes of elbow injuries managed according to the Wrightington classification of elbow fracture-dislocations.

This study aims to review the functional outcomes of patients managed by the application of the Wrightington elbow fracture-dislocation classification system and its corresponding management algorithms. This is a retrospective consecutive case series of patients over the age of 16 with an elbow fracture-dislocation managed according to the Wrightington classification. The primary outcome was the Mayo Elbow Performance Score (MEPS) at the last follow-up. Range of movement (ROM) and complications were collected as a secondary outcome. Sixty patients qualified for inclusion (32 female, 28 male) with a mean age of 48 years (19-84). Fifty-eight (97%) patients completed a minimum of three months follow-up. Mean follow-up was six months (3-18). The median MEPS at the final follow-up was 100 (interquartile range [IQR] 85-100) and median ROM of 123° (IQR 101-130) degrees. Four patients underwent secondary surgery and had improved outcomes with the average MEPS score improving from 65 to 94 following the second surgery. The results of this study show that good outcomes can be achieved for complex elbow fracture-dislocations through pattern recognition and management with an anatomically based reconstruction algorithm as described by the Wrightington classification system.

The radiological findings in complex elbow fracture-dislocation injuries.

Elbow fracture-dislocation is a complex injury which can lead to significant bony and soft tissue damage. Surgical intervention is guided towards restoring joint stability, allowing early mobilization and preventing long-term joint stiffness. The most common types are posterolateral, posteromedial, Monteggia type (and variants), and anterior trans-olecranon fracture-dislocations. Posterolateral fracture-dislocation is characterized by a radial head fracture (± anterolateral coronoid fracture) and typically capsuloligamentous disruption (lateral collateral ligaments injury is the most common). A posterolateral fracture-dislocation with radial head and coronoid anterolateral facet fractures is termed a terrible triad injury. In posteromedial fracture-dislocation, there is a fracture of the anteromedial facet of the coronoid, typically with proximal avulsion of the lateral collateral ligaments (± injury to the posterior bundle of the ulnar collateral ligament). Monteggia fracture-dislocation injuries demonstrate proximal ulnar fracture (with possible involvement of the olecranon and the coronoid) and radial head dislocation. These can be divided into apex anterior or apex posterior variants. The latter are commonly associated with radial head fractures and lateral ligamentous injury, and have a worse prognosis. In trans-olecranon fracture-dislocation, there is significant disruption of the greater sigmoid notch and the olecranon, with various involvement of the coronoid and the proximal ulna. The article describes the radiological findings and outlines the management principles in complex elbow fracture-dislocation injuries.

The three-column concept of elbow joint stability and the Wrightington elbow fracture-dislocation classification, emphasizing the role of cross-sectional imaging.

Elbow fracture-dislocation is a complex injury with a combination of osseous and soft tissue disruption. Different classification systems have been used to describe the injury pattern and help guide the management. The article describes the important cross-sectional findings in complex elbow fracture-dislocation injuries based on the relatively new Wrightington classification. This includes the various elements and patterns seen in elbow fracture-dislocations providing a simple and comprehensive system to classify these injuries and help guide the surgical management. The article also describes the three-column concept of elbow joint stability, dividing the elbow joint osseous structures into lateral, middle and medial columns. Detailed radiological assessment of the fractures pattern is vital to understand the mechanism of injury, allowing clinicians to predict the associated capsuloligamentous injury and help guide the management decisions. The Wrightington elbow fracture-dislocation classification categorizes the injuries according to the ulnar coronoid process and radial head fractures. Type A is an anteromedial coronoid fracture. Type B is a bifacet or basal coronoid fracture, with B + indicating associated radial head fracture. Type C is a combined anterolateral facet and radial head or comminuted radial head fractures. Type D is a diaphyseal ulnar fracture, with D + indicating associated radial head fracture.

Long-Term Outcomes of Radial Head Arthroplasty in Complex Elbow Fracture Dislocation.

The purpose of the current study was to investigate the long-term outcomes of radial head arthroplasty in complex elbow injuries through radiographic analysis and functional correlation. We evaluated 24 radial head arthroplasties in 24 consecutive patients with complex elbow fracture dislocation. All patients were treated with a single type of modular monopolar prosthesis containing smooth stem in press-fit implantation. Clinical survey using the Mayo Elbow Performance Score (MEPS), self-reported scales of shortened Disabilities of the Arm, Shoulder, and Hand (QuickDASH) and the visual analog scale (VAS) at more than 10-year follow-up were reported and compared to 2-year outcomes. Periprosthetic osteolysis was measured in the 10 zones of prosthesis-cortical interface with a modified radiolucency score, which was calibrated by each prosthesis size. Pearson correlation analysis was performed to detect the association between periprosthetic radiolucency and clinical assessment. At the final follow-up, MEPS, QuickDASH score and VAS score averaged 82.5 ± 15, 14.1 ± 14.3 and 1.6 ± 1.2 respectively. A decline in functional status was noted, with decreased mean MEPS and increased mean QuickDASH and VAS scores as compared to the 2-year results while the difference was insignificant. Periprosthetic osteolysis was more prevalent around stem tip of zone 3 and zone 8. The final and 2-year radiolucency scores averaged 7.4 ± 4.2 and 2.6 ± 2.3 respectively with significant difference. Pearson correlation analysis indicated that the difference between radiolucency scores and clinical outcomes in MEPS/QuickDASH/VAS was −0.836, 0.517 and 0.464. Progression of periprosthetic osteolysis after postoperative 10 years is more prevalent around the stem tip with moderate to high correlation to clinical outcomes. Sustained follow-up is warranted to justify subsequent surgery for revision or implant removal.

Complex Fracture-Dislocations of the Elbow in the Pediatric Population.

Complex fracture-dislocations of the elbow, including terrible triad of the elbow, are serious injuries with guarded outcomes in adults. Although described extensively in adults, little is known about similar complex fracture-dislocations of the elbow in the pediatric population. The purpose of this study was to describe patterns of elbow dislocations with associated fractures in children and report the outcomes of these injuries. This was a retrospective review of patients who presented to a level I trauma center from 2007 to 2019 with an elbow dislocation and at least 2 associated fractures. Demographic data, fracture locations, and treatment modality were recorded. Operative reports and radiographs were reviewed to determine clinical outcomes and complications. A total of 26 patients (mean age, 9.8 y) were identified. The majority of patients sustained an elbow dislocation and a medial epicondyle fracture (n=16). The most common third fractures involved the lateral condyle (n=8) or radial neck (n=7). At mean 6.03±3.11 months follow-up, 3 patients lacked ≥10 degrees of extension, and 2 patients lacked ≥15 degrees of flexion. Most patients had a Flynn score of "excellent" (n=20, 76.9%) or "good" (n=2, 7.7%). One patient with significant residual stiffness (>30 degrees flexion contracture) eventually underwent open contracture release. The most common complex elbow fracture-dislocation pattern in this series was an elbow dislocation with fracture of the medial epicondyle and lateral condyle or radial neck. In contrast to adult terrible triad injuries, most patients had a favorable clinical outcome, with nearly 80% excellent results and a low rate of complications. Therapeutic Level IV-case series.

Comparison of arthroscopy-assisted vs. open reduction and fixation of coronoid fractures of the ulna

The purpose of this study was to compare clinical and radiographic outcomes and complications for arthroscopy-assisted vs. open reduction and fixation of coronoid fractures in patients with complex elbow fracture-dislocations. This retrospective study analyzed patients with complex elbow fracture-dislocations who underwent surgical fixation for coronoid fractures of the ulna from March 2009 to January 2016. Subjects included those who received either arthroscopy-assisted (group A) or open surgery (group O) for coronoid fractures and concurrent reconstruction of the lateral column (radial head and/or lateral ulnar collateral ligament) with follow-up for at least 2 years. Clinical outcomes were assessed using the visual analog scale for pain, range of motion, Mayo Elbow Performance Score, and Disabilities of the Arm, Shoulder, and Hand score at 2 years after surgery. For radiographic assessment, union of the coronoid, development of heterotopic ossification, and arthritic changes were evaluated. We also reviewed surgery-related complications. Twenty-five patients (mean age, 40.0 ± 12.4 years) were enrolled in this study (group A, 15 patients; group O, 10 patients), and there were no statistical differences in baseline data between the 2 groups. Clinical outcomes did not differ between the 2 groups. All fractures were united and that the prevalence of heterotopic ossification and arthritic changes were similar between the 2 groups. However, operation-related complications were more common in group O than in group A (group A, 13.3%; group O, 40.0%), including 1 patient who underwent ulnar nerve neurolysis and anterior transposition at 3 months after the initial operation. Eliciting fewer complications, arthroscopy-assisted reduction and fixation of coronoid fractures shows union rates and clinical results comparable to open fixation in patients with complex elbow fracture-dislocation.

Radial Head Arthroplasty, Excision and Osteosynthesis in Complex Elbow Fracture-Dislocations in Young Adults: What is Preferred?

Complex elbow fractures are common injuries in young adults. Results in recent studies with various operative treatment protocols are equivocal. We compared the results of radial head arthroplasty, excision with osteosynthesis in such injuries at two follow-ups 1year apart. Thirty-five patients of complex elbow fracture-dislocations including, posterior/anterior olecranon dislocation of elbow, terrible triad injury, anteromedial facet of coronoid fracture, Type IV Monteggia fracture-dislocation and unclassified elbow dislocation were enrolled. They were managed operatively by standardized protocol similar to McKee et al. radial head reconstruction with miniplates, lag screws or non-operative treatment for undisplaced fractures. Arthroplasty of radial head with cemented prosthesis + LCL repair with suture anchor/transosseous tunnel was done. Coronoid and olecranon fixation was always performed. Patients were evaluated as follows: Q-DASH score, MEPI, pain according to VAS, range of motion, complications and radiographic findings and fracture union, and elbow instability. The mean length of follow-up among the patients was 18months. There were statistically significant differences between the DASH score/MEPS between radial head excision and replacement/reconstruction. Instability was significantly reduced in those with LCL reconstruction. Excising the comminuted radial head without replacement had the worst outcome. Best PROM was reported in patients with osteosynthesis. Provided a standard protocol is applied, radial head osteosynthesis has preferable outcomes in terms of patient-related outcomes as compared to arthroplasty, although not statistically significant. Radial head excision though has acceptable outcomes but there is a restriction of movements especially flexion-extension. Acceptable rate of complications major or minor warrants need of secondary surgical procedures or a staged treatment.

Progress on diagnosis and treatment of the terrible triad of elbow joint

The terrible triad of elbow is a kind of complex elbow fracture dislocation, after reduction, it should get a concentric circles joint reduction and elbow stability, if radial and coronoid process fractures is less piece, the conservative treatment can be performed, but regularly follow up is mandatory. If surgical treatment was chosen, radial head fractures and the lateral collateral ligament complex must be repaired. Single lateral approach can be used and also can be combined with anteromedial approach in surgery. Some problems are still controversial in the treatment of coronoid process fracture with Morry type I and type II, such as fixation or not, whether additional external fixation and repair of the medial collateral ligament injury at the same time.

Treatment of complex elbow fracture-dislocations.

Successful management of complex elbow fracture-dislocations requires, in part, recognition of the overall injury pattern, which can aid in the identification of concomitant bony and soft tissue injuries. Trans-olecranon fracture-dislocations are best treated surgically with stable anatomic restoration of the trochlear notch. Terrible triad elbow injuries are believed to be caused by a valgus posterolateral force. Although select terrible triad injuries can be managed non-operatively, the majority of injuries are treated with stable surgical repair to allow early elbow motion. Unlike terrible triads, varus posteromedial forces are theorized to cause anteromedial coronoid fractures. These are usually associated with LCL disruptions, but do not have concomitant MCL or radial head injuries. A subset of anteromedial coronoid fractures can also be managed non-operatively. Internal fixation is recommended for injuries associated with large fracture fragments or elbow instability preventing early motion.

Hinged external fixation for complex fracture-dislocation of the elbow in elderly people

The authors report their experience of treating complex elbow fracture-dislocations in elderly people, using a minimally-invasive approach with a new articulated external fixator that is associated with minimal internal fixation. The clinical results for 19 patients are presented according to outcome factors, such as range of motion, pain and function, rate and type of complications, and reoperation rate. The results indicate that this treatment strategy should be considered as a good alternative to other treatment options reported in the literature, including conservative treatment, ORIF with angular stable plates and total elbow arthroplasty.

Good functional recovery of complex elbow dislocations treated with hinged external fixation: a multicenter prospective study.

After a complex dislocation, some elbows remain unstable after closed reduction or fracture treatment. Function after treatment with a hinged external fixator theoretically allows collateral ligaments to heal without surgical reconstruction. However, there is a lack of prospective studies that assess functional outcome, pain, and ROM. We asked: (1) In complex elbow fracture-dislocations, does treatment with a hinged external fixator result in reduction of disability and pain, and in improvement in ROM, function, and quality of life? (2) Does delayed treatment (7 days or later) have a negative effect on ROM after 1 year? (3) What are the complications seen after external fixator treatment? During a 2-year period, 11 centers recruited 27 patients 18 years or older who were included and evaluated at 2 and 6 weeks and at 3, 6, and 12 months after surgery as part of this prospective case series. During the study period, the participating centers agreed on general indications for use of the hinged external fixator, which included persistent instability after closed reduction alone or closed reduction combined with surgical treatment of associated fracture(s), when indicated. Functional outcome was evaluated using the Quick Disabilities of the Arm, Shoulder and Hand (QuickDASH; primary outcome) score, the Mayo Elbow Performance Index (MEPI), the Oxford Elbow Score, and the level of pain (VAS). ROM, adverse events, secondary interventions, and radiographs also were evaluated. A total of 26 of the 27 patients (96%) were available for followup at 1 year. All functional and pain scores improved. The median QuickDASH score decreased from 30 (25(th)-75(th) percentiles [P25-P75], 23-40) at 6 weeks to 7 (P25-P75, 2-12) at 1 year with a median difference of -25 (p < 0.001). The median MEPI score increased from 80 (P25-P75, 64-85) at 6 weeks to 100 (P25-P75, 85-100) at 1 year with a median difference of 15 (p < 0.001). The median Oxford Elbow Score increased from 60 (P25-P75, 44-68) at 6 weeks to 90 (P25-P75, 73-96) at 1 year with a median difference of 29 (p < 0.001). The median VAS decreased from 2.8 (P25-P75, 1.0-5.0) at 2 weeks to 0.5 (P25-P75, 0.0-1.9) at 1 year with a median difference of -2.1 (p = 0.001). ROM also improved. The median flexion-extension arc improved from 50° (P25-P75, 33°-80°) at 2 weeks to 118° (P25-P75, 105°-138°) at 1 year with a median difference of 63° (p < 0.001). Similarly, the median pronation-supination arc improved from 90° (P25-P75, 63°-124°) to 160° (P25-P75, 138°-170°) with a median difference of 75° (p < 0.001). At 1 year, the median residual deficit compared with the uninjured side was 30° (P25-P75, 5°-35°) for the flexion-extension arc, and 3° (P25-P75, 0°-25°) for the pronation-supination arc. Ten patients (37%) experienced a fixator-related complication, and seven patients required secondary surgery (26%). One patient reported recurrent instability. A hinged external elbow fixator provides enough stability to start early mobilization after an acute complex elbow dislocation and residual instability. This was reflected in good functional outcome scores and only slight disability despite a relatively high complication rate.

Treatment of Monteggia and Transolecranon Fracture-Dislocations of the Elbow: A Critical Analysis Review.

The uninjured elbow is an inherently stable joint. The skeletal articulations, surrounding capsuloligamentous structures, and muscular attachments maintain stability. The primary stabilizers of the elbow are the coronoid process, olecranon, trochlea, and collateral ligaments1. Traumatic dislocations without substantial skeletal injury are considered simple and usually do not require operative repair. In contrast, complex dislocations, which are associated with fracture and may involve one or more of the primary stabilizing structures of the elbow, are unstable and typically require operative reduction and internal fixation to achieve stability. Complex elbow fracture-dislocations follow a subluxation or dislocation event. These injuries range from ulnohumeral dislocations with radial head and coronoid process fracture (“terrible triad” injuries) to ulnar fractures with an associated injury of the proximal part of the radius, proximal radioulnar joint, radiocapitellar joint, or ulnohumeral joint. Monteggia injuries involve a proximal ulnar fracture with disruption of the proximal radioulnar joint. Transolecranon fracture-dislocations involve a proximal ulnar fracture at the greater sigmoid notch and anterior dislocation of the elbow, without disruption of the proximal radioulnar joint. Some fracture-dislocations do not follow either pattern but have features consistent with one or the other that help to guide treatment. The focus of this article …

Non surgically managed anteromedial coronoid fractures in posteromedial rotatory instability: three cases with 2 years follow-up

Varus posteromedial rotatory instability refers to one of the complex elbow fracture-dislocation caused by anteromedial coronoid fracture with disruption of lateral collateral ligament (LCL). Recent clinical and biomechanical studies have demonstrated that this unstable complex injury resulted in incongruence of joint, which could lead to early posttraumatic arthritis. With reports of poor result after conservative treatment, surgical treatment including anteromedial fixation and LCL repair has been strongly recommended to achieve stable joint. This case series describes three patients with anteromedial coronoid fracture who were managed conservatively with excellent outcomes. This report suggests that anteromedial coronoid fracture associated with posteromedial rotatory instability might be treated using conservative treatment in selective cases when anteromedial coronoid fracture is minimally displaced and there is no evidence of elbow subluxation.

Osteology of the coronoid process with clinical correlation to coronoid fractures in terrible triad injuries

Terrible triad complex elbow fracture-dislocations are represented by elbow dislocations associated with fractures of the coronoid and radial head. Published literature has focused on classifying coronoid fractures by their radiographic morphology on plain x-ray images and computed tomography imaging. No study has specifically related native coronoid osteology to in situ fracture morphology. We identified 3 distinct bony regions of the coronoid, (medial, intermediate, and lateral ridges) with correlation to common fracture patterns associated with terrible triad injuries. Coronoid osteology in 8 fresh frozen cadaveric elbows was examined, and three distinct ridges were identified and dimensions measured. The measurements were compared with retrospective intraoperative measurements taken of coronoid fracture fragments being stabilized during terrible triad injury repair. Classification of native coronoid process anatomy into functional ridges (medial, intermediate, lateral) may improve our understanding of coronoid fracture patterns in unstable terrible triad injuries. Basic Science, Anatomic Study, Cadaver and In Vivo.

Elbow Dislocations: A Review Ranging from Soft Tissue Injuries to Complex Elbow Fracture Dislocations

This review on elbow dislocations describes ligament and bone injuries as well as the typical injury mechanisms and the main classifications of elbow dislocations. Current treatment concepts of simple, that is, stable, or complex unstable elbow dislocations are outlined by means of case reports. Special emphasis is put on injuries to the medial ulnar collateral ligament (MUCL) and on posttraumatic elbow stiffness.

Comment on the anterior approach for coronoid process fracture

We are very interested in the article by Han et al. [1] entitled ‘‘anterior approach for fixation of isolated type III coronoid process fracture’’. It’s well known that the coronoid process is the anterior portion of the proximal articular surface of the ulna and the important bone structure providing ulnohumeral joint anterior stability. There are two osseous eminences in the coronoid process, the tip and the sublime tubercle. Some important soft tissue structures insert on the coronoid process: the anterior articular capsule, the tendon of the brachialis muscle, and the anterior band of the medial collateral ligament (AMCL). The structures maintain the anterior stability of elbow together. The study of coronoid process fracture has been the central issue of elbow trauma and instability in recently years. The fractures of coronoid process are commonly associated with complex elbow fracture-dislocation, and isolated coronoid process fractures are uncommon. There is some controversy about fixation means of the coronoid process fragment. As described in the article that many published papers with treatment of coronoid fractures, but little has been published about the surgical approach related to operative fixation. The most common approach for fixation of coronoid process fractures has been described from medial and posterior. The anterior approach is seldom used, and rare relevant literatures about anterior approach for coronoid process fractures were reported. Because the brachial artery and its branches, median nerve, which lie in the anterior of the elbow. There is great risk of iatrogenic injury to the neurovascular structures. The medial approach is the most commonly used in our institution. But we found that it is usually hard to exposure the fragments of the coronoid process from the medial incision clearly, because of the very thick flexor-pronator mass. We had performed some dissection research about the anterior approach to expose the coronoid process. In the course of our study, we found that there are some branches from the proximal radial artery and ulna artery, which constitute the vascular tree in the superficial structure of the brachialis insertion. Especially, the radial recurrent artery traverses the brachialis muscle surface. The distance of the brachial artery retracted medially is restricted by the anatomical characteristics. There are some difficulties to reduce and fix the coronoid fragment with a buttress plate in this area, but the cannulated screw is convenient to be used. We admired the authors’ skilled technique and courage. So we also want to consult some detail technique about the exposure of the coronoid process during the operation. How to optimally handle the artery branches to harvest more operating space? Whether the radial recurrent artery must be cut? The anterior approach can not be used to repair the associated ligament injury (lateral collateral ligament or medial collateral ligament). In the article, the author described that the cases were all isolated coronoid process fracture without associated ligament injury resulting in joint instability. The study was retrospective, so the incision position must be determined preoperatively. In other words, the patients with coronoid process fracture and elbow dislocation, without ligament injury, should be made a definite diagnosis before operation. How to ensure that the patients were not associated ligament injury resulting in instability of ulnohumeral joint? What accessory examination should be performed? We think that it is not accurate to diagnose the ligament without injury only through X. Zhu X. Wang (&) Z. Ma Department Orthopedic Surgery, Tongji Hospital, Tongji University School of Medicine, Shanghai 200065, China e-mail: wangxin1681@126.com