Proximal Ulna Fractures Research Articles

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 …

Capitellum fracture combined with proximal ulnar fracture; a case report

Capitellum fracture combined with proximal ulnar fracture; a case report

Midterm Results of 58 Fractures of the Coronoid Process of the Ulna and their Concomitant Injuries.

Background:In general, fractures of the coronoid process are rare and usually occur in combination with additional elbow joint injuries. The treatment of these injuries aims to regain a stable as well as a flexible and loadable joint. Although there is currently little evidence, therapy recommendations remain controversial. Therefore, the aim of this study was to prognostically determine relevant factors for therapy recommendation by analysing a representative patient population of two trans-regional trauma centres.Material and Methods:Seventy-seven patients with a fracture of the coronoid process were treated within an 8-year period (2001 to 2009). After an average of 48 months (SD 31), treatment outcome of 58 patients (75%) was acquired. The results were statistically analysed.Results:The average age of the patient was 51.8 years (SD 13.6); 36 were male and 34 had a fracture on the right arm. Applying the fracture types of the coronoid process in accordance with Regan/Morrey, the result was: Type I (19), II (17) and III (22). Further injuries were also detected: 40 radial head fractures, 17 proximal ulnar fractures and 2 fractures of the olecranon. A luxation was detected in 44 of the 58 patients (76%). The patients’ average MEPS (Mayo Elbow Performance Score) was 80.6 points (SD 18), with significant differences between the various therapy strategies. Fifteen% of the coronoid process fractures were reconstructable to a limited extent only by means of osteosynthesis. In 33% of the patients, instabilities remained. The average extension/flexion came to 107° (SD 28), and pronation and supination 153° (SD 38).Conclusion:At present, a surgical therapy of ligamentary injuries cannot be statistically justified. A stable osseous reconstruction appears to make more sense. The strongest negative prognostic parameters in our patient population were: therapy with an external fixator, immobilisation for more than 21 days, the occurrence of complications and unstable osteosyntheses on the coronoid process.

Clinical Results of Olecranon Fractures Treated With Multiplanar Locked Intramedullary Nailing

Proximal ulnar fractures have traditionally been fixed with either tension band wiring or plate and screw fixation. These traditional techniques often irritate the surrounding soft tissues, potentially leading to subsequent secondary hardware removal surgeries. Intramedullary proximal ulnar fixation provides similar rigid fixation, however, no review yet exists to support the clinical use of currently available implants. To investigate the clinical and radiographic short-term outcomes for multiplanar locked intramedullary nails used to treat proximal ulnar fractures. A retrospective multicenter review was conducted in 28 patients with unstable olecranon fractures treated with a new multiplanar locked intramedullary nailing system (OlecraNail, Mylad Orthopedic Solutions, McLean, VA). Radiographic union was estimated, and serial clinical outcome up to one year was assessed by strength, motion, pain (visual analog scale), and a subcutaneous ulna border palpation (SCUBP) test to assess hardware prominence. All fractures achieved union by 8 weeks. At 12 weeks postoperatively, all motion was within 10 degrees of the contralateral side in all directions. Of the 18 patients who underwent SCUBP testing, all 18 patients reported to have no pain at 12 weeks. At one-year follow-up, all patients had resumed normal activities, including work and athletics. All of the patients who underwent the SCUBP testing continued to have no pain. Multiplanar locked intramedullary nails offer effective management for proximal ulna fractures similar to those reported with plating techniques. Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Management of Fractures of the Proximal Ulna

Proximal ulna fractures can be difficult to manage because of the elbow's complex anatomy. Advances in understanding elbow anatomy and biomechanics, however, have led to new insights. Careful preoperative evaluation is critical because failure to restore normal anatomy of the proximal ulna could have a detrimental effect on postoperative elbow function. Management options include anatomic plates, intramedullary devices, and strong tension band materials. Determining the most appropriate option for an individual fracture is based on analysis of radiographs and CT scans, including three-dimensional reconstruction. Coronoid fractures, olecranon fractures, and associated elbow instability influence the indications for any given fixation device. Appreciating the subtleties of proximal ulna anatomy and biomechanics can lead to improved clinical outcomes. Recent concepts affecting fracture management include proximal ulna dorsal angulation, the importance of the anteromedial facet of the coronoid, and intermediate fragments of the olecranon.

Management of Fractures of the Proximal Ulna

Proximal ulna fractures can be difficult to manage because of the elbow's complex anatomy. Advances in understanding elbow anatomy and biomechanics, however, have led to new insights. Careful preoperative evaluation is critical because failure to restore normal anatomy of the proximal ulna could have a detrimental effect on postoperative elbow function. Management options include anatomic plates, intramedullary devices, and strong tension band materials. Determining the most appropriate option for an individual fracture is based on analysis of radiographs and CT scans, including three-dimensional reconstruction. Coronoid fractures, olecranon fractures, and associated elbow instability influence the indications for any given fixation device. Appreciating the subtleties of proximal ulna anatomy and biomechanics can lead to improved clinical outcomes. Recent concepts affecting fracture management include proximal ulna dorsal angulation, the importance of the anteromedial facet of the coronoid, and intermediate fragments of the olecranon.

Results of Proximal Ulna Fractures Treated with a Multiplanar, Locked Intramedullary Nail: First Multicenter Experience: Level 4 Evidence

28 consecutive patients with displaced olecranon fractures underwent open reduction and internal fixation using a multiplanar, locked intramedullary implant (OlecraNail, Mylad Orthopedic Solutions) and were followed for a minimum of 12 months (range: 12-18 months). Of the 28 fractures, 18 were transverse or oblique (AO/OTA 21-B1.1), 10 were comminuted (AO/OTA 21-B1.2; B1.3), 4 of which also involved the coronoid, and 7 were nonunions. Average patient age was 45 years (range: 25 to 65 years). Patient clinical outcome measures where monitored at approximately six weeks, twelve weeks, and one year following the surgery. Included in this evaluation was range of motion, visual analog pain score, and strength. Patients were immobilized for 3-5 days postoperatively, after which motion was allowed. Strengthening was initiated at 6 weeks. Radiographs were taken at each follow up visit until union. Complications and subjective complaints were noted. The purpose of this study is to evaluate a new multiplanar, locked intramedullary implant indicated for both transverse and comminuted olecranon fractures. This is the first clinical report of this particular type of implant.

Fractures in Brief: Olecranon Fractures

Olecranon fractures are relatively common injuries, accounting for approximately 10% of upper extremity fractures in adults [26]. These fractures may result from a direct blow to the proximal ulna, or indirectly, via the forceful contraction of the triceps against resistance (typically, during a fall onto an outstretched hand). Less commonly, the olecranon may fracture when the elbow is hyperextended, as the bone is impacted against the olecranon fossa of the distal humerus. For unstable injuries, operative fixation typically is required. Even after recovery, loss of ROM is not uncommon. This article provides an overview of olecranon fractures in adults; therefore, discussion of olecranon fractures in skeletally immature patients is beyond the scope of this article.

Interventions for treating isolated diaphyseal fractures of the ulna in adults.

Isolated fractures of the shaft of the ulna, which are often sustained when the forearm is raised to shield against a blow, are generally treated on an outpatient basis. This is an update of a Cochrane review first published in 1998 and last updated in 2009. To assess the effects of various forms of treatment for isolated fractures of the ulnar shaft in adults. We searched the Cochrane Bone, Joint and Muscle Trauma Group Specialised Register (April 2012), the Cochrane Central Register of Controlled Trials (The Cochrane Library 2012, Issue 3), MEDLINE (1966 to April week 1 2012), EMBASE (1981 to week 15 2012), CINAHL (1982 to 16 April 2012), various trial registers, various conference proceedings and bibliographies of relevant articles. Randomised or quasi-randomised trials of conservative and surgical treatment of isolated fractures of the ulnar shaft in adults. Excluded were fractures of the proximal ulna and Monteggia fracture dislocations. We performed independent assessment of risk of bias and data extraction. We contacted trialists for more information. There was no pooling of data. The updated search resulted in the identification of one ongoing trial comparing surgery versus conservative treatment.Four trials, involving a total of 237 participants, were included. All four trials were methodologically flawed and potentially biased.Three trials tested conservative treatment interventions. One trial, which compared short arm (below elbow) pre-fabricated functional braces with long arm (elbow included) plaster casts, found there was no significant difference in the time it took for fracture union. Patient satisfaction and return to work during treatment were significantly better in the brace group. The other two trials, both quasi-randomised, had three treatment groups. One trial compared Ace Wrap elastic bandage versus short arm plaster cast versus long arm plaster cast. The large loss to follow-up in this trial makes any data analysis tentative. However, the need for replacement of the Ace wrap by other methods due to pain indicates the potential for a serious problem with this intervention. The other trial, which compared immediate mobilisation versus short arm plaster cast versus long arm plaster cast for minimally displaced fractures, found no significant differences in outcome between these three interventions.The fourth trial, which compared two types of plates for surgical fixation, found no significant differences in functional or anatomical outcomes nor complications between the two groups. There is insufficient evidence from randomised trials to determine which method of treatment is the most appropriate for isolated fractures of the ulnar shaft in adults. Well designed and reported randomised trials of current forms of conservative treatment are recommended.

Ipsilateral Supracondylar Fracture and Forearm Bone Injury in Children: A Retrospective Review of Thirty one Cases

Pediatric supracondylar fracture and forearm bone fracture is common in isolation but combined supracondylar fracture with ipsilateral forearm bone fracture, known as floating elbow is not common injury. The incidence of this association varies between 3% and 13%. Since the injury is rare and only limited literatures are available, choosing best management options for floating elbow is challenging. In retrospective review of 759 consecutive supracondylar fracture managed in between July 2005 to June 2011, children with combined supracondylar fracture with forearm bone injuries were identified and their demographic profiles, mode of injury, fracture types, treatment procedures, outcome and complications were analyzed. Thirty one patients (mean age 8.91 yrs, range 2-14 yrs; male 26; left side 18) had combined supracondylar fracture and ipsilateral forearm bone injury including four open fractures. There were 20 (64.51%) Gartland type III (13 type IIIA and 7 type III B), seven (22.58 %) type II, three (9.67 %) type I and one (3.22 %) flexion type supracondylar fracture. Nine patients had distal radius fracture, six had distal third both bone fracture, three had distal ulna fracture, two had mid shaft both bone injury and one with segmental ulna with distal radius fracture. There were Monteggia fracture dislocation, proximal ulna fracture, olecranon process fracture, undisplaced radial head fracture of one each and two undisplaced coronoid process fracture. Displaced forearm fracture required closed reduction and fixation with Kirschner wires or intramedullary nailing. Nineteen patients with Gartland type III fracture underwent operative intervention. Among them nine had closed reduction and K wire fixation for both supracondylar fracture and forearm bone injury. There were three radial nerve, one ulnar nerve and one median nerve injury and two postoperative ulnar nerve palsy. Three patients had pin tract related complications. Among type III, 16 (80%) patients had good to excellent, two had fair and one had poor result in terms of Flynn criteria in three months follow up. Displaced supracondylar fracture with ipsilateral displaced forearm bone injuries need early operative management in the form of closed reduction and percutaneous pinning which provides not only stable fixation but also allows close observation for early sign and symptom of development of any compartment syndrome.

Modular prosthesis replacement for comminuted and unreconstructable radial head fractures

Objective To analyze the results of modular prosthesis replacement for treatment of comminuted and unreconstructable radial head fractures associated with other elbow fractures and sof-tissue injuries. Methods From November 2009 to March 2011,22 patients with comminuted radial head fracture of Mason type Ⅲ were treated with Acumed modular prosthesis replacement. Repair of collateral ligaments and associated elbow fractures was carried out simultaneously.They were 16 men and 6 women,with an average age of 41.5 years (from 21 to 62 years).The left side was involved in 9 cases and the right in 13.One patient was associated with posterior olecranon fracture-dislocation of Monteggia type Ⅱ,13 with elbow terrible triad,one with elbow dislocation but without coronoid process fracture,3 with Essex-Lopresti injury and 4 with medial collateral ligament injury.The coronoid process fracture was fixated with Kirschner wire and the proximal ulnar fracture with plate and screw.Hinged external fixators were used in 2 cases of elbow terrible triad.Patients were evaluated by the Mayo Elbow Performance Score (MEPS). Results The follow-ups averaged 12.95 months ( range,6 to 22 months ).One patient had disturbed elbow flexion of less than 90° due to prosthesis overstuffing,one patient had elbow instability in spite of full range of motion gained due to prosthesis understuffing,and one patient had elbow ankylosis at elbow flexion of 70° with a heterotopic ossification bridge.The results in the other 19 patients were good to excellent. Their average flexion was 131.5°±4.4° (from 130° to 140°),average extension 5.4°±6.3° (from 0 to 20°),average range of extension-flexion motion 126.1 ° ± 7.7° ( from 120° to 140°),average pronation 81.6° ± 6.4° ( from 70°to 90°),average supination 85.6° ± 3.1° (from 80° to 90°),and average range of rotation 167.2° ± 8.2°(from 150° to 180°).Their mean postoperative MEPS score was 94.2 ± 5.1 points (from 85 to 100points). Conclusions The Acumed modular radial head prosthesis offers 200 standard combinations (10left and 10 right stem options with 5 diameters and 4 collar height options) to accommodate different sizes and provide proper restoration of the overall length of the radius,replicates natural radial head geometry,provides improved articulation with the capitellum,prevents loosening and maintains the proper relationship between the radial neck and the plane of the head.Consequently,it is a fine treatment option for radial head fractures of Mason type Ⅲ complicated with additional elbow fractures and soft-tissue injuries,but it can also lead to complications. Key words: Elbow joint; Fractures; Surgical procedures, operative; Arthroplasty, replacement

Surgeon perceptions and patient outcomes regarding proximal ulna fixation: a multicenter experience

Our objective was to determine surgeon- and patient-based perceptions concerning proximal ulna fixation, including rates of implant removal and overall satisfaction. Orthopedic surgeons were surveyed about surgical experience managing proximal ulna fractures and their perception regarding implant removal/revision. A retrospective chart review identified all patients who underwent fixation for proximal ulna fractures and osteotomies between January 2004 and December 2008. In total, 583 surgeons responded to the survey (80%). Of these, 67% believed that their implant removal rate was the same as other surgeons whereas 31% believed that their rate was lower. Seventy-one percent believed that patients required hardware removal less than 30% of the time. Ninety-eight percent believed that they were the same surgeons to remove the implant. In total, 138 consecutive patients were surveyed about their proximal ulna implant. Plating was performed in 80 (58%), and tension banding was performed in 55 (40%). The overall rate of implant removal was 64.5% (89 of 138) at 18.8 months. A second surgeon performed the removal in 68 patients (76%). Of the 49 patients without implant removal, 11 (22%) reported satisfaction with the implant and 19 (39%) reported a functional impairment because of the implant. If guaranteed a safe surgery, 36 (73%) would have the implant removed. Surgeons underestimate the rates of proximal ulna implant removal and patient dissatisfaction. Because 76% of the implant removals were performed by a second surgeon, in sharp contrast to the surgeon-perceived rate of 2%, we challenge surgeons to become more aware of this problem in their practices.

Treatment for proximal ulna fractures with anatomical locking plate

Treatment for proximal ulna fractures with anatomical locking plate

Combined posterior and medial plate fixation of complex proximal ulna fractures

Olecranon fracture dislocations often create complex fractures of the proximal ulna including fragmented coronoid fractures. Olecranon fracture dislocations can occur in an anterior or a posterior direction. In an anterior olecranon (transolecranon) fracture dislocation, the radius and ulna both dislocate anteriorly, the forearm relationships remain intact and the coronoid fracture is usually simple. Posterior olecranon fracture dislocations and varus posteromedial rotational injuries can have greater coronoid fragmentation. Coronoid fragmentation can be difficult to repair with a posterior plate and screws alone. The recently recognised fractures of the anteromedial facet of the coronoid are typically secured with a medial plate and screws, usually acting as a buttress plate. Recently, we have begun treating complex proximal ulna fractures – particularly those with fragmentation of the coronoid – with combined posterior and medial plating of the proximal ulna.

Radial Neck Fractures in Children

To review records of 108 children with radial neck fractures and develop an algorithm for treatment. Records of 50 girls and 58 boys aged 2 to 14 (mean, 8.7) years with radial neck fractures were reviewed. The most common injury mechanism was tripping and falling on an outstretched hand while running (n=44), followed by falling from monkey bars (n=11). Fractures were classified into grade 1 (n=25), grade 2 (n=60), grade 3 (n=16), grade 4a (n=6), and grade 4b (n=1). 21 patients had associated fractures involving the olecranon, proximal ulna, and/or the humeral supracondyle. The time from injury to treatment ranged from 0 to 7 days. Treatments included casting without manipulation (n=86), closed reduction and casting (n=8), percutaneous Kirschner wire-assisted reduction and casting (n=7), and open reduction and casting (n=7). Patients were followed up for a mean of 2.7 (range, 1-5) years. Outcome was excellent in 93 patients, good in 11, and fair in 4. Higher fracture grades correlated positively with poorer outcomes (p=0.001) and more invasive treatment (p=0.001). Nonetheless, the post-reduction angles of all the patients were not significantly different (p>0.05). Older children sustained more severe fractures (p=0.04) and had poorer outcomes, even after correction for fracture grade (p=0.007). Patients with associated fractures had significantly poorer outcomes (p<0.05). Two patients developed synostosis of the proximal radioulnar joint. One of whom had an associated olecranon fracture and underwent open reduction and casting. The other had an associated proximal ulnar fracture and underwent repeated percutaneous Kirschner wire-assisted reduction owing to loss of reduction. Five patients developed heterotopic ossification. Four of whom had associated fractures (3 involved the olecranon and one the proximal ulna). 14 patients developed cubitus valgus deformity of 3º to 10º. Open reduction should only be performed after more conservative treatments fail to achieve reduction.

Proximale Ulnafrakturen

Proximal ulna fractures are common injuries in the upper extremity. The severity of injury ranges from isolated olecranon fractures to complex elbow fracture dislocations. Relevant anatomic features of the proximal ulna for fracture management are presented in the first part of this article. Furthermore, standard and recent techniques of surgical treatment are described in detail for olecranon and Monteggia fractures as well as for fractures of the coronoid process. Functional outcome and complications of fracture treatment are discussed.

Proximal ulna comminuted fractures: Fixation using a double-plating technique

Comminuted fractures of the proximal ulna are severe injuries often associated with bone and ligament injuries of the elbow joint (Monteggia lesion, radial head fractures, dislocation of the elbow). The treatment of these fractures is very demanding and the functional results often fairly mediocre due to associated injuries. Based on a single-center retrospective study, we report the results of the treatment of these fractures fixed using a double-plate technique. The aim was to evaluate the feasibility and reliability of this fixation mode and to compare it with other fractures series using a single plate fixation (in terms of bone union, elbow joint function, and complications stemming from the plates). Eighteen patients sustained a comminuted proximal ulna fracture between 2002 and 2006. The fractures were associated in five cases with a Monteggia type lesion, in two cases with elbow dislocation, and in four cases with a Mason 3 radial head fracture. Four patients had an open fracture. These comminuted ulna fractures included nine Mayo Clinic IIIB fractures. Bone fixation was performed with two third-cylinder tubular plates, one plate on each side of the proximal ulna. This allows more versatile solutions for screw insertion. Functional assessment (according to Broberg and Morrey) and radiological evaluation (bone healing) were provided at 6 months and at the longest follow-up by an independent surgeon. Sixteen of 18 patients achieved bone union. No septic complications occurred and no hardware removal was required on patient request. In 67% of the cases, the Morrey score indicated excellent or good results with a mean score of 82. There are no reports in the literature on the technical point of fixation concerning complex fractures of the ulna. Two plates mean the possibility of twice the number of screw insertions for epiphyseal reconstruction . This fixation remains easy to perform and provides stable anatomic reconstruction of the ulna. Level IV. Retrospective study.

A rare Wilkins group II fracture of the proximal radial metaphysis

In this study, we report a rare fracture of the proximal radial metaphysis in an 11-year-old child, involving an anterior displacement of the proximal radial metaphysis instead of a displacement of the epiphysis, which preserved its normal connections with the capitellum. This fracture was successfully treated by closed reduction and wire fixation. The reduction maneuver attempted to reduce the proximal radial metaphysis under the epiphysis instead of doing the opposite. The mechanism of this injury is probably an extension strain on a forearm in pronation associated with a violent contraction of the biceps brachialis muscle. This fracture is considered as a rare example of Wilkins group II angular fracture of the proximal radial metaphysis, without proximal ulnar fracture.

Comminuted proximal Ulna fractures: injury pattern surgical techniques and outcome

Hypothesis Recently doubt has been shown in relationship between congruency of olacrenon fracture and outcome. The aim of this study was to assess the functional outcome of the comminuted proximal ulnar fractures following open reduction and internal fixation employing various fixation techniques and to study the impact of non-anatomical reduction. Methods Fifty-two consecutive comminuted olacrenon fractures presenting to our unit were retrospectively studied. Results There was a bimodal distribution of age. Twenty-four patients (46%) had associated elbow dislocations. Twenty patients (38%) had concurrent radial fractures. Five different fixation techniques were used to stabilise the fracture. Twenty patients (38%) were noted to have incongruent reduction. There were eight cases of non-union, one case of plate fracture, five cases of heterotopic ossification, four cases of synostosis, and one case of deep infection. Conclusions The functional outcome was associated with congruency of fixation rather than severity of comminution. All major bony complications were noted to be associated with incongruent fixation.

Treatment of Proximal Ulna and Olecranon Fractures by Dorsal Plating

Anatomic reconstruction of proximal ulna and olecranon fractures allowing early mobilization and prevention of ulnohumeral arthritis. Comminuted olecranon or proximal ulna fractures (including Monteggia fractures), olecranon fractures extending distally from the coronoid process, nonunions of the proximal ulna, segmental fractures of the proximal ulna extending into the shaft, fractures of the proximal ulna associated with a coronoid fracture. Patients in poor general condition. Soft-tissue defects around the elbow preventing wound closure over the plate. Pediatric fractures with open growth plates where screws would cross the physis. Posterior approach to the elbow. Hinging the fracture site open by extension of the proximal fragment based on triceps insertion. Fracture involvement of the coronoid with a large displaced fracture fragment can generally be reduced through the fracture side. Reconstruction with temporary Kirschner wires. Fixation by placing a (precontoured) plate around the tip of the olecranon with a long intramedullary screw and orthogonal (uni)cortical screws in the shaft. Radial head pathology can be addressed - if needed - through the same incision. Internal fixation, resection or prosthetic replacement of the radial head is done based on injury pattern/stability. Functional rehabilitation using active assisted range of motion of the elbow may be started immediately out of splint. Posterior splint for 7-10 days to allow wound healing. Between 2003 and July 2008, 26 patients were treated with posterior plating of the proximal ulna and olecranon using this strategy. There were 23 acute fractures (of which one was referred for revision after suboptimal fixation a few days earlier), one nonunion that became traumatized, and two nascent malunions. A midline posterior approach allowed addressing both ulna and radial head pathology. The plate was contoured to wrap around the olecranon. All fractures healed. There were one postoperative infection, one transient ulnar neuropathy, one transient radial neuropathy, and one nonresolving ulnar/median neuropathy in a complex upper extremity injury. At follow-up after an average of 18 months, range of motion was on average 132 degrees /18 degrees of flexion/extension, and 75 degrees /70 degrees of pronation/supination. All fractures had healed at an average of 4.8 months. Ten patients had their hardware removed.