Transolecranon Fracture-dislocation Research Articles

Ulnar Nerve Management in Complex Elbow Dislocations: A Retrospective Monocentric Study

Background/Objectives: The ulnar nerve’s unique anatomy makes it vulnerable to complex elbow dislocations. Depending on the nature of the injury, the clinical treatment and outcomes related to the nerve may vary. Unfortunately, the current literature provides limited and fragmented information on managing the ulnar nerve and the incidence of neuropathy in complex elbow dislocations. This study aimed to determine the occurrence of ulnar nerve pain and its relationship with transposition. Methods: A retrospective evaluation was conducted on a consecutive series of 44 patients who underwent surgery for complex elbow dislocations. The average follow-up period was 29 months. Patients were categorized based on their condition (trans-olecranon fracture–dislocation, Terrible Triad, Monteggia-like lesions, and injuries not falling into the previous categories). The study assessed whether the ulnar nerve was released from the cubital tunnel and underwent transposition. Additionally, the study examined the number of patients experiencing ulnar pain in the postoperative period and its duration over time. All patients were also evaluated using the Mayo Elbow Performance Score (MEPS), Disabilities of Arm, Shoulder, and Hand (DASH) score, and Oxford Elbow Score (OES). Results: Patients who underwent simultaneous ulnar nerve transposition surgery with complex elbow dislocation showed a higher incidence of neuropathy. In these patients, the symptoms were less severe but lasted longer. MEPS, DASH, and OES did not show statistically significant differences between the two groups; however, they were slightly better for the group without ulnar nerve transposition. Conclusions: Surgeons should refrain from routinely transposing the ulnar nerve in complex elbow dislocations. However, further studies involving larger populations are necessary.

Coronoid fractures and complex elbow instability: current concepts.

Fractures of the coronoid process typically occur as part of more complex injury patterns, such as terrible triads, trans-olecranon fracture-dislocations, posteromedial rotatory injuries or Monteggia-like lesions. Each pattern is associated with a specific type of coronoid fracture with regard to shape and size and specific soft-tissue lesions. O' Driscoll classification incorporates those associations identifying three major types of fractures: tip, anteromedial facet, and basal fractures. The objective of this study is to review the most common types of complex elbow instability, identify the indications for coronoid fixation and guide the appropriate management. Tip fractures as those seen in terrible triads can conditionally left untreated provided that elbow stability has been restored after radial head fixation and ligaments repair. Anteromedial facet fractures benefit from a buttress plate, while large basilar fractures can be effectively secured with posteroanterior screws. Coronoid reconstruction with a graft should be considered in post-traumatic cases of chronic coronoid deficiency.

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

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. 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. 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). 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.

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. 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. 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. 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.

Transolecranon Fracture-Dislocations

Transolecranon fracture-dislocations are a rare type of olecranon fracture-dislocation of the elbow involving an olecranon fracture with an anterior radiocapitellar dislocation. In these fractures, the relationship between the proximal radioulnar joint is maintained. Principles of surgical fixation involve anatomic articular reduction of the olecranon, reduction of the radiocapitellar joint, and restoring elbow stability to allow early range of motion. With proper recognition of this fracture pattern and application of fixation principles, good outcomes can be expected for the majority of patients after this high-energy injury.

TRANSOLECRANON FRACTURE-DISLOCATION: CONCEPTS AND FUNCTIONAL RESULTS OF SURGICAL TREATMENT.

This study aimed to evaluate the functional results of the treatment protocol for the treatment of transolecranon fracture-dislocation, by surgical reduction and osteosynthesis with plate and screws, in patients attended at a referral hospital for orthopedic trauma, with a minimum follow-up period of six months. Twenty-five individuals treated surgically from January 2014 to November 2018 were selected for a primary observational longitudinal study using questionnaires to assess upper limb and elbow function (DASH and MEPS), quality of life (SF-12), pain (visual analog scale - VAS), and radiographic evaluation in anteroposterior and lateral views of the elbow. Fifteen patients were male, and the mean age was 46.8 years. All participants had their fractures consolidated, with no radiolgraphic signs of implant failure, or degenerative arthritis. Mean range of motion was reduced relative to the contralateral limb: 102.6º for flexion-extension and 132.8º for pronation-supination. The mean MEPS and DASH scores were 89.6 and 16.5 respectively. There was no residual pain in 84% of the cases according to the VAS. The surgical treatment proposed for transolecranon fracture-dislocations showed satisfactory results according to MEPS, DASH scores and quality of life measures. Evidence Level IV; Retrospective observational study.

The characteristics and treatment strategy for transolecranon fracture-dislocation of the elbow in children: a retrospective study

BackgroundTransolecranon fracture-dislocation of the elbow is rarely seen in children. The purpose of this retrospective study was to discuss the pathological characteristics and treatment strategy for this injury in children.MethodsFrom October 2016 to March 2019, 15 patients seen and treated at our institutions for transolecranon fracture-dislocation of the elbow were identified, and their medical records and radiographs were reviewed retrospectively. There were 11 boys and 4 girls, with an average age of 8.3 years (from 5 to 14 years). The left arm was involved in 10 cases, and the right arm was involved in 5 cases. Type I (simple fracture) was found in 11 cases, and type II (comminuted fracture) was found in 4 cases, 3 of which with coronoid process involved. Closed reduction was successful under local anaesthesia in 14 cases but failed in 1 case. In 11 patients with type I fractures, 10 received fixation of Kirschner wire and tension band, and one patient underwent bone plate fixation. In 4 patients with comminuted fractures (type II), internal fixation was performed with Kirschner wires combined with reconstruction plates.ResultsThe 15 patients were followed up for 24 to 48 months (average, 30.2 months). The final evaluation showed fine anatomical relationship of the elbow in all with no complications observed. Failure of internal fixation did not occur in any patient. The fractures acquired bony union in all patients after 8 to 12 weeks (average, 9.6 weeks). The therapeutic efficacy was evaluated at the final follow-up by the Mayo elbow performance score (MEPS) as excellent in 11 cases, good in 3 cases and fair in one case.ConclusionsAs a type of complicated fracture-dislocation of the elbow, the transolecranon fracture-dislocation is rare in children. The fracture is mainly simple type. Treatment options depend on the type of fracture-dislocation. Only anatomical reduction of the olecranon fracture and restoration of a normal trochlear notch can lead to a stable humeroradial joint and good clinical efficacy.

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.

Trans-olecranon fracture-dislocation of the elbow in children.

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. 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). 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). 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: How should we treat them?

BackgroundTrans-olecranon fracture dislocations are the least frequent complex elbow instability. Proper surgical treatment should be performed to avoid postoperative complications. MethodsA retrospective design study was performed. Patients that suffered from this injury, treated at our center from 2010 to 2016 were included. Fifteen patients were analyzed. Functional results were measured using DASH, MEPS and VAS scores. Average time from injury to first surgical treatment was 4.87 days. Radial head fracture was present in seven cases and coronoid process in three patients. Most frequent complication was hardware disturbances in five patients. Mean follow up was 3.65 years. ResultsMean range of motion (ROM) was evaluated 1 year postoperatively: 129° flexion, 6° flexion contracture, and less than 5° deficit of pronation/supination. Clinical and functional results are encouraging, DASH 36.38, MEPS 100 and VAS 0.46. ConclusionTrans-olecranon fracture dislocations could obtain functional range of movement, pain relief and good functional outcomes with a standardized protocol of surgical fixation. It is important to achieve proper ulnar fixation, focusing in reestablishing dorsal angulation, and also to treat radial head and coronoid injuries properly, if present.

Post-traumatic elbow osteoarthritis after radial head arthroplasty: Prevalence and risk factors

BackgroundOne of the treatment options for comminuted radial head fractures is radial head arthroplasty (RHA), especially when the elbow is also dislocated. While the clinical outcomes of RHA have been well documented, the incidence of post-traumatic osteoarthritis after RHA and its risk factors are not well known. ObjectiveTo determine the incidence of post-traumatic elbow osteoarthritis (humeroulnar and humeroradial joints) after RHA and identify its risk factors. MethodsAll patients who underwent RHA at our hospital between 2008 and 2016 were included retrospectively. The inclusion criteria were primary RHA, recent radial head fracture (isolated or associated with elbow dislocation), minimum 1 year of follow-up, clinical and radiographic examination at final assessment. The exclusion criteria were pre-existing elbow osteoarthritis, RHA revision, multiple fractures of the ipsilateral upper limb or polytrauma. The final assessment consisted of a clinical examination [joint range of motion (ROM) and Mayo Elbow Performance Score (MEPS)] and standard radiographs. The correlation between the incidence and severity of osteoarthritis and various risk factors was determined. ResultsSeventy-three patients were included in the analysis with a mean age of 56 years (21–85). The injuries consisted of 41 terrible triad, 15 isolated radial head fractures, 11 Monteggia fractures and 6 transolecranon fracture-dislocations. The mean follow-up was 3.4 years (1–10.9). At the final assessment, osteoarthritis was visible in the humeroulnar compartment in 56% of cases and in the humeroradial compartment in 72% of cases. There was a statistical correlation between the presence of humeroulnar osteoarthritis at the final assessment and ROM in flexion-extension (p=0.003), MEPS (p<0.001), duration of immobilization (p=0.03) and presence of posterior subluxation on immediate postoperative radiographs (p=0.012). The correlation between humeroradial osteoarthritis at the final assessment and ROM in flexion-extension (p=0.0054), RHA implant position (p<0.01), and unipolar configuration (p=0.027) was statistically significant. ConclusionIn our study, elbow osteoarthritis incidence after RHA was 56% in the humeroulnar joint and 72% in the humeroradial joint. RHA implant placement, posterior subluxation immediately postoperative and the duration of immobilization were significantly corelated with osteoarthritis. Level of evidenceIV; case series without control group.

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.

Transolecranon fracture-dislocations of the elbow: a case series of 15 patients

&lt;p&gt;Transolecranon fracture-dislocations are rare, misdiagnosed, and challenging traumatic injuries. Consensually, they are managed surgically to restore a mobile, stable and painless elbow joint. &lt;em&gt;There&lt;/em&gt; is a relative &lt;em&gt;paucity of studies&lt;/em&gt; on this &lt;em&gt;subject&lt;/em&gt; in the &lt;em&gt;literature. &lt;/em&gt;The purpose of this case series was to establish the epidemiological profile and to describe clinical, radiological, therapeutic and outcome characteristics of these lesions. Between 2007 and 2016, fifteen patients with median age of 36 years (18-65 years) presented to us with transolecranon fracture-dislocations. They were treated surgically and followed regularly with a mean follow-up of 46 months. The &lt;em&gt;cause in&lt;/em&gt; the majority of cases was high-energy trauma, &lt;em&gt;mainly traffic accidents&lt;/em&gt; (80%). Proximal ulna fractures were comminuted in 12 patients (80%) and open in three cases (25%). Open reduction and internal fixation with 3.5 mm reconstruction plates through a posterior approach was used in all cases. During follow up, one patient (6%) had developed wound infection with skin necrosis which was successfully managed by antibiotics and controlled wound healing. Solid osseous union was confirmed for all fractures with an average of 13.5 weeks. At final follow-up, 14 patients (93%) reported excellent outcome with a mean Broberg and Morrey score (BMS) of 86.3. Although rare, transolecranon fracture-dislocations found in patients hospitalized in a high-complexity service occurred in young men who were involved in motor vehicle accidents. These injuries can be treated successfully with reconstruction plate through a posterior approach to achieve and maintain &lt;em&gt;anatomical reduction&lt;/em&gt; by rigid internal fixation, which is essential for promoting early rehabilitation.&lt;/p&gt;

Biomechanical significance of the collateral ligaments in transolecranon fracture-dislocations

It is widely accepted that transolecranon fracture-dislocations are not associated with collateral ligament disruption. The aim of the present study was to investigate the significance of the collateral ligaments in transolecranon fractures. Twenty cadaveric elbows with a mean age of 46.3 years were used. All soft tissue was dissected to the level of the capsule, leaving the anterior band of the medial collateral ligament (MCL) and lateral collateral ligament (LCL) intact. A standardized, oblique osteotomy starting from the distal margin of the cartilage bare area of the ulna was made. The elbows were loaded with an inferiorly directed force of 5 and 10 N in the intact, MCL cut, LCL cut, and both ligaments cut states. All measurements were recorded on lateral calibrated radiographs. The mean inferior translation with intact ligaments (n = 20) when the humerus was loaded with 5 and 10 N was 1.52 mm (95% confidence interval [CI], 1.02-2.02) and 2.23 mm (95% CI, 1.61-2.85), respectively. When the LCL was cut first (n = 10), the inferior translation with 5 and 10 N load was 4.11 mm (95% CI, 0.95-7.26) and 4.82 mm (95% CI, 1.91-7.72), respectively. When the MCL was cut first (n = 10), the inferior translation when loaded with 5 and 10 N was 3.94 mm (95% CI, 0.796-7.08) and 5.68 mm (95% CI, 3.03-8.33), respectively. The inferior translation when loaded with 5 and 10 N and both ligaments cut was 15.65 mm (95% CI, 12.59-18.79) and 17.50 mm (95% CI, 14.86-20.13), respectively. There was a statistical difference between the intact and MCL cut first at 10 N and when both ligaments were cut at 5 and 10 N. The findings suggest that collateral ligament disruption is a prerequisite for a transolecranon fracture-dislocation. An inferior translation of more than 3 mm suggests that at least one of the collateral ligaments is disrupted, and more than 7.5 mm indicates that both collateral ligaments are disrupted.

Patient Outcomes After Transolecranon Fracture-Dislocation.

There are few small case series that discuss patient outcomes after a transolecranon fracture-dislocation, and they suggest that patients have reasonable function after injury. The purpose of this study was to describe the injury pattern and clinical outcomes of transolecranon fracture-dislocations. After Institutional Review Board approval, transolecranon fracture-dislocations treated at two academic level 1 trauma centers between 2005 and 2018 were retrospectively reviewed. Fracture characteristics and postsurgical complications were recorded. Radiographs were reviewed for arthrosis, and Quick Disabilities of Arm, Shoulder, and Hand (QuickDASH) scores were obtained at a minimum of 12 months after injury. Thirty-five patients with a mean follow-up of 28 months (range, 12 to 117 months) were included. Nine patients had associated radial head fracture, 23 patients had associated coronoid fracture, four patients had ligamentous injury, and two patients had capitellum fracture. Four patients (11%) developed infection and required irrigation and débridement with intravenous antibiotics. Thirteen patients (13 of 35, 37%) developed radiographic arthrosis with most (11 of 13) having grade 2 or three changes. Patients who had associated radial head fracture, coronoid fracture, capitellum fracture, and/or ligamentous injury had significant arthrosis (10 of 24, 42%) more commonly than patients with olecranon fracture alone (1 of 11, 9%) (P = 0.05). Twenty-eight patients completed patient outcomes instrument and achieved a mean QuickDASH score of 9 (range, 0 to 59). Patients with isolated transolecranon fracture had a significantly better QuickDASH score (0.93, 0 to 4) than patients with transolecranon fracture variant with associated coronoid fracture, radial head fracture, distal humeral fracture, or ligamentous injury (11.74, 0 to 59) (P = 0.04). Patients with transolecranon fracture-dislocation had excellent return to function based on the QuickDASH outcome assessment. Patients with transolecranon fracture with associated radial head fracture, coronoid fracture, humeral condyle fracture, and/or ligamentous injury tend to have worse functional outcome than patients with simple transolecranon fracture. Level IV-case series.

Anterior transolecranon fracture-dislocation of the elbow in a 4-year-old child

Anterior transolecranon fracture-dislocation of the elbow in a 4-year-old child

Progress in treatment of elbow fracture-dislocation combined with coronary fractures

Elbow fracture-dislocations are typically high-energy injury. Fractures of the coronoid process are usually part of this injury. Successful management of elbow fracture-dislocations associated with coronoid fracture requires recognition of the injury pattern and early treatment to obtain adequate elbow stability. Although some special cases of terrible triad of the elbow can be managed non-operatively, the majority of the frac-ture-dislocations are repaired by surgery. Tip fractures are usually repaired with a lasso suture, steel wire tension band or loop plating along with repair or replacement of the radial head and the lateral collateral ligament. Fractures of the anteromedial coronoid are theorized to occur from varus posteromedial rotatory injury. A subset of the injury can be managed non-operatively. Internal fixation with a buttress plate and reattachment of the lateral collateral ligament is recommended for injuries associated with large fracture fragments or elbow instability. Transolecranon fracture-dislocations are best treated surgically with stable restoration of the trochlear notch. If the elbow is still unstable, it is required to repair the medial collateral ligament or to apply hinged external fixators to maintain concentric reduction and initiate early exercises. Key words: Elbow joint; Dislocations; Fractures, bone; Surgical procedures, operative

Combined anterior and posterior approach in treatment of transolecranon fracture-dislocation

Objective To observe the treatment of transolecranon fracture-dislocation using combined anterior and posterior approach. Methods From September 2010 to October 2014, 6 patients(4 males and 2 females)with transolecranon fracture-dislocation were treated via the combined anterior and posterior approach at our department. Their average age was 42. 5 years(from 25 to 63 years). One case had open injury(Gustilo-Anderson type I)and 5 closed injury. Six cases were associated with coronoid process fracture and 5 with radial head fracture. Bone union was assessed by elbow anterioposterior and lateral radiographs. The elbow function was assessed at the last follow-up according to the Broberg-Morrey functional rating indexes. Results All the 6 patients achieved primary incision healing with no early complications. They were followed up for an average period of 14 months(from 9 to 22 months). All fractures healed 6 months post-operation. At the last follow-up, the average elbow flexion range was 127°(from 90° to 145°)and the average rotation range was 112°(from 80° to 150°). The mean Broberg and Morrey functional score was 89 points(from 74 to 96 points). Two cases were excellent, 3 good, and one moderate. No implant failure, heterotopic ossification or elbow instability was observed at the last follow-up. Conclusion In treatment of transolecranon fracture-dislocation, combined anterior and posterior approach provides clear vision which benefits anatomical reduction and stable fixation. Also it allows early mobilization of the elbow and leads to good short-term results. Key words: Ulnar fractures; Dislocations; Fracture fixation, internal

Complex elbow instability: surgical management of elbow fracture dislocations.

There are three main patterns of complex elbow instability: posterolateral (terrible triad), varus posteromedial (anteromedial coronoid fracture with lateral collateral ligament complex disruption), and trans-olecranon fracture dislocations.Radial head fractures, in the setting of complex elbow instability, often require internal fixation or arthroplasty; the outcome of radial head replacement is dictated by adequate selection of the head diameter, correct restoration of radial length, and proper alignment and tracking.Small coronoid fractures can be ignored. Larger coronoid fractures, especially those involving the anteromedial facet, require fixation or graft reconstruction, particularly in the presence of incongruity.The lateral collateral ligament complex should be repaired whenever disrupted. Medial collateral ligament disruptions seem to heal reliably without surgical repair provided all other involved structures are addressed.The most common mistakes in the management of trans-olecranon fracture dislocations are suboptimal fixation, lack of fixation of coronoid fragments, and lack of restoration of the natural dorsal angulation of the ulna.Cite this article: Sanchez-Sotelo J, Morrey M. Complex elbow instability. EFORT Open Rev 2016;1:183-190.

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.