Results of standardized treatment of elbow fracture dislocations as per their injury pattern: a retrospective cohort of 89 patients

Abstract

Background: Elbow fracture dislocations represent difficult injuries to treat, with a high percentage of complications. Classically, they are divided into posterolateral, posteromedial and transulnar pattern. It is essential to distinguish them to guide intraoperative treatment to achieve an anatomic and stable reduction that allows early mobility.

Methods: A retrospective study of 89 adult patients diagnosed with elbow fracture dislocations who underwent a standardized surgery between 2013 and 2018 with a minimum follow-up of 12 months. Demographic data, characteristics of the injury, and associated procedures were collected. Patients were evaluated with functional scores (Mayo elbow performance score/Broberg and Morrey score) and ranges of movement at the end of the follow-up.

Results: The mean age was 41 ± 12 years, mostly men (82%), with an average follow-up of 29 months. We present 42 patients with posterolateral fracture dislocation (47%), 21 posteromedial (24%) and 26 transulnar (29%). The average range of motion at the end of follow-up was -12 ± 11° extension, 124 ± 20° flexion, 76 ± 16° pronation, and 73 ± 20° supination, with a Mayo elbow performance score of 88.7 ± 12 points and 87.2 ± 12 points in the Broberg and Morrey scale. Reoperation rate was 23%, with no infection or heterotopic ossification cases. Transulnar fracture dislocations have significantly worse extension and supination. As per the functional result (Mayo elbow performance score/Broberg and Morrey scale), there are no significant differences between the different patterns.

Conclusion: Proper injury pattern recognition and a standardized surgical management lead to a stable joint and good results in range of motion. Functional results are encouraging at least at short term, despite the high reoperations rate.

Keywords: Clinical outcomes; Coronoid fracture; Elbow fracture dislocations; Elbow instability; Elbow terrible triad; Transulnar fracture; Workers compensation.

Figure 1

Complex elbow dislocations patterns after primary or spontaneous reduction (x-ray/3D CT). (A) Posterolateral fracture dislocation in valgus (PLRV) or terrible triad with a comminuted radial head and coronoid tip fracture. (B) Posteromedial rotary in varus (PMRV) with an anteromedial facet fracture. (C) Transulnar (basal coronoid) fracture dislocation (TUFD) with a fracture of the greater sigmoid notch and base of the coronoid process. 3D, 3-dimensional; CT, computed tomography.

Figure 2

The standardized surgical procedure according to the type of lesion. FCU, flexor carpi ulnaris; PLRV, posterolateral fracture dislocation in valgus or terrible triad; PMRV, posteromedial rotary in varus; TUFD, transulnar (basal coronoid) fracture dislocation. ∗∗ If a different type of classification was found among observers, coronoid fracture type was used as the most important part to classify the injuries.

Figure 3

Posterolateral rotary pattern surgery. (A) Kocher approach, lesion of humeral insertion of U-LCL. (B) Radial head replacement and suture anchor for LCL repair. (C) Close lateral approach. (D) Postoperative x-ray.

Figure 4

Posteromedial rotary pattern surgery. (A) Medial approach, ulnar nerve release, for FCU-split, (B) Identify the fracture of coronoid. (C) Reduction of fracture. (D) Fixation with coronoid plate. (E) Lateral Kocher approach, for repair U-LCL. (F) Postoperative x-ray. FCU-split, splint in flexor carpi ulnaris.

Figure 5

Transulnar pattern surgery. (A) Transolecranon approach for coronoid fracture fixation. (B) Accessory medial approach for additional anatomic coronoid plate. (C) 3D CT preoperative. (D-E) Intraoperative fluoroscopy of two different patients. (F) Postoperative x-ray. 3D, 3-dimensional; CT, computed tomography.

Figure 6

Comparative analysis of degree of Flexion and extension according to the classification pattern. (1) PLRV, (2) PMRV, (3) TUFD.

Figure 7

Comparative analysis of degree of Pronation and Supination according to the classification pattern. (1) PLRV, (2) PMRV, (3) TUFD.

Figure 8

Comparative analysis Mayo elbow performance and Broberg & Morrey Scores according to the classification pattern. (1) PLRV, (2) PMRV, (3) TUFD. N.S., Not Significant.