Morphological Characteristics of Proximal Ulna Fractures: A Proposal for a New Classification and Agreement for Validation

Abstract

Historically, proximal ulna fractures have been simplistically diagnosed and treated as simple olecranon fractures, leading to an unacceptable number of complications. Our hypothesis was that the recognition of lateral, intermediate, and medial stabilizers of the proximal ulna and ulnohumeral and proximal radioulnar joints would facilitate decision-making, including the choice of approach and type of fixation. The primary aim was to propose a new classification for complex fractures of the proximal ulna based on morphological characteristics seen on three-dimensional computed tomography (3D CT). The secondary aim was to validate the proposed classification regarding its intra- and inter-rater agreement. Three raters with different levels of experience analyzed 39 cases of complex fractures of the proximal ulna using radiographs and 3D CT scans. We presented the proposed classification (divided into four types with subtypes) to the raters. In this classification, the medial column of the ulna involves the sublime tubercle and is where the anterior medial collateral ligament is inserted, the lateral column contains the supinator crest and is where the lateral ulnar collateral ligament is inserted, and the intermediate column involves the coronoid process of the ulna, olecranon, and anterior capsule of the elbow. Intra- and inter-rater agreement was analyzed for two different rounds, and the results were evaluated according to Fleiss kappa, Cohen kappa, and Kendall coefficient. Intra- and inter-rater agreement values were very good (0.82 and 0.77, respectively). Good intra- and inter-rater agreement attested to the stability of the proposed classification among the raters, regardless of the level of experience of each one. The new classification proved to be easy to understand and had very good intra- and inter-rater agreement, regardless of the level of experience of each rater.

Keywords: classification; elbow trauma; proximal ulna fracture; validation.

Figure 1

Selection process used for defining the images.

Figure 2

Type IA fracture—transolecranon fracture of the proximal ulna with no involvement of the sublime tubercle and supinator crest.

Figure 3

Type IB fracture—transolecranon fracture of the proximal ulna with associated fracture of the coronoid process and no involvement of the sublime tubercle and supinator crest.

Figure 4

Type IIA fracture—transolecranon fracture of the proximal ulna with associated fracture of the sublime tubercle.

Figure 5

Type IIB fracture—transolecranon fracture of the proximal ulna with associated fracture of the sublime tubercle and coronoid process.

Figure 6

Type IIIA fracture—transolecranon fracture of the proximal ulna with associated fracture of the supinator crest.

Figure 7

Type IIIB fracture—transolecranon fracture of the proximal ulna with associated fracture of the supinator crest and coronoid process.

Figure 8

Type IV fracture—transolecranon fracture of the proximal ulna with associated fracture of the sublime tubercle, supinator crest, and coronoid process.