Transolecranon fracture dislocation and transolecranon basal coronoid fracture dislocation; results of standardized treatment in a retrospective cohort

Abstract

Background: Our understanding of transolecranon fracture dislocation (TOFD) has evolved to include associated ligament, coronoid, and radial head lesions impacting stability, rather than solely bone stability. Similarly, the understanding of coronoid fracture patterns has progressed. O'Driscoll et al state that basal subtype 2 coronoid fractures correspond to a TOFD, with a fracture passing through the base of the coronoid. In the literature, there is no clear differentiation between basal coronoid TOFD (BC-TOFD) and pure-TOFD outcomes. The main objective of this study is to evaluate the functional results and complications of TOFD using a standardized surgical technique. The secondary objectives are to describe the associated injuries and to compare the results between pure-TOFD and BC-TOFD.

Methods: This retrospective study included all patients with a TOFD treated with a standardized surgical procedure and rehabilitation protocol between 2013 and 2018 in a single trauma level 1 center. The surgical procedure mainly consisted of fixing the olecranon with a plate, using the same screws for coronoid fixation and coronoid plate if necessary. Radial head management involved either arthroplasty or screw fixation, with ligament repair performed as needed. Demographic data and the associated bone and ligament injuries were reviewed. The clinical outcomes (range of motion, Mayo Elbow Performance Score (MEPS), and Broberg and Morrey (B&M) scores) were evaluated at the final follow-up, after a minimum of 2 years. Complications and reoperations were assessed.

Results: 24 patients were included, and 75.0% were men. The average follow-up was 57.9 ± 22.0 months. The mean age was 42.0 ± 15.1 years. 18 (75.0%) were BC-TOFD and 6 (25.0%) were pure-TOFD. Ligament injuries requiring repair and radial head fracture were present in 8 (33.3%) and 11 (45.8%), respectively. The average range of motion were flexion 119.0° ± 17.6, extension deficit 20.4° ± 12.6°, pronation 68.9° ± 20.4°, and supination 63.1° ± 27.4°. MEPS and B&M mean scores were 82.3 ± 16.5 and 82.0 ± 16.1, respectively. The reoperation rate was 33.3%. No significant differences were found between pure-TOFD and BC-TOFD. A significant distribution difference was found in MEPS (P = .001), B&M (P = .002), range of flexion (P = .011), and extension deficit (P = .005) between patients who had reintervention and those who did not.

Conclusion: A standardized protocol for TOFD allows good to excellent functional results. There are no significant differences between pure-TOFD and BC-TOFD. One-third underwent reintervention. Patients with reintervention presented worse outcomes.

Keywords: Complex elbow dislocation; Coronoid fracture; Elbow fracture dislocation; Elbow instability; Transolecranon fracture; Transolecranon fracture dislocation.

Figure 1

Case 9 TOFD with a basal subtype 2 coronoid fracture treated with olecranon and coronoid anatomic plates. (A-D) preoperative after reduction left elbow fracture-dislocations (A) AP view X-ray, (B) lateral view X-ray, (C) CT scan 2D sagittal view, (D) CT scan 3D reconstruction. (E and F) postoperative X-ray (E) AP view, (F) lateral view. (G and H) 3D reconstruction of the 3rd month CT scan, advance healing process. AP, anteroposterior; CT, computed tomography; TOFD, transolecranon fracture-dislocation.

Figure 2

Range of motion based on complications.

Figure 3

Functional scores based on complications. MEPS, Mayo elbow performance; B&M score, Broberg and Morrey score.

Figure 4

Case 17 example of pure-TOFD. (A-C) preoperative left elbow fracture-dislocations, (A) AP view X-Ray, (B) lateral view X-ray, (C) CT scan 3D reconstruction. (D and E) postoperative X-ray (D) AP view, (E) lateral view. (F) 3D reconstruction of the 6th month CT scan, complete healing. CT, computed tomography; TOFD, transolecranon fracture-dislocation.

Figure 5

Case 21 example of TOFD with a basal subtype 2 coronoid fracture. (A-C) preoperative right elbow fracture-dislocations (A) AP view X-ray, (B) lateral view X-ray, (C) CT scan 3D reconstruction. (D and E) postoperative X-ray, (D) AP view and (E) lateral view. (F and G) postoperative 3rd month X-ray; (F) AP view and (G) lateral view. CT, computed tomography; TOFD, transolecranon fracture-dislocation.