Magnetic resonance imaging findings in 46 elbows with a radial head fracture

Background and purpose Radial head fractures are common, and may be associated with other injuries of clinical importance. We present the results of a standard additional MRI scan for patients with a radial head fracture.

Patients and methods 44 patients (mean age 47 years) with 46 radial head fractures underwent MRI. 17 elbows had a Mason type-I fracture, 23 a Mason type-II fracture, and 6 elbows had a Mason type-III fracture.

Results Associated injuries were found in 35 elbows: 28 elbows had a lateral collateral ligament lesion, 18 had capitellar injury, 1 had a coronoid fracture, and 1 elbow had medial collateral ligament injury.

Interpretation The incidence of associated injuries with radial head fractures found with MRI was high. The clinical relevance should be investigated.     

A figure-eight suture loop with Kirschner wires for fixation of anteromedial coronoid process fractures: A case series

PurposeSufficient fixation of an anterior or anteromedial facet fracture of the coronoid process in fracture-dislocation of elbow is important to maintain joint stability. The purpose of this study was to report our experience with 11 patients who were managed with an original fixation technique using a “figure-eight” suture loop.MethodsFrom February 2010 to March 2011, 11 cases with a fracture of the anterior or anteromedial facet of the coronoid process were treated by coronoid fixation using a figure-eight suture loop. For cases with comminuted fractures, to prevent a suture from sliding into the fracture line, a 3- or 4-hole phalanx plate was enclosed in the suture loop to compress multiple fragments. Accompanying injuries, such as a radial head fracture or olecranon fracture, were fixed with repair of lateral collateral ligament injuries.ResultsOn final evaluations at an average of 18 months after injury, the mean elbow arc of motion was 125.5° and the mean forearm rotation arc of 124.1°. All fractures were united with an average postoperative score according to the Mayo Elbow Performance Index of 91 points. All patients achieved satisfactory scores (seven excellent, four good). All 11 fractures were united at final follow-up with no joint incongruity, dislocation, or subluxation of the injured elbow.ConclusionsThe figure-eight suture loop technique is an easy and effective technique to fix anterior or anteromedial facet fractures of the coronoid process.     

Surgical management of medial and lateral elbow instability secondary to acute atypical complex elbow dislocation: Case report and literature review

Introduction and importanceElbow dislocation is common in adults, and complex elbow dislocations are generally associated with bone fractures. Anteromedial coronoid fracture, in association with lateral collateral ligament (LCL) disruption, often results from varus posteromedial forces. “Terrible triad” injuries are more likely to result from valgus posterolateral forces. However, our case presentation has combined medial and lateral elbow instability in addition to “terrible triad” injury of the elbow with no radial head injury.Case presentationThe patient was a 38-year-old man with an atypical complex elbow dislocation. He was successfully treated by stabilizing the medial epicondyle and coronoid anterolateral facet fractures, in addition to LCL repair and medial collateral ligament (MCL) reconstruction. A radial head fracture was unnoted. The procedure yielded satisfactory functional outcome, with a stable and painless full elbow range of motion.Clinical discussionMulti-ligament injuries with coronoid fractures result in highly unstable elbow joints, forming a variant of the “terrible triad” injury. Surgical options vary according to the surgeon’s experience and equipment availability. In this case, direct LCL repair and MCL reconstruction were performed and were well tolerated. Elbow stability improved and the patient experienced improved functionality with minimal pain. However, it may be premature to report a definite outcome in this case because of short follow-up time postoperatively.ConclusionThe injury described in this case has a unique presentation as a multi-ligamentous injury will make the elbow very unstable. Thus, careful clinical judgment, knowledge, and experience are needed to identify the underlying injury and for optimal management.     

尺骨冠状突前内侧面骨折伴肘关节外侧副韧带损伤的手术治疗

目的探讨尺骨冠状突前内侧面骨折伴肘关节外侧副韧带损伤的手术治疗方法及临床疗效。 方法回顾性分析2011年4月至2014年7月四川省骨科医院收治且获完整随访的9例尺骨冠状突前内侧面骨折伴肘关节外侧副韧带损伤患者临床资料。其中男6例,女3例;年龄20~62岁,平均41岁。致伤原因：跌伤3例,自行车伤1例,电动自行车伤3例,交通事故伤2例。均为新鲜闭合骨折;无神经、血管损伤。受伤至手术时间4~12 d,平均7.2 d。均为O'Driscoll分型2型,其中1亚型1例,2亚型5例,3亚型3例。其中肘关节外侧副韧带肱骨外髁止点撕脱骨折4例,其余5例术中证实肘关节外侧副韧带肱骨外髁止点撕脱。伴有尺骨鹰嘴骨折或为肘关节恐怖三联征患者未纳入本组。经肘关节前侧或内侧入路复位,以支撑钢板、缝合锚、螺钉固定冠状突骨折及修复前侧关节囊。经后外侧入路,以缝合锚修复外侧副韧带。 结果术后切口均Ⅰ期愈合,无血管神经损伤。随访时间12~48个月,平均25.6个月,X线片示骨折均愈合。随访期间无内固定物失效、肘关节不稳定、创伤后骨关节炎等并发症发生。末次随访时患肘关节活动范围：伸肘0~10°,平均1.1°;屈肘110~135°,平均128.9°;前臂旋前40~70°,平均61.1°;旋后80~90°,平均88.9°。Broberg和Morrey肘关节功能评分为82~100分,平均95分;优6例,良3例,优良率100%。疼痛视觉模拟评分为0~2分,平均0.7分。 结论重视和识别尺骨冠状突前内侧面骨折伴肘关节外侧副韧带损伤,对于存在肘关节内翻后内侧旋转不稳定者,根据冠状突骨折块的大小、部位及形态,经肘关节前侧或内侧入路复位,以支撑钢板、缝合锚及螺钉固定,修复前侧关节囊,经肘关节后外侧入路,以缝合锚修复外侧副韧带,术后早期活动锻炼,可获得满意疗效。     

Avulsion of the distal triceps tendon with fracture of the radial head

We present a rare case of associated distal triceps tendon avulsion with radial head fracture; the lateral and medial collateral ligaments of the elbow were also ruptured. The patient underwent surgical procedure for the reinsertion of the triceps tendon using metallic anchors, radial head prosthetic replacement, and repair of the lateral collateral ligament. We believe this combined injury pattern of radial head fracture with triceps tendon rupture or avulsion should be considered according to the concept of the spectrum of elbow instability.     

Anterior approach for operative fixation of coronoid fractures in complex elbow instability

The coronoid process has been shown to play a critical role in ulnohumeral stability. Coronoid process fractures can occur in isolation or as part of a complex injury pattern. The most common complex pattern, known as the "terrible triad," includes a radial head fracture and elbow dislocation along with the coronoid fracture. Failure to address these fractures and ligamentous injuries can result in recurrent instability and progression to painful arthrosis. Both medial and lateral approaches to the coronoid have been popularized in recent literature, but there is no universally accepted approach. Common fixation techniques include suture lasso, suture anchors, lag screws, and plating all of which have various drawbacks. We describe a direct anterior approach to address coronoid process fractures made in addition to a lateral approach to address radial head and lateral collateral ligament injuries. Coronoid fractures addressed through the anterior approach were stabilized with anterior to posterior screw fixation combined with buttress plating, which allowed anatomic reduction and stable internal fixation at short-term follow-up.     

双线锚钉内固定治疗撕脱性跟骨骨折

目的：对于跟骨撕脱性骨折,当前较常用的方法是螺钉固定或克氏针固定骨折块,本文旨在探讨应用双线锚钉固定器治疗撕脱性跟骨骨折的可行性与临床疗效。方法：自2007年7月至2010年11月共21例跟骨骨折患者,男15例,女6例;年龄49～65岁,平均58.7岁;右跟骨结节12例,左跟骨结节9例;均为闭合性骨折。术前典型症状：足跟后上部疼痛,提踵无力。查体：足跟后部可扪及骨擦感,患处肿胀、压痛明显。手术以TwinFix双线锚钉固定：锚钉旋入跟骨主体,于骨折块上钻孔,双股缝线穿过孔隙后打结固定骨折块,剩余缝线缝合于跟腱以加强固定。采用美国足踝外科协会AOFAS标准对跟腱功能恢复情况进行评估,包括疼痛、功能、力线3项指标。结果：术后AOFAS总平均分（95.5±3.12）分,其中疼痛平均得分（38.5±2.18）分,功能平均得分（49.5±3.09）分,力线均为10分;优16例,良5例。结论：应用双线锚钉治疗撕脱性跟骨骨折,手术简捷,疗效优良,值得推广。     

胫骨平台外侧缘撕脱骨折的特点及临床诊治分析

目的 :探讨膝关节损伤中胫骨平台外侧缘撕脱骨折的特点及临床诊治。方法 :自2011年1月至2015年12月运用关节镜技术微创治疗关节内损伤结合双锚钉内固定胫骨平台外侧缘撕脱骨折29例,男17例,女12例;年龄27~62岁,平均41岁。20例合并前交叉韧带断裂(包含前交叉韧带胫骨止点撕脱骨折),3例合并后交叉韧带断裂,1例同时合并前交叉韧带和后交叉韧带断裂,3例合并侧副韧带撕裂,2例合并胫骨平台骨折(内侧平台骨折和外侧平台骨折各1例)。术前均行X线、CT及MRI检查明确诊断,在受伤后5~14 d进行手术,平均7 d。采用Lysholm膝关节评分对膝关节术前、术后功能进行评价。结果:手术时间40~125 min,平均85 min;出血量10~30 ml,平均15 ml。术后所有患者获随访,时间12~18个月,平均14个月。Lysholm膝关节评分由术前的52.0±4.2明显提高至术后1年的91.9±1.4(t=-49.24,P0.05)。抽屉试验、Lachman试验及侧方应力试验均阴性,骨折均骨性愈合。结论 :胫骨平台外侧缘撕脱骨折提示合并有膝关节静力稳定结构(关节韧带、关节囊、半月板等)的损伤,甚至关节内骨折。常规要行CT和MRI检查,建议行关节镜探查,防止漏诊,以使患者能得到及时、全面的治疗,为膝关节功能最大限度恢复创造有利条件。     

Isolated avulsion fracture of the coronoid process requiring open reduction in a paediatric patient: a case report

Coronoid process fractures are reported to occur from avulsion by the brachialis muscle or to be associated with elbow dislocations. We report a rare case of coronoid process fracture due to avulsion by the anterior bundle of the medial collateral ligament rendering the elbow unstable. In children, small fracture fragments of the coronoid process (types 1 & 2) are in reality often much larger but the actual size is not appreciated radiographically, as the coronoid process contains considerable amounts of cartilage. If the fragment is seen to be significantly displaced it may have resulted from avulsion by important structures such as the medial collateral ligament and open reduction is required to stabilise the elbow.     

The pathoanatomy of lateral ligamentous disruption in complex elbow instability

We sought to determine the lateral soft-tissue injury pattern in a consecutive series of patients with elbow dislocation (10 cases) or fracture-dislocation (52 cases) that required open operative repair. Patients who were seen more than 3 months after injury or those in whom previous operative intervention had obscured the anatomy were excluded. There were 42 men and 19 women (mean age, 43 years; range, 13-82 years). One patient had bilateral injuries. The mean time to surgery was 15 days after injury, with a range from 1 to 76 days. There were associated fractures in 52 elbows: coronoid (39), radial head (36), proximal ulna (14), and distal humerus (6). Disruption of the lateral collateral ligament (LCL) complex was seen in all 62 elbows in one of six patterns of injury: proximal avulsion in 32, bony avulsion of the lateral epicondyle in 5, midsubstance rupture in 18, ulnar detachment of the LCL in 3, ulnar bony avulsion in 1, and combined patterns in 3. We found concomitant rupture of the common extensor origin in 41 cases (66%). Operative tactics included anatomic fixation of associated fractures, fixation or replacement of the radial head, and lateral soft-tissue repair. Disruption of the LCL was a universal finding in our patients. Avulsion from the distal humerus was the most common pattern, followed by midsubstance rupture; ulnar detachment or bony avulsion was rare. Disruption of the common extensor origin (a secondary constraint) was seen in 66% of cases. Repair of these lateral soft-tissue structures should be an integral part of the surgical strategy for elbow dislocations and fracture-dislocations that require operative treatment.     

The effect of radial head fracture size on elbow kinematics and stability.

This study determined the effect of radial head fracture size and ligament injury on elbow kinematics. Eight cadaveric upper extremities were studied in an in vitro elbow simulator. Testing was performed with ligaments intact, with the medial collateral (MCL) or lateral collateral (LCL) ligament detached, and with both the MCL and LCL detached. Thirty degree wedges were sequentially removed from the anterolateral radial head up to 120 degrees . Valgus angulation and external rotation of the ulna relative to the humerus were determined for passive motion, active motion, and pivot shift testing with the arm in a vertical (dependent) orientation. Maximum varus-valgus laxity was calculated from measurements of varus and valgus angulation with the arm in horizontal gravity-loaded positions. No effect of increasing radial head fracture size was observed on valgus angulation during passive and active motion in the dependent position. In supination, external rotation increased with increasing fracture size during passive motion with LCL deficiency and both MCL and LCL deficiency. With intact ligaments, maximum varus-valgus laxity increased with increasing radial head fracture size. With ligament disruption, elbows were grossly unstable, and no effect of increasing radial head fracture size occurred. During pivot shift testing, performed with the ligaments intact, subtle instability was noted after resection of one-third of the radial head. In this in vitro biomechanical study, small subtle effects of radial head fracture size on elbow kinematics and stability were seen in both the ligament intact and ligament deficient elbows. These data suggest that fixation of displaced radial head fractures less than or equal to one-third of the articular diameter may have some biomechanical advantages; however, clinical correlation is required.     

Rehabilitation of the Medial- and Lateral Collateral Ligament-deficient Elbow: An In Vitro Biomechanical Study

DesignIn vitro biomechanical research using an elbow motion simulator.IntroductionThe optimal rehabilitation of elbow dislocations with medial collateral ligament (MCL) and lateral collateral ligament (LCL) injuries has not been defined.PurposeTo determine a safe rehabilitation protocol for elbow dislocations with MCL and LCL injuries.MethodsEight cadaveric elbows underwent simulated active and passive motions with the arm in multiple orientations. Varus–valgus angulation and internal–external rotation of the ulna relative to the humerus were quantified for the intact joint and with injured MCL and LCL.ResultsActive motion with injured MCL and LCL in the horizontal and vertical orientations resulted in kinematics similar to the intact elbow, whereas passive motion resulted in significant kinematic alterations. Marked elbow instability was noted in the varus and valgus orientations using both active and passive motion.ConclusionsElbows with MCL and LCL injuries should be rehabilitated using active motion in the horizontal or vertical orientations.Level of EvidenceBasic science research.     

Magnetic resonance imaging findings in 46 elbows with a radial head fracture

Background and purpose

Radial head fractures are common, and may be associated with other injuries of clinical importance. We present the results of a standard additional MRI scan for patients with a radial head fracture.

Patients and methods

44 patients (mean age 47 years) with 46 radial head fractures underwent MRI. 17 elbows had a Mason type-I fracture, 23 a Mason type-II fracture, and 6 elbows had a Mason type-III fracture.

Results

Associated injuries were found in 35 elbows: 28 elbows had a lateral collateral ligament lesion, 18 had capitellar injury, 1 had a coronoid fracture, and 1 elbow had medial collateral ligament injury.

Interpretation

The incidence of associated injuries with radial head fractures found with MRI was high. The clinical relevance should be investigated.     

Avulsion fracture of the supinator crest of the proximal ulna in the context of elbow joint injuries

Purpose

While performing CT examinations of the elbow, we frequently observed a previously undescribed fracture fragment of the supinator crest of the ulna. According to the anatomy of the lateral collateral ligament complex, this fracture might be an avulsion fracture of the annular ligament and/or the lateral ulnar collateral ligament. The aim of this study was to further characterize these fragments and document their associated injuries.

Methods

Retrospective evaluation of CT scans of the elbow was performed. Conventional X-ray and CT diagnoses were used to systematically document any associated injuries.

Results

A total of 152 CT scans were evaluated. The fragment in question was discovered in 17 patients (11.2 %). The average age of the patients was 40 years (±14.9; 9–71 years). The fragment size varied between a few millimetres and 2.4 cm. Multifragmented fractures were observed. In 82.3 % of the cases, associated radial head fractures were diagnosed. In 29.4 %, a coronoid process fracture was present. Distal humerus fractures were found in 23.5 %. Instability in the medial collateral ligament and an Osborne-Cotterill lesion were found in 11.8 % of the patients, respectively.

Conclusions

In a significant percentage of the population, a previously undescribed fracture fragment of the supinator crest of the ulna could be detected. The most frequently occurring associated injuries were fractures of the radial head, the coronoid process, and the distal humerus. The aetiology of these lesions is unknown; however, bony avulsion of the annular or the lateral ulnar collateral ligament seems to be the most likely cause. If this fragment is to be diagnosed by CT, the possibility of lateral or posterolateral instability should be considered.     

Elbow dislocation with intra-articular fracture: the results of operative treatment without repair of the medial collateral ligament

PURPOSE: To determine the effectiveness of a protocol for the treatment of fracture-dislocations of the elbow based on the concept that, if dislocation of the elbow with associated fractures can be made to resemble a simple elbow dislocation by repairing or reconstructing the fractured structures, repair of the medial collateral ligament (MCL) will not be necessary. METHODS: Over a 5-year period, a single surgeon operated on 34 patients with a posterior dislocation of the elbow associated with one or more intra-articular fractures. The mean age of these 19 men and 15 women was 48 years. Associated fractures included the capitellum, trochlea, and lateral epicondyle in 3 patients; the olecranon in 1 patient; and the radial head in 30 patients (with concomitant fracture of the coronoid process-the so-called "terrible triad" of the elbow-in 22 patients, and concomitant fracture of the coronoid and olecranon in 1 patient). Operative treatment consisted of open reduction internal fixation (ORIF) or prosthetic replacement of all fractures and reattachment of the origin of the lateral collateral ligament (LCL) complex to the lateral epicondyle. The MCL was not repaired. RESULTS: Two patients (1 with a terrible triad injury and 1 with fracture of the capitellum and trochlea) had postoperative instability related to noncompliance, had reconstructive procedures, and were considered failures. An average of 32 months after injury, the remaining 32 patients regained an average of 120 degrees ulnohumeral motion and 142 degrees forearm rotation. Twenty-five of 34 patients (74%) had good or excellent results according to the system of Broberg and Morrey. Patients with terrible triad injuries had an average of 117 degrees ulnohumeral motion and 137 degrees forearm rotation, and 17 of 22 patients (77%) had good or excellent results. CONCLUSIONS: MCL repair is unnecessary in the treatment of dislocation of the elbow with associated intra-articular fractures, provided that the articular fractures and the LCL are repaired or reconstructed.     

Unstable Simple Elbow Dislocation Treated with the Repair of Lateral Collateral Ligament Complex

Background

Unstable simple elbow dislocation (USED) repair is challenged by the maintenance of joint reduction; hence, primary repair or reconstruction of disrupted ligaments is required to maintain the congruency and allow early motion of the elbow. We evaluated the effectiveness and the outcome of lateral collateral ligament (LCL) complex repair with additional medial collateral ligament (MCL) repair in cases of USED.

Methods

We retrospectively reviewed 21 cases of diagnosed USED without fractures around the elbow that were treated with primary ligament repair. In all cases, anatomical repair of LCL complex with or without common extensor origin was performed using suture anchor and the bone tunnel method. Next, the instability and congruency of elbow for a full range of motion were evaluated under the image intensifier. MCL was repaired only if unstable or incongruent elbow was observed. Clinical outcomes were evaluated using the Mayo elbow performance score (MEPS) and radiographic outcomes on last follow-up images.

Results

All cases achieved a stable elbow on radiographic and clinical results. LCL complex repair alone was sufficient to obtain the stable elbow in 17 of 21 cases. Four cases required additional MCL repair after restoration of the LCL complex. The overall mean MEPS was 91 (range, 70 to 100): excellent in 12 cases, good in 7 cases, and fair in 2 cases. All 17 cases with LCL complex repair only and 2 of 4 cases with additional MCL repair had excellent or good results by MEPS.

Conclusions

USED requires surgical treatment to achieve a congruent and stable joint. If the repair of lateral stabilizer such as LCL complex acquires enough joint stability to maintain a full range of motion, it may not be necessary to repair the medial stabilizer in all cases of USED.     

Coronoid fixation and lateral collateral ligament repair in varus posteromedial rotatory instability of the elbow

BackgroundVarus posteromedial rotatory instability is a relatively rare elbow injury, that has been infrequently reported in published literature. We intended to evaluate the outcomes of surgical management of this rare injury with anteromedial coronoid fixation, and, in selected patients, lateral ulnar collateral ligament (LUCL) repair.MethodsBetween 2017 and 2020, we identified 12 patients with anteromedial coronoid fractures, and a varus posteromedial rotatory instability, who underwent surgery for fixation of the coronoid fracture, with or without LCL repair. All the included patients were either O'Driscoll subtype 2-2, or subtype 2–3. All the 12 patients were followed up for a minimum of 24 months, and their functional outcomes assessed using the Mayo Elbow Performance Score (MEPS).ResultsThe mean MEPS recorded in our study was 92.08, and the mean range of elbow flexion achieved was 124.2°. The mean flexion contracture in our patients was 5.83°. Three of our twelve patients (25%) suffered from elbow stiffness even at final follow-up. The results were graded as Excellent in eight, Good in three, and Fair in one patient.ConclusionCoronoid fractures and LUCL disruptions associated with varus posteromedial rotatory instability can be reliably managed by employing a protocol that combines radiographic parameters, as well as intra-operative assessments of stability. While surgical intervention successfully restored stability, there is a learning curve to the management of these injuries and complications are not uncommon, particularly elbow stiffness. Hence, in addition to surgical fixation, emphasis should also be placed on intensive post-operative rehabilitation to improve outcomes.     

Technique for internal fixation of capitellum and lateral trochlea fractures

Internal fixation for fractures of the humeral capitellum is a technically challenging procedure. Controversy exists regarding the optimal surgical approach and fixation technique. The benefit of stable fixation of the capitellum fragment is early mobilization. Our preferred technique involves anatomic reduction of the capitellar fragment and fixation with headless screws placed from anterior to posterior. When possible, the surgical exposure employed preserves the lateral ulnar collateral ligament (LUCL) and minimizes disruption of the soft tissues posterior to the capitellum.     

Valgus instability of the elbow due to medial epicondyle nonunion: treatment by fragment excision and ligament repair--a report of 5 cases

We identified 5 patients with valgus instability of the elbow due to nonunion of a previous fracture of the medial epicondyle. There were 4 male patients and 1 female patient with a mean age of 35 years (range, 15-54 years). The original avulsion fracture of the medial epicondyle had occurred a mean of 10.1 years previously (range, 4 months to 25 years), and all patients had had their initial fracture treated nonoperatively. After the development of medial epicondyle nonunion, 3 patients had been treated nonoperatively and 2 had undergone unsuccessful attempts at osteosynthesis. All patients were treated with excision of the medial epicondyle, advancement of the medial collateral ligament, and fixation to the distal humerus with suture anchors. The mean Mayo Elbow Performance Score improved from 66 preoperatively to 91 postoperatively (P <.05), and all patients were satisfied with the increased stability provided by the procedure. On the basis of our experience with these 5 patients, it appears that excision of the nonunion fragment and repair of the medial collateral ligament to the distal humerus can provide satisfactory outcomes in these patients.     

桡骨远端骨折合并同侧肘关节损伤的手术治疗体会

目的探讨桡骨远端骨折合并同侧肘关节周围骨折或脱位的治疗方法,提高临床治疗效果。 方法回顾性分析本院自2012年1月至2016年10月收治的桡骨远端骨折合并同侧肘关节脱位或骨折病例22例。22例桡骨远端骨折中13例伴尺骨茎突骨折,3例伴尺骨远端骨折,2例伴舟状骨骨折。22例肘关节周围损伤中5例为尺桡骨近端骨折,3例为肱骨远端骨折,14例发生肘关节后脱位。 结果所有患者均获得随访,术后平均随访时间为13.6个月（11~26个月）,所有骨折均愈合,未发生感染。Cooney腕关节评分平均为92.5分（55~100分）,其中优13例、良7例、中1例、差1例。Mayo肘关节功能评分平均为87.5分（50~100分）,其中优10例、良8例、中3例,差1例。其中1例就诊时已出现骨筋膜室综合征,尺神经、正中神经、桡神经均损伤,肌肉部分坏死切除,功能恢复较差。 结论桡骨远端骨折合并同侧肘关节损伤多为高能量损伤,早期积极而恰当的处理能为患者二次手术提供良好的条件,结合积极的康复锻炼,能取得良好的治疗效果。