More Anteromedial Coronoid Involvement in Combined Fractures of the Coronoid and Radial Head Than Traditional Teaching.

IF 4.2 2区 医学 Q1 ORTHOPEDICS
Huub H de Klerk, Neal C Chen, Nadia Azib, Nadalini Nettuno, Robert Kaspar Wagner, Michel P J van den Bekerom, Abhiram R Bhashyam, Job N Doornberg
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引用次数: 0

Abstract

Background: The terrible triad injury involves an ulnohumeral dislocation, radial head fracture, and coronoid process fracture. According to traditional teaching, these injuries are strongly associated with anterolateral coronoid tip fractures and can be addressed via a lateral approach to the elbow. However, recent small clinical series suggest that some terrible triad injuries have larger coronoid fractures involving the anteromedial facet. It is important to understand how often these larger coronoid fractures occur because anteromedial facet fractures may need a different approach and different implants for fixation. An improved understanding of coronoid fracture morphology in terrible triad injuries may help surgeons construct a surgical plan.

Questions/purposes: To better define coronoid fracture morphology in combined coronoid and radial head fractures, we therefore asked: What is the distribution of anterolateral facet versus anteromedial facet coronoid fragments in combined coronoid and radial head fractures without an ulnar shaft fracture?

Methods: This retrospective, multicenter descriptive study evaluated preoperative CT scans from adult patients (18 years or older) diagnosed with combined coronoid and radial head fractures. Between February 2014 and March 2023, we identified 10,016 adult patients with elbow or forearm injuries who underwent CT scans. Among these patients, we considered those diagnosed with combined coronoid and radial head fractures without an ulnar shaft fracture based on elbow CT scans performed within 4 weeks of the injury as potentially eligible. During that time, elbow CT scans were generally ordered to assess complex fractures, confirm diagnoses when radiographs were inconclusive, evaluate joint involvement, or plan for surgical interventions. Based on that, 2% (175 of 10,016) were eligible; a further 0.001% (8 of 10,016) were excluded because of preexisting elbow pathology, prior surgery, or low-quality CT images (including slice thickness greater than 2 mm, motion artifacts, and incomplete visualization of the osseous structure of the elbow and all its articulations), leaving 2% (167 of 10,016) for analysis. The mean age was 50 ± 15 years, and more than half of the patients were female (54% [90 of 167]). Coronoid fractures in patients with combined coronoid and radial head fractures were classified using the O'Driscoll classification into three types: Type 1 (anterolateral tip fractures), Type 2 (anteromedial facet fractures), and Type 3 (base fractures). Each type was further subcategorized based on specific fracture characteristics. Two of three trained researchers independently classified the coronoid fracture type of each patient using radiographs, two-dimensional (2D) CT scans, three-dimensional (3D) CT scans, and intraoperative findings, with interrater reliability assessed by the Cohen kappa, yielding a substantial agreement value of 0.658. Disagreements were resolved through discussions with a fellowship-trained orthopaedic trauma surgeon.

Results: Sixty-five percent (109 of 167) of patients had a Type 1 anterolateral coronoid tip fracture, 30% (50 of 167) had a Type 2 anteromedial facet fracture, and 5% (8 of 167) had a Type 3 basal fracture.

Conclusion: Surgeons should recognize that anteromedial facet involvement in coronoid fractures is more prevalent in combined coronoid and radial head fractures than previously appreciated. Future research should investigate whether these anteromedial fractures are more likely to need an additional medial approach to improve patient outcomes.

Clinical relevance: This study suggests that anteromedial facet involvement is more common than traditionally recognized in terrible triad injuries, and surgeons should be prepared to address a larger fragment when treating these injuries.

冠桡骨头合并骨折前内侧冠受累程度高于传统教学。
背景:可怕三联损伤包括尺骨脱位、桡骨头骨折和冠突骨折。根据传统教学,这些损伤与前外侧冠状突尖端骨折密切相关,可通过肘部外侧入路治疗。然而,最近的小型临床研究表明,一些可怕的三联征损伤有较大的冠状面骨折累及前内侧关节面。了解这些较大的冠状面骨折发生的频率是很重要的,因为前内侧突面骨折可能需要不同的入路和不同的内固定物。对可怕三联征损伤中冠状突骨折形态的进一步了解有助于外科医生制定手术计划。问题/目的:为了更好地定义冠状和桡骨头合并骨折的冠状面骨折形态,我们提出了这样的问题:在没有尺骨轴骨折的冠状和桡骨头合并骨折中,前外侧小面和前内侧小面冠状面碎片的分布是怎样的?方法:这项回顾性、多中心描述性研究评估了18岁以上诊断为冠状头和桡骨头合并骨折的成年患者的术前CT扫描。在2014年2月至2023年3月期间,我们确定了10016名肘部或前臂损伤的成年患者,他们接受了CT扫描。在这些患者中,我们认为根据损伤后4周内肘部CT扫描诊断为冠状头和桡骨头合并骨折而无尺干骨折的患者可能符合条件。在此期间,肘部CT扫描通常用于评估复杂骨折,在x线片不确定时确认诊断,评估关节受累情况,或计划手术干预。在此基础上,2%(10016人中的175人)符合条件;另有0.001%(10016例中有8例)因肘部病变、既往手术或CT图像质量低(包括肘部切片厚度大于2mm、运动假影、肘部骨性结构及其所有关节的可视化不完整)而被排除,留下2%(10016例中有167例)用于分析。平均年龄50±15岁,半数以上患者为女性(54%[90 / 167])。冠状头和桡骨头合并骨折患者的冠状骨折采用O'Driscoll分类法分为三类:1型(前外侧尖端骨折)、2型(前内侧小面骨折)和3型(基底骨折)。每种类型根据特定的裂缝特征进一步细分。三名训练有素的研究人员中有两名使用x线片、二维(2D) CT扫描、三维(3D) CT扫描和术中发现对每位患者的冠状突骨折类型进行了独立分类,并通过Cohen kappa评估了相互间的可靠性,一致性值为0.658。分歧通过与一名接受过奖学金培训的骨科创伤外科医生的讨论得以解决。结果:65%(109 / 167)的患者为1型前外侧冠突尖端骨折,30%(50 / 167)为2型前内侧小面骨折,5%(8 / 167)为3型基底骨折。结论:外科医生应该认识到,冠状突骨折累及前内侧小关节面比以前认为的冠状突和桡骨头合并骨折更为普遍。未来的研究应该调查这些前内侧骨折是否更有可能需要额外的内侧入路来改善患者的预后。临床相关性:本研究表明,在可怕的三联征损伤中,前内侧关节突受累比传统认识的更常见,外科医生在治疗这些损伤时应准备好处理更大的碎片。
本文章由计算机程序翻译,如有差异,请以英文原文为准。
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来源期刊
CiteScore
7.00
自引率
11.90%
发文量
722
审稿时长
2.5 months
期刊介绍: Clinical Orthopaedics and Related Research® is a leading peer-reviewed journal devoted to the dissemination of new and important orthopaedic knowledge. CORR® brings readers the latest clinical and basic research, along with columns, commentaries, and interviews with authors.
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