Evaluation of complex elbow dislocations outside of the triads. Comparison of Monteggia, transolecranon, and transulnar fractures.

Introduction: Proximal ulna fractures account for approximately 10% of elbow fractures. Fracture-dislocations present a complex challenge due to their difficulty in analysis and repair. We compared fracture-dislocations according to the Mayo classification. The aim of this study was to compare the clinical and radiological outcomes of Monteggia, transolecranon, and transulnar fracture-dislocations, while excluding terrible triads (Mayo classification). We hypothesized that 46 transulnar fractures involving the basal coronoid would be associated with worse functional results, more advanced arthritis, and higher complication rates.

Material and methods: We reviewed 36 patients who underwent surgery for proximal ulna fracture-dislocations between 2004 and 2019, with a minimum follow-up of 9 months. This was a monocentric retrospective study. We analyzed 9 Monteggia fractures, 13 true olecranon fractures, and 14 ulna fractures with basal coronoid fractures. Clinical parameters (MEPS, QDASH, range of motion), radiological criteria (osteoarthritis, heterotopic ossification, pseudarthrosis, quality of reduction), and complications (stiffness, pseudarthrosis, neurological complications, etc.) were analyzed.

Results: Monteggia fractures had an average MEPS of 87 and an average QDASH of 21.3. The average range of motion for Flexion-Extension was 112 °. Six patients had arthritis at the last follow-up (67%). There were five cases of ossification (56%), one case of pseudarthrosis (11%), and two cases of stiffness (22%). For true olecranon fracture-dislocations, the average MEPS was 74 and the average QDASH was 31. The average range of motion for Flexion-Extension was 92 °. Eleven patients had arthritis at the last follow-up (87.5%). There were eight cases of ossification (62%), two cases of pseudarthrosis (15%), and four cases of stiffness (46%). For ulna fractures with basal coronoid fractures, the average MEPS was 68, and the average QDASH was 41.7. The average range of motion for Flexion-Extension was 85 °. Thirteen patients had arthritis at the last follow-up (93%). There were eight cases of ossification (57%), four cases of pseudarthrosis (29%), and nine cases of stiffness (64%).

Discussion: Ulna fractures with basal coronoid fractures had worse functional outcomes and more complications. Therefore, a strict preoperative assessment of the lesions is necessary for optimal functional recovery.

Level of evidence: IV.