Trans-ulnar Fracture Dislocations of the Elbow: A Systematic Review and Clarification of Classification Systems.

INTRODUCTION: Complex elbow dislocations in which the dorsal cortex of the ulna is fractured can be difficult to classify and therefore treat. These have variably been described as either Monteggia variant injuries or trans-olecranon fracture-dislocations. Additionally, O'Driscoll et al classified coronoid fractures that exit the dorsal cortex of the ulna as "basal coronoid, subtype 2" fractures. The Mayo classification of trans-ulnar fracture-dislocations categorizes these injuries in three types according to what the coronoid remains attached to: Trans-olecranon fracture-dislocations, Monteggia variant fracture-dislocations, and trans-ulnar basal coronoid fracture-dislocations. The purpose of this study was to evaluate the outcomes of these injury patterns as reported in the literature. Our hypothesis was that trans-ulnar basal coronoid fracture-dislocations would have a worse prognosis.

MATERIALS & METHODS: We conducted a systematic review to identify studies with trans-ulnar fracture-dislocations that had documentation of associated coronoid injuries. A literature search identified 16 qualifying studies with 296 fractures. Elbows presenting with basal subtype 2 or Regan/Morrey III coronoid fractures and Jupiter IIA and IID injuries were classified as trans-ulnar basal coronoid fractures. Patients with trans-olecranon or Monteggia fractures were classified as such if the coronoid was not fractured or an associated coronoid fracture had been classified as O'Driscoll tip, anteromedial facet, basal subtype I or Regan Morrey I/II.

RESULTS: The 296 fractures reviewed were classified as trans-olecranon in 44 elbows, Monteggia variant in 82 elbows, and trans-ulnar basal coronoid fracture-dislocations in 170 elbows. Higher rates of complications and reoperations were reported for trans-ulnar basal coronoid injuries (40%, 25%) compared to trans-olecranon (11%, 18%) and Monteggia variant injuries (25%, 13%). The mean flexion-extension arc for basal coronoid fractures was 106° compared to 117° for Monteggia (p<.01) and 121° for trans-olecranon injuries (p=.02). The mean Mayo Elbow Performance Score (MEPS) was 84 points for trans-ulnar basal coronoid, 91 for Monteggia (p<.01), and 93 for trans-olecranon fracture-dislocations (p<.05). Disabilities of the Arm, Shoulder and Hand (DASH) and American Shoulder and Elbow Surgeons (ASES) scores were 22 and 80 for trans-ulnar basal coronoid, respectively, compared to 23 and 89 for trans-olecranon fractures. ASES was not available for any Monteggia injuries, but the mean DASH was 13.

DISCUSSION: Trans-ulnar basal coronoid fracture-dislocations are associated with inferior patient reported outcome measures, decreased range of motion, and increased complication rates compared to trans-olecranon or Monteggia variant fracture-dislocations. Further research is needed to determine the most appropriate treatment for this difficult injury pattern.