BACKGROUND: Trans-ulnar fracture-dislocations of the elbow are complex injuries that can be difficult to classify and treat. Trans-ulnar basal coronoid injuries, in which the coronoid is not attached to either the olecranon or the metaphysis, present substantial challenges to achieve anatomic reduction and stable internal fixation. The purpose of this study was to analyze the outcome of surgical treatment of trans-ulnar basal coronoid fracture-dislocations.
METHODS: Between 2002 and 2019, 32 consecutive trans-ulnar basal coronoid fracture-dislocations underwent open reduction and internal fixation at our institution. Four elbows were lost to follow-up within the first 6 months after surgery and were excluded. Among the 28 elbows remaining, there were 13 females and 15 males with a mean age of 56 (range 28-78) years at the time of injury. The mean clinical and radiographic follow-up times were 37 months and 29 months, respectively. Radiographs were reviewed to determine rates of union, Hastings and Graham heterotopic ossification (HO) grade, and Broberg and Morrey arthritis grade.
RESULTS: Union occurred in 25 elbows. Union could not be determined for 1 elbow at most recent follow-up and the remaining 2 elbows developed nonunion of the coronoid. Complications occurred in 10 elbows (36%): deep infection (4), ulnar neuropathy (2), elbow contracture (2), and nonunion (2). There were reoperations in 11 elbows (39%): irrigation and débridement with hardware removal (4), hardware removal (2), ulnar nerve transposition (2), contracture release with HO removal (2), and revision with iliac crest autograft (1). At most recent follow-up, the mean flexion-extension arc was 106° (range 10°-150°), and the mean pronation-supination arc was 137° (range 0°-170°). The mean Quick Disabilities of Arm, Shoulder, and Hand score was 11 (range 0-39) points with a mean Single Assessment Numeric Evaluation-Elbow score of 81 (range 55-100) points. At final radiographic follow-up, 16 elbows (57%) had HO (8 class I and 8 class II), and 20 elbows (71%) had arthritis (8 grade 1, 6 grade 2, and 6 grade 3).
CONCLUSIONS: Trans-ulnar basal coronoid fracture-dislocations are severe injuries associated with high rates of reoperation, HO, and post-traumatic arthritis. However, the majority of elbows achieve union, a functional range of motion, and reasonable patient reported outcome measures. Over the study period, surgeons were more likely to utilize multiple deep approaches and separate fixation of the coronoid (either with lag screws or anteromedial plates) to ensure anatomic reduction.

BACKGROUND: Complex elbow fracture dislocations, dislocation with fracture of one or several surrounding bony stabilizers, are difficult to manage and associated with poor outcomes. While many studies have explored treatment strategies but a lack of standardization of patient-reported outcome measures (PROMs) makes cross-study comparison difficult. In this systematic review, we aim to describe what injury patterns, measured outcomes, and associated complications are reported in the complex elbow fracture dislocation literature to provide outcome reporting recommendations that will facilitate improved future cross-study comparison.
METHODS: A systematic review was performed per Preferred Reporting Items for Systematic reviews and Meta-Analyses guidelines. We queried PubMed/MEDLINE, Embase, Web of Science, and Cochrane databases to identify articles published between 2010 and 2022 reporting on adult patients who had a complex elbow fracture dislocation. Pathologic fractures were excluded. A bias assessment using the methodological index for nonrandomized studies criteria was conducted. For each article, patient demographics, injury pattern, outcome measures, and complications were recorded.
RESULTS: Ninety-one studies reporting on 3664 elbows (3654 patients) with an elbow fracture and dislocation (weighted mean age 44 years, follow-up of 30 months, 41% female) were evaluated. Of these, the injury pattern was described in 3378 elbows and included 2951 (87%) terrible triad injuries and 72 (2%) transolecranon fracture-dislocations. The three most commonly reported classification systems were: Mason classification for radial head fractures, Regan and Morrey coronoid classification for coronoid fractures, and O\'Driscoll classification for coronoid fractures. Range of motion was reported in 87 (96%) studies with most reporting flexion (n = 70), extension (n = 62), pronation (n = 68), or supination (n = 67). Strength was reported in 11 (12%) studies. PROMs were reported in 83 (91%) studies with an average of 2.6 outcomes per study. There were 14 outcome scores including the Mayo Elbow Performance Score (n = 69 [83%]), the Disabilities of Arm, Shoulder and Hand (DASH) score (n = 28 [34%]), the visual analog scale for pain (n = 27 [33%]), QuickDASH score (n = 13 [15.7%]), and Oxford Elbow score (n = 5 [6.0%]). No significance was found between the number of PROMs used per article and the year of publication (P = .313), study type (P = .689), complex fracture pattern (P = .211), or number of elbows included (P = .152).
CONCLUSIONS: There is great heterogeneity in reported PROMs in the complex elbow fracture dislocation literature. Although there is no gold standard PROM for assessing complex elbow fracture dislocations, we recommend the use of at least the Mayo Elbow Performance Score and DASH outcomes measures as well as visual analog scale pain rating scale in future studies to facilitate cross-study comparisons.

BACKGROUND: Proximal ulna fractures with a large zone of comminution, such as in the context of Monteggia injuries, require mechanically strong osteosyntheses as they occur in regions with high physiological joint load. Consequently, implant failure and pseudarthrosis are critical and devastating complications, especially with the background of mainly young patients being affected. An effective solution could be provided by adding a small second plate 90° angulated to the standard dorsal plate in the area of non-union. Thus, this study investigates whether, from a biomechanical point of view, the use of such a mini or baby plate is worthwhile.
METHODS: Comminuted fractures distal to the coronoid process, equivalent to Jupiter type IIb fractures, are generated on artificial Sawbones® of the ulna and stabilized using two different plate osteosyntheses: in the first group, a dorsal locking compression olecranon plate is used (LCP group). In the second group, a small, ulnar 5-hole olecranon plate is added as a baby plate in addition to the mother plate at the level of the fracture zone (MBP group). Dynamic biomechanical loading in degrees of flexion from 0° to 90° is carried out to determine yield load, stiffness, displacement, and changes in fracture gap width as well as bending of the dorsal plate.
RESULTS: The \"mother-baby-plate\" osteosynthesis had a significantly higher yield load (p < 0.01) and stiffness (p = 0.01) than the LCP group. This correlates with the increased movement of the proximal fracture element during cyclic testing for the LCP group compared to the MBP group as measured by an optical metrology system.
CONCLUSIONS: Here, we show evidence that the addition of a small plate to the standard plate is highly effective in increasing the biomechanical stability in severe fractures equivalent to Jupiter type IIb. As it hopefully minimizes complications like pseudarthrosis and implant failure and as the additional preparatory effort leading to compromised blood supply is regarded to be negligible, this justifies and highly advises the use of a mother-baby-plate system.

BACKGROUND: Monteggia-like fractures (MLF) are complex injuries with high complication rates and frequently unsatisfying clinical results. Total elbow arthroplasty (TEA) represents the only option to salvage the functional requirements in some patients with pronounced posttraumatic arthropathy. This case series provides clinical results of TEA following failed treatment of MLF.
METHODS: All patients who underwent TEA from 2017 to 2022 for failed treatment of MLF were retrospectively included in this study. Complications and revisions before and after TEA and functional results, measured by the Broberg/Morrey score, were evaluated.
RESULTS: In this study 9 patients with a mean age of 68 (±7; 54-79) years were included. The mean follow-up was 12 (±9; 2-27) months. The main reasons leading to posttraumatic arthropathy were chronic infections (44.4%), bony instability due to coronoid deficiency (33.3%) or a combined coronoid and radial head deficiency (22.2%) and non-union of the proximal ulna with radial head necrosis (11.1%). The mean number of surgical revisions between primary fixation and TEA was 2.7 (±1.8; 0-6). The revision rate following TEA was 44%. The mean Broberg/Morrey score at the time of the latest follow-up was 83 (±10; 71-97) points.
CONCLUSIONS: Chronic infection and coronoid deficiency are the main reasons for posttraumatic arthropathy after MLF leading to TEA. While the overall clinical results are satisfying, the indications should be reserved for selected cases due to high revision rates.
UNASSIGNED: HINTERGRUND: Monteggia-like-Frakturen (MLF) sind komplexe Verletzungen mit hohen Komplikationsraten und häufig unbefriedigenden funktionellen Ergebnissen. Bei posttraumatischer Gelenkdestruktion nach MLF stellt die Implantation einer Ellenbogentotalendoprothese (EB-TEP) oftmals die einzige Option zum Erhalt der Funktionalität des Ellenbogens dar. Diese Fallserie beleuchtet die klinischen Ergebnisse der EB-TEP nach gescheiterter Behandlung einer MLF.
METHODS: Alle Patienten mit EB-TEP-Implantation (2017–2022) nach Therapieversagen bei MLF wurden retrospektiv eingeschlossen. Die Komplikationen sowie Revisionen vor und nach EB-TEP und das funktionelle Ergebnis, bemessen mittels Broberg and Morrey-Score, wurden evaluiert.
UNASSIGNED: In diese Studie wurden 9 Patienten mit einem Alter zum Zeitpunkt der EB-TEP-Implantation von 68 (±7; 54 bis 79) Jahren inkludiert. Der Nachbetrachtungszeitraum betrug 12 (±9; 2 bis 27) Monate. Die wesentlichen Ursachen, die zur Gelenkdestruktion führten, waren die chronische Osteomyelitis (44,4 %), die knöcherne Instabilität durch einen Processus-coronoideus-Defekt (33,3 %) bzw. einen kombinierten Processus-coronoideus- und Radiuskopfdefekt (22,2 %) sowie die Pseudarthrose der proximalen Ulna mit Radiuskopfnekrose (11,1 %). Die Anzahl an Revisionsoperationen von der Primärversorgung bis zur EB-TEP lag bei 2,7 (±1,8; 0 bis 6) Eingriffen. Die Revisionsrate nach EB-TEP betrug 44 %. Der Broberg/Morrey Score lag zum Zeitpunkt der letzten Nachuntersuchung bei 83 (±10; 71 bis 97) Punkten.
UNASSIGNED: Die chronische Osteomyelitis und der Defekt des Processus coronoideus sind die führenden Ursachen für eine Gelenkdestruktion nach MLF, die zur EB-TEP führen. Wenngleich die klinischen Ergebnisse insgesamt zufriedenstellend sind, so muss angesichts der hohen Revisionsrate die Indikationsstellung streng selektiert werden.

UNASSIGNED: Chronic radial head dislocation in old standing or neglected Monteggia fracture is a devastating complication. We present our case regarding managing such a case using plating and fascial slip annular ligament reconstruction (ALR).
UNASSIGNED: A 40-year-old male patient, farmer by profession presented with a 4-month-old neglected Monteggia fracture. He was treated with open reduction and internal fixation of fracture ulna with ALR using forearm deep fascial slip. The patient underwent regular physiotherapy post-operatively after 2 weeks of surgery. The patient was followed for 6 months, and DASH score was used to evaluate functional outcome.
UNASSIGNED: Excellent results were obtained as regards to pain, wrist range of motion, fracture union, and resuming routine activities at the follow-ups.

UNASSIGNED: The aim of the study is to evaluate the use of ultrasound imaging in diagnostics of Monteggia lesion in children where conventional radiographs and the use of the radiocapitellar line fail to provide an accurate diagnosis.
UNASSIGNED: Prospective diagnostic study of 70 patients treated between May 2018 and July 2021 in a pediatric level 1 trauma center. In 20 patients with the confirmed radiographic diagnosis of Monteggia lesion, an ultrasound of the humeroradial joint was performed to determine signs of both normal and dislocated elbow joint. In 36 patients with suspected humeroradial dislocation on plain radiographs, ultrasound imaging was performed to determine the definitive diagnosis. Overall, 14 patients with elbow joint injury other than humeroradial dislocation were excluded from the study.
UNASSIGNED: The \"double-hump sign\" and the \"congruency sign\" were determined as normal findings on ultrasound of the humeroradial joint. These signs were applied to patients with unclear findings on radiographs. In three patients, the dislocation of the humeroradial joint was confirmed by ultrasound. In two patients, \"defect in congruency sign\" was seen during reduction despite normal radiographs, which required re-reduction. In 31 patients, dislocation of the humeroradial joint was refuted. In 34 out of the 36 patients, the diagnosis determined by ultrasound was confirmed in follow-up. Two patients did not attend the follow-up examination.
UNASSIGNED: Ultrasound imaging is an accessible, non-invasive, and dynamic point-of-care method that can be applied in children suffering from suspected humeroradial dislocation and/or subluxation.
UNASSIGNED: Level III-diagnostic study.

In children, traumatic radial head dislocation (RHD) is usually associated with ulnar fracture or deformation as reported in a Monteggia injury or its Monteggia variant. Isolated traumatic RHD is extremely rare and exceptional. Traumatic RHD is frequently missed on initial radiographs, particularly if it is isolated. The management of missed RHD is challenging and remains controversial. We report a Case of chronic post-traumatic RHD in a three-year-old child treated with open reduction and reconstruction of the annular ligament. The child\'s elbow was stable during the follow-up, without swelling or deformity, and the elbow function was normal. The injury of the reported case does not belong to any lesion described in the Monteggia-variant classification, which might explain the reason for missing the associated dislocation. The authors recommend urgent open reduction when a chronic RHD is diagnosed and annular ligament reconstruction, particularly when the open reduction is unstable.
الخلع الرضحي لرأس عظمة الكعبرة لدى الأطفال غالبا يصاحبه كسر أو تشوه في عظمة الزند، وهذا ما يسمى بإصابة مونتيجيا أو متشابهات مونتيجيا. إن خلع رأس عظمة الكعبرة الرضحي المنفرد نادر الحدوث ويعتبر استثنائيا. وغالبا لا يتم التشخيص في التصوير الشعاعي الأولي، خاصة لو كان منفردا. ويمثل علاج الخلع الرضحي لرأس عظمة الكعبرة فائت التشخيص تحديا كبيرا ويبقى مثيرا للخلاف والجدل.في هذا التقرير نقدم حالة خلع مزمن تال للرضح لرأس عظمة الكعبرة وذلك لدى طفل عمره ثلاث سنوات، وتم علاجه عن طريق رد مفتوح للخلع مع إعادة تشكيل الرباط الحلقي. وفي آخر زيارة متابعة للطفل، كان المرفق المصاب في حالة ثبات ولم يكن هناك تورم أو تشوه وكانت وظيفة المرفق طبيعية.إن الإصابة في هذه الحالة لا تنتمي إلى أي من أنواع إصابة مونتيجيا أو متشابهات مونتيجيا، وهذا ربما يفسر التأخر في التشخيص. بناء على هذا التقرير يوصي المؤلفون بسرعة رد هذا الخلع فور تشخيصه والقيام بإعادة تشكيل الرباط الحلقي وبالأخص في حالة عدم ثبات المرفق.

BACKGROUND: The term Monteggia fracture refers to a class of injuries encompassing the fracture of the proximal end of the ulna with subluxation or dislocation of the radial head. These injuries account for 0.4-1% of all forearm fractures in children. Despite its low incidence, Monteggia fractures require particular attention, since as much as 30-50% of the cases may be unrecognized, which subsequently leads to complications. The purpose of this paper is to evaluate treatment outcomes of Monteggia fractures in children. Both conservative treatment and surgery were analyzed.
METHODS: 15 children (7 boys and 8 girls) between the ages of 4-16.3 years (mean age 8.3 years) with Monteggia fractures were hospitalized at our center in the years 2015-2020. Closed reduction and immobilization in a cast were performed in 12 patients, while three children underwent surgical treatment with internal fixation of the ulna. The radial head dislocation was reduced successfully in every patient.
RESULTS: Every child from the study group who received conservative treatment regained full elbow mobility as well as normal forearm supination and pronation. Only one of the patients who underwent the surgery demonstrated a 20° deficit in elbow flexion that did not affect limb function.
CONCLUSIONS: 1. Our experience shows that closed reduction together with immobilization in a cast is usually a sufficient treatment in Monteggia fractures. 2. However, the dislocated radial head should be properly reduced in all patients. 3. Correct diagnosis and treatment followed by appropriate rehabilitation result in full recovery and no mobility limitations in children and teenagers.

UNASSIGNED: A paediatric floating elbow involves fractures of the supracondylar region of the humerus with ipsilateral fracture of the forearm bones. A floating elbow is very uncommon with an incidence of 3 to 13% of all supracondylar fractures. A concomitant supracondylar and Monteggia fracture is extremely rare with only six cases reported in the literature.
METHODS: We present the unusual case of an eight-year-old girl with a concomitant ipsilateral supracondylar humerus fracture and open Monteggia fracture. Physical examination showed a neurovascularly intact limb. Surgical management was carried out in the form of closed and open reduction, percutaneous pinning using Kirschner (K) wires and Titanium Elastic Nails (TENs), and wound washout and debridement of the open lesion. The patient developed pin site infection six weeks post operation and subsequently underwent surgery for removal of pins. She was later followed up with normal radiographic and physical examination findings.
UNASSIGNED: The complexity of these fractures can lead to debilitating complications if proper management is not initiated. It is imperative that neurovascular and motor function be assessed in great detail and early surgical fixation be carried out in order to prevent these complications.
CONCLUSIONS: A paediatric floating elbow is a rare surgical emergency. Although no guidelines for the management of these fractures exist, we recommend surgical management in a step-by-step approach be used over conservative management. We also stress the importance of regular follow up to address any post operative complications that may arise such as the one in our case.

UNASSIGNED: Monteggia fracture-dislocation is defined as a proximal third ulna fracture with radiocapitellar joint dislocation. The term \"Monteggia equivalent or variant\" describes various injuries with similar radiographic patterns and injury biomechanics. Several isolated cases of unusual injuries associated with Monteggia fractures have been reported. However, an associated TFCC injury has not been described in the literature before. We present a rare report of a 24-year-old female with a Monteggia fracture and associated TFCC injury - a crisscross type of injury.
UNASSIGNED: A 24-year-old female was involved in a road traffic accident and presented to our level I trauma center with pain and deformity in the left forearm. On evaluation, she was found to have type I Monteggia fracture-dislocation. Intraoperatively, once the proximal ulna was fixed, she had clicking in the wrist during rotations. Fluoroscopic images showed DRUJ subluxation, but it was stable in supination. Hence was splinted in a reduced position. The patient continued to have persistent symptoms in the wrist despite adequate conservative measures. Hence, she underwent arthroscopic TFCC repair and DRUJ pinning. At her last follow-up (3 months), the patient was clinically better with a good range of motion and no pain.
UNASSIGNED: In treating Monteggia fracture-dislocations, high index of suspicion is needed to diagnose radioulnar joint instability. If they are missed, they can result in long-term disability, so appropriate evaluation to diagnose TFCC and DRUJ injuries is required. DRUJ stabilization and TFCC repair can produce consistent results when treated adequately.