Extensor digitorum communis split approach combined with loop-plate technique for treatment of ulnar coronoid fracture in terrible triad of elbow_Chinese Journal of Reparative and Reconstructive Surgery

Authors：

YANG Jiarui ¹ , HE Xiao ² , QIAO Rui ¹ , WANG Zhimeng ¹ , LI Shuhao ¹ , HUANG Wei ³ , WANG Xiaolong ³ , FAN Wei ³ , HENG Lisong ³ , ZHU Yangjun ³ ,  ZHANG Kun ³

1. Xi’an Medical University, Xi’an Shaanxi, 710068, P.R.China;
2. Medical Department of Yan’an University, Yan’an Shaanxi, 716000, P.R.China;
3. Department of Orthopaedic Trauma, Honghui Hospital Affiliated to Xi’an Jiaotong University, Xi’an Shaanxi, 710054, P.R.China;

Corresponding author：

ZHANG Kun, Email: hhyyzk@126.com

Keywords：

Terrible triad of elbow; extensor digitorum communis split approach; loop-plate; ulnar coronoid fracture

DOI：

10.7507/1002-1892.202010081

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Objective To explore the effectivenesss of simple lateral extensor digitorum communis (EDC) split approach combined with loop-plate fixation in the treatment of ulnar coronoid fracture in terrible triad of elbow (TTE).Methods The clinical data of 60 patients with TTE who met the selection criteria between January 2015 and May 2018 were retrospectively analyzed. There were 48 males and 12 females, aged from 18 to 60 years (mean, 37.4 years). All the patients were closed fractures. Injury causes included fall injury in 28 cases, falling from height in 20 cases, and traffic accident injury in 12 cases. All patients had no vascular and nerve injury, and the time from injury to operation was 1-14 days, with an average of 4.8 days. The height and size of the fracture of the coronal process were measured by CT and accurate classifications were made. All the 60 patients were treated with simple lateral EDC split approach combined with loop-plate to fix the ulnar coronoid fracture; 20 patients of radial head fracture were fixed with hollow screw, 32 patients with mini-plate fixation, 8 patients with radial head prosthesis replacement; 16 patients with suture and 44 patients with suture anchor to reconstruct lateral collateral ligament complex; 10 patients with residual instability of elbow joint were fixed with hinge external fixator, and others were fixed with adjustable tension brace after operation. Postoperative imaging examination was performed to evaluate fracture healing and complications, such as loosening or breakage of internal fixator, osteoarthritis, and heterotopic ossification, etc. During follow-up, the range of motion (ROM) of the elbow joint was recorded, including elbow flexion, extension, and forearm pronation, supination. Mayo elbow function score system (MEPS) was used to evaluate elbow joint function at last follow-up.Results All patients were followed up 16-24 months (mean, 20.2 months). All incisions healed by first intention after operation, and no complications such as vascular nerve injury, elbow joint instability, internal fixation failure, and infection occurred; the fracture healing time was 9-17 weeks (mean, 11.7 weeks). Four cases developed elbow stiffness after operation, and all underwent elbow joint lysis with internal fixator removal within 12-15 months after operation; 10 cases developed heterotopic ossification without special treatment. At last follow-up, the ROM of elbow flexion ranged from 85° to 135° (mean, 116°), the ROM of elbow extension ranged from 0° to 20° (mean, 11°), the ROM of forearm pronation ranged from 55° to 75° (mean, 70°), and the ROM of forearm supination ranged from 60° to 90° (mean, 83°). The MEPS score ranged from 55 to 100 (mean, 86.1); the effectiveness were excellent in 40 patients, good in 10 patients, fair in 6 patients, and poor in 4 patients, with an excellent and good rate of 83.3%.Conclusion The simple lateral EDC split approach is fully exposed, and the loop-plate can fix the ulnar coronoid fractures firmly and stably, which can restore the stability of the elbow joint, and the effectiveness is satisfactory.

Citation： YANG Jiarui, HE Xiao, QIAO Rui, WANG Zhimeng, LI Shuhao, HUANG Wei, WANG Xiaolong, FAN Wei, HENG Lisong, ZHU Yangjun, ZHANG Kun. Extensor digitorum communis split approach combined with loop-plate technique for treatment of ulnar coronoid fracture in terrible triad of elbow. Chinese Journal of Reparative and Reconstructive Surgery, 2021, 35(4): 420-425. doi: 10.7507/1002-1892.202010081 Copy

1.	Hotchkiss RN. Fractures and dislocations of the elbow//Rockwood CA, Green DP, Bucholz RW. Rockwood and Green’s fractures in adults. 4th ed. Philadelphia: Lippincott Raven, 1996: 929-1024.
2.	Micic I, Kim SY, Park IH, et al. Surgical management of unstable elbow dislocation without intra-articular fracture. Int Orthop, 2009, 33(4): 1141-1147.
3.	Zhang J, Tan M, Kwek EBK. Outcomes of coronoid-first repair in terrible triad injuries of the elbow. Arch Orthop Trauma Surg, 2017, 137(9): 1239-1245.
4.	Ring D, Jupiter JB, Zilberfarb J. Posterior dislocation of the elbow with fractures of the radial head and coronoid. J Bone Joint Surg (Am), 2002, 84(4): 547-551.
5.	Kim BS, Kim DH, Byun SH, et al. Does the coronoid always need to be fixed in terrible triad injuries of the elbow? Mid-term postoperative outcomes following a standardized protocol. J Clin Med, 2020, 9(11): 3500.
6.	Pugh DM, Wild LM, Schemitsch EH, et al. Standard surgical protocol to treat elbow dislocations with radial head and coronoid fractures. J Bone Joint Surg (Am), 2004, 86(6): 1122-1130.
7.	王鹏飞, 庄岩, 魏巍, 等. 袢钢板治疗 Regan-MorryⅠ型冠状突骨折. 中华创伤骨科杂志, 2015, 17(4): 277-281.
8.	王正明, 赵钢生, 金国华, 等. 袢钢板技术治疗肘关节恐怖三联征的临床研究. 浙江创伤外科, 2019, 24(5): 931-932.
9.	O’Driscoll SW, Jupiter JB, Cohen MS, et al. Difficult elbow fractures: pearls and pitfalls. Instr Course Lect, 2003, 52: 113-134.
10.	Regan W, Morrey B. Fractures of the coronoid process of the ulna. J Bone Joint Surg (Am), 1989, 71(9): 1348-1354.
11.	Mason ML. Some observations on fractures of the head of the radius with a review of one hundred cases. Br J Surg, 1954, 42(172): 123-132.
12.	Garrigues GE, Wray WH, Lindenhovius AL, et al. Fixation of the coronoid process in elbow fracture-dislocations. J Bone Joint Surg (Am), 2011, 93(20): 1873-1881.
13.	Broberg MA, Morrey BF. Results of delayed excision of the radial head after fracture. J Bone Joint Surg (Am), 1986, 68(5): 669-674.
14.	Beingessner DM, Stacpoole RA, Dunning CE, et al. The effect of suture fixation of type I coronoid fractures on the kinematics and stability of the elbow with and without medial collateral ligament repair. J Shoulder Elbow Surg, 2007, 16(2): 213-217.
15.	Schneeberger AG, Sadowski MM, Jacob HA. Coronoid process and radial head as posterolateral rotatory stabilizers of the elbow. J Bone Joint Surg (Am), 2004, 86(5): 975-982.
16.	Doornberg JN, van Duijn J, Ring D. Coronoid fracture height in terrible-triad injuries. J Hand Surg (Am), 2006, 31(5): 794-797.
17.	O’Driscoll SW, Bell DF, Morrey BF. Posterolateral rotatory instability of the elbow. J Bone Joint Surg (Am), 1991, 73(3): 440-446.
18.	Rausch V, Hackl M, Seybold D, et al. Plate osteosynthesis of the coronoid process of the ulna. Oper Orthop Traumatol, 2020, 32(1): 35-46.
19.	Pugh DM, McKee MD. The “terrible triad” of the elbow. Tech Hand Up Extrem Surg, 2002, 6(1): 21-29.
20.	Rodriguez-Martin J, Pretell-Mazzini J, Andres-Esteban EM, et al. Outcomes after terrible triads of the elbow treated with the current surgical protocols. A review. Int Orthop, 2011, 35(6): 851-860.
21.	衡立松, 朱养均, 张堃, 等. 前后路联合固定治疗尺骨冠状突 O’Driscoll ⅢB 型骨折. 临床骨科杂志, 2016, 19(5): 603-605.
22.	向明, 杨国勇, 胡晓川, 等. 肘关节前方血管神经间入路治疗尺骨冠状突骨折的中期研究. 中华骨科杂志, 2018, 38(1): 8-15.
23.	公茂琪, 黄晓文, 李国珅, 等. 单一外侧切口和内外侧双切口治疗肘关节三联征的对比研究. 中华创伤杂志, 2017, 33(5): 389-396.
24.	Desloges W, Louati H, Papp SR, et al. Objective analysis of lateral elbow exposure with the extensor digitorum communis split compared with the Kocher interval. J Bone Joint Surg (Am), 2014, 96(5): 387-393.
25.	Schimizzi A, MacLennan A, Meier KM, et al. Defining a safe zone of dissection during the extensor digitorum communis splitting approach to the proximal radius and forearm: an anatomic study. J Hand Surg (Am), 2009, 34(7): 1252-1255.
26.	Mekhail AO, Ebraheim NA, Jackson WT, et al. Vulnerability of the posterior interosseous nerve during proximal radius exposures. Clin Orthop Relat Res, 1995, (315): 199-208.
27.	Liu G, Ma W, Li M, et al. Operative treatment of terrible triad of the elbow with a modified Pugh standard protocol: Retrospective analysis of a prospective cohort. Medicine (Baltimore), 2018, 97(16): e0523. doi: 10.1097/MD.0000000000010523.

1. Hotchkiss RN. Fractures and dislocations of the elbow//Rockwood CA, Green DP, Bucholz RW. Rockwood and Green’s fractures in adults. 4th ed. Philadelphia: Lippincott Raven, 1996: 929-1024.
2. Micic I, Kim SY, Park IH, et al. Surgical management of unstable elbow dislocation without intra-articular fracture. Int Orthop, 2009, 33(4): 1141-1147.
3. Zhang J, Tan M, Kwek EBK. Outcomes of coronoid-first repair in terrible triad injuries of the elbow. Arch Orthop Trauma Surg, 2017, 137(9): 1239-1245.
4. Ring D, Jupiter JB, Zilberfarb J. Posterior dislocation of the elbow with fractures of the radial head and coronoid. J Bone Joint Surg (Am), 2002, 84(4): 547-551.
5. Kim BS, Kim DH, Byun SH, et al. Does the coronoid always need to be fixed in terrible triad injuries of the elbow? Mid-term postoperative outcomes following a standardized protocol. J Clin Med, 2020, 9(11): 3500.
6. Pugh DM, Wild LM, Schemitsch EH, et al. Standard surgical protocol to treat elbow dislocations with radial head and coronoid fractures. J Bone Joint Surg (Am), 2004, 86(6): 1122-1130.
7. 王鹏飞, 庄岩, 魏巍, 等. 袢钢板治疗 Regan-MorryⅠ型冠状突骨折. 中华创伤骨科杂志, 2015, 17(4): 277-281.
8. 王正明, 赵钢生, 金国华, 等. 袢钢板技术治疗肘关节恐怖三联征的临床研究. 浙江创伤外科, 2019, 24(5): 931-932.
9. O’Driscoll SW, Jupiter JB, Cohen MS, et al. Difficult elbow fractures: pearls and pitfalls. Instr Course Lect, 2003, 52: 113-134.
10. Regan W, Morrey B. Fractures of the coronoid process of the ulna. J Bone Joint Surg (Am), 1989, 71(9): 1348-1354.
11. Mason ML. Some observations on fractures of the head of the radius with a review of one hundred cases. Br J Surg, 1954, 42(172): 123-132.
12. Garrigues GE, Wray WH, Lindenhovius AL, et al. Fixation of the coronoid process in elbow fracture-dislocations. J Bone Joint Surg (Am), 2011, 93(20): 1873-1881.
13. Broberg MA, Morrey BF. Results of delayed excision of the radial head after fracture. J Bone Joint Surg (Am), 1986, 68(5): 669-674.
14. Beingessner DM, Stacpoole RA, Dunning CE, et al. The effect of suture fixation of type I coronoid fractures on the kinematics and stability of the elbow with and without medial collateral ligament repair. J Shoulder Elbow Surg, 2007, 16(2): 213-217.
15. Schneeberger AG, Sadowski MM, Jacob HA. Coronoid process and radial head as posterolateral rotatory stabilizers of the elbow. J Bone Joint Surg (Am), 2004, 86(5): 975-982.
16. Doornberg JN, van Duijn J, Ring D. Coronoid fracture height in terrible-triad injuries. J Hand Surg (Am), 2006, 31(5): 794-797.
17. O’Driscoll SW, Bell DF, Morrey BF. Posterolateral rotatory instability of the elbow. J Bone Joint Surg (Am), 1991, 73(3): 440-446.
18. Rausch V, Hackl M, Seybold D, et al. Plate osteosynthesis of the coronoid process of the ulna. Oper Orthop Traumatol, 2020, 32(1): 35-46.
19. Pugh DM, McKee MD. The “terrible triad” of the elbow. Tech Hand Up Extrem Surg, 2002, 6(1): 21-29.
20. Rodriguez-Martin J, Pretell-Mazzini J, Andres-Esteban EM, et al. Outcomes after terrible triads of the elbow treated with the current surgical protocols. A review. Int Orthop, 2011, 35(6): 851-860.
21. 衡立松, 朱养均, 张堃, 等. 前后路联合固定治疗尺骨冠状突 O’Driscoll ⅢB 型骨折. 临床骨科杂志, 2016, 19(5): 603-605.
22. 向明, 杨国勇, 胡晓川, 等. 肘关节前方血管神经间入路治疗尺骨冠状突骨折的中期研究. 中华骨科杂志, 2018, 38(1): 8-15.
23. 公茂琪, 黄晓文, 李国珅, 等. 单一外侧切口和内外侧双切口治疗肘关节三联征的对比研究. 中华创伤杂志, 2017, 33(5): 389-396.
24. Desloges W, Louati H, Papp SR, et al. Objective analysis of lateral elbow exposure with the extensor digitorum communis split compared with the Kocher interval. J Bone Joint Surg (Am), 2014, 96(5): 387-393.
25. Schimizzi A, MacLennan A, Meier KM, et al. Defining a safe zone of dissection during the extensor digitorum communis splitting approach to the proximal radius and forearm: an anatomic study. J Hand Surg (Am), 2009, 34(7): 1252-1255.
26. Mekhail AO, Ebraheim NA, Jackson WT, et al. Vulnerability of the posterior interosseous nerve during proximal radius exposures. Clin Orthop Relat Res, 1995, (315): 199-208.
27. Liu G, Ma W, Li M, et al. Operative treatment of terrible triad of the elbow with a modified Pugh standard protocol: Retrospective analysis of a prospective cohort. Medicine (Baltimore), 2018, 97(16): e0523. doi: 10.1097/MD.0000000000010523.

Chinese Journal of Reparative and Reconstructive Surgery

Extensor digitorum communis split approach combined with loop-plate technique for treatment of ulnar coronoid fracture in terrible triad of elbow

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