de Klerk Huub H, Chen Neal C, Azib Nadia, Nettuno Nadalini, Wagner Robert Kaspar, van den Bekerom Michel P J, Bhashyam Abhiram R, Doornberg Job N
Hand and Arm Research Collaborative, Department of Orthopaedic Surgery, Massachusetts General Hospital, Boston, MA, USA.
Amsterdam Shoulder and Elbow Center of Expertise, OLVG, Amsterdam, the Netherlands.
Clin Orthop Relat Res. 2025 May 1;483(5):881-888. doi: 10.1097/CORR.0000000000003337. Epub 2024 Dec 2.
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?
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.
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.
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.
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.
可怕三联征损伤包括尺骨鹰嘴脱位、桡骨头骨折和冠状突骨折。根据传统教学，这些损伤与前外侧冠状突尖骨折密切相关，可通过肘部外侧入路进行处理。然而，最近的小型临床系列研究表明，一些可怕三联征损伤存在涉及前内侧小面的较大冠状突骨折。了解这些较大冠状突骨折的发生频率很重要，因为前内侧小面骨折可能需要不同的入路和不同的植入物进行固定。更好地了解可怕三联征损伤中冠状突骨折的形态可能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突和桡骨头联合骨折中的冠状突骨折形态，我们因此提出问题：在无尺骨干骨折的冠状突和桡骨头联合骨折中，前外侧小面与前内侧小面冠状突碎片的分布情况如何？
这项回顾性、多中心描述性研究评估了成年患者（18岁及以上）术前诊断为冠状突和桡骨头联合骨折的CT扫描。在2014年2月至2023年3月期间，我们确定了10016例接受CT扫描的肘部或前臂损伤成年患者。在这些患者中，我们将那些根据受伤后4周内进行的肘部CT扫描诊断为冠状突和桡骨头联合骨折且无尺骨干骨折的患者视为潜在合格患者。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规划手术干预。基于此，2%（10016例中的175例）符合条件；另有0.001%（10016例中的8例）因既往肘部病变、既往手术或低质量CT图像（包括切片厚度大于2mm、运动伪影以及肘部及其所有关节的骨结构可视化不完整）被排除，剩余2%（10016例中的167例）用于分析。平均年龄为50±15岁，超过一半的患者为女性（54%[167例中的90例]）。将冠状突和桡骨头联合骨折患者的冠状突骨折按照奥德里斯科尔分类法分为三种类型：1型（前外侧尖部骨折）、2型（前内侧小面骨折）和3型（基部骨折）。每种类型根据特定骨折特征进一步细分。三名经过培训的研究人员中的两名使用X线片、二维（2D）CT扫描、三维（3D）CT扫描和术中发现独立对每位患者的冠状突骨折类型进行分类，通过科恩kappa评估评分者间信度，得出的一致性值为0.658。分歧通过与一名接受过专科培训的骨科创伤外科医生讨论解决。
65%（167例中的109例）患者为1型前外侧冠状突尖骨折，30%（167例中的50例）患者为2型前内侧小面骨折，5%（167例中的8例）患者为3型基部骨折。
外科医生应认识到，在冠状突和桡骨头联合骨折中，冠状突骨折累及前内侧小面的情况比之前认为的更为普遍。未来的研究应调查这些前内侧骨折是否更有可能需要额外的内侧入路以改善患者预后。
本研究表明，在可怕三联征损伤中，前内侧小面受累比传统认识更为常见，外科医生在治疗这些损伤时应准备好处理更大的骨折块。
