![]() ![]() 60 Magnetic resonance imaging (MRI) can be a useful add-on diagnostic tool however, operative management is rarely adjusted as a result of MRI scanning. For example, small fragments of the coronoid as a sign of a possible instability can easily be overlooked and might delay the correct operative treatment. While simple olecranon fractures do not routinely require a computerized tomography (CT) scan, CT scanning (ideally as 3D reconstruction) in multi-fragmented fracture types is recommended to assess the extent of the injury and not to omit relevant (co)pathologies. First, a standard two-plane x-ray of the elbow should be performed to confirm the clinical suspicion of a fracture and/or more complex dislocation. ![]() In order to accurately evaluate the injury pattern and thus plan the necessary therapeutic steps, a thorough and most of all, standardized diagnostic approach should be conducted. 5 In particular, rotatory forces of the forearm may cause posterolateral, posteromedial or trans-olecranon fracture dislocations. ![]() Different loads across the elbow joint at the time of injury lead to specific fracture patterns and elbow instability. The mechanism of injury may already guide the surgeon in what to expect. 14 Furthermore, the blood flow of the ulnar and radial artery needs to be verified to exclude any vessel damage at the elbow level. Careful evaluation of all nerves, and in particular the ulnar nerve, is obligatory (due to its close pathway next to the bone). The asymmetry of the Hueter triangle may already suggest a possible dislocation and/or instability of the elbow. Patients with fractures of the proximal ulna and/or more complex pathologies involving the (sub-)dislocation of the elbow usually present with immobilizing pain and swelling of the joint. 54, 55 In general, a precise evaluation of the fracture mechanism in respect to the resulting gravitational stresses is paramount to understand possible injuries and aid the surgeon in finding all anatomical mishaps. 56, 57 An improper reconstruction and denial of the exact elbow anatomy may result in sequelae such as elbow instability, persistent pain and osteoarthritis. PUDA), some ‘anatomical’ plates do not include these facts in their designs. 12, 13, 36 Despite knowledge of the specific proximal ulna anatomy (e.g. 8– 11 Furthermore, the ulnar bowing (varus angulation = VA) as well as the proximal ulna dorsal angulation (PUDA) and the olecranon-diaphysis angle (ODA) have to be strictly considered when reconstructing the osseous anatomy ( Fig. 6, 7 Recent studies have identified the anteromedial facet of the coronoid as a key factor for posteromedial stability of the elbow and thus its importance in an exact anatomical reconstruction. The coronoid and the olecranon are separated by a cartilage-free ‘bare area’ of approximately 3–5 mm. The coronoid process of the proximal ulna is the most important stabilizer against posterior joint dislocation and the olecranon against anterior dislocation, respectively. The humeroulnar joint resembles a hinge between the humeral trochlea and the proximal ulna. The aim of this review article is to illustrate the proper surgical management of these complex injuries using modern osteosynthetic implants and novel techniques while taking the complex biomechanics of the elbow joint into account. 5 Consequently, the appropriate treatment of proximal ulna fractures still remains a challenge for the orthopaedic surgeon. 4 An improper osseous reconstruction of the ulna as well as a failed/missed reattachment of elbow stabilizing structures will otherwise result in persistent pain, poor function and progressive joint degeneration due to chronic elbow instability. Thus, the surgeon carefully needs to address all aspects of the injury to allow early (active) rehabilitation and thereby prevent elbow stiffness. 3 The anatomical restoration of ulnar alignment (in length, rotation and axis) has to be the primary goal of surgical treatment to regain an unrestricted elbow function. 1, 2 While these fractures are common injuries in the upper extremity at any age, in adults they peak during the seventh decade of life. Fractures of the proximal ulna range in severity from simple olecranon fractures to complex Monteggia fractures or Monteggia-like lesions involving damage to stabilizing key structures of the elbow (i.e. ![]()
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