Functional and radiographic outcomes after surgical management of complex proximal ulna fractures: a retrospective case series

Abstract

Background: Complex proximal ulna fractures (including comminuted olecranon fractures and fracture-dislocations of the elbow) pose challenging management due to concomitant injuries to key stabilizers (radial head, coronoid process, and collateral ligaments). This study evaluates functional and radiographic outcomes following surgical treatment and explores the prognostic value of associated injuries, age stratification, and a new coronoid-centric classification system.

Methods: We retrospectively reviewed 43 patients with complex proximal ulna fractures treated between 2019 and 2024, with a minimum of 12 months of follow-up (mean, 28 months). Fractures were categorized as complex olecranon (32.6%), transolecranon (16.3%), Monteggia (4.6%), or Monteggia-like (46.5%). We also applied the Mayo Clinic's coronoid-centric classification of proximal trans-ulnar fracture-dislocations, classifying cases as transolecranon (type I), Monteggia variant (type II), or transulnar basal coronoid (type III) fractures. According to this coronoid-centric classification, we obtained 11 transolecranon cases, 8 Monteggia variant, and 10 transulnar basal coronoid fractures. Associated injuries included radial head fractures in 56% (58.3% Mason IV) and coronoid fractures in 44.2%. Functional outcomes were assessed via range of motion, Mayo Elbow Performance Index, and Quick Disabilities of the Arm, Shoulder, and Hand. Subgroup analysis by age (≤65 vs. >65 years) was performed. Radiographs were reviewed for arthrosis, subluxation/dislocation, and heterotopic ossification. Complications were recorded.

Results: Mean age was 68 years. Mayo Elbow Performance Index and Quick Disabilities of the Arm, Shoulder, and Hand scores averaged 100 (85-100) and 6.8 (2.3-22.7), respectively. Mean range of motion was flexion 129.6°±9°, extension -21.7°±11°, pronation 90° (40°-90°), and supination 80° (45°-90°). Complications occurred in 14% of cases, including ulnar neurapraxia, nonunion, and hardware intolerance. Patients with coronoid and/or radial head fractures had significantly worse outcomes. Worse results were also observed in patients aged ≤65 years (P = .008). Radiographic arthrosis occurred in 37% of cases, mainly grades 2 or 3.

Conclusions: Despite the complexity of these injuries, outcomes were generally favorable with a low complication rate. However, the presence of associated injuries to elbow stabilizers and transulnar basal coronoid fracture patterns per the Mayo classification was linked to poorer outcomes and higher arthrosis rates. Older age correlated with better functional recovery.