Patterns of Heterotopic Ossification in Fractures About the Elbow
Elizabeth P. Wahl, MD1; Peter M. Casey, MD1; Marc J. Richard, MD2; David S. Ruch, MD1
1Duke University, Durham, NC, 2Duke University Medical Center, Durham, NC
Heterotopic ossification (HO) is a well-known sequela after injury about the elbow. HO is widely studied given the morbidity associated with decreased elbow range of motion. Hastings and Graham originally described HO locations broadly as anterior, posterior or collateral ligaments. However, the specific location of HO development for different injury patterns about the elbow has not been reported. The purpose of this study is to compare the patterns of HO after a periarticular elbow fracture and/or dislocation for two upper extremity surgeons at a single institution.
Materials & Methods
A retrospective chart review was performed for patients with a preoperative diagnosis of a periarticular elbow fracture and/or dislocation who underwent an elbow contracture release over a ten-year period. The fracture patterns were grouped using the AO classification, specifically, 13A.1-C.3 and 21A.1-C.3, as well as terrible triad (TT) injuries. The HO location was determined by reviewing elbow radiographs and were classified as anterior capsule, posterior/triceps, medial or lateral soft tissues. The location of the incision from the index procedure was also recorded.
Fifty-three patients met the inclusion criteria. There were 17 TT injuries, 14 type C distal humerus (DH), 7 13B.3 (articular shear DH), 7 21B.1 (olecranon), 8 21B.2 (radial head) and 3 21A (extraarticular proximal radius/ulna) fractures. All (7/7) articular shear DH fractures developed HO medially and/or laterally while all (14/14) type C DH fractures developed anterior capsule HO. The TT injury developed HO either in the anterior capsule or medial and/or lateral soft tissues (Figure 1). The index incision location did not correlate to development of HO.
Our findings suggest that articular shear DH fractures affect the collateral ligaments whereas the type C intercondylar or transcondylar DH fractures affect the anterior capsule. In the type C fractures, the pattern of HO along the anterior capsule uniformly originated from the capsular attachment on the anterior surface of the distal humerus. Similarly, our data suggests that olecranon fractures affect the posterior capsule and triceps whereas radial head fracture affect the collateral ligaments. This is consistent with the understanding that HO is the abnormal ossification of normal structures. Further, as TT injuries represent a spectrum of fracture-dislocations, the discrepancy in HO development may be due to the severity of initial injury, specifically the soft tissue components involved.
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