The coronoid opening angle: a novel radiographic technique to assess bone loss in coronoid trauma.

BACKGROUND: Elbow fracture dislocations are complex injuries that often require surgical treatment in order to obtain a stable and congruent elbow joint. The coronoid plays a key role in the stability of this joint. Accurately identifying the degree of coronoid bone loss in the setting of traumatic elbow injuries is challenging. The purpose of this study is to describe a new radiographic measure, the coronoid opening angle (COA), to assist in estimating bone loss in these challenging fractures. METHODS: Radiographs were drawn from a regional database in a consecutive fashion. Candidate radiographs were excluded on the basis of radiographic evidence of degenerative changes, previous surgery or injury, bony deformity, and inadequate lateral view of the elbow. Normal COA, coronoid height, and calculated COA at varying amounts of bone loss were determined by 3 reviewers. RESULTS: A total of 120 subjects were included. The normal coronoid opening angle was 34° (95% CI 32.9°-34.0°) and the coronoid height, 18.8 mm (18.1-19.6). Ninety-five percent of the population had an opening angle greater than 29° (95% CI 27.2°-29°). The COA limit was calculated at 20%, 33%, and 50% of baseline coronoid height corresponding to degree of bone loss. Coronoid opening angles of 24°, 20°, and 16°, respectively, indicate the minimum bone loss of interest in 95% of the population. The intraclass correlation coefficient was found to be 0.89 or higher. CONCLUSION: In the setting of elbow trauma, it is often challenging to predict the amount of coronoid bone loss. The coronoid opening angle is a new technique and an adjunct for lateral elbow radiographs to predict the minimum coronoid bone loss. This can be used to guide clinical decision making, aid in predicting instability, and guide treatment. Future research will aim to validate this tool in the clinical trauma setting.

Damage Control Orthopaedics in Spinal Trauma.

There has been a shift in the management of the polytrauma patients from early total care to damage control orthopaedics (DCO), whereby patients with borderline hemodynamic stability may be temporized with the use of external fixators, traction, or splinting with delayed osteosynthesis of fractures. Recently, there has been an increasing trend toward a middle ground approach of Early Appropriate Care for polytrauma patients. The concepts of DCO for the spine are less clear, and the management of trauma patients with combined pelvic ring and spinal fractures or patients with noncontiguous spinal injuries present unique challenges to the surgeon in prioritization of patient needs. This review outlines the concept of DCO and Early Appropriate Care in the spine, prioritizing patient needs from the emergency department to the operating room. Concepts include the timing of surgery, minimally invasive versus open techniques, and the prioritization of spinal injuries in the setting of other orthopaedic and nonorthopaedic injuries. Contiguous and noncontiguous spinal injuries are considered in construct planning, and the principles are discussed.