Heterotopic ossification, also known as heterotopic bone formation, is the ectopic formation of lamellar bone within soft tissues such as muscle, ligament, or tendon. It can be genetic or acquired. It is most commonly acquired and can be categorized into 3 etiologies: neurogenic from central nervous system injury; traumatic after burns or high-velocity impact; or orthopedic, entailing fracture fixations, repairs, and joint replacements.1,2 Unfortunately, the exact underlying mechanism for heterotopic ossification remains unclear. Regardless, it is widely accepted that heterotopic ossification results from a combination of an inflammatory response and differentiation of multipotent cells in the ectopic tissue where bone forms.1–5
When it occurs, heterotopic ossification can decrease patient satisfaction and impact recovery and rehabilitation efforts. It can lead to a variety of complications, ranging from pain and reduced range of motion to ankylosis of the joint.6,7 Incidence rates of heterotopic ossification after surgery for different traumatic elbow fractures have varied tremendously in the literature. In 2016, a study of 38 patients by Chen and Bi8 on the outcomes of repair of terrible triad injuries reported an incidence rate of 0% for heterotopic ossification. In 1982, Garland and O'Hollaren9 reported an incidence rate of 89% for heterotopic ossification in patients with elbow fracture/dislocation injuries. Neither study used a classification system to define heterotopic ossification. In 2015, Hong et al10 performed a study of risk factors of 124 elbow fractures of several different types, finding an overall incidence of heterotopic ossification of 31%; this study used the Hastings and Graham classification system. Finally, in 2015, Shukla et al11 studied heterotopic ossification formation after elbow fractures/dislocations specifically. They found an incidence of 43% and reported heterotopic ossification data using the modified Brooker classification system.11
The authors believe that there are several reasons for this variation in the incidence of heterotopic ossification, noting the numerous fracture possibilities present at the elbow joint and the absence of classification or the use of multiple classification systems in particular. To the authors' knowledge, there is limited literature using a standardized protocol to compile incidence rates of heterotopic ossification after surgical repair of several types of elbow fractures in a comparable manner. As such, the goal of this systematic review was to use specific inclusion and exclusion criteria to provide updated data on the incidence and prevalence of heterotopic ossification after surgical repair of various types of elbow fractures.
Materials and Methods
A systematic literature review was performed in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses statement. Scopus (EMBASE, MEDLINE, COMPENDEX) and PubMed (MEDLINE) databases were queried for articles using the keywords “elbow”, “fracture”, and “trauma” and the phrase “heterotopic ossification”. The search was kept broad in an attempt to capture all relevant literature. All articles in print or epub ahead of print were included. The search was limited to articles written in English or easily translatable to English during a 26-year period, from 1994 to the present. Initial screening was based on title and abstract, and all articles relevant to the current review were included for examination. For completeness, the references of the articles included were also reviewed to ensure accurate data capture. The title and abstract of each article were screened initially for relevance, and then the full text of articles was checked against specific inclusion and exclusion criteria by an independent reviewer (Z.J.H.).
Case-control studies, randomized trials, case series, and prospective and retrospective cohort analyses with patients older than 18 years reporting cases of heterotopic ossification after elbow fracture and surgical repair were included. To accurately assess and compare the heterotopic ossification, an additional inclusion criterion was use of the Hastings and Graham classification system (class I, radiograph with positive findings for ectopic bone with no functional impairment clinically; class II, ectopic bone causing subtotal, functional limitation of flexion, extension, pronation, and/or supination; class III, ectopic bone with ankylosis of the joint that eliminates motion) for the heterotopic ossification that occurred. The authors chose to only include studies that used the Hastings and Graham classification system as it was originally designed for evaluation of heterotopic ossification at the elbow.12 Studies that included isolated fracture types or studies with multiple fracture types (different classifications, different anatomic regions about the elbow) that supplied individual patient data specifically delineating which patients with which fracture patterns had postoperative heterotopic ossification were also included. Finally, all patients whose data were used in analysis must have adhered to follow-up protocols in the individual studies.
To obtain information on a broad, general incidence, no exclusion criteria were applied based on presence or absence of prophylactic measures (radiation therapy/nonsteroidal anti-inflammatory drug use) or type or severity of elbow fracture. No exclusion criteria were applied for type of surgical treatment for the elbow injury, age of patients in the studies, underlying calcium metabolism disorder of patients, additional complications besides heterotopic ossification, or length of follow-up.
Studies were excluded if they did not report the specific number of heterotopic ossification formations compared with the total number of elbow fracture repairs. Studies that focused on the treatment of populations entirely with heterotopic ossification were excluded because incidence could not be calculated. Studies that reported the incidence of elbow heterotopic ossification after head, spinal cord, or burn injuries (without elbow fractures and surgical repair) were excluded. Studies that reported the incidence of heterotopic ossification after surgery indicated for elbow pathology other than a fracture, such as rheumatoid arthritis, osteoarthritis, or tumor, were also excluded.
Ultimately, the included studies were used as evidence for the review. All studies included were assigned a level of evidence using the Oxford Centre for Evidence-Based Medicine table of guidelines and recommendations.13 Additionally, the authors conducted an analysis of potential bias in all included studies using the Risk Of Bias In Non-randomized Studies–of Interventions (ROBINS-I) tool14 and the Cochrane risk-of-bias in randomized studies (RoB 2.0) tool.15 Bias results were formatted with the visualization tool for risk of bias assessments in a systematic review (robvis) tool.16
Included fracture types were stratified according to anatomic location about the elbow or injury pattern. Fractures were not stratified by presence or absence of concomitant nerve or ligamentous injury or as being opened or closed. The authors grouped fractures into 6 categories: distal humerus, proximal radius, proximal ulnar, terrible triad injury, elbow fracture/dislocation, and complex fracture without dislocation. The distal humerus category included distal humerus fractures as well as capitellum and coronal shear fractures. Proximal radius fractures included radial head and neck fractures and Essex-Lopresti lesions if present.17 The proximal ulnar group included coronoid process, olecranon process, and proximal ulnar fractures. The terrible triad group included fractures with the characteristic features of the “terrible triad” injury described by Hotchkiss18 in 1966. This consists of the combination of radial head and coronoid process fractures with an associated elbow dislocation. The elbow fracture/dislocation group consisted of Monteggia-like lesions and any other combination of distal humerus, proximal radius, proximal ulnar, olecranon process, or coronoid process fracture with concomitant elbow dislocation that was not otherwise classified as a terrible triad injury.19,20 Finally, the complex fracture without dislocation group involved a combination of fractures of 2 or more of the following: olecranon process, coronoid process, proximal ulna, radial head/neck, and/or distal humerus without associated elbow dislocation.
Data Extraction and Statistical Analysis
Standardized data extraction was performed. The overall (combination of all 3 Hastings and Graham classes) incidence of heterotopic ossification was calculated by dividing the total number of cases of heterotopic ossification by the total number of fractures in the studies. The incidence of heterotopic ossification was calculated separately for those studies that used any form of heterotopic ossification prophylaxis postoperatively vs those studies that did not. The authors calculated odds ratios and 95% CIs to compare the overall incidence of heterotopic ossification with and without the use of prophylaxis. Additionally, the overall incidence of heterotopic ossification in the studies was divided according to Hastings and Graham classes I, II, and III. Furthermore, Hastings and Graham classes II and III were combined to produce an incidence of “clinically relevant” heterotopic ossification, as class I heterotopic ossification has no functional impairment. The incidence of heterotopic ossification by fracture group was also calculated by dividing the number of cases of heterotopic ossification in a fracture group by the total number of fractures in that fracture group. Within each fracture group, the prevalence of heterotopic ossification was broken down by Hastings and Graham classes. The authors calculated odds ratios and 95% CIs to compare the overall incidence of heterotopic ossification by fracture category. Statistical significance was defined as P<.05 and a 95% CI that did not contain a value of 1.
The initial search identified 1766 articles using the keywords. An additional 17 articles were found and included from references of included studies. After duplicates were removed, 1375 articles remained. All articles were screened based on title and abstract. A total of 1174 were excluded due to irrelevance to topic, not being in English, or being older than publication year of 1994. A total of 201 full-text articles were reviewed, with 178 being excluded for failure to meet inclusion criteria. Thus, 23 studies were included for final data analysis.21–43Figure 1 shows the search details and study selection process.
Preferred Reporting Items for Systematic Reviews and Meta-Analyses database search and study selection process.
Of the 23 studies included, there were 1 level II study, 7 level III studies, and 15 level IV studies. Seven were prospective and 16 were retrospective. The 1 randomized trial was assessed as having “some concerns” of bias.24 Of the non-randomized studies, 11 were assessed as having “moderate” risk of bias.21–23,26,29,32–34,38–40 Eleven were assessed as having “serious” risk of bias by the bias assessment tools used.25,27,28,30,31,35–37,41–43 These data are presented in Figure A and Figure B (available in the online version of the article).
Assessed risk of bias in the randomized study.
Assessed risk of bias in the non-randomized studies.
Demographic data, study information, and results regarding the incidence of heterotopic ossification per study are presented in Table A (available in the online version of the article). Overall, 659 fractures were reviewed in 659 patients with a mean age of 51.5 years (range, 18–90 years). All but 1 study42 reported sex. There were 334 males (52.5%) and 302 females (47.5%). The average follow-up was 42 months (range, 9–171 months). The incidence rate of heterotopic ossification (of any class) was found to be 189 per 659 (28.7%).
Demographic Data, Study Information, and HO Incidence
Seven studies used prophylaxis postoperatively to prevent heterotopic ossification. This included radiation therapy, indomethacin, and/or celecoxib.22–24,29,31,33,40 In these studies, the incidence of heterotopic ossification was 19.9% (43 of 216). The remaining 16 studies did not use any form of heterotopic ossification prophylaxis.21,25–28,30,32,34–39,41–43 The incidence of heterotopic ossification in this group was 33.0% (146 of 443). Analysis suggested that the odds of heterotopic bone formation are less with any form of prophylaxis than without prophylaxis (odds ratio, 0.51; 95% CI, 0.34–0.75; P=.0006).
Of the total 189 cases of heterotopic ossification, prevalence by Hastings and Graham classification was as follows: 54.5% (103 cases) class I; 43.9% (83 cases) class II; and 1.6% (3 cases) class III. Additionally, the overall incidence of class I, class II, and class III heterotopic ossification was 15.6%, 12.6%, and 0.5%, respectively. The authors found a result of 13.1% when calculating the incidence of clinically relevant heterotopic ossification by Hastings and Graham classes II and III (Table 1).
Prevalence and Incidence of Heterotopic Ossification by Hastings and Graham Classification
As stated earlier, the fractures in the studies included were grouped according to anatomic region about the elbow or type (Table 2). Fractures in the distal humerus group included distal humerus fractures that were AO/OTA classification A, B, and C (class A, extra-articular; class B, partial articular; class C, complete articular).44 No studies involving isolated capitellum or coronal shear fractures met inclusion and exclusion criteria. Distal humerus AO/OTA fractures that included capitellum or coronal shear fracture elements were placed in the distal humerus group as well. There were 367 total fractures; 16 (4.4%) were AO/OTA class A, 8 (2.2%) were AO/OTA class B, and 343 (93.5%) were AO/OTA class C. The overall incidence of heterotopic ossification in the distal humerus fracture group was 21.8% (n=80). Of the heterotopic ossification cases, 42.5% (n=34) were class I and 57.5% (n=46) were class II. There were no class III cases.
Incidence of Heterotopic Ossification by Anatomic Region/Fracture Type Group
Fractures in the proximal radius group consisted of type II and type III radial head fractures by Mason-Johnston classification (type II, fractures with >2 mm displacement; type III, comminuted fractures without dislocation).45 One study did not use the Mason-Johnston classification but included only radial head fractures that were greater than 2 mm but less than 5 mm displaced. This study was included. The group also contained 1 Essex-Lopresti lesion. There were 132 total fractures: 101 (76.5%) were classified as Mason-Johnston type II or III, 1 (0.8%) was an Essex-Lopresti lesion, and 30 (22.7%) were greater than 2 mm but less than 5 mm displaced but not classified by Mason-Johnston. The overall incidence of heterotopic ossification in the proximal radius group was 31.8% (n=42). Of the heterotopic ossification cases, 78.6% (n=33) were class I and 21.4% (n=9) were class II. There were no class III cases.
In the terrible triad injury group, the Mason-Johnston classification system was used for radial head fractures and the Regan and Morrey classification system (type I, coronoid process tip; type II, fracture of 50% or less of height; type III, fracture of more than 50% of height) was used for coronoid process fractures.46 There were 97 total fractures. The overall incidence was 42.3% (n=41). Of the heterotopic ossification cases, 61.0% were class I (n=25), 34.1% (n=14) were class II, and 4.9% (n=2) were class III.
Fractures in the elbow fracture/dislocation group consisted of Mason-Johnston type IV (radial head fracture with associated dislocation), Monteggia-like lesions, and any other combination of distal humerus, olecranon, or coronoid process fracture with an associated elbow dislocation that did not meet criteria for terrible triad injury. There were 49 fractures in this group. The incidence of heterotopic ossification was 42.9% (n=21). Of the heterotopic ossification cases, 47.6% (n=10) were class I, 47.6% (n=10) were class II, and 4.8% (n=1) were class III.
Fractures in the complex fracture without dislocation group consisted of combinations of olecranon process, coronoid process, proximal ulnar, radial head/neck, and/or distal humerus fractures without associated dislocations. There were 14 total fractures in this group. The incidence of heterotopic ossification was 35.7% (n=5). Of the heterotopic ossification cases, 20.0% (n=1) were class I and 80.0% (n=4) were class II. There were no class III cases.
No studies involving isolated proximal ulnar fractures or isolated coronoid or olecranon process fractures met inclusion and exclusion criteria. Any coronoid or olecranon fracture was sustained in a combination of fractures or as part of an elbow fracture/dislocation, Monteggia-like lesion, or terrible triad injury. This group was thus omitted, and the fractures were grouped accordingly.
Additionally, the authors compared the overall incidence of heterotopic ossification by fracture anatomic region and injury type. Proximal radius fractures (odds ratio, 1.67; 95% CI, 1.08–2.61; P=.02), terrible triad injuries (odds ratio, 2.63; 95% CI, 1.64–4.22; P=.0001), and elbow fractures/dislocations (odds ratio, 2.69; 95% CI, 1.45–4.99; P=.002) were all associated with a statistically significant higher incidence of heterotopic ossification than distal humerus fractures. No other comparisons were associated with statistically significant increased or decreased incidence of heterotopic ossification (Table 3).
Odds Ratios, 95% CIs, and P Values for Fracture Grouping Comparisons
The results of this study suggested an overall incidence rate of 28.7% for heterotopic ossification and an incidence rate for clinically relevant heterotopic ossification of 13.1% when multiple elbow fracture surgical repair results were compiled. Comparisons, odds ratios, and 95% CIs also suggested a smaller chance of having any heterotopic ossification after surgical repair of distal humerus fractures than after proximal radius, terrible triad, or elbow fracture/dislocation repairs. It was further suggested that there was no difference in the chance of acquiring any heterotopic ossification after surgical repair of proximal radius fractures, elbow fractures/dislocations, terrible triad injuries, or complex elbow fractures.
Limited studies are present in the literature that compile and comment on the incidence of heterotopic ossification after surgical repair of multiple different types of elbow fracture. In 2012, Bauer et al47 reported a case-control study in two institutions of 786 elbow fractures between 2002 and 2009. The fracture types included distal humerus, isolated radial head, Monteggia lesions, terrible triad, isolated olecranon, and floating elbow injuries. They set out to quantify the rate of clinically relevant heterotopic ossification after elbow fracture surgery (incidence of heterotopic ossification for Hastings and Graham classes II and III combined). They found an incidence rate of 7%. Comparatively, in the current study, the incidence of clinically relevant heterotopic ossification for Hastings and Graham classes II and III was 13.1%. Bauer et al47 also broke down the incidence of clinically relevant heterotopic ossification by fracture type. In their results, terrible triad injuries (18%; 14 cases of 76 fractures) and floating elbow injuries (36%; 4 cases of 11 fractures) had the highest incidence of clinically relevant heterotopic ossification.47 The current study compiled the overall incidence and not the clinically relevant incidence of heterotopic ossification, yet the terrible triad (42.3%), elbow fracture/dislocation (42.9%), and complex fracture without dislocation (35.7%) groups had the highest overall incidences.
In 2015, Hong et al10 reported a retrospective analysis from 2007 to 2011 of 124 elbow fractures and the incidence of heterotopic ossification after surgical repair. Injury types included terrible triad, floating elbow and combined fractures, elbow fractures/dislocations, distal humerus, isolated radial head, isolated olecranon, and Monteggia lesions. They found an overall incidence of heterotopic ossification of 30.6%. This is comparable with the current study's overall incidence of 28.7%. Additionally, Hong et al10 reported an incidence of clinically relevant heterotopic ossification (Hastings and Graham classes II and III) of 21%. This is higher than the currently reported incidence of clinically relevant heterotopic ossification of 13.1%. Although the samples were small, Hong et al10 found the overall incidence of heterotopic ossification after surgical repair of distal humerus fractures to be 25% (8 of 32), proximal radius fractures to be 50% (8 of 16), terrible triad injuries to be 58.3% (7 of 12), and floating elbow/combined fractures to be 83.3% (5 of 6). The current study's reported incidence of heterotopic ossification after distal humerus fracture repair is comparable, at 21.8%. However, the current reported incidence rates of heterotopic ossification after proximal radius (31.8%), terrible triad (42.3%), and combined fractures (35.7%) are lower than those reported by Hong et al.10
Additionally, in 2014, Wiggers et al48 reported a retrospective review of 284 elbow fractures from 2001 to 2007. Fracture types included distal humerus, radial head, olecranon, coronoid, and elbow fracture/dislocation. The study found an overall incidence of heterotopic ossification of 33.8% and an incidence of clinically relevant heterotopic ossification of 10%.48 These results are comparable to the current findings for overall incidence of heterotopic ossification (28.7%) and incidence of clinically relevant heterotopic ossification (13.1%).
Although most have much smaller samples, numerous studies have reported heterotopic ossification incidence rates after isolated fracture types. These rates tend to have large ranges when compared across the literature. For example, in the studies used in the current systematic review, the incidence of heterotopic ossification after isolated distal humerus fracture repair ranged from 4.0% to 41.6%.29,34 The incidence of heterotopic ossification after surgical repair of isolated proximal radius fractures ranged from 0.0% to 52.0%.26,38 The incidence of heterotopic ossification after terrible triad repair ranged from 27.3% to 58.3%.41,43 The incidence of heterotopic ossification in the one study with isolated elbow fracture/dislocation was 27.3%.22 Due to the large number of individual studies, their small samples, and different techniques for surgical repair, it is difficult to compare the variable results of these studies for individual fracture types with the current results compiled into a much larger sample.
A limitation of the current study was the inherent nature of a systematic review, which relies on the quality of the individual studies from which it collects data. This study was also limited by publication bias for the individual studies included and any potential bias introduced by those involved in reporting radiologic results. In an attempt to collect general information about multiple fracture types at the elbow, several of the studies included used different repair mechanisms, had different patient age ranges and follow-up periods, and had varied implementation of heterotopic ossification prophylactic measures. Future research should have stricter inclusion criteria and exclusion criteria, such as specific fracture types, surgical treatments, patient populations, and use of prophylactic measures, to specify the effect of different variables on the incidence of heterotopic ossification.
Heterotopic ossification is a potentially serious complication after surgical repair of elbow fractures. As updates continue in technique, technology, and literature regarding the surgical treatment of elbow fractures, the incidence of complications such as heterotopic ossification must be re-examined. Wide incidence ranges of heterotopic ossification after surgical treatment of the elbow are present in the literature. In the current updated systematic review, the authors set out to compile various data points on the incidence of heterotopic ossification after several different types of fractures about the elbow. Moreover, the authors conclude that their results are similar to those of other studies that have assembled results of larger samples of various elbow fracture repairs. Additionally, the authors conclude that, on the basis of their results, the overall chance of developing heterotopic ossification may be less after distal humerus fractures than after proximal radius fractures, terrible triad injuries, and elbow fractures/dislocations. There may be no statistically significant difference regarding the chance of acquiring heterotopic ossification after surgical treatment of proximal radius fractures, terrible triad injuries, elbow fractures/dislocations, or complex fractures without dislocation.
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Prevalence and Incidence of Heterotopic Ossification by Hastings and Graham Classification
|I (no functional impairment)||54.5% (n=103)||15.6% (n=103)|
|II (subtotal functional impairment of any kind)||43.9% (n=83)||12.6% (n=83)|
|III (ankylosis of the joint eliminating motion)||1.6% (n=3)||0.5% (n=3)|
Incidence of Heterotopic Ossification by Anatomic Region/Fracture Type Group
|Group||No. of HO cases (by Hastings and Graham class)||Total no. of fractures||Incidence of HO (no./total no.)|
|Distal humerus||80 (34 class I; 46 class II)||367||21.8% (80/367)|
|Proximal radius||42 (33 class I; 9 class II)||132||31.8% (42/132)|
|Terrible triad||41 (25 class I; 14 class II; 2 class III)||97||42.3% (41/97)|
|Elbow fracture/dislocation||21 (10 class I; 10 class II; 1 class III)||49||42.9% (21/49)|
|Complex fracture without dislocation||5 (1 class I; 4 class II)||14||35.7% (5/14)|
Odds Ratios, 95% CIs, and P Values for Fracture Grouping Comparisons
|Group comparison||Odds ratio||95% confidence interval||P||Statistically significant?|
|Proximal radius to distal humerus||1.67||1.08–2.61||.02||Yes|
|Terrible triad to distal humerus||2.63||1.64–4.22||.0001||Yes|
|Elbow fracture/dislocation to distal humerus||2.69||1.45–4.99||.002||Yes|
|Complex fracture to distal humerus||1.99||0.65–6.11||.23||No|
|Terrible triad to proximal radius||1.57||0.91–2.70||.11||No|
|Terrible triad to complex fracture||1.32||0.41–4.23||.64||No|
|Elbow fracture/dislocation to terrible triad||1.02||0.51–2.05||.95||No|
|Elbow fracture/dislocation to proximal radius||1.61||0.82–3.15||.17||No|
|Elbow fracture/dislocation to complex fracture||1.35||0.39–4.62||.63||No|
|Complex fracture to proximal radius||1.19||0.38–3.77||.77||No|
Demographic Data, Study Information, and HO Incidence
|Lead Author||Year||Level of Evidence||Study Design||No. Patients (M/F)||Mean age (years)||Mean Follow-Up (months)||Total Fracture||HO cases||HO Prophylaxis||Injury type(s)|
|Popovic21||2000||IV||Prospective||11 (6/5)||52.7||32||11||1||No||radial head, fracture/elbow dislocation, terrible triad|
|Stein22||2003||IV||Retrospective||11 (3/8)||51||12||11||3||Yes; radiation therapy||fracture/elbow dislocation|
|Gofton23||2003||IV||Retrospective||23 (12/11)||53||45||23||7||Yes; indomethacin||distal humerus|
|Shin24||2010||II||Prospective||35 (12/23)||52.5||40.3||35||2||Yes; radiation therapy||distal humerus|
|Burkhart25||2010||IV||Retrospective||15 (13/2)||45.5||107.7||15||11||No||terrible triad, radial head, andfracture/elbow dislocation|
|Chien26||2010||IV||Prospective||13 (9/4)||38.6||38.3||13||0||No||isolated radial head|
|Frattini27||2011||IV||Retrospective||34 (19/15)||50||53||34||4||No||distal humerus|
|Schmidt-Horlohé28||2012||IV||Prospective||31 (14/17)||50||12.3||31||4||No||distal humerus|
|Tian29||2013||III||Retrospective||25 (15/10)||40||19.1||25||1||Yes; celecoxib||distal humerus|
|Giannicola30||2013||IV||Prospective||18 (8/10)||47||26||18||3||No||terrible triad, coronoid fracture/elbow dislocation|
|Berschback31||2013||III||Retrospective||24 (13/11)||48.7||31.2||24||13||Yes; indomethacin, celecoxib, and/or radiation therapy||radial head, concomitant proximal ulnar fracture, terribletriad|
|Yoon32||2014||III||Retrospective||30 (16/14)||39||54||30||8||No||isolated radial head|
|Zhang33||2014||III||Retrospective||67 (25/42)||69.3||34||67||9||Yes; indomethacin||distal humerus|
|Foruria34||2014||IV||Retrospective||89 (45/44)||58||Not Available||89||37||No||distal humerus|
|Burkhart35||2015||IV||Prospective||21 (13/8)||50||12.1||21||4||No||radial head, terrible triad, fracture/elbow dislocation|
|Phadnis36||2015||IV||Prospective||16 (3/13)||78.7||35||16||6||No||distal humerus, some with a coronal shear element|
|Van Hoecke37||2016||IV||Retrospective||13 (12/1)||51.4||115.8||13||8||No||radial head, fracture/elbow dislocation, terrible triad|
|Lópiz38||2016||III||Retrospective||25 (10/15)||54.1||50.1||25||13||No||radial head|
|Chou39||2016||IV||Retrospective||48 (27/19)||41||44.2||48||11||No||distal humerus|
|Tarallo40||2017||IV||Retrospective||31 (21/10)||52||30||31||8||Yes; celecoxib||radial head and coronoid process fractures|
|Mazhar41||2018||III||Retrospective||44 (28/16)||39.1||31.7||44||12||No||terrible triad|
|Gregori42||2019||III||Retrospective||23 (not available)||45||75.7||23||17||No||radial head, fracture/elbowdislocation, terrible triad|
|Zaidenberg43||2019||IV||Retrospective||12 (8/4)||55||111.6||12||7||No||terrible triad|
|Totals||23 studies||1 II; 7 III; 15 IV||6 P; 17 R||659 [334 (52.5%)/302 (47.5%)]||51.5||42||659||189||7 yes; 16 no||Total Incidence: 28.7% (189/659)|