Complex fractures of the Elbow

N. A. Darlis, MD, PhD

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Unstable elbow Combination injuries

Mechanism

• Posterolateral rotatory stress

Pathoanatomy

• Injured structures– 1: LCL-ulnar– 2: LCL-radial

capsule– 3a: MCL-post– 3b: MCL-ant

Pathoanatomy• Posterolateral rotatory stress

Horii circle

Pathoanatomy• Valgus deformity

Schreiber JJ et al., JHS(A), 2013

Pathoanatomy

• All 16 acute elbow dislocations had MCL injury• Complete tears at the medial side were more common than

the lateral

Schreiber JJ et al., JHS(A), 2014

Pathoanatomy• Valgus deformity

Horii circle reversed ?

Mechanism

Valgus PRLI

Forearm instability• “The forearm as a

ring” concept

• Key role of– Radial Head– IOM– TFCC

• Double or Multiple injuries to the ring common

Forearm Interossous Membrane

• Contributes 70% of forearm stability

• Can be injured in association with elbow fractures

Radius

Ulna

CB

Injury patterns commonly associated with instability:

• Terrible Triad of the Elbow• Transolecranon Fracture dislocation • Essex-Lopresti Injury• Posterior Monteggia lesion and equivalents• “Floating Elbows”

Terrible Triad

• Elbow dislocation• Radial head fracture• Coronoid fracture

• Diagnosis can be missed!

• Careful screening of radiographsCourtesy : C.G. Zalavras, MD

Essex-Lopresti Injury

Courtesy : D.G. Sotereanos, MD

Transolecranon fracture dislocations

Posterior Monteggia lesion

Courtesy : C.G. Zalavras, MD

• Anterior fragment includes the coronoid

Jupiter et al. JOT, 1991

Posterior Monteggia lesion

Courtesy : C.G. Zalavras, MD

Monteggia type 2 equivalent lesion

Monteggia type 2 equivalent lesion

… Other double injuries

Floating elbow

• Type IIa IIb III

Courtesy : K. Ditsios, MD

Floating elbow

• Type IIa III

Courtesy : K. Ditsios, MD

Open/ Neurovascular injury

UN

Open/ Neurovascular injury

Nerve grafts

Complex elbow instability

• Operative treatment• No role for conservative management

• Goal: Early, concentric mobilization

Skin incision

• Posterolateral (Kocher)

• Posterior midline (Universal)

– when medial approach is

contemplated

Kocher approach

Lateral approach

Or… use the paths of soft tissue injury

1/2

123

45

6

Proximal Ulna

• Anatomic Reduction

• Pre-contoured proximal ulnar plates useful

1

Will need plating most of the times

Posterior Monteggia lesion

Radial Head • Excision not recommended in complex

elbow instability– radial head is essential if MCL is injured

• ORIF• Prosthetic replacement

2

Radial Head: ORIF

• If fracture amenable to internal fixation

• Safe zone of hardware placement

• Radial neck fracture fixation challenging

Radial Head: Prosthesis

– Comminuted fractures associated with elbow dislocations may be better treated by prosthetic replacement

– Side-table re-assembly and ORIF not favored

Ring et al. JBJS-Am 2002

Radial Head: Prosthesis

– Remove radial head fragments

– Perform neck osteotomy

– Measure head diameter

– Coronoid first then RH implant

Coronoid

Regan-Morrey classification

3

Coronoid

Retrograde screw fixation

Coronoid

Medial facet fracture

Coronoid

• Suture fixation through anterior capsule ?

• Fixation of small avulsion fractures???

Lateral collateral ligament

• Usually avulsed from its origin from lateral epicondyle

• Repair with suture anchors to lateral epicondyle

4

Lateral collateral ligament

• Repair with suture anchors to lateral epicondyle

• With extensor origin sleeve

Intraoperative assessment of stability

• Clinical• Radiological (C-arm)

– Forearm in pronation

– Note stable range of motion

– If stable to aprx 500 of flexion immobilize in pronation and start early ROM in hinged brace within the range of stability

Intraoperative assessment of stability

• If stable in narrow ROM or unstable after the above consider:

– Hinged elbow external fixation

– MCL repair• Consider especially if dislocation occurs with

forearm in pronation

Hinged external fixator

• Allows early joint motion

• Maintains concentric reduction

• Protects any repair/fixation

5

Monteggia type 2 equivalent lesion

MCL

• Repair/ Reconstruct• Medial approach

– ulnar nerve symptoms– medial coronoid facet

fracture– medial epicondyle

fracture

6

Essex-Lopresti Injuries

• Radial Head Reconstruction- Replacement

• DRUJ reduction- pinning in supination

• TFCC repair?• IOM reconstruction ?

Courtesy : D.G. Sotereanos, MD

Total Elbow Arthroplasty• Comminuted fractures in elderly patients

may not be obvious; may not be obvious; maintain high index of suspicionmaintain high index of suspicion

http://www.flickr.com/photos/katiedee/4884263411/lightbox/

address the specific components address the specific components of the injuryof the injury

• Bone– Radial head (repair or replacement)– Coronoid (repair or bone block)– Proximal ulna (anatomic repair)

• Ligaments– LUCL/ extensor origin reattachment– MCL

Poor prognosis in older series with Poor prognosis in older series with no consistent treatment protocolno consistent treatment protocol

– all 4 redislocations out of 23 elbow fracture-dislocations occurred in terrible triad cases

– severe arthrosis in 12 of 19 elbows @3 to 34 years.

Josefsson et al. CORR 1989

– 7 of 11 patients unsatisfactory result– arthrosis in 9 of 10 patients @7 years

Ring et al. JBJS-Am, 2002

http://www.flickr.com/photos/doug88888/4627497417/

Modern Treatment Protocol Modern Treatment Protocol Studies (after 2004) encouraging…Studies (after 2004) encouraging…

Flexion arc 1100, Rotation 1300, Mayo score 85

…but long term but long term DJD unknownDJD unknown

No redislocationsMild arthritis

@ 2,5years

Pugh et al., JBJS (A) 2004, Egol et al, Bull NYU Hosp Jt Dis.2007, Forthman et al., JHS(A) 2008, Lindenhovius et al, JHS(A) 2008, Zeiders et al., JBJS 2008

THANK YOU

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