elbow fracture dislocations adam watts

$: Elbow fracture dislocations adam watts$
Elbow fracture dislocations

Adam C Watts Consultant Elbow and Upper Limb Surgeon, Wrightington

Hospital

Visiting Professor, Manchester University

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www.wrightington.com

92 F Active

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Fracture Dislocations

Recognisable patterns of injury

Management plan based on anatomical principles

Consider “hidden” injury

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1.Posterior rotatory a.pronation lateral rotation

b.pronation medial rotation

2.Trans-olecranon a.extension

b.flexion

3.Longitudinal

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Posterior lateral rotation Terrible triad

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O’Driscoll Classification

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3

from Ring et al.


Terrible Triad algorithm

Restore coronoid

Restore radial head

Restore lateral soft tissue restraints

Restore medial soft tissue if still unstable

Apply hinged ex-fix

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Arguments around the coronoid?


O’Driscoll Classification


Does the coronoid need to be fixed?

Cohort study of 14 consecutive patients (Level 4)

2 Regan-Morrey type I, 12 type 2

No coronoid fixation - Min f/u 24 months

Mean arc of motion 123°

DASH 14

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How do we manage the radial head?

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Radial Head ORIF

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Intracapsular Fracture

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Blood Supply

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Fix or Replace?

No difference in ROM (Level 4)

ORIF more likely to be unstable

33% risk of arthrosis with arthroplasty

Equivalent re-operation rates

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“Hidden” injury

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Medial Collateral Ligament

Not fixing MCL is acceptable (Ring 2007)

Fix if having to go medially

If not leave it alone

Argument for decompression of ulnar nerve

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Timing of fixation

Best results if fixed acutely (within 2 weeks)

Stability and strength can be restored subacutely

ROM better in acute

Earlier treatment is more straightforward (Lindenhovius 2008)

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25 Male PE teacher

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Cat like observation not neglect

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Terrible triad with concentric reduction and small or undisplaced radial head and coronoid fragments

no sign of subluxation on radiographs rapid return to elbow flexion/extension no mechanical block to forearm rotation no neurovascular deficit patient choice

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Outcome Non-Op Management

DASH 8 (Level 4 evidence)

ROM 134°

1/12 required surgery for early instability

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My View

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Fix coronoid if large fragment or anteromedial facet fracture

Fix or replace radial head

Fix lateral soft tissue structures

Fix medial soft tissue structures if still unstable

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Posterior medial rotation Posteromedial rotatory instability


Transolecranon Monteggia Fracture Dislocations

Proximal ulna fracture with dislocation of radial head from radiocapitellar joint and proximal radioulnar joint


Bado Classification

Anterior

Posterior

Lateral

Radial diaphyseal fracture

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Jupiter Classification of Type II Fractures

IIa Coronoid level

IIb Metaphyseal/Diaphyseal junction

IIc Distal to coronoid

IId Fracture extending to distal 1/2 ulna

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Ring Classification

Type I Apex anterior diaphyseal ulna fracture with anterolateral dislocation of radiocapitellar and PRUJ

Type II Metaphyseal buckle fractures with anterolateral radiocapitellar dislocation (paediatric only)

Type III Apex posterior ulna fractures with posterior dislocation radiocapitellar joint

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Aims of treatment

Restoration of normal ulna alignment

Restoration of elbow stability

coronoid buttress radial head lateral ligament complex

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Bado I, Ring I

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Jupiter IIb, Ring III

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Jupiter IIa, Ring III


Longitudinal - Essex-Lopresti


“Hidden Injury” - IOM

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Load transfer

Prevent radius and ulna bowing

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Role of IOM


Tightrope Reconstruction

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Bone-ligament-bone graft

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Ligament Augmentation and Reconstruction System (LARS)

Polyester rope

Ultimate stress 2600N

Residual Strain at 2500N = 1.5%

Stiffness = 209N/mm (cf 129 native IOM)

No damage after 5 million cycles

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Experience to date

15 Procedures (chronic injuries) min follow-up 18

months

1 persistent axial instability - revised to OBF

No other recurrent proximal migration

Mean DASH improved 77 to 41/100

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1.Posterior rotatory a.pronation lateral rotation

b.pronation medial rotation

2.Trans-olecranon a.extension

b.flexion

3.Longitudinal

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Terrible TriadPMRI

Ring Type 1Ring Type 3

Essex-Lopresti


92 F Active

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elbow fracture dislocations adam watts

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