5/9/2017

1

Elbow Fracture Dislocations: My Algorithm

Charles M. Jobin, MDAssistant Professor of Orthopedic SurgeryResidency Program DirectorShoulder & Elbow SurgeryColumbia UniversityNew York, NY

29th Annual Orthopaedic Trauma CourseFriday May 5th, 2017

2

Disclosures

Consultant – Acumed, Wright/Tornier, Zimmer/Biomet

JSES, JBJS, JAAOS, JOR – Reviewer

JAAOS Shoulder/Elbow Deputy Editor

Orthobullets.com – Author

Definition: Fracture-Dislocation of the Elbow• Dislocation• Intra-articular fracture

Elbow Fracture Dislocations

5/9/2017

2

Not All The Same!

Not All The Same!

Patterns of Elbow Instability with Fracture

TransOlecranonFracture-Dislocations

Posterior MonteggiaVariant

AnteriorRadial head

fracture

Terrible Triad

AnteromedialFacet Coronoid Fracture: VarusInstability

Coronoid fracture

5/9/2017

3

Dislocation vs. Disruption

Dislocation Disruption

Slide Courtesy or David Ring

Dislocation vs. Disruption

Dislocation Disruption

Slide Courtesy or David Ring

Dislocation vs. Disruption

Dislocation Disruption

Slide Courtesy or David Ring

5/9/2017

4

Dislocation vs. Disruption

Dislocation Disruption

Slide Courtesy or David Ring

Disruption

Slide Courtesy or David Ring

Posterior Dislocation with Radial Head Fracture

23 patientsExcision of radial head and castINSTABILITY with CORONOID fractures (4 patients)

5/9/2017

5

Terrible TriadPosterior dislocation Radial head fractureCoronoid fracture

“Terrible Triad”

Ring, Jupiter, Zilberfarb JBJS 200211 patientsRegan and Morrey Type 2 coronoid fractures

7 redislocated in splint or cast5 redislocated after operation

Only 4 patients with satisfactory results

Regan and Morrey

5/9/2017

6

Terrible Triad

• fixation or replacement of the radial head • fixation of the coronoid fracture if possible, • repair of associated capsular and lateral ligamentous injuries,• Select repair of the medial collateral ligament and/or adjuvant hinged external fixation

48 yo MTerrible Traid

Closed reduction, unstable 

5/9/2017

7

Type 2 Coronoid, Comminuted Radial Head

Terrible Triad Systematic Repair

1) Posterior Universal Incision (vs Lateral Incision)2) Lateral Deep Interval (Kaplan vs Kocher)

…usually bare lateral epicondyle stripped of LUCL3) Radial head fragment removal to access coronoid4) Coronoid ORIF from lateral (screw, sutures, both)

… bail to medial coronoid approach if techincal fail5) Radial head ORIF vs replacement (commonly replaced)6) LUCL repair (always)7) Stability Assessment (repair MUCL if still unstable)8) Static Ex-Fix if still unstable

20

4M ROM 10‐135, 75/80

5/9/2017

8

9 months Post‐Op Terrible Traid

22

23

24 year old M– FOOSH, “no dislocation”, non-displaced coronoid fracture

24

24 year old M– FOOSH, “no dislocation”, MRI arthrogram OSH

5/9/2017

9

25

90 deg Splint x 3 weeks

26

2 months after initial injury, FOOSH, now with dislocation requiring ER reduction

27

5/9/2017

10

28

29

30

2 months post op

5/9/2017

11

31

2 Months Post-Op

34 yo Male, skateboarding fall, AM Coronoid Fx

5/9/2017

12

1 32

Varusposteromedial rotational instability

5 months, ROM 5‐140

5/9/2017

13

Varus Posteromedial Rotational Injuries

Slide Courtesy or David Ring

Inadequate Treatment

Olecranon Fracture-Dislocations/Disruptions

Anterior: Trans-Olecranon FracturePosterior: Posterior Monteggia Variant

ANTERIOR: Trans-Olecranon Fracture-Dislocation

5/9/2017

14

Principles of Treatment – Trans-Olecranon Fx-Disloc

Fixation of Coronoid Important Fixation of Sublime Tubercle (MCL) and Supinator Crest (LUCL)Restore olecranon articular surface to trochleaContoured dorsal plate to match Proximal Ulnar Diaphyseal Angle “PUDA”Bridge comminution

Surgical Approach to Coronoid?Posterior thru olecranon fracture (like osteotomy)

5/9/2017

15

Surgical Approach to Coronoid?Medial thru cubittal tunnel floor or FCU split

15 yo Girl, Fall down 2 flights

Trans‐Olecranon Fx‐Dislocation (anterior)

5/9/2017

16

Trans‐Olecranon Fx‐Dislocation (anterior)Distal Humerus Trochlear Sheer Fx

Work thru Olecranon FxRepair Distal Humerus Fx

5/9/2017

17

Repair Olecranon Fracture, Elevate depressed segment,  and assess MCL/LUCL insertions

3.5M

5/9/2017

18

2 Years Post‐OP: 5‐145

52

52 yo Psychiatrist – fall in AmsterdamTrans‐Olecranon

Posterior Monteggia Variant

Ligaments Likely Intact 

5/9/2017

19

Comminuted Radial Head, Coronoid Intact, Supinator Crest Fracture

2.5months post‐opROM 25‐130, 70/65

1.5 years

57

“…my arm feels normal, and I can do everything that I formerly was able to physically accomplish. I am working out on a regular basis…”

5/9/2017

20

Summery– Trans-Olecranon Fx Dislocation

Fix Coronoid First thur Olecranon FractureFix MCL/LUCL Fx Avulsions:

Sublime Tubercle and Supinator Crest Restore olecranon articular surface to trochlea

Contoured dorsal plate to match Proximal Ulnar Diaphyseal Angle “PUDA”Bridge comminution

Patterns of Elbow Instability with Fracture

TransOlecranonFracture-Dislocations

Posterior

AnteriorRadial head

fracture

Terrible Triad

Varusposteromedial rotational instability

Coronoid fracture

Summary: Elbow Fracture Dislocations

Fx-Dislocation different than Fx-Disruption (trans olec)Recognize the various injury patternsSystematic Approach to Terrible TriadAppreciate Trans-Olec Fx VariantsLCL is more important than the MUCLMUCL will heal if you keep joint concentricEven small coronoid fractures can be a BIG problemWatch out for AM coronoid facet fracture and fix LUCL if Varus unstable

5/9/2017

21

Thank You!

jobin@columbia.edu

61