Fractures and Dislocations of the Elbow

Eric M Lindvall

UCSF- Fresno, CA

Injuries – excluding humerus

• Olecranon fractures• Radial head fractures• Elbow Dislocations• Coronoid Fractures• Terrible triad injuries• Trans-olecranon fracture dislocations• Monteggia injuries

SpectrumNot so bad… …not so good

Olecranon Fractures

Olecranon Fractures

Triceps & Brachialis compressive forces across joint

Tension band principles - review

Dynamic – compressive forces increase

Static - compression when applied

Tensile force converted to compression during loading

Treatment

Nonoperative< 2mm step or gap with intact extensor mechanism

Early active ROM, no resistance initially

OperativeGreater displacement, marginal impaction

Positioning

supine

Lateral/prone

Tension Band Wire Fixation

• < 50% Articular Surface• No comminution (simple

fx)• Transverse fracture• 18 or 20 g wire• Place under triceps• Use 14 or 16 g angiocath• 0.62” or Larger K-wires

which engage anterior cortex

Screw Fixation• Medullary screw with or

without washer (transverse fxs)

• 10° angulation (radial apex)

• Avoid:

• translation or eccectric gapping (difficult to match canal diameter to screw thread)

• Leaving screw proud

• Additional fixation for oblique fractures

~10°

Plate Fixation

Comminution

Fracture obliquity

Marginal Impaction

Types of plates

Anatomic designs

Hand Contoured 3.5 Recontruction

Other

Surgical Treatment Options Plate Fixation Surgical Tactic

Excision with Triceps Advancement

• Highly comminuted “nonreconstructable” olecranon fractures

• < 80%, place anteriorly (McKeever)

• Less complications with olecranon excision than with ORIF (Gartsman)

• Increased joint forces with excision vs. ORIF (Moed)

• Posterior advancement - “incorrect”

• Anterior advancement “correct” (Hastings)

• Rarely first line treatment …

Rehabilitation

Simple patterns with stable fixation no splint

If wound or skin issues, splint to allow soft tissue healing

Comminuted / poor bone quality can splint up to 6 weeks

Variations obviously exist

Complications

Limited ROM

Nonunion: 10%

Fixation Failure: 3-53%

Reoperation 2° (prominent HW): 18-82%

< with plate fixation

Infection: <5%

Radial Neck / Head Fractures

Goals of treatment

• Restore forearm rotation

• Restore elbow flexion• Union

Radial head/neck - anatomy

• Articulates with capitellum

• 10° angle of neck with shaft

Radial head/neck - anatomy

• 240° of circumference articulates with ulna at lesser sigmoid notch

• ~90-100 degree arc of safe hardware placement

Hotchkiss RN JAAOS 5:1-10 (1997)

Classification - Mason

Type I – nondisplaced radial head fracture

Type II – displaced partial articular radial head fracture

Type III – displaced, comminuted fracture of the entire radial head

Surgical treatment

• Indications– Loss of pronation or

supination (mechanical block)• Intra-articular lidocaine

injection may be helpful for examination

– Fracture associated with elbow instability

– Incarcerated intraarticular osseous fragments

Surgical management

Head Excision?– Avoid acute excision

unless replace• Result in chronic pain• Result instability

– If chronic, may excise– Can always excise

later!

Surgical approach

• Kocher approach– Interval between

anconeus and ECU– Exploit tears in fascia

if already present– Avoid dissection

posterior to anterior border anconeus to avoid damaging LCL

www.wheelessonline.com

Fixation

• Place implants within 110° “safe zone”– Away from articulation

with proximal ulna• Disimpact articular

segments if necessary– Be prepared to graft

• Lag screws vs. positioning screws– Don’t overcompress

Fixation

• Plating– Buttress plating for

partial articular fractures (rare)

– Supporting role for complete articular fractures• Mini blade plates• Locked plates

Replacement• Consider for Mason III

fractures (>2 articular fragments and complete articular pattern)

• “Spacer”• Don’t overstuff joint!

ulnohumeral articulation congruent M-L

• Template with resected radial head (fragments)

Outcomes

• Mason III fractures have historically worse outcomes

• Nonunion• Implant failure – use stiff implants or

consider replacement• Malunion• Loss of forearm rotation or elbow motion

Terrible Triad

• Injury complex– Radial head fracture– Coronoid fracture– Elbow dislocation

• Historically poor results

• Recently, improved

Terrible Triad

• Treatment principles– Repair coronoid/anterior capsular attachment– Repair or replace radial head– Repair LCL

• NEVER– Ignore “small” (fleck) coronoid fractures– Resect radial head without replacing it

• MCL does not usually need operative repair

Terrible Triad – tactic

• Kocher approach to elbow (ECU-anconeus interval)

• LCL often avulsed from lateral epicondyle

• If resecting radial head, do it prior to coronoid fixation - improves access

Terrible Triad - tactic

• Repair coronoid or anterior capsule– Suture tunnels through

proximal ulna– Screws– Consider medial approach

for plating type 3 coronoid fracture

• Posterior extensile approach allows medial (coronoid) and lateral access (radial head, LCL)

Regan and Morrey, Orthopaedics(1992) 15:845

Transolecranon fracture-dislocation

• Not a simple olecranon fracture• Requires plate fixation – no tension band• Olecranon fracture - humerus driven through olecranon

- intact proximal radioulnar joint• Lateral / Medial ligaments may be intact!

Transolecranon – tactic

• Address coronoid fractures through olecranon fracture line

• Anatomically reduce olecranon

• Ligaments are usually spared

Monteggia variant fracture-disloc

• Most often posterior dislocations with associated proximal ulna/olecranon fractures

• May have associated radial head fractures• Principles similar to treatment of standard

Monteggia injuries of forearm

Monteggia variant - tactic

• Principle: anatomical reduction of ulna is critical for maintenance of reduction of radial head

• Radial head• Ligaments

Summary – fracture-dislocations

• The LCL and ligamentous structures must be assessed / repaired

• Achieve adequate stability to allow early ROM – stiffness main complication

• Avoid acute radial head resection without replacing

• Tension band wiring appropriate only in simple cases