ELBOW TRAUMA

RADIAL HEAD FRACTURES

MASON CLASSIFICATION

NON-OP TREATMENT Indications: Tx: Sling for comfort Mason 1 Mason 2 Tx: Sling for comfort Immobilization no more than 2 weeks to prevent elbow stiffness! Fracture displacement and nonunion is usually asymtomatic and inconsequential (Ring - CORR 2002, Cobb – Orthopedics 1998)

OPERATIVE INDICATIONS Traditionally >2 mm displacement >30% of joint involvement Most Importantly: Blocked forearm rotation Mason 3 fracture (displaced comminuted)

OPERATIVE TX OPTIONS Excision ORIF Arthroplasty

RADIAL HEAD EXCISION Isolated radial head fracture No Essex-Lopresti lesion No terrible triad No MCL injury In older patients with limited functional demands

ORIF Mason type 2: 15/15 had satisfactory result Mason type 3 with 2-3 fragments: 1/12 nonunion Mason type 3 with >3 fragments: 13/14 had unsatisfactory results (Ring JBJS Am 2002) If >3 fragments, consider arthroplasty

ARTHROPLASTY N=16 80% good or excellent results at 2.8y f/u Early mobilization important for satisfactory outcome (Bain JBJS Am 2005)

SURGICAL ANATOMY Pronation of forearm translates PIN 1 cm away from operative field Safe zone of lateral radius: Proximal 38 mm Supination decreases safe zone to 22 mm (Diliberti JBJS Am 2000)

IMPLANT PLACEMENT ON RADIAL HEAD 110° safe zone on lateral aspect to prevent impingement in sigmoid notch Make horizontal marks in forearm in neutral, pronation and supination Limits: Anterior: ½ distance from between mark in neutral and supination Posterior: 2/3 distance from between mark in neutral and pronation (Corresponds to region between Listers tubercle and radial styloid)

PROXIMAL ULNA FRACTURES

PROXIMAL ULNA FRACTURES: Treatment Options Plating Tension Band

TENSION BAND (Macko JBJS Am 1985) Most common complication: Prominent hardware Indication: Transverse fracture with no comminution

PLATING (Bailey JOT 2001) 22/25 good or excellent results 20% requested plate removal

CORONOID FRACTURES

CORONOID FRACTURE: Morrey and Regan Classification Type 1: Avulsion of the tip of the process Type 2: 50% of the process Type 3: >50% of the process

CORONOID FRACTURES Type 1: Sutures around the fragment Type 2: Sutures through drill holes in ulna Type 3: Screws Small fragments associated with more challenging injury pattern!

CORONOID FRACTURE: O’Driscoll’s Classification

ELBOW DISLOCATIONS

Lateral collateral ligament Coronoid Radial head ELBOW STABILIZERS Lateral collateral ligament Coronoid Radial head

ELBOW DISLOCATION Non-op or Radial head excision + Cast Good results if no coronoid fracture Radial head was ultimate determinant of outcome with many radial head resections needed to restore forearm rotation (Broberg & Morrey CORR 1987)

Elbow dislocation Coronoid fracture Radial head fracture TERRIBLE TRIAD Elbow dislocation Coronoid fracture Radial head fracture

CURRENT MANAGEMENT Radial head ORIF or arthroplasty Coronoid fixation If still unstable (dislocation with 30° Ext) 

LCL + MCL REPAIR

CROSS PINS

EX-FIX

HINDGED BRACE