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

Spectrum Not so bad… …not so good

Olecranon Fractures

Triceps & Brachialis  compressive forces across joint 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 Operative Greater displacement, marginal impaction

Positioning Lateral/prone supine

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° 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

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 Historically poor results Radial head fracture Coronoid fracture Elbow dislocation Historically poor results Recently, improved

Terrible Triad Treatment principles NEVER 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