1. Fractures and Dislocations of the Elbow
Eric M Lindvall
UCSF- Fresno, CA

2. Injuries – excluding humerus
Olecranon fractures
Radial head fractures
Elbow Dislocations
Coronoid Fractures
Terrible triad injuries
Trans-olecranon fracture dislocations
Monteggia injuries

3. Spectrum
Not so bad…
…not so good

4. Olecranon Fractures

5. Triceps & Brachialis  compressive forces across joint
Olecranon Fractures
Triceps & Brachialis  compressive forces across joint

6. Tension band principles - review
Dynamic – compressive forces increase
Static - compression when applied
Tensile force converted to compression during loading

7. Treatment Nonoperative
< 2mm step or gap with intact extensor mechanism
Early active ROM, no resistance initially
Operative
Greater displacement, marginal impaction

8. Positioning
Lateral/prone
supine

9. 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

10. 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

11. Plate Fixation Comminution Fracture obliquity Marginal Impaction
Types of plates
Anatomic designs
Hand Contoured 3.5 Recontruction
Other

12. Surgical Treatment Options Plate Fixation Surgical Tactic

13. 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 …

14. 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

15. Complications Limited ROM Nonunion: 10% Fixation Failure: 3-53%
Reoperation 2° (prominent HW): 18-82%
< with plate fixation
Infection: <5%

16. Radial Neck / Head Fractures

17. Goals of treatment Restore forearm rotation Restore elbow flexion
Union

18. Radial head/neck - anatomy
Articulates with capitellum
10° angle of neck with shaft

19. Radial head/neck - anatomy
240° of circumference articulates with ulna at lesser sigmoid notch
~ degree arc of safe hardware placement
Hotchkiss RN JAAOS 5:1-10 (1997)

20. 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

21. 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

22. Surgical management Head Excision? Avoid acute excision unless replace
Result in chronic pain
Result instability
If chronic, may excise
Can always excise later!

23. 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

24. 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

25. Fixation
Plating
Buttress plating for partial articular fractures (rare)
Supporting role for complete articular fractures
Mini blade plates
Locked plates

26. 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)

27. 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

28. Terrible Triad Injury complex Historically poor results
Radial head fracture
Coronoid fracture
Elbow dislocation
Historically poor results
Recently, improved

29. 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

30. 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

31. 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

32. 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!

33. Transolecranon – tactic
Address coronoid fractures through olecranon fracture line
Anatomically reduce olecranon
Ligaments are usually spared

34. 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

35. Monteggia variant - tactic
Principle: anatomical reduction of ulna is critical for maintenance of reduction of radial head
Radial head
Ligaments

36. 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