ELBOW INJURY STABILISERS OF ELBOW TERRIBLE TRAID OF ELBOW RADIAL HEAD, OLECRANON,CORONOID FRACTURES WITH ELBOW DISLOCATION DIAGNOSIS AMD TREATMENT PLANNING,SURGICAL APPROACHSTABILISERS OF ELBOW TERRIBLE TRAID OF ELBOW RADIAL HEAD, OLECRANON,CORONOID FRACTURES WITH ELBOW DISLOCATION DIAGNOSIS AMD TREATMENT PLANNING,SURGICAL APPROACH

1. ELBOW INSTABILITY AND
TERRIBLE TRAID INJURIES
DR.M.S.DHINESH
DEPARTMENT OF ORTHOPAEDICS
MAPIMS

2. ELBOW STABILISERS
• STATIC STABILISERS
• PRIMARY CONSTRAINTS
• SECONDARY CONSTRAINTS
• DYNAMIC STABILISERS

3. STATIC CONSTRAINTS OF ELBOW

5. LATERAL COLLATERAL LIGAMENT
COMPLEX

6. MEDIAL COLLATERAL LIGAMENT
COMPLEX

7. DYNAMIC STABILISERS OF ELBOW

10. TRAUMATIC ELBOW INSTABILITY
• Mechanism of injury
• Primary mechanism is posterolateral
• Other mechanisms postulated - controversial
• Valgus-external rotation
• Valgus-hyperextension
• Sequence of injury progression also debated
• Medial dislocations

11. Posterolateral Mechanism - Injury progression

12. O’DRISCOLL’S RING OF INSTABILITY
O'Driscoll et al. described a valgus, axial, and posterolateral force that
results in the typical posterolateral dislocation of the elbow joint

13. LATERAL PIVOT SHIFT TEST

14. O’DRISCOLL’S RING OF INSTABILITY

15. TRAUMATIC ELBOW INSTABILITY
• Simple Dislocations
• Complex Dislocations – Fracture-
dislocations
• Coronoid fractures
• Radial Head Fractures
• Monteggia Fractures
• Trans-olecranon dislocations
• Terrible Triad
• Chronic Dislocations

16. • Not associated with fracture
• Posterior and Posterolateral (M/C)– all directions and divergent
dislocations can occur
• Beware patterns other than posterior/posterolateral – can be more unstable
after reduction
• Mechanism of Injury
• Partially flexed elbow
• Axial load, supination, and valgus
• Varus mechanisms also described
• Medial ligamentous injuries in most cases
SIMPLE DISLOCATION

17. REDUCTION MANNEOVUR

18. REHABILITATION PROTOCOL

19. 56/M, POSTEROLATERAL ELBOW D/L

20. 56/M,POST REDUCTION

21. UNSTABLE AFTER REDUCTION
• Uncommon in simple dislocations
• May require soft tissue reconstruction
• Do what needs to be done to hold a concentric
reduction
• Splint in more flexion
• External fixator – static vs hinged
• Elbow cross pinning
• Internal fixator

22. ALGORITHM
FOR
SIMPLE
ELBOW D/L

24. • Associated with a fracture
• Sub-Types
• Coronoid Fracture
• Monteggia Fracture
• Radial Head Fracture
• Epicondyle fractures - adolescents
• Trans-Olecranon fracture-Dislocations
• Terrible Triad Elbow
COMPLEX ELBOW DISLOCATION

25. VALGUS INSTABILITY

26. RADIAL HEAD FRACTURE
Mechanism of Injury:
Valgus force + axial load
RADIAL HEAD FRACTURE

27. RADIAL HEAD FRACTURE

28. • Comprehensive classification of radial head fracture with
description of associated injuries (van Riet and Morrey)

31. Valgus stability-MCL and Radial head
Importance: Valgus force
Primary stabilisers – anterior bundle of MCL
Secondary stabilisers- Radial Head
So,whenever excise the radial head in case of MCL rupture- no
resist to valgus force- valgus instability

32. Radial head
communited
fracture
Radial head
excised
Intact
intraosseous
membrane
Radial head
excised
Ruptured
intraosseous
membrane
Radius migrated
proximally-
causing damage
to elbow joint,
Ulna move
towards distally-
causing damage
to ulnocarpal jt.
So, whenever Radial
head fracture
Always look for
DRUJ
Disruption/intraoss
eous membrane
damage
ESSEX LOPRESSETI #

33. UNSTABLE RADIAL HEAD #
No MCL + Radial head excision = valgus instability =
Early osteoarthritis
UNSTABLE RADIAL HEAD FRACTURE

34. DECISION MAKING
• Fragment number
• Displacement
• Articular surface
• Age and bone quality
• Dislocation
• Ass. Ligamentous injury
• Ass. Elbow fractures
DECISION MAKING

35. STABLE FIXATION AND EARLY MOBILISATION

36. RADIAL HEAD- SMALL NON ARTICULAR
PORTION

37. RADIAL HEAD AND NECK- SAFE ZONE
• 240° of circumference
articulates with ulna at
lesser sigmoid notch
• ~90-100 ° arc of safe
hardware placement
Caput et al recommended using the radial styloid and listers
tubercle as guides

39. FRAGMENT EXCISION

41. RADIAL HEAD EXCISION

42. ALGORITHM FOR RADIAL HEAD FRACTURE

43. COMMINUTED RADIAL HEAD FRACTURE
ROLE OF THE RADIAL HEAD ARTHROPLASTY
▪ Excision will lead to instability
▪ Functional spacer
▪ Creates stability by increasing radial length & restoring valgus restraint

45. RADIAL HEAD FRACTURE-
OVERSTUFFING
Radial Head Should be in line with
proximal edge of the lesser sigmaoid
notch to avoid overstuffing

46. RADIAL HEAD FRACTURE-
OVERSTUFFING

47. RADIAL HEAD FRACTURE-
OVERSTUFFING

48. ▪ Direct visualization
▪ Most accurate way to
determine appropriate head
size
▪ Radial head should be just
at or proximal to radial
notch of the ulna
▪ Intra-op Fluoro
• Needs to be assessed in
flexion and extension
• Less reliable • > 6mm
overstuffing must be present
to consistently be seen on
fluoro
RADIAL HEAD FRACTURE-OVERSTUFFING

49. POST-OP PROTOCOL
▪ For all stabilized fxs and dislocations regardless of fixation
• Initially
• Immobilization for 10-14 days
• Secondarily
• Early ACTIVE range of motion
• Allows dynamic stabilizers to help hold reduction of joint
▪ Will reduce pseudosubluxations
• Limits elbow stiffness
• Some limit active shoulder abduction if LUCL was repaired

50. APPROACHES
• KAPLAN APPROACH
• KOCHER APPROACH
• EDC Split
• Modified Boyd
• Posterior approach
• Elevate LUCL from lateral epicondyle
• Can be used for combined olecranon/radial head
fxs
RARELY USED APPROACH

51. KOCHER APPROACH
Plane Between ECU and anconeus
Most often utilized for radial head
• Interval
• Anconeus – Radial Nerve
• ECU – PIN
• 5cm incision from lateral epicondyle distally
• Angled posteriorly 30-45 degrees
• Often deep soft tissues will be disrupted by injury

52. • Damage to LUCL
• Stay on anterior half of radial
head
• Damage to PIN
• Pronate the arm to move nerve
distally
• Carefully dissect distal to annular
ligament
KOCHER PITFALLS

53. • Distal extension becomes dorsal
Thompson approach
• More often used for radial neck/proximal
radial shaft fxs
• Interval
• ECRB – Radial nerve or PIN (variable) •
EDC – PIN
10cm incision from lateral epicondyle to
Lister’s Tubercle
KAPLAN APPROACH

54. CORONOID PROCESS FRACTURE

58. CLASSIFICATION: CORONOID
FRACTURES
▪ Regan & Morrey
• Type 1: tip
• Type 2 : < 50%y be ste
• Type 3 > 50%
▪ Highly unstable

59. CLASSIFICATION: CORONOID
FRACTURES
▪O’Driscoll Classification
▪Type I: Tip
▪Type II: anteromedial facet
▪Type III: base

60. PROXIMAL ULNA - ANTERIOR
CORONOID
•Anterior capsule
•Brachialis
•Anterior bundle of MCL
•Anteromedial facet of coronoid
▪ Fx propagation into this region
may cause functional MCL
incompetancy

61. CORONOID FRACTURE-
INDICATION
1.An isolated fracture (Type 3)
2.As a part of fracture dislocation
3.As a part of communited fractures of
proximal ulna

62. CORONOID FRACTURE
Complex instability of the
elbow results from posterior
directed forces
• TR(Triceps)
• BR(Brachialis)
• BC(Biceps)

65. OLECRANON FRACTURE
Mechanism of Injury
• Acute Tension overload: Tension applied by
the triceps with flexion of the elbow
• Direct Trauma
• Chronic overload: eg. stress fractures seen
commonly with osteopaenic or pediatric
patients

67. CLASSIFICATION
Many Classifications:
– Colton
– Morrey
– Schatzker
– AO/ASIF
– OTA
Criteria
– Displacement
– Direction of fracture
– Degree of comminution
– Percent involvement
– Associated injuries

68. OLECRANON
FRACTURE

69. TREATMENT -AIM
Restoration of elbow motion and prevention
of stiffness
– Goal is to begin early ROM
• Restoration and preservation of the elbow
extensor mechanism.
• Restoration of the articular surface.
• Prevention of complications.

70. TREATMENT METHOD
• Non operative method
• Operative method
• Excision of olecranon and triceps repair
• Open reduction with internal fiaxtion
• TBW with pins or intramedullary
screws
• Plate

72. PUDA
Olecranon Process
– 96% of proximal ulna
exhibit a ~ 4 degrees dorsal
angulation (PUDA)

73. VARUS ANGULATION
Proximally the ulna
demonstrates ~ 12 degrees
varus angulation
– The articular surface
extends beyond the “joint
space” visualized on the
lateral radiograph

74. SURGICAL ANATOMY
• Coronoid process: preserve
height
– Coronoid Height ~ 2 x Olecranon
height
– Tip of Coronoid to tip of
Olecranon subtends angle of ~30
degrees from long axis of ulnar
shaft
Articular cartilage
– Sigmoid notch of ulna: bare
spot centrally between tip and
coronoid
– Pearl: Beware of narrowing
sigmoid fossa when treating
comminuted olecranon fx’s.

75. TBW
For most simple, transverse,
non-comminuted fractures
• Use 18- or 20-gauge steel
wire or small braided cable.
– Be sure wires cross over
dorsal cortex.
– 2 smaller (22 gauge) wires
may be less prominent
• May use with either parallel
K-wires or an
intramedullary screw

79. For simple and transverse fracture fracture
If fracture goes beyond the coronoid,TBW
principle not work

80. INTRAMEDULLARY SCREWS
Need to add tension band
wire
• Long/large screw required
– 6.5mm cancellous
– 85-110 mm long
• Risk of shortening…
osteopaenic bone, oblique
fracture and comminution

81. ANATOMY OF PROXIMAL ULNA

82. HOW TO DECIDE
TBW/PLATES?

84. PLATE FIXATION

85. LOCKED ANATOMICAL PLATE
Disadvantages
• More difficult to contour
anatomically
• Locking configurations do
not prevent violation of
proximal articulations
• More expensive
• Not necessarily less
prominent
Advantages
• Simplify plate fixation
May accommodate
- Slight varus proximal angulation
- Slight rocker bottom proximal
subcutaneous border
- requires extensive triceps split
- may improve proximal fixation

86. “TERRIBLE TRIAD” FRACTURE-DISLOCATIONS OF THE ELBOW

87. WHAT IS A TERRIBLE TRIAD?
1. Elbow dislocation
2. Coronoid fracture
3. Radial head fracture

88. TERRIBLE TRIAD INJURIES: MECHANISM OF
INJURY
▪ Fall on an outstretched hand
▪ Axial load
▪ Relative elbow extension
▪ Valgus
▪ Forearm rotation
▪ Supination
The ultimate
“Posterolateral rotatory instability”

89. TERRIBLE TRIAD FRACTURE-
DISLOCATION
▪ What is so terrible about it?
▪ Extremely unstable
▪ Loss of joint congruency
▪ Instability
▪ Fracture fragments are usually quite small
▪ Difficult to repair
▪ Patients don’t routinely do “well”
▪ Unaware of the magnitude of the injury
for the elbow
▪ Residual instability
▪ Stiffness

90. TERRIBLE TRIAD INJURIES
PATIENT AND INJURY ASSESSMENT
• Patient evaluation
▪ Associated injuries
▪ Mechanism of injury
▪ Soft tissue status
▪ Radiographs (possible traction views)
▪ Post-reduction CT w/ 3D recons
• Operative timing
▪ As urgently as possible but during the
daytime
▪ Pre-op planning for appropriate equipment

91. INJURY PATTERNS
•Posterior dislocation & radial head fracture

92. INJURY PATTERNS
▪Posterior dislocation, radial head & coronoid fractures
▪ “Terrible Triad”

93. INJURY PATTERNS
▪Posterior dislocation & radial
head fracture
▪Posterior dislocation, radial head
& coronoid fractures
▪ “Terrible Triad”
▪Transolecranon fracture-
dislocations
▪ Anterior
▪ Posterior

94. 47 yo trip and fall down stairs

95. TERRIBLE TRIAD –TREATMENT PROTOCOL
(MCKEE, PUGH, SCHEMITSCH,ET AL JBJS(A) ’04)
▪ 36 consecutive patients treated:
1. Fix or suture coronoid
2. Repair / replace radial head
3. Repair LCL
4. If still unstable, repair MCL
5. If still unstable, hinged ex-fix

96. SURGICAL PLANNING: APPROACHES
▪What’s injured?
▪ Radial head only
▪ Radial head
▪ type 1 coronoid
▪ Radial head
▪ type 2 or 3 coronoid
▪ Proximal ulna / olecranon
●Medial Approach Needed if:
▪ plate coronoid fracture
▪ transpose ulnar nerve
▪ repair or reconstruct MCL
Radial head replacement &
common proximal ulna fracture
exposes coronoid tip

97. INTERNAL FIXATION
▪3 steps:
▪ Repair radial head
▪ Secure radial head to the radial neck
▪ Avoid impingement of plates during
forearm rotation.
▪Small K wires used provisionally.
▪“mini-fragment” screws (1.5 to
2.7 mm), countersink heads
▪Secure radial head to neck with
2.0 or 2.7 L-shaped plates or mini
blade plates

98. TERRIBLE TRIAD: MEDIAL INSTABILITY ?
▪ Repair MCL
▪ Reconstruct through bone tunnels
▪ Suture Anchors
▪ Palmaris autograft or allograft tendon
▪ Repair muscle origins
FC
U
Ulnar
Nerve
Ulnohumeral
joint reduced

99. TERRIBLE TRIAD: PERSISTENT
INSTABILITY ?
▪ Hinges
Uniplanar Lateral Frame Multiplanar Compass Hinge

100. SURGICAL PLANNING
▪ Positioning: supine vs lateral
▪ Supine:
▪ Better access and visualization of anterior joint & coronoid
▪ Lateral
▪ facilitates ulnar length, lessens needs for assistants
▪ Surgical approach:
▪ Midline Posterior
▪ Kocher (posterolateral) vs Kaplan
(anterolateral)
▪ Anteromedial
▪ Posteromedial
▪ Percutaneous coronoid fixation

101. INCISION MIDLINE POSTERIOR

102. LATERAL: KAPLAN APPROACH
• Anterior column
exposure
▪ Supracondylar ridge
▪ Anterior to mid-axis of
radiocapitellar joint
▪ Utilize LCL tear
▪ Incise anterior capsule
▪ Exposes anterior
coronoid
▪ Replacement or
fixation

103. LATERAL APPROACH: DEEP DISSECTION
• Access to anterior ulno-
humeral joint
▪ Elevate the extensors
▪ Stay superior to the LCL
▪ Able to visualize the PIN
• Arthrotomy
▪ Release of the lateral
capsule and annular
ligament

104. ANTEROMEDIAL APPROACH TO CORONOID
•Medial supracondylar ridge
•Pronator teres - brachialis interval
•Incise anterior 1/2 flexor-pronator
mass
•Anterior capsule

105. ANTEROMEDIAL APPROACH TO CORONOID
•Medial supracondylar ridge
•Pronator teres - brachialis interval
•Incise anterior 1/2 flexor-pronator
mass
•Anterior capsule

106. ANTEROMEDIAL APPROACH TO CORONOID
•Medial supracondylar ridge
•Pronator teres - brachialis interval
•Incise anterior 1/2 flexor-pronator mass
•Anterior capsule

107. POSTEROMEDIAL APPROACH TO
CORONOID
Exposure of:
• Coronoid
• Sublime tubercle
• MCL
• Proximal ulna
▪MCL reconstruction or repair
▪ORIF AM facet of coronoid
▪Buttress plating of coronoid

108. POSTEROMEDIAL APPROACH TO CORONOID
▪Necessitates ulnar nerve exposure and transposition
▪Palpate sublime tubercle
▪Incise FCU ulnar attachment distal to sublime tubercle and proceed proximally ->
anterior bundle of MCL.

109. TERRIBLE TRIAD INJURIES:
REHABILITATION
▪ Rehab
▪ Stiffness vs. Instability
▪ Cautious
▪ Posterior splint
▪ 14 days post-op
▪ Cuff and collar
▪ Guided rehab is essential
▪ Flexion first!
▪ Active and passive
▪ Active and passive forearm rotation at
90°
▪ Begin extension at 3 weeks, active only
▪ Start supine—active against gravity

110. TERRIBLE TRIAD INJURIES: SUMMARY
▪ Not so Terrible
▪ Isolated injury & cooperative patient
▪ Stable repairs & motion
▪ Coronoid fixation
▪ Radial head arthroplasty vs. ORIF
▪ LCL repair
▪ Terrible
▪ Poor stability after repairs complete
▪ Multi-trauma
▪ ICU stay
▪ Head injuries
▪ Non-weight bearing on lower extremities
▪ Uncooperative patient

111. THANK YOU.