Complex fractures of the elbow Ομιλία στο συνέδριο Ελληνικής Εταιρείας Χειρουργικής & Τραυματολογίας "Σύνθετα Κατάγματα του Αγκώνα"

1. Complex fractures
of the Elbow
N. A. Darlis, MD, PhD
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2. Unstable elbow Combination injuries

3. Mechanism
• Posterolateral rotatory stress

7. Pathoanatomy
• Injured structures
– 1: LCL-ulnar
– 2: LCL-radial
capsule
– 3a: MCL-post
– 3b: MCL-ant

8. Pathoanatomy
• Posterolateral rotatory stress
Horii circle

9. Pathoanatomy
• Valgus deformity
Schreiber JJ et al., JHS(A), 2013

10. Pathoanatomy
• All 16 acute elbow dislocations had MCL injury
• Complete tears at the medial side were more common than
the lateral
Schreiber JJ et al., JHS(A), 2014

11. Pathoanatomy
• Valgus deformity
Horii circle reversed ?

12. Mechanism
Valgus PRLI

13. Forearm instability
• “The forearm as a ring”
concept
• Key role of
– Radial Head
– IOM
– TFCC
• Double or Multiple
injuries to the ring
common

14. Forearm Interossous Membrane
• Contributes 70% of forearm stability
Radius
• Can be injured in association with elbow fractures
Ulna
CB

15. Injury patterns commonly associated
with instability:
• Terrible Triad of the Elbow
• Transolecranon Fracture dislocation
• Essex-Lopresti Injury
• Posterior Monteggia lesion and equivalents
• “Floating Elbows”

16. Terrible Triad
• Elbow dislocation
• Radial head fracture
• Coronoid fracture

19. • Diagnosis can be missed!

20. • Careful screening of radiographs
Courtesy : C.G. Zalavras, MD

26. Essex-Lopresti Injury
Courtesy : D.G. Sotereanos, MD

27. Transolecranon fracture
dislocations

28. Posterior Monteggia lesion
Courtesy : C.G. Zalavras, MD

29. Posterior Monteggia lesion
• Anterior fragment
includes the
coronoid
Jupiter et al. JOT, 1991
Courtesy : C.G. Zalavras, MD

30. Monteggia type 2 equivalent lesion

31. Monteggia type 2 equivalent lesion

32. … Other double injuries

33. Floating elbow
• Type IIa IIb III
Courtesy : K. Ditsios, MD

34. Floating elbow
• Type IIa III
Courtesy : K. Ditsios, MD

35. Open/ Neurovascular injury
UN

36. Open/ Neurovascular injury
Nerve grafts

37. Complex elbow instability
• Operative treatment
• No role for conservative management
• Goal: Early, concentric mobilization

38. Skin incision
• Posterolateral
(Kocher)
• Posterior midline
(Universal)
– when medial
approach is
contemplated

39. Kocher approach

40. Lateral approach
1/2
Or… use the paths of soft tissue injury

45. 3
2 1
4
5
6

46. Proximal Ulna
• Anatomic Reduction
• Pre-contoured
proximal ulnar plates
useful
1
Will need
plating most of
the times

47. Posterior Monteggia lesion

48. Radial Head
2
• Excision not recommended in complex
elbow instability
– radial head is essential if MCL is injured
• ORIF
• Prosthetic replacement

49. Radial Head: ORIF
• If fracture amenable to
internal fixation
• Safe zone of hardware
placement
• Radial neck fracture
fixation challenging

51. Radial Head: Prosthesis
– Comminuted fractures associated
with elbow dislocations may be
better treated by prosthetic
replacement
– Side-table re-assembly and ORIF
not favored
Ring et al. JBJS-Am 2002

52. Radial Head: Prosthesis
– Remove radial head
fragments
– Perform neck
osteotomy
– Measure head
diameter
– Coronoid first then
RH implant

54. Coronoid
3
Regan-Morrey
classification

55. Coronoid
Retrograde screw
fixation

56. Coronoid
Medial facet fracture

57. Coronoid
• Suture fixation
through anterior
capsule ?
• Fixation of small
avulsion
fractures???

58. Lateral collateral ligament
4
• Usually avulsed
from its origin from
lateral epicondyle
• Repair with suture
anchors to lateral
epicondyle

59. Lateral collateral ligament
• Repair with suture
anchors to lateral
epicondyle
• With extensor
origin sleeve

62. Intraoperative assessment of
stability
• Clinical
• Radiological (C-arm)
– Forearm in pronation
– Note stable range of motion
– If stable to aprx 500 of
flexion immobilize in
pronation and start early
ROM in hinged brace within
the range of stability

64. Intraoperative assessment of stability
• If stable in narrow ROM or unstable after
the above consider:
–Hinged elbow external fixation
–MCL repair
• Consider especially if dislocation occurs with
forearm in pronation

65. Hinged external fixator
5
• Allows early joint
motion
• Maintains concentric
reduction
• Protects any
repair/fixation

68. Monteggia type 2 equivalent lesion

69. MCL
6
• Repair/ Reconstruct
• Medial approach
– ulnar nerve symptoms
– medial coronoid facet
fracture
– medial epicondyle
fracture

71. Essex-Lopresti Injuries
• Radial Head
Reconstruction-
Replacement
• DRUJ reduction-pinning
in supination
• TFCC repair?
• IOM reconstruction ?
Courtesy : D.G. Sotereanos, MD

72. Total Elbow Arthroplasty
• Comminuted fractures in elderly patients

73. mmaayy nnoott bbee oobbvviioouuss;;
mmaaiinnttaaiinn hhiigghh iinnddeexx ooff ssuussppiicciioonn
http://www.flickr.com/photos/katiedee/4884263411/lightbox/

74. aaddddrreessss tthhee ssppeecciiffiicc ccoommppoonneennttss
ooff tthhee iinnjjuurryy
• Bone
– Radial head (repair or replacement)
– Coronoid (repair or bone block)
– Proximal ulna (anatomic repair)
• Ligaments
– LUCL/ extensor origin reattachment
– MCL

75. PPoooorr pprrooggnnoossiiss iinn oollddeerr sseerriieess wwiitthh
nnoo ccoonnssiisstteenntt ttrreeaattmmeenntt pprroottooccooll
– all 4 redislocations out of 23 elbow fracture-dislocations
occurred in terrible triad cases
– severe arthrosis in 12 of 19 elbows @3 to 34 years.
Josefsson et al. CORR 1989
– 7 of 11 patients unsatisfactory result
– arthrosis in 9 of 10 patients @7 years
Ring et al. JBJS-Am, 2002
http://www.flickr.com/photos/doug88888/4627497417/

76. MMooddeerrnn TTrreeaattmmeenntt PPrroottooccooll
SSttuuddiieess ((aafftteerr 22000044)) eennccoouurraaggiinngg……
Flexion arc 1100,
Rotation 1300,
Mayo score 85
…bbuutt lloonngg tteerrmm
DDJJDD uunnkknnoowwnn
No redislocations
Mild arthritis
@ 2,5years
Pugh et al., JBJS (A) 2004, Egol et al, Bull NYU Hosp Jt Dis.2007, Forthman et al.,
JHS(A) 2008, Lindenhovius et al, JHS(A) 2008, Zeiders et al., JBJS 2008

77. THANK YOU
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