1. The document discusses fracture dislocations of the elbow, which are complex injuries that often require surgical intervention due to associated fractures. 2. Common fracture patterns include posterior dislocations with radial head or coronoid fractures. Surgical fixation may involve screws, plates, or replacement of fractured bone. 3. Soft tissue injuries like lateral collateral ligament avulsions must also be repaired to prevent recurrent instability. 4. Potential complications addressed include heterotopic ossification, recurrent instability, ulnar neuropathy, arthrofibrosis, and post-traumatic arthrosis. Careful restoration of bony and soft tissue anatomy can help reduce complications.

1. Fracture Dislocations
of the Elbow
OCNA 2016, 1
Jennings et. al.

2. •The elbow is a highly congruent
trochoginglymoid joint with a significant amount
of stability conferred from its bony structures.
•Functional range of motion at the elbow is
classically described as 50 degrees of pronation
and supination with a 100degree arc of flexion,
ranging from 30 to 130 degrees

3. •In general, complex dislocations are described as
anterior or posterior based on the translation of the
ulna with respect to the distal humerus.
•Posterior dislocations are typically the result of an
axial load applied through a supinated elbow with
valgus stress.
•Conversely, anterior dislocations occur in the setting
of a posterior force applied to the elbow in a flexed
position or hyperextension trauma.

4. •The Horii circle,
described by
O’Driscoll and
colleagues,outlines
the typical pattern
of soft tissue injury
for elbow
dislocations
proceeding from
lateral to medial

5. Ring and Jupiter noted 4 common patterns of
injury:
1. Posterior dislocation of the elbow with fracture of the radial head
2. Posterior dislocation with fracture of both the radial head and
coronoid, described by Hotchkiss as the “terrible triad”
3. Anterior transolecranon fracture dislocation
4. Proximal Monteggia posterior fracture dislocations

6. •Elbow dislocations with associated
periarticular fractures (ie, complex
dislocations); frequently necessitate surgical
intervention, and the indications are
predicated on the specific fracture pattern.
•For this reason, CT scan is often helpful in
preoperative planning

7. Posterior elbow
dislocation. (A) Lateral
and (B) AP views of a
posteriorly dislocated
elbow. Visualization
and assessment of
small periarticular
fractures is difficult on
plain film imaging;
however, CT images
clearly demonstrate
fractures of the (C)
coronoid and (D)
lateral epicondyle.

8. 1. Radial Head Fractures
•Always conserve the radial head as far as
possible in the setting of acute elbow dislocation
•Nonoperative treatment is reserved only for
cases where concentric reduction is achieved,
there are no blocks to motion, and fracture
fragments are small and nondisplaced

9. 2. Coronoid fractures
Surgical fixation is indicated for elbow dislocations
with fractures greater than 10% of coronoid
height as well as the well-known terrible triad
injury of simultaneous elbow dislocation with
coronoid and radial head fractures

10. 3.Olecranon fracture
The ulnar articular surface must be anatomically
restored and any associated injuries to the
coronoid, distal humerus, or radial head
addressed at the time of fixation

11. 4. Soft Tissue Injury
• O’Driscoll and colleagues described the disruption of soft tissue
structures from lateral to medial in elbow dislocations originating at
the lateral ulnar collateral ligament (LUCL) and, in cases of high
energy trauma, progressing to disruption of the medial ulnar
collateral ligament (MUCL).
• After bony anatomy is restored, attention should be turned to the
soft tissue structures for reconstruction. The annular ligament and
LUCL should be repaired, because rotatory instability ensues with any
deficit in the lateral collateral ligament (LCL) complex

12. 4. Soft Tissue Injury ……contd
• The medial collateral ligament (MCL), however, needs only to be
restored if the elbow remains unstable after all other fractures and
soft tissue structures have been addressed.
• An alternative option is to place a hinged external fixator in this
situation

13. Decision-making
algorithm

15. Positioning

16. The Kocher’s approach

17. The Kaplan Approach

18. Regardless of the interval chosen,
dissection should be carried out with
the elbow in pronation to reduce risk
of injury to the posterior
interosseous nerve (PIN)

19. •Medially, an anteromedial interval between the
pronator teres and brachialis may be used to
access the anterior capsule.
•The posteromedial (flexor carpi ulnaris [FCU]-
splitting) exposure necessitates anterior ulnar
nerve transposition and the FCU is divided
between the 2 heads of the muscle

20. The Hotchkiss over-the-top approach splits the flexor-pronator
mass and the pronator teres is released from the epicondyle to
provide access to the coronoid and medial elbow structures

21. Surgical Procedures

22. For Coronoid
• Type I requires only suture fixation
• Suture fixation may also be used for type 2 fractures if adequate
screw fixation is not possible due to fracture size or bone quality or to
augment internal fixation

23. •The coronoid can frequently be approached through the
lateral approach, because the radial-sided structures are
commonly already interrupted.
•If suture fixation is chosen 2 drill holes are created along
the subcutaneous border of the ulna to serve as tunnels
for the suture, directed toward either side of the
coronoid footprint
•Typically the coronoid fragment is too small to
accommodate drill holes and, therefore, is most
commonly captured by passing a number-1 braided
suture through its anterior capsular attachment

24. Suturing for small coronoid fragment

25. •Types 2 and 3 fractures often require a medialsided
approach because they are commonly fixed with formal
open reduction and internal fixation.
•Smaller fractures can be fixed with a headless screw that
can be augmented with the addition of suture fixation.
•In this case, the fragment must be large enough to
accommodate the screw and the bone must be of
adequate quality.
•The screw should be placed in the posterior to anterior
direction to achieve greater fixation strength and to
reduce the risk of injury to anterior neurovascular
structure

26. •For larger fragments, anteromedial buttress
plating can be used with or without combined
headless compression screws.
•Occasionally, a surgeon is faced with multiple
coronoid fragments that may necessitate
separate medial and dorsal plates, which again
may be augmented with suture or screw
fixation.

28. For radial head
• If a few large fragments exist and bone is healthy enough to achieve
secure fixation, headless compression screws may be used.
• The radial ead articular surface is anatomically restored and
maintained with pointed reduction forceps.
• Kirschner wires are placed and cannulated headless compression
screws are implanted over their respective pins.
• If standard screws are used, it is important to place these implants in
the nonarticulating safe zone of the radius to avoid any symptoms
with pronation or supination

29. The Safe Zone

30. •Fracture extension into the neck is treated
with a buttress plate, again placed in the
safe zone of the proximal radius to avoid
impingement
•It is important to restore anatomic
alignment and length to avoid future
instability

32. •If the radial head is extensively comminuted or
osteopenic, internal fixation may not be ideal.
•In this situation, radial head replacement is
advisable and has demonstrated good results
•The most important aspects of replacement are
appropriate sizing and positioning of the
prosthesis.
•Importantly, the radial head must not be
overstuffed, which inevitably leads to increased
radiocapitellar contact pressures, elbow pain,
loss of range of motion, and component failure

33. For soft tissue injury
• Due to the critical role of the LCL as the primary lateral elbow
stabilizer, soft tissue repair is mandatory at the time of surgery
because failure to address this injury is a significant cause for
recurrent instability.
• Most commonly, the LCL and posterolateral capsule are avulsed as a
sleeve from the lateral condyle, leaving a characteristic bare spot
• Surgical repair with suture anchors or bone tunnels placed at the
origin of the LCL at the bare area on the epicondyle with the elbow in
supination

34. Complications

35. Heterotopic Ossification
• Indomethacin prophylaxis

36. Recurrent
Elbow
Instability
External fixators have also
been used to restore and
stabilize a congruent
elbow articulation and
facilitate early motion

37. Ulnar Neuropathy
• Seldom requires anterior transpositioning

38. Arthrofibrosis
• Usually anatomic in nature

39. Post traumatic Arthrosis
• Difficult to tackle