Complex elbow injuries involving radial head

Complex elbow injuries
involving the radial head
Adam C Watts
Consultant Elbow and Upper Limb Surgeon, Wrightington Hospital
Visiting Professor, Manchester University
1

www.wrightington.com
92 F Active
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Fracture Dislocations
Recognisable patterns of injury
Management plan based on anatomical principles
Consider “hidden” injury
3

Elbow fracture dislocations
1.Posterior rotatory
a.pronation lateral rotation
b.pronation medial rotation
2.Trans-olecranon
a.extension
b.flexion
3.Longitudinal
4

Posterior lateral rotation
Terrible triad
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Terrible Triad algorithm
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Restore coronoid
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Restore coronoid
Restore radial head
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Restore coronoid
Restore radial head
Restore lateral soft tissue restraints
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Restore coronoid
Restore radial head
Restore medial soft tissue if still unstable
6

Restore coronoid
Restore radial head
Restore medial soft tissue if still unstable
Apply hinged ex-fix
6

8
O’Driscoll Classification
1
2
3
from Ring et al.

Does the coronoid need to be
fixed?
Cohort study of 14 consecutive patients (Level 4)
2 Regan-Morrey type I, 12 type 2
No coronoid fixation - Min f/u 24 months
Mean arc of motion 123°
DASH 14
9

How do we manage the radial
head?
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Radial Head ORIF
12

Intracapsular Fracture
14

Fix or Replace?
No difference in ROM (Level 4)
ORIF more likely to be unstable
33% risk of arthrosis with arthroplasty
Equivalent re-operation rates
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“Hidden” injury
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Posterior medial rotation
Posteromedial rotatory instability

21
Transolecranon
Monteggia Fracture Dislocations
Proximal ulna fracture with dislocation of radial head from
radiocapitellar joint and proximal radioulnar joint

Bado Classification
Anterior
Posterior
Lateral
Radial diaphyseal fracture
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Jupiter Classification of Type II
Fractures
IIa Coronoid level
IIb Metaphyseal/Diaphyseal
junction
IIc Distal to coronoid
IId Fracture extending to
distal 1/2 ulna
23

Ring Classification
Type I
Apex anterior diaphyseal ulna fracture with anterolateral
dislocation of radiocapitellar and PRUJ
Type II
Metaphyseal buckle fractures with anterolateral radiocapitellar
dislocation (paediatric only)
Type III
Apex posterior ulna fractures with posterior dislocation
radiocapitellar joint
24

Aims of treatment
Restoration of normal ulna alignment
Restoration of elbow stability
coronoid buttress
radial head
lateral ligament complex
25

Bado I, Ring I
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Jupiter IIb, Ring III
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31
Jupiter IIa, Ring III

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Longitudinal -
Essex-Lopresti

“Hidden Injury” - IOM
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Tightrope Reconstruction
47

Bone-ligament-bone graft
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Ligament Augmentation and
Reconstruction System (LARS)
Polyester rope
Ultimate stress 2600N
Residual Strain at 2500N = 1.5%
Stiffness = 209N/mm (cf 129 native IOM)
No damage after 5 million cycles
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Experience to date
15 Procedures (chronic injuries) min follow-up 18
months
1 persistent axial instability - revised to OBF
No other recurrent proximal migration
Mean DASH improved 77 to 41/100
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2.Trans-olecranon
a.extension
b.flexion
3.Longitudinal
55

2.Trans-olecranon
a.extension
b.flexion
3.Longitudinal
55
Terrible Triad

2.Trans-olecranon
a.extension
b.flexion
3.Longitudinal
55
Terrible Triad
PMRI

2.Trans-olecranon
a.extension
b.flexion
3.Longitudinal
55
Terrible Triad
PMRI
Ring Type 1

2.Trans-olecranon
a.extension
b.flexion
3.Longitudinal
55
Terrible Triad
PMRI
Ring Type 1
Ring Type 3

2.Trans-olecranon
a.extension
b.flexion
3.Longitudinal
55
Terrible Triad
PMRI
Ring Type 1
Ring Type 3
Essex-Lopresti

92 F Active
56

Complex elbow injuries involving radial head

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