Elbow fracture dislocations adam watts
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This document discusses the classification and management of various elbow fracture dislocations. It begins by outlining three main types of elbow fracture dislocations: posterior rotatory, trans-olecranon, and longitudinal. It then focuses on specific injuries such as terrible triad injuries, Monteggia fractures, and Essex-Lopresti injuries. For each injury, the document discusses recognition of injury patterns, surgical treatment options, and management principles based on anatomical restoration. It emphasizes restoring bony and soft tissue structures to restore stability and proper elbow function.
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Elbow fracture dislocations adam watts
- 1. Elbow fracture dislocations Adam C Watts Consultant Elbow and Upper Limb Surgeon, Wrightington Hospital Visiting Professor, Manchester University 1
- 3. www.wrightington.com Fracture Dislocations Recognisable patterns of injury Management plan based on anatomical principles Consider “hidden” injury 3
- 4. www.wrightington.com Elbow fracture dislocations 1.Posterior rotatory a.pronation lateral rotation b.pronation medial rotation 2.Trans-olecranon a.extension b.flexion 3.Longitudinal 4
- 8. www.wrightington.com Terrible Triad algorithm Restore coronoid Restore radial head Restore lateral soft tissue restraints Restore medial soft tissue if still unstable Apply hinged ex-fix 8
- 9. www.wrightington.com 9 Arguments around the coronoid?
- 15. www.wrightington.com 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 15
- 18. www.wrightington.com How do we manage the radial head? 18
- 30. www.wrightington.com 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 30
- 32. www.wrightington.com Medial Collateral Ligament Not fixing MCL is acceptable (Ring 2007) Fix if having to go medially If not leave it alone Argument for decompression of ulnar nerve 32
- 33. www.wrightington.com Timing of fixation Best results if fixed acutely (within 2 weeks) Stability and strength can be restored subacutely ROM better in acute Earlier treatment is more straightforward (Lindenhovius 2008) 33
- 34. www.wrightington.com 25 Male PE teacher 34
- 37. www.wrightington.com Cat like observation not neglect 37
- 38. www.wrightington.com Terrible triad with concentric reduction and small or undisplaced radial head and coronoid fragments no sign of subluxation on radiographs rapid return to elbow flexion/extension no mechanical block to forearm rotation no neurovascular deficit patient choice 38
- 39. www.wrightington.com Outcome Non-Op Management DASH 8 (Level 4 evidence) ROM 134° 1/12 required surgery for early instability 39
- 40. www.wrightington.com My View 40 Fix coronoid if large fragment or anteromedial facet fracture Fix or replace radial head Fix lateral soft tissue structures Fix medial soft tissue structures if still unstable
- 43. www.wrightington.com 43 Posterior medial rotation Posteromedial rotatory instability
- 52. www.wrightington.com 52 Transolecranon Monteggia Fracture Dislocations Proximal ulna fracture with dislocation of radial head from radiocapitellar joint and proximal radioulnar joint
- 53. www.wrightington.com Bado Classification Anterior Posterior Lateral Radial diaphyseal fracture 53
- 54. www.wrightington.com 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 54
- 55. www.wrightington.com 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 55
- 56. www.wrightington.com Aims of treatment Restoration of normal ulna alignment Restoration of elbow stability coronoid buttress radial head lateral ligament complex 56
- 57. www.wrightington.com Bado I, Ring I 57
- 60. www.wrightington.com Jupiter IIb, Ring III 60
- 73. www.wrightington.com “Hidden Injury” - IOM 73
- 74. www.wrightington.com Load transfer Prevent radius and ulna bowing 74 Role of IOM
- 85. www.wrightington.com 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 85
- 87. www.wrightington.com 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 87
- 88. www.wrightington.com Elbow fracture dislocations 1.Posterior rotatory a.pronation lateral rotation b.pronation medial rotation 2.Trans-olecranon a.extension b.flexion 3.Longitudinal 88 Terrible Triad PMRI Ring Type 1 Ring Type 3 Essex-Lopresti