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ELBOW INJURY AND TERRIBLE TRAID.pptx
- 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
- 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
- 19. 56/M, POSTEROLATERAL ELBOW D/L
- 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
- 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
- 26. RADIAL HEAD FRACTURE Mechanism of Injury: Valgus force + axial load 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
- 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
- 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
- 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
- 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
- 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
- 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.