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Management of Elbow Fracture Dislocation.pptx
- 1. Management of Elbow Fracture Dislocation By Dr Abdi L. ( GSR2) Moderator : Dr Lemesa ( Assistant prof. of orthopedics & trauma surgery) June, 2023 GC
- 2. Objectives ā¢ To briefly discuss clinical anatomy of elbow joint ā¢ To classify elbow dislocations ā¢ To explain mechanism of injury of elbow dislocation ā¢ To discuss management principles of elbow dislocation ā¢ To list some complications associated with elbow dislocation Elbow dislocation 2
- 3. Outlines ā¢ Introduction ā¢ Anatomy ā¢ Classification ā¢ Simple ā¢ Complex ā¢ Management ā¢ Complications ā¢ Summary ā¢ References Elbow dislocation 3
- 4. Introduction ā¢ The elbow is the 2nd most commonly dislocated joint in adults next to the shoulder. ā¢ Acute dislocations are usually reducible by closed methods and most are stable after reduction. ā¢ Broadly classified as simple Vs complex depending on associated injury to nearby structures. Elbow dislocation 4
- 5. Anatomy ā¢ Elbow stability is provided equally by soft tissues and bony articulations of the joint itself. ā¢ The Elbow joint involves 3 separate articulations 1. joint b/n trochlear notch of ulna & trochlea of humerus 2. b/n head of radius & capitulum of humerus 3. b/n head of radius & radial notch of ulna ( PRUJ) Elbow dislocation 5
- 7. Anatomyā¦ ā¢ Soft tissue stabilizers : static Vs dynamic ā¢ Static stabilizers: joint capsule, LCL & MCL ā¢ Dynamic stabilizers: Biceps, brachialis & triceps ā¢ Lateral collateral ligament (LCL) has components:- ā¢ Radial collateral ligament ā¢ Annular ligament ā¢ Lateral ulnar collateral ligament ā¢ Posterior collateral ligament Elbow dislocation 7
- 9. Simple Elbow Dislocation ā¢ Definition: there are no associated fractures. ā¢ Nearly half of them are due to sport injuries( football, gymnastics, skating) ā¢ Adolescent males are the highest risk group ā¢ Usually become stable after closed reduction ā¢ But in elderly & high-energy mechanism injury may have residual instability Elbow dislocation 9
- 10. Pathoanatomy ā¢ Valgus, axial and posterolateral forces result in posterolateral dislocation ā¢ Can be associated with disruption of collateral ligaments ā¢ Soft tissue injury begins on lateral side with disruption of LCL ā¢ Ulnar nerve is the most commonly injured nerve ā¢ Most daily activities exert a Varus force on the elbow Elbow dislocation 10
- 11. Evaluation ā¢ With elbow flexed to 90 degrees, the 2 epicondyles & olecranon process form a triangle ā¢ See for open wounds, assess peripheral neurovascular structures ā¢ Imaging: Radiographs, CT scans (rarely) Elbow dislocation 11
- 12. Classification ā¢ based on direction or time ā¢ Posterior/posterolateral, anterior, medial, lateral, & divergent ā¢ Acute, subacute(<6weeks) or chronic Elbow dislocation 12
- 13. Management ā¢ Non-operative treatment Elbow dislocation 13 Indications Relative Contraindications Closed dislocation -Open dislocation -Vascular injury -Instability after closed reduction or recurrent dislocation. Indications for operative mgt
- 14. Closed reduction techniques Elbow dislocation 14
- 15. Non-operative mgtā¦ ā¢ Immobilize the elbow with plaster splint at 90 degree of flexion & pronated forearm ā¢ Isometric exercises encouraged while immobilized ā¢ Remove splint after 1 week and start on active flexion- extension ā¢ Avoid Varus/valgus loading until 12 weeks ā¢ Prolonged immobilization results in flexion contracture/residual pain Elbow dislocation 15
- 16. Operative management ā¢ Approach: Posterior midline incision ā¢ Open reduction with repair of ligaments, capsule & muscle origin ā¢ Application of Ex-fix, cross pinning or bridge plating ā¢ Splint the elbow at 90 degrees of flexion & forearm pronation ā¢ Active motion stabilizes the elbow more ā¢ Varus positioning of arm avoided in LCL injured/repaired patients Elbow dislocation 16
- 18. Complications Problem Solution Elbow stiffness and heterotopic ossification Initiate early motion Redislocation Careful follow-up, recognize, and treat surgically Residual subluxation Active motion protocol, proceed with operative treatment if persists Elbow dislocation 18
- 19. COMPLEX ELBOW FRACTURE- DISLOCATION ā¢ Association with fracture of one or more major bony stabilizers ā¢ Radial head fractures ā¢ Coronoid fractures ā¢ Terrible triad injuries ā¢ Posteromedial rotatory instability of the elbow ā¢ Proximal ulnar # Elbow dislocation 19
- 20. Radial head fractures ā¢ Constitute 20-30% of all adult elbow fractures ā¢ Majority are minimally displaced & isolated injuries ā¢ Have good functional outcome with nonsurgical treatment ā¢ Mechanism of fracture: ā¢ Valgus load; rupture of MCL ā¢ Posterolateral rotatory subluxation; rupture of LCL ā¢ Axial forearm load; coronoid #, rupture of interosseous membrane & distal RUJ ligaments Elbow dislocation 20
- 21. Evaluation ā¢ Pain, swelling & stiffness of elbow and forearm ā¢ Tenderness over lateral epicondyle; LCL injury ā¢ Assess for the alignment of elbow to rule out associated Monteggia fracture-dislocation ā¢ Imaging : AP & L Xrays ā¢ CT scan: better characterize the size, location & displacement of radial head #s. ā¢ Also to look for concomitant injuries of coronoid,& capitellum Elbow dislocation 21
- 22. Classification ā¢ Modified mason ā¢ A type I = is undisplaced or displaced less than 2 mm and involves less than 30% of the articular surface. ā¢ A type II = is displaced greater than 2 mm and involves greater than 30% of the articular surface. ā¢ A type III fractures is comminuted. Elbow dislocation 22
- 23. Pathoanatomy ā¢ Radial head : 2 articulations ā¢ Concave dish- articulates with capitellum ā¢ Flattened articular margin- articulates with lesser sigmoid notch of ulna ā¢ Non-articular margin : 1/3rd of diameter of radius ā¢ āSafe zoneā for placement of plate without interfering with forearm rotation ā¢ laterally with the forearm in neutral rotation. Elbow dislocation 23
- 25. Nonoperative Treatment of Radial Head Fractures: Indications and Contraindications Indications Relative Contraindications Undisplaced fracture Block to forearm rotation Displaced fracture without motion impairment -Incarcerated intra-articular fragment -Concomitant injuries requiring surgical management Elbow dislocation 25
- 26. Non-operative mgtā¦ ā¢ Immobilized for 2-3 days & then active motion is encouraged ā¢ Undispalced fractures can be managed non-operatively with good long-term outcomes ā¢ But; Pain, functional limitations & osteoarthritis may happen Elbow dislocation 26
- 27. Operative Treatment of Radial Head Fractures ā¢ Indications: ā¢ Displaced radial head fractures with a block to motion, ā¢ those who have concomitant injuries which require surgical intervention such as unstable fracture dislocations, or ā¢ those with retained intra-articular loose bodies are best treated surgically ā¢ Treatment options include radial head fragment excision, radial head excision, ORIF, and radial head arthroplasty Elbow dislocation 27
- 28. Operativeā¦ ā¢ Fragment excision performed when fixation canāt be done due to comminution, small fragment size or osteopenia ā¢ Avoid fragment excision in ligament injury & osseous injuries ā¢ Radial head arthroplasty - preferred in unreconstructible comminuted fractures ā¢ Contraindicated in contaminated wound or if capitellum is deficient Elbow dislocation 28
- 29. Open radial head excision ā¢ Surgical approach: lateral or posterior skin incision ā¢ Kocher approach: b/n ECU & anconeus is used when LCL is ruptured ā¢ A more anterior approach splitting the common extensor tendon at mid-portion of the radial head is preferred when ligaments are intact ā¢ To protect PIN ā¢ maintain forearm in pronation during surgery ā¢ Donāt place retractors anterior to radial neck ā¢ Donāt dissect distal to biceps tuberosity Elbow dislocation 29
- 30. Excisionā¦ ā¢ Long term outcomes: arthritis, increase carrying angle & proximal radial migration ā¢ Radial head excision in fracture-dislocations may lead to Essex- Lopresti instability ā¢ For isolated fractures- good functional outcomes in the majority of patients. Elbow dislocation 30
- 31. ORIF of Radial Head and Neck Fracture ā¢ Best candidates for ORIF: ā¢ Younger patients with good bone quality ā¢ Fewer fragments ā¢ Partial articular fractures ā¢ K-wires, screws, plates ā¢ Indomethacin 25mg po TID for 3 weeks t prevent heterotopic ossification/HO/ Elbow dislocation 31
- 32. Complications in Radial Head Fractures ā¢ Post-traumatic arthritis ā¢ Stiffness ā¢ Symptomatic malunion, nonunion, or AVN ā¢ Elbow instability Elbow dislocation 32
- 34. Coronoid fractures ā¢ Comprise 10-15% of elbow injuries ā¢ The O'Driscoll classification of coronoid fractures includes: ā¢ Type I(fractures of the tip); associated with terrible triad fracture- dislocations, ā¢ Type II(fractures involving the anteromedial facet); associated with Varus posteromedial rotatory instability; almost always have a concomitant avulsion of the LCL ā¢ Type III(basal fractures); associated with olecranon and proximal ulna fracture-dislocations; less ligamentous injuries Elbow dislocation 34
- 35. Terrible Triad Injuries of The Elbow ā¢ A highly unstable form ā¢ Due to fall onto outstretched arm with supination, valgus & axial ādirected force ā¢ Ipsilateral upper limb injuries 10-20% ā¢ CT scan may better visualize # pattern Elbow dislocation 35
- 36. Nonoperative Treatment of Terrible Triad Injuries: Indications Relative Contraindications Concentric elbow following closed reduction of dislocation Nonconcentric elbow reduction Undisplaced radial head fracture or displaced radial head fracture without a block to rotation Displaced radial head fracture interfering with forearm rotation Regan and Morrey subtype I coronoid fracture, undisplaced subtypes II and III coronoid fractures ļ· If there is a stable arc of motion to 30 degrees of flexion. Displaced Regan and Morrey subtypes II and III coronoid fractures. Fracture fragment interposed in articulation Elbow dislocation 36
- 37. Operative Treatment of Terrible Triad Injuries ā¢ ORIF: fix radial head, fix coronoid fragment & repair of LCL ā¢ Approach: Posterior midline elbow incision ā¢ Kocher approach: allows repair of LCL ā¢ Taylor & Scham approach: for type III basal fractures, excellent exposure for coronoid & MCL ā¢ If reconstruction of coronoid is not possible: ā¢ Iliac crest, resected radial head, allografts, fragment of ipsilateral proximal olecranon,& coronoid prosthesis ā¢ Overhead rehabilitation protocol begins 10-14 days later Elbow dislocation 37
- 39. Terrible Triad Injuries: Complications Problem Solution Elbow stiffness and heterotopic ossification Initiate early motion Redislocation Careful follow-up and recognize and treat surgically Residual subluxation Active motion protocol, proceed with operative treatment if persists Elbow dislocation 39 * Ulnar nerve is at risk with medial approaches * Radial nerve is at risk with plate fixation or Ex-Fix * Good outcome if stable fixation of coronoid is achieved
- 41. POSTEROMEDIAL Rotatory Instability of the Elbow/PMRI/ ā¢ Anteromedial coronoid fracture accompanied by injuries to LCL& MCL ā¢ Unlike terrible triads, radial head is not fractured in these patients ā¢ Size of the fracture & presence of concomitant LCL injury are determinants of the need for ORIF ā¢ Neutral position is selected for flexion-extension exercises and for immobilization. ā¢ Non-operative mgt: minimally displaced, congruent elbow, stable ROM to minimum of 30 degrees of extension Elbow dislocation 41
- 43. Proximal Ulna Fractures ā¢ Account for approximately 10% of fractures around the elbow ā¢ Comprise: ā¢ Olecranon fractures , ā¢ transolecranon fracture-dislocations and ā¢ the posterior Monteggia lesion Elbow dislocation 43
- 44. Olecranon fractures ā¢ The Mayo classification is based on: ā¢ Displacement of the fracture, ā¢ Subluxation of the articulation, and ā¢ Presence of comminution. ā¢ Type I -nonoperative management ā¢ Type II and III- require operative treatment. ā¢ Type B fractures = plate fixation ā¢ Type A fractures = TBW Elbow dislocation 44
- 45. Transolecranon fracture-dislocations ā¢ Anterior fracture-dislocations of the olecranon ā¢ Also represented by mayo type III classification ā¢ Usually Coronoid is fractured, but PRUJ, radial head & collateral ligaments are intact. Elbow dislocation 45
- 46. Posterior Monteggia lesions ā¢ Posterior fracture-dislocations, Bado type II Elbow dislocation 46
- 47. Summary ā¢ Elbow joint is the 2nd most common dislocated joint in adults ā¢ Nearby sturctures are usually damaged during elbow dislocations ā¢ Closed reduction can be tried in EOPD ā¢ Complex elbow dislocations are usually treated surgically ā¢ Majority of them have good outcome even with non-operative mgt ā¢ In general, a stiff stable elbow is preferred over a loose incongruous one. Elbow dislocation 47
- 48. References ā¢ Rockwood and Greenās fractures in adults, 9th ed ā¢ Campellās operative orthopedic, 14th ed ā¢ Grays anatomy, 2nd ed ā¢ Moore clinical anatomy, 7th ed ā¢ Kaityln A. stevens, terrible triad of elbow, national library of medicine, www.ncbi.nlm.nih.gov Elbow dislocation 48
- 49. THANK YOU Elbow dislocation 49
Editor's Notes
- *Approximately 20% of dislocations are associated with fractures and up to 50% in children. ** less than 10% of pts report residual instability after reduction.
- *The first 2 joints are primarily involved with hinge-like flexion & extension of forearm on arm; they are the principal articulations of elbow joint. * The PRUJ is involved with pronation & supination of the forearm
- *the lateral ulnar collateral ligament is the most important for stability. *The fibrous membrane of the joint capsule is thickened medially and laterally to form collateral ligaments. **Dynamic stabilizers provide compressive stability to the elbow; particularly important when static stabilizers have been injured. ***Common extensor muscles provide varus stability and the common flexor muscles provide valgus stability.
- *The radial head is surrounded by the annular ligament which attaches to the anterior and posterior margins of the radial notch of the proximal ulna. *The annular ligament of radius and related joint capsule allow the radial head to slide against the radial notch of the ulna and pivot on the capitulum during pronation and supination of the forearm.
- *Fall on an outstretched hand.
- *Residual instability is usually due to incompetence of the LCL in the majority of patients. *Pronation will stabilize the LCL-deficient elbow, while supination decreases its stability. **Horri circle= the predictable apttern of disruption from lateral to anterior/posterior & then medial
- *Posterolateral dislocation is the commonest type.
- *After reduction, the elbow is taken through an arc of flexionāextension in pronation, neutral, and supination in order to evaluate for residual instability. **If the elbow re-dislocates when flexed to less than 30 degrees, operative treatment should be considered.
- TECHNIQUES The medial and lateral epicondyles are palpated and their relationship to the olecranon is determined in order to first correct the medial/lateral displacement in the coronal plane. The elbow is typically flexed to approximately 30 degrees, and traction is placed through the forearm while stabilizing the humerus. Direct pressure over the olecranon may help to guide it over the distal humerus and into joint. Supination of the forearm may be helpful to gain the reduction. The reduction maneuver should employ a steady slow force in order to avoid iatrogenic fracture of the distal humerus or proximal forearm.
- *The position of forearm depends on maximal stability( neutral, pronation, supination) **Since the lateral-sided soft tissue injuries are typically more severe(LCL), pronation of the forearm often improves stability.
- *If the MCL has been injured but not repaired and the LCL is competent, then flexionāextension of the elbow should be performed with the forearm maintained in supination. **Passive stretching of the elbow is not performed until ligament healing is progressing, typically beginning 6 weeks postoperatively.
- *Essex-Lopresti injury includes fracture of radial head, disruption of the forearm interosseus membrane, & dislocation of the DRUJ.
- Broberg & Morrey
- *A safe zone-best identified during surgery by positioning the forearm in neutral rotation and placing the plate 10-degree anterior to the mid-axial line
- *Partial articular fractures of the radial head which are displaced > 2mm and involve more than 30% of articulation( modified mason type 2) should be considered for ORIF. Also displaced radial head fractures which have crepitus with forearm rotation is indicated for surgery.
- *Fragment excision is indicated in patients with a block to forearm motion by a small (less than 25% of the articular diameter) non-reconstructible displaced articular fracture of the radial head. **Avoid fragment excision in the setting of associated ligament and osseous injuries as the radial head is an important secondary stabilizer in this situation
- Posterior interosseous nerve/PIN/; Extensor Carpi Ulnaris/ECU/
- *early radial head excision should be avoided **Radial head excision should be avoided in patients with fracture dislocations of the elbow. *
- *The surgeon should be prepared to proceed with arthroplasty if unexpected comminution or damage is found.
- *arthroplasty ā if capitellar cartilage is well preserved; if the cartilage or bone has severe disease excision may be preferred; BUT if arthritis is associated with elbow instability, excision is contraindicated **Chronic valgus or axial instability is most commonly seen in patients who have had a radial head excision without replacement
- The O'Driscoll classification of coronoid fractures includes: - Type I,fractures of the tip; /terrible triad fracture-dislocations, -Type II, fractures involving the anteromedial facet; associated with varus posteromedial rotatory instability; always have avulsion of the LCL -Type III, basal fractures; associated with olecranon and proximal ulna fracture-dislocations; less ligamentous injuries **The management of coronoid fractures is best understood by considering the patterns of injury rather than focusing on the isolated treatment of the coronoid.
- *The primary stabilizers of the elbow joint are the coronoid, MCL, and LCL. *The secondary constraints are the capsule, the radiocapitellar articulation, and the common extensor and flexor origins **ligament repair and radial head arthroplasty can restore near-normal elbow kinematics and stability if the coronoid fracture is small (type I)
- *immobilized in splint for 7-10days, at 90degree elbow flexion *full extension not permitted for 4 weeks *Varus/valgus loading avoided until 12 weeks
- *patients who have at risk medical comorbidities, non functional upper limb dur to neurologic problem are contraindicated for operative mgt. *systematic approach **intraop check for stability, to determine if MCL repair or if EX-Fix is needed **A Taylor and Scham: detaching the flexor pronator mass from the medial epicondyle and supracondylar ridge and provides excellent exposure to the entire coronoid and MCL. Use the interval between the two heads of the flexor carpi ulnaris (FCU) **Ex-Fix indicated: to protect osteoporotic # of coronoid when unstable or if , residual instability present despite repair of radial head, coronoid & both ligaments.
- *While pronation stabilizes the LCL-deficient elbow, supination stabilizes the coronoid-deficient elbow.
- *This classification helps direct treatment ** simple olecranon #= TBW, Plating, intramedullary rod * Significant communition with osteoporosis= excision+ triceps advancement
- A- # at coronoid B- distal to coronoid C- diaphyseal D- complex # extending from olecranon to diaphysis A& D= involve proximal ulna, & joint surface of sigmoid notch: emcompass posterior angulation of the proximal ulna, a radial head fracture, a coronoid fracture, and collateral ligament injuries