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Elbow Fractures

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by

Craig Yager

on 4 February 2013

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Transcript of Elbow Fractures

Outline Anatomy
Coronoid Fracture
Olecranon Fracture
Radial Head Fracture Elbow Anatomy Five Key Points Coronoid Fractures Olecranon Fractures Radial Head Fractures Craig A. Yager
February 4, 2013 Elbow Fractures 60% of anteromedial facet is unsupported by ulnar metaphysis Epidemiology
Classification
Treatment } Epidemiology Classification Regan and Morrey, 1989
Type I: tip avulsion
Type II: fragment involving less than 50%
Type III: fragment involving greater than 50%
O'Driscoll
Type I: Tip
1: < 2 mm
2: > 2 mm
Type II: Anteromedial
1: Anteromedial rim
2: Anteromedial rim and tip
3: Anteromedial rim and sublime tubercle
Type III: Basal
1: Coronoid body and base
2: Transolecranon basal coronoid fractures Treatment Comprise approximately 10-15% of elbow injuries

Pathognomonic of episode of elbow instability
Isolated coronoid fractures rare
Most commonly occur with elbow dislocation

Frequently have associated injuries
LCL, MCL, radial head fracture, olecranon fracture Mechanism
Distal humerus exerts shear force to coronoid during posterior subluxation
NOT avulsion fracture
Anteromedial facet subtype: varus force, associated with LCL injury
"Terrible triad" Coronoid is intraarticular and the anterior bundle of MCL is primary valgus restraint, MCL inserts on sublime tubercle
Terrible triad consists of posterolateral dislocation, radial head fracture, coronoid fracture
Plate fixation appropriate for comminuted olecranon fractures
Excision and advancement for olecranon fractures in the osteoporotic elderly with less than 50% involvement of articular surface
ORIF is appropriate for radial head fractures with three pieces or fewer Coronoid Process Cornoid articulates with the trochlea
Coronoid process and olecranon form the greater sigmoid notch of the ulna
Coronoid provides anterior buttress
Intraarticular structure
Sublime tubercle
Attachment of the anterior bundle of MCL
Widens medially Radial Head Radial head articulates with capitellum and lateral portion of coronoid
Important secondary elbow stabilizer
Radiocapitellar contact resists valgus stress
Valgus stabilization increased in MCL incompetent elbow
Longitudinal restraint Olecranon Forms greater sigmoid notch with coronoid
Triceps insertion posteriorly
Anconeus inserts laterally Terrible Triad
Radial head fracture, posterolateral elbow dislocation, coronoid tip fracture
Mechanism is valgus and supination moment to the forearm
Capsuloligamentous structures fail lateral to medial
Anterior bundle of MCL is usually spared Depends on associated injuries and elbow stability

Most elbows with coronoid fracture will require operative intervention

Exam under anesthesia may help delineate exact injuries present

Minimally displaced type 1 or 2 fractures without associated injury and a stable elbow can be treated nonoperatively
Brief period of immobilization with early range of motion exercises Operative Fixation Indications
Type I, II, or III with persistent elbow instability
Varus posteromedial rotatory instability
Loss of medial ulnohumeral joint space, absence of radial head fracture, anteromedial coronoid fracture >20%
Valgus posterolateral rotatory instability
Elbow dislocation with radial head fracture and small coronoid tip fracture
Olecranon fracture dislocation Type I Stable Elbow
Non-operative therapy
Short term immobilization with early range of motion
Unstable Elbow
Suture placed through drill holes placed in the proximal ulna using an ACL guide Type II Type III ORIF
Screw fixation
Two partially threaded cannulated screws
Plate fixation
Buttress against posterior subluxation of the ulna ORIF
Screw fixation
Two partially threaded cannulated screws
Plate fixation
Buttress against posterior subluxation of the ulna Epidemiology Bimodal distribution
High-energy trauma in young patients
Low-energy trauma in old patients

Incidence of 11.5 per 100,000 per year

8-10% of all elbow fractures Mechanism
Direct: fall on point of the elbow or direct trauma to the olecranon
More comminuted
Indirect: strong eccentric contraction of the triceps upon a flexed elbow
Transverse or oblique Classification Treatment Operative Fixation Indications
Disruption of extensor mechanism
Articular incongruity
Procedures
Tension band
Intramedullary fixation
Plate and screws
Excision and triceps advancement Tension Band Intramedullary Fixation Plate Fixation May be used in conjunction with tension band wiring or alone in simple transverse fractures

Large diameter cancellous lag screw fixation

Common complications: poor reduction, loss of compression, fixation failure, bent screw Indications
Comminuted fractures where tension band wiring is not feasible
Oblique fractures distal to trochlear notch
Fractures that involve the coronoid
Monteggia fracture-dislocations
Complications: prominent hardware necessitating removal Operative Fixation Indications
Block to motion
Fragment > 3 mm
Mason type III fractures
Mason type IV fractures Open Reduction Internal Fixation Preferred treatment if technically possible
Radial head with three or fewer fragments can typically be reconstructed
Typically performed with the Kocher posterolateral approach
Interval between anconeus and ECU
Pronating the forearm rotates the PIN into a more protected position
Multiple options present for fixation
1.5 - 2 mm mini-fragment screws, headless screw with differential pitch
If fracture extends into radial neck, plate fixation is indicated
T plate or a blade plate placed in the safe zone Radial Head Arthroplasty Radial Head Excision Indications
Displaced, comminuted fractures not amenable to ORIF if the fracture involves > 33% of the radial head
Fractures with associated ligamentous injury or associated fracture
Prosthesis
Diameter and length of implant are both important considerations Indicated only in low demand, sedentary patients
Radial head was once thought to be entirely expendable
Recent studies illustrated the importance of the radial head on elbow stability
Acute excision in an MCL or interosseous membrane deficient elbow is contraindicated
Complications include arthritis, weakness, wrist pain, valgus instability, proximal migration Goals: correction of any block to forearm rotation, early range of motion, stability of forearm and elbow, limit potential for development of arthrosis

Most nondisplaced and minimally displaced (< 3 mm) fractures can be treated non-operatively
Exception is mechanical block to motion

Brief immobilization in a sling or posterior splint with early range of motion Treatment Classification Epidemiology Comprise approximately 33% of elbow fractures

33% have associated injuries
DRUJ
Interosseous membrane
Coronoid fracture
MCL/LCL injury
Essex-Lopresti
Elbow dislocation
Terrible Triad
Carpal fracture Mechanism
Fall on outstretched hand with forearm in pronation
Causes axial load at the elbow

Part of the "terrible triad" injury Mayo
Type I: Nondisplaced
Type II: Displaced but stable
Type III: Unstable
Colton
Type I: Nondisplaced
Type II: Displaced
A: Avulsion
B: Oblique
C: Comminuted
D: Fracture-dislocation
Schatzker
Type A: Transverse
Type B: Transverse impacted
Type C: Oblique
Type D: Comminuted
Type E: Distal, extra-articular
Type F: Fracture dislocation Goals of treatment include articular restoration, preservation of extensor mechanism, elbow stability, avoidance of stiffness

Nonoperative management appropriate for nondisplaced fractures
Splint in 45 - 90 degrees elbow flexion with initiation of range of motion after 5 - 7 days
Some advocate immobilization for 3-4 weeks Excision and Triceps Advancement Indications
Elderly patients with osteoporotic bone and fracture too comminuted for ORIF involving less than 50% of the articular surface
Must be have stable MCL, DRUJ, interosseous membrane

Triceps is reattached to adjacent to the remaining articular surface, creating a sling for the trochlea Indicated for simple, noncomminuted transverse fractures

Converts tensile forces from the triceps into compressive forces at the articular surface Mason
Type I: Displaced < 2 mm
No block to forearm rotation
Type II: Displaced > 2 mm
Possible mechanical block
Type III: Severely comminuted fracture
Type IV: Fracture with associated elbow dislocation Procedures
ORIF
Radial head excision
Radial head arthroplasty
Partial excision Questions? Question One Question Two Question Three
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