Elbow fracture dislocation treatment strategies

Elbow fracture dislocations
Adam C Watts
Consultant Elbow and Upper Limb Surgeon, Wrightington
Hospital
Visiting Professor, Manchester University
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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
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1.Posterior rotatory
a.pronation lateral rotation
b.pronation medial rotation
2.Trans-olecranon
a.extension
b.flexion
3.Longitudinal
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Posterior lateral rotation
Terrible triad
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O’Driscoll Classification
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2
3
from Ring et al.

Terrible Triad algorithm
Restore coronoid
Restore radial head
Restore lateral soft tissue restraints
Restore medial soft tissue if still unstable
Apply hinged ex-fix
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Arguments around the coronoid?

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O’Driscoll Classification

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
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How do we manage the radial
head?
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Radial Head ORIF
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Intracapsular Fracture
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Blood Supply
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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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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
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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)
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25 Male PE teacher
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Cat like observation not neglect
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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
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Outcome Non-Op Management
DASH 8 (Level 4 evidence)
ROM 134°
1/12 required surgery for early instability
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My View
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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

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Posterior medial rotation
Posteromedial rotatory instability

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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
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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
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Aims of treatment
Restoration of normal ulna alignment
Restoration of elbow stability
coronoid buttress
radial head
lateral ligament complex
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Bado I, Ring I
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Jupiter IIb, Ring III
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Jupiter IIa, Ring III

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Longitudinal -
Essex-Lopresti

“Hidden Injury” - IOM
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Load transfer
Prevent radius and ulna
bowing
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Role of IOM

Tightrope Reconstruction
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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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1.Posterior rotatory
a.pronation lateral rotation
b.pronation medial rotation
2.Trans-olecranon
a.extension
b.flexion
3.Longitudinal
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Terrible Triad
PMRI
Ring Type 1
Ring Type 3
Essex-Lopresti

92 F Active
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Elbow fracture dislocation treatment strategies

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