Post on 01-Jun-2015
description
transcript
Complex fractures of the Elbow
N. A. Darlis, MD, PhD
To access this presentation on the web:
Unstable elbow Combination injuries
Mechanism
• Posterolateral rotatory stress
Pathoanatomy
• Injured structures– 1: LCL-ulnar– 2: LCL-radial
capsule– 3a: MCL-post– 3b: MCL-ant
Pathoanatomy• Posterolateral rotatory stress
Horii circle
Pathoanatomy• Valgus deformity
Schreiber JJ et al., JHS(A), 2013
Pathoanatomy
• All 16 acute elbow dislocations had MCL injury• Complete tears at the medial side were more common than
the lateral
Schreiber JJ et al., JHS(A), 2014
Pathoanatomy• Valgus deformity
Horii circle reversed ?
Mechanism
Valgus PRLI
Forearm instability• “The forearm as a
ring” concept
• Key role of– Radial Head– IOM– TFCC
• Double or Multiple injuries to the ring common
Forearm Interossous Membrane
• Contributes 70% of forearm stability
• Can be injured in association with elbow fractures
Radius
Ulna
CB
Injury patterns commonly associated with instability:
• Terrible Triad of the Elbow• Transolecranon Fracture dislocation • Essex-Lopresti Injury• Posterior Monteggia lesion and equivalents• “Floating Elbows”
Terrible Triad
• Elbow dislocation• Radial head fracture• Coronoid fracture
• Diagnosis can be missed!
• Careful screening of radiographsCourtesy : C.G. Zalavras, MD
Essex-Lopresti Injury
Courtesy : D.G. Sotereanos, MD
Transolecranon fracture dislocations
Posterior Monteggia lesion
Courtesy : C.G. Zalavras, MD
• Anterior fragment includes the coronoid
Jupiter et al. JOT, 1991
Posterior Monteggia lesion
Courtesy : C.G. Zalavras, MD
Monteggia type 2 equivalent lesion
Monteggia type 2 equivalent lesion
… Other double injuries
Floating elbow
• Type IIa IIb III
Courtesy : K. Ditsios, MD
Floating elbow
• Type IIa III
Courtesy : K. Ditsios, MD
Open/ Neurovascular injury
UN
Open/ Neurovascular injury
Nerve grafts
Complex elbow instability
• Operative treatment• No role for conservative management
• Goal: Early, concentric mobilization
Skin incision
• Posterolateral (Kocher)
• Posterior midline (Universal)
– when medial approach is
contemplated
Kocher approach
Lateral approach
Or… use the paths of soft tissue injury
1/2
123
45
6
Proximal Ulna
• Anatomic Reduction
• Pre-contoured proximal ulnar plates useful
1
Will need plating most of the times
Posterior Monteggia lesion
Radial Head • Excision not recommended in complex
elbow instability– radial head is essential if MCL is injured
• ORIF• Prosthetic replacement
2
Radial Head: ORIF
• If fracture amenable to internal fixation
• Safe zone of hardware placement
• Radial neck fracture fixation challenging
Radial Head: Prosthesis
– Comminuted fractures associated with elbow dislocations may be better treated by prosthetic replacement
– Side-table re-assembly and ORIF not favored
Ring et al. JBJS-Am 2002
Radial Head: Prosthesis
– Remove radial head fragments
– Perform neck osteotomy
– Measure head diameter
– Coronoid first then RH implant
Coronoid
Regan-Morrey classification
3
Coronoid
Retrograde screw fixation
Coronoid
Medial facet fracture
Coronoid
• Suture fixation through anterior capsule ?
• Fixation of small avulsion fractures???
Lateral collateral ligament
• Usually avulsed from its origin from lateral epicondyle
• Repair with suture anchors to lateral epicondyle
4
Lateral collateral ligament
• Repair with suture anchors to lateral epicondyle
• With extensor origin sleeve
Intraoperative assessment of stability
• Clinical• Radiological (C-arm)
– Forearm in pronation
– Note stable range of motion
– If stable to aprx 500 of flexion immobilize in pronation and start early ROM in hinged brace within the range of stability
Intraoperative assessment of stability
• If stable in narrow ROM or unstable after the above consider:
– Hinged elbow external fixation
– MCL repair• Consider especially if dislocation occurs with
forearm in pronation
Hinged external fixator
• Allows early joint motion
• Maintains concentric reduction
• Protects any repair/fixation
5
Monteggia type 2 equivalent lesion
MCL
• Repair/ Reconstruct• Medial approach
– ulnar nerve symptoms– medial coronoid facet
fracture– medial epicondyle
fracture
6
Essex-Lopresti Injuries
• Radial Head Reconstruction- Replacement
• DRUJ reduction- pinning in supination
• TFCC repair?• IOM reconstruction ?
Courtesy : D.G. Sotereanos, MD
Total Elbow Arthroplasty• Comminuted fractures in elderly patients
may not be obvious; may not be obvious; maintain high index of suspicionmaintain high index of suspicion
http://www.flickr.com/photos/katiedee/4884263411/lightbox/
address the specific components address the specific components of the injuryof the injury
• Bone– Radial head (repair or replacement)– Coronoid (repair or bone block)– Proximal ulna (anatomic repair)
• Ligaments– LUCL/ extensor origin reattachment– MCL
Poor prognosis in older series with Poor prognosis in older series with no consistent treatment protocolno consistent treatment protocol
– all 4 redislocations out of 23 elbow fracture-dislocations occurred in terrible triad cases
– severe arthrosis in 12 of 19 elbows @3 to 34 years.
Josefsson et al. CORR 1989
– 7 of 11 patients unsatisfactory result– arthrosis in 9 of 10 patients @7 years
Ring et al. JBJS-Am, 2002
http://www.flickr.com/photos/doug88888/4627497417/
Modern Treatment Protocol Modern Treatment Protocol Studies (after 2004) encouraging…Studies (after 2004) encouraging…
Flexion arc 1100, Rotation 1300, Mayo score 85
…but long term but long term DJD unknownDJD unknown
No redislocationsMild arthritis
@ 2,5years
Pugh et al., JBJS (A) 2004, Egol et al, Bull NYU Hosp Jt Dis.2007, Forthman et al., JHS(A) 2008, Lindenhovius et al, JHS(A) 2008, Zeiders et al., JBJS 2008
THANK YOU
To access this presentation on the web: