4/19/2016

Orthopaedic Trauma Association Challenge

• Olecranon fractures Fractures and Dislocations of the Elbow • Radial head fractures Eben A. Carroll, MD • Terrible triad injuries • Trans-olecranon fracture dislocations • Posterior Monteggia injuries

Resident Comprehensive Fracture Course

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Spectrum Goals Bad Worse • Tension band

• Terrible triad not so terrible

• Differentiate trans-olecranon fracture dislocations from Monteggia variants

Mechanism

*Direct Fall on dorsal aspect Olecranon fractures Indirect Hyperextension of elbow Eccentric pull of triceps

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Olecranon Fractures Tension band principles - review

Dynamic – compressive Static - compression when Triceps & Brachialis  compressive forces forces increase applied across

Tensile force converted to compression during loading

Classification Treatment

• AO/OTA classification Diagnosis - complex XR to evaluate completely • 21-A extra-articular Fracture lines, marginal impaction Radiocapitellar, ulnohumeral joint, PRUJ • 21-B involves proximal or Nonoperative ulna only < 2mm step or gap, intact extensor mechanism • 21-C involves both Early active ROM, no resistance initially

Operative

Positioning Tension Band Wire Fixation

Lateral/prone • < 50% Articular Surface supine • No comminution (simple fx) • Transverse fracture • 18 or 20 g wire • Place under triceps • Use 14 or 16 g angiocath • 0.62 or Larger K-wires which engage anterior cortex

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Surgical Treatment Options Plate Fixation Plate Fixation Surgical Tactic > 50% Comminution Fracture obliquity Marginal Impaction Dorsal fixation

Rehabilitation

Splint in extension 1-2 days (my choice) Early AROM/AAROM Balancing stability with stiffness Radial head/neck fractures

Goals of treatment Radial head/neck - anatomy

• 240° of • Restore forearm circumference rotation articulates with ulna at lesser sigmoid notch • Restore elbow flexion

• Stable healing

Hotchkiss RN JAAOS 5:1-10 (1997)

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Classification - Mason Surgical treatment

Type I – nondisplaced • Indications Type II – displaced partial articular radial head fracture – Loss of pronation or Type III – displaced, comminuted fracture of the entire supination radial head (mechanical block) • Intra-articular lidocaine injection may be helpful for examination – Fracture associated with elbow instability – Incarcerated intraarticular osseous fragments

Surgical management Surgical management

• Excision? • Direct repair – Be sure there is no – Partial articular associated elbow fractures (Mason II) instability or forearm – Keep fixation away axis injury (Essex- from articulating Lopresti) portion of radial head – Lower-demand (240° arc) patients – Check stability after excision – Can always excise later!

Surgical approach Replacement • Consider for Mason III • Kocher approach fractures (>2 articular – Interval between fragments and anconeus and ECU complete articular – Exploit tears in fascia pattern) if already present • “Spacer” – Avoid dissection •Don’t overstuff joint posterior to anterior – Radiocapitellar joint anconeus border to avoid damaging LCL – Template with resected radial head www.wheelessonline.com (fragments)

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Tips Spectrum Bad Worse • Watch for other associated injuries – Periarticular fracture-dislocations • Protect LCL during dissection. Repair it when damaged • If fixing, keep implants out of proximal radioulnar joint articulation • If replacing, don’t overstuff joint

Terrible Triad Terrible Triad Tactic • Injury complex – Radial head fracture – Coronoid fracture – Elbow dislocation

• Historically abysmal results

•Why? – Injury to primary elbow stabilizers – No big pieces of

Terrible Triad - tactic Transolecranon fracture-dislocation

• Repair coronoid or • of anterior capsule elbow – Suture tunnels through proximal ulna • Olecranon fracture –Screws (comminuted, – Consider medial approach for plating type 3 coronoid impacted) fractures • Coronoid involvement • Complete repair or replacement of radial • Anterior dislocation of head radial head • Repair LCL during closure • PRUJ, ligaments intact Regan and Morrey, Orthopaedics (1992) 15:845

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Transolecranon – tactic Monteggia variant fracture-disloc

• Anatomically reduce • Olecranon fracture olecranon (coronoid involvement) • Plate-and-screw constructs often necessary • Posterior radial head dislocation • Normally, ligaments are relatively spared • Radial head fracture

• Ligaments often injured (LCL)

Posterior Monteggia variant - tactic Summary

• Principle: anatomical • Success depends on understanding reduction of ulna and osseous and ligamentous injuries coronoid • Understand tension band wiring • Simple compressible, < 50% • Radial head • Terrible triad not so terrible • Rebuild primary and secondary stabilizers • Ligaments • Transolecranon fracture dislocations and posterior Monteggia variants • Osseous injury, ligamentous injury

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