Intra- articular elbow fractures - , capitellum fracture ,olecranon, radial head / elbow dislocations Flashcards
what type of joint is the elbow ?
ulnohumeral joint - it is a hinged joint (between the ulnar and the trochlea)
radiocapitellar - pivot joint - 60 recent of load transfer
what does the capitellum articulate with ?
the proximal radius
what causes capitellum fractures ?
low energy fall on outstretched hand
direct axial compression with the elbow in a semi flexed position creates shear forces
capitallum fracture are usually in what plane ?
coronal plane (1)
capitellum fractures are difficult in the lateral elbow view so how can we know ?
elbow effusion and displacement of the fat pad may indicate radial head fracture or capitellum
what is the classification used for capitellum fracture ?
bryan and morrey classification
type 1 - where a large osseous piece of the capitellum involved involves the lateral half of trochlea
(1)
type 2
Kocher Lorenz fracture
Shear fracture of articular cartilage
articular cartilage separation with very little subchondral (cartilage) bone
type 3 -
comminuted capitellum fracture
type 4
McKee modification -
the fracture extends medially and involves more than the lateral half of trochlea
how do we treate the capitellum fracture according to bryan morrey classification ?
type 1 -
less than 2 mm displacement = posterioir splint immobilisation
more than 2mm and isolated :
open reductio with lateral column approach and internal fixation by herbert screws (HEADLESS):
isolated capitellar fractures
isolated type I fractures with good bone stock:
arthroscopic-assisted ORIF
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type 2 -
non displaced - less than 2mm = posterioir splint immobilisation
> 2mm surgical excision
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type 3 -
more than 2mm displacement surgical excision
and arthroplasty if needed
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type 4 -
open reduction lateral column approach
and internal fixation by HERBERT screws
or elbow athroplasty in elderly patients
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ORIF with posterior approach with or without olecranon osteotomy
indications:
capitellar fractures with associated fractures/injuries to distal humuers/olecranon and/or medial side of the elbow
capitellar fracture on diagnosis ?
double bubble on LATERAL elbow x ray (2)
the arch which is lower represents the capitulum and the arch which is above the trochlea
what are the complication of capitellum fractures ?
elbow stiffness - most common
nonunion with ORIF
ulnar nerve injury
hetertopic ossification (ORIF)
AVN of capitellum
instability of elbow
post traumatic arthritis
cubital valgus
coronoid fracture is associated with ?
varus instability
commonly occur with elbow dislocation
fractures at the coronoid base can amplify elbow instability given that anterior bundle of the medial ulnar collateral ligament attaches here
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radial head / neck fracture
rupture of the lateral radial collateral ligament (with possible medial ulnar collateral ligament involved)
posterolateral elbow dislocation
known as the terrible triad needing reoperation and multiple elbow dislocation afterwards
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associated with olecranon fractures
the coronoid process is an important site for what ?
insertion the medial ulnar collateral ligaments esp the anterior bundle
which originates from the medial epicondyle
(there is anterior , posterioir and oblique)
if gets damaged it leads to elbow instability = important for varus stability
insertion of brachilis
etiology of coronoid fracture ?
isolated fracture is less common
occurs as distal humerus is driven against coronoid with an episode of severe varus stress or posterior subluxation
what is the classification of coronoid fracture ?
Regan and morrey classification
type 1 - tip of the coronoid process is fractured
type 2 - less than 50 percent of the coronoid process is fractures
=unstable
give cubital varus or valgus
type 3 - more than 50 percent of the coronoid process is fractures
=very unstable
give cubital varus our valgus
anteromedial facet fracture
anteromedial cornoid compaction fracture
there is also lateral radial collateral ligament tear
also subluxation or luxation of the elbow
POSTEROmedial rotatory deficit
caused by a varus posteromedial rotational injury force
leading to instability in the ulnohumeral joint.
these fractures are usually accompanied by avulsion of the lateral ulnar collateral ligament (LUCL).
------------------------- posteroLATERAL rotatory instability coronoid tip fracture radial head fracture lateral radial collateral ligament -----------------
terrible triad
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olecranon fracture-dislocation
usually associated with a large coronoid fracture
what is the clinical presentation of coronoid fracture ?
(elbow deformity & swelling elbow pain forearm or wrist pain may be a sign of associated injuries ecchymosis & swelling = in all)
varus/valgus instability stress test
varus = for radial collateral or lateral collateral lig instability
valgus = ulnar collateral or medial collateral lig
range of motion not normal such as flexion , extension , supination and pronation
what is the treatment for coronoid fracture ?
type 1 , 2 ,3 if its minimally displaced and stable elbow we breifly immobilise with early range of motion
open reduction and internal fixation medial approach
FOR displacement and persistant elbow instability
for type 1 - cerclage wire
2,3 = retrograde cannulated screws or buttress plate fixation
posteromedial rotatory instability / anteromedial faucet fracture =
open reduction
buttress plate fixation of the coronoid process or pins
and lateral ligament repair
terrible triad - ORIF posterior approach
elbow dislocation = open reduction
coronoid process =
retrograde cannulated screws or buttress plate fixation
radial head open reduction and
herbert screw fixation
or
butters t plate fixation on the posterolateral area the non articulating portion of the radial head
if comminuted - radial head arthroplasty
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olecranon fracture-dislocation
ORIF with posterior approach
what are the complications of coronoid fracture ?
recurrent elbow instability
elbow stiffness
post traumatic arthritis
heterotypic ossification
what causes olecranon fractures ?
high energy injuries in the young - direct blow - comminuted fracture.
low energy falls in the elderly- fall onto the outstreched upper extremity - usually resulting in trasnsvrerse or oblique fractures
what are the muscles associated with the olecranon ?
insertion of the triceps brachi
(innervate by radial nerve) - extensor
anconeus
inserts on the lateral aspect of the olecerenon
innervated by the radial nerve
extensor
what is the classification for the olecranon fracture?
colton classification
non displaced :
is stable
less than 2 mm separation
separation does not increase with elbow flexion
extensor is intact - and will be able to extend
displaced : avulsion fracture oblique or traverse fracture comminuted fracture fracture dislocation
what is the clinical presentation of olecranon fracture ?
unable to extend the elbow because of the tricep extensor mechanism
and palpable defect meaning a displaced fracture
what are the types of x ray used in olecranon fracture ?
true lateral view essential
what is the goal of treatment of olecranon fracture ?
because stiffness is very common
restoration of the articular surface
and the extensor mechanism
maintain elbow stability
what is the treatment for olecranon fracture
non operative :
non displaced fracture
immobilise in flexion at 45-90 degrees put into a splint
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operative
displaced fracture :
transverse fracture with no communition - we can do closed reduction? then :
tension band wiring - with k wires and cerclage wires
engage the anterior cortex of the ulna to prevent wire migration
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or is intramedullary screw - must engage distal intramedullary canal and has to be supplemented with tension wire binding
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comminuted fractures monteggia fractures fracture dislocation oblique fracture - with lag screw open reduction and bridge plate fixation on the dorsal side or buttress plate
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if the fracture involves less than 50 percent of the joint space and if elderly patient and especially if comminuted
and the elbow has to be stable
or nonunion
:
excise the olecerenon fracture and reattach the triceps
salvage procedure that leads to decreased extension strength
when we do tension band wiring in olecranon fractures why do we want to avoid over penetration ?
affect the forearms rotation and injure the anterior interosseous nerve
after the tension band wiring of the olecranon what do we check for ?
patient can perform pronation and supination
what is the effect of the tension band wiring of the olecranon
the force of the tricep which pulls on the olcecron (distraction force ) is converted to compressive force
what is the complication of the tension band wire technique ?
hard ware irritation and prominence
does not provide axial stability
what is the complication of olecranon fracture ?
followed by stiffness of the patient in 50 parent of patients but does not affect the function
post traumatic arthritis
hetertopic ossification
ulnar nerve
anterior interosseous nerve injury
how is the radial head fractured ?
most common elbow fractures
fall on outstretched hand
elbow in extension and forearm in pronation
what are the associated injury of radial head fracture?
lateral collateral complex
injury
(radial collateral , lateral ulna = primary stabilizer to varus and external rotation stress
deficiency results in posterolateral rotatory instability
+ accessory collateral +annular lig )
medial (ulnar) collateral lig injury (three bundles anterior bundle primary stabilizer to valgus stress (radial head is second) posterior bundle transverse bundle
essex lopresti injury - where
there is distal radioulnar joint injury and interosseous membrane injury
and radial head fracture
terrible triad
the radial head gives two type of stability to the elbow which are ?
valgus stability especially if the medial ulnar collateral ligament is insufficient
longitudinal stability - restraint to proximal migration of radius
loss of longitudinal stability occurs with essex lopresti injury
what is the classification of radial head fracture ?
mason classification
non displaced , or minimally displaced less than 2mm - no block to rotation
type 2 - displaced more than 2mm or angulated
possible mechanical block to forearm rotation
type 3 - comminuted and displaced- block to forearm rotation
type 4 - radial head fracture with associated elbow dislocation
what is the clinical presentation of radial head fracture ?
lack of supination and pronation
lack of flexion or extension
elbow stability
lateral pivot shift test (tests LUCL)
valgus stress test (tests MCL)
if essex lopresti injury - palpate wrist for tenderness
palpate interosseous membrane for tenderness
radius pull test - more than 3 mm longitudinal forearm instability
what kind of X-ray view takes for radial head ?
radiocapitellar view (1)
Ap view
LATERAL ELBOW VIEW
what is the treatment for radial head fractures ?
type 1 - SHORT period of immobilisation with early ROM
elbow stiffness with prolonged immobilisation
PLASTER OF PARIS
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open reduction internal fixation
type 2 - herbert screw
or
plate fixation one on the posterolateral area the non articulating portion of the radial head
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type 3
ORIF has shown to have bad results if 3 or more fragments
or greater that 25 percent of the radial head surface is involved
= excision of the fragment and radial head arthroplasty
if less than 3
excision of the head and cut the end of the radius to flat surface , gap between the radius and the capitellum fills with scar tissue - not much force transferred from radial head and capitellum but important that the radius is stable against the ulna for pronation and supination
or plate fixation
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type 4
radial head arthroplasty
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essex lopresti
radial head arthroplasty
percutaneous pinning with k wires of the distal radioulnar joint in supination
why is excision a not good technique ?
exacerbate elbow wrist instability and result in proximal radial head migration
what are the complications of radial head fracture ?
Displacement of fracture
elbow stiffness
posterioir interossues nerve injury
Loss of forearm rotation
radiocapitella joint arthritis
what is the most common elbow joint dislocation ?
posterolateral
what is the cause for posterolateral dislocation
combination of axial loading supination
valgus posterolateral force
what is the classification of elbow dislocation ?
simple - elbow dislocation with no associated fractures
most common
complex
elbow dislocation with other fractures
terrible triad injury
radial head fracture
coronoid tip fracture
and lateral ulnar collateral ligament tear
or posteromedial rotatory instability from anteromedial facet fracture of coronoid
with radial collateral ligament and damage to medial ulnar collateral ligament
and elbow dislocation
what is the treatment for simple stable dislocation ?
closed reduction and splinting at at-least 90 degrees for 10 days and early active range of motion
what is the treatment for complex
posteromedial rotatory instability / anteromedial faucet fracture = open reduction
buttress plate fixation of the coronoid process or pins
and lateral ligament repair
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terrible triad
elbow dislocation = open reduction of the elbow dislocation
coronoid process =
retrograde cannulated screws or plate fixation
radial head
herbert screw
or
plate fixation one on the posterolateral area the non articulating portion of the radial head
if comminuted - radial head arthroplasty
and repair of lateral ulnar collateral ligmant
what are the complication of elbow instability ?
early stiffness - early active ROM prevents this
neuromuscular
brachial artery injury
ulnar nerve
median nerve - branch
recurrent instability
