Intra- articular elbow fractures - , capitellum fracture ,olecranon, radial head / elbow dislocations

Question 1

what type of joint is the elbow ?

Answer 1

ulnohumeral joint - it is a hinged joint (between the ulnar and the trochlea)

radiocapitellar - pivot joint - 60 recent of load transfer

Question 2

what does the capitellum articulate with ?

Answer 2

the proximal radius

Question 3

what causes capitellum fractures ?

Answer 3

low energy fall on outstretched hand

direct axial compression with the elbow in a semi flexed position creates shear forces

Question 4

capitallum fracture are usually in what plane ?

Answer 4

coronal plane (1)

Question 5

capitellum fractures are difficult in the lateral elbow view so how can we know ?

Answer 5

elbow effusion and displacement of the fat pad may indicate radial head fracture or capitellum

Question 6

what is the classification used for capitellum fracture ?

Answer 6

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

Question 7

how do we treate the capitellum fracture according to bryan morrey classification ?

Answer 7

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

Question 8

capitellar fracture on diagnosis ?

Answer 8

double bubble on LATERAL elbow x ray (2)

the arch which is lower represents the capitulum and the arch which is above the trochlea

Question 9

what are the complication of capitellum fractures ?

Answer 9

elbow stiffness - most common

nonunion with ORIF

ulnar nerve injury

hetertopic ossification (ORIF)

AVN of capitellum

instability of elbow

post traumatic arthritis

cubital valgus

Question 10

coronoid fracture is associated with ?

Answer 10

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

Question 11

the coronoid process is an important site for what ?

Answer 11

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

Question 12

etiology of coronoid fracture ?

Answer 12

isolated fracture is less common

occurs as distal humerus is driven against coronoid with an episode of severe varus stress or posterior subluxation

Question 13

what is the classification of coronoid fracture ?

Answer 13

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).

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 posteroLATERAL rotatory instability
coronoid tip fracture
radial head fracture
lateral radial collateral ligament
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terrible triad

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olecranon fracture-dislocation
usually associated with a large coronoid fracture

Question 14

what is the clinical presentation of coronoid fracture ?

Answer 14

(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

Question 15

what is the treatment for coronoid fracture ?

Answer 15

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

Question 16

what are the complications of coronoid fracture ?

Answer 16

recurrent elbow instability

elbow stiffness

post traumatic arthritis

heterotypic ossification

Question 17

what causes olecranon fractures ?

Answer 17

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

Question 18

what are the muscles associated with the olecranon ?

Answer 18

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

Question 19

what is the classification for the olecranon fracture?

Answer 19

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

Question 20

what is the clinical presentation of olecranon fracture ?

Answer 20

unable to extend the elbow because of the tricep extensor mechanism

and palpable defect meaning a displaced fracture

Question 21

what are the types of x ray used in olecranon fracture ?

Answer 21

true lateral view essential

Question 22

what is the goal of treatment of olecranon fracture ?

Answer 22

because stiffness is very common
restoration of the articular surface
and the extensor mechanism
maintain elbow stability

Question 23

what is the treatment for olecranon fracture

Answer 23

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

Question 24

when we do tension band wiring in olecranon fractures why do we want to avoid over penetration ?

Answer 24

affect the forearms rotation and injure the anterior interosseous nerve

Question 25

after the tension band wiring of the olecranon what do we check for ?

Answer 25

patient can perform pronation and supination

Question 26

what is the effect of the tension band wiring of the olecranon

Answer 26

the force of the tricep which pulls on the olcecron (distraction force ) is converted to compressive force

Question 27

what is the complication of the tension band wire technique ?

Answer 27

hard ware irritation and prominence

does not provide axial stability

Question 28

what is the complication of olecranon fracture ?

Answer 28

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

Question 29

how is the radial head fractured ?

Answer 29

most common elbow fractures

fall on outstretched hand
elbow in extension and forearm in pronation

Question 30

what are the associated injury of radial head fracture?

Answer 30

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

Question 31

the radial head gives two type of stability to the elbow which are ?

Answer 31

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

Question 32

what is the classification of radial head fracture ?

Answer 32

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

Question 33

what is the clinical presentation of radial head fracture ?

Answer 33

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

Question 34

what kind of X-ray view takes for radial head ?

Answer 34

radiocapitellar view (1)
Ap view
LATERAL ELBOW VIEW

Question 35

what is the treatment for radial head fractures ?

Answer 35

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

Question 36

why is excision a not good technique ?

Answer 36

exacerbate elbow wrist instability and result in proximal radial head migration

Question 37

what are the complications of radial head fracture ?

Answer 37

Displacement of fracture

elbow stiffness

posterioir interossues nerve injury

Loss of forearm rotation

radiocapitella joint arthritis

Question 38

what is the most common elbow joint dislocation ?

Answer 38

posterolateral

Question 39

what is the cause for posterolateral dislocation

Answer 39

combination of axial loading supination

valgus posterolateral force

Question 40

what is the classification of elbow dislocation ?

Answer 40

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

Question 41

what is the treatment for simple stable dislocation ?

Answer 41

closed reduction and splinting at at-least 90 degrees for 10 days and early active range of motion

Question 42

what is the treatment for complex

Answer 42

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

Question 43

what are the complication of elbow instability ?

Answer 43

early stiffness - early active ROM prevents this

neuromuscular
brachial artery injury
ulnar nerve
median nerve - branch

recurrent instability