Trauma - Upper Extremity (Complete) Flashcards
Components of the MCL of the elbow
- Anterior bundle
- Most important for stability (resists valgus)
- Inserts on sublime tubercle (anteromedial facet of coronoid)
- Posterior bundle
- Transverse bundle

Components of the LCL of the elbow
- Lateral ulnar collateral ligament
* Inserts on the supinator crest - Radial collateral ligament
* Inserts on the annular ligament - Annular ligament
* Inserts on the supinator crest - Accessory lateral collateral ligament
* Inserts on the supinator crest

Components of the cubital tunnel
- Roof
- Formed by FCU fascia and Osborne’s ligament
- Travels from the medial epicondyle to the olecranon
- Floor
* Formed by posterior and transverse bands of MCL and elbow joint capsule - Walls
* Formed by medial epicondyle and olecranon

What is/are the classifications for radial head fracture?
[JBJS REVIEWS 2017;5(12):e3]
- Mason
- Type I - Fissure or marginal fractures without displacement
- Type II - Marginal sector fractures with displacement
- Type III - Comminuted fractures involving the whole head of the radius
- Broberg and Morrey
- Type I - displaced <2mm
- Type II - displaced ≥2mm and involving >30% of the radial head
- Type III - comminuted fracture of the radial head
- Type IV - elbow dislocation complicated by any of the above fractures
- Hotchkiss
- Type I - nondisplaced or displaced <2mm without true mechanical block to motion
- Type II - displaced ≥2mm
- Possible mechanical block
- No comminution (ie. amenable to ORIF)
- Type III - severely comminuted and not reconstructible based on radiographic or intraoperative evidence

What injuries are associated with radial head fracture?
- Rupture of MCL
- Capitellum fracture
- Elbow dislocation
- Terrible triad
- Monteggia fracture
- Essex-Lopresti lesions and variants
* AKA Acute radioulnar longitudinal instability - DRUJ injuries
- Carpal injuries
What is the radial head safe zone?
- Nonarticular area of the radial head located posterolateral
- 90-110o arc inline with the radial styloid and lister’s tubercle
- Identified intraoperatively as area of thin cartilage relative to articular portion

What is the treatment of radial head fractures based on fracture displacement and size?
[JBJS REVIEWS 2017;5(12):e3]
Determine the nature of the fracture based on size and displacement
- Undisplaced/minimally displaced fracture (displacement <2mm) OR Displaced and small area of fracture (displacement >2mm and size <33%)
- If no block to motion = treat with early motion
- If block to motion = treat with ORIF (consider fragment excision)
- Displaced and large area of fracture (displacement >2mm and size >33%)
- If reconstructible = treat with ORIF
- Consider radial head arthroplasty
- If not reconstructible = treat with radial head arthroplasty
- If reconstructible = treat with ORIF
What are the contraindications to radial head excision?
- Essex-lopresti lesion
* Defined as radial head fracture plus disruption of the interosseous membrane and DRUJ - Elbow instability
- MCL deficiency
- Coronoid fracture
When performing radial head excision, what should be tested intraoperatively after excision?
[JBJS. 2002 Nov;84-A(11):1970-6.][Journal of Orthopedics 2018; 15(1): 78]
Longitudinal forearm stability
- Radius pull test
- Longitudinal traction applied to proximal radius with clamp (9.1kg) with wrist xray
- >3mm of proximal radial migration indicates IOM disruption
- Radial axial interosseous load (RAIL) test
- Axial load applied through hand and carpus with elbow at 90 degrees
- >3mm of proximal radial migration indicates IOM disruption
- ≥6mm indicates IOM and DRUJ disruption
How many radial head fragments can be present to consider ORIF?
[Tornetta]
≤3 fragments
- If >3, consider arthroplasty
What fixation options are preferred for radial head ORIF?
- One or two countersunk 2.0- or 2.7-mm AO cortical screws perpendicular to the fracture
- Cannulated, headless, resorbable, variable pitched (ie. Biotrak – Acumed)
- AO 2.0- or 2.7-mm mini-plates along the safe zone if fracture extends into the neck
What approach is used for radial head arthroplasty?
[JBJS 2010;92:250-257]
- EDC split if LUCL intact
- Kocher (ECU/anconeus) if LUCL disrupted
* Pronate forearm to protect PIN- Do not dissect distal to radial tuberosity
* Stay above LUCL (above radial head equator)
- Do not dissect distal to radial tuberosity

What is the Mayo classification of olecranon fractures?
[JAAOS 2013;21:149-160]
- Type I = undisplaced
- Type II = displaced but stable
- Type III = displaced but unstable
***Note: each group is subdivided into noncomminuted (A) or comminuted (B)

What is the Schatzker classification for olecranon fractures?
[JAAOS 2013;21:149-160]
- Type A = simple transverse
- Type B = transverse with central articular surface impaction
- Type C = simple oblique
- Type D = comminuted
- Type E = oblique fractures distal to the mid-sigmoid notch
* ‘Oblique distal’ to the greater sigmoid notch - Type F = combined olecranon and radial head fracture
* Often with MCL tear

Which olecranon fractures have intermediate fragments?
[JAAOS 2013;21:149-160]
- Schatzker B+D
- Mayo IIB and IIIB

What is the recommended fixation construct for olecranon fractures based on Schatzker fracture type?
[JAAOS 2013;21:149-160]
- Type A = tension band wire through posterior approach
* Precontoured plates provide greater compressive force than tension band wire - Type B+D = plating with interfragment screws
- Type C+E = plating
- Type F = plating with intefragment screws, radial head and ligament repair

What is the PUDA angle?
[JAAOS 2013;21:149-160]
PUDA = proximal ulna dorsal angulation
- The average PUDA is 6° measured 5cm distal to the tip of the olecranon
- Increased PUDA associated with decreased terminal elbow extension

How do you use the radiocapitellar ratio (RCR) to measure radial head alignment?
[JAAOS 2013;21:149-160]
On a lateral XR, the RCR measurement is the minimal distance between the axis of the radial head and the center of the capitellum, divided by the diameter of the capitellum
- RCR is a valid measurement to assess radial head translation about the capitellum
- Malalignment is an RCR value outside the normal range of -5% to 13%

What is the angulation of the proximal ulna in the coronal plane?
[JAAOS 2013;21:149-160]
Mean varus angulation of 14°+/-4°
- Measured between the axis of the olecranon and axis of the ulna midshaft
What are important considerations in fixation of comminuted olecranon fractures?
[JAAOS 2013;21:149-160]
- Avoid narrowing the greater sigmoid notch
- Obtain anatomic articular reduction with direct visualization of articular surface
- Rigid fixation
- Fixation of fragments should occur from distal to proximal utilizing interfragment screws when possible
- Intermediate fragments can be stabilized with “home run screws”
- Triceps insertion should be reinforced with Krakow stitch in presence of small or comminuted proximal fragments
- When triceps repaird to bone, should be reattached as dorsally as possible to maximize strength
- 24% strength loss still occurs
***Some bone loss can be accepted in the bare area
- Will fill with fibrous tissue as long as posterior cortex is rigidly fixed
Indications for nonoperative treatment of olecranon fractures?
[Rockwood and Green 8th ed. 2015]
- Undisplaced fracture
- Poor surgical candidate
- Displaced fracture in low-demand elderly patient with multiple comorbidities
What are the surgical options for olecranon fractures?
- Olecranon fragment excision and triceps advancement
- Tension band wiring
- Contoured plate
- Intramedullary screw
What are the indications for olecranon fragment excision and triceps advancement?
[Rockwood and Green 8th ed. 2015]
Elderly patients with osteoporosis and/or comminution, involving less than 75% of the olecranon (some sources <50%)
What is the influence of anterior vs. posterior triceps repair following fragment excision and triceps advancement?
[JOT2011;25:420–424]
- Posterior repair = higher triceps extension strength
- Anterior repair = slightly more stable but not statistically significant











































