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dislocations & fractures of Elbow in adults

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fractures and dislocations of elbow

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dislocations & fractures of Elbow in adults

  1. 1. Dislocation & Fracture of Elbow in Adults
  2. 2. Bone of elbow Humerus Radius Ulna
  3. 3. Bony part The elbow joint is a modified hinge joint The 3 separate articulations are Ulnotrochlear(hinge) Radocapitellar(rotation) Proximal radioulnar(rotation)
  4. 4. Ligaments 1- radial collateral lig. 2- anular lig. Of radius 3- ulnar collateral lig. 4- transverse lig.
  5. 5. Ulnar ligament is also called asthe medial collateral ligament. It prevent abduction of elbow joint. It cosists of 3 bands: Anterior, posterior, Transverse. Radial ligament is also called as the lateral collateral ligament.it prevent adduction of elbow
  6. 6. • The soft tissue restriants can be divided into -static stabilizers & -dynamic stabilizers • Static stabilizers include : joint capsule LCL & MCLs • Dynamic stabilizers include: biceps, brachialis & ticeps -these provide compressive stability to the elbow due to their joint reactive forces & they are particularly important when the static stabilizers have been injured.
  7. 7. • Stability • Anterior-posterior: trochlea-olecranon fossa(extension),coronoid fossa, radiocapitellar joint, biceps-triceps-brachialis (flexion) • Valgus: the medial collateral ligament complex:the anterior bundle is primary stabilizer in flexion & extension, & the anterior capsule & radiocapitellar joint function in extension • Varus:the lateral ulnar collateral ligament is static & the anconeus muscle is dynamic
  8. 8. --Two sits of movements occur in the region of elbow A-flexion and extension . at the elbow joint B-pronation and supination . At Superior radio-ulnar joint Flexors muscle- 1/brachialis 2/biceps 3/brachio-radialis 4/flexore of forearm Extensors muscle -1/triceps 2/anconeus Pronator- 1/pronator teres 2/pronator quadratus Supinators- 1/biceps 2/supinator. --- Normal range of motion:0 to 150 degrees flexion, 85 degrees supination & 80 degrees pronation ---Functional range of motion: a 100 degrees arc, 30 to 130 degrees flexion, 50 dregrees supination & 50 degrees pronation
  9. 9. Movement of elbow
  10. 10. Dislocation of the elbow Dislocation of ulnohumeral joint Mechanism of injury -Most commonly injury is caused by fall onto an out stretched hand or elbow, resulting in levering force to unlock the olecranon from the trochlea combined with translation of articular surfaces to produce the dislocation
  11. 11. • Posterior dislocation:this is a combination of elbow hyperextention, valgus stress, arm abduction and forearm supination • Anterior dislocation:a direct force strikes the posterior forearm with elbow in flexed position • Most elow dislocations & fracture dislocations result in injury to all capsuloligamentous stabilizers of elbow joint • The capsuloligamentous injury progresses from lateral to medial ( HORI CIRCLE)
  12. 12. Signs and Symptoms Patients with fractures and dislocations of the elbow present with varying degrees of pain, swelling, and ecchymosis. In many cases, there is also instability, crepitation, and deformity With the elbow flexed at 90 degrees,the medial & lateral epicondyles & olecranon process should from isosceles triangle. A complete peripheral neurological examination should be performed for both motor & sensory functions Radial & ulnar pulses should be compared on both sides
  13. 13. CLASSIFICATON According to direction of displacement of ulna relative to the humerus • Posterior • Posterolateral • Posteromedial • Lateral • Medial • Anterior
  14. 14. TREATMENT PRINCIPLES • RESTORATION OF THE INHERENT bony stability is goal • Restoration of trochear notch of ulna, particularly the coronoid process. • Radiocapitellar contact is very important to the stability of injured elbow. • The LCL is more important than MCL in setting of most cases of traumatic elbow instability. • The trochear notch(coronoid & OLECRANON),RADIAL HEAD ,LCL should be repaired • MCL will usually heal properly without any repair
  15. 15. • Treat ment-Simple elbow dislocation. • Non operative • Acute simple dislocation should undergo CR with pt under sedation and adequate analgesia. • Correction of medial r lateral displacement followed by longitudal traction and flexsion is usually sucessesfull for post dislocation • For post dislocation,reduction should be performed with elbow flexed while providing distal traction.
  16. 16. • Parvin’s method of CR of an elbow dislocation-the pt lie prone on a stretcher and the physician applies gentle downward traction of the wrist for few min,as the olecranon begin to slip distally,the physician lift up gentely on the arm.
  17. 17. • In Meyn and Quigley’s method of reduction - only the forearm hangs from the side of the stretcher .as gentle downward traction is applied on the wrist,the physican gudies the reduction of olecranon with the opposite hand.
  18. 18. -Surgical repair- • -Direct repair of the ligaments,capsule and m/s. • Static r hinged external fixator application, • Cross pining of the joint . • Temporary bridge plating of the elbow
  19. 19. Approach • Posterior midline incision is employed and full thickness lateral flap is elevated on deep fasia.in some dislocations thr is visible disruption of the lateral fascia and muscular orgin from the injury itself.however if thr is not , then a fascial incision is made through kocher interval b/w anconeus and ecu for the exposure of lcl. • If the medial structures require repair , full thickness elevation of medial flap is performed and ulnar nerve is identified and protected but not transposed. • An alternative approach is to make paired medial and lateral skin incision if post skin quality is not suitable
  20. 20. • Tech of soft tissue repair • The lcl can be repaired using tranosseous bone tunnels r suture anchors,a single drill hole is placed at the center of the flexsion –extension axis located at the center of arc of curvature of the capitulum. • 2 drill holes on then placed on the post column of lat supra condylar ridge. • shuttle sutures r placed through the drill holes . • The sutures r tensioned by maintaining the forearm in pronation and elbow at 90` of flexsion,avoid over tensioning of lateral ligaments if the mcl is deficient as medial gaping of elbow can occur. • Reduction is verified both clinically and fluoroscopically.
  21. 21. • If the elbow remains unstable inspite of repair to lateral structures the medial side of the elbow is approached with care taken to protect the ulnar nerve. • Repair of mcl is performed using drill holes located at the ant inferior aspect of medial epicondyle and 2 holes more proximally. • If the elbow is still unstable then an ext fixator should be placed.
  22. 22. • Tech of external fixator • A hinged fixator will allow for range of motion. static fixator r easier to apply and r more widely available. • The frame is left in place for 4-6weeks.the elbow is placed in 90`of flexsion with jt concentrically reduced.2 pins r placed in the humeral shaft laterally and 2 pins in ulnar shaft laterally in a position that allows fore arm rotation. • Open pin placement is recommended to avoid injury to radial nerve.
  23. 23. • Tech for cross pins r screws • The elbow is concentrically reduced and screw r pin is placed around the post aspect of ulna ,across the jt ,exiting on the post border of the humerus. • 4.5mm cortical screw r shaft screw is apporate. • The elbow is placed into a cast for 3-4 wks,and the screw is then removed.
  24. 24. • Tech of bridge plate • Indicated in where maintaince of reduction is challenging such as morbid obesity ,pt with neurologic injury such as spasticity and flaccid paralysis. • A narrow 4.5mm large fragment locking plate is bend to 90` . • A tricep’s splitting approach is employed proximally to identify and protect the radial nerve.3-4 locking screws r placed in ulna and distal humerus avoiding the articulation and fossae. • After 4 wks.post capsulectomy and elbow manipulation can be considered at the time of plate removal to increase the recovery of motion..
  25. 25. • Post-op care- • The pt is placed in a well padded lite splint with the elbow at 90`in flexsion and forearm in pronation.elbow should not be immobilized for longer than 1 week.active motion is preffered over passive motion as this tends to stabilize the elbow . • If the mcl is intact and lcl requires protection then the forearm should be in pronation with prosupination only performed at 90` flexsion .varus position of the arm is avoided in lcl injuries. • If the mcl is injured and lcl is competent then flexion and extension should be performed with forearm maintained in supination. • If both mcl and lcl r injured active range of motion should be initiated with forearm in neutral position. • Passive stretching of the elbow is not performed until ligament healing is progressing,typically beginning 6wks post oply
  26. 26. Complications • vascular injury of brachial artery may occur but with a lesser frequency than in cases of supracondylar fracture . • nerve injury . the medial ulnar nerve may be affected .c/myositis ossification ,which is more common if passive exercise is inflicted on the patient. • Recurrent of the dislocation may occur if the bony , ligamentous, and muscular support structure are disrupted sufficeintly. • late complications 1/stiffness 2/heterotopic ossification 3/unreduced dislocation 4/recurrent dislocation 5/osteoarthritis after sever fracture dislocation.
  27. 27. Fractures OF THE ELBOW • Fractures of distal end of the humerus • Fracture of proximal end of radius • Fracture of the proximal of the ulna • Avulsion fracture – Avulsion of the epiphysis of the medial epicondyle – Avulsion fracture of the epiphysis of the lateral epicondyle
  28. 28. RADIAL HEAD FRACTURE
  29. 29. MECHANISM OF INJURY (1) FALL ON OUTSTRECHED HAND(MOST COMMON) (2)VALGUS INJURY TO ELBOW/DIRECT INJURY CLINICAL ELEVALUTION • SWELLING • ECCHMOSIS • RANGE OF MOTION RESTRICTION • STABILITY • ACTIVE FINGER EXTENSION • FOREARM/INTEROSSI MEMBRANE TENDERNESS • WRIST TENDERNESS ESSEX LAPROSTI INJURY
  30. 30. CLASSIFICATION OF RADIAL HEAD FRACTURE Mason classification Type I Minimally displaced fx, no mechanical blockto rotation, intra-articular displacement <2mm Type II Displaced fx >2mm or angulated, possible mechanical block to forearm rotation Type III Comminuted and displaced fx, mechanical block to motion Type IV (Hotchkiss/JOH NSTON modification OF TYPE 3) Radial head fracture with elbow dislocation
  31. 31. TREATMENT • CORRECTION OF ANY BLOCK TO FOREARM ROTATION • EARLY ROM OF ELBOW AND FOREARM • STABILITY OF ELBOW AND FOREARM • PREVENTION OF SECONDARY OSTEOARTHROSIS OF ELBOW
  32. 32. NON OPERATIVE TREATMENT • INDICATION: -----ISOLATED RADIAL HEAD FRACTURE WITH MASON TYPE 1 (UNDISPLACED <2MM) PLASTER SLAB FOR 3 WEEKS EARLY ACTIVE MOBILIZATION OF ELBOW • PERSISTANT PAIN.INFLAMMATION,CONTRACTURE SUSPECT CAPITELLAR FRACTURE
  33. 33. OPERATIVE MANAGEMENT OPEN REDUCTION & INTERNAL FIXATION • INDICATION FOR ORIF: • Mason type II with mechanical block(displaced) • Large fragment >2 mm • Mason type III where ORIF feasible(>3 FRAGMENT POOR OUTCOME) • Mechanical block to motion (lignocaine inj in elbow joint) • Presence of other complex ipsilateral elbow injuries(without metaphyseal bone loss)
  34. 34. • Isolated Partial Radial Head Fractures • displaced partial radial head fracture (Mason II) - block to motion. This can be assessed by lidocaine injection into the elbow joint. • In displacement greater than 2 mm of a large fragmen • A lateral (Kocher or Kaplan) exposure with the patient positioned supine and the arm placed on a hand table can be used to approach the radial head; this approach uses the interval between the anconeus and extensor carpi ulnaris. One should take care to protect the uninjured lateral collateral ligament complex. Hardware should be placed only within the 90-degree arc between the radial styloid and the Lister tubercle (safe zone) • The anterolateral aspect of the radial head is usually involved and is readily exposed through these intervals. • After the fragment has been reduced, it is stabilized using one or two small screws
  35. 35. Safe Zone
  36. 36. COMPLICATION OF ORIF • PIN INJURY • HARDWARE FAILURE • HARDWARE IMPINGEMENT • STIFFNESS OF ELBOW • RESTRICTION OF SUPINATIONPRONATION
  37. 37. • Prosthetic Replacement • To prevent proximal migration of the radius. • Long-term studies of fracture-dislocations and Essex– Lopresti lesions demonstrated poor function with silicone implants • Silicone implants- silicone synovitis • Metallic (titanium, Vitallium) radial head implants have been used with increasing frequency and are the prosthetic implants of choice in the unstable elbow. • A major problem with a metal radial head prosthesis is oversizing the radial head implant and thus potentially “overstuffing” the joint.
  38. 38. RADIAL HEAD REPLACEMENT • Indication: • Extensive communition of radial head/excess bone loss • Elbow instability: • essex lapresti lesion • coronoid fracture, • elbow dislocation, • collateral ligament injury, • olecranon fracture
  39. 39. RADIAL HEAD REPLACEMENT PROSTHESIS • LOOSE STEMMED PROSTHESIS • THAT ACTS AS A STIFF SPACER
  40. 40. BIPOLAR PROSTHESIS • That is cemented into the neck of the radius • COMPLICATIONS: • Overstuffing of joint • capitellar wear problems • Malalignment instability
  41. 41. COMPLICATION OF REPLACEMENT • Post operative infection of implant • Ulnar nerve/pin injury • Immediate post operative dislocation • Recurrent instability • Heterotrophic ossification • Contracture /stiffness
  42. 42. RADIAL HEAD EXCISION • INDICATION: • Low demand, sedentary patients • In a delayed setting for continued pain of an isolated radial head fracture • CONTRAINDICATION: • In children • Presence of destabilizing injuries (Essex-lopresti lesion,fracture dislocation elbow(mason type 4),monteggia) • Terrible triad of elbow(coronoid fracture,MCL deficiency)
  43. 43. COMPLICATION OF EXCISION • PROXIMAL MIGRATION OF RADIUS • INFERIOR RADIO ULNAR JOINT DISTURBANCE • PAIN & WEAKNESS OF WRIST • Joint instability • Decreased strength • Cubitus valgus • EXCESSIVE PROXIMAL MIGRATION REQUIRE RADIO ULNAR SYNOSTOSIS.
  44. 44. • Terrible triad – Radial head fx – Post dislocation – Coronoid fx
  45. 45. Regan & Morrey classification Based on size of fragment ■ Type I, avulsion of the tip of the coronoid process ■ Type II, a single or comminuted fragment involving 50% of the coronoid process or less ■ Type III, a single or comminuted fragment involving >50% of the process
  46. 46. treatment Treatment
  47. 47. Fractures of distal end of the Humerus
  48. 48. Distal humerus is a cylindrical diaphysis that flattens above the elbow and diverges into triangular medial and lateral columns. -The articulating surface of the medial condyle is called as trochlea -Similarly the articulation surface of the lateral condyle is capitellum. -Anterior surface has two fossa the coronoid and radial fossa -Posterior surface has olecranon fossa.
  49. 49. • The carrying angle: a line drawn from the long axis of the arm and forearm forms an angle, with elbow in extension and forearm in supination. • This is normal carrying in males is 7-9 degrees and female it is 9-11 degree.
  50. 50. • CLASSIFICATION • Supracondylar fractures • Transcondylar fractures – m/c in adults with osteopenia • Intercondylar fractures – m/c • Condylar fractures - m/c in pediatric • Capitellum fractures • Trochlea fractures - RARE • Lateral epicondylar fracture • Medial epicondylar fracture
  51. 51. • CLINICAL EVALUATION • Swelling and displacement. • Normal relationship of the olecranon, medial, and lateral condyles should be maintained, roughly delineating an equilateral triangle. • Crepitus with range of motion • A careful neurovascular evaluation is essential because the sharp, fractured end of the proximal fragment may impale or contuse the brachial artery, median nerve, or radial nerve. • Serial neurovascular examinations with compartment pressure monitoring may be necessary with massive swelling; cubital fossa swelling may result in vascular impairment or the development of a volar compartment syndrome.
  52. 52. Supracondylar fractures Extension type – m/c Flexion type Treatment Nonoperative For nondisplaced or minimally displaced fractures, as well as for severely comminuted fractures in elderly patients with limited functional ability. ■ A posterior long arm splint is placed in at least 90 degrees of elbow flexion if swelling and neurovascular status permit, with the forearm in neutral. ■ Posterior splint immobilization is continued for 1 to 2 weeks, after which range-of-motion exercises are initiated in a hinged brace. The splint or brace may be discontinued after approximately 6 weeks, when radiographic evidence of healing is present. ■ Frequent radiographic evaluation is necessary to detect loss of fracture reduction.
  53. 53. • Operative- Indicated in Displaced fractures Vascular injury Open fracture Inability to maintain acceptable reduction Implant options ■ Plate fixation Plate fixation is used on each column, either in parallel or 90 degrees from one another. Use of locked plates has gained in popularity and affords much better metaphyseal fixation than conventional no nlocked plates. Parallel plating has been shown to be biomechanically superior to orthogonal plating for distal fractures. Use of parallel plating allows for longer length screws directed from lateral to medial than a posterolateral plate in which screw length is limited by the anterior articular surface. ■ Total elbow replacement Indicated in elderly patients with a severely comminuted fracture of the distal humerus deemed unreconstructable Use of elbow arthroplasty requires lifelong restriction of 5 kg weight bearing in that ar ----- Range of motion exercises should be initiated as soon as the patient is able to tolerate therapy.
  54. 54. Transcondylar Fractures • Occur primarily in elderly patients with osteopenia • Treatment Nonoperative - Indicated for nondisplaced or minimally displaced fractures or in elderly patients who are debilitated and functioning poorly. - Range-of-motion exercises should be initiated as soon as the patient is able to tolerate therapy. Operative - For open fractures, unstable fractures, or displaced fractures. - Open reduction and plate fixation are the preferred treatment. Precontoured locked plates should be utilized in order to enhance fixation in this usually osteopenic fracture pattern. - Total elbow arthroplasty (semiconstrained) may be considered in the elderly patient with good preinjury functional status if fixation cannot be obtained
  55. 55. Intercondylar Fractures – M/C TYPE • Comminution is common. • Fracture fragments are often displaced by unopposed muscle pull at the medial (flexor mass) and lateral (extensor mass) epicondyles, which rotate the articular surfaces. • Mechanism of Injury---- Force is directed against the posterior aspect of an elbow flexed >90 degrees, thus driving the ulna into the trochlea.
  56. 56. • Type I: Nondisplaced. • Type II: slight displacement with no rotation between the condylar fragment in the frontal plane • Type III: Displacement with rotation. • Type IV: Severe comminution of the articula surface. Riseborough and Radin Classification
  57. 57. • Nonoperative For nondisplaced fractures, elderly patients with displaced fractures and severe osteopenia and comminution, or patients with significant comorbid conditions precluding operative management. Nonoperative options for displaced fractures include: • Cast immobilization • “Bag of bones”: The arm is placed in a collar and cuff with as much flexion as possible after initial reduction is attempted; gravity traction helps effect reduction. • The idea is to obtain a painless “pseudarthrosis,” which allows for motion.
  58. 58. • Operative For displaced reconstructible fractures. Goals of fixation are to restore articular congruity and to secure the supracondylar component. • Methods of fixation include: Interfragmentary screws Dual plate fixation: one plate medially and another plate placed posterolaterally, 90 degrees from the medial plate or two plates on either column, 180 degrees from one another Total elbow arthroplasty (cemented, semiconstrained): This may be considered in markedly comminuted fractures and with fractures in osteoporotic bone.
  59. 59. Condylar Fractures Rare in adults and more common in the pediatric age. TYPES - 1) Medial condyle fractures: These include the trochlea and medial epicondyle 2)Lateral condyle fractures: These include the capitellum and lateral epicondyle • Mechanism of Injury Abduction or adduction of the forearm with elbow extension • Milch Classification Two types are designated for medial and lateral condylar fractures; the key is the lateral trochlear ridge Type I:Lateral trochlear ridge left intact Type II:Lateral trochlear ridge part of the condylar fragment (medial or lateral
  60. 60. Milch classification
  61. 61. Milch classification
  62. 62. • Treatment Anatomic restoration of articular congruity is essential to maintain the normal elbow arc of motion and to minimize the risk of posttraumatic arthritis. Nonoperative For nondisplaced or minimally displaced fractures or for patients with displaced fractures who are not considered candidates for operative treatment. This consists of posterior splinting with the elbow flexed to 90 degrees and the forearm in supination or pronation for lateral or medial condylar fractures, respectively.
  63. 63. • Operative Indicated for open or displaced fractures. Consists of screw fixation with or without collateral ligament repair if necessary. • Prognosis depends on: The degree of comminution The accuracy of reduction The stability of internal fixation • Range-of-motion exercises should be instituted as soon as the patient can tolerate therapy.
  64. 64. • Complications Lateral condyle fractures: Improper reduction or failure of fixation may result in cubitus valgus and tardy ulnar nerve palsy requiring nerve transposition. Medial condyle fractures: Residual incongruity is more problematic owing to involvement of the trochlear groove. These may result in: Posttraumatic arthritis, especially with fractures involving the trochlear groove Ulnar nerve symptoms with excess callus formation or malunion Cubitus varus with inadequate reduction or failure of fixation
  65. 65. complications Early complications: • Vascular injury • Nerve injury • Malunion • Wound infection Delayed complications • Heterotrophic ossification • Elbow stiffness • osteoarthritis
  66. 66. Fractures of the Olecranon The subcutaneous position of olecranon makes it vulnerable to direct trauma. Bimodal distribution: Younger individuals: High-energy trauma Older individuals: Simple falls
  67. 67. Mechanism of injury • Direct: Fall on the point of elbow or direct trauma to olecranon. – Typically results in a comminuted olecranon fracture. • Indirect: Fall onto the outstretched upper extremity accompanied by a strong, sudden contraction of triceps. – Typically results in a transverse or oblique fracture. • A combination of these may produce displaced, comminuted fractures, or, in cases of extreme violence, fracture-dislocation with anterior displacement of the distal ulnar fragment and radial head.
  68. 68. Clinical Presentation • Patients typically present with the upper extremity supported by the contralateral hand with the elbow in relative flexion. • Abrasions over olecranon or hand • Palpable defect at fracture site • Inability to extend the elbow actively against gravity indicates discontinuity of triceps mechanism • Associated ulnar nerve injury is possible, esp. with comminuted fractures resulting from high-energy injuries.
  69. 69. Radiographic Evaluation • True lateral radiograph: –Demonstrates: • extent of the fracture • degree of comminution • degree of articular surface involvement • displacement of the radial head, if present.
  70. 70. Radiographic Evaluation • AP view: –This should be evaluated to exclude associated fractures or dislocations. –The distal humerus may obscure osseous details of the olecranon fracture.
  71. 71. Mayo Classification • Type I: nondisplaced or minimally displaced: – Subcategories: Noncomminuted (IA); Comminuted (IB). – Treatment: Nonoperative. • Type II: displaced proximal fragment without elbow instability: – Subcategories: • IIA: noncomminuted, can be treated by tension band wire fixation. • IIB: comminuted & require plate fixation. – Treatment: Operative. • Type III: features instability of the ulnohumeral joint. – Treatment: Operative.
  72. 72. Schatzker classification (Based on Fracture Pattern) • Transverse: Occurs at apex of sigmoid notch. Usually represents an avulsion fracture. • Transverse-impacted: A direct force leads to comminution & depression of articular surface. • Oblique: results from hyperextension injury; it begins at midpoint of sigmoid notch and runs distally. • Comminuted fractures with associated injuries: result from direct high-energy trauma; fractures of coronoid process may lead to instability. • Oblique-distal: Fractures extend distal to the coronoid & compromise elbow stability. • Fracture-dislocation: usually associated with severe trauma.
  73. 73. Treatment objectives • Restoration of articular surface • Restoration & preservation of elbow extensor mechanism • Restoration of elbow motion & prevention of stiffness • Prevention of complications
  74. 74. Nonoperative Treatment • Indications: –nondisplaced fractures –displaced fractures in poorly functioning older individuals
  75. 75. Nonoperative Treatment • Immobilization in a long arm cast with the elbow in 45- 90° of flexion is favored by many authors. • In reliable patients a posterior splint or orthosis with gradual initiation of ROM after 5-7 days may be used. • Follow-up radiographs should be obtained within 5-7 days after treatment to rule out fracture displacement.
  76. 76. Nonoperative Treatment • Osseous union is usually not complete until 6-8 weeks. • In general, there is adequate fracture stability at 3 weeks to remove the cast and to allow protected ROM exercises, avoiding flexion past 90°.
  77. 77. Operative Treatment • Indications: –Disruption of extensor mechanism (any displaced fracture) –Articular incongruity –Open fractures
  78. 78. Principles of Surgical Treatment • Rigid fixation is required. a) Plate fixation: • Often the best choice, esp. when comminution is present, to maintain ulnar length and alignment. • A number of plate fixation techniques have been described, most involving a contoured posterior or lateral plate with, when possible, interfragmentary screws. b) In addition to internal fixation, use of an external fixation device or distraction device can be helpful or necessary to maintain joint congruity while allowing an early motion program.
  79. 79. Surgical options Tension band wiring • Commonly used for noncomminuted, transverse olecranon fractures. • Tension band wiring in combination with 2 parallel K-wires counteracts the tensile forces & converts them to compressive forces and is indicated for avulsion-type olecranon fractures. • Various techniques have been described.
  80. 80. Surgical options Tension band wiring Standard AO technique: • This technique uses 2 intramedullary K-wires and a figure-of-eight wire with a single knot. • To avoid proximal migration and hardware prominence, the K-wires can be directed anteriorly to engage the ulnar cortex at the base of the coronoid. a) This provides stronger fixation than the usual intramedullary placement of the K-wires. b) Some concerns have been raised over the potential for neurovascular injury with this technique, although no reports of such injuries could be found.
  81. 81. Surgical options Intramedullary fixation • Currently, the accessibility and ease of cannulated screw systems have made intramedullary screw fixation an attractive treatment option. • Indications for intramedullary screw placement: – Similar to tension band wiring. – Include simple, noncomminuted transverse fracture patterns.
  82. 82. Surgical options Intramedullary fixation • 6.5-mm cancellous lag screw fixation. • The screw must be of sufficient length to engage the distal intramedullary canal for adequate fixation. • This may be used in conjunction with tension band wiring.
  83. 83. Surgical options Intramedullary fixation • Other forms of intramedullary fixation have also been introduced. – Interlocking intramedullary nailing devices have been created to treat simple, transverse olecranon fractures.
  84. 84. Surgical options Plate and screws • Plating has become an increasingly important method of treating displaced olecranon fractures.
  85. 85. Surgical options Plate and screws • Although plate fixation can be used for virtually any type of olecranon fracture, it is ideal for the following indications: – comminuted olecranon fractures – Monteggia fracture-dislocations – olecranon fracture-dislocations • A plate should also be for oblique fractures and for fractures that extend distal to the coronoid.
  86. 86. Surgical options Plate and screws • Low-profile, locking precontoured plates are now available. • Standard manually contoured 3.5-mm limited contact DCPs are also available.
  87. 87. Surgical options Plate and screws • Plate fixation allows neutralization of forces across the fracture site and should provide adequate rigid internal fixation to begin early motion. • Interfragmentary compression screws should be utilized when possible. • Augmentation with an external fixation or distraction device may be beneficial when elbow stability is lacking despite fracture fixation. • Articular step-off of > 2 mm has been associated with poorer results.
  88. 88. Surgical options Total Elbow Arthroplasty • Indications: –Total elbow arthroplasty may be considered in elderly patients with significant comminution and > 60% articular involvement.
  89. 89. Postoperative management • The patient should be placed in a posterior elbow splint. • With a stable repair, initiate early ROM exercises. • In cases with severe soft tissue injury, early motion may need to be delayed until the soft tissue healing is adequate to tolerate motion.
  90. 90. Complications • Hardware failure (1%-5%). • Infection (0%-6%). • Pin migration (15%). • Ulnar neuritis (2%-12%). • Heterotopic ossification (2%-13%). • Nonunion (5%). • Decreased ROM (Stiffness): may complicate up to 50% of cases. Loss of elbow extension is most common.

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