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Ulnar ligament is also called asthe
medial collateral ligament. It
prevent abduction of elbow joint. It
cosists of 3 bands: Anterior,
Radial ligament is also called as
the lateral collateral ligament.it
prevent adduction of elbow
• The soft tissue restriants can be divided into
• 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
• Anterior-posterior: trochlea-olecranon
radiocapitellar joint, biceps-triceps-brachialis
• Valgus: the medial collateral ligament
complex:the anterior bundle is primary
stabilizer in flexion & extension, & the anterior
capsule & radiocapitellar joint function in
• Varus:the lateral ulnar collateral ligament is
static & the anconeus muscle is dynamic
--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
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
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
• 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)
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
A complete peripheral neurological examination
should be performed for both motor & sensory
Radial & ulnar pulses should be compared on both
According to direction of displacement of ulna
relative to the humerus
• RESTORATION OF THE INHERENT bony stability is
• 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
• MCL will usually heal properly without any repair
• Treat ment-Simple elbow dislocation.
• Non operative
• Acute simple dislocation should undergo CR
with pt under sedation and adequate
• 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
• 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.
• 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.
• -Direct repair of the ligaments,capsule and
• Static r hinged external fixator application,
• Cross pining of the joint .
• Temporary bridge plating of the elbow
• 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
• 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
• 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.
• Tech of external fixator
• A hinged fixator will allow for range of motion.
static fixator r easier to apply and r more widely
• 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
• Open pin placement is recommended to avoid
injury to radial nerve.
• 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
• 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.
• 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
• 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..
• 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
• 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
• 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
• 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
• late complications 1/stiffness 2/heterotopic ossification
3/unreduced dislocation 4/recurrent dislocation
5/osteoarthritis after sever fracture dislocation.
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
MECHANISM OF INJURY
(1) FALL ON OUTSTRECHED HAND(MOST COMMON)
(2)VALGUS INJURY TO ELBOW/DIRECT INJURY
• RANGE OF MOTION RESTRICTION
• ACTIVE FINGER EXTENSION
• FOREARM/INTEROSSI MEMBRANE
• WRIST TENDERNESS ESSEX LAPROSTI
CLASSIFICATION OF RADIAL HEAD
Minimally displaced fx, no
mechanical blockto rotation,
Displaced fx >2mm or angulated,
possible mechanical block to
Comminuted and displaced fx,
mechanical block to motion
Radial head fracture with elbow
• CORRECTION OF ANY BLOCK TO FOREARM
• EARLY ROM OF ELBOW AND FOREARM
• STABILITY OF ELBOW AND FOREARM
• PREVENTION OF SECONDARY OSTEOARTHROSIS
NON OPERATIVE TREATMENT
-----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
OPEN REDUCTION & INTERNAL
• 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
• Presence of other complex ipsilateral elbow
injuries(without metaphyseal bone loss)
• 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
COMPLICATION OF ORIF
• PIN INJURY
• HARDWARE FAILURE
• HARDWARE IMPINGEMENT
• STIFFNESS OF ELBOW
• RESTRICTION OF SUPINATIONPRONATION
• 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 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.
RADIAL HEAD REPLACEMENT
• Extensive communition of radial
head/excess bone loss
• Elbow instability:
• essex lapresti lesion
• coronoid fracture,
• elbow dislocation,
• collateral ligament injury,
• olecranon fracture
RADIAL HEAD REPLACEMENT
• LOOSE STEMMED PROSTHESIS
• THAT ACTS AS A STIFF SPACER
• That is cemented into the neck of
• Overstuffing of joint
• capitellar wear problems
• Malalignment instability
COMPLICATION OF REPLACEMENT
• Post operative infection of implant
• Ulnar nerve/pin injury
• Immediate post operative dislocation
• Recurrent instability
• Heterotrophic ossification
• Contracture /stiffness
RADIAL HEAD EXCISION
• Low demand, sedentary patients
• In a delayed setting for continued pain of an isolated radial
• In children
• Presence of destabilizing injuries (Essex-lopresti
lesion,fracture dislocation elbow(mason type 4),monteggia)
• Terrible triad of elbow(coronoid fracture,MCL deficiency)
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
• Terrible triad
– Radial head fx
– Post dislocation
– Coronoid fx
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
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
-Posterior surface has olecranon fossa.
• 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
• This is normal carrying in males is 7-9 degrees
and female it is 9-11 degree.
• CLINICAL EVALUATION
• Swelling and displacement.
• Normal relationship of the olecranon, medial, and lateral
condyles should be maintained, roughly delineating an
• 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
• 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
Extension type – m/c
For nondisplaced or minimally displaced fractures, as well as for
severely comminuted fractures in elderly patients with limited functional
■ 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
■ 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
• Operative- Indicated in
Inability to maintain acceptable reduction
■ 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
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.
• Occur primarily in elderly patients with osteopenia
- 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.
- 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
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
• Mechanism of Injury---- Force is directed against the
posterior aspect of an elbow flexed >90 degrees, thus
driving the ulna into the trochlea.
• Type I: Nondisplaced.
• Type II: slight
displacement with no
rotation between the
condylar fragment in
the frontal plane
• Type III: Displacement
• Type IV: Severe
comminution of the
Riseborough and Radin Classification
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.
For displaced reconstructible fractures.
Goals of fixation are to restore articular congruity
and to secure the supracondylar component.
• Methods of fixation include:
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
Total elbow arthroplasty (cemented,
semiconstrained): This may be considered in markedly
comminuted fractures and with fractures in osteoporotic
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
Anatomic restoration of articular congruity is
essential to maintain the normal elbow arc of motion
and to minimize the risk of posttraumatic arthritis.
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,
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.
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
Cubitus varus with inadequate reduction or failure of
Fractures of the Olecranon
The subcutaneous position of olecranon
makes it vulnerable to direct trauma.
Younger individuals: High-energy trauma
Older individuals: Simple falls
Mechanism of injury
• Direct: Fall on the point of elbow or direct trauma to
– Typically results in a comminuted olecranon fracture.
• Indirect: Fall onto the outstretched upper extremity
accompanied by a strong, sudden contraction of
– 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.
• 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
• Associated ulnar nerve injury is possible, esp.
with comminuted fractures resulting from
• True lateral radiograph:
• extent of the fracture
• degree of comminution
• degree of articular surface
• displacement of the radial
head, if present.
• AP view:
–This should be evaluated to
exclude associated fractures or
–The distal humerus may
obscure osseous details of the
• Type I: nondisplaced or minimally displaced:
– Subcategories: Noncomminuted (IA); Comminuted
– Treatment: Nonoperative.
• Type II: displaced proximal fragment without
• IIA: noncomminuted, can be treated by tension band
• IIB: comminuted & require plate fixation.
– Treatment: Operative.
• Type III: features instability of the ulnohumeral
– Treatment: Operative.
(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
• Restoration of articular surface
• Restoration & preservation of elbow
• Restoration of elbow motion &
prevention of stiffness
• Prevention of complications
• Immobilization in a long arm
cast with the elbow in 45-
90° of flexion is favored by
• In reliable patients a
posterior splint or orthosis
with gradual initiation of
ROM after 5-7 days may be
• Follow-up radiographs should be
obtained within 5-7 days after
treatment to rule out fracture
• 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°.
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,
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.
Tension band wiring
• Commonly used for
• 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
• Various techniques have been
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
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.
• Currently, the accessibility and
ease of cannulated screw
systems have made
intramedullary screw fixation an
attractive treatment option.
• Indications for intramedullary
– Similar to tension band wiring.
– Include simple,
• 6.5-mm cancellous lag screw
• The screw must be of
sufficient length to engage
the distal intramedullary
canal for adequate fixation.
• This may be used in
conjunction with tension
• Other forms of intramedullary
fixation have also been
– Interlocking intramedullary
nailing devices have been
created to treat simple,
transverse olecranon fractures.
Plate and screws
• Plating has become an increasingly
important method of treating displaced
Plate and screws
• Although plate fixation can be used for virtually
any type of olecranon fracture, it is ideal for the
– 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.
Plate and screws
• Low-profile, locking
precontoured plates are
• Standard manually
limited contact DCPs are
Plate and screws
• Plate fixation allows neutralization of forces
across the fracture site and should provide
adequate rigid internal fixation to begin early
• 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
• Articular step-off of > 2 mm has been
associated with poorer results.
Total Elbow Arthroplasty
–Total elbow arthroplasty may be considered
in elderly patients with significant
comminution and > 60% articular
• The patient should be placed in a
posterior elbow splint.
• With a stable repair, initiate early ROM
• In cases with severe soft tissue injury,
early motion may need to be delayed
until the soft tissue healing is adequate
to tolerate motion.
• 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