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British Medical Books Health Issues Computerized Tomography

Elbow Fracture Dislocations

  • one of the most inherently stable articulations of the skeleton
  • dislocation without a fracture –> early mobilization after closed reduction is associated with a low risk of redislocation
  • osseous or articular structures disrupted >> risk of recurrent or chronic instability & arthrosis

Components That Contribute to Stability of the Elbow

  • functional requirements of the elbow
    • spatial positioning of the hand and the need f
    • sufficient stability to allow for the manipulation of heavy objects, throwing & bearing weight
  • flexion & extension (ulnohumeral jt.) – alters length of strut holding the hand away from the trunk
  • rotational motion occurs at the proximal & distal radio-ulnar joints

Preserve the stability of the elbow

  • anterior tilt of the ulno-trochlear articulation
  • deep trochlear notch with a prominent coronoid process
  • inter-digitation of a ridge in the trochlear notch with a groove in the trochlea
  • maintenance of the force-transferring role of the radius

Osseous and Articular Components

distal articular surface of the humerus tilted 30° anteriorly ulno-humeral articular surface

    • shape & contour enhance stability
    • antero-posterior stability & also to varus-valgus & rotatory stability
  • remainder of the resistance is contributed by capsulo-ligamentous structures
  • # of olecranon or coronoid process occurs with a fracture-dislocation of the elbow –> stability depends on anatomical restoration of the trochlear notch

Fracture of the coronoid process

    • inherent stability of the trochlear notch
    • anterior band of the medial collateral ligament attaches near the base

Radial head

    • contributes to stability and force transmission across the elbow joint
    • resistance to valgus stress
    • articulation between the radial head & capitellum (lateral osseous column of elbow) is essential in maintaining stability of the elbow when the collateral ligaments are damaged

Capsulo-ligamentous Components

Medial collateral ligament complex

    • posterior and transverse bundles - subtle thickenings in the capsule
    • anterior bundle is stronger structure - provides 1/3rd resistance to valgus stress

Lateral collateral ligament complex

    • originates from the lateral epicondyle
    • inserts onto the annular ligament & directly onto the ulna
    • ulnar (more NB) & radial
    • resistance to posterolateral rotatory instability

Musculo-tendinous Components

  • muscles crossing the elbow joint also contribute to its stability

Patterns of Injury

  • thesis of Helm
    • patterns of fracture-dislocation categorized according to the extent of the disruption of the capsular ligaments & injury to the osseous & articular components
    • structural ring with anterior, posterior, medial and lateral columns
    • more components of the ring inured >> risk of recurrent or chronic instability

Anterior Column

    • coronoid process
    • brachialis muscle
    • anterior aspect of capsule

Lateral Column

    • radial head
    • capitellum
    • lateral collateral ligament complex

Medial Column

    • medial collateral ligament
    • coronoid process
    • medial condyle/eplcondyle

Posterior Column

    • olecranon process
    • triceps muscle
    • posterior aspect of capsule

Ligamentous injuries

  • can occur with simple dislocation as well as with dislocation associated with #
  • complete capsulo-ligamentous disruption is associated with most posterior or postero-lateral dislocations
  • closed reduction can usually restore sufficient stability of the elbow to allow early active mobilisation
  • instability & arthrosis uncommon
  • intrinsic stability to the elbow by the osseous and articular components of the articulation is sufficient to ensure healing and restoration of function of the capsulo-ligamentous stabilizers
  • persistent instability following closed reduction of a dislocation may be related to soft-tissue interposition or entrapment of a chondral or osteochondral fragment in the joint
    • stability should be re-evaluated with the forearm in pronation (>> tension on lateral ST constraints)
  • early mobilisation
    • pain, stiffness & instability more common in the elbows that had been immobilised for > 2/52

Injuries of the Ligaments and the Radial Head

  • more energy involved
  • no contact compression of the radial head against the capitellum > compromise the ability of the lateral and medial collateral ligament complexes to heal with physiological tension
  • treatment of a fracture-dislocation of the elbow with excision of the radial head without prosthetic replacement can lead to problems

Modified Mason’s classification system

  • for fractures of the radial head

Type I

    • small marginal #s
    • minimally displaced (< 2mm)
    • do not restrict rotation of the forearm

Type II

    • larger two-part #s displaced > 2mm
    • any fracture that restricts rotation of the forearm
    • amenable to operative fixation

Type III

    • #s so comminuted that operative fixation is not possible
    • This scheme is
  • useful in directing the treatment of fracture-dislocations of the elbow
    • Type I #s - rarely need surgery
    • Type II fractures –> ORIF
    • Type III fractures –> resection & replacement with a prosthesis to restore lateral column
  • goal of operative fixation –> anatomical reduction & secure fixation of the radial head
  • be prepared to resect the radial head & replace it with a prosthesis

Replacement of the radial head

  • viable option type-III fracture
  • silicone prosthesis
    • not rigid enough to restore support to the lateral column
    • better results than simple resection
    • often need to be removed d/t fragmentation & synovitis
    • after healing of the ligaments is ensured (> 6/12)
  • prostheses made of various types of metal
  • osteo-articular allograft - experimental

Stability of the elbow assessed

  • after repair or replacement of radial head
  • moving the joint through a full ROM
  • if re-dislocates at > 30° of flexion - re-evaluated after lateral collateral ligament complex repaired
  • if still unstable –> hinged distractor (Orthofix ext. fix.)

Injuries of the Ligaments, Radial Head and Coronoid Process

  • terrible triad of the elbow by Hotchkiss
  • threat of recurrent and chronic instability, post-traumatic arthrosis

Regan and Morrey classification of coronoid fracture

  • Type I
    • a small marginal fragment
  • Type II
    • bigger fragment
    • not including insertion of anterior bundle of medial collateral ligament
  • Type III
    • fragment including insertion
  • ORIF for larger #s
  • rarely possible for smaller fractures
  • fixation achieved with a small screw, a wire or non-absorbable suture
  • hinged distractor if still instability after all repair

Injuries of the Ligaments, Radial Head, Coronoid Process & Olecranon

  • # olecranon adds to the complexity of traumatic instability of the elbow
  • large coronoid process #s (Regan & Morrey type III) common
  • requires stable anatomical fixation of both olecranon & coronoid process

2 types

  • anterior or trans-olecranon fracture-dislocation of the elbow
    • high-energy direct blow applied to the dorsal aspect of the forearm with elbow in mid-flexion
    • distinguished from Monteggia lesions –> both radius & ulna dislocate anteriorly & remain associated
    • anatomical fixation of the ulna with restoration of the trochlear notch restores stability
  • posterior Monteggia lesions
    • fracture of the ulna with dislocation of the proximal radio-ulnar joint in a posterior direction
    • fractures of the radial head are common
    • anatomical reduction olecranon & coronoid processes #s and re-alignment of the bones of the forearm effecting stable reduction of the proximal RUJ

Complications and their Treatment

Chronic instability

    • reconstruction of a chronically unstable elbow is extremely difficult if the instability related to articular malalignment or loss of bone
    • reconstruction - reinforcement of coronoid process with a bone block or deepening of trochlear notch
    • healing structures protected with a hinged elbow distractor

Stiffness of the Elbow

    • immobilization > 2/52 in dislocation without # –> risk of a stiff painful elbow
    • dislocation with #s –> stable fixation & early active mobilisation

Heterotopic Ossification

  • risk factors
    • trauma
    • injury to CNS
    • severe burn
    • patient-related factors such as gender, age & genetics
    • forceful manipulation
  • prophylactic Rx
    • Indocid 25 mg 6/52
    • irradiation
  • excise if
    • traumatic- if bone mature on x-ray (6/12)
    • CNS injury - if spastic, wait until spasticity resolves

Arthrosis

  • more common with complex #-dislocations, high energy injuries

Rx

  • total elbow replacement
  • fascial arthroplasty