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5/9/2017
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Elbow Fracture Dislocations: My Algorithm
Charles M. Jobin, MDAssistant Professor of Orthopedic SurgeryResidency Program DirectorShoulder & Elbow SurgeryColumbia UniversityNew York, NY
29th Annual Orthopaedic Trauma CourseFriday May 5th, 2017
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Disclosures
Consultant – Acumed, Wright/Tornier, Zimmer/Biomet
JSES, JBJS, JAAOS, JOR – Reviewer
JAAOS Shoulder/Elbow Deputy Editor
Orthobullets.com – Author
Definition: Fracture-Dislocation of the Elbow• Dislocation• Intra-articular fracture
Elbow Fracture Dislocations
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Not All The Same!
Not All The Same!
Patterns of Elbow Instability with Fracture
TransOlecranonFracture-Dislocations
Posterior MonteggiaVariant
AnteriorRadial head
fracture
Terrible Triad
AnteromedialFacet Coronoid Fracture: VarusInstability
Coronoid fracture
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Dislocation vs. Disruption
Dislocation Disruption
Slide Courtesy or David Ring
Dislocation vs. Disruption
Dislocation Disruption
Slide Courtesy or David Ring
Dislocation vs. Disruption
Dislocation Disruption
Slide Courtesy or David Ring
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Dislocation vs. Disruption
Dislocation Disruption
Slide Courtesy or David Ring
Disruption
Slide Courtesy or David Ring
Posterior Dislocation with Radial Head Fracture
23 patientsExcision of radial head and castINSTABILITY with CORONOID fractures (4 patients)
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Terrible TriadPosterior dislocation Radial head fractureCoronoid fracture
“Terrible Triad”
Ring, Jupiter, Zilberfarb JBJS 200211 patientsRegan and Morrey Type 2 coronoid fractures
7 redislocated in splint or cast5 redislocated after operation
Only 4 patients with satisfactory results
Regan and Morrey
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Terrible Triad
• fixation or replacement of the radial head • fixation of the coronoid fracture if possible, • repair of associated capsular and lateral ligamentous injuries,• Select repair of the medial collateral ligament and/or adjuvant hinged external fixation
48 yo MTerrible Traid
Closed reduction, unstable
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Type 2 Coronoid, Comminuted Radial Head
Terrible Triad Systematic Repair
1) Posterior Universal Incision (vs Lateral Incision)2) Lateral Deep Interval (Kaplan vs Kocher)
…usually bare lateral epicondyle stripped of LUCL3) Radial head fragment removal to access coronoid4) Coronoid ORIF from lateral (screw, sutures, both)
… bail to medial coronoid approach if techincal fail5) Radial head ORIF vs replacement (commonly replaced)6) LUCL repair (always)7) Stability Assessment (repair MUCL if still unstable)8) Static Ex-Fix if still unstable
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4M ROM 10‐135, 75/80
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9 months Post‐Op Terrible Traid
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24 year old M– FOOSH, “no dislocation”, non-displaced coronoid fracture
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24 year old M– FOOSH, “no dislocation”, MRI arthrogram OSH
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90 deg Splint x 3 weeks
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2 months after initial injury, FOOSH, now with dislocation requiring ER reduction
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2 months post op
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2 Months Post-Op
34 yo Male, skateboarding fall, AM Coronoid Fx
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1 32
Varusposteromedial rotational instability
5 months, ROM 5‐140
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Varus Posteromedial Rotational Injuries
Slide Courtesy or David Ring
Inadequate Treatment
Olecranon Fracture-Dislocations/Disruptions
Anterior: Trans-Olecranon FracturePosterior: Posterior Monteggia Variant
ANTERIOR: Trans-Olecranon Fracture-Dislocation
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Principles of Treatment – Trans-Olecranon Fx-Disloc
Fixation of Coronoid Important Fixation of Sublime Tubercle (MCL) and Supinator Crest (LUCL)Restore olecranon articular surface to trochleaContoured dorsal plate to match Proximal Ulnar Diaphyseal Angle “PUDA”Bridge comminution
Surgical Approach to Coronoid?Posterior thru olecranon fracture (like osteotomy)
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Surgical Approach to Coronoid?Medial thru cubittal tunnel floor or FCU split
15 yo Girl, Fall down 2 flights
Trans‐Olecranon Fx‐Dislocation (anterior)
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Trans‐Olecranon Fx‐Dislocation (anterior)Distal Humerus Trochlear Sheer Fx
Work thru Olecranon FxRepair Distal Humerus Fx
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Repair Olecranon Fracture, Elevate depressed segment, and assess MCL/LUCL insertions
3.5M
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2 Years Post‐OP: 5‐145
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52 yo Psychiatrist – fall in AmsterdamTrans‐Olecranon
Posterior Monteggia Variant
Ligaments Likely Intact
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Comminuted Radial Head, Coronoid Intact, Supinator Crest Fracture
2.5months post‐opROM 25‐130, 70/65
1.5 years
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“…my arm feels normal, and I can do everything that I formerly was able to physically accomplish. I am working out on a regular basis…”
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Summery– Trans-Olecranon Fx Dislocation
Fix Coronoid First thur Olecranon FractureFix MCL/LUCL Fx Avulsions:
Sublime Tubercle and Supinator Crest Restore olecranon articular surface to trochlea
Contoured dorsal plate to match Proximal Ulnar Diaphyseal Angle “PUDA”Bridge comminution
Patterns of Elbow Instability with Fracture
TransOlecranonFracture-Dislocations
Posterior
AnteriorRadial head
fracture
Terrible Triad
Varusposteromedial rotational instability
Coronoid fracture
Summary: Elbow Fracture Dislocations
Fx-Dislocation different than Fx-Disruption (trans olec)Recognize the various injury patternsSystematic Approach to Terrible TriadAppreciate Trans-Olec Fx VariantsLCL is more important than the MUCLMUCL will heal if you keep joint concentricEven small coronoid fractures can be a BIG problemWatch out for AM coronoid facet fracture and fix LUCL if Varus unstable
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Thank You!
jobin@columbia.edu
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