elbow fracture dislocations adam watts
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Elbow fracture dislocations
Adam C Watts Consultant Elbow and Upper Limb Surgeon, Wrightington
Hospital
Visiting Professor, Manchester University
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Fracture Dislocations
Recognisable patterns of injury
Management plan based on anatomical principles
Consider “hidden” injury
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Elbow fracture dislocations
1.Posterior rotatory a.pronation lateral rotation
b.pronation medial rotation
2.Trans-olecranon a.extension
b.flexion
3.Longitudinal
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Posterior lateral rotation Terrible triad
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O’Driscoll Classification
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from Ring et al.
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Terrible Triad algorithm
Restore coronoid
Restore radial head
Restore lateral soft tissue restraints
Restore medial soft tissue if still unstable
Apply hinged ex-fix
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Arguments around the coronoid?
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O’Driscoll Classification
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Does the coronoid need to be fixed?
Cohort study of 14 consecutive patients (Level 4)
2 Regan-Morrey type I, 12 type 2
No coronoid fixation - Min f/u 24 months
Mean arc of motion 123°
DASH 14
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How do we manage the radial head?
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Radial Head ORIF
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Intracapsular Fracture
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Blood Supply
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Fix or Replace?
No difference in ROM (Level 4)
ORIF more likely to be unstable
33% risk of arthrosis with arthroplasty
Equivalent re-operation rates
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“Hidden” injury
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Medial Collateral Ligament
Not fixing MCL is acceptable (Ring 2007)
Fix if having to go medially
If not leave it alone
Argument for decompression of ulnar nerve
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Timing of fixation
Best results if fixed acutely (within 2 weeks)
Stability and strength can be restored subacutely
ROM better in acute
Earlier treatment is more straightforward (Lindenhovius 2008)
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25 Male PE teacher
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Cat like observation not neglect
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Terrible triad with concentric reduction and small or undisplaced radial head and coronoid fragments
no sign of subluxation on radiographs rapid return to elbow flexion/extension no mechanical block to forearm rotation no neurovascular deficit patient choice
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Outcome Non-Op Management
DASH 8 (Level 4 evidence)
ROM 134°
1/12 required surgery for early instability
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My View
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Fix coronoid if large fragment or anteromedial facet fracture
Fix or replace radial head
Fix lateral soft tissue structures
Fix medial soft tissue structures if still unstable
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Posterior medial rotation Posteromedial rotatory instability
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Transolecranon Monteggia Fracture Dislocations
Proximal ulna fracture with dislocation of radial head from radiocapitellar joint and proximal radioulnar joint
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Bado Classification
Anterior
Posterior
Lateral
Radial diaphyseal fracture
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Jupiter Classification of Type II Fractures
IIa Coronoid level
IIb Metaphyseal/Diaphyseal junction
IIc Distal to coronoid
IId Fracture extending to distal 1/2 ulna
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Ring Classification
Type I Apex anterior diaphyseal ulna fracture with anterolateral dislocation of radiocapitellar and PRUJ
Type II Metaphyseal buckle fractures with anterolateral radiocapitellar dislocation (paediatric only)
Type III Apex posterior ulna fractures with posterior dislocation radiocapitellar joint
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Aims of treatment
Restoration of normal ulna alignment
Restoration of elbow stability
coronoid buttress radial head lateral ligament complex
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Bado I, Ring I
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Jupiter IIb, Ring III
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Jupiter IIa, Ring III
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Longitudinal - Essex-Lopresti
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“Hidden Injury” - IOM
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Load transfer
Prevent radius and ulna bowing
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Role of IOM
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Tightrope Reconstruction
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Bone-ligament-bone graft
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Ligament Augmentation and Reconstruction System (LARS)
Polyester rope
Ultimate stress 2600N
Residual Strain at 2500N = 1.5%
Stiffness = 209N/mm (cf 129 native IOM)
No damage after 5 million cycles
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Experience to date
15 Procedures (chronic injuries) min follow-up 18
months
1 persistent axial instability - revised to OBF
No other recurrent proximal migration
Mean DASH improved 77 to 41/100
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Elbow fracture dislocations
1.Posterior rotatory a.pronation lateral rotation
b.pronation medial rotation
2.Trans-olecranon a.extension
b.flexion
3.Longitudinal
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Terrible TriadPMRI
Ring Type 1Ring Type 3
Essex-Lopresti
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