elbow fracture dislocations adam watts
TRANSCRIPT
![Page 1: Elbow fracture dislocations adam watts](https://reader031.vdocuments.us/reader031/viewer/2022012318/58ececac1a28ab544d8b470f/html5/thumbnails/1.jpg)
Elbow fracture dislocations
Adam C Watts Consultant Elbow and Upper Limb Surgeon, Wrightington
Hospital
Visiting Professor, Manchester University
1
![Page 2: Elbow fracture dislocations adam watts](https://reader031.vdocuments.us/reader031/viewer/2022012318/58ececac1a28ab544d8b470f/html5/thumbnails/2.jpg)
www.wrightington.com
92 F Active
2
![Page 3: Elbow fracture dislocations adam watts](https://reader031.vdocuments.us/reader031/viewer/2022012318/58ececac1a28ab544d8b470f/html5/thumbnails/3.jpg)
www.wrightington.com
Fracture Dislocations
Recognisable patterns of injury
Management plan based on anatomical principles
Consider “hidden” injury
3
![Page 4: Elbow fracture dislocations adam watts](https://reader031.vdocuments.us/reader031/viewer/2022012318/58ececac1a28ab544d8b470f/html5/thumbnails/4.jpg)
www.wrightington.com
Elbow fracture dislocations
1.Posterior rotatory a.pronation lateral rotation
b.pronation medial rotation
2.Trans-olecranon a.extension
b.flexion
3.Longitudinal
4
![Page 5: Elbow fracture dislocations adam watts](https://reader031.vdocuments.us/reader031/viewer/2022012318/58ececac1a28ab544d8b470f/html5/thumbnails/5.jpg)
www.wrightington.com
Posterior lateral rotation Terrible triad
5
![Page 6: Elbow fracture dislocations adam watts](https://reader031.vdocuments.us/reader031/viewer/2022012318/58ececac1a28ab544d8b470f/html5/thumbnails/6.jpg)
www.wrightington.com6
![Page 7: Elbow fracture dislocations adam watts](https://reader031.vdocuments.us/reader031/viewer/2022012318/58ececac1a28ab544d8b470f/html5/thumbnails/7.jpg)
www.wrightington.com7
O’Driscoll Classification
12
3
from Ring et al.
![Page 8: Elbow fracture dislocations adam watts](https://reader031.vdocuments.us/reader031/viewer/2022012318/58ececac1a28ab544d8b470f/html5/thumbnails/8.jpg)
www.wrightington.com
Terrible Triad algorithm
Restore coronoid
Restore radial head
Restore lateral soft tissue restraints
Restore medial soft tissue if still unstable
Apply hinged ex-fix
8
![Page 9: Elbow fracture dislocations adam watts](https://reader031.vdocuments.us/reader031/viewer/2022012318/58ececac1a28ab544d8b470f/html5/thumbnails/9.jpg)
www.wrightington.com9
Arguments around the coronoid?
![Page 10: Elbow fracture dislocations adam watts](https://reader031.vdocuments.us/reader031/viewer/2022012318/58ececac1a28ab544d8b470f/html5/thumbnails/10.jpg)
www.wrightington.com10
![Page 11: Elbow fracture dislocations adam watts](https://reader031.vdocuments.us/reader031/viewer/2022012318/58ececac1a28ab544d8b470f/html5/thumbnails/11.jpg)
www.wrightington.com11
![Page 12: Elbow fracture dislocations adam watts](https://reader031.vdocuments.us/reader031/viewer/2022012318/58ececac1a28ab544d8b470f/html5/thumbnails/12.jpg)
www.wrightington.com12
O’Driscoll Classification
![Page 13: Elbow fracture dislocations adam watts](https://reader031.vdocuments.us/reader031/viewer/2022012318/58ececac1a28ab544d8b470f/html5/thumbnails/13.jpg)
www.wrightington.com13
![Page 14: Elbow fracture dislocations adam watts](https://reader031.vdocuments.us/reader031/viewer/2022012318/58ececac1a28ab544d8b470f/html5/thumbnails/14.jpg)
www.wrightington.com14
![Page 15: Elbow fracture dislocations adam watts](https://reader031.vdocuments.us/reader031/viewer/2022012318/58ececac1a28ab544d8b470f/html5/thumbnails/15.jpg)
www.wrightington.com
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
15
![Page 16: Elbow fracture dislocations adam watts](https://reader031.vdocuments.us/reader031/viewer/2022012318/58ececac1a28ab544d8b470f/html5/thumbnails/16.jpg)
www.wrightington.com16
![Page 17: Elbow fracture dislocations adam watts](https://reader031.vdocuments.us/reader031/viewer/2022012318/58ececac1a28ab544d8b470f/html5/thumbnails/17.jpg)
www.wrightington.com17
![Page 18: Elbow fracture dislocations adam watts](https://reader031.vdocuments.us/reader031/viewer/2022012318/58ececac1a28ab544d8b470f/html5/thumbnails/18.jpg)
www.wrightington.com
How do we manage the radial head?
18
![Page 19: Elbow fracture dislocations adam watts](https://reader031.vdocuments.us/reader031/viewer/2022012318/58ececac1a28ab544d8b470f/html5/thumbnails/19.jpg)
www.wrightington.com19
![Page 20: Elbow fracture dislocations adam watts](https://reader031.vdocuments.us/reader031/viewer/2022012318/58ececac1a28ab544d8b470f/html5/thumbnails/20.jpg)
www.wrightington.com
Radial Head ORIF
20
![Page 21: Elbow fracture dislocations adam watts](https://reader031.vdocuments.us/reader031/viewer/2022012318/58ececac1a28ab544d8b470f/html5/thumbnails/21.jpg)
www.wrightington.com21
![Page 22: Elbow fracture dislocations adam watts](https://reader031.vdocuments.us/reader031/viewer/2022012318/58ececac1a28ab544d8b470f/html5/thumbnails/22.jpg)
www.wrightington.com22
![Page 23: Elbow fracture dislocations adam watts](https://reader031.vdocuments.us/reader031/viewer/2022012318/58ececac1a28ab544d8b470f/html5/thumbnails/23.jpg)
www.wrightington.com
Intracapsular Fracture
23
![Page 24: Elbow fracture dislocations adam watts](https://reader031.vdocuments.us/reader031/viewer/2022012318/58ececac1a28ab544d8b470f/html5/thumbnails/24.jpg)
www.wrightington.com
Blood Supply
24
![Page 25: Elbow fracture dislocations adam watts](https://reader031.vdocuments.us/reader031/viewer/2022012318/58ececac1a28ab544d8b470f/html5/thumbnails/25.jpg)
www.wrightington.com25
![Page 26: Elbow fracture dislocations adam watts](https://reader031.vdocuments.us/reader031/viewer/2022012318/58ececac1a28ab544d8b470f/html5/thumbnails/26.jpg)
www.wrightington.com26
![Page 27: Elbow fracture dislocations adam watts](https://reader031.vdocuments.us/reader031/viewer/2022012318/58ececac1a28ab544d8b470f/html5/thumbnails/27.jpg)
www.wrightington.com27
![Page 28: Elbow fracture dislocations adam watts](https://reader031.vdocuments.us/reader031/viewer/2022012318/58ececac1a28ab544d8b470f/html5/thumbnails/28.jpg)
www.wrightington.com28
![Page 29: Elbow fracture dislocations adam watts](https://reader031.vdocuments.us/reader031/viewer/2022012318/58ececac1a28ab544d8b470f/html5/thumbnails/29.jpg)
www.wrightington.com29
![Page 30: Elbow fracture dislocations adam watts](https://reader031.vdocuments.us/reader031/viewer/2022012318/58ececac1a28ab544d8b470f/html5/thumbnails/30.jpg)
www.wrightington.com
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
30
![Page 31: Elbow fracture dislocations adam watts](https://reader031.vdocuments.us/reader031/viewer/2022012318/58ececac1a28ab544d8b470f/html5/thumbnails/31.jpg)
www.wrightington.com
“Hidden” injury
31
![Page 32: Elbow fracture dislocations adam watts](https://reader031.vdocuments.us/reader031/viewer/2022012318/58ececac1a28ab544d8b470f/html5/thumbnails/32.jpg)
www.wrightington.com
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
32
![Page 33: Elbow fracture dislocations adam watts](https://reader031.vdocuments.us/reader031/viewer/2022012318/58ececac1a28ab544d8b470f/html5/thumbnails/33.jpg)
www.wrightington.com
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)
33
![Page 34: Elbow fracture dislocations adam watts](https://reader031.vdocuments.us/reader031/viewer/2022012318/58ececac1a28ab544d8b470f/html5/thumbnails/34.jpg)
www.wrightington.com
25 Male PE teacher
34
![Page 35: Elbow fracture dislocations adam watts](https://reader031.vdocuments.us/reader031/viewer/2022012318/58ececac1a28ab544d8b470f/html5/thumbnails/35.jpg)
www.wrightington.com35
![Page 36: Elbow fracture dislocations adam watts](https://reader031.vdocuments.us/reader031/viewer/2022012318/58ececac1a28ab544d8b470f/html5/thumbnails/36.jpg)
www.wrightington.com36
![Page 37: Elbow fracture dislocations adam watts](https://reader031.vdocuments.us/reader031/viewer/2022012318/58ececac1a28ab544d8b470f/html5/thumbnails/37.jpg)
www.wrightington.com
Cat like observation not neglect
37
![Page 38: Elbow fracture dislocations adam watts](https://reader031.vdocuments.us/reader031/viewer/2022012318/58ececac1a28ab544d8b470f/html5/thumbnails/38.jpg)
www.wrightington.com
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
38
![Page 39: Elbow fracture dislocations adam watts](https://reader031.vdocuments.us/reader031/viewer/2022012318/58ececac1a28ab544d8b470f/html5/thumbnails/39.jpg)
www.wrightington.com
Outcome Non-Op Management
DASH 8 (Level 4 evidence)
ROM 134°
1/12 required surgery for early instability
39
![Page 40: Elbow fracture dislocations adam watts](https://reader031.vdocuments.us/reader031/viewer/2022012318/58ececac1a28ab544d8b470f/html5/thumbnails/40.jpg)
www.wrightington.com
My View
40
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
![Page 41: Elbow fracture dislocations adam watts](https://reader031.vdocuments.us/reader031/viewer/2022012318/58ececac1a28ab544d8b470f/html5/thumbnails/41.jpg)
www.wrightington.com 41
![Page 42: Elbow fracture dislocations adam watts](https://reader031.vdocuments.us/reader031/viewer/2022012318/58ececac1a28ab544d8b470f/html5/thumbnails/42.jpg)
www.wrightington.com 42
![Page 43: Elbow fracture dislocations adam watts](https://reader031.vdocuments.us/reader031/viewer/2022012318/58ececac1a28ab544d8b470f/html5/thumbnails/43.jpg)
www.wrightington.com43
Posterior medial rotation Posteromedial rotatory instability
![Page 44: Elbow fracture dislocations adam watts](https://reader031.vdocuments.us/reader031/viewer/2022012318/58ececac1a28ab544d8b470f/html5/thumbnails/44.jpg)
www.wrightington.com44
![Page 45: Elbow fracture dislocations adam watts](https://reader031.vdocuments.us/reader031/viewer/2022012318/58ececac1a28ab544d8b470f/html5/thumbnails/45.jpg)
www.wrightington.com45
![Page 46: Elbow fracture dislocations adam watts](https://reader031.vdocuments.us/reader031/viewer/2022012318/58ececac1a28ab544d8b470f/html5/thumbnails/46.jpg)
www.wrightington.com46
![Page 47: Elbow fracture dislocations adam watts](https://reader031.vdocuments.us/reader031/viewer/2022012318/58ececac1a28ab544d8b470f/html5/thumbnails/47.jpg)
www.wrightington.com47
![Page 48: Elbow fracture dislocations adam watts](https://reader031.vdocuments.us/reader031/viewer/2022012318/58ececac1a28ab544d8b470f/html5/thumbnails/48.jpg)
www.wrightington.com 48
![Page 49: Elbow fracture dislocations adam watts](https://reader031.vdocuments.us/reader031/viewer/2022012318/58ececac1a28ab544d8b470f/html5/thumbnails/49.jpg)
www.wrightington.com 49
![Page 50: Elbow fracture dislocations adam watts](https://reader031.vdocuments.us/reader031/viewer/2022012318/58ececac1a28ab544d8b470f/html5/thumbnails/50.jpg)
www.wrightington.com 50
![Page 51: Elbow fracture dislocations adam watts](https://reader031.vdocuments.us/reader031/viewer/2022012318/58ececac1a28ab544d8b470f/html5/thumbnails/51.jpg)
www.wrightington.com 51
![Page 52: Elbow fracture dislocations adam watts](https://reader031.vdocuments.us/reader031/viewer/2022012318/58ececac1a28ab544d8b470f/html5/thumbnails/52.jpg)
www.wrightington.com52
Transolecranon Monteggia Fracture Dislocations
Proximal ulna fracture with dislocation of radial head from radiocapitellar joint and proximal radioulnar joint
![Page 53: Elbow fracture dislocations adam watts](https://reader031.vdocuments.us/reader031/viewer/2022012318/58ececac1a28ab544d8b470f/html5/thumbnails/53.jpg)
www.wrightington.com
Bado Classification
Anterior
Posterior
Lateral
Radial diaphyseal fracture
53
![Page 54: Elbow fracture dislocations adam watts](https://reader031.vdocuments.us/reader031/viewer/2022012318/58ececac1a28ab544d8b470f/html5/thumbnails/54.jpg)
www.wrightington.com
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
54
![Page 55: Elbow fracture dislocations adam watts](https://reader031.vdocuments.us/reader031/viewer/2022012318/58ececac1a28ab544d8b470f/html5/thumbnails/55.jpg)
www.wrightington.com
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
55
![Page 56: Elbow fracture dislocations adam watts](https://reader031.vdocuments.us/reader031/viewer/2022012318/58ececac1a28ab544d8b470f/html5/thumbnails/56.jpg)
www.wrightington.com
Aims of treatment
Restoration of normal ulna alignment
Restoration of elbow stability
coronoid buttress radial head lateral ligament complex
56
![Page 57: Elbow fracture dislocations adam watts](https://reader031.vdocuments.us/reader031/viewer/2022012318/58ececac1a28ab544d8b470f/html5/thumbnails/57.jpg)
www.wrightington.com
Bado I, Ring I
57
![Page 58: Elbow fracture dislocations adam watts](https://reader031.vdocuments.us/reader031/viewer/2022012318/58ececac1a28ab544d8b470f/html5/thumbnails/58.jpg)
www.wrightington.com58
![Page 59: Elbow fracture dislocations adam watts](https://reader031.vdocuments.us/reader031/viewer/2022012318/58ececac1a28ab544d8b470f/html5/thumbnails/59.jpg)
www.wrightington.com59
![Page 60: Elbow fracture dislocations adam watts](https://reader031.vdocuments.us/reader031/viewer/2022012318/58ececac1a28ab544d8b470f/html5/thumbnails/60.jpg)
www.wrightington.com
Jupiter IIb, Ring III
60
![Page 61: Elbow fracture dislocations adam watts](https://reader031.vdocuments.us/reader031/viewer/2022012318/58ececac1a28ab544d8b470f/html5/thumbnails/61.jpg)
www.wrightington.com61
![Page 62: Elbow fracture dislocations adam watts](https://reader031.vdocuments.us/reader031/viewer/2022012318/58ececac1a28ab544d8b470f/html5/thumbnails/62.jpg)
www.wrightington.com62
Jupiter IIa, Ring III
![Page 63: Elbow fracture dislocations adam watts](https://reader031.vdocuments.us/reader031/viewer/2022012318/58ececac1a28ab544d8b470f/html5/thumbnails/63.jpg)
www.wrightington.com63
![Page 64: Elbow fracture dislocations adam watts](https://reader031.vdocuments.us/reader031/viewer/2022012318/58ececac1a28ab544d8b470f/html5/thumbnails/64.jpg)
www.wrightington.com64
![Page 65: Elbow fracture dislocations adam watts](https://reader031.vdocuments.us/reader031/viewer/2022012318/58ececac1a28ab544d8b470f/html5/thumbnails/65.jpg)
www.wrightington.com65
![Page 66: Elbow fracture dislocations adam watts](https://reader031.vdocuments.us/reader031/viewer/2022012318/58ececac1a28ab544d8b470f/html5/thumbnails/66.jpg)
www.wrightington.com66
![Page 67: Elbow fracture dislocations adam watts](https://reader031.vdocuments.us/reader031/viewer/2022012318/58ececac1a28ab544d8b470f/html5/thumbnails/67.jpg)
www.wrightington.com67
![Page 68: Elbow fracture dislocations adam watts](https://reader031.vdocuments.us/reader031/viewer/2022012318/58ececac1a28ab544d8b470f/html5/thumbnails/68.jpg)
www.wrightington.com68
![Page 69: Elbow fracture dislocations adam watts](https://reader031.vdocuments.us/reader031/viewer/2022012318/58ececac1a28ab544d8b470f/html5/thumbnails/69.jpg)
www.wrightington.com69
![Page 70: Elbow fracture dislocations adam watts](https://reader031.vdocuments.us/reader031/viewer/2022012318/58ececac1a28ab544d8b470f/html5/thumbnails/70.jpg)
www.wrightington.com70
Longitudinal - Essex-Lopresti
![Page 71: Elbow fracture dislocations adam watts](https://reader031.vdocuments.us/reader031/viewer/2022012318/58ececac1a28ab544d8b470f/html5/thumbnails/71.jpg)
www.wrightington.com71
![Page 72: Elbow fracture dislocations adam watts](https://reader031.vdocuments.us/reader031/viewer/2022012318/58ececac1a28ab544d8b470f/html5/thumbnails/72.jpg)
www.wrightington.com72
![Page 73: Elbow fracture dislocations adam watts](https://reader031.vdocuments.us/reader031/viewer/2022012318/58ececac1a28ab544d8b470f/html5/thumbnails/73.jpg)
www.wrightington.com
“Hidden Injury” - IOM
73
![Page 74: Elbow fracture dislocations adam watts](https://reader031.vdocuments.us/reader031/viewer/2022012318/58ececac1a28ab544d8b470f/html5/thumbnails/74.jpg)
www.wrightington.com
Load transfer
Prevent radius and ulna bowing
74
Role of IOM
![Page 75: Elbow fracture dislocations adam watts](https://reader031.vdocuments.us/reader031/viewer/2022012318/58ececac1a28ab544d8b470f/html5/thumbnails/75.jpg)
www.wrightington.com75
![Page 76: Elbow fracture dislocations adam watts](https://reader031.vdocuments.us/reader031/viewer/2022012318/58ececac1a28ab544d8b470f/html5/thumbnails/76.jpg)
www.wrightington.com76
![Page 77: Elbow fracture dislocations adam watts](https://reader031.vdocuments.us/reader031/viewer/2022012318/58ececac1a28ab544d8b470f/html5/thumbnails/77.jpg)
www.wrightington.com77
![Page 78: Elbow fracture dislocations adam watts](https://reader031.vdocuments.us/reader031/viewer/2022012318/58ececac1a28ab544d8b470f/html5/thumbnails/78.jpg)
www.wrightington.com78
![Page 79: Elbow fracture dislocations adam watts](https://reader031.vdocuments.us/reader031/viewer/2022012318/58ececac1a28ab544d8b470f/html5/thumbnails/79.jpg)
www.wrightington.com79
![Page 80: Elbow fracture dislocations adam watts](https://reader031.vdocuments.us/reader031/viewer/2022012318/58ececac1a28ab544d8b470f/html5/thumbnails/80.jpg)
www.wrightington.com
Tightrope Reconstruction
80
![Page 81: Elbow fracture dislocations adam watts](https://reader031.vdocuments.us/reader031/viewer/2022012318/58ececac1a28ab544d8b470f/html5/thumbnails/81.jpg)
www.wrightington.com81
![Page 82: Elbow fracture dislocations adam watts](https://reader031.vdocuments.us/reader031/viewer/2022012318/58ececac1a28ab544d8b470f/html5/thumbnails/82.jpg)
www.wrightington.com
Bone-ligament-bone graft
82
![Page 83: Elbow fracture dislocations adam watts](https://reader031.vdocuments.us/reader031/viewer/2022012318/58ececac1a28ab544d8b470f/html5/thumbnails/83.jpg)
www.wrightington.com83
![Page 84: Elbow fracture dislocations adam watts](https://reader031.vdocuments.us/reader031/viewer/2022012318/58ececac1a28ab544d8b470f/html5/thumbnails/84.jpg)
www.wrightington.com84
![Page 85: Elbow fracture dislocations adam watts](https://reader031.vdocuments.us/reader031/viewer/2022012318/58ececac1a28ab544d8b470f/html5/thumbnails/85.jpg)
www.wrightington.com
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
85
![Page 86: Elbow fracture dislocations adam watts](https://reader031.vdocuments.us/reader031/viewer/2022012318/58ececac1a28ab544d8b470f/html5/thumbnails/86.jpg)
www.wrightington.com86
![Page 87: Elbow fracture dislocations adam watts](https://reader031.vdocuments.us/reader031/viewer/2022012318/58ececac1a28ab544d8b470f/html5/thumbnails/87.jpg)
www.wrightington.com
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
87
![Page 88: Elbow fracture dislocations adam watts](https://reader031.vdocuments.us/reader031/viewer/2022012318/58ececac1a28ab544d8b470f/html5/thumbnails/88.jpg)
www.wrightington.com
Elbow fracture dislocations
1.Posterior rotatory a.pronation lateral rotation
b.pronation medial rotation
2.Trans-olecranon a.extension
b.flexion
3.Longitudinal
88
Terrible TriadPMRI
Ring Type 1Ring Type 3
Essex-Lopresti
![Page 89: Elbow fracture dislocations adam watts](https://reader031.vdocuments.us/reader031/viewer/2022012318/58ececac1a28ab544d8b470f/html5/thumbnails/89.jpg)
www.wrightington.com
92 F Active
89
![Page 90: Elbow fracture dislocations adam watts](https://reader031.vdocuments.us/reader031/viewer/2022012318/58ececac1a28ab544d8b470f/html5/thumbnails/90.jpg)
www.wrightington.com90
![Page 91: Elbow fracture dislocations adam watts](https://reader031.vdocuments.us/reader031/viewer/2022012318/58ececac1a28ab544d8b470f/html5/thumbnails/91.jpg)
www.wrightington.com91
![Page 92: Elbow fracture dislocations adam watts](https://reader031.vdocuments.us/reader031/viewer/2022012318/58ececac1a28ab544d8b470f/html5/thumbnails/92.jpg)
www.wrightington.com92