CHAPTER 17 Arthroscopic Treatment of Elbow Fractures
Arthroscopic techniques are having a dramatic impact in the arenas of trauma and fracture management. Proponents are advocating arthroscopically assisted treatment of intra-articular and other periarticular injuries throughout the appendicular skeleton, including management of triangular fibrocartilage complex injuries, distal radius fractures, and carpal fractures. During the past decade, the indications for elbow arthroscopy have expanded to encompass the management of various elbow fractures. Little has been published on the subject, because the field is in its infancy. This chapter offers an overview of this innovative frontier of elbow arthroscopy to the advanced arthroscopist and encourages an appreciation of the creativity that is leading to future developments in the field.
Careful attention to the regional anatomy is essential to prevent direct or indirect injury to the neurovascular structures of the elbow, the most feared complication of elbow arthroscopy. The surgeon should be thoroughly familiar and agile with portal placement and the use of retractors. The various fracture classifications and their relevance are discussed in more detail in the sections on surgical management that follow.
History and Physical Examination
Clinical assessment is often limited or impaired by pain, soft tissue swelling, and hemarthrosis. In these circumstances, aspiration of the hemarthrosis, followed by an intra-articular infusion of bupivacaine, may provide sufficient analgesia to facilitate the assessment of motion and stability. The technique may also provide a means to differentiate patient guarding from a true mechanical block to elbow motion.
At presentation, patients often have imaging studies offering suboptimal radiographic detail because of limited emergency room evaluation. Imaging may also be limited by the inability of patients to tolerate positioning of the injured joint for adequate assessment. As with the physical examination, aspiration and infiltration of the joint with an anesthetic may facilitate positioning for optimal radiography. A surgeon should have a low threshold for the application of computed tomography or magnetic resonance imaging for preoperative planning when interpreting fracture lines and the three-dimensional relationships of fracture fragments or loose bodies. Magnetic resonance imaging provides further detail regarding ligament integrity in the setting of coronoid fractures and elbow dislocations.
Indications and Contraindications
Arthroscopic management of elbow fractures is a rapidly evolving indication for the use of elbow arthroscopy in the identification and treatment of intra-articular pathology. The technique provides for a minimally invasive surgical exposure, minimizing further soft tissue trauma in a region notorious for wound complications. Arthroscopic débridement of fibrinous and osseous debris facilitates postoperative elbow range of motion. Visualization of fracture fragments and chondral injuries is often superior to that achieved with open approaches, and it minimizes the requirements for intraoperative fluoroscopy. Identification of intra-articular pathology not evident on preoperative imaging enables appropriate treatment measures and a more accurate prognosis. Elbow arthroscopy can be used in combination with indirect reduction techniques to maximize articular congruity, or it can be used for direct arthroscopic reduction with fixation devices passed into the joint.
Absolute contraindications to arthroscopic treatment of acute elbow fractures include infection or gross contamination, neurovascular injuries, concomitant chest wall injuries in which positioning would interfere with ventilation, and severely osteoporotic bone for which fixation will be inadequate. Relative contraindications include severe soft tissue swelling and severely displaced intra-articular fractures in which altered anatomic landmarks and orientation compromise safe arthroscopic access. Open nerve exploration may be necessary in patients with previous ulnar nerve transposition. Arthroscopic treatment of open fractures is controversial but may facilitate irrigation and débridement and minimize further soft tissue injury in selected cases.
Open exploration of the posterior interosseous nerve is recommended for radial head fractures in which fracture fragments penetrate the capsule and the brachialis muscle anteriorly. Injury to the nerve is possible with arthroscopic extraction of fracture fragments from this location because of the proximity to or entanglement with the nerve. Open removal of these fragments is essential to eliminate nerve entrapment in scar tissue that may result in shearing and traction injuries during the rehabilitation process.
Most intra-articular fractures of the distal humerus can be effectively treated with open reduction and internal fixation (ORIF), and superior results are achieved with this approach compared with skeletal traction or cast immobilization. Khalfayan and colleagues1 concluded that patients with displaced Mason type II radial head fractures who were treated conservatively had more pain, decreased strength, and decreased elbow motion compared with patients treated with open osteosynthesis. Radial head fracture treatment depends on the fracture pattern and displacement and includes early mobilization, ORIF, and resection or prosthetic replacement. Open treatment options for displaced olecranon fractures include tension band wiring, lag screw placement, neutralization plating, and excision with extensor mechanism reconstruction. Capitellar fractures can likewise be excised or stabilized with standard open techniques. Cadaveric research has drawn attention to the important stabilizing role of the coronoid and has provided compelling evidence for surgical management of these fractures in various circumstances.2,3
The patient is placed prone or in the lateral decubitus position. The lateral decubitus position typically requires a supportive device to provide arm suspension. With the patient in the prone position, the arm is elevated on a 4-inch padded block with the elbow flexed to 90 degrees over an arm board located at the patient’s side parallel to the table (Fig. 17-1). This method avoids compression of neurovascular structures in the axilla and facilitates medial or lateral access (in case an open procedure becomes necessary) by internal or external rotation of the forearm onto the arm board. The forearm and hand should be wrapped with compressive wrapping material to restrict swelling and fluid extravasation. Intravenous prophylactic antibiotics are routinely administered preoperatively.
Most procedures can be accomplished with the 4.0-mm, 30-degree arthroscopic camera. A 70-degree camera can provide visualization of the capitellum or radial head from a posterior portal when instrumentation is required from the soft spot portal. Graspers with teeth and smooth outer surfaces are preferred to prevent hang-up on soft tissue. A 3.5-mm, full-radius arthroscopic shaver is useful for removal of organized fracture hematoma and debris (Fig. 17-2). Various implants can be used for fixation, contingent on the fracture configuration (discussed later).
FIGURE 17-2 Débridement and removal of fracture debris are possible arthroscopically, as shown by the use of a shaver in this intercondylar humerus fracture.
After fracture stabilization has been achieved, the surgeon should thoroughly evaluate elbow stability. This can be accomplished with the assistance of fluoroscopy, but it can also be readily assessed arthroscopically. Diagnosis and management of associated ligamentous injuries of the elbow are discussed in Chapters 13 and 14.
A small drain can be placed through one of the elbow joint portals at the conclusion of the procedure. Portals can be closed with a locked horizontal mattress stitch to minimize prolonged drainage, which is a frequent minor complication. Concomitant elbow incisions or lacerations should be managed in the manner deemed appropriate by the surgeon and should be considered carefully, given the propensity of the traumatized soft tissue envelope of the elbow to develop wound problems.
Radial Head Fractures
Radial head fractures are the most common type of elbow fracture in adults, and they offer an excellent opportunity for arthroscopic evaluation and management (Fig. 17-3A). In patients with persistent locking and pain despite radiographic evidence of minimally displaced radial head fractures, diagnostic arthroscopy enables accurate assessment of articular cartilage, identification of any osteochondral flaps or loose bodies, and débridement with minimal morbidity. Displaced two-part radial head fractures can be visualized through a proximal anteromedial or posterolateral portal to assess the degree of articular incongruity, fracture fragment stability, and any impingement to forearm rotation. A direct lateral portal can also provide visualization of the posterior aspect of the radial head during confirmation of fracture reduction. If arthroscopic reduction with internal fixation is desired, visualization is best achieved with a 70-degree camera from a posterolateral portal, with instruments and implants introduced through a soft spot portal.
FIGURE 17-3 Radial head fractures are easily visualized arthroscopically and can be accessed for internal fixation through several portals. A, Posteroanterior (left) and lateral (right) radiographs show a radial head fracture. B, The initial view shows the fracture after the hematoma has been removed. C, The depressed fragments are mobilized using a Kirschner wire joystick technique. D, The screw fixation device is inserted. E, The final fixation was obtained by means of arthroscopically assisted techniques. F, Final radiographs show the fracture with internal fixation in place.
After débridement and lavage, Kirschner wires can be positioned through the anterolateral or soft spot portals in conjunction with arthroscopic probes, graspers, and occasionally, a reduction tenaculum to allow for manipulation, reduction, and provisional fixation of larger fracture fragments. Visualization can often be facilitated by rotating the forearm into maximal supination. Definitive fixation can then be performed using absorbable pins or cannulated screws (see Fig. 17-3D). Herbert-Whipple screws (Zimmer, Inc., Warsaw, IN) and headless variable-pitch screws (Acutrak screws, Acumed, LLC, Hillsboro, OR) are advantageous in providing secure fixation with compression to allow early motion, while being buried beneath the articular surface to avoid impingement. Reduction and stability of the fixation can be directly assessed during full rotation of the elbow (see Fig. 17-3E).
Rolla and colleagues4 reported preliminary results for six patients who underwent arthroscopic reduction and internal fixation for radial head fractures classified as Mason5