of the Elbow and Forearm

Fig. 19.1

(a) X-rays of an open posteromedial elbow dislocation. (b) The exposed median nerve tented over the trochlea

Physical therapy will improve the final results, but many patients either live too far away or have trouble following simple instructions. The surgeon can play a vital role if reliable therapy is not available, by taking the time to teach and make sure the patient and his caregivers know what and what not to do.

Fracture/Dislocation: Terrible Triad

This fracture/dislocation—torn collateral ligaments and fractures of the radial head and coronoid process—produces an unstable elbow that is best treated by open reduction and fixation (https://www.orthobullets.com/trauma/1021/terrible-triad-injury-of-elbow). The results are less than ideal under the best circumstances, and without radial head implants, small headless compression screws, suture anchors, and small surgical instruments, results are compromised. ORIF of the radial head with whatever is available should be attempted. Even if excised later, a damaged radial head provides the necessary acute stability to prevent valgus deformity and distal radioulnar problems. Even without a coronoid fracture, the lateral ulnar collateral ligament may have to be repaired if the elbow remains unstable. The medial collateral ligament rarely needs acute repair, but if torn it is important to save the radial head. Otherwise valgus instability is virtually assured.

Dislocation with Coronoid Fracture

Type I coronoid fractures—avulsions of the tip that do not adversely affect elbow stability—need not be fixed, and dislocations with such fractures need a well-thought-out rehabilitation program to prevent stiffness. Type II fractures, involving approximately 50%, and type III, involving greater than 50% of the coronoid, are usually unstable and require open stabilization (Fig. 19.2). Exposure of the coronoid can be difficult. With a radial head fracture that is deemed fixable, a lateral Kocher interval incision can be used. Once the elbow is reduced and the radial head repaired, stability should be rechecked. If the elbow is stable at 30° flexion, the coronoid need not be repaired. If unstable, the lateral ulnar collateral ligament is taken down from its humeral origin to visualize the joint. If large enough, the coronoid fragment is fixed with a small fragment screw or a suture around or through the fragment and tied on the posterior surface of the olecranon. After coronoid fixation the lateral ulnar collateral ligament can be repaired at its origin with drill holes in the center of the lateral epicondyle.

../images/270913_2_En_19_Chapter/270913_2_En_19_Fig2_HTML.png — Fig. 19.2

Lateral view of terrible triad with type I coronoid fracture

For coronoid fractures with a sagittal component or medial extension, fixation with a small plate may be necessary. Without the need for a lateral approach to the radial head, the coronoid can be approached medially. Care must be taken to protect the ulnar nerve and the anterior fibers of the medial collateral ligament.

If the elbow is stable after repair, early motion at 7–10 days will lead to better long-term function than longer immobilization. A removable long arm splint can be used between exercise periods. If the repair is not stable, casting or splinting for 3–4 weeks is necessary. In this situation, stiffness is likely.

Fractures About the Elbow

Distal Humerus Fractures

In the developing world, these fractures can be a real test of the abilities and judgment of the surgeon. Basic principles used in resource-rich environments should be applied as circumstances allow. Most locations will have a small fragment set. Reconstruction plates placed in a 90°/90° fashion or parallel plates at 180° are the best choice, and DC plates contoured to fit are the second choice. Two semi-tubular plates stacked together to improve the implants’ strength will also work. For isolated one-column fractures, a single plate may be adequate if screw fixation is secure (Fig. 19.3). For fractures of both columns and intra-articular fractures, a 90°/90° plate configuration—lateral column plate placed posteriorly and medial column plate placed medially—is recommended. Parallel plating with the lateral plate along the lateral epicondyle is also acceptable. In this case the screws from both sides can interlock and provide more rigid fixation, especially in comminuted intra-articular fractures. In general, before plates are applied, the intra-articular pieces should be reduced as best as possible with either K-wires or cannulated screws. The medial plate is contoured to the medial supracondylar ridge and may extend as distal as the ulnar groove. Identify and mobilize the ulnar nerve early. If the nerve ends up lying over hardware without soft tissue interposition, transposition may be indicated. The preferred technique is the simplest: subcutaneous anterior transposition, securing the position with a couple of nonrestrictive sutures or fascial slings in the subdermalfascial plane.

../images/270913_2_En_19_Chapter/270913_2_En_19_Fig3_HTML.png — Fig. 19.3

(a) Comminuted lateral column fracture with high medial column involvement. (b) Fracture can be well fixed with only a lateral column plate as long as adequate inter-fragmentary fixation is used for the articular surface and the large medial condylar fragment

In the 90°/90° plate configuration, the lateral plate is applied posteriorly and contoured so its distal end abuts the articular surface of the capitellum. Intra-articular fractures usually require an olecranon osteotomy for adequate exposure. Other than accurately reconstructing the articular components of the joint, it is important, especially in very comminuted fractures, to maintain the proper width of the distal humerus (Fig. 19.4) (Video of distal humerus plating. https://www.youtube.com/watch?v=gBfg8Dfbi24).

../images/270913_2_En_19_Chapter/270913_2_En_19_Fig4_HTML.png — Fig. 19.4

(a) AP x-ray of a low bicondylar distal humeral fracture. (b) Lateral of same. (c) Postoperative AP x-ray. Note the 90°/90° position of the plates with the lateral plate posterior and the medial plate contoured around the medial epicondyle. Non-locking, contoured, reconstruction plates were used here. Note the inter-fragmentary screw used to fix the intra-articular fragments. The olecranon osteotomy was fixed with K-wires and tension band wiring. (d) Lateral x-ray view emphasizes the 90°/90° plate placement

If an olecranon osteotomy is performed for better exposure of the distal humerus, an intra-articular chevron or straight osteotomy gives good visualization of the humeral articular surface. Bicortical drill holes are made in the olecranon at the proposed osteotomy, taking care not to damage the distal humerus articular cartilage. An osteotome or power saw connects the holes in an incomplete cut, allowing the far cortex to be cracked open, minimizing damage to the articular cartilage. The osteotomy is repaired using a tension band technique supplemented with either a pre-drilled 6.5 cancellous screw and washer or two parallel K-wires.

Over the years, many of these fractures have been fixed with only K-wires if either surgeon skill or equipment is lacking. This is a risky technique since loss of fixation, early and late stiffness, infection, reoperation to remove motion-obstructing pins, nonunion, and post-traumatic arthritis are common results (Fig. 19.5). In severely comminuted distal humerus fractures, the nonoperative “bag of bones” approach may give better results while limiting iatrogenic disaster. This is especially useful in elderly patients with highly comminuted osteopenic fractures. This can be accomplished using an olecranon pin or winged screw overhead or lateral traction if the patient and hospital are geared for lengthy stays and such traction setups are available. Traction is kept for 3–4 weeks, allowing early elbow ROM in traction as tolerated. When the fracture is sticky, traction is discontinued, and a splint or cast is applied, until there is enough stability for unprotected ROM (Fig. 19.6).

../images/270913_2_En_19_Chapter/270913_2_En_19_Fig5_HTML.png — Fig. 19.5

(a) X-ray of comminuted intra-articular distal humerus fracture. (b) X-rays show early, inadequate proximal callus in the face of unstable fixation with K-wires and cerclage wires. (c) The end result is nonunion with more motion at the nonunion than the elbow

../images/270913_2_En_19_Chapter/270913_2_En_19_Fig6_HTML.png — Fig. 19.6

(a) X-ray of comminuted, bicondylar, intra-articular fracture of the distal humerus. (b) Olecranon pin is used for traction in a nonoperative “bag of bones” treatment

For patients who cannot tolerate or afford bed rest, the elbow can be stabilized in a back slab for 7–10 days until gentle active and passive range of motion is initiated, hoping eventually for a painless nonunion. The elbow is very prone to stiffness even in the face of minor injuries and short immobilization times. Whatever technique is selected to treat these injuries, the surgeon should aim for motion as early as possible.

Capitellum

With a large capitellum fragment, ORIF with a headless screw is ideal. Burying a headed screw or fixation from the posterior aspect of the lateral column is a viable alternative. Temporary K-wire fixation is a mechanically poor alternative and requires at least 3 weeks immobilization in neutral position before the wires can be removed. In a worst-case scenario, excision of the capitellum may be the only option. The results of this approach are mixed, just as those with excision of the radial head. Proximal migration of the radius will produce pain in the wrist with either capitellar or radial head excision in about one-third of patients.

Radial Head

Mason type 1 and 2 radial head fractures can be treated with nonoperative management. Radial head excision with prosthetic replacement for fractures with comminution greater than four components or inability to achieve an accurate articular reduction is the general recommendation (Mason type III) (Fig. 19.7). Without radial head replacements, ORIF, even if not perfect, may be a better option using buried K-wires, intraosseous wiring, or intraosseous sutures. Some authors have reported good results with late excision of Mason type IV fractures (any radial head fracture combined with an elbow dislocation), and this may be a reasonable approach for certain situations. Take care to examine the wrist for pain in the face of a radial head injury—the Essex–Lopresti lesion—as the distal radioulnar joint may be disrupted. When there is associated medial instability, the radial head should be reconstructed as best as possible to serve as a spacer, to prevent valgus displacement while the soft tissues are healing. It can be excised later. The only caveat to this is if a fragment of the radial head is widely displaced, it should be excised early, but the rest of the radial head, even if fractured, can be left in place and excised later if necessary (https://www.vumedi.com/video/orif-radial-neck-fracture/).