3. ELBOW ANATOMY
Articulations The elbow joint is made up of
three articulations
1)Radiohumeral: capitellum of the
humerus with the radial head
2)Ulnohumeral: trochlea of the humerus
with the trochlear notch of the ulna
3)Radioulnar: radial head with the radial
notch of the ulna (proximal radioulnar
joint)
5. MEDIAL COLLATERAL LIGAMENTS
• MCL consists of the
1) Anterior bundle -The anterior bundle is the
key valgus stabilizer of the elbow, arising from
the anteriorinferior aspect of the medial
epicondyle to insert on the sublime tubercle of
the proximal ulna.
2) The posterior bundle provides a secondary
restraint to valgus load and also resists ulnar
rotation.
3) Transverse bundle.
6. LATERAL COLLATERAL LIGAMENTS.
• Primary varus and posterolateral rotational
stabilizer
• LCL has three components:-
1) The radial collateral ligament- The radial
collateral ligament arises from the lateral
epicondyle and blends with the annular
ligament
2) Annular ligament - The radial head is
surrounded by the annular ligament which
attaches to the anterior and posterior
margins of the radial notch of the proximal
ulna
3) The lateral ulnar collateral ligament- The
lateral ulnar collateral ligament is posterior to
the radial collateral ligament
7. • Oblique cord - thickening of supinator muscle
fascia,runs from tuberosity of the ulna to just distal
to radial tuberosity.
• Quadrate ligament (of Denuce) - thickening of the
inferior aspect of the joint capsule , runs from just
inferior to the radial notch of the ulna to insert to
the medial surface of the radial neck
8. Soft tissue restraints can be divided into two:-
• Static stabilizers-joint capsule and the LCLs and MCLs, Oblique cord,
Quadrate ligament.
• Dynamic restraints - Biceps, brachialis, and triceps, common flexors
tendons and common extensors.
9. INTRODUCTION
• The subcutaneous position of olecranon makes it vulnerable to direct
trauma.
• Bimodal age distribution:-
• Young active individuals- high energy trauma.
• Elderly – Simple fall.
10. MECHANISM OF INJURY
• Acute Tension overload: Tension applied by the triceps with flexion of
the elbow
• Direct Trauma
• Chronic overload: eg. stress fractures seen commonly with
osteopaenic or pediatric patients
11. EVALUATION
• Check integrity of skin
• Check extension of elbow
• Evaluate neurovascular status, especially ulnar nerve
• X-rays - two views (AP, Lateral)
16. TREATMENT OBJECTIVES
• Restoration of elbow motion and prevention of stiffness
– Goal is to begin early ROM
• Restoration and preservation of the elbow extensor mechanism.
• Restoration of the articular surface.
• Prevention of complications.
17.
18. TREATMENT METHODS
NONOPERATIVE
Indicated in low demand individual with stable elbow joint.
Non-displaced fractures.
Extensor mechanism in intact.
Immobilization in long arm splint at 45-90 degrees for 3 weeks ,then
active flexion is started (avoiding extension) and after 6 weeks
extension is started
19. INDICATIONS FOR SURGERY
• Disruption of extensor mechanism
Unable to actively extend elbow
• Articular incongruity
Any displaced fracture
• Open fractures
20. OPERATIVE
Open reduction and internal fixation
• Tension band wiring
• Intramedullary screws
• Plating
Excision of olecranon and triceps repair
• Comminuted, unreconstructable fractures
• Typically, Elderly patients with loss of active elbow extension
21. Approach
A posterior midline incision is made and full thickness medial and
lateral fasciocutaneous flaps are raised. The interval between the ECU
and FCU is developed and the subcutaneous border of the ulna is
exposed. On the ulnar side, the FCU is elevated from the olecranon to
visualize the joint. On the radial side, the anconeus fascia is incised
and the muscle can be elevated from the olecranon fragment for
further visualization if needed.
22. TENSION BAND WIRE
• Converts extensor force of triceps (tensile
forces) -compression forces along articular
surface
• For simple, transverse, non-comminuted
fractures
• Use 18- or 20-gauge steel wire
• Be sure wires cross over dorsal cortex.
• May use with either parallel K-wires or an
intramedullary screw.
23.
24. INTRAMEDULLARY SCREW
• Need to add tension band wire
• Long/large screw required
• 6.5mm cancellous
• 85-110 mm long
• Osteopaenic bone, oblique fracture
25. PLATE FIXATION
• Indications:
• comminuted fractures
• fractures with shaft extension
• oblique fracture line
• Plate choice…
• Traditional…
• LCDCP, Recon, 1/3 tubular
• Anatomic, locking
• Plates designed for proximal Ulna
26. OLECRANON EXCISION
• Elderly patients
• those with osteoporosis
• involving <50% of joint
• Re-attach triceps anteriorly
• At joint surface
27. POTENTIAL SURGICAL COMPLICATIONS
• Hardware symptoms in 3 - 80%
• 34-66% require hardware removal
• Non-union /malunion rates < 5%; essentially all in TBW
• Infection 0-9%
• Pin migration up to ~ 44%; ~ 5-15% when anterior cortex engaged.
• Ulnar neuritis/AIN injury 2-5%
29. INTRODUCTION
Most common elbow fracture
2-5% of all fractures
33% of elbow fractures.
15-20% involve the neck
50% is associated with another injury
10% of Radial head fracture associated with elbow dislocation
30. RADIAL HEAD
Important valgus stabilizer of elbow
Equally important axial stabilizer
Also Resists varus and posterolateral rotatory instability by tensioning
lateral collateral ligament
Approx. 60% of load transfer across elbow joint occurs through radio-
capitellar articulation
31. BIOMECHANICS
Radial head resection overloads the coronoid process
The elbow then depends on the MCL to prevent valgus deformity
If interosseous membrane is disrupted the radius will proximally
migrate
For each mm of radial shortening, the distal ulnar load increases by
approximately 10%.
32. MECHANISM OF FRACTURE
• fall on an outstretched hand
• Axial, valgus and posterolateral rotational forces
34. TESTS FOR ASSOCIATED INJURIES
Lateral pivot shift test → LCL- supine position, arm overhead flexed,
with axial force forearm is supinated,flexed and valgus force is
applied- patient feels like joint is about to dislocate.
Valgus stress test → MCL- standing with elbow 30°flexed and
supinated, valgus force applied- patient pain on medial side of elbow.
Radius pull test → Essex Lopresti
Piano key sign → DRUJ
35. CLINICAL FEATURES
Pain around elbow.
Swelling
Ecchymosis
Stiffness
Presence of clicking or crepitus with forearm rotation.
37. CLASSIFICATION - MASON
• TYPE 1 - Nondisplaced radial head fracture.
• TYPE 2 - Displaced partial articular radial head fracture.
• TYPE 3 - Displaced, comminuted fracture of radial head.
• TYPE 4 – radial head fracture associated with an elbow dislocation
38. MODIFIED MASON CLASSIFICATION
The most popular classification is the Broberg and Morrey
modification of the original Mason classification.
• TYPE I - Fracture is undisplaced or displaced less than 2
mm and involves less than 30% of the articular surface.
• TYPE 2 - Fracture is displaced greater than 2 mm and
involves greater than 30% of the articular surface.
• TYPE 3 - Fractures is comminuted.
• TYPE 4 – Radial head fracture with associated elbow
dislocation. ( Hotchkiss modification )
41. NON –OPERATIVE TRAETMENT
• Most series report 85 - 95 % good results with early range of motion
• If symptomatic: delayed fragement or head excision - provided
interosseous membrane and medial collateral ligament are intact
42. OPERATIVE TRAETMENT
• Patients with displaced radial head fractures with a block to motion,
those who have concomitant injuries which require surgical
intervention such as unstable fracture-dislocations, or those with
retained intra-articular loose bodies are best treated surgically.
Treatment options include:-
Radial head fragment excision.
Open reduction and internal fixation.
Radial head excision.
Radial head arthroplasty
43. SURGICAL APPROACH
• KOCHERS APPROACH
• Most often utilized for radial head
• Interval
• Anconeus – Radial Nerve
• ECU – PIN
• 5cm incision from lateral epicondyle distally
• Angled posteriorly 30-45 degrees
44. KAPLAN APPROACH
• Kaplan
• More often used for radial
neck/proximal radial shaft fracture
• Interval
• ECRB – Radial nerve or PIN
(variable)
• EDC – PIN
• 10cm incision from lateral
epicondyle
45. FRAGMENT EXCISION
• Fragment excision is indicated in patients with a block to forearm
motion by a small (less than 30% of the articular diameter)
nonreconstructable displaced articular fracture of the radial head.
• The excision of large fragments of the radial head can cause painful
clicking and contribute to instability as a consequence of loss of
concavity–compression stability of the radiocapitellar joint.
46. ORIF
• The indications for open reduction and internal fixation
remain controversial.
• Indications include displaced, noncomminuted fractures
of the radial head limit forearm rotation.
• Fractures displaced greater than 2 mm and involving
greater than 30% of the articular surface (a Type II
fracture in the modified Mason classification) might be
best treated with surgery.
• three or fewer fragments.
• Low-profile tripod screw fixation has been shown to
provide improved results relative to plate fixation
47. SAFE ZONE FOR FIXATION
• Radius articulates with the ulna in 280 degree arc
• The posterolateral 80 degrees is non-articular
• Hence, it is safe for fixation without causing loss of motion
• The zone corresponds to a region between longitudinal lines along
the radial styloid and Lister's tubercle in mid-prone forearm
position
48. RADIAL HEAD EXCISION
• Radial head excision may be considered for displaced fractures of the
radial head that are not amenable to internal fixation.
• No in ligamentous injury
• 3 or more fragments
• Elderly, low demand patients
• Even in the presence of intact collateral ligaments, radial head
excision has been documented to alter load transfer and kinematics
across the elbow
49. RADIAL HEAD ARTHROPLASTY
INDICATED IN :
• Unreconstructedly displaced
radial head fractures.
• Associated elbow dislocations.
• With Disruption of collateral or
interosseous ligaments
52. SURGICAL ANATOMY
• Articular cartilage
Sigmoid notch of ulna: bare spot
centrally between tip and coronoid
Pearl: Beware of narrowing sigmoid
fossa when treating comminuted
olecranon fractures.
• Coronoid process: preserve height
Coronoid Height ~ 2 x Olecranon
height
Tip of Coronoid to tip of Olecranon
subtends angle of ~30 degrees from
long axis of ulnar shaft
