complex elbow injuries involving radial head

Complex elbow injuries involving the radial head

Adam C WattsConsultant 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 rotatorya.pronation lateral rotation

b.pronation medial rotation

2.Trans-olecranona.extension

b.flexion

3.Longitudinal

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Posterior lateral rotation Terrible triad

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Terrible Triad algorithm

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Restore coronoid

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Restore coronoid

Restore radial head

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Restore coronoid

Restore radial head

Restore lateral soft tissue restraints

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Restore coronoid

Restore radial head


Restore medial soft tissue if still unstable

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Restore coronoid

Restore radial head


Restore medial soft tissue if still unstable

Apply hinged ex-fix

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O’Driscoll Classification

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from Ring et al.


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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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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Posterior medial rotation Posteromedial rotatory instability


Transolecranon Monteggia Fracture Dislocations

Proximal ulna fracture with dislocation of radial head from radiocapitellar joint and proximal radioulnar joint


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 IApex anterior diaphyseal ulna fracture with anterolateral dislocation of radiocapitellar and PRUJ

Type IIMetaphyseal buckle fractures with anterolateral radiocapitellar dislocation (paediatric only)

Type IIIApex 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 buttressradial headlateral 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


Longitudinal -Essex-Lopresti


“Hidden Injury” - 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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b.flexion

3.Longitudinal

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b.flexion

3.Longitudinal

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Terrible Triad






b.flexion

3.Longitudinal

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Terrible TriadPMRI






b.flexion

3.Longitudinal

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Terrible TriadPMRI

Ring Type 1






b.flexion

3.Longitudinal

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Terrible TriadPMRI

Ring Type 1Ring Type 3






b.flexion

3.Longitudinal

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Terrible TriadPMRI

Ring Type 1Ring Type 3

Essex-Lopresti


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complex elbow injuries involving radial head

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