Upper limb trauma Flashcards Preview

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Flashcards in Upper limb trauma Deck (184):
1

Scapula Fracture
i. Incidence / Mechanism

ii. Mortality rate + cause(s)

iii. ____% involve body and spine

i. uncommon / <1% all fractures / high energy trauma

ii. 2-5% (usually from Pulmonary OR Neurological injury)

iii. 50%

2

Scapula Fracture

i. Associated injuries occur in __to___%

ii. Types of assoc injuries (orthopaedic)

i. 80-90%

ii. Types of assoc injuries (ortho):
1. rib fractures (52%); 2. ipsilateral clavicle fracture (25%); 3. Spine fracture (29%)
4. brachial plexus injury (5%) --> (75% of brachial plexus injuries resolve)




3

Scapula Fracture

i. Types of assoc injuries (medical)

iii. Types of assoc injuries (medical):
1. Pulmonary injury
2. Pneumothorax (32%)
3. Pulmonary contusion (41%)
4. Head injury (34%)
5. Vascular injury (11%)

4

Scapula Fracture: Classification (Broad)

Classification is based on the location of the fracture and includes:
1. coracoid fractures
2. acromial fractures
3. glenoid fractures
4. scapular neck fractures
*** look for "floating shoulder"***
5. scapular body fractures
6. scapulothoracic dissociation

5

Scapula Fracture

What is floating shoulder

SCAPULAR NECK fractures with associated ACJ SEPARATION or CLAVICLE fracture

6

Scapula Fracture: Corocoid Fracture Classifcation

Type 1 : Proximal to the CC ligament

Type 2: Tip of corocoid fracture

7

Scapula Fracture: Acromial Fracture Classifcation

Type 1: Non-displaced or mininmally displaced
1a. tip of acromion
1b. neck of acromion

Type 2: Displaced but does not compromise SA space

Type 3: Displaced and compromising SA space
3a. High acromion #
3b. Low acromion #

8

Scapula Fracture: Glenoid Fracture Classifcation

1. Eponymous name

2. Types

1. Ideberg (Types 1 - 6)

2. Types
Ia= anterior rim; 1b = posterior rim
II= Exiting laterally
III= Exiting superiorly
IV= Exiting medially
Va= Combination of II + IV
Vb = Combination III + IV
Vc = Combined II + III + IV
VI = Severe comminution

9

Scapula Fracture: imaging

i. XR views (3)

ii. CT indications

i. true AP, scapular Y and axillary lateral view

ii. Indications for CT
(1) intra-articular fracture
(2) significant displacement (3) 3D recon useful

10

Scapula Fracture: Treatment

Non-operative

i. Technique

ii. indications

iii. Outcomes

i. Sling for 2 weeks followed by early motion

ii. indicated for vast majority of scapula fractures (90% are minimally displaced and acceptably aligned)

iii. union at 6 weeks / can expect no functional deficits

11

Scapula Fracture:Treatment

Operative
i. Technique

ii. indications (5)

iii. Outcomes: ______% good to excellent outcomes with ORIF

i. ORIF

ii. Indication for ORIF
1. glenohumeral instability - denoted by:
- > 25% glenoid involvement + sublux
- > 5mm of glenoid articular surface step off or major gap
- excessive medialization of glenoid

2. Displaced scapula neck fx (>40 degrees angulation or 1 cm translation)

3. open fracture

4. loss of rotator cuff function

5. coracoid fx with > 1cm of displacement

iii. 70%

12

Scapula Fracture:Treatment

Surgical Technique
i. approach (most common) ?

ii. internervous plane between ________ muscle (___________nerve) and Teres ________ (_______ nerve)


i. Judet approach is most common

ii. internervous plane between infraspinatus muscle (suprascapular nerve) and teres minor (axillary nerve)







13

Clavicle shaft fractures: Introduction

1. Middle third fractures acocunt for __to__% of all clavicle fractures

2.

1. 75-80%

2

14

Clavicle shaft fractures

1. Deforming forces

2. Associated injuries (rare) but include:

1.
- sternocleidomastoid muscle pulls the medial fragment posterosuperiorly

- pectoralis and weight of arm pull the lateral fragment inferomedially
- open fractures buttonhole through platysma

2. ipsilateral scapular fx; rib fracture; pneumothorax; NV injury (consider S-T dissoc in high energy etc)

15

Clavicle shaft fractures

Anatomy:
1. Static stabilisers (2)
a) ___________

b) ___________

c) ___________
2. Which is strongest - conoid OR trapaziod lig?

3) Dynamic stabilisers (2)

1a. Acromioclavicular ligament
◾provides AP stability
◾has sup, inf, ant and post components
◾superior ligament is strongest, followed by posterior


1b. Coracoclavicular ligaments (trapezoid and conoid)
◾provides sup/inf stability ◾trapezoid inserts 3 cm from end of clavicle
◾conoid inserts 4.5 cm from end of clavicle in the posterior border

1c. Capsule

2. Conoid ligament strongest

3. Deltoid and Trapezius

16

Clavicle shaft fractures:

Classification middle third fractures

1. Neer
- Displaced
- Nondisplaced

2. AO
A=Simple
B= Wedge
C= Complex

* not widely used

17

Clavicle shaft fractures

Standard Xray views ?

What is ZANCA View ?

1. Routine views
- sitting/standing upright,
- standard AP view of bilateral shoulders

2. Additional views
- 15° cephalic tilt (ZANCA view)
- determine superior/inferior displacement
- may consider having the patient hold 5 to 10 lbs weight in affected hand


18

Clavicle shaft fractures: Treatment

Non-operative
1. Details

2. Indications

1. Sling immobilization with gentle ROM exercises at 2-4 weeks and strengthening at 6-10 weeks

2. Controversial / Evolving
- min displaced (middle third)
◾shortening and displacement <2cm
◾no neurologic deficit
◾no significant displacement to the superior shoulder suspensory complex (<10mm displacement)

19

Clavicle shaft fractures:

1. What structures make up the superior shoulder suspensory complex? (6)

Ring formed by:
1. CC lig
2. AC lig
3. Corocoid process
4. Distal clavicle
5. Acromion tip
6. CA lig

20

Clavicle shaft fractures: Treatment

Non-operative

1. Outcomes

1. Outcomes

(i) Nonunion (1-5%)
Risk factors for nonunion:
-> comminution;
-> 100% displacd
-> shortening >2 cm
-> advanced age
-> female gender

(ii) Poorer cosmesis

(iii) Decreased shoulder strength and endurance
-> seen with displaced midshaft clavicle fracture healed with > 2 cm of shortening

21

Clavicle shaft fractures: Treatment

Operative: ORIF

1. Indications: absolute

2. Relative and controversial indications

1. Indications: absolute
- open fxs
- displaced fracture with skin tenting
- subclavian artery or vein injury
- floating shoulder (clavicle and scapula neck fx)
- symptomatic nonunion
- symptomatic malunion

2. Relative / Controversial
- Displaced middle third with >2cm shortening
- bilateral, displaced clavicle fractures
- brachial plexus injury (questionable b/c 66% have spontaneous return)
- closed head injury
- seizure disorder
- polytrauma patient



22

Clavicle shaft fractures: Treatment

Operative: ORIF

Outcomes

1. Pro's

2. Con's

1. Advantages of ORIF
- improved results with ORIF for clavicle fractures with >2cm shortening and 100% displacement
- improved functional outcome / less pain with overhead activity
- faster time to union
- decreased symptomatic malunion rate
- improved cosmetic satisfaction
- improved overall shoulder satisfaction
- increased shoulder strength and endurance

2. Disadvantages of ORIF
- Increased risk of need for future procedures (implant removal; debridement for infection)
- NVI
- Infection

23

Proximal Humerus Fractures

Epidemiology
1. incidence ____% of all fractures
2. _______ most common non-vertebral fracture in pts >65yo

Demographics
3. __:__ female to male ratio
4. ____________ associated with more complex fracture types

Epidemiology
1. incidence: 4-6% of all fractures

2. THIRD most common non-vertebral fracture in pts >65yo

Demographics

3. Female:male ratio = 2:1

4. INCREASING AGE associated with more complex fracture types

24

Proximal Humerus Fractures

Pathoanatomy
1. Displacing forces ?

2. Vascularity of articular segment is more likely to be preserved if ≥ _______ is attached to articular segment

3. The 3 most accurate predictors of humeral head ischemia are:
a) ____ of calcar length attached to articular segment

b) disrupted _______

c) basic fracture pattern

1. Displacing forces
- Pec Major displaces shaft ant. & medial
- SSpin, InfSpin, and Teres Minor ext rotate GT
- Subscap Int rotates articular segment/LT

2. >8mm of calcar


3a) <8 mm of calcar length attached to articular segment

3b) Disrupted medial hinge (medial cortex congruence)

3c) Basic fracture pattern

NOTE **** predictors of humeral head ischemia do not necessarily predict subsequent AVN

25

Proximal Humerus Fractures

Associated conditions (2 broad groups)

Q. Incidence of Arterial injury around __to__%

Associated conditions

1. nerve injury (axillary most common)

2. Arterial injury (uncommon)

A. incidence 5-6%
- higher likelihood in older patients
- most often occur at level of surgical neck or with subcoracoid dislocation of the head

26

Proximal Humerus Fractures

Vascular anatomy
1. Arcuate artery branches from which larger artery?

2. Anterolateral ascending branch is a branch of the __________

3. Which artery is main supply to greater tuberosity?

4. _______ artery : recent studies suggest it is the main blood supply to humeral head ?

Vascular anatomy ◦

1. Anterior humeral circumflex artery
- Large number of anastamoses with other vessels in the proximal humerus
2. Anterolateral ascending branch is a branch of the anterior humeral circumflex artery

3. Arcuate artery is the terminal branch and main supply to GT

4. Posterior humeral circumflex artery

27

Proximal Humerus Fractures: Classification

1. Name (eponymous)

2. descibe

1. Neer classification

2. Based on anatomic relationship of 4 segments
◾greater tuberosity
◾lesser tuberosity
◾articular surface
◾shaft
(***Note: Considered a separate part if: ◾displaced > 1 cm OR
◾45° angulation

28

Proximal Humerus Fractures:

XRAY views

1. Standard views (3)

2. Special views (3)

3. Combined Cortical thickness (medial +lateral cortex) >____mm on XR correlates with _____________ ?

1. complete trauma series
i. true AP (Grashey)
ii. scapular Y
iii. axillary

2. Additional views
i. apical oblique
ii. Velpeau
iii. West Point axillary

3. Combined cortical thickness (medial + lateral thickness >4 mm)
studies suggest correlation with increased lateral plate pullout strength

29

Proximal Humerus Fractures: Treatment

Non-operative (Sling immobilization followed by progressive rehab):

1. Indications:


2. Start early mobilisation with ____ days

1. Indications: most Prox humerus fx's including:
-> Min. displaced surgical/anatomic neck fractures
-> GT Fx's displaced < 5mm
-> Fractures in patients who are not surgical candidates

Additional variables to consider: (age / fracture type /
fracture displacement / bone quality / dominance / general medical condition / concurrent injuries

2. 14 days

30

Proximal Humerus Fractures: Treatment

Operative

1. Fixation vs Arthroplasty

a.) Fixation techniques

b.) Arthroplasty

1a.) Fixation
- CRPP (closed reduction percutaneous pinning)
- ORIF
- Intramedullary nailing

1b.) Arthroplasty
- Hemiarthroplasty
- RTSR

31

Proximal Humerus Fractures: Treatment

CRPP (closed reduction percutaneous pinning)

1. Indications

2. Outcomes

1. Indications:
-> 2-part surgical neck
-> 3-part and valgus-impacted
--> 4-part fractures in patients with good bone quality, minimal metaphyseal comminution, and intact medial calcar

2. Outcomes:
- considerably higher complication rate compared to ORIF, HA, and RSA

32

Proximal Humerus Fractures: Treatment

ORIF

1. Indications

2. Outcomes

1. Indications:
- GT displaced > 5mm
- 2, 3 and 4-part Fx in younger patients
- Head-split Fx in younger patients

2. Outcomes
- medial support necessary for fx's with posteromedial comminution
- calcar screw placement critical to decrease varus collapse of head

33

Proximal Humerus Fractures: Treatment

IMN

1. Indications

2. Outcomes

1. Indications
- surgical neck fractures or 3-part GT in
- younger patients
- Combined prox. humerus and humeral shaft fractures

2. Outcomes
- biomechanically inferior with torsional stress compared to plates
- favorable rates of fracture healing and ROM compared to ORIF

34

Proximal Humerus Fractures: Treatment

Hemiarthroplasty

1. Indications

2. Outcomes

a) Good if (2)

b) Bad if (2)

1. Indications = controversial
- younger patients (40-65) with complex fractures or head-splitting components likely to have complications with ORIF
- recommended use of convertable stems to permit easier conversion to RSA if necessary in future

2a. Outcomes- Good results if:
- accurate tuberosity reduction
- restoration of humeral height and version

2b. Outcomes- Poor results if:
- tuberosity nonunion or malunion
- retroversion of humeral component > 40°

(***note: inconsistent results reported in literature)

35

Proximal Humerus Fractures: Treatment

Reverse TSR

1. Indications

2. Outcomes

3. Complications/Cons

1. Indications
- low-demand elderly individuals with nonreconstructible tuberosities and poor bone stock
- functioning deltoid needed

2. Outcomes
- Early results demonstrate equivalent +/- better ROM and clinical outcome scores compared to ORIF and Hemi

3. Incidence of scapular notching, glenoid loosening, instability, and infection have all increased with the increasing popularity of the procedure

36

Proximal Humerus Fractures: Treatment

1. CRPP : Technique

2. Complications

1. Technique
- Threaded pins but do not cross cartilage
- Ext. rotate shoulder during pin placement
- Engage cortex 2 cm inferior to inferior border of humeral head

2. Complications

- With lateral pins risk of injury to axillary nerve

- With anterior pins risk of injury to biceps tendon, musculocutaneous n., cephalic vein

- Possible pin migration

37

Proximal Humerus Fractures: Treatment

ORIF : Technique

1. Approach

2. Technique

1. Approach
- anterior (deltopectoral)
- lateral (deltoid-splitting): incr. risk of axillary nerve injury

2. Technique

a) Heavy nonabsorbable sutures:
- Figure-of-8 technique should be used for isolated GT fx reduction and fixation (avoid hardware due to impingement)

b) Isolated screw
- May be used for GT fx reduction and fixation in young patients with good bone stock

c) Locking plate
- screw cut-out (up to 14%) is the most common complication following fixation of 3- and 4- part proximal humeral fractures and fractures treated with locking plates
- More elastic than blade plate making it a better option in osteoporotic bone
- Place plate lateral to the bicipital groove and pec. major tendon to avoid injury to the ascending branch of anterior humeral circumflex artery
- Placement of an inferomedial calcar screw(s) can prevent post-operative varus collapse, especially in osteoporotic bone

38

Proximal Humerus Fractures: Treatment

IMN

1. Approach

2. Technique

3. Complications

1. Approach
- superior deltoid-splitting

2. Technique
- lock nail with trauma or pathologic fractures

3. Complications
- rod migration in older patients with osteoporotic bone is a concern
- shoulder pain from violating rotator cuff
- nerve injury with interlocking screw placement

39

Proximal Humerus Fractures: Treatment

Hemiarthroplasty

1. Approach

2. Technique:

1. Approach
- anterior (deltopectoral)

2. Technique:

- Cerclage wire or suture passed through hole in prosthesis and tuberosities improves fracture stability

-Place GT 10 mm below articular surface of humeral head (HTD = head to tuberosity distance)
(***note: impairment in ER kinematics and 8-fold increase in torque with nonanatomic placement of tuberosities)

- Height of the prosthesis best determined off the superior edge of the pectoralis major tendon (5.6 cm between top of humeral head and superior edge of tendon)

- Post-operative passive external rotation places the most stress on the lesser tuberosity fragment

40

Proximal Humerus Fractures: Treatment

Reverse TSR : Technique

1. Approach

2. Technique

1. Approach
- anterior (deltopectoral)

2. Technique
- ensure adequate glenoid bone stock
- ensure functioning deltoid muscle
- repair of tuberosities recommended despite ability of RSA design to compensate for non-functioning tubersosities/rotator cuff

41

Proximal Humerus Fractures:

Rehab

1. Best results with guided 3-phase program:
a) Phase 1
b) Phase 2
c) Phase 3

1a. Early passive ROM

1b. Active ROM and progressive resistance

1c. Advanced stretching and strengthening program

(*** Note: prolonged immobilization leads to stiffness)

42

Proximal Humerus Fractures: Complications

Malunion
1a) usually _______

1b) Results inferior if converting from _______ malunited fracture to TSA
use ________ instead

Nonunion
2a. Nonunion usually with ______ and ______ fx

2b. Rx of chronic nonunion/malunion in the elderly should include _____

2c. LT nonunion leads to weakness with ____ testing

2d. GT nonunion leads to lack of ________

2e. Greatest risk factors for non-union are age and smoking

1a. varus apex-anterior or malunion of GT

1b. Varus; Use RTSR instead

2b. Nonunion

2a. usually with surgical neck and tuberosity fx

2b. Arthroplasty

2c. Lift-off testing

2d. active shoulder elevation

2e. age and smoking

43

Proximal Humerus Fractures: Complications

1. Screw cut-out = most common complication after ___________ (up to ___%)

2. AVN

3. Nerve injury
a) ______ nerve injury most common (up to 58% with studies using EMG)

b) increased risk with ________ approach

c) Axillary nerve is usually found ~__cm distal to the tip of the acromion

d) _______ nerve 2nd most common injured (up to 48%)

1. Screw cut out = most common complication after locked plating fixation (up to 14%)

1. AVN
- better tolerated than in lower extremity
- no relationship to type of fixation (plate or cerclage wires)

3a. Axillary

3b. Lateral (deltoid-splitting) approach

3c. ~7cm

3d. Suprascapular nerve

44

Proximal Humerus Fractures: Complications

1. Screw cut-out
2. Avascular necrosis
3. Nerve injury
4. Malunion
5. Nonunion
6. Rotator cuff injuries and dysfunction
7. Missed posterior dislocation (especially in cases with lesser tuberosity fractures)
8. Adhesive capsulitis
9. Posttraumatic arthritis
10. Infection

45

Terrible Triad Injury of Elbow

Definition:

A traumatic injury pattern of the elbow characterized by
- elbow dislocation (often associated with posterolateral dislocation or LCL injury )
- radial head or neck fracture
- coronoid fracture

46

Terrible Triad Injury of Elbow

1. Pathophysiology
a) Mechanism

b) Pathoanatomy
- Structures of elbow fail from _____ to ______

2. Prognosis: Historically poor due to:
a.
b.
c.

Pathophysiology

1a. Mechanism

- fall on extended arm that results in a combination of
valgus, axial, and posterolateral rotatory forces (produces posterolateral dislocation)

1b. Pathoanatomy
- structures of elbow fail from lateral to medial (LCL disrupted first--> ant capsule--> possible MCL disruption

2a. persistent instability
2b. stiffness
2c. arthrosis

47

Terrible Triad Injury of Elbow

Anatomy

Radial head:

1a. Primary restraint to ______ instability
1b. Secondary _____ stabilizer

1c. Forearm in neutral rotation, lateral portion of articular margin devoid of cartilage (roughly between ______ and ______)

Coronoid process
2a. Provides an _____ and _____ buttress to ulnohumeral joint.

2b. Resists ________ beyond 30 deg of flexion

2c. Fracture fragment always has some ______ attached
(useful in repair)

1. Radial head
1a. Posterolateral rotatory instability (PLRI)

1b. Valgus stabilizer

1c. radial styloid and listers tubercle

2. Coronoid process
2a. Anterior and varus

2b. Post subluxation

2c. Anterior capsule (**useful in repair)

48

Terrible Triad Injury of Elbow

Medial collateral ligament (MCL)

1. Three components of MCL?

1. MCL - 3 components:
a. Anterior bundle
- most important to stability: restraint to valgus and PMRI
- inserts on sublime tubercle (AM facet of coronoid)
- specifically inserts 18.4mm dorsal to tip of coronoid process

b. Posterior bundle

c. Transverse ligament

49

Terrible Triad Injury of Elbow

Lateral collateral ligament (LCL)

1. Insertion

2. Primary restraint to ____?

3. Four components of LCL

4. When injured is usually avulsed off of the ______?

1. Supinator crest distal to lesser sigmoid notch

2. Posterolateral rotatory instability

3. Four components
a. lateral UCL ligament (most important for stability)
b. Radial collateral ligament
c. Annular ligament
d. Accessory collateral ligament

4. Lateral epicondyle

50

Terrible Triad Injury of Elbow

Treatment : Nonop

1. immobilize in 90 deg of flexion for 7-10 days

2. Indications (rare)
- ulnohumeral and radiocapitellar joints must be concentrically reduced
- radial head fx must not meet surgical indications
- coronoid fx must be small
- elbow should be sufficiently stable to allow early ROM

3. Technique
- one week of immobilization followed by progressive ROM
- active motion initiated with resting splint at 90 degrees, avoiding terminal extension
- static progressive extension splinting at night after 4-6 weeks
- strengthening protocol after 6 weeks

51

Terrible Triad Injury of Elbow

Treatment : Operative

1. ORIF versus radial head arthroplasty, LCL reconsutrction, coronoid ORIF, possible MCL reconstruction

2. Indications
- terrible triad elbow injury that includes an unstable radial head fracture, a type III
- coronoid fracture, and an associated elbow dislocation
coronoid avulsion fractures involving less than 10% of the coronoid do not confer elbow stability in cadaveric studies and therefore do not require repair
(Note: should instability persist after addressing the radial head and the LCL complex in the presence of a small coronoid avulsion fracture, the next best step is MCL reconstruction)

52

Terrible Triad Injury of Elbow

Complications

1. Instability
-> more common following type I or II coronoid fractures

2. Failure of internal fixation
--> most common following repair of radial neck fractures (poor vascularity leading to osteonecrosis and nonunion)

3. Post-traumatic stiffness
- very common complication
- initiate early ROM to prevent

4. Heterotopic ossification
- consider prophylaxis in pts with head injury or in setting of revision surgery

5. Post-traumatic arthritis
- due to chondral damage at time of injury and/or residual instability

53

Capitellum Fractures


1. Definition

2. Epidemiology

a. __% of elbow fractures

b. __% of all distal humerus fractures

1. Coronal fracture of the distal humerus at capitellum

2. Epidemiology

a. 1% of elbow fractures

b. 6% of all distal humerus fractures

54

Capitellum Fractures

Pathophysiology

1. Mechanism

2. Pathoanatomy

1. Mechanism
- Typically, low-energy fall on outstretched hand
- Direct, axial compression with the elbow in a semi-flexed position creates shear forces

2. Pathoanatomy
- radiocapitellar joint is an important static stabilizer of the elbow
- capitellar fracture can cause potential block to motion and instability due to loss of the radiocapitellar articulation

55

Capitellum Fractures

1. Associated injuries

2. Prognosis

3. Reoperation rates

1. Associated conditions
- injuries to radial head and/or LUCL can occur up to 60% of the time

2. Prognosis
- most patients will gain functional range of motion but have residual stiffness
- surgical treatment results are generally favorable

3. Reoperation rates as high as 48% (mostly due to stiffness)

56

Capitellum Fractures

Classification

Bryan and Morrey Classification (with McKee modification)

Type I:
- Large osseous piece of the capitellum involved
- Can involve trochlea

Type II (Kocher-Lorenz fracture):
- Shear fracture of articular cartilage
- Articular cartilage separation with very little subchondral bone attached

Type III (Broberg-Morrey fracture):
- Severely comminuted
- Multifragmentary:

Type IV (McKee modification)
- Coronal shear fracture that includes the capitellum and trochlea

57

Capitellum Fractures

Non-op

Nonoperative
posterior splint immobilization for < 3 weeks
indications
nondisplaced Type I fractures (<2 mm displacement)
nondisplaced Type II fractures (<2 mm displacement)

58

Capitellum Fractures

Operative

1. ORIF
a. indications:
- displaced Type I fractures (>2 mm displacement)
- Type IV fractures

b. ORIF with lateral column approach: indications
- isolated capitellar fractures
- Type IV with trochlear involvement

c. ORIF with posterior approach +/- olecranon osteotomy: indications
- capitellar fractures with associated fractures/injuries to distal humuers/olecranon and/or medial side of the elbow

2. Arthroscopic-assisted ORIF: indications
- isolated type I # with good bone stock

3. Fragment excision: indications
- displaced Type II/III (>2 mm displ.)

4. Total elbow arthroplasty: indications
- unreconstructable capitellar fractures in elderly patients with associated medial column instability

59

Capitellum Fractures

Complications: (11)

1. Elbow contracture/stiffness (most common)

2. Nonunion (1-11% with ORIF)

3. Ulnar nerve injury

4. Heterotopic ossification (4% with ORIF)

5. AVN of capitellum

6. Nonunion of olecranon osteotomy

7. Instability

8. Post-traumatic arthritis

9. Cubital valgus

10. Tardy ulnar nerve palsy

11. Infection

60

Monteggia Fractures

1. define

2. epidemiology

3. prognosis

1. Proximal 1/3 ulnar fracture with associated radial head dislocation/instability

2. Epidemiology
- rare in adults
- more common in children with peak incidence between 4 and 10 years of age

*** NOTE: different treatment protocol for children

3. Prognosis
- If diagnosis is delayed greater than 2-3 weeks complication rates increase significantly

61

Monteggia Fractures

Classification


Bado Classification
Type I (60%): Fracture of the proximal or middle third of the ulna with anterior dislocation of the radial head (most common in children and young adults)

Type II (15%): Fracture of the proximal or middle third of the ulna with posterior dislocation of the radial head (70 to 80% of adult Monteggia fractures)

Type III (20%): Fracture of the ulnar metaphysis (distal to coronoid process) with lateral dislocation of the radial head

Type IV (5%): Fracture of the proximal or middle third of the ulna and radius with dislocation of the radial head in any direction

62

Monteggia Fractures

1. Most common nerve injury ?

2. Other complication to be aware of ?

1. PIN neuropathy (up to 10% in acute injuries - spontaneously resolves in most cases)

2. Malunion with radial head dislocation
- usually caused by failure to obtain anatomic alignment of ulna
- Treatment: ulnar osteotomy and open reduction of the radial head

63

Monteggia Fractures: Treatment

1. Adult

2. Paediatric

1. most adult fractures treated with operation

2. Closed reduction can be successful; MUST ensure stabilty and anatomic alignment of ulna fracture

64

Humeral Shaft Fractures

Incidence/Epidemiology
1. __to__% of all fracture

Epidemiology

2. Age group most often involved ?

1. Incidence ◦3-5% of all fractures

2. Bimodal age distribution

◾young patients with high-energy trauma

◾elderly, osteopenic patients with low-energy injuries

65

Humeral Shaft Fractures

Relevant anatomy

1. Muscle insertions (3)

2. Muscle origins (3)

3. Radial nerve course
3a. ___cm proximal to lateral epicondyle
3b. ____cm proximal to medial epicondyle

1. Insertion for: pec. major / deltoid / coracobrachialis

2. Origin for: brachialis / triceps / brachioradialis

3. Radial nerve (courses along spiral groove)

3a. 14cm proximal to the lateral epicondyle

3b. 20cm proximal to the medial epicondyle

66

Humeral Shaft Fractures

1. Classification system

2. What is a Holstein-Lewis fracture?

Descriptive:
- Fracture location: proximal, middle or distal third
- Fracture pattern: spiral, transverse, comminuted

2. Holstein-Lewis fracture:
◦ A spiral fracture of the distal one-third of the humeral shaft commonly associated with neuropraxia of the radial nerve (22% incidence)

67

Humeral Shaft Fractures

1. Indications for Non-op management? (ie. Criteria for acceptable alignment)

2. Is radial nerve palsy a contraindication to functional bracing/non-op Rx?

Indicated in vast majority of humeral shaft fractures

1. Criteria for acceptable alignment include:
◾< 20° anterior angulation
◾< 30° varus/valgus angulation
◾< 3 cm shortening

2. No

68

Humeral Shaft Fractures

Indications for surgery

1. Absolute indications for ORIF? (5)

2. Fracture type requiring orif (relative)

1a. open fracture
1b. vascular injury requiring repair
1c. brachial plexus injury
1d. ipsilateral forearm fracture (floating elbow)
1e. compartment syndrome

2. TV or short oblique

69

Humeral Shaft Fractures

Outcomes of treatment

1. Non-op:

1. Non-operative
- 90% union rate (>risk with prox third, oblique or spiral fx)
- varus ang is common but rarely has functional or cosmetic sequelae


70

Humeral Shaft Fractures: Operative Treatment

ORIF
1. Approach (2 main options)
a.
b.

1. Approaches

a) Anterolateral approach:
◾used for prox to middle third fx's
◾distal extension of the deltopectoral approach
◾radial nerve identified between the brachialis and brachioradialis distally

b) Posterior approach
◾used for distal to middle third fx's (can be extensile)
◾triceps may either be split or elevated with a lateral paratricipital exposure
◾radial nerve is found medial to the long and lateral heads and 2cm proximal to the deep head of the triceps
◾radial nerve exits the posterior compartment through lateral intramuscular septum 10 cm proximal to radiocapitellar joint
◾lateral brachial cutaneous/posterior antebrachial cutaneous nerve serves as an anatomic landmark leading to the radial nerve during a paratricipital approach


◦techniques ◾plate osteosynthesis commonly with 4.5mm plate (narrow or broad) ◾3.5mm plates may function adequately

◾absolute stability with lag screw or compression plating in simple patterns
◾apply plate in bridging mode in the presence of significant comminution

◦postoperative ◾full crutch weight bearing shown to have no effect on union

71

Humeral Shaft Fractures

ORIF

Technique

1. Plate used?

2. Absolute vs relative stability?

3. Post-op WB status?

Techniques
1. Plate osteosynthesis
-> commonly with 4.5mm plate (narrow or broad
-> 3.5mm plates may function adequately

2. Attain absolute stability with lag screw or compression plating in simple patterns
-> apply plate in bridging mode in the presence of significant comminution

3. Postoperative
-> full crutch weight bearing shown to have no effect on union

72

Humeral Shaft Fractures

Closed IMN: Technique
1. Antegrade OR retrograde ?

Closed IMN vs ORIF

2. Overall complication rates compared to ORIF?

3. Non-union rates compared to ORIF ?

4. Shoulder pain and functional outcomes compared to ORIF

5. Nerves at risk with distal (a) and prox (b) locking

6. WB status post-op (IMN)

1. Can be done antegrade or retrograde

2. IM nailing associated with higher total complication rates

3. Nonunion rates not shown to be different between IMN and plating in recent meta-analyses

4. increased rate in IMN vs ORIF (16-37%)
HOWEVER...
functional shoulder outcome scores (ASES scores) not shown to be different between IMN and ORIF

5a. Radial nerve

5b. Musculocutaneous nerve

6. FWB had no effect on union

73

Humeral Shaft Fractures

Complications

1. non-union
a. with operation ___%
b. without operation ___%

2. Malunion
a. Most common deformity?
b. higher risk in what # pattern?

1a. 5 to 10% in nonop

1b. 2 to 10% with surgery

2a. Varus angulation (rarely a functional or cosmetic issue)

2b. Tranverse

74

Humeral Shaft Fractures: Complications

Radial nerve palsy

1. incidence

2. What percent will improve with observation alone?

3. Spontaneous recovery found at a mean _(a)_ weeks, with full recovery at an average of _(b)_ months

4. Surgical exploration indications ?

1. Incidence
- 8-15% of closed fractures
- increased incidence distal third fractures
- neuropraxia most common injury in closed fractures and neurotomesis (injury) in open fractures

2. 85-90% improve with observation over 3 months

3a. 7 weeks

3b. 6 months

4. Surgical explortion
a) Open fx with radial nerve palsy (likely neurotomesis injury to the radial nerve)

b) closed fracture that fails to improve over ~ 3-6 months

c) Fibrillations (denervation) seen at 3-4 months on EMG

75

Distal Humerus Fractures

What are the 4 broad groups/types?

1. supracondylar fractures

2. single column (condyle) fractures

3. bicolumn fractures

4. coronal shear fractures

76

Distal Humerus Fractures

Epidemiology

1. incidence

2. Demographics

1. Incidence
◾distal intercondylar fractures are the most common fracture pattern

2. Demographics
◾most common in young males and older females

77

Distal Humerus Fractures

Pathophysiology

1. mechanism

2. pathoanatomy: elbow position affects fracture type
a) elbow flex< 90degrees
b) elbow flex> 90degrees



•Pathophysiology ◦mechanism ◾low energy falls in elderly
◾high energy impact in younger population

2. pathoanatomy
a) Elbow flexed < 90 degrees:
-> axial load leads to transcolumnar fracture
-> direct posterior blow leads to olecranon fracture with or without distal humerus involvement

b) Elbow flexed > 90 degrees
-> may lead to intercondylar fracture



78

Distal Humerus Fractures

Prognosis

Prognosis

◦majority of patients regain 75% of elbow motion and strength

◦goal is to restore elbow ROM 30-130 degrees of flexion

◦unsatisfactory outcomes in up to 25%

◦ treatment complex due to:
-> low fx line of one or both column
-> metaphyseal fragmentation of one or both columns
-> articular comminution
-> poor bone quality


79

Distal Humerus Fractures

1. Classification for Single column fractures

2. Classification for Two-column fractures

1. Milch: type I= lateral trochlear ridge intact / type II= fracture through lateral trochlear ridge

2. Jupiter
i. High T (above/at olecranon fossa)
ii. Low-T (below olecronon fossa - ***common)
iii. Y
iv. H (trochlea is free fragment - High AVN risk)
v. Medial Lambda (prox fx line exists medially)
vi. Lateral Lambda (prox fx line exists laterally)
vii. Multiplane T (T-type + coronal plane fx)

80

Distal Humerus Fractures: Treatment

1. Indications: Non-op

2. Indications: CRPP

3. Indications: ORIF

4. Indications: Total elbow arthropalsty

1. nondisplaced Milch Type I
(*** note: immobilize in pronation for medial condyle fractures vs supination for lateral condyle fractures)

2. Displaced Mich Type I fractures

3. ORIF
- supracondylar fractures
- intercondylar / bicolumnar fractures
- Milch Type II fractures

4. Distal bicolumnar fractures in elderly patients



81

Distal humerus fractures

Approach for ORIF

1. Best approach for increased articular surface exposure ?

Articular surface exposure ◾olecranon osteotomy 57%
◾triceps-reflecting 46%
◾triceps-splitting 35%

82

Distal humerus fractures

Approaches for ORIF

1. Posterior superficial approach
- raise full thickness medial and lateral soft tissue flaps
- elevate deep fascia to identify ulnar and radial nerves

2. Triceps splitting (Campbell):

3. Tricep sparing (known as paratricipital, Alonso-Llames, medial and lateral windows)
- Indications: extra articular fractures or fractures with simple articular split
- can be converted to olecranon osteotomy if needed

4. Olecranon osteotomy ◾indications: complex intra articular fragments and/or presence of coronal splint)

5. Triceps reflecting (Bryan-Morrey)

6. Triceps-reflecting anconeous pedicle (O'Driscoll)

7. Lateral muscles interval

83

Distal humerus fractures

What are the 2 fixation principles (O'Driscoll)



1. Fixation in the distal fragment must be maximized

2. All fixation in distal fragments should contribute to stability between the distal fragments and the shaft.

84

Distal humerus fractures

What are the fixation objectives (O'Driscoll)?

1. Every screw in the distal fragments should pass through a plate

2. Engage a fragment on the opposite side that is also fixed to a plate

3. As many screws as possible in the distal fragments

4. Screw should be as long as possible

5. Each screw should engage as many articular fragments as possible

6. The screws in the distal fragments should lock together by interdigitation, creating a fixed-angle structure
(note: this creates the architecural equivalent of an arch, which gives the most biomechanical stability)

7. Plates should be applied such that compression is achieved at the supracondylar level for both columns

8. The plates must be strong enough and stiff enough to resist breaking or bending before union occurs at the supracondylar level.

85

Distal humerus fractures

Technique and sequence of ORIF

1. countersunk / headless screw to fix articular fragments 1st after provisional reduction with k-wires
- if metaphyseal injury is not comminuted, reducing one column to the metaphysis first may be beneficial
- consider using positional screws when reducing trochlea to avoid narrowing it with compression

2. Next address condyles and epitrochlear ridge (lateral epicondyle- can fix with tension band wire or plate)

3. Two plates in orthogonal planes used to fix articular segment to shaft
- 3.5-mm LCDC plate or one of equivalent strength on lateral side
- place 2.7-mm or 3.5-mm LCDC plate on medial side
- interdigitate screws if possible to increase strength

4. New literature supports parallel plates

5. If ulnar nerve contacts medial hardware during flexion/extension, can transpose however literature does not support decreased ulnar n. symptoms with transposition

86

Distal humerus fractures

Post ORIF rehab

> place in splint with elbow in approx 70 degrees of flexion

> remove splint at 48 hours post-operatively, initiate ROM exercises

> If osteotomy performed patient may do active and active assisted flexion and extension for 6 weeks; no active extension against gravity or resistance

> if not osteotomy, permitted to do active motion against gravity without restrictions

> no restrictions to rotation

> Start gentle strengthening program at 6 weeks, and full strengthening program at 3 months

87

Distal humerus fractures

Complications

1. Elbow stiffness (most common)

2. Heterotopic ossification ◦reported rate of 8%
◦routine prophylaxis is not warranted (** >rate of nonunion in pt rx with indomethacin)

3. Nonunion
◦low incidence
◦avoid excessive soft-tissue stripping

4. Malunion: Avoided by proper surgical technique:
◾cubitus valgus (lateral column fxs)
◾cubitus varus (medial column fxs)

5. PTOA
6. Ulnar nerve injury
7. AIN Injury (can be seen with olecranon osteotomy)

88

Radial Head Fractures

Epidemiology
1. incidence = __to__% of all fractures

2. Represent ___% of all elbow fractures

Pathophysiology
3. mechanism of injury


Epidemiology

1. incidence = 1.5-4% of all fractures

2. 33% (among the most common elbow fractures)

3. FOOSH elbow ext + forearm in pronation (most force transmitted from wrist to radial head)

89

Radial Head Fractures

Associated injuries

35% have associated soft tissue OR bony injuries incl:
◾ligamentous injury
> LCL injury (most common - up to 80% on MRI)
> MCL injury
> Combined LCL/MCL

◾Essex-Lopresti injury:
>DRUJ injury
>iO membrane disruption

◾other elbow fractures
> coronoid fracture
> olecranon fracture

◾elbow dislocation
> terrible triad (elbow dislocation, radial head fracture, coronoid fracture)

◾carpal fractures
> scaphoid fracture


90

Radial Head Fractures

What is Essex-Lopresti injury?

Loss of longitudinal stability occurs when:
> radial head fracture + DRUJ injury + interosseous membrane disruption
◾radial head must be fixed or replaced to restore stability, preventing proximal migration of the radius and ulnocarpal impaction

91

Radial Head Fractures

Anatomy

1. Lateral collateral ligament complex made up of 4 ligaments ?

1. LCL
a. lateral ulnar collateral ligament (LUCL)

b. radial collateral ligament (RCL)

c. accessory lateral collateral ligament

d. annular ligament

92

Radial Head Fractures

Classification

Mason classification (modified by Hotchkiss and Broberg-Morrey)

Type I: Non- or min-displaced (<2mm) + no mechanical block

Type II: Displaced >2mm or angulated, possible mechanical block

Type III: Comminuted and displaced, mechanical block to motion

Type IV: Radial head fracture with associated elbow dislocation

93

Radial Head Fractures

Anatomy : MCL

1. Name the three bundles of MCL

1. Three bundles of MCL

a) anterior bundle

b) posterior bundle

c) transverse bundle

94

Radial Head Fractures

Imaging

1. XR

2. XR special views

1. recommended views:
- AP and lateral elbow (check for sail sign)

2. Additional views ◾radiocapitellar view (Greenspan view)
> oblique lateral view of elbow
> allows visualization of the radial head without coronoid overlap





95

Radial Head Fractures:

1. Assessing DRUJ

2. Assessing IO membrane

1. DRUJ
- palpate wrist for tenderness
- translation in sagittal plane > 50% compare to contralateral side is abnormal
may be difficult to determine on exam, can get dynamic CT scan in neutral, pronation and supination for subtle injury

2. Interosseous membrane
-> palpate along IO for tenderness
-> radius pull test
- >3mm translation concerning for longitudinal forearm instability (Essex-Lopresti)

96

Radial Head Fractures: Treatment

Surgical treatment

ORIF
1. Indications

2. Outcomes

1. ORIF: indications
- Mason Type II with mechanical block
- Mason Type III where ORIF feasible
- presence of other complex ipsilateral elbow injuries

2.ORIF: outcomes
- ORIF with 3 or more fragments worse outcome compared to ORIF with < 3

- ORIF of isolated fx's vs. complex fx's (other associated fracture/dislocation) show no significant difference in outcomes at 4 years

- Isolated fractures trended towards better Patient-Rated Elbow Evaluation score, lower complication rate and lower rate of secondary capsular release

97

Radial Head Fractures

Surgical treatment

1. Fragment excision

a.) Indications

b.) Outcomes

2. Radial Head Resection

a.) Indications

b.) Contraindications

1. Fragment excision (partial excision)

a. Indications
- fragments less than 25% of the surface area of the radial head or 25%-33% of capitellar surface area

b. Outcomes
- even small fragment excision may lead to instability

2. Radial head resection (complete excision)

a. Indications
- low demand, sedentary patients
- in a delayed setting for continued pain of an isolated radial head fracture

b. Contraindications
- presence of destabilizing injuries
- forearm interosseous ligament injury (>3mm translation with radius pull test)
- coronoid fracture
- MCL deficiency

98

Radial Head Fractures: Treatment

Surgical treatment

1. Radial Head Arthroplasty

a. Indications

b. Outcomes

2. Retrograde titanium nail reduction and stabilization

a. Indications

b. Outcomes

1. Radial Head Arthroplasty

a. Indications
- comminuted fractures (Mason Type III) with 3 or more fragments where ORIF not feasible and involves greater than 25% of the radial head

- elbow fracture-dislocations or Essex Lopresti lesions (**radial head excision will exacerbate elbow/wrist instability and may result in proximal radial migration and ulnocarpal impingement)

b. Outcomes
- radial head fractures requiring replacement have shown good clinical outcomes with metallic implants
- compared to ORIF for fracture-dislocations and Mason Type III fractures, arthroplasty results in greater stability, lower complication rate and higher patient satisfaction

2. Retrograde titanium nail reduction and stabilization

a. Indications
- not yet considered mainstream treatment as it is in the pediatric population

b. outcomes
- small powered case studies show good outcomes

99

Radial Head Fractures: Treatment

Approaches (2)

1. Kocher

2. Kaplan

Note:
* PIN crosses prox radius from ant to post within the supinator muscle 4cm distal to radial head

* In both Kocher and Kaplan, forearm pronated to protect PIN

100

Radial Head Fractures: Treatment

Kocher Approach

1. Interval

2. Key Steps

3. Pros (1)

4. Cons (1)

1. Btwn ECU (PIN) and Anconeus (radial n.)

2. Key steps
i. Incise post fibers of sup.

ii. Incise capsule in mid-radiocapitellar plane
(ant to crista supinatoris to avoid LUCL injury)

3. Pros: Less risk of PIN injury than Kaplan (more posterior)

4. Cons : risk of destabilizing elbow if capsule incision is too posterior and LUCL is violated, which lies below the equator of the capitellum

101

Radial Head Fractures: Treatment

Kaplan Approach

1. Interval

2. Key Steps

3. Pros (1)

4. Cons (1)

1. Btwn EDC (PIN) and ECRB (radial n.)

2. Key steps: i) incise mid-fibers of supinator
--> incise capsule ant- to mid-radiopatellar plane (have access)

3. Pros:
- Less risk of disrupting LUCL and destabilizing elbow than Kocher approach (more anterior)
- Better visualization of the coronoid

4. Cons: greater risk of PIN and radial nerve injury

102

Radial Head Fractures: Treatment

1. Safe-zone (non-articular) for plate placement

1. Safe-zone: posterolateral plate placement
consists of 90-110 degree arc from radial styloid to Lister's tubercle, with arm in neutral rotation to avoid impingement of ulna with forearm rotation

103

Galeazzi Fractures

1. Definition

2. Mechanism of injury

1. Definition: distal 1/3 radius shaft fx AND
associated distal radioulnar joint (DRUJ) injury

2. MOI
a. Direct wrist trauma (typically dorsolateral aspect)
b. FOOSH with forearm in pronation

104

Galeazzi Fractures

Incidence of DRUJ instability

Incidence of DRUJ instability

-> If radial fracture is <7.5 cm from articular surface = DRUJ unstable in 55%

-> If radial fracture is >7.5 cm from articular surface = DRUJ unstable in 6%

105

Galeazzi Fractures

DRUJ anatomy

1. What is the sigmoid notch ?

2. What 2 ligaments are the primary stabilisers of the DRUJ ?

3. Is the DRUJ more stable in pronation OR supination?

1. Sigmoid notch: found along ulnar border of distal radius it is a shallow concavity for the articulating ulnar head

2. Volar and dorsal radioulnar ligaments
function as the primary stabilizers of the DRUJ

3. Most stable in supination

106

Galeazzi Fractures

Xray signs of DRUJ injury (4)

1. ulnar styloid fx

2. widening of joint on AP view

3. dorsal or volar displacement on lateral view

4. radial shortening (≥5mm)

107

Proximal Humerus Fracture Malunion and Nonunion

Risk factors for nonunion

1. Fracture problems :
◾ 3 or 4 part fracture patterns
◾humeral head split
◾displaced tuberosity fractures

2. Patient problems
◾osteoporosis
◾chronic renal disease
◾chronic ETOH or steriod use
◾smoking

108

Proximal Humerus Fracture Malunion and Nonunion

Malunion happens due to:
1. ___________
2. ___________
3. ___________

Humeral head Malunion defined as:
4. Impaction >____cm
5.
6.

1. initial fracture displacement

2. secondary displacement after loss of reduction

3. failure of internal fixation

109

Proximal Humerus Fracture Malunion and Nonunion

Humeral head Malunion defined as:

Humeral head Malunion

110

Proximal Humerus Fracture Malunion and Nonunion

1. Humeral head

2. Greater Tuberosity

3. Lesser Tuberosity

1. Humeral head malunion: varus/valgus; impacted (>1cm displacement); articular surface incongruity (e.g. head split)]

2. Greater tuberosity malunion: (usually displaced posterior, superior and externally rotated)

3. Lesser tuberosity malunion (usually displaced medial

111

Proximal Humerus Fracture Malunion

Classification:

1. Beredjiklian

1. Beredjiklian
- Type I: Malposition of the GT or LT >1 cm

- Type II: Articular incongruity

- Type III: Articular surface malalignment >45° in the coronal, sagittal, or axial planes

112

Proximal Humerus Fracture Malunion

Classification:

1. Boileau et al.

Type I • Humeral head necrosis or impaction

Type II • Chronic dislocations or fracture-dislocations

Type III • Nonunion of the surgical neck

Type IV • Severe malunion of the tuberosity

113

Radius and Ulnar Shaft Fracture

1. Epidemiology ◦more

2. Associated conditions

3. Prognosis = functional results depend on restoration of ______________ ?

1. Epidemiology
- M > F
- Ratio of open:closed fx highest for any other fx except tibia

2. Associated conditions

◦ Elbow injuries
-> Galeazzi fractures
-> Monteggia fractures

◦ Compartment syndrome

3. Radial bow

114

Radius and Ulnar Shaft Fractures

Anatomy

1. Osteology

2. Interosseous membrane (IOM) is comprised of 5 key ligaments.
i
ii
iii
iv
v

Anatomy
1. Osteology
◦ axis of rotation of forearm runs through radial head (proximal) and ulna fovea (distal)
◦ distal radius effectively rotates around the distal ulna in pronosupination


2. Interosseous membrane (IOM) is comprised of 5 ligaments:
i) central band (key portion of IOM to be reconstructed)
ii) accessory band
iii) distal oblique bundle
iv) proximal oblique cord
v) dorsal oblique accessory cord



115

Elbow Dislocation

Epidemiology

1. Incidence

2. Demographics

Epidemiology

1. Incidence
◾elbow dislocations are the 2nd most common major joint dislocation after shoulder **(most common dislocated joint in children)
◾account for 10-25% of injuries to the elbow
◾posterolateral is the most common type of dislocation (80%)

2. demographics
◾predominantly affects patients between age 10-20 years old

116

Elbow Dislocation

What is the pathoanatomic cascade (ie. progression of injury / sequence of injury-ligament rupture) in elbow dislocation ?

1. Progression of injury is from lateral to medial:

◾LCL fails first (primary lesion)
--> by avulsion of the lateral epicondylar origin
--> midsubstance LCL tears are less common but do occur
◾MCL fails last depending on degree of energy

117

Elbow Dislocation: Classification

1. Anatomically

2. Simple vs Complex

1. Based on anatomic location of olecranon relative to humerus: (posterolateral=most common)

2. Simple vs. complex:
◾Simple=elbow dislocation with no associated fracture
--> accounts for 50-60% of elbow dislocations

◾Complex=elbow dislocation with associated fracture, may take form of:
i.) Terrible triad injury (Disloc+LUCL tear+radial head fracture+coronoid tip fracture
ii) Varus posteromedial rotatory instability=elbow injury assoc with LCL tear + coronoid fracture




118

Elbow Dislocation: Treatment

Non-operative
1. indications

Operative
2. indications

1. Non-op: Indications
◾acute simple stable dislocations
◾recurrent instability after simple dislocations is rare (<1-2% of dislocations)

2. ORIF (coronoid, radial head, olecranon), LCL repair, +/- MCL repair: Indications
◾acute complex elbow dislocations
◾persistent instability after reduction
◾unable to reduce closed



119

Elbow Dislocation: Surgical treatment

Coronoid ORIF
1. Rarely needed as most are tip fractures - ie proximal to insertion of __________?

Radial head fracture
2. what is the 'safe zone'

LCL/MCL repair
3. LCL _____ commonly repaired compared to MCL

4. MCL should be repaired or recon if ________ following LCL repair

1. Brachialis

2. 90° arc in the radial head that does not articulate with the proximal ulna (Arc between Lister's tubercle and the radial styloid)

3. LCL MORE commonly repaired compared to MCL
◾LCL - can repair or recon
◾ext origin avulsion common and may be repaired

4.MCL should be repaired or recon if ONGOING INSTABILITY following LCL repair

120

Radius and Ulnar Shaft Fractures

Nightstick fracture: Treatment

1. Indications for non-op Rx

2. Outcomes

Functional fx brace with good interosseous mold

1. Indications : Isolated nondisplaced or distal 2/3 ulna shaft fx (nightstick fx) with:
◾< 50% displacement and
◾< 10° of angulation

2. Outcomes
◾union rates > 96%
◾acceptable to fix surgically due to long time to union

121

Radius and Ulnar Shaft Fractures

1. Indications

2. Outcomes: Most important for functional outcome is ____?_____.

Operative: ORIF
1. Indications
◾displaced distal 2/3 isolated ulna fxs
◾proximal 1/3 isolated ulna fxs
◾all radial shaft fxs (even if nondisplaced)
◾both bone fxs
◾Gustillo I, II, and IIIa open fractures may be treated with primary ORIF (Gustillo IIIb/IIIc should have Ex-Fix initially)

2. Outcomes: most important variable in functional outcome RESTORING RADIAL BOW


122

Radius and Ulnar Shaft Fractures

Complications

1. Synostosis
- uncommon with an incidence of 3 to 9%
- assoc. with ORIF using a single incision approach
- Heterotopic bone excision can be performed with low recurrence risk as early as 4-6 months post-injury when prophylactic radiation therapy and/or indomethacin are used postoperatively

2. Infection
- 3% incidence with ORIF

3. Refracture: increased risk with:
◾removing plate too early
◾large plates (4.5 mm)
◾comminuted fx
◾persistent radiographic lucency
(◦do not remove plates before 15 mos / ◦wear functional forearm brace for 6 weeks and protect activity for 3 mos. after plate removal)

123

Distal Radial Ulnar Joint (DRUJ) Injuries

1. Associated injuries (5)

2. Prognosis

1. Associated conditions
◦ulnar styloid and distal ulna fractures
◦TFCC tears
◦ulnar impaction syndrome
◦Essex-Lopresti injuries
◦Galeazzi fractures

2. Prognosis
◦primary method to prevent disability related to DRUJ injuries is anatomic reduction of the distal radius which often results in an anatomically-reduced DRUJ

124

Distal Radial Ulnar Joint (DRUJ) Injuries

Ulnar Styloid Fractures

• Reflects high degree of initial fracture displacement

• Fractures through base often associated with TFCC rupture and instability

•Painful hypertrophic nonunions can occur in the absence of instability

Treatment (nonop): indications=nondisplaced fx's proximal to the ulnar styloid

Operative: ORIF, symptomatic fragment excision:
(i.) Indications:
◾displaced fractures through the base with associated instability
◾sigmoid notch fractures
◾Galeazzi fracture patterns
◾TFCC avulsions in the face of an unstable DRUJ

(ii.) Techniques
◾preserve ulnar attachments of TFCC with fragment excision




125

Distal Radial Ulnar Joint (DRUJ) Injuries

TFCC injury

1. Mechanism

2. Classfication

1. Mechanism of injury
◦wrist extension, forearm pronation
- in pronation, volar ligaments prevent dorsal subluxation / in supination, dorsal ligaments prevent volar subluxation

2. Classification
◦ Type I - traumatic
◦ Type II - degenerative (ulnocarpal impaction)
◾IIA - TFCC thinning
◾IIB - IIA + lunate and/or ulnar chondromalacia
◾IIC - IIB + TFCC perforation
◾IID - IIC + LT ligament disruption
◾IIE - IID + ulnocarpal and DRUJ arthritis


126

Distal Radial Ulnar Joint (DRUJ) Injuries

Ulnar Impaction Syndrome

1. Define

2. Sequelae include

3. Operative treatment

1. Radial shortening leads to positive ulnar variance and altered mechanics

2. Sequelae includes:
◦lunate chondromalacia
◦degenerative TFCC tears

3. Operative treatment
◦TFCC debridement
◦radial osteotomy
◦ulnar shortening post
◦distal ulnar resection (Wafer procedure) -> preserve ulnar attachment of TFCC


127

Brachial Plexus Injuries

1. Definition

2. Causes / Types (4)

1. Definition
- Traumatic brachial plexus injuries (BPIs) can involve any degree of injury at any level of the plexus
- More severe injury such as rupture of plexal segments or root avulsions are associated with higher energy trauma

2. Brachial Plexus injuries include
◾ Traumatic injury (this topic)
◾ Obstetric brachial plexus injury topic
- Erb's palsy (C5 and C6 upper trunk)
- Klumpke palsy
◾ Burners and stingers topic
◾ Parsonage-Turner Syndrome topic

128

Brachial Plexus Injuries

Epidemiology

1. Supraclavicular injuries

a. complete involvement of all roots is most common
__%-__% of traumatic BPIs

b. C5 and C6 upper trunk (Erb palsy)
__%-__% of traumatic BPIs

c. C8, T1 or lower (Klumpke palsy): ___%-___% of traumatic BPIs

Epidemiology

1. Supraclavicular injuries

a. complete involvement of all roots is most common
75%-80% of traumatic BPIs

b. C5 and C6 upper trunk (Erb palsy) - 20%-25% of traumatic BPIs

c. C8, T1 or lower (Klumpke palsy)- 0.6%-3.0% of traumatic BPIs

129

Brachial Plexus Injuries

1. Mechanism : high speed vehicular accidents (mostly motorcycle)
- account for 83% of traumatic BPIs

2. Caudally forced shoulder
- predominantly affect upper brachial plexus
- with high enough energy all roots can be affected

3. Forced arm abduction (as in grabbing onto something while falling)
- predominantly affects lower roots

130

Brachial Plexus Injuries

Prognosis

Prognosis
- recovery of reconstructed plexus can take up to 3 years
- nerve regeneration occurs at speed of 1mm/day
- infraclavicular plexus injuries have better prognosis than supraclavicular injuries
- upper plexus injuries have improved prognosis (*preservation of hand function)
- root avulsion (preganglionic injuries) have worst prognosis (*not repairable)
- other surgeries such as arthrodesis and tendon transfers may be needed

131

Brachial Plexus Injuries

Anatomy

1. Musculocutaneous (roots? )
a. roots
b. muscles
c. sensory

1. Musculocutaneous
a. C5-7
b. Coracobrachialis / Biceps / Brachialis
c. Lateral Cutaneous N. Forearm /

132

Brachial Plexus Injuries: Classification

Preganglionic vc Postganglionic

1. Define preganglionic

2. Define postganglionic

1. Preganglionic
◾avulsion proximal to dorsal root ganglion
◾involves CNS which does not regenerate – little potential recovery of motor function (poor prognosis)

2. Postganglionic
◾involve PNS
◾capable of regeneration (better prognosis)

133

Brachial Plexus Injuries: Classification

Preganglionic - presentation

Lesions suggesting preganglionic (2)
1.________
2._______


1. Horners syndrome (disruption of sympathetic chain)

2. Winged scapula medially
◾loss of serratus anterior (long thoracic nerve) rhomboids (dorsal scapular nerve) leads to medial winging (inferior border goes medial)

134

Brachial Plexus Injuries: Classification

Preganglionic

1. Signs preganglionic lesion (other than Horners and Winging scapula) [7]

2. Evaluation

i. Histamine test ?

ii. EMG ?

1. Signs preganglionic lesion
a) presents with motor deficits (flail arm)
b) sensory intact
c) absence of a Tinel sign or tenderness to percussion in the neck
d) elevated hemidiaphragm (phrenic nerve
e) rhomboid paralysis (dorsal scapular nerve)
f) supraspinatus/infraspinatus (suprascapular nerve)
g) latissimus dorsi (thoracodorsal)

Evaluation:
i. normal histamine test (C8-T1 sympathetic ganglion)
◾intact triple response (redness, wheal, flare)
ii. EMG may show loss of innervation to cervical paraspinals

135

Brachial Plexus Injuries: Classification

Postganglionic

Signs Postganglionic lesion
1. Motor?
2. Sensory

3. Evaluation
i. EMG ?
ii. Histamine test ?

Signs Postganglionic lesion
1. motor deficit (flail arm)
2. sensory deficits

3. Evaluation:
i. EMG shows maintained innervation to cervical paraspinals
ii. Abnormal histamine test ◾only redness and wheal, but NO flare

note: NCS shows absent motor conduction w/ intact sensory conduction; afferent sensory fibers will not undergo Wallerian degeneration following nerve root avulsion becuase because cell bodies of afferent sensory fibers are located in dorsal root gangion which resides distally; if nerve conduction velocity demonstrates absence of both sensory and motor then lesion is post gangionic.

136

Brachial Plexus Injuries: Preganglionic vc Postganglionic

Histamine test - explain ?

Histamine test:
- differentiate preganglionic and postganglionic lesions;
- if the nerve is interrupted proximal to ganglion, there is anesthesia along its cutaneous course, but the normal axon response will be seen;
- normal axon response can be demonstrated by placing a drop of histamine on the skin;
- the skin is scratched thru the histamine;
- triple response:
- vasodilatation, wheel formation, and flare;
- a sequential response consisting of cutaneous vasodilation and wheal formation are seen, the flare response is present;
- a normal response implies a preganglionic lesion and has a poor prognosis;
- if the flare response is negative then the lesion may be at a site where recovery may be possible after repair

137

Brachial Plexus Injuries: Preganglionic vc Postganglionic

EMG findings- explain ?

EMG findings:
- denervating potentials in the segmental paraspinal muscles innervated by the posterior primary rami;
- NCS shows absent motor conduction w/ intact sensory conduction
- afferent sensory fibers will not undergo Wallerian degeneration following nerve root avulsion becuase because cell bodies of afferent sensory fibers are located in dorsal root gangion which resides distally
- if nerve conduction velocity demonstrates absence of both sensory and motor then lesion is post gangionic;

138

Brachial Plexus Injuries

Upper Lesion: Erb's Palsy (C5,6)

1. Most common __________ brachial plexopathy
2. Results from ?
3. Etiology ?
4. Prognosis

1. Obstetric

2. Excessive displacement of head to opposite side and depression of shoulder on same side producing traction on plexus

3. Occurs during difficult ____in_____ or fall onto ______in______.

4. Best prognosis

139

Brachial Plexus Injuries

Upper Lesion: Erb's Palsy (C5,6)

Physical exam findings
1. Arm position ?
2. Deficits ?

1. Arm will be adducted, internally rotated, at shoulder; pronated, extended at elbow (“waiter’s tip”)

2. Deficits
• C5 deficiency
◦ weakness in deltoid, teres minor (axillary n.)
◦ weakness in supraspinatus, infraspinatus (SScap n)
◦ weakness to biceps (muscut n.)
•C6 deficiency
◦ weakness in brachioradialis, supinator (radial n)

140

Brachial Plexus Injuries

Lower Lesion: Klumpke Palsy (C8,T1)

1. ______ in obstetric palsy
2. Usually avulsion injuries caused by excessive ________
3. Other causes may include ?
4. Frequently associated with a ____ganglion injury and ________ Syndrome
5. Prognosis?

1. Rare

2. Excessive abduction (eg. person falling from height clutching on object to save himself)

3. Cervical rib, or lung mets in lower deep cervical lymph nodes

4. PREganglion injury and HORNERS syndrome

5. POOR prognosis

141

Brachial Plexus Injuries

Total Palsy (C5-T1)

Overview

• A form of brachial plexopathy

• Worst prognosis

• Leads to a flaccid arm

• Involves both motor and sensory

142

Brachial Plexus Injuries

Presentation

1. What is Horners syndrome

2. How long after injury does it present?

3. What does it represents?

1. Horner's syndrome: features include
◾drooping of the left eyelid
◾pupillary constriction
◾anhidrosis

2. Usually show up three days after injury

3. Disruption of sympathetic chain via C8 and/or T1 root avulsions

143

Brachial Plexus Injuries

Presentation

1a. Important muscles to test and assoc nerve
1b. Why ?

2. Pulses

1a. Serratus anterior (long thoracic nerve) and rhomboids (dorsal scapular nerve)

1b. If they are functioning then it is more likely the C5 injury is postganglionic

2. Pulses
◾check radial, ulnar and brachial pulses
◾arterial injuries common with complete BPIs

144

Brachial Plexus Injuries

Imaging ...

145

Brachial Plexus Injuries

Studies ...
emg
ncs
ncv
nap

146

Brachial Plexus Injuries: Treatment

Nonoperative

1. Details

2. Indications

3. early signs of recovery


1. observation alone waiting for recovery

2. indications
◾most managed with closed observation
◾guns shot wounds (in absence of major vascular damage can observe for three months)

3. signs of neurologic recovery
◾advancing Tinel sign is best clinical sign of effective nerve regeneration

147

Brachial Plexus Injuries: Treatment - Operative

Immediate surgical exploration = less than 7 days)
1. Indications (5)
2. Techniques (3)

Early surgical intervention (3-6 weeks)
3. Indicated for near total plexus involvement and with high mechanism of energy

Delayed surgical intervention (3-6 months)
4. Indications:
5. techniques :


Immediate surgical exploration = less than 7 days)
1. Indications: ◾sharp penetrating trauma (excluding GSWs); ◾iatrogenic injuries; ◾open injuries; ◾progressive neurologic deficits; ◾expanding hematoma or vascular injury
2. Techniques (◾nerve repair; ◾nerve grafting; ◾neurotization)

Early surgical intervention (3-6 weeks)
3. indicated for near total plexus involvement and with high mechanism of energy

Delayed surgical intervention (3-6 months)
4. Indications: (◾partial upper plexus involvement and low energy mechanism; ◾plateau in neurologic recovery ◾best not to delay surgery beyond 6 months)
5. techniques : ◾usually involves tendon/muscle transfers to restore function

148

Brachial Plexus Injuries: Treatment - Operative

Technique ....

149

Distal Third Clavicle Fractures

1. incidence = __to__% of clavicle fracture occur in the distal third segment
2. More commonly in __________ ?
3. Less common in _________ patients?
4. Mechanism ?
5. Fracture displacement depends on ? (4)


1. 10-15%

2. older or osteoportic patients

3. pediatric patients

4. similar mechanism to mid-shaft clavicle fractures- usually occur after a direct, compressive force applied to the shoulder after a fall or trauma

5. (i) Location (ii) pattern (iii) integrity of CC-ligs (iv) age

150

Distal Third Clavicle Fractures: Relevant Anatomy

AC joint stability consist of

1. static stabilizing factors (3)

2. dynamic stabilizing factors (2)



1 Static stabilizing factors
i) Acromioclavicular ligament (provides AP stability)

ii) Coracoclavicular ligaments (trapezoid and conoid)◾provides superior + inferior translation stability
◾trapezoid ligament (lateral)
◾inserts 3 cm from end of clavicle
◾conoid ligament (medial) **note: strongest
◾inserts 4.5 cm from end of clavicle

iii) capsule

2. Dynamic stabilizing factors
i) deltoid
ii. trapezius

151

Distal Third Clavicle Fractures Classification

Two most common classification systems

1. Eponymous name / Details
2. Which types are stable?

* also AO Classification - not tested here. Addit - Allman classification divides fractures into 3 grps: medial / midshaft / lateral)




1. Neer
Type 1: Fx LATERAL to CC-ligs with CC-ligs INTACT

Type 2a: Fx MEDIAL to CC-ligs

Type 2b: (2 types) between CC-ligs with Conoid torn but Trapezoid intact OR...Lateral to CC-lig and BOTH torn

Type 3: INTRA-ARTICULAR fracture extending into AC joint; Distal to CCligs which remain INTACT

Type 4: PHYSEAL Fx in paediatric popluation; Conoid and trapezoid ligaments remain INTACT

Type 5: COMMINUTED fracture pattern; Conoid and trapezoid ligaments remain INTACT and attached to comminuted fragment

3. Types 1 / 3 / 4 are STABLE injuries

152

Distal Third Clavicle Fractures: Treatment

Nonoperative
1. Details
2. Indications
3. Nonunion rate __to__%
4. Risk factors for nonunion
◾Neer group II = up to __%
◾_______ CC ligaments
◾______ age and ______ gender




1. sling immobilization with gentle ROM exercises at 2-4 weeks and strengthening at 6-10 weeks

2. Indications
◾stable fractures (Neer Type I, III, IV)
◾pediatric distal clavicle fractures (skeletally immature)

3. Nonunion (1-5%)

4. Risk factors for nonunion
◾56%
◾Disrupted CC-Ligs
◾advanced age and female gender

153

Distal Third Clavicle Fractures : Operative

ORIF - Absolute indications (4)

ORIF - Relative indications (5)

Absolute
◾open, or impending open, fractures
◾subclavian artery or vein injury
◾floating shoulder (e.g., distal clavicle and scapula neck fx with >10mm of displacement)
◾symptomatic nonunion

Relative
◾unstable fracture patterns (Type IIA, Type IIB, Type V)
◾brachial plexus injury (questionable b/c 66% have spontaneous return)
◾closed head injury
◾seizure disorder
◾polytrauma patient

154

Distal Third Clavicle Fractures

ORIF outcomes - advantages of ORIF (5)

ORIF outcomes - disadvantages of ORIF (3)


PROS
◾higher union rates
◾faster time to union
◾improved functional outcome / less pain with overhead activity
◾decreased symptomatic malunion rate
◾improved cosmetic satisfaction
CONS
◾ increased risk of need for future procedures
◾symptomatic hardware
◾infection

155

Distal Third Clavicle Fractures

Sling Immobilization

1. Details

2. Sling vs figure-of-eight outcomes ?

1. Details
◾sling or figure-of-eight
◾after 2-3 weeks begin gentle range of motion exercises
◾strengthening exercises begin at 6-8 weeks
◾no attempt at reduction should be made

2. Prospective studies have not shown difference between sling and figure-of-eight braces

156

Distal Third Clavicle Fractures

Open Reduction Internal Fixation

Options and use (2)



1. Limited contact dynamic compression plate (LC-DCP)
◾need larger distal fragment for multiple locking screws
◾>3 or 4 bicortical screws into medial fragment to reduce the risk of screw pull out

2. Hook plate
◾hook plates are generally used when there is insufficent bone in the distal fragment for conventional clavicle plate fixation
◾the hook should be placed posterior to AC joint and positioned as far lateral as possible to avoid hook escape
◾>3 or 4 bicortical screws should be placed into the medial fragment to reduce the risk of screw pull out
◾proper hook depth ensures the AC joint is not over- or under-reduced

(NOTE: approach same for both = ◾superior approach to AC joint ◾temporary fixation with k wires)

157

Distal Third Clavicle Fractures

Open Reduction Internal Fixation

Other types of fixation (apart from LC-DCP or Hook plate

1. AC joint spanning fixation
◾usually used as an alternative to hook plates

2. tension band wire

3. intramedullary screw

4. coracoclavicular ligament reconstruction (tightrope etc)

158

Distal Third Clavicle Fractures

Postoperative rehabilitation

1. early

2. late

1. Early
◾sling for 7-10 days followed by active motion

2. Late
◾strengthening at ~ 6 weeks when pain free motion and radiographic evidence of union
◾full activity including sports at ~ 3 month
◾hardware removal considered usually after 3 months

159

Distal Third Clavicle Fractures: Complications

Nonoperative treatment

1. nonunion = __to__%

2. Risks of non-union (5)

3. Treatment of nonunion?


1. Rate of nonunion = 1 to 5 %

2. Risk Factors for non-union
◾Fracture: comminution / Z deformity
(note: distal clavicle higher risk than middle third)
◾Patient factors: female ; older age ; smoker
(note: distal clavicle higher risk than middle third)

3. Treatment of nonunion
◾if asymptomatic, no treatment necessary
◾if symptomatic, ORIF with plate and bone graft (particularly atrophic nonunion)

160

Distal Third Clavicle Fractures: Complications

Operative treatment
1. hardware prominence
◾~___% of patient request plate removal
◾superior plates associated with _______ irritation
2. Hardware removal
◾mostly with ________ plates
3. Neurovascular injury = __%
◾_______ plates ssociated with increased risk of subclavian artery or vein penetration
4. nonunion = __to___%)
5. infection = ~____%
6. mechanical failure ~____%
7. Adhesive capulitis ____%
8. other

1. hardware prominence
◾30% of patient request plate removal
◾SUPERIOR plates associated with increased irritation
2. Hardware removal
◾mostly with HOOK plates
3. Neurovascular injury (3%)
◾SUPERIOR plates associated with increased risk of subclavian artery or vein penetration ◾subclavian thrombosis
4. Nonunion (1-5%)
5. Infection (~4.8%)
6. Mechanical failure (~1.4%)
7. Adhesive capsulitis
◾4% in surgical group develop adhesive capsulitis requiring surgical intervention
8. pneumothorax

161

Coronoid Fractures: Overview

1. Coronoid fractures are pathognomonic of ______

2. Coronoid fractures may be
a) isolated coronoid fracture : ______ common than previously thought

b) coronoid fracture + associated injuries
◾commonly occur with ________
◾associated with ________ after dislocation



1. An episode of elbow instability

2. Coronoid fractures may be
a) isolated coronoid fracture
◾LESS common than previously thought

b) coronoid fracture + associated injuries
◾commonly ccur with ELBOW DISLOCATION
◾associated with RECURRENT INSTABILITY after dislocation

162

Coronoid Fractures

1. Mechanism

2. Epidemiology: incidence = __to__% of elbow injuries

3. Prognosis

1. Mechanism = traumatic shear injury
◾typically occurs as distal humerus is driven against coronoid with an episode of severe varus stress or posterior subluxation
◾not an avulsion injury as nothing inserts on tip

2. 10-15%

3. Complications and reoperation rates are high

163

Coronoid Fractures : Pathoanatomy

Fractures at the coronoid base can amplify elbow instability given that _____ ?

Fractures at the coronoid base can amplify elbow instability given that

◾anterior bundle of the medial ulnar collateral ligament attaches to the sublime tubercle 18 mm distal to tip

◾anterior capsule attaches 6 mm distal to the tip of the coronoid

164

Coronoid Fractures

Associated conditions (4)

1. posteromedial rotatory instability
◾coronoid anteromedial facet fracture and LCL disruption
◾results from a varus deforming force

2. posterolateral rotatory instability
◾coronoid tip fracture, radial head fracture, and LCL injury

3. olecranon fracture-dislocation
◾usually associated with a large coronoid fracture

4. terrible triad of elbow
◾coronoid fracture (transverse fracture pattern)
◾ radial head fracture
◾elbow dislocation

165

Coronoid Fractures : Anatomy

Coronoid osteology

1. coronoid tip is an ______articular structure

2. Medial facet is important for ______ stability

Coronoid biomechanics

3. coronoid functions as an _____?

4. Primary resistor of __________ ?

1. Intraarticular (can be visualized during elbow arthroscopy)

2. VARUS stability (provides insertion for the medial ulnar collateral ligament)

3. Anterior buttress of the olecranon greater sigmoid notch (important in preventing recurrent posterior subluxation)

4. elbow subluxation or dislocation

166

Coronoid Fractures

Classification

1. Regan and Morrey

2. O'Driscoll

** note: sublime tubercle on the ulna is where the anterior bundle of the medial UCL attaches distally

1. Regan and Morrey
- Type 1 coronoid process tip fracture
- Type 2 fracture of 50% or less of height
- Type 3 fracture of more than 50% of height

2. O'Driscoll
- Subdivides coronoid injuries based on location and number of coronoid fragments
- Recognizes anteromedial facet fractures caused by varus posteromedial rotatory force
◾Fracture Tip: Subtype I <2mm coronoid ht /Subtype II >2mm
◾Fracture Anteromedial: types I = anteromedial rim; type 2 = anteromedial rim and tip; type 3 = anteromedial rim and sublime tubercle
◾Fracture Basal: Type 1 = coronoid body and base; type 2 = transolecranon basal coronoid fracture

167

Coronoid Fractures : Treatment

Nonoperative

1. details

2. indications


1. brief period of immobilization, followed by early range of motion

2. Indications
◾Type I, II, and III that are minimally displaced with stable elbow


168

Coronoid Fractures: treatment

Operative

Options and indications (4)
1 . _______
2 . _______
3. _______
4. _______


1a. ORIF with medial approach
◾Indications
◾Type I, II, and III with persistent elbow instability
◾posteromedial rotatory instability

2. ORIF with posterior approach
◾indications
◾olecranon fracture dislocation
◾terrible triad of elbow

3. Hinged external fixation
◾indications
◾large fragments
◾poor bone quality
◾difficult revision cases to help maintain stability

4. Hinged internal-external fixation
◾indications = same as 3

169

Coronoid Fractures: treatment

Operative technique

ORIF with medial approach

1. approach

2. technique

3. postoperative rehabilitation

1. approach
◾medial exposure through an interval between two heads of FCU
◾exposure more anteriorly through a split in flexor pronator mass

2. technique
◾cerclage wire or No. 5 suture through ulna drill holes for Type I injuries
◾ORIF with retrograde cannulated screws or plate for Type II or III injuries
◾ORIF with buttress plate fixation or pins and lateral ligament repair for posteromedial rotatory instability

3. Postoperative rehabilitation
◾depends on intraoperative exam following the procedure
◾thermoplastic resting splint
- applied with elbow at 90° and forearm in neutral
- restrict terminal 30° extension for 2-4 weeks
◾avoid shoulder abduction for 4-6 weeks
- to prevent varus moment on arm
◾early active motion
- dynamic muscle contraction may improve gapping of the ulnohumeral joint after surgical repair

170

Coronoid Fractures: treatment

Operative technique

ORIF with posterior approach ◦approach ◾posterior

1. approach

2. technique

1. approach
◾posterior

2. technique
◾mobilize olecranon fracture to access coronoid fracture for associated olecranon fracture-dislocations
◾repair coronoid fragment first prior to reducing main ulnar fracture
◾olecranon ORIF with dorsal plate and screws

171

Coronoid Fractures: treatment

Operative technique

ORIF with posterior approach ◦approach ◾posterior

1. approach

2. technique

1. approach
◾posterior

2. technique
◾mobilize olecranon fracture to access coronoid fracture for associated olecranon fracture-dislocations
◾repair coronoid fragment first prior to reducing main ulnar fracture
◾olecranon ORIF with dorsal plate and screws

172

Coronoid Fractures

1. Complications (5)

2. Early Failure is associated with _____________?


1. Complications (5)
i. Recurrent elbow instability ◦especially medial-sided
ii. Elbow stiffness
iii. Posttraumatic arthritis
iv. Heterotopic ossification
v. Early failure

2. Failure to recognize and repair underlying elbow instability

173

Olecranon Fractures

1. Epidemiology : age / injury type

2. Pathophysiology : mechanism





1. Epidemiology
◦bimodal distribution
◾high energy injuries in the young
◾low energy falls in the elderly

2. Pathophysiology
◦mechanism
◾direct blow -usually results in comminuted fracture
◾indirect blow
◾fall onto outstretched upper extremity
◾usually results in transverse or oblique fracture

174

Olecranon Fractures :Anatomy
Osteology
1. Together with coronoid process, forms the ___________ ?
2. greater sigmoid notch articulates with _____?
2a. provides _____________movement
2b. adds to ______ of elbow joint
Muscles: Triceps
3. Inserts onto ___________
4. blends with ___________
5. innervated by _________ (C_)
Muscles: anconeus
6. inserts on ?
7. innervated by _________ (C_)

1. greater sigmoid (semilunar) notch
2. trochlea
2a. flexion-extension
2b. stability

Triceps
3. posterior, proximal ulna
4. periosteum
5. radial nerve (C7)

Aconeus
6. lateral aspect of olecranon
7. radial nerve (C7)

175

Olecranon Fractures: Classification

Schatzker Classification



Schatzker Classification
Type A: Simple transverse fracture
Type B: Transverse impacted fracture
Type C: Oblique fracture
Type D: Comminuted fracture
Type E: More distal fracture, extra-articular
Type F: Fracture-dislocation

176

Olecranon Fractures: Classification

Colton Classification

◾Nondisplaced - Displacement does not increase with elbow flexion

◾Avulsion (displaced)

◾Oblique and Transverse (displaced)

◾Comminuted (displaced)

◾Fracture dislocation

177

Olecranon Fractures: Classification

Mayo

Based on comminution, displacement, fracture-dislocation

◾Type 1: Undisplaced (simple and comminuted)

◾Type 2: Displaced + stable elbow joint (simple and comminuted)

◾Type 3: Displaced + unstable elbow joint (simple and comminuted)

178

Olecranon Fractures: Presentation

1. Symptoms

2. Physical exam


1 Symptoms
◦pain well localized to posterior elbow

2. Physical exam
◾palpable defect: indicates displaced fracture or severe comminution
◾inability to extend elbow: indicates discontinuity of triceps (extensor) mechanism

179

Olecranon Fractures:Treatment

Nonoperative

1. Details

2. Indications

1. Details
◾immobilization in 45-90 degrees of flexion initially
◾begin motion at 1 week

2. Indications
◾nondisplaced fractures
◾displaced fracture is low demand, elderly individuals

180

Olecranon Fractures:Treatment

Operative Options (4)
1. Technique
1a. Indications
1b. Outcomes

2. Technique
2a. Indications

3. Technique
3a. Indications

4. Technique
4a. Indications
4b. Outcomes

1. Tension band technique
a) indications
◾transverse fracture with no comminution
b) outcomes
◾excellent results with appropriate indications

2. Intramedullary fixation
a) indications
◾transverse fracture with no comminution (same as tension band technique)

3. Plate and screw fixation
a) indications
◾comminuted fractures
◾Monteggia fractures
◾fracture-dislocations
◾oblique fractures that extend distal to coronoid

4. Excision and triceps advancement
a) indications
◾elderly patients with osteoporotic bone
◾fracture must involve <50% of joint surface
◾nonunions
b) outcomes
◾salvage procedure that leads to decreased extension strength
◾may result in instability if ligamentous injury is not diagnosed before operation

181

Olecranon Fractures: Operative

Tension band technique
1. Explain TBW biomechanics

2. engaging anterior cortex of ulna with Kirschner wires may prevent ___________.
3. HOWEVER avoid overpenetration of wires as may:
a.________________
b.________________

4. use ___-gauge wire in figure-of-eight fashion through drill holes in ulna

5. Cons (2)

1. converts distraction force of triceps into a compressive force

2. Wire migration

3a. May injury anterior interosseous nerve (AIN)

3b. May lead to decreased forearm rotation

4. 18-gauge wire

5. Cons:
◾high % of second surgeries for hardware removal (40-80%)
◾does not provide axial stability in comminuted fractures

182

Olecranon Fractures: Operative

Plate and screw fixation
1. place plate on ______ side
2. ______ fractures benefit from lag screws in addition to plate fixation
3. one-third tubular plates may not provide sufficient strength in ____________ fractures
4. May advance distal triceps tendon over plate to __________________?
5. Pros (1)
6. Cons (1)

1. Dorsal (tension) side

2. Oblique fractures

3. Comminuted fractures

4. Avoid hardware prominence

5. more stable than tension band technique

6. 20% need second surgery for plate removal

183

Olecranon Fractures

Complications (8)

1. Symptomatic hardware (most frequent reported complication)

2. Stiffness (occurs in ~50% of patients -usually doesn't alter functional capabilities)

3. Heterotopic ossification (more common with associated head injury)

4. Posttraumatic arthritis

5. Nonunion = rare

6 Ulnar nerve symptoms

7. Anterior interosseous nerve injury

8. Loss of extension strength

184

day 21 - DR#

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