Shoulder and Elbow Trauma and its Complications: Volume 2: The Elbow (Woodhead Publishing Series in Biomaterials) [1 ed.] 1782424504, 9781782424505

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Shoulder and Elbow Trauma and its Complications

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Woodhead Publishing Series in Biomaterials: Number 105

Shoulder and Elbow Trauma and its Complications Volume 2: The Elbow

Edited by

R. Michael Greiwe, MD

AMSTERDAM • BOSTON • CAMBRIDGE • HEIDELBERG LONDON • NEW YORK • OXFORD • PARIS • SAN DIEGO SAN FRANCISCO • SINGAPORE • SYDNEY • TOKYO Woodhead Publishing is an imprint of Elsevier

Woodhead Publishing is an imprint of Elsevier 80 High Street, Sawston, Cambridge, CB22 3HJ, UK 225 Wyman Street, Waltham, MA 02451, USA Langford Lane, Kidlington, OX5 1GB, UK Copyright © 2016 Elsevier Ltd. All rights reserved. No part of this publication may be reproduced or transmitted in any form or by any means, electronic or mechanical, including photocopying, recording, or any information storage and retrieval system, without permission in writing from the publisher. Details on how to seek ­permission, further information about the Publisher’s permissions policies and our ­arrangements with organizations such as the Copyright Clearance Center and the Copyright Licensing Agency, can be found at our website: www.elsevier.com/permissions. This book and the individual contributions contained in it are protected under copyright by the Publisher (other than as may be noted herein). Notices Knowledge and best practice in this field are constantly changing. As new research and ­experience broaden our understanding, changes in research methods, professional practices, or medical treatment may become necessary. Practitioners and researchers must always rely on their own experience and knowledge in evaluating and using any information, methods, compounds, or experiments described herein. In using such information or methods they should be mindful of their own safety and the ­safety of others, including parties for whom they have a professional responsibility. To the fullest extent of the law, neither the Publisher nor the authors, contributors, or ­editors, assume any liability for any injury and/or damage to persons or property as a matter of ­products liability, negligence or otherwise, or from any use or operation of any methods, ­products, instructions, or ideas contained in the material herein. ISBN: 978-1-78242-450-5 (print) ISBN: 978-1-78242-473-4 (online) British Library Cataloguing-in-Publication Data A catalogue record for this book is available from the British Library Library of Congress Control Number: 2015942311 For information on all Woodhead Publishing publications visit our website at http://store.elsevier.com/

Contents

List of contributors Woodhead Publishing Series in Biomaterials

Part One   Elbow trauma

xi xiii

1

1 Simple elbow dislocation 3 J.N. Shillingford and W.N. Levine 1.1 Introduction 3 1.2 Epidemiology 3 1.3 Elbow anatomy and biomechanics 4 1.4 Evaluation and initial management 5 1.5 Nonoperative management 8 1.6 Patient outcomes 8 1.7 Complications 9 1.8 Further directions 11 References11 2 Complex elbow dislocations 13 J.D. Wyrick and S.K. Dailey 2.1 Introduction 13 2.2 Anatomy 13 2.3 Elbow biomechanics 15 2.4 Valgus posterolateral rotatory injury 18 2.5 Varus posteromedial rotatory injury 29 2.6 Axial loading injuries 33 2.7 Complications of complex elbow dislocations 38 2.8 Future directions 40 2.9 Summary 41 References41 3 Management of acute and chronic distal biceps ruptures A.V. Metzler and R.M. Greiwe 3.1 Introduction 3.2 Distal biceps anatomy 3.3 Surgical anatomy 3.4 Epidemiology 3.5 Etiology

47 47 47 48 49 49

Contents

3.6 Clinical evaluation 49 3.7 Imaging 50 3.8 Treatment 50 3.9 Outcomes 57 3.10 Future trends 61 3.11 Conclusion 61 Disclosures62 References62











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4 Distal humerus fractures: open reduction and internal fixation 65 R.M. Greiwe 4.1 Introduction 65 4.2 Anatomy and biomechanics 66 4.3 Classification system 72 4.4 Preoperative evaluation 74 4.5 Surgical decision-making 77 4.6 Technical considerations 77 4.7 Principles of fixation 79 4.8 Surgical technique 81 4.9 Surgical factors that affect outcome 84 4.10 Coronal shear fractures 84 4.11 Postoperative rehabilitation 87 4.12 Outcomes 87 4.13 Complications 89 4.14 Future trends/additional sources of reference 92 References92 5 Arthroplasty for treatment of distal humerus fractures 99 B.M. Steen, M.M. Hussey and M.A. Frankle 5.1 Introduction 99 5.2 Evaluation and workup 102 5.3 Surgical techniques 105 5.4 Outcomes 110 5.5 Complications and their management 112 5.6 Important points 114 5.7 Future directions 115 5.8 Other resources and information 116 References116 6 Fractures of the proximal forearm N. Kazemi and R.M. Greiwe 6.1 Introduction 6.2 Anatomy 6.3 Evaluation of patients with proximal forearm fractures 6.4 Olecranon fractures 6.5 Radial head and neck fractures

119 119 119 121 121 131

vii

6.6 Summary 136 6.7 Future trends 137 References137



Contents

7 Fractures of the proximal radius and ulna: coronoid fractures 145 J.D. Wyrick and A.W. Jimenez 7.1 Introduction 145 7.2 Anatomy 145 7.3 Imaging 146 7.4 Mechanisms of injury and fracture patterns 148 7.5 Classification 150 7.6 Biomechanics 151 7.7 Management 153 7.8 Outcomes 161 7.9 Complications 162 7.10 Future directions 162 References163 8 Olecranon fractures 167 G.N. Lervick 8.1 Introduction 167 8.2 Anatomy 167 8.3 Fracture anatomy/classification 168 8.4 Epidemiology 169 8.5 Initial evaluation 170 8.6 Treatment 171 8.7 Rehabilitation 182 8.8 Complications 185 8.9 Future directions 187 8.10 Summary 187 Bibliography188 9 Fractures of the proximal radius and ulna: Monteggia injuries193 T.J. Parisi and J.B. Jupiter 9.1 Background 193 9.2 Anatomy 193 9.3 Classification/pattern of injury 194 9.4 Preoperative evaluation 198 9.5 Management 201 9.6 Postoperative management 210 9.7 Expected outcomes 212 9.8 Complications 213 9.9 Future directions 218 9.10 Sources for further reference 218 References218

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Part Two   Managing complications of elbow trauma

Contents

223

10 Persistent elbow instability 225 J.D. Wyrick and T.J. Keller 10.1 Introduction 225 10.2 Anatomy and biomechanics 225 10.3 Injury patterns 227 10.4 Imaging 230 10.5 Previous studies 230 10.6 Management 232 10.7 Surgical approach 233 10.8 Coronoid reconstruction 239 10.9 Postoperative management 240 10.10 Complications 240 10.11 Future developments 242 10.12 Summary 242 References243 11 Fracture of the radial head: fixation, failure, and replacement 247 T.C. Moen, D. Worrel and R.C. Ostermann 11.1 Introduction 247 11.2 Incidence/epidemiology 247 11.3 Anatomy/biomechanics of the radial head 247 11.4 Radial head fractures: clinical and radiographic assessment 248 11.5 Classification 248 11.6 Decision-making 249 11.7 Nonoperative treatment 249 11.8 Operative treatment—ORIF 250 11.9 Operative treatment—prosthetic replacement 250 11.10 Failure of treatment of radial head fractures 251 11.11 Conclusion 252 11.12 Future directions for research 253 References253 12 Distal humerus nonunion 257 E.C. Fu and D. Ring 12.1 Background/epidemiology 257 12.2 History and physical exam 257 12.3 Radiographic evaluation 258 12.4 Classification 258 12.5 Treatment techniques 258 12.6 Conclusions 266 12.7 Source for further reference 266 References267

Contents

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13 Olecranon and proximal ulna nonunion 269 M. Mighell 13.1 Introduction 269 13.2 Nonunions of nonoperatively treated olecranon and proximal ulna fractures 269 13.3 Nonunions of operatively treated olecranon fractures 277 13.4 Nonunions of operatively treated proximal ulna fractures 285 13.5 Technical pearls 289 13.6 Future trends/additional resources 289 References290 14 Treatment of the stiff elbow: capsular contracture and heterotopic ossification293 B.P. Kleinhenz 14.1 Introduction 293 14.2 Pathophysiology 294 14.3 Epidemiology 294 14.4 Classification 294 14.5 Presentation 296 14.6 Physical examination 297 14.7 Imaging 298 14.8 Management 299 14.9 Nonsurgical treatment 299 14.10 Surgical treatment 300 14.11 Lateral “column” procedure 301 14.12 Medial “over-the top” approach 301 14.13 Posterior “Outerbridge-Kashiwagi” procedure 302 14.14 Elbow arthroscopy for capsular stiffness 302 14.15 Arthroscopic debridement 303 14.16 Outcomes section 303 14.17 Complications section 304 14.18 Rehabilitation 305 14.19 Heterotopic ossification 306 14.20 Prophylaxis of HO 307 14.21 Conclusions 307 14.22 Areas for further research 308 References308 15 Complex post-traumatic elbow stiffness: nonunion, malunion, and post-traumatic arthritis G.A. Fierro Porto and R.M. Greiwe 15.1 Introduction 15.2 Pathophysiology 15.3 Classification

313 313 313 325

Contents

15.4 Medical decision-making 325 15.5 Treatment 327 15.6 Complications 339 15.7 Conclusions/future trends 342 References343







x

Index353

List of contributors

S.K. Dailey University of Cincinnati, Cincinnati, OH, USA G.A. Fierro Porto Universidad del Rosario – Fundación Santa Fe de Bogotá, Bogotá, Colombia M.A. Frankle Florida Orthopaedic Institute, Temple Terrace, FL, USA E.C. Fu Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA R.M. Greiwe Commonwealth Orthopaedic Centers, Edgewood, KY, USA M.M. Hussey Arkansas Specialty Orthopaedics, Little Rock, AR, USA A.W. Jimenez University of Cincinnati, Cincinnati, OH, USA J.B. Jupiter Massachusetts General Hospital, Harvard Medical School, ­Boston, MA, USA N. Kazemi Mount Sinai Medical Center, New York, NY, USA T.J. Keller University of Cincinnati, Cincinnati, OH, USA B.P. Kleinhenz TriHealth Hand Surgery Specialists, Cincinnati, OH, USA G.N. Lervick Minnesota Orthopedic Sports Medicine Institute (MOSMI), Twin ­Cities Orthopedics, Edina, MN, USA W.N. Levine New York Presbyterian/Columbia University Medical Center, New York, NY, USA A.V. Metzler Commonwealth Orthopaedic Centers, Edgewood, KY, USA M. Mighell The American Board of Orthopaedic Surgery, Chapel Hill, NC, USA; Department of Orthopaedic Surgery, University of South Florida, Tampa, FL, USA; Shoulder and Elbow Fellowship Program, Florida Orthopaedic Institute Tampa, FL, USA; Uniformed Services University of the Health Sciences, F. Edward Hébert School of Medicine, Bethesda, MD, USA

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List of contributors

T.C. Moen Carrell Clinic, Dallas, TX, USA R.C. Ostermann Medical University of Austria, Vienna, Austria T.J. Parisi Massachusetts General Hospital, Harvard Medical School, B ­ oston, MA, USA D. Ring Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA J.N. Shillingford New York Presbyterian/Columbia University Medical Center, New York, NY, USA B.M. Steen Florida Orthopaedic Associates, DeLand, FL, USA D. Worrel Carrell Clinic, Dallas, TX, USA J.D. Wyrick University of Cincinnati, Cincinnati, OH, USA

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Part One Elbow trauma

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Simple elbow dislocation J.N. Shillingford, W.N. Levine New York Presbyterian/Columbia University Medical Center, New York, NY, USA

1

1.1  Introduction The elbow is a highly congruent joint with significant inherent stability [1]. It is the second most commonly dislocated upper extremity joint after the glenohumeral joint [2]. The mechanism of injury typically involves a fall onto an outstretched hand with the forearm positioned in extension and the upper arm in abduction. The nondominant upper extremity is more commonly affected. In younger patients, elbow dislocations usually occur secondary to high-energy trauma involving sports, a fall from height, or a motor vehicle accident. Elbow dislocations account for 10–25% of all elbow injuries [3]. Associated fractures of the upper extremity that may occur along with an elbow dislocation include fractures of the distal radius, ulnar styloid, and carpal bones as well as perilunar dislocations [2]. Residual loss of motion frequently occurs, but recurrent instability after a simple elbow dislocation is rare [1]. Impaired elbow function can significantly affect activities of daily living [4]. Simple elbow dislocation is defined as a disarticulation of the ulnohumeral and radiocapitellar joints secondary to capsuloligamentous disruption without persistent instability or concomitant fractures of the ulna, radius, or distal humerus [5] (see Figure 1.1). Simple dislocations are most often stable after closed reduction and rarely require operative intervention [6]. Contrastingly, complex dislocations of the elbow involve fractures of the ulna, radial head, and/or coronoid process leading to an unstable elbow joint.

1.2  Epidemiology The average yearly incidence of acute elbow dislocations is approximately 6 per 100,000, with the majority being simple dislocations [2]. There is a bimodal distribution, in which men more commonly dislocate in the second, third, and tenth decades secondary to high-energy injures whereas women are more likely to suffer this injury at all other age distributions, most commonly after low-energy trauma [7]. Simple dislocations are typically described by the direction of the dislocated ulna in relation to the proximal humerus. Approximately 90% of dislocations are posterior or posterolateral. Lateral, medial, and anterior dislocations are less common injuries. Anatomic features that predispose patients toward elbow dislocations include ligamentous laxity, as seen in patients with Ehlers-Danlos or Marfan’s syndrome, increased carrying angle, and a shallow olecranon fossa [8].

Shoulder and Elbow Trauma and its Complications. http://dx.doi.org/10.1016/B978-1-78242-450-5.00001-0 Copyright © 2016 Elsevier Ltd. All rights reserved.

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(a)

Shoulder and Elbow Trauma and its Complications

(b)

Figure 1.1  Anteroposterior (a) and lateral (b) radiographs of a 25-year-old right-handed man who fell from an 8-ft ledge, landing onto his outstretched dominant hand. Radiographs show a simple posterolateral elbow dislocation. Figures courtesy of Columbia University Center for Shoulder, Elbow, and Sports Medicine.

1.3  Elbow anatomy and biomechanics A thorough understanding of elbow biomechanics and the relevant anatomical stabilizers about the elbow is paramount in guiding treatment. Collectively, three complex articulations make up the elbow joint. These articulations include the radiocapitellar, ulnotrochlear, and the proximal radioulnar joints, which functionally allow for 2° of freedom about the elbow [7]. The ulnohumeral joint controls flexion and extension in the sagittal plane whereas the radiocapitellar and radioulnar joints control pronation and supination in the axial plane [9]. The highly conforming articulation between the trochlea and the greater sigmoid notch of the proximal ulna provides the primary bony stabilization to the elbow. The coronoid process acts as a buttress to prevent against varus and axial forces that may cause posterior subluxation beyond 30° of elbow flexion. Laterally, the radial head articulates with the capitellum and the proximal ulna at the lesser sigmoid notch, providing secondary stability against valgus forces and posterior subluxation. Morrey et al. investigated the articular and ligamentous contributions to elbow joint stability in cadaver models and found that the joint articulation provided more than 50% of the resistance to varus stress in extension and approximately 75% at 90° of flexion [1]. Contrastingly, valgus stability was equally distributed among the anterior capsule, medial collateral ligamentous (MCL), and bony articulation in extension and accounted for approximately one-third of the resistance at 90° of flexion. The osseous articulations about the elbow provide minimal constraint against joint distraction compared with the collateral ligaments and capsule. The primary soft tissue stabilizers about the elbow include the MCL and lateral collateral ligamentous (LCL) complexes. The MCL complex is composed of

Simple elbow dislocation

5

Figure 1.2  Dissection of a right elbow with the flexor carpi ulnaris split demonstrating the medial collateral ligament complex. Note the articular cartilage directly beneath the ligament. Figures courtesy of Columbia University Center for Shoulder, Elbow, and Sports Medicine.

the transverse, posterior, and anterior bundles—the latter of which provides the primary contribution to elbow stability. The anterior bundle provides a primary restraint against valgus and posteromedial rotatory instability. It originates from the anteroinferior medial epicondyle, inferior to the axis of rotation, and inserts distal to the coronoid tip onto the sublime tubercle at the inferomedial border of the anteromedial facet [10] (see Figure 1.2). The LCL complex is composed of four distinct ligaments, including the annular, radial collateral, accessory lateral collateral, and the lateral ulnar collateral ligament (LUCL). The LUCL originates from the lateral epicondyle and inserts onto the proximal ulna at the supinator crest, providing primary restraints against both varus and posterolateral destabilizing forces. The secondary soft tissue stabilizers around the elbow include the joint capsule and the surrounding musculature. The anterior capsule inserts distal to the coronoid process and is typically ruptured during simple dislocations of the elbow [11]. The common extensor origin and flexor-pronator mass originate from the lateral and medial epicondyles, respectively, providing dynamic restraint against valgus and varus forces [12].

1.4  Evaluation and initial management A thorough history and physical exam are integral to the diagnosis and effective treatment of an acute simple elbow dislocation. The mechanism and precipitants leading to the dislocation are important factors that can be useful in parsing out the severity of the injury as well as any undiagnosed medical comorbidities (syncope, alcohol

6

Shoulder and Elbow Trauma and its Complications

dependence, neurologic diseases, etc.) [13]. High-energy trauma typically results in bony and ligamentous injuries whereas low-energy trauma involves primarily ligamentous and capsular disruption. The physical exam should begin with a visual inspection of the involved extremity. The examiner should assess for skin and tissue integrity (open wound, abrasions, etc.), obvious deformity, swelling, and areas of ecchymosis. An open wound in proximity to a dislocated elbow is considered a surgical emergency that may affect the timing of surgery. Medial-sided ecchymoses and swelling should alert the practitioner to a flexor-pronator, MCL, or medial coronoid injury (see Figure 1.3). The long bones and joints above and below the level of the injury should be examined for concomitant osseous or ligamentous pathology. Palpation of the joint surface for areas of tenderness may direct the examiner toward injured areas of interest. Examination of the interosseous membrane of the forearm for tenderness, and the distal radioulnar joint for instability, are essential to determining the presence of additional injuries. A thorough neurovascular exam should be performed and documented to note any signs or symptoms of compromise to the surrounding nerves or arteries before and after manipulative reduction. After reduction, gentle elbow range of motion (ROM) should be performed to assess for any blocks to motion and assess the degree at which the elbow is unstable. The recently dislocated elbow is most unstable in extension. Radiographs of the elbow must be obtained before and after manipulative reduction of the elbow joint to evaluate the direction of dislocation and associated periarticular fractures and to confirm concentric reduction of the elbow. Elbow radiographs should always include anteroposterior, lateral, and oblique views (see Figure 1.1). Radiocapitellar joint alignment can be assessed in any plane by drawing a line through the center of the radial neck, which should pass through the center of the capitellum. The initial treatment of a simple elbow dislocation involves manipulative reduction in the emergency room with the use of an intra-articular block with local

Figure 1.3  Clinical photo of a 21-year-old male after a simple dislocation. Note the profound ecchymoses diffusely but especially around the medial side of the elbow. Figure courtesy of Columbia University Center for Shoulder, Elbow, and Sports Medicine.

Simple elbow dislocation

7

anesthetics and/or conscious sedation for adequate analgesia and muscular relaxation [3]. On occasion, closed reduction may be immediately performed on the scene by trained medical personnel. However, if immediate closed reduction is challenging, caution is advised because nondisplaced fractures may be worsened by aggressive manipulation techniques. For closed reduction, the distal humerus and olecranon must be aligned in the coronal plane to correct for medial or lateral translation. The forearm should be flexed to 90° and fully supinated. Traction is applied across the joint in the axial plane while an assistant applies firm pressure over the olecranon tip as the forearm is flexed to slide the olecranon over the distal humerus. One typically appreciates an audible or palpable clunk signifying a stable reduction. The elbow must be taken through a full passive ROM [14] to assess for any blocks to motion, instability (typically in extension or to valgus stress), and degree at which there is a tendency to redislocate. This information is useful for the postreduction therapy protocol because braces may be used that prevent positions of instability. A thorough postreduction neurovascular examination is necessary to evaluate for and document any changes in the patient’s neurovascular status. Postreduction radiographs must be obtained to confirm a concentric reduction of the ulnohumeral and radiocapitellar joints and assess for any periarticular fractures (see Figure 1.4). A block to motion along with joint space widening may signify the presence of an entrapped chondral or osteochondral fragment, which requires surgical intervention [3]. Periarticular fractures require further assessment with computed tomography imaging of the elbow, particularly with fine cuts of the distal humerus in the axial plane as well as axial cuts of the proximal ulna and radius. Three-dimensional reconstruction views of the elbow should be obtained in all planes

Figure 1.4  Postreduction radiographs of same patient from Figure 1.1. (a) Postreduction anteroposterior radiograph and (b) postreduction lateral radiograph demonstrating concentric reduction without evidence of fractures. Figures courtesy of Columbia University Center for Shoulder, Elbow, and Sports Medicine.

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Shoulder and Elbow Trauma and its Complications

with inclusion of all three bones as well as subtracted views of the distal humerus and subtracted views of the radius and ulna.

1.5  Nonoperative management After stable concentric reduction of a simple dislocation, the elbow can be splinted in a long arm posterior splint at 90° of flexion for approximately 7–10 days [15]. Immobilization for periods longer than 3 weeks can result in elbow stiffness [16]. Studies have shown that early motion leads to improved functional outcomes and is integral to the prevention of elbow stiffness [17]. Elbows that are unstable at terminal extension require either a cast brace or orthosis with a block to extension. Early ROM exercises should be started after a short period of immobilization, with use of a sling or ROM brace for comfort. If still unstable in terminal extension, then interval splinting with gradual increases in extension over several weeks can be used. Radiographs should be obtained at 7 and 14 days to ensure maintenance of concentric reduction after the injury. In an elbow with suspected MCL or LUCL injuries, valgus and varus loading across the joint should be avoided during the initial postinjury period.

1.6  Patient outcomes Surgical intervention is rarely necessary for a simple elbow dislocation. Josefsson et al. retrospectively compared nonsurgical versus operative treatment for simple elbow dislocations and found no significant benefit to surgical intervention at 2 or more years postinjury [18]. The most common complaint in both treatment groups was limited ROM with a primary decrease in extension. In the surgically treated group, significantly more patients thought that their affected elbow was not as good as their uninjured elbow. A 2007 retrospective study by Maripuri et al. compared plaster immobilization for approximately 2 weeks versus sling with early mobilization of the elbow and found that the final functional outcome in the early mobilization group was significantly better when compared with the longer immobilization group [17]. At a minimum follow-up of 2 years, subjective questionnaire scores, including the Mayo Elbow Performance Index and the Quick Disabilities of the Arm, Shoulder, and Hand questionnaire were significantly greater in the early mobilization group and patients were able to return to work in half of the time. Ross et al. similarly noted 95% excellent functional outcomes and near full elbow motion with closed reduction followed by an early motion protocol, which involved immediate active ROM and absence of immobilization in a splint or sling [19]. It is thought that longer immobilization leads to a larger flexion contracture, stiffness, and pain after a simple elbow dislocation [17]. Early motion appears to inhibit periarticular adhesion formation and stimulate joint lubrication as well as orderly collagen formation, which deter the development of elbow stiffness [19].

Simple elbow dislocation

9

A recent prognostic study by Anakwe et al. reported long-term clinical and patient-reported outcomes after simple elbow dislocation. In this study, 56% of the patients reported residual subjective stiffness, 62% reported residual pain, and 8% noted subjective instability [20]. Satisfaction and questionnaire scores correlated with elbow ROM. Poorer scores were associated with limited flexion-extension arcs of motion, signifying that elbow ROM is a predictor of patient-reported outcomes and satisfaction.

1.7  Complications 1.7.1   Stiffness One of the most common complications after elbow dislocation includes loss of terminal extension and post-traumatic stiffness [3]. Stiffness tends to occur in the setting of capsular thickening and fibrous changes, which limit the arc of motion of the elbow necessary for activities of daily living. A retrospective long-term follow-up study by Josefsson et al. showed that loss of extension was the most common complication after nonoperative simple dislocation of the elbow [21]. In that study, more than onethird of the patients were found to have a decrease in the range of extension averaging 12 ± 12° that was associated with mild degenerative joint changes or periarticular calcification. Limiting the period of immobilization after injury and early motion exercises have been advocated to avoid this complication. Elbow stiffness after a dislocation can be addressed initially with dynamic elbow splints or progressive static splints by 4 weeks after injury [3]. Failure of nonoperative management after 6 months requires surgical treatment of post-traumatic elbow stiffness with a capsular release.

1.7.2   Neurovascular injuries Neurovascular injuries are uncommon in the setting of a simple elbow dislocation. Neurovascular complications tend to occur after more violent high-energy dislocations [2]. Damage to the brachial artery with distal ischemia can occur but is more commonly seen in open elbow dislocations with associated fractures. Arterial injury requires surgical intervention with direct repair using an interposition vein graft [3]. Delayed reconstruction with ischemia greater than 4 h requires prophylactic forearm fasciotomies to prevent the development of compartment syndrome [3]. Neurapraxia of the ulnar nerve is the most common nerve injury observed with elbow dislocations, followed closely by a median nerve compromise. The neurapraxia is typically secondary to traction on the nerve during the time of dislocation, which often resolves with time.

1.7.3   Heterotopic ossification Periarticular heterotopic ossification (HO) is a common occurrence after elbow dislocation. Calcification and ectopic bone formation within the surrounding ligamentous and soft tissue structures occur and may limit elbow ROM. HO occurs in less than 30%

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Shoulder and Elbow Trauma and its Complications

of all elbow dislocations and is typically located more often below the medial epicondyle compared with the lateral [2]. HO primarily involves short segments of the collateral ligaments and the anterior capsule. In his long-term follow-up study of simple elbow dislocation, Josefsson et al. noted the development of periarticular calcification in more than 75% of patients at an average of 24 years after the injury, which correlated with a significant loss of extension of approximately 10° [21]. Patients who may be at high risk for the development of HO include those with closed head injuries, aggressive joint manipulation after dislocation, or those in which surgical intervention was delayed [3]. Nonsteroidal anti-inflammatory medication or low-dose irradiation can be used to prevent the development of HO in high-risk patients. Surgical intervention should be delayed until the ossification has matured, which can take up to 6 months [3].

1.7.4  Recurrent instability Recurrent instability occurs in less than 1–2% of simple elbow dislocations and often requires significant soft tissue damage around the distal humerus [2,3]. Instability occurs secondary to disruption of the medial and lateral ligamentous complexes primarily at their humeral origins as well as disruption of the secondary muscular stabilizers [22]. According to O’Driscoll et al., dislocation in the setting of a posterolateral rotational moment is the final of three sequential stages of elbow instability that progresses from lateral to medial in regard to capsuloligamentous tissues around the elbow [23]. Each stage correlates with a clinical degree of instability with the first stage representing posterolateral rotatory subluxation secondary to a primary disruption of the LUCL. Persistent symptomatic snapping with a positive lateral-pivot shift sign represents posterolateral rotatory instability [23]. In this study, release of the LCL complex and anterior capsule resulted in an incomplete posterior dislocation labeled the “perched” position, which represents the second stage of instability. There is increased anterior and posterior capsule disruption along with increased varus instability. In this stage, the anterior MCL is intact and the elbow is stable to valgus stress. Recurrent dislocations occur in stage 3 instability, with stage 3a involving complete dislocation after transection of the posterior portion of the MCL and posterior capsule with an intact anterior MCL. The final stage, 3b, involves complete disruption of the anterior MCL with resulting gross instability. Prior studies have shown no advantage to early collateral ligament repair compared with early motion in the treatment of simple elbow dislocations [24]. Surgical treatment is rarely necessary for simple elbow dislocations, except for the patient experiencing recurrent instability. Articular congruence in combination with an intact musculotendinous complex work in concert to stabilize the elbow, allowing the damaged ligaments to heal. Surgery should be considered for elbows that require more than 50° of flexion to remain reduced [3]. The medial and lateral ligamentous complexes are surgically repaired in elbows that are persistently unstable after simple dislocations. In older patients, a lateral soft tissue repair is often adequate whereas in younger patients who have suffered a high-energy injury, the medial capsuloligamentous structures must be addressed [6]. On the lateral side of the elbow, both the lateral ligamentous complex and extensor mass can be repaired using transosseous sutures

Simple elbow dislocation

11

or bone anchors. Likewise, the MCL and flexor-pronator mass can be repaired on the medial side of the elbow, taking care to protect the ulnar nerve. In younger patients, the stability of the repair can be enhanced by repairing the anterior capsule to the coronoid process. In a study of 31 simple elbow dislocations, Josefsson et al. noted that all elbows were unstable to valgus stress, less than one-third were unstable to varus stress, and approximately one-third were redislocatable when examined under anesthesia [22]. Upon surgical exploration, all ligaments on the medial side were found to be ruptured or avulsed requiring repair. Lateral instability was then assessed, and repair of the lateral ligaments were required in less than 60% of the study patients. All elbows in the study were also found to have significant anterior capsule damage and varying degrees of musculotendinous ruptures. Recurrently unstable elbows or chronically unreduced elbow dislocations can also be treated with a static or dynamic external fixator, which keeps the elbow in a concentrically reduced position while the surrounding soft tissues heal [25]. Static fixators are advantageous because of ease of application, ready availability, and the temporary nature of their use. Dynamic fixators are more difficult to apply, but they allow early and controlled motion about the elbow. The most challenging and important step in dynamic fixator application involves the humeral axis pin. In the sagittal plane, the axis pin should pass through the center of the capitellum and just anterior and distal to the medial epicondyle.

1.8  Further directions A few studies have shown improved subjective scores, functional outcomes, less pain, and improved ROM in patients who have undergone functional treatment for a simple elbow dislocation compared with plaster immobilization or surgical intervention [26]. However, the level and quality of evidence is low given the lack of randomized controlled trials investigating the treatment of simple elbow dislocations. More high-quality randomized controlled trials with larger sample sizes and power are necessary to determine whether functional treatment for a simple elbow dislocation is the best treatment compared with bracing or surgical intervention. Early active mobilization has been shown to be a safe and cost-effective treatment for simple elbow dislocations, leading to favorable functional outcomes and improved satisfaction. Studies focusing on the development of a more highly structured rehabilitation and early mobilization program are necessary to promote successful recovery after simple dislocation of the elbow.

References [1] Morrey BF, An KN. Articular and ligamentous contributions to the stability of the elbow joint. Am J Sports Med 1983;11(5):315–9. [2] Linscheid RL, Wheeler DK. Elbow dislocations. JAMA 1965;194(11):1171–6. [3] Cohen MS, Hastings 2nd H. Acute elbow dislocation: evaluation and management. J Am Acad Orthop Surg 1998;6(1):15–23.

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[4] Fornalski S, Gupta R, Lee TQ. Anatomy and biomechanics of the elbow joint. Tech Hand Up Extrem Surg 2003;7(4):168–78. [5] Kuhn MA, Ross G. Acute elbow dislocations. Orthop Clin North Am 2008;39(2):155–61. v. [6] Rockwood CA, Green DP, Bucholz RW. Rockwood and Green’s fractures in adults. 7th ed. Philadelphia, PA: Wolters Kluwer Health/Lippincott Williams & Wilkins; 2010. [7] Stoneback JW, et al. Incidence of elbow dislocations in the United States population. J Bone Joint Surg Am 2012;94(3):240–5. [8] Habernek H, Ortner F. The influence of anatomic factors in elbow joint dislocation. Clin Orthop Relat Res 1992;274:226–30. [9] Tashjian RZ, Katarincic JA. Complex elbow instability. J Am Acad Orthop Surg 2006;14(5):278–86. [10] Cage DJ, et al. Soft tissue attachments of the ulnar coronoid process. An anatomic study with radiographic correlation. Clin Orthop Relat Res 1995;320:154–8. [11] Ashwood N, Bain GI, Unni R. Management of Mason type-III radial head fractures with a titanium prosthesis, ligament repair, and early mobilization. J Bone Joint Surg Am 2004;86-A(2):274–80. [12] Ikeda M, et al. Open reduction and internal fixation of comminuted fractures of the radial head using low-profile mini-plates. J Bone Joint Surg Br 2003;85(7):1040–4. [13] Mathew PK, Athwal GS, King GJ. Terrible triad injury of the elbow: current concepts. J Am Acad Orthop Surg 2009;17(3):137–51. [14] Wadstrom J, Kinast C, Pfeiffer K. Anatomical variations of the semilunar notch in elbow dislocations. Arch Orthop Trauma Surg 1986;105(5):313–5. [15] Mehlhoff TL, et al. Simple dislocation of the elbow in the adult. Results after closed treatment. J Bone Joint Surg Am 1988;70(2):244–9. [16] Broberg MA, Morrey BF. Results of treatment of fracture-dislocations of the elbow. Clin Orthop Relat Res 1987;216:109–19. [17] Maripuri SN, et al. Simple elbow dislocation among adults: a comparative study of two different methods of treatment. Injury 2007;38(11):1254–8. [18] Josefsson PO, et al. Surgical versus nonsurgical treatment of ligamentous injuries following dislocations of the elbow joint. Clin Orthop Relat Res 1987;214:165–9. [19] Ross G, et al. Treatment of simple elbow dislocation using an immediate motion protocol. Am J Sports Med 1999;27(3):308–11. [20] Anakwe RE, et al. Patient-reported outcomes after simple dislocation of the elbow. J Bone Joint Surg Am 2011;93(13):1220–6. [21] Josefsson PO, Johnell O, Gentz CF. Long-term sequelae of simple dislocation of the elbow. J Bone Joint Surg Am 1984;66(6):927–30. [22] Josefsson PO, Johnell O, Wendeberg B. Ligamentous injuries in dislocations of the elbow joint. Clin Orthop Relat Res 1987;221:221–5. [23] O’Driscoll SW, et al. Elbow subluxation and dislocation. A spectrum of instability. Clin Orthop Relat Res 1992;280:186–97. [24] Josefsson PO, et al. Surgical versus non-surgical treatment of ligamentous injuries following dislocation of the elbow joint. A prospective randomized study. J Bone Joint Surg Am 1987;69(4):605–8. [25] Jupiter JB, Ring D. Treatment of unreduced elbow dislocations with hinged external fixation. J Bone Joint Surg Am 2002;84-A(9):1630–5. [26] de Haan J, et al. Simple elbow dislocations: a systematic review of the literature. Arch Orthop Trauma Surg 2010;130(2):241–9.

Complex elbow dislocations J.D. Wyrick, S.K. Dailey University of Cincinnati, Cincinnati, OH, USA

2

2.1  Introduction Elbow dislocations with an associated elbow fracture are referred to as complex elbow dislocations. Complex elbow dislocations are now widely recognized as inherently unstable injuries. Unlike simple elbow dislocations, which rarely require operative intervention, complex elbow dislocations are typically managed surgically (Broberg & Morrey, 1987; Josefsson et al., 1989; Mezera & Hotchkiss, 2001; Tashjian & Katarincic, 2006). Complex dislocations are associated with various fractures, including radial head, proximal ulna, coronoid, or distal humeral fractures. Expected fracture patterns have been identified, allowing for the development of treatment protocols that yield predictable results (O’Driscoll et al., 2003; Pugh et al., 2004). Even the most unstable injury, the terrible triad, can be managed with acceptable outcomes (Hotchkiss, 1996; Mathew, Athwal, & King, 2009). Successful treatment of these complex injuries requires a thorough understanding of the associated anatomy, biomechanics, and injury patterns. Complex elbow dislocations can be categorized according to the mechanism of injury. This methodology is useful because it guides the surgeon as to where to look for injury, appreciate the severity, and subsequently plan treatment in a logical fashion (Ring & Jupiter, 1998; Steinmann, 2008; Wyrick et al., 2015). This chapter discusses the anatomy and biomechanics specific to elbow dislocations, the proper clinical evaluation of a patient with a complex elbow dislocation, and finally the different mechanisms of injury that cause fracture-dislocations of the elbow. Within the mechanism of injury framework, clinical and surgical decision-making, surgical technique, postoperative therapy, outcomes, and complications will be discussed.

2.2  Anatomy A thorough understanding of elbow anatomy is crucial for the treatment of complex elbow dislocations. The elbow is a constrained joint; therefore, stability is dependent on bony architecture. The joint is a complex structure consisting of three separate articulations: ulnohumeral, proximal radioulnar (PRUJ), and radiocapitellar joints. The greater sigmoid notch of the proximal ulna comprises the coronoid and olecranon processes, which are separated by a bare area (Figure 2.1). The greater sigmoid notch articulates with the trochlea of the distal humerus, forming the ulnohumeral joint, a tightly conformed joint responsible for the primary stability of the elbow. Forearm Shoulder and Elbow Trauma and its Complications. http://dx.doi.org/10.1016/B978-1-78242-450-5.00002-2 Copyright © 2016 Elsevier Ltd. All rights reserved.

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Shoulder and Elbow Trauma and its Complications

Figure 2.1  Cadaveric photograph of proximal ulna illustrates the greater sigmoid notch. The coronoid and olecranon processes are separated by a bare area.

(a)

(b) Posterior bundle Anterior bundle

Transverse ligament

Anterior capsule Radial collateral ligament Annular ligament

Posterior capsule Lateral ulnar collateral ligament

Figure 2.2  Illustration of the (a) medial and (b) lateral elbow demonstrates ligamentous restraints. Reprinted with permission from Tashjian and Katarincic (2006).

rotation occurs through the PRUJ, comprising the radial head and the lesser sigmoid notch of the ulna. The radial head is angled 15° relative to the shaft, which is important to remember during open reduction and internal fixation (ORIF) of radial head fractures. Cartilage covers approximately 270° of the circumference of the radial head, allowing for low-profile internal fixation that will not impinge on the ulna. The radial head and coronoid serve as important anterior buttresses for elbow stability. The coronoid is divided into the tip, the anterolateral facet, and the anteromedial (AM) facet. The AM facet provides varus stability and its sublime tubercle is the attachment site for the anterior band of the medial collateral ligament (MCL). The MCL and lateral ligament complexes are essential primary stabilizers of the elbow (Figure 2.2). The lateral ligament complex is composed of the lateral ulnar collateral ligament (LUCL), the radial collateral ligament, and the annular ligament. The LUCL originates from the lateral epicondyle of the distal humerus and inserts onto the crista supinatoris of the ulna, just distal to the annular ligament. It contributes to varus stability and is the major constraint against supination of the forearm away from the distal humerus (Dunning et al., 2001; Imatani et al., 1999). The annular ligament

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attaches to the anterior and posterior aspects of the lesser sigmoid notch, stabilizing the radial head position. The radial collateral ligament is a fan-shaped band extending from the lateral epicondyle to the annular ligament. The MCL comprises the anterior, posterior, and transverse bands. The anterior band originates from the anterior-inferior surface of the medial epicondyle, inserts onto the sublime tubercle of the medial facet of the coronoid, and provides valgus stability (Cage et al., 1995; O’Driscoll et al., 1992a).

2.3  Elbow biomechanics The ability to conservatively treat simple elbow dislocations, coupled with the tendency for complex dislocations to remain unstable without surgery, accentuates the importance of the bony architecture to elbow stability. Multiple cadaveric studies divided the local elbow structures into primary and secondary restraints and analyzed their contributions to elbow stability (Morrey & An, 1983; Morrey, Tanaka, & An, 1991). Although these studies provided an excellent foundation of knowledge, these studies were oversimplified, focusing primarily on varus and valgus forces. It is now appreciated that elbow fracture-dislocations are more complex and involve rotational and anterior-posterior forces in addition to varus and valgus forces.

2.3.1   Primary stabilizers The ulnohumeral articulation is a primary stabilizer of the elbow and provides approximately 50% of overall joint stability (Morrey & An, 1983). The MCL and lateral collateral ligament (LCL) are the other primary stabilizers providing the primary restraints to valgus and varus instability, respectively. Complex elbow dislocations have injury to one or more of the primary stabilizers, placing even more responsibility on the secondary stabilizers for elbow stability.

2.3.2   Secondary stabilizers Secondary stabilizers include the radial head, joint capsule, and the flexor and extensor origins (O’Driscoll et al., 2001). The radial head becomes essential to stability when the primary stabilizers, particularly the MCL, are damaged. The radial head and coronoid serve as anterior buttresses against posteriorly directed forces on the ulna (Schneeberger, Sadowski, & Jacob, 2004). The LCL is the primary constraint to posterolateral rotatory (PLR) instability, which is the most common mechanism for elbow dislocations (Charalambous & Stanley, 2008). The radial head also contributes to posterolateral stability by tensioning the LCL complex, and its removal even with intact ligaments results in almost 10° of increased posterolateral laxity (Schneeberger et al., 2004).

2.3.3  Mechanism of injury It is useful to consider injury patterns when managing complex elbow dislocations. O’Driscoll, Bell, and Morrey (1991) described the PLR instability pattern, in which the LUCL fails, allowing the radial head to roll out posteriorly from the capitellum.

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Shoulder and Elbow Trauma and its Complications

Figure 2.3  Illustration depicting the sequence of events after a PLR elbow dislocation mechanism. Reprinted with permission from O’Driscoll et al. (1992b).

The injury progresses from lateral to medial with failure of the anterior capsule, posterior dislocation of the ulna, and finally disruption of the MCL (Figure 2.3). This mechanism causes injuries ranging from simple dislocations to complex dislocations with associated radial head and coronoid fractures, also known as the terrible triad (O’Driscoll et al., 2003, 1992b; Ring, 2006). Injury to the LCL is a consistent finding in complex elbow dislocations. McKee et al. (2003) found that all cases (62 of 62) requiring operative treatment for unstable elbow dislocations had a concomitant LCL injury. These findings corroborate that the posterolateral mechanism is the most common mechanism for complex elbow dislocations. Another mechanism for elbow fracture-dislocations is the varus posteromedial mechanism, in which the body rotates externally around the planted hand, causing a varus deformity (Figure 2.4). The LCL ruptures and the AM facet of the coronoid fractures, allowing the forearm to internally rotate. The coronoid then clears the trochlea and dislocates posteriorly. This is opposite the more typical valgus posterolateral injury and highlights the importance of the medial bony structures. The AM facet of the coronoid particularly provides stability in the presence of a varus and posteromedial rotational force (Doornberg & Ring, 2006b). Without the AM buttress, the trochlea subluxes into the fracture defect, often resulting in subluxation without frank dislocation. During this injury mechanism, the radial head is not loaded; therefore, it is not fractured. A third mechanism of fracture-dislocations results from an axial loading force and is known as the transolecranon fracture-dislocation. With the elbow flexed, force is applied to the proximal ulna, resulting in the distal humerus being driven into the sigmoid notch of the ulna (Figure 2.5). The ligaments typically maintain their attachments to bony fragments; therefore, stable repair of the fracture will yield a stable elbow. Understanding the injury mechanism associated with complex elbow injuries allows the treating physician to anticipate and identify specific injury patterns. This

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Figure 2.4  Illustration of the varus posteromedial injury mechanism. Reprinted with permission from Wyrick et al. (2015).

Figure 2.5  Illustration of an axial loading mechanism, which may result in a transolecranon fracture-dislocation. Reprinted with permission from Wyrick et al. (2015).

knowledge can be used to formulate and apply a treatment strategy that results in consistently good outcomes for these very challenging injuries.

2.3.4   Clinical evaluation A thorough history should be obtained to understand the mechanism and amount of energy involved because higher energy mechanisms will often result in more structural damage as well as an increased likelihood of associated injuries. Specific injury patterns may be recognized and should be anticipated. After the history, a detailed physical examination should be performed. Inspection of the elbow should note any

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deformity and soft-tissue injuries such as open wounds, abrasions, or blisters that may affect the timing of surgery. A neurovascular examination should be completed and documented before any manipulation. If a dislocation is suspected, then basic radiographic imaging studies should be obtained before manipulating or testing range of motion (ROM) to avoid further damage to articular surfaces. Standard anteroposterior (AP) and lateral radiographs should be obtained. The dislocated elbow should be reduced using conscious sedation or general anesthesia as quickly as medically feasible. The reduction maneuver is axial traction with the elbow in extension, followed by flexion once the coronoid and radial head clear the distal humerus. Once reduced, the elbow is put through an arc of motion to assess stability. The position at which the elbow begins to dislocate should be noted. If the elbow is unstable at a flexion angle of 30° or more, then surgery is indicated. The elbow is splinted at 90°. The shoulder and wrist should also be examined for associated injuries, including evaluation of the distal radioulnar joint for a possible Essex-Lopresti injury. Postreduction radiographs are obtained and examined for concentric reduction and fractures about the elbow. The coronoid should be carefully examined to evaluate for fracture. If a terrible triad injury or coronoid fracture is suspected, then a computed tomography (CT) scan is recommended to assess the size of the coronoid fracture and determine the need for surgical intervention. The elbow should be reduced before obtaining the CT scan.

2.4  Valgus posterolateral rotatory injury Valgus posterolateral rotatory (VPLR) loading is felt to be the most common mechanism of injury leading to posterior elbow dislocations, both simple and complex (Ebrahimzadeh, Amadzadeh-Chabock, & Ring, 2010; Mathew et al., 2009). As a person falls on the outstretched arm, the hand is planted and the elbow is flexed slightly while the body rotates internally, exerting an external rotational force on the elbow (Figure 2.6). This supination of the forearm ruptures the LUCL, which allows rollout of the radial head posterior to the capitellum. The injury then progresses from lateral to medial, disrupting capsuloligamentous structures with the MCL being the last to rupture (O’Driscoll et al., 1991,2001). Depending on the degree and direction of valgus and axial forces, this mechanism can result in simple dislocations, dislocations with associated radial head fractures, or terrible triad injuries. The complex nature of these injuries makes it difficult to analyze biomechanical studies on elbow dislocations for guidance in treatment. Early studies on primary and secondary restraints focused on varus or valgus instability (An & Morrey, 2000; Hotchkiss & Weiland, 1987; Morrey & An, 1983; Morrey et al., 1991). As knowledge of clinical case series progressed, more studies have focused on the importance of the bony anatomy to elbow stability, especially when combined with capsuloligamentous injuries. It has been shown that if a complex dislocation can be converted to a simple dislocation, the elbow typically remains stable (Forthman, Henket, & Ring, 2007). In a series of 34 complex elbow dislocations, Forthman et al. (2007) found that stability was restored by reconstructing the bony injuries, with additional repair of the

Complex elbow dislocations

19

Figure 2.6  Illustrations of the valgus PLR injury. Reprinted with permission from Wyrick et al. (2015).

LUCL when ruptured. No patients required repair of the MCL. Repair or reconstruction of the LUCL has been shown to reliably restore stability clinically and in a VPLR instability model (Dunning et al., 2001; O’Driscoll et al., 1991). Because LUCL injury is consistently present in this mechanism, repair is a crucial component of treatment. Biomechanical studies have demonstrated the importance of the coronoid and radial head as stabilizers of the elbow in axial and posterolateral loading (Closkey et al., 2000; Jeon et al., 2012; Schneeberger et al., 2004). These structures form an anterior buttress with the coronoid making up 60% and the radial head 40% of the buttressing surface area (Jeon et al., 2012). The size of a coronoid fracture has also been demonstrated to affect elbow stability in biomechanical studies. Tip fractures of 10% or less of total height have minimal impact on elbow stability. Fractures involving 30% or more of the coronoid result in increasing instability of the elbow when combined with ligamentous injury (Schneeberger et al., 2004; Jeon et al., 2012). Management of VPLR injuries is dependent on the associated injury pattern. This section addresses the management of injury patterns that occur secondary to a VPLR injury.

2.4.1  Radial head fracture with dislocation Radial head fractures have been classified by the Hotchkiss modification of the Mason classification and are covered in more detail in Chapter 11 (Figure 2.6). Type I fractures are nondisplaced. Type II fractures are repairable fractures with 2 mm or less of

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Shoulder and Elbow Trauma and its Complications

displacement and no mechanical block to motion. Type III fractures are comminuted, irreparable fractures that require surgical excision with or without radial head replacement. Type IV fractures are any fracture with an associated elbow dislocation (Hotchkiss, 1997; Johnston, 1962; Mason, 1954). Management of these fractures with concomitant elbow dislocation is dependent on elbow stability. Small partial articular fractures may not require surgery, but fragments that involve 25% or more of the radial head require operative repair (­Beingessner et al., 2004; Mathew et al., 2009; Mezera & Hotchkiss, 2001). Although there are reported series treating comminuted radial head fractures with excision alone, even with associated elbow dislocation (Broberg & Morrey, 1987; Josefsson et al., 1989), more recent studies stress the importance of radial head replacement or repair when associated ligamentous injury is present (Mathew et al., 2009; O’Driscoll et al., 2003; Pugh et al., 2004; Tashjian & Katarincic, 2006). Nonoperative treatment may be considered if the elbow is able to extend to at least 30° before becoming unstable after reduction and there is no concomitant mechanical block to forearm rotation (Mathew et al., 2009). When comparing radial head replacement versus ORIF in terrible triad injuries, no significant difference in outcome scores has been shown (Leigh & Ball, 2012; Watters et al., 2014). Leigh and Ball (2012) reported on 24 patients—13 treated with ORIF and 11 with radial head replacement. No difference was noted in the American Shoulder and Elbow Surgeons (ASES) score, stability, or ROM. The patients with radial head replacement had slightly higher DASH (Disabilities of Arm, Shoulder, and Hand) scores and trended toward better pronation and supination. In a study by Watters et al. (2014), 39 patients with terrible triad injuries were treated—30 with radial head replacement and 9 with ORIF. The indication for replacement was the presence of four or more fracture fragments. Although no statistical difference was noted between groups in DASH, Broberg and Morrey scores, or ROM, 3 of 9 elbows treated with ORIF were unstable at final follow-up compared with 0 of 30 with radial head replacement. In addition, two patients who underwent ORIF had early fixation failures and three required revision surgery for instability. Pronation and supination outcomes were not reported. The replacement group was noted to have higher incidence of radiographic arthrosis at 18 months compared with ORIF, but this did not correlate with a difference in outcome scores. The difference in stability observed postoperatively may be explained by the better visualization afforded by radial head excision for fixation of the coronoid before replacement compared with ORIF. A laboratory study demonstrated increased stability with a rigid monopolar radial head prosthesis compared with a bipolar design (Moon et al., 2009). The literature currently supports ORIF and radial head replacement for unstable elbows with radial head fractures. In general, ORIF is indicated for less comminuted fractures and in younger patients.

2.4.2  Terrible triad injury The combination of a radial head fracture, coronoid fracture, and elbow dislocation, known as the terrible triad, is the most unstable injury pattern in the elbow. Recent biomechanical and technical advances have resulted in improved understanding and

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management of the terrible triad injury. For example, surgical protocols now address each component of the injury and have demonstrated improved outcomes over previous series (Forthman et al., 2007; Pugh et al., 2004). Coronoid fractures have most often been classified by the Regan and Morrey classification, which describes three categories of fracture (Regan & Morrey, 1989). Type I fractures involve only the tip of the coronoid, Type II fractures involve less than 50%, and Type III fractures involve more than 50% of the coronoid (Figure 2.7). A more comprehensive classification system introduced by O’Driscoll correlates with mechanism of injury and divides the fractures into three main groups: (1) tip fractures, (2) fractures of the AM facet, and (3) body or basal fractures (O’Driscoll et al., 2003;

(a)

(b)

(c)

(d)

Figure 2.7  Hotchkiss modification of Mason classification of radial head fractures. (a) Type I fractures are nondisplaced. (b) Type II fractures are repairable fractures with ≤2 mm displacement and no mechanical block to motion. (c) Type III fractures are comminuted, irreparable fractures that require surgical excision with or without radial head replacement. (d) Type IV fractures are any fracture with an associated elbow dislocation. Reprinted with permission from Mathew et al. (2009).

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Shoulder and Elbow Trauma and its Complications

Figure 2.8). Coronoid fractures associated with terrible triad injuries can be of any size but are most commonly less than 30–50% of the coronoid height (Dodds & Fishler, 2013; Doornberg & Ring, 2006a). As more research becomes available, it is evident that not all coronoid fractures need to be repaired. However, some authors have recommended repair of all coronoid fractures because of the unpredictable outcomes associated with this injury (­Ebrahimzadeh et al., 2010; Forthman et al., 2007; Mathew et al., 2009). Small tip fractures are felt to have minimal impact on overall stability and do not typically require surgical repair. Beingessner et al. (2007) studied the effect of Type I coronoid fractures in a repaired terrible triad model and found that repairing the MCL had a greater effect on stability than repairing the coronoid. Unfortunately, instability is assessed after the lateral structures are repaired, at which point the coronoid is no longer accessible and would require a second exposure. However, a recent clinical series reported successful treatment of terrible triad injuries with Regan and Morrey Type I and II coronoid fractures without repair of the coronoid or MCL, but these findings may be due to lower energy mechanisms observed in the series (Papatheodorou et al., 2014). In addition, Jeon et al. (2012) reported that removing 42% of the coronoid did not cause instability when the collateral ligaments and radial head were intact. However, when combined with radial head excision, the elbow became unstable. Despite this research, it is our opinion that Regan and Morrey Type II fractures should be repaired when encountered in a terrible triad injury because of the significant complications that follow recurrent elbow instability and that Type I fractures should be repaired if there are obvious signs of MCL damage. Simulated Regan and Morrey Type III fractures resulted in frank instability despite an intact radial head and collateral ligaments. Schneeberger et al. (2004) looked at simulated coronoid fractures of 30%, 50%, and 70% of the height, combined with radial head excision and intact ligaments. All variations of coronoid fracture resulted in instability, but only a fracture of 30% could be stabilized with radial head replacement alone. Fractures representing 50% and 70% of the coronoid required repair of the coronoid combined with radial head replacement

Figure 2.8  Regan and Morrey classification of coronoid fractures. Type I fractures involve only the tip of the coronoid, Type II fractures involve 50% of the coronoid. Reprinted with permission from Doornberg and Ring (2006a).

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23

to restore stability, even with intact ligaments. It is also important to realize that fractures of more than 50% of the coronoid include the sublime tubercle and the MCL attachment (Jeon et al., 2012). Therefore, it is recommended to repair the coronoid fracture in a terrible triad injury if the fracture is more than 30% of the coronoid height.

2.4.3   Clinical decision-making 2.4.3.1   Nonoperative management Complex elbow dislocations are rarely treated without surgery. Nonoperative management is only recommended if specific criteria are met (Mathew et al., 2009). The radial head fracture must be small and minimally or nondisplaced with no block of motion. The coronoid fracture must be a small tip fracture confirmed by CT. In addition, the elbow must be congruently reduced and, most importantly, stable with ROM to 30° of flexion (Chan et al., 2014). If all criteria are met, then the elbow is splinted at 90° flexion for 10–14 days and then placed in a hinged elbow brace blocking terminal extension. Depending on the assessment of elbow stability, the brace is set to allow 60° to full flexion and progressed 30° every 2 weeks so that full motion is allowed by 4 weeks.

2.4.3.2   Surgical management The protocol proposed by Pugh et al. (2004) has been shown to result in consistently successful outcomes. It was developed to address all components of the VPLR injury to the elbow. In summary, it includes (1) repair of the coronoid, (2) repair or replacement of the radial head, (3) repair of the LUCL, and (4) possible repair of the MCL or application of an external fixator if elbow instability persists.

2.4.3.3   Approach The surgical approach is either through a lateral or a universal posterior incision. The advantages of a lateral incision include a more direct exposure with the creation of smaller skin flaps. Most cases can be addressed from the lateral exposure, especially if replacement of the radial head is planned. The posterior incision allows for exposure from the lateral and medial aspects via a single incision, but it does create larger skin flaps with the potential, albeit uncommon, for hematoma and wound edge necrosis. The extensor digitorum communis (EDC) split is preferred over the standard Kocher interval between the anconeus and extensor carpi ulnaris, although the lateral interval may already be created in very high-energy injuries (Desloges et al., 2014; Hotchkiss & Weiland, 1987). This interval is located at the equator of the radial head and protects the LUCL for later repair. The anterior portion of the extensor origin is elevated off of the distal humerus along with the brachioradialis and brachialis. This provides excellent exposure of the anterior radial head, which is commonly sheared off, and the coronoid fragment.

24

(a)

Shoulder and Elbow Trauma and its Complications

(b)

(c)

Figure 2.9  O’Driscoll classification of coronoid fractures: (a) coronoid tip fractures, (b) fractures of the AM facet, and (c) body or basal fractures. Reprinted from Doornberg and Ring (2006a).

2.4.3.4  Management of the coronoid Starting from deep and working to superficial structures, the coronoid is addressed first. The exposure is simplified if the radial head is excised. In most terrible triad injuries, a suture-lasso technique is used to repair the coronoid as demonstrated by Garrigues et al. (2011). This particular technique has been shown to be superior to lag screws and suture anchors in restoring elbow stability while minimizing implant failure and fracture nonunion (Pugh et al., 2004; Figure 2.10). Lag screws placed posterior to anterior have been described, but it is technically challenging to achieve adequate stability utilizing this technique because these fractures are usually comminuted and small. The suture-lasso technique can be performed through a small supplemental incision made over the posterior border of the ulna. An anterior cruciate ligament (ACL) type drill guide is useful to drill from posterior to anterior. A nonabsorbable #2 braided suture is then passed around the coronoid fragment (making sure to capture the anterior capsule) and through the drill holes using a suture passer. The sutures are not tied until the radial head and LUCL have been repaired to ensure the coronoid is reduced and secured with the elbow joint reduced and flexed. Before repairing the radial head, one should visualize that the coronoid reduces appropriately by pulling on the sutures. It is not necessary that the coronoid be anatomically reduced (Dyer & Ring, 2010). Large basilar-type fractures should be anatomically repaired and may need a supplemental medial approach for fixation. The medial approach will be discussed in more detail in the section on varus posteromedial injuries.

2.4.3.5  Management of the radial head It should be reiterated that the radial head should not be excised without replacement when associated with an elbow dislocation. The goal should be to retain the native radial head, especially in the younger population. However, if stable fixation

Complex elbow dislocations

(a)

25

(b)

Figure 2.10  (a) Illustration of coronoid fixation using the suture-lasso technique (Reprinted with permission from Garrigues et al., 2011). (b) Illustration of an ACL guide used to aid the passage of suture for coronoid fixation (Reprinted from Mathew et al., 2009).

cannot be achieved, then better outcomes have been demonstrated with replacement (Chen et al., 2011; Ring, Quintero, & Jupiter, 2002; Watters et al., 2014). On the basis of recent literature, if the head is in three or more fragments, has missing fragments, or neck comminution is present, then radial head replacement is recommended, especially in the setting of the unstable elbow (Mathew et al., 2009; Ring et al., 2002). Partial articular fractures are usually more amenable to internal fixation. Appropriate screws are typically 1.5–2.0 mm and may be either traditional countersunk or headless screws. Neck fractures are fixed with mini-fragment 2.0- to 2.4-mm plates using newer anatomical locking plates or countersunk oblique screws (Mathew et al., 2009; Watters et al., 2014; Figure 2.11). If plates are required, then they should be positioned in the “safe zone” opposite the lesser sigmoid notch and PRUJ to prevent impingement with pronation and supination (Figure 2.12). When considering replacement, radial head fragments are excised and pieced together to measure for the appropriate-sized head and ensure that all fragments have been accounted for. Many severe terrible triad injuries can result in a radial head fragment lodged in the ulnar soft tissues. Most prostheses are modular, allowing for different head diameters and stem/neck heights. The implant must be correctly sized to avoid overstuffing the joint, which is associated with excessive wear on the capitellum and varus malalignment of the elbow (Doornberg et al., 2006, 2007). An estimation of the neck and head height required for reconstruction should be made before replacement. The prosthesis should match the coronoid surface of the lesser sigmoid notch and, on an AP radiograph, sit approximately 2 mm distal to the tip of the coronoid (Mathew et al., 2009; Figure 2.13).

26

Shoulder and Elbow Trauma and its Complications

(a)

(c)

(b)

Figure 2.11  (a) Lateral radiograph of the elbow demonstrates an elbow dislocation with concomitant radial head fracture. (b) Lateral and (c) AP radiographs demonstrate subsequent ORIF.

(a)

(b)

Figure 2.12  (a) Lateral radiograph of the elbow demonstrates a terrible triad fracture-dislocation with a comminuted radial head fracture. (b) Lateral radiograph of the elbow demonstrates reduction and radial head replacement.

Complex elbow dislocations

27

Figure 2.13  AP radiograph of the elbow demonstrates appropriate placement of radial head prosthesis.

2.4.3.6  Lateral ulnar collateral ligament The LUCL, or lateral ligament complex, is almost always avulsed from the distal humeral attachment and amenable to repair. This can be repaired with suture anchors or by passing sutures through transosseous tunnels. A running locking stitch passed through tunnels allows for excellent tensioning of the ligament, which can be difficult to achieve with suture anchors. Either technique requires attachment to the isometric point on the epicondyle, corresponding to the center of curvature of the capitellum. A #2 or #5 braided suture is used in a running locking stitch technique and passed through drill holes (Figure 2.14). The elbow is flexed to 90° and the sutures tied for the LUCL repair. The coronoid suture is then tied over the posterior ulna. Stability is tested by ranging the elbow under a lateral fluoroscopic view. A hanging arm test has also been described in which a bump is placed under the distal humerus, allowing the elbow to extend with gravity and again inspected under lateral fluoroscopy for subluxation (Forthman et al., 2007; Garrigues et al., 2011). There is concern that loosening of the coronoid or LUCL repair under gravity stress may occur (Dodds & Fishler, 2013). If subluxation is noted, particularly at 30° or more of flexion, then further intervention is required to ensure postoperative stability. Surgical options at this point are to explore the MCL and/or any additional coronoid fragment that has not been stabilized, apply a hinged or static external fixator, or cross-pin the ulnohumeral joint (Dyer & Ring, 2010; Mathew et al., 2009; Ring, Bruinsma, & Jupiter, 2014).

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Shoulder and Elbow Trauma and its Complications

Anterior capsule Radial collateral ligament Annular ligament

Posterior capsule

Lateral ulnar collateral ligament

Figure 2.14  Illustration of the elbow. A Krakow stitch is used to repair the LUCL with #2 or #5 braided suture.

2.4.3.7  MCL repair and external fixation The MCL or coronoid fragment can be approached through a flexor carpi ulnaris (FCU)-splitting or a Hotchkiss over-the-top approach. The ligament is repaired utilizing transosseous drill holes or a suture anchor if avulsed from the medial epicondyle. As techniques for repairing coronoid fractures via the lateral approach have improved, the need for MCL repair has decreased (Forthman et al., 2007). The use of hinged or static external fixators in acute cases has also decreased, except to protect tenuous fixation. These are more often required in cases of delayed or failed treatment. If the elbow can be held in a reduced position for 3–4 weeks, then it will typically remain stable (Figure 2.15). This can be accomplished with hinged or static external fixation or cross-pinning of the elbow. Ring et al. (2014) recently advocated cross-pinning because of its simplicity, reduced number of complications, and similar outcomes when compared with external fixators.

2.4.3.8  Postoperative protocol The elbow is splinted at 90° in neutral or pronated forearm rotation. Depending on elbow stability, motion is typically initiated within 1 week after surgery while terminal extension is blocked with a brace. Some authors have advocated using only a sling. Early motion is essential to avoid stiffness. Patients should be instructed not to abduct the shoulder to avoid varus stress on the elbow and protect the LUCL repair (Duckworth et al., 2008; Dyer and Ring, 2010). Another rehabilitation technique is the use of an overhead ROM protocol, which is especially useful for patients with mild postoperative subluxation or ulnohumeral gapping on radiographs. The patient lies supine with the humerus vertical, allowing gravity to flex the elbow, and the patient actively extends against gravity (Mathew et al., 2009).

Complex elbow dislocations

(a)

29

(b)

Figure 2.15  (a) Lateral radiograph of the elbow demonstrates residual instability after elbow ORIF. (b) A hinged external-fixator was used to restore elbow congruency.

If a static fixator or cross-pins are used, then they are typically removed by postoperative week 3 or 4 and elbow stability is assessed under anesthesia. Gentle elbow manipulation may be performed at the time of removal. Static progressive splinting may be useful and is initiated at week 6. Strengthening can be started after week 8.

2.4.3.9   Outcomes Terrible triad injuries have historically been very challenging injuries with poor and inconsistent outcomes. Better understanding of elbow biomechanics and modern treatment protocols have resulted in consistently improved functional outcomes. A summary of results from several series report an average arc of motion of 100–115° flexion-extension and approximately 135° pronation-supination. According to the Mayo Elbow Performance Score (MEPS), Pugh et al. (2004) reported 15 excellent, 13 good, 7 fair, and 1 poor outcome. Forthman et al. (2007) reported 6 excellent, 11 good, 3 fair, and 2 poor outcomes using the Broberg and Morrey outcome scores.

2.5  Varus posteromedial rotatory injury The varus posteromedial rotatory injury is infrequent and often results in subluxation rather than frank dislocation. The injury pattern can be subtle but is now recognized as a cause of early post-traumatic arthritis of the elbow (Steinmann, 2008). As mentioned above, radiographs must be carefully assessed for a medial coronoid fracture. On the AP radiograph, widening of the radiocapitellar joint space and narrowing or an incongruent medial ulnohumeral joint space indicates a varus posteromedial injury pattern (Figure 2.16). The lateral radiograph may show a “double crescent” sign from

30

(a)

Shoulder and Elbow Trauma and its Complications

(b)

Figure 2.16  (a) AP radiograph of the elbow reveals an AM coronoid facet fracture. (b) Fluoroscopic radiograph of the elbow taken under varus stress reveals a displacement of the AM coronoid facet fracture with concomitant widening of the radiocapitellar joint.

a depressed AM facet (Sanchez-Sotelo et al., 2005). CT scans with three-dimensional (3D) reconstructions are extremely helpful for fracture recognition and preoperative planning and are recommended (Figure 2.17).

2.5.1  Mechanism and biomechanics This type of injury occurs after a fall onto an outstretched hand. With the hand planted, the body then exerts a varus stress to the elbow. This varus and posteromedial rotatory load first ruptures the LUCL complex from the humerus and, with further stress, the AM facet of the coronoid contacts the medial trochlea and fractures. The radial head is not loaded; therefore, it is not fractured. As the forearm internally rotates further, the coronoid may dislocate or sublux posteriorly (Doornberg & Ring, 2006b; O’Driscoll et al., 2003). Biomechanical studies have demonstrated the unstable nature of these injuries, especially when the LCL complex is ruptured. Pollock et al. (2009) demonstrated that even small AM fractures of 2.5-mm size cause significant instability if they extend to the tip of the coronoid or sublime tubercle. If the fracture involves the sublime tubercle and includes the MCL attachment, then it can also result in valgus instability.

2.5.2  Classification The O’Driscoll classification is better suited for classifying these injuries compared with the Regan and Morrey classification for coronoid fractures (O’Driscoll et al., 2003;

Complex elbow dislocations

31

Figure 2.17  CT 3D reconstruction of the elbow demonstrates a fracture of the AM facet of the coronoid.

Regan & Morrey 1989). The Type I fractures are tip fractures most commonly associated with terrible triad complex dislocations. Oblique AM coronoid facet fractures are classified as O’Driscoll Type II injuries and are associated with a varus posteromedial rotatory injury. These fractures are further subdivided based on extension of the fracture with Subtype 1 involving only the AM facet, Subtype 2 has extension into the tip, and Subtype 3 has extension into the sublime tubercle with or without extension into the tip (Figure 2.9). O’Driscoll Type III fractures are basal fractures involving more than 50% of the coronoid and are associated with transolecranon fracture-dislocations.

2.5.3   Surgical management Although there are reports of successful nonoperative management of these fractures, most are treated operatively because of the potential for elbow instability and progression to early arthrosis (Doornberg & Ring, 2006b; Moon et al., 2013). An examination under anesthesia is extremely helpful because instability with varus posteromedial loading indicates the need for surgical repair of the coronoid. One can also perform a fluoroscopic evaluation by applying varus stress with the elbow in extension. Widening of the radiocapitellar joint under C-arm fluoroscopy indicates injury to the LCL complex, necessitating repair (Figure 2.18). The incision is a matter of preference, but the universal midline posterior incision is typically used because it provides access to medial and lateral structures requiring repair. Alternatively, separate medial and lateral incisions may be used. The medial side is approached first and the ulnar nerve is identified and released between the split in the FCU. The nerve does not typically need to be transposed in the acute injury but

32

(a)

Shoulder and Elbow Trauma and its Complications

(b)

Figure 2.18  (a) Lateral radiograph of the elbow demonstrates a transolecranon fracturedislocation. (b) Lateral radiograph of the elbow after ORIF of the transolecranon fracture-dislocation.

may be indicated if a neurolysis is performed as in a revision surgery. The muscular interval is typically performed through either an FCU-splitting or Hotchkiss over-thetop approach (Hotchkiss & Kasparyan, 2000; Huh et al., 2013). The FCU-splitting approach has been shown to offer better exposure of the medial coronoid, proximal ulna, and medial ligaments, whereas the Hotchkiss approach provides better access to the tip of the coronoid.

2.5.3.1  Hotchkiss approach This approach splits the flexor-pronator origin approximately 1 cm anterior to the anatomic split in the FCU and utilizes the internervous interval between the FCU (ulnar nerve) and pronator teres (median nerve). The pronator and flexor carpi radialis origins are elevated from the medial epicondyle and medial coronoid. More anterior exposure can be obtained by further elevation off of the supracondylar ridge and elevating the brachialis from the anterior distal humerus and anterior capsule. This provides excellent exposure to the tip and AM facet of the coronoid. The ulnar nerve can be left in its bed in the FCU.

2.5.3.2  FCU split After a medial or posterior approach, the raphe between the two heads (ulnar and humeral) of the FCU is exposed and longitudinally split. The FCU is carefully dissected free of the anterior ulna with care to protect the UCL. As with the Hotchkiss approach, the pronator teres and flexor carpi radialis are elevated for more anterior exposure. The ulnar nerve is mobilized enough to permit posterior retraction and exposure of the fracture with placement of hardware. It need not be transposed unless extensive mobilization is necessary for exposure. The AM coronoid is exposed and the fracture site is cleaned. Frequently, there is extreme comminution to the AM facet and interfragmentary fixation is not possible. However, when possible, the AM facet is reduced and stabilized using headless compression screws or small 2.0- or 2.4-mm screws. A buttress plate is recommended

Complex elbow dislocations

33

to stabilize the AM facet so as to prevent dislocation or subluxation. The AM facet fragments are often amenable to plate fixation with a 2.0- or 2.4-mm buttress plate and screws. If the fragments are too small, a suture-lasso technique may be used. After stabilizing the AM facet, the lateral skin flap is raised to expose the common extensor origin. The LCL complex is exposed with an EDC-splitting approach and is repaired with transosseous sutures or suture anchors as previously described.

2.5.4   Postoperative protocol It is imperative to avoid varus stress on the repair after surgery; therefore, the patient is instructed to avoid shoulder abduction. The elbow is initially splinted at 90° flexion in neutral rotation. ROM exercises are started at 1 week in a hinged brace blocking the terminal 30° of extension. Full ROM should be allowed by 4 weeks and strengthening started by 6–8 weeks.

2.5.5   Outcomes Because of the uncommon occurrence and the relatively recent recognition of this injury pattern, there are few reported outcomes in the literature. Doornberg and Ring (2006b) described 18 patients with fractures of the AM facet. Nine patients were felt to have inadequate treatment of the fracture: three treated nonoperatively, four did not have the AM fragment addressed at surgery, and two had inadequate fixation. Seven of the nine patients inadequately treated had elbow instability during follow-up. The final outcome was excellent in three, fair in five, and poor in one according to Broberg and Morrey scores. Of the nine patients with adequately treated fractures, seven outcomes were rated excellent and two good. This particular study highlights the importance of pattern recognition and identification of the medial coronoid fracture.

2.6  Axial loading injuries Axial loading injuries are less frequently encountered than terrible triad injuries, but they are important to recognize because of their significant morbidity. The hallmark of these injuries is the involvement of the olecranon and at times the coronoid. Two separate patterns have been described: the anterior transolecranon fracture-dislocation and the posterior transolecranon fracture-dislocation (also called the posterior Monteggia lesion).

2.6.1  Mechanism of injury and biomechanics These injuries result from an axial force that impacts the greater sigmoid notch and distal humerus. In general, this occurs during a fall onto the posterior aspect of the forearm. The anterior transolecranon fracture-dislocation pattern is a high-energy injury in which the forearm displaces anterior to the distal humerus. This particular fracture can be severely comminuted with involvement of the entire coronoid (Figure 2.19).

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Shoulder and Elbow Trauma and its Complications

Figure 2.19  Intraoperative fluoroscopy demonstrates use of a home-run screw for coronoid fixation during ORIF of a transolecranon fracture-dislocation.

The injury has been confused with a Bado Type I Monteggia lesion, but the PRUJ and capsuloligamentous structures remain intact in the transolecranon fracture pattern. Therefore, anatomic bony reconstruction results in a stable elbow. Posterior transolecranon fracture-dislocations have been documented as occurring in an older patient population, often as the result of a fall from standing height (Jupiter et al., 1991). The radial head dislocates posterior to the distal humerus and often fractures in the process. The coronoid is part of a large triangular fragment that remains with the distal humerus. Again, stable reconstruction of the fracture, most importantly the large coronoid fragment, restores elbow stability. Occasionally, the elbow may remain unstable despite anatomical reconstruction of the fracture because of an injury to the LCL complex, which has been noted in some patients (Doornberg, Ring, & Jupiter, 2004; Ring et al., 1997, 1998; Ring & Jupiter, 1998).

2.6.2  Clinical and surgical decision-making These injuries occur most often from high-energy injuries and require operative intervention. Open fractures, ipsilateral injuries, and neurovascular injuries must be evaluated at the time of presentation and the neurovascular status of the upper extremity should be documented. Closed reduction and splinting should be performed if possible to minimize further bony or soft-tissue damage. The goal of surgery is to anatomically repair the greater sigmoid notch with particular attention paid to the coronoid (Doornberg et al., 2004). The patient is placed in the lateral decubitus position. A posterior midline incision is utilized with care taken to preserve the triceps insertion on the olecranon. The olecranon fracture is used to access the coronoid and further exposure is obtained with medial and lateral subperiosteal

Complex elbow dislocations

(a)

35

(c)

(b)

(d)

Figure 2.20  (a) AP and (b) lateral radiographs of the elbow demonstrate a transolecranon fracture-dislocation with concomitant radial head fracture. (c) and (d) Definitive fixation was achieved with plate fixation.

elevation. Depending on the fracture pattern, the coronoid can be reduced to the ulnar shaft fragment or the olecranon. After the coronoid is reduced, the shaft of the ulna should be anatomically reduced by lag screws or mini-fragment plates before application of the larger plate. Attention should be given to preserving the MCL attachment at the sublime tubercle and the LUCL at the crista supinatoris. Mini-fragment screws and plates are useful for provisional fixation and as lag screws for comminuted fragments. Precontoured anatomical proximal ulna plates with locking screw options are available and provide excellent fixation and contour in these fractures. Initially, the oblong hole of the locking plate is filled and then the “home-run screw” is placed to compress the plate. Home-run screws provide excellent fixation and are angled from the tip of the olecranon to the coronoid fragment (Figure 2.20). Plates are placed through a split in the triceps tendon, making the implant less prominent. It may be helpful to

36

Shoulder and Elbow Trauma and its Complications

Figure 2.21  Illustration of the Colton-Barford pie technique. The wedge-shaped section is removed and closed down whereas the radius of curvature of the greater sigmoid notch remains. Reprinted with permission from Colton (1973).

provisionally pin the olecranon fragment to the distal humerus when there is a great deal of comminution. Colton (1973) describes a technique for use when a portion of the articular surface is missing because of comminution (Figure 2.21). The fragments are cut with a saw to create even, oblique cuts. The wedge-shaped section is removed and the olecranon is advanced to the coronoid. Care is taken to maintain the radius of curvature of the greater sigmoid notch during the process (Figure 2.22). Tension-band wiring (TBW) is not recommended in transolecranon fracturedislocations. It is a popular technique in the fixation of olecranon fractures, but it is associated with higher failure rates compared with plate fixation for more comminuted fractures. To be used successfully, TBW needs a stable transverse fracture pattern, which is rarely present in these high-energy injuries (Mortazavi, Asadollahi, & Tahririan, 2006; Mouhsine et al., 2007; Ring et al., 1997). Some authors recommend addressing the radial head fracture through the olecranon fracture, at times elevating the anconeus and LCL (Boyd, 1940). A concern is that the exposure may exacerbate or create instability. In addition, because the ulna has not been reconstructed, it is difficult to determine the appropriate height for a radial head prosthesis. If the LUCL is elevated during the approach, then it must be repaired (Roidis, Papadakis, & Karachalios, 2004). We prefer to stabilize the ulna first (reconstituting height) and make a separate EDC-splitting approach (sparing the LUCL) for the radial head. If the radial head is in three or fewer pieces, the radial head is repaired.

Complex elbow dislocations

37

(a)

(b)

(d)

(c)

(e)

Figure 2.22  (a) Preoperative injury film demonstrates significant comminution of the olecranon. Intraoperative fluoroscopy shows (b) provisional and (c) definitive stabilization after wedge osteotomy of the olecranon. Postoperative (d) AP and (e) lateral radiographs of the elbow after definitive fixation.

38

Shoulder and Elbow Trauma and its Complications

Most commonly, the radial head is replaced. A microsagital saw is used to cut the radial neck and the remaining pieces of the radial head are removed. At this point, the elbow is taken through a ROM and the elbow is checked for full supination, pronation, flexion, and extension. If the coronoid has not been properly addressed, then the elbow subluxes anteriorly in extension. In situations such as these, it is advisable to properly address the coronoid, or if not constructible, apply a static or hinged external fixator.

2.6.3  Postoperative protocol The elbow is splinted 5–7 days and then allowed to begin active ROM exercises including flexion, extension, and forearm rotation. Fixation stability determines the aggressiveness of ROM. A hinged elbow brace may be used for protection, but full ROM is often allowed. In older patients with poor bone quality in whom fixation may be tenuous, it is preferable to delay motion up to 4 weeks rather than risk failure of the fixation. Generally speaking, extension is more dangerous than flexion because the coronoid has been fractured and is the weak area of the fixation. Resistive exercises are started by 6–8 weeks.

2.6.4  Outcomes When stable fixation is achieved in transolecranon fracture-dislocations, particularly the coronoid fragment, excellent or good outcomes are routinely obtained. Lindenhovius et al. (2008) reported on long-term follow-up of 20 patients including anterior and posterior olecranon fracture-dislocations. At an average of 18 years, the mean elbow flexion-extension arc of motion was 124°. Although 70% of patients had evidence of radiographic arthrosis, five patients were rated as excellent, three good, and only two poor according to Broberg and Morrey outcome scores. Fixation may be compromised using TBW techniques for the ulna. Mouhsine et al. (2007) reported on 14 anterior transolecranon fracture-dislocations, 7 of which were treated with TBW and 7 with plate fixation. Three early failures treated with TBW had successful revision with plate fixation.

2.7  Complications of complex elbow dislocations Because of the often high-energy and complex nature of these injuries, complications are frequently encountered. These include, but are not limited to, recurrent instability, stiffness, heterotopic ossification, malunion, nonunion, infection, ulnar neuropathy, and arthrosis. The risk of complication increases with the severity of the injury.

2.7.1  Persistent instability One of the more feared complications is recurrent or persistent instability, especially with terrible triad injuries and transolecranon fracture-dislocations (Figure 2.23). The

Complex elbow dislocations

(a)

39

(b)

(c)

(d)

Figure 2.23  (a) Lateral radiograph of the elbow demonstrates a terrible triad injury. (b) Recurrent instability and subsequent dislocation persisted after surgery. (c) A hinged external-fixator was applied to reestablish elbow congruency. (d) Stability was achieved and the external-fixator removed.

treatment will be more thoroughly discussed in Chapter 10 (Persistent elbow instability), but it involves reapplying the algorithm for the treatment of acute instability to address the specific injuries. Most commonly, the complication occurs secondary to lateral ligament insufficiency in the terrible triad injury and inadequate coronoid fixation in transolecranon fracture-dislocations. Still, an algorithmic approach is necessary to rule out and address potential causes. Radial head replacement is an option for failed fixation of the radial head. Ligament reconstruction should be used to augment an incompetent LUCL. In all recurrent elbow instability situations, a hinged external fixator is a useful adjunct to maintain elbow stability while allowing for ROM (McKee et al., 1998).

2.7.2   Elbow stiffness Elbow stiffness is an expected finding after complex elbow dislocation. Authors advocate initiating early elbow ROM to prevent elbow stiffness when adequate stability is obtained. That being said, it is preferable to have a stiff, yet stable elbow rather than

40

Shoulder and Elbow Trauma and its Complications

Figure 2.24  CT 3D reconstruction of the elbow demonstrates the formation of heterotopic ossification.

an unstable elbow with painful motion. Motion can typically be safely initiated with a supine overhead therapy program within a week after surgery. Commercial static progressive splints or turnbuckle splints are useful adjuncts to the therapy program and can be started by 4–6 weeks in patients who are stable but stiff. Patients with excessive stiffness and/or heterotopic ossification will generally benefit from an open or arthroscopic anterior and posterior capsular release along with excision of the heterotopic bone (Ring et al., 2006). This intervention is considered after the fourth postoperative month and can be performed through a ligament-sparing lateral approach (Figure 2.24). Prophylactic indomethicin at 75 mg per day in single or divided doses should be given for 3 weeks to prevent recurrence of heterotopic ossification (Mathew et al., 2009).

2.8  Future directions Complex elbow dislocations continue to be a vexing problem for patients and surgeons alike. Although significant progress has been made, several areas will require more research. For example, controversy still exists in determining which coronoid fractures require fixation. Recommendations range from fixing all fractures (even tip fractures) to not fixing Type II coronoid fractures in terrible triad injuries (Forthman et al., 2007; Mathew et al., 2009; Papatheodorou et al., 2014). With further collective experience, it is expected that more specific indications will be defined regarding coronoid fracture fixation.

Complex elbow dislocations

41

Another area that needs improvement is the exposure and fixation of the coronoid in the complex elbow dislocation with an intact radial head. This fracture is technically challenging, especially when the coronoid is comminuted. Future surgery incorporating arthroscopic techniques may possibly improve the ease with which we treat the coronoid. A new technique has been described using an internal joint stabilizer for elbows remaining unstable after repairing injured structures. It may be indicated in place of transarticular pinning of the joint or external fixation. It has the advantage of keeping all fixation internal while still permitting motion (Orbay & Mijares, 2014). A great deal of interest has also been given to methods of reconstructing the coronoid that is too comminuted for repair. Methods described have included osteochondral autografts from a resected radial head, the olecranon, or even coronoid replacement (Alolabi et al., 2012; Moritomo et al., 1998; Ring, Guss, & Jupiter, 2012).

2.9  Summary Complex elbow dislocations are challenging injuries to treat. Knowledge gained over the past 2 decades from clinical and laboratory research has shed light on the mechanisms associated with these injury patterns. Recognition of the mechanism of injury allows identification of the associated injured anatomical structures and guides surgical planning. Restoration of elbow anatomy allows for early mobilization and good functional outcomes. The goal of treatment is to provide a stable and functional elbow. Unfortunately, these patients are still at high risk for complications such as stiffness, arthrosis, and early instability. If elbow stability is restored, then reconstructive options are available to improve function should arthrosis or stiffness become an issue. Future studies should offer improved techniques for fixation and better options for reconstruction of the irreparable coronoid fracture.

References Alolabi, B., et al. (2012). Reconstruction of the coronoid using an extended prosthesis: an in vitro biomechanical study. Journal of Shoulder and Elbow Surgery, 21(7), 969–976. An, K., & Morrey, B. (2000). Biomechanics of the elbow. In B. Morrey (Ed.), Biomechanics of the elbow (pp. 43–60). Philadelphia, PA: WB Saunders. Beingessner, D. M., et al. (2004). The effect of radial head excision and arthroplasty on elbow kinematics and stability. The Journal of Bone and Joint Surgery. American Volume, 86-A(8), 1730–1739. Beingessner, D. M., et al. (2007). The effect of suture fixation of type I coronoid fractures on the kinematics and stability of the elbow with and without medial collateral ligament repair. Journal of Shoulder and Elbow Surgery, 16(2), 213–217. Boyd, H. (1940). Surgical exposure of the ulna and proximal third of the radius through one incision. Surgery, Gynecology & Obstetrics, 71, 86–88.

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Broberg, M. A., & Morrey, B. F. (1987). Results of treatment of fracture-dislocations of the elbow. Clinical Orthopaedics and Related Research, 216, 109–119. Cage, D. J., et al. (1995). Soft tissue attachments of the ulnar coronoid process. An anatomic study with radiographic correlation. Clinical Orthopaedics and Related Research, 320, 154–158. Chan, K., et al. (2014). Can we treat select terrible triad injuries nonoperatively? Clinical Orthopaedics and Related Research, 472(7), 2092–2099. Charalambous, C. P., & Stanley, J. K. (2008). Posterolateral rotatory instability of the elbow. The Journal of Bone and Joint Surgery. British Volume, 90-B(3), 272–279. Chen, X., et al. (2011). Comparison between radial head replacement and open reduction and internal fixation in clinical treatment of unstable, multi-fragmented radial head fractures. International Orthopaedics, 35(7), 1071–1076. Closkey, R. F., et al. (2000). The role of the coronoid process in elbow stability. A biomechanical analysis of axial loading. The Journal of Bone and Joint Surgery. American Volume, 82-A(12), 1749–1753. Colton, C. L. (1973). Fractures of the olecranon in adults: classification and management. Injury, 5(2), 121–129. Desloges, W., et al. (2014). Objective analysis of lateral elbow exposure with the extensor digitorum communis split compared with the Kocher interval. The Journal of Bone and Joint Surgery. American Volume, 96(5), 387–393. Dodds, S. D., & Fishler, T. (2013). Terrible triad of the elbow. The Orthopedic Clinics of North America, 44(1), 47–58. Doornberg, J. N., Ring, D., & Jupiter, J. B. (2004). Effective treatment of fracture-dislocations of the olecranon requires a stable trochlear notch. Clinical Orthopaedics and Related Research, 429, 292–300. Doornberg, J. N., et al. (2006). Reference points for radial head prosthesis size. The Journal of Hand Surgery, 31(1), 53–57. Doornberg, J. N., et al. (2007). Radial head arthroplasty with a modular metal spacer to treat acute traumatic elbow instability. The Journal of Bone and Joint Surgery. American Volume, 89(5), 1075–1080. Doornberg, J. N., & Ring, D. (2006a). Coronoid fracture patterns. The Journal of Hand Surgery, 31(1), 45–52. Doornberg, J. N., & Ring, D. (2006b). Fracture of the anteromedial facet of the coronoid process. The Journal of Bone and Joint Surgery. American Volume, 88(10), 2216–2224. Duckworth, A. D., et al. (2008). Residual subluxation of the elbow after dislocation or fracturedislocation: treatment with active elbow exercises and avoidance of varus stress. Journal of Shoulder and Elbow Surgery, 17(2), 276–280. Dunning, C. E., et al. (2001). Ligamentous stabilizers against posterolateral rotatory instability of the elbow. The Journal of Bone and Joint Surgery. American Volume, 83-A(12), 1823–1828. Dyer, G., & Ring, D. (2010). My approach to the terrible triad injury. Operative Techniques in Orthopaedics, 20(1), 11–16. Ebrahimzadeh, M. H., Amadzadeh-Chabock, H., & Ring, D. (2010). Traumatic elbow instability. The Journal of Hand Surgery, 35(7), 1220–1225. Forthman, C., Henket, M., & Ring, D. C. (2007). Elbow dislocation with Intra-articular fracture: the results of operative treatment without repair of the medial collateral ligament. Journal of Hand Surgery, 32(8), 1200–1209. Garrigues, G. E., et al. (2011). Fixation of the coronoid process in elbow fracture-dislocations. The Journal of Bone and Joint Surgery. American Volume, 93(20), 1873–1881. Hotchkiss, R. (1996). Fractures and dislocations of the elbow. In D. Green, R. Bucholz, & J. Heckman (Eds.), Rockwood and greens fractures in adults (pp. 929–1024). Philadelphia, PA: Lippincott-Raven.

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Hotchkiss, R. (1997). Displaced fractures of the radial head: internal fixation or excision? The Journal of the American Academy of Orthopaedic Surgeons, 5(1), 1–10. Hotchkiss, R., & Kasparyan, G. (2000). The medial “Over the top” approach to the elbow. Techniques in Orthopaedics, 15(2), 105–112. Hotchkiss, R., & Weiland, A. (1987). Valgus stability of the elbow. Journal of Orthopaedic Research, 5(3), 372–377. Huh, J., et al. (2013). Medial elbow exposure for coronoid fractures: FCU-split versus over-thetop. Journal of Orthopaedic Trauma, 27(12), 730–734. Imatani, J., et al. (1999). Anatomic and histologic studies of lateral collateral ligament complex of the elbow joint. Journal of Shoulder and Elbow Surgery, 8(6), 625–627. Jeon, I., et al. (2012). The contribution of the coronoid and radial head to the stability of the elbow. The Journal of Bone and Joint Surgery. British Volume, 94(1), 86–92. Johnston, G. W. (1962). A follow-up of one hundred cases of fracture of the head of the radius with a review of the literature. The Ulster Medical Journal, 31, 51–56. Josefsson, P. O., et al. (1989). Dislocations of the elbow and intraarticular fractures. Clinical Orthopaedics and Related Research, 246, 126–130. Jupiter, J. B., et al. (1991). The posterior Monteggia lesion. Journal of Orthopaedic Trauma, 5(4), 395–402. Leigh, W. B., & Ball, C. M. (2012). Radial head reconstruction versus replacement in the treatment of terrible triad injuries of the elbow. Journal of Shoulder and Elbow Surgery, 21(10), 1336–1341. Lindenhovius, A. L. C., et al. (2008). Long-term outcome of operatively treated fracturedislocations of the olecranon. Journal of Orthopaedic Trauma, 22(5), 325–331. Mason, M. L. (1954). Some observations on fractures of the head of the radius with a review of one hundred cases. The British Journal of Surgery, 42(172), 123–132. Mathew, P. K., & Athwal, G. S., King, G. J. W. (2009). Terrible triad injury of the Elbow. Journal of the American Academy of Orthopaedic Surgeons, 17(3), 137–151. McKee, M. D., et al. (1998). Management of recurrent, complex instability of the elbow with a hinged external fixator. The Journal of Bone and Joint Surgery. British Volume, 80(6), 1031–1036. McKee, M. D., et al. (2003). The pathoanatomy of lateral ligamentous disruption in complex elbow instability. Journal of Shoulder and Elbow Surgery, 12(4), 391–396. Mezera, K., & Hotchkiss, R. (2001). Fractures and dislocations of the elbow. In H. J. Hehne, D. P. Green, & R. W. Bucholz (Eds.), Rockwood and green’s fractures in adults (pp. 921–952). Philadelphia, PA: Lippincott-Raven. Moon, J., et al. (2009). Radiocapitellar joint stability with bipolar versus monopolar radial head prosthesis. Journal of Shoulder and Elbow Surgery, 18(5), 779–784. Moon, J., et al. (2013). Non surgically managed anteromedial coronoid fractures in posteromedial rotatory instability: three cases with 2 years follow-up. Archives of Orthopaedic and Trauma Surgery, 133(12), 1665–1668. Moritomo, H., et al. (1998). Reconstruction of the coronoid for chronic dislocation of the elbow: use of a graft from the olecranon in two cases. The Journal of bone and joint surgery. British Volume, 80(3), 490–492. Morrey, B. F., & An, K. N. (1983). Articular and ligamentous contributions to the stability of the elbow joint. The American Journal of Sports Medicine, 11(5), 315–319. Morrey, B. F., Tanaka, S., & An, K. N. (1991). Valgus stability of the elbow. A definition of primary and secondary constraints. Clinical Orthopaedics and Related Research, 265, 187–195. Mortazavi, S. M. J., Asadollahi, S., & Tahririan, M. A. (2006). Functional outcome following treatment of transolecranon fracture-dislocation of the elbow. Injury, 37(3), 284–288.

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Mouhsine, E., et al. (2007). Transolecranon anterior fracture dislocation. Journal of Shoulder and Elbow Surgery, 16(3), 352–357. O’Driscoll, S. W., et al. (2001). The unstable elbow. Instructional Course Lectures, 50, 89–102. O’Driscoll, S. W., et al. (2003). Difficult elbow fractures: pearls and pitfalls. Instructional Course Lectures, 52, 113–134. O’Driscoll, S. W., Bell, D. F., & Morrey, B. F. (1991). Posterolateral rotatory instability of the elbow. The Journal of Bone and Joint Surgery. American Volume, 73(3), 440–446. O’Driscoll, S. W., Jaloszynski, R., et al. (1992a). Origin of the medial ulnar collateral ligament. The Journal of Hand Surgery, 17(1), 164–168. O’Driscoll, S. W., Morrey, B. F., et al. (1992b). Elbow subluxation and dislocation: a spectrum of instability. Clinical Orthopaedics and Related Research, 280, 186–197. Orbay, J. L., & Mijares, M. R. (2014). The management of elbow instability using an internal joint stabilizer: preliminary results. Clinical orthopaedics and related research, 472(7), 2049–2060. Papatheodorou, L. K., et al. (2014). Terrible triad injuries of the elbow: does the coronoid always need to be fixed? Clinical Orthopaedics and Related Research, 472(7), 2084–2091. Pollock, J. W., et al. (2009). The effect of anteromedial facet fractures of the coronoid and lateral collateral ligament injury on elbow stability and kinematics. The Journal of Bone and Joint Surgery. American Volume, 91(6), 1448–1458. Pugh, D. M. W., et al. (2004). Standard surgical protocol to treat elbow dislocations with radial head and coronoid fractures. The Journal of Bone and Joint Surgery. American Volume, 86-A(6), 1122–1130. Regan, W., & Morrey, B. (1989). Fractures of the coronoid process of the ulna. The Journal of Bone and Joint Surgery. American Volume, 71(9), 1348–1354. Ring, D. (2006). Fractures of the coronoid process of the ulna. The Journal of Hand Surgery, 31(10), 1679–1689. Ring, D., Bruinsma, W. E., & Jupiter, J. B. (2014). Complications of hinged external fixation compared with cross-pinning of the elbow for acute and subacute instability. Clinical Orthopaedics and Related Research, 472(7), 2044–2048. Ring, D., et al. (1997). Transolecranon fracture-dislocation of the elbow. Journal of Orthopaedic Trauma, 11(8), 545–550. Ring, D., et al. (2006). Elbow capsulectomy for posttraumatic elbow stiffness. The Journal of Hand Surgery, 31(8), 1264–1271. Ring, D., Guss, D., & Jupiter, J. B. (2012). Reconstruction of the coronoid process using a fragment of discarded radial head. The Journal of Hand Surgery, 37(3), 570–574. Ring, D., & Jupiter, J. B. (1998). Fracture-dislocation of the elbow. The Journal of Bone and Joint Surgery. American Volume, 80(4), 566–580. Ring, D., Jupiter, J. B., & Simpson, N. S. (1998). Monteggia fractures in adults. The Journal of Bone and Joint Surgery. American Volume, 80(12), 1733–1744. Ring, D., Quintero, J., & Jupiter, J. B. (2002). Open reduction and internal fixation of fractures of the radial head. The Journal of Bone and Joint Surgery. American Volume, 84-A(10), 1811–1815. Roidis, N., Papadakis, S., & Karachalios, T. (2004). Radial head fractures. In R. Mirzayan, & J. Itamura (Eds.), Shoulder and elbow trauma (pp. 22–35). New York, NY: Thieme Medical Publishers. Sanchez-Sotelo, J., et al. (2005). Medial oblique compression fracture of the coronoid process of the ulna. Journal of Shoulder and Elbow Surgery, 14(1), 60–64.

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Schneeberger, A. G., Sadowski, M. M., & Jacob, H. A. C. (2004). Coronoid process and radial head as posterolateral rotatory stabilizers of the elbow. The Journal of Bone and Joint Surgery. American Volume, 86-A(5), 975–982. Steinmann, S. P. (2008). Coronoid process fracture. The Journal of the American Academy of Orthopaedic Surgeons, 16(9), 519–529. Tashjian, R. Z., & Katarincic, J. A. (2006). Complex elbow instability. The Journal of the American Academy of Orthopaedic Surgeons, 14(5), 278–286. Watters, T. S., et al. (2014). Fixation versus replacement of radial head in terrible Triad: is there a difference in elbow stability and prognosis? Clinical Orthopaedics and Related Research, 472(7), 2128–2135. Wyrick, J., et al. (2015). A mechanistic approach to complex elbow dislocation. Journal of the American Academy of Orthopaedic Surgeons, 23(5), 297–306..

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Management of acute and chronic distal biceps ruptures

3

A.V. Metzler, R.M. Greiwe Commonwealth Orthopaedic Centers, Edgewood, KY, USA

3.1  Introduction The most commonly injured tendon of the elbow is the distal biceps. These injuries can be acute, chronic, or partial tears. The reported incidence of distal biceps ruptures is noted to be between 3% and 10%.1,2 The injury typically occurs in the dominant arm in patients 40–60 years of age and often results from forced eccentric loading of the flexed elbow. Patients often report a sudden painful pop or tearing sensation in the antecubital fossa. Examination typically demonstrates ecchymosis and often proximal retraction of the biceps with a positive hook test.3 Magnetic resonance imaging (MRI) is beneficial in distinguishing between partial and full tears as well as preoperative determination of tendon location. Historically, distal biceps ruptures were nonoperatively treated. However, more recently, operative management has been favored in most patients because of the persistent deficits experienced with nonsurgical management. Many repair techniques have been developed over the last few decades, including the classic two-incision technique described by Boyd and Anderson in 1961 and the single-incision technique.4 Both techniques have been shown to have good results, each with their own set of complications.5 Complication rates with repair have been reported to be as high as 36%, with the vast majority being transient nerve injury.6 Postoperative rehabilitation emphasizes tendon healing early on with protected range of motion and progressive strengthening. Rehabilitation with modern reconstruction techniques allows for early motion with return to activities in 3–6 months depending on the work/sports requirements. The objective of this chapter is to discuss the anatomy, epidemiology, etiology, treatment options, biomechanics, outcomes, postoperative rehabilitation, future trends, and complications of distal biceps tendon injuries.

3.2  Distal biceps anatomy The biceps tendon is a bipennate muscle comprising a short and a long head. The long head originates from the supraglenoid tubercle and the short head from the coracoid process. In the shoulder, the long head travels through the rotator interval and into the intertubercle groove, where it meets with the short head in the upper arm. The biceps is innervated by the musculocutaneous nerve. The tendon proceeds into the antecubital fossa, and distally the two heads of the biceps insert at the bicipital tuberosity on Shoulder and Elbow Trauma and its Complications. http://dx.doi.org/10.1016/B978-1-78242-450-5.00003-4 Copyright © 2016 Elsevier Ltd. All rights reserved.

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the proximal aspect of the radius. Each head of the biceps has a distinct insertion onto the radius. The short head distal tendon has an oval shape, and its insertion is more superficial and distal than the long head insertion. The long head insertion is more crescent shaped and is more proximal and deep. It is speculated that the short head is positioned in such a way that it acts as a more powerful elbow flexor, with the long head acting as a more powerful supinator.7 The biceps insertion on the tuberosity has been studied and has been shown to have a mean length of 21 mm and a mean width of 7 mm. The insertion site of the biceps does not occupy the entire bicipital tuberosity because the mean length and width of the tuberosity are 22–24 mm and 15–19 mm, respectively.8,9 The tendon inserts on average 23 mm distal to the articular margin and is located on the posterior and ulnar aspect of the bicipital tuberosity. The center of the biceps insertion on the bicipital tuberosity is oriented 30° anterior to the coronal plane with the arm in full supination. This makes a single-incision approach less anatomic in patients with loss of forearm rotation.10

3.3  Surgical anatomy Various incisions can be used for reconstruction of the distal biceps. A single anterior incision in either the horizontal plane or vertical plane can be used to access the bicipital tuberosity for repair. The two-incision approach places a secondary incision on the dorsal aspect of the forearm in addition to the anterior incision. In the antecubital fossa, the biceps tendon lies just lateral to the brachial artery and the median nerve, respectively. The lateral antebrachial cutaneous nerve (LABCN) is the terminal branch of the musculocutaneous nerve and exits between the biceps brachii and the brachialis in the antecubital fossa. It is the most commonly injured nerve during biceps repair and should be identified and protected throughout the case.6 Care should be taken not to place the biceps tendon anterior to the LABCN during repair. The LABCN lies on the medial border of the brachioradialis in the proximal forearm. The lacertus fibrosus is contiguous with the biceps tendon in the antecubital fossa and attaches to the fascia overlying the common flexor-pronator mass in the proximal forearm. The lacertus may need to be released to allow for mobilization and biceps repair. The brachial artery and median nerve lie just deep to the lacertus fibrosus. The brachial artery bifurcates into the radial and ulnar arteries at the level of the radial head. The radial recurrent vessels branch from the radial artery and pass laterally and proximally across the antecubital fossa. The biceps tendon lies anterior to the radial recurrent vessel. The radial recurrent vessels often need to be ligated to gain access to the bicipital tuberosity during repair and, if not properly coagulated or ligated, can be a source of significant bleeding and hematoma. The radial nerve exits the arm between the brachialis and the brachioradialis, dividing into the posterior interosseous nerve (PIN) and the superficial branch of the radial nerve just anterior to the lateral humeral epicondyle. The superficial radial nerve (SRN) travels under the brachioradialis in the forearm and exits out dorsally in the mid-forearm to provide sensation to the mid-dorsal forearm and dorsal hand. The PIN passes around the lateral side of the proximal radius and pierces the supinator muscle. The PIN supplies all motor function to the wrist

Management of acute and chronic distal biceps ruptures

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extensors except the extensor carpi radialis longus. Care must be taken to respect the location of the PIN at all times. Hooked retractors should be avoided on the radial side of the biciptal tuberosity.

3.4  Epidemiology Biceps injuries typically occur in male laborers in the fourth and fifth decades of life in the dominant arm. Overall, these are rare injuries, with the reported incidence of 1.2 distal biceps ruptures per 100,000 patients each year. The dominant extremity is affected 86% of the time and the incidence is 7.5 times higher in smokers. Few instances of complete rupture in females have been reported in the literature. Various conditions such as rheumatoid arthritis, gout, systemic lupus erythematosus, syphilis, tuberculosis, malignancy, ankylosing spondylitis, and end-stage renal disease have all been associated with distal biceps ruptures.2

3.5  Etiology Rupture of the distal biceps most commonly occurs with the elbow flexed and the forearm in supination, followed by an eccentric load. The tendon typically avulses off of the tuberosity, but it can also rupture in the avascular zone. Some authors have reported rupture occurring in stages, with the radial aspect of the biceps tendon avulsing first, and some cases progressing to completion.11 The pathogenesis of distal biceps ruptures is poorly understood. Mechanical compression and hypovascularity have both been proposed as underlying causes for distal biceps ruptures. Anatomic studies have shown that distance between the bicipital tuberosity and the lateral ulna decreases by 48% from a fully supinated position to a fully pronated forearm position, theoretically causing increased mechanical abrasion of the tendinous insertion.12 These two theories are most commonly cited in the literature as the source of distal biceps ruptures, but no definitive cause has been elucidated.

3.6  Clinical evaluation Although the clinical history of most distal biceps tears is similar, the clinical presentation of distal biceps injuries varies depending on the timing and severity of the injury and the degree of retraction of the tendon. Most acute ruptures will present after a painful pop, with ecchymosis in the antecubital fossa and retraction of the biceps proximally. This is referred to as a “reverse Popeye” deformity. With complete tears, the hook test will be positive.3 Chronic tears will not present with bruising, but the hook test is still positive. In addition, chronic tears should not have the pain associated with acute tears, but they still exhibit similar weakness patterns. Deficits of 40% in supination, 30% in flexion, and 15% in grip strength can be expected later, but more

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profound strength loss is initially present, likely because of pain.1 Partial tears will present with a negative, but painful, hook test. The hook test is performed with elbow flexed to 90° and the forearm supinated. The examiner’s finger is used to “hook” the biceps tendon from lateral to medial. Caution is advised if the hook test is performed from medial to lateral because the lacertus fibrosus may be intact despite a ruptured tendon, misleading the examiner into a negative hook test. The absence of proximal migration does not rule out the diagnosis of a distal biceps rupture. The biceps could be torn and, if the lacertus fibrosus is intact, the biceps may not retract.

3.7  Imaging Radiographs rarely provide diagnostic value in the acute biceps rupture; however, they should be obtained, especially in the acute setting, to rule out a fracture. MRI is utilized for biceps injuries to evaluate partial tendon rupture, determine the level of proximal migration of the tendon, and identify the location of the tear in the tendon. MRI has been shown to be 92% sensitive and 85% specific, compared with the 100% specific and sensitive hook test.3 MRI is not necessary to make the diagnosis or proceed forth with surgery in the acute setting; however, both authors obtain MRI scans before distal biceps repairs are performed. The flexed, abducted, supinated (FABS) view has been promoted as a more accurate means of MRI diagnosis of distal biceps rupture because the full length of the biceps can be seen on one or two sections.13 Ultrasound has also been shown to be effective in the diagnosis of biceps injuries.14

3.8  Treatment 3.8.1  Treatment of partial ruptures Partial distal biceps ruptures are rare injuries. The diagnosis is more difficult to make given the more subtle clinical findings compared with a complete rupture. The patient may still report a tearing sensation or a pop. The hook test will be negative; however, antecubital pain and swelling may be present. The tendon is frequently palpable but painful along its course. Weakness with supination and flexion will usually be seen on exam, but to a lesser degree than with complete ruptures. MRI is useful in determining the size of the partial biceps tendon tear and to rule out other causes of antecubital pain such as biceps tendonitis, bursitis, or pronator syndrome. Most partial biceps tears occur on the radial side of the radial tuberosity.11,15 The initial management of most partial distal biceps ruptures should be conservative management. This includes activity modification, nonsteroidal anti-inflammatory drugs (NSAIDs), and physical therapy. However, partial ruptures can be painful and require a prolonged recovery. Partial distal biceps ruptures that fail to respond to conservative management are surgically treated. The literature supports releasing the partially torn biceps, debriding the diseased tendon and anatomic reinsertion of the distal biceps as in a complete rupture. Tears less than 50% of the biceps tendon have been

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successfully treated with conservative management whereas those greater than 50% are more likely to require surgery.16 Repair of partial distal biceps ruptures has been described with both one- and two-incision techniques. Results of partial rupture repair are comparable to those of acute complete biceps rupture repair.11,15,17

3.8.2  Treatment for acute ruptures The rationale for acute treatment of distal biceps ruptures stems from two landmark studies demonstrating fatigue and weakness of both biceps flexion and supination strength.1,18 The results of those studies showed a 21% and 30% loss of elbow flexion strength and a 27% and 40% reduction in supination strength compared with the nonoperative contralateral side. After surgical reattachment, strength recordings were near normal. In general, considering the positive outcomes reported after anatomic repair of distal biceps injuries, most complete distal biceps ruptures should be surgically treated. Nonoperative treatment should be considered for patients willing to sacrifice elbow flexion and supination strength or in those patients who are poor surgical candidates for medical reasons. Single- and two-incision techniques have been described to treat these injures. Three main fixation methods have been utilized, including cortical button fixation with or without interference screw, transosseous tunnels, and suture anchors. The single- and two-incision techniques and the fixation methods are described in the following subsections.

3.8.3   Two-incision technique The two-incision technique was initially described by Boyd and Anderson in 1961 after high complication rates were noted after single-incision repair techniques. This approach has been modified and is now referred to as the modified Boyd-Anderson approach. The modifications to the Boyd-Anderson technique include avoiding the ulna by approaching the bicipital tuberosity through a posterior muscle-splitting approach and by using a high-speed burr to make the biceps trough.4,19,20 The patient is positioned in the supine position and a sterile tourniquet is applied. The repair begins with a small transverse or vertical incision that starts 2–3 cm distal to the antecubital crease. Upon entering the subcutaneous fascia, a large hematoma is frequently encountered. The LABCN should be identified and protected. The biceps tendon is identified, freed of adhesions, and tendon excursion is evaluated. If tendon excursion is limited, then the lacertus fibrosis may be released. A proximal incision is sometimes necessary if the biceps is not accessible through the distal incision. This incision should be made 2–3 cm above the antecubital crease to allow for access to the biceps and tunneling of the biceps tendon to the distal incision. After retrieving the biceps, the tendon is grasped with an Alice clamp or tag suture. The distal diseased 5–10 mm of the biceps tendon is resected and the tip of the tendon is tapered. Two #2 or #5 nonabsorbable sutures are placed through the distal 5–7 cm of the tendon using a Bunnel or Krackow stitch. Next, the bicipital tuberosity is palpated with the index finger and a Kelly clamp or hemostat is passed on the ulnar side of the bicipital tuberosity.

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The hemostat is advanced deep and tents the skin of the dorsal forearm with the arm maximally pronated. A second counterincision is made over the hemostat and the tuberosity is exposed through a muscle splitting incision. Blunt retractors are placed through the dorsal muscle-splitting approach and, with the bicipital tuberosity exposed, a high-speed burr is used to create a 1.5-cm trough in the tuberosity in line with the radial shaft. Three drill holes are placed 7–8 mm apart and 5 mm from the edge of the posterior wall of the bone trough. The hemostat is then used to deliver the biceps tendon through the anterior incision and the previously created path, delivering the tendon and sutures into the dorsal incision. The sutures are passed through the transosseous tunnels and are tied with the forearm in neutral rotation. The wounds are closed and the patient is placed in a posterior splint with the arm at 90° until the first postoperative visit in 7–10 days.21,22

3.8.4  One-incision technique The one-incision technique can be performed through various types of incisions, including a single transverse incision centered over the bicipital tuberosity, a single longitudinal incision starting just distal to the antecubital fossa and centered over the bicipital tuberosity (Figure 3.1), a two-incision approach with incisions above plus a proximal incision to retrieve the biceps from, or an s-shaped incision that crosses the antecubital fossa (Figure 3.2). The authors prefer a single longitudinal incision that is centered over the bicipital tuberosity with extension across the antecubital fossa if

Figure 3.1  A single incision has been made a few centimeters distal to the antecubital fossa in line with the bicipital tuberosity. The bicipital tuberosity tunnel has been reamed. The near cortex has been over reamed with the cannulated 8-mm reamer, and the far cortex is only reamed with the beath pin. The biceps tendon has been whip-stitched and is seen on the left side of the image. The Hohman retractor has been placed on the ulnar side of the radius, and the Army/Navy retractor is placed on the radial side of the radius.

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Figure 3.2  Extensile approach for 4-week-old retracted distal biceps rupture.

a chronic tear is present or if the tendon is retracted and not accessible (Figure 3.1). Using the one-incision approach, one must be cognizant that access to the true anatomic insertion of the biceps is difficult and should not be performed in any patient that does not have full forearm rotation. The patient is positioned as above and the preferred incision made. Large subcutaneous veins will often need to be ligated or cauterized. The distal biceps tract is identified and soft tissue releases are performed as described above. The LABCN should be identified and protected throughout the case. The tendon is prepared as above and deep exposure to the bicipital tuberosity is obtained. An Army/Navy or finger retractor can be placed on the radial side of the incision. Hohman or pointed retractors should never be placed on the radial side of the tuberosity to avoid injury to the PIN and over-retraction on the LABCN. The recurrent radial artery and its accompanying veins will often need to be ligated running over the bicipital tuberosity. Care must be taken not to stray medially to avoid injury to the radial artery and the median nerve. A Hohman retractor or other pointed retractor can be placed on the ulnar side of the tuberosity, allowing excellent visualization of the tuberosity (Figure 3.3). Once the tuberosity is exposed, the biceps can be repaired with suture anchors, cortical button, or cortical button with interference screw fixation (Figures 3.4 and 3.5).

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Figure 3.3  Bicipital tuberosity exposed with small longitudinal incision used for the approach.

Figure 3.4  The biceps tendon has been docked into the prepared tunnel with the cortical button flipped on the radial cortex.

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Figure 3.5  The biceps tendon has been docked into the prepared tunnel with the cortical button flipped on the radial cortex with the interference screw placed on the radial aspect of the tendon.

3.8.5   Cortical/suspensory fixation Cortical fixation for biceps repairs was first described by Bain et al. in 2000. Their technique utilized the Endobutton (Smith and Nephew Endoscopy, Andover, MA).23 The biceps tendon is retrieved and a Krakow weave or Bunnel stitch is placed. The tendon is then sized such that the appropriate size reamer may be utilized. The bicipital tuberosity is exposed and the forearm is maximally supinated (Figure 3.3). A beath pin is advanced across the bicipital tuberosity, crossing both cortices. Next, a 4.5-mm reamer is used to ream bicortically and the proximal cortex is reamed with a larger reamer matching the size of the tendon. A Kerrison rongeur or high-speed burr can be used to lengthen the proximal tunnel to create a trough in which the tendon will sit. The cortical button is tied over the previously placed sutures in the tendon, leaving approximately a 2- to 3-mm gap between the tendon and the button to allow room for the button to be flipped. During reaming, bone fragments should be retrieved and the wound irrigated to prevent heterotopic ossification (HO). Next, a beath pin is advanced across the previously drilled tunnel, with the arm in maximal supination. Passing sutures are placed in the cortical button and fed into the eyelet of the beath pin, and the pin is pulled out the dorsal aspect of the forearm with the passing sutures. The cortical button is advanced across the radius and flipped on its dorsal aspect. A Mini-C-Arm is used to confirm the button has flipped.

3.8.6  Cortical button with interference screw This technique is often referred to as the “tension-slide technique.” Various manufacturers have developed kits that include the cortical fixation button and the interference screw. The theoretical advantage of adding the interference screw is to allow more early active motion as the biceps tendon is firmly affixed in the tunnel.

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The tendon is prepared in a standard fashion and the free sutures are placed through the central tunnels of the cortical button, allowing the tendon to freely slide back and forth on the cortical button. The tendon is sized and the appropriate size reamer is used to drill the proximal tunnel (Figure 3.1). The button is advanced across the tunnel, often with an insertion guide, and the button is flipped on the dorsal side of the radius. Tension is pulled on the sutures, sliding the tendon into the drill tunnel (Figure 3.4). Frequently, the elbow must be flexed to allow for appropriate seating of the tendon. An arthroscopic knot pusher is used to tie the sutures while constant tension is maintained on the sutures. An interference screw is then placed on the radial side of the tendon, forcing the tendon to the ulnar side of the radius (Figure 3.5).

3.8.7  Suture anchors The suture anchor technique also utilizes a single-incision approach with two anchors inserted into the ulnar aspect of the radial tuberosity. They are placed longitudinally along the bicipital tuberosity. The tendon is first tied to the distal suture anchor to ensure that the tendon is placed out to length, and the proximal sutures are tied next. Various suture techniques can be used, but the authors prefer to use double-armed anchors. One limb of each suture is placed in a locking manner up and then down the tendon and subsequently tied to its reciprocal suture, allowing for a sliding locking knot. The other suture on each anchor is placed in a Mason Allen fashion. With suture anchor fixation, only the proximal cortex is drilled, decreasing the risk of PIN injury.

3.8.8  Treatment of chronic ruptures Chronic ruptures are frequently encountered and can be challenging for the patient and surgeon. They are often a result of missed diagnosis or patient neglect. Tears older than 12 weeks can result in loss of elasticity, tissue retraction, and early atrophy, making primary reattachment to the tuberosity difficult. Patients typically present with weakness in flexion and supination and little pain. MRI should be obtained on all chronic ruptures to confirm the diagnosis and determine the level of retraction of the tendon. Chronic biceps repairs are performed through an extensile approach (Figure 3.2). The surgeon should choose their preferred fixation technique (cortical button, tension slide, or two-incision) based on comfort level. In chronic tears, scarring in the antecubital fossa is usually noted, making anatomical planes less obvious and surgical dissection more difficult. In some instances, the tendon is minimally retracted and maintains good elasticity, allowing for reduction of the biceps tendon to the tuberosity as in acute repairs. Primary repair has been recommended for tendons that can be re-approximated with 45–90° of elbow flexion.24,25 However, in many instances, the tendon will not be reducible and will require interposition or onlay allografting. Semitendinosus allografts, autografts, or Achilles tendon allografts may be used for this purpose. Semitendinosus tendons are typically woven through the proximal muscle whereas Achilles tendon allografts (with or without bone block attachment to the tuberosity) should be sewn around the proximal biceps muscle belly.

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The decision on whether to use an Achilles tendon allograft or hamstring graft is based on surgeon discretion. However, most surgeons agree that if a significant portion of tendon remains, a semitendinosus graft may be a better option because it can be weaved through the existing distal tendon. When a small amount of distal tendon is available, the Achilles may be a better choice. If graft options are not available, or the patient is unwilling to utilize a graft, then tenodesis of the biceps tendon to the underlying brachialis is an option, although this technique results in 50% loss of supination strength compared with that of anatomical repair.26

3.8.9   Biomechanics Because there are numerous fixation options available, it is imperative for the surgeon to have a thorough understanding of biomechanical failure testing. Two early studies evaluated the load to failure of suture anchors versus bone tunnel fixation. These studies showed that bone tunnel fixation was significantly stiffer and failed at greater loads compared with suture fixation.27,28 However, one of these studies only used one anchor and the other used varying numbers of suture strands and anchors. A more recent study that standardized the number of suture strands and used two anchors showed suture anchor fixation resulted in higher yield strength compared with bone tunnel fixation.29 A landmark study by Mazzocca et al. evaluated the use of suture anchors, interference screw, bone tunnels, and endobutton fixation for distal biceps tendon repair. No significant difference was noted in displacement of the tendon under physiologic load. When comparing these fixation methods, the highest load to failure was seen in the endobutton (440N), followed by suture anchors (381N), bone tunnels (310N), and interference screw (232N). Although significant differences may be seen in the laboratory, they may be less relevant in the clinical setting.30 All techniques are likely sufficient to allow for early passive motion whereas the endobutton may allow for early active motion. A study that looked at active elbow flexion in cadaveric specimens showed that the largest force required for full active elbow flexion was 123N. Therefore, the pullout strength of the weakest construct (interference screw) far surpasses the in vitro forces required for immediate active elbow flexion.

3.9  Outcomes 3.9.1  Acute repair outcomes Both one- and two-incision approaches have shown excellent results with no discernible difference in outcomes. The modified two-incision approach has demonstrated excellent clinical results with regard to endurance, motion, and strength. Patients also report a high postoperative satisfaction, with most returning to preinjury level of function. A series of 21 patients with a two-incision approach showed that isometric and dynamic flexion strength improved compared with the uninjured side and supination strength 11% within normal.31 In a retrospective review of 41 patients with a

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two-incision approach, all patients regained normal motion and neurologic function.32 Another two-incision study demonstrated that flexion strength and supination strength were 91% and 84%, respectively, compared with the contralateral side.33 D’Alessandro reviewed 10 athletes that underwent two-incision repair and noted that all 10 athletes were able to return to full and unlimited activities with normal biceps contour.34 Single-incision repair techniques have also shown good results with most patients regaining full motion and full or near-full flexion strength and supination.35–37 Multiple larger studies have reported good results with single-incision suture anchor fixation.38–40 Khan et al. retrospectively evaluated 17 patients and noted at an average of 45 months: a Disabilities of Arm, Shoulder, and Hand (DASH) score of 14.15; flexion-in-supination strength was 82.1% of that on the uninjured side; and an average loss of 5.3°of extension and 6.2° of flexion.38 McKee et al. reported on 53 patients with an average follow-up of 29 months and showed an average DASH score of 8.2, and no patient lost more than 5° in the flexion-extension or pronation-supination arc.39 Studies evaluating cortical button fixation for distal biceps tendon repairs have also shown good results.23,41,42 Peeters et al. evaluated 23 patients, demonstrating an average Mayo Elbow Performance score of 91% of that of the contralateral extremity; flexion and supination strength of 80% and 91% of the contralateral extremity, respectively; and all patients had good or excellent results as noted by their post-operative Mayo elbow performance scores.41 Greenberg et al. evaluated 14 patients and showed that motion was nearly equivalent compared with the contralateral side, with 97% return of flexion strength and 82% return of supination strength compared with the uninjured side.42 Bain et al. reported the first series on cortical button fixation examining 12 patients. The mean flexion-extension arc was from 5° to 146°. All patients had a full return of strength.23 Heinzelmann et al. reported on 31 patients who underwent distal biceps repair with cortical button fixation augmented with an interference screw. At 24 months follow-up, the authors reported excellent average postoperative Andrews-Carson elbow scores with an average time to return to normal activities of 6.5 weeks. They advocated more aggressive rehabilitation based on the dual fixation.43 El-Hawary et al. performed a prospective study comparing the modified BoydAnderson technique to single-incision suture anchor fixation. At 1 year, the nine patients in the single-incision group had regained 11.7 more degrees of elbow flexion than the two-incision group. There was no difference in flexion or supination strength noted at final follow-up between the two groups.44 Chavan et al. performed a systematic review comparing single- and two-incision distal biceps repairs. The authors reported a 94% satisfactory outcome rate in the single-incision group compared with 69% in the two-incision group based on their criteria (80% of strength).45

3.9.2  Chronic repair outcomes The outcomes of chronic repairs have shown good results, but not as optimal of outcomes as acute repairs. One study showed that patients treated with semitendinosus allograft augmented reconstruction regained normal supination and flexion strength

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compared with the uninjured side, whereas those treated without surgery demonstrated a 20% loss of supination and flexion strength.46 Other studies have also shown good results with 80–90% return to normal for supination and flexion strength.25,47

3.9.3   Rehabilitation There is a wide range of rehabilitation protocols after distal biceps tendon repair. With modern fixation methods, more aggressive rehabilitation protocols have been used. The authors’ preferred postoperative protocol involves immobilization of the elbow in a posterior splint for 5–10 days postoperation with the arm at 70° of flexion. On the first follow-up visit, the patient is placed in a hinged elbow brace with active motion immediately started. Range of motion is from 30° of terminal extension to full flexion for the first 3 weeks. At 3 weeks postoperation, the brace is opened up all of the way. Gentle strengthening is started at approximately 6 weeks and progressively increased. The brace is discontinued at 6 weeks. Return to work is dependent on work demands. Patients can expect to return to full lifting at approximately 4 months after surgery. If tissue quality is poor or the repair is chronic, then the same rehabilitation protocol is used; however, active motion is delayed until 6 weeks after surgery. More aggressive rehabilitation protocols have been described with cortical button fixation with an interference screw. With this fixation, the author allowed patients to remove their postoperative splint 3–5 days after surgery and apply a compressive dressing. At 1 week, 1-lb weight strengthening is initiated with a return to activities of daily living by 2–3 weeks with active motion as tolerated. No excessive elbow resistance was allowed for 2–3 months postoperation. Most patients were able to return to normal activity by 4 weeks postoperation.43 Full trust in patient compliance is imperative with this highly aggressive rehabilitation protocol.

3.9.4   Complications Surgical complications of distal biceps tendon reattachment are not infrequent and can be serious. The known complications, as reported in the literature, are hematoma, infection, LABCN palsy, PIN palsy, SRN injury, HO, and re-rupture.32,48–51 Each complication will be reviewed in detail, and a focus on preventative measures and pitfalls will be discussed in the sections to follow.

3.9.4.1   Hematoma A hematoma after a distal biceps reconstruction is not unusual, and an exact incidence is not available in the literature. In fact, a case report of spontaneous bacterial seeding of a biceps hematoma has been reported.52 An arcade of veins is typical in the muscular individual who sustains a biceps tendon rupture. During the approach to the radial tuberosity, all crossing veins may be safely ligated because of the large anastamosis of veins around the elbow. Frequently, just distal to the radial tuberosity and at times just over it, the radial recurrent vessels traverse across the distal elbow. These vessels can safely be ligated and should not interfere with proper anatomic reattachment when

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using a single-incision approach. A hematoma may stem from muscular bleeding, bony bleeding, or bleeding from the network of veins or radial recurrent vessels in the surgical field. At the end of the reconstruction, the tourniquet should be let down to check for any bleeding. Any aggressive bleeding should be cauterized to prevent hematoma formation. In addition, postoperative placement of a splint with adequate compression may assist in hematoma prevention.

3.9.4.2  Infection Infection is also not uncommon after distal biceps tendon reconstruction. In cases of infection, immediate surgical debridement is recommended, followed by intravenous antibiotics for 4–6 weeks. Subsequent surgeries are occasionally necessary and monitoring the patient’s erythrocyte sedimentation rate and C-reactive protein levels is recommended. Duncan et al. reported on a case series of 37 distal biceps repairs with three cases of infection—an incidence of 8%. Duncan et al. also noted that their patients did not suffer loss of the biceps tendon itself, or the hardware, and range of motion and function were maintained across all patients.50

3.9.4.3  Neurologic injury Nerve injury after distal biceps tendon reconstruction is fairly common, especially to the LABCN. The LABCN is commonly injured because of its proximity to the field, its quick arborization and attachment distal to the surgical field (creating little give with retraction), and the ease with which the nerve may be placed under or over the tendon incorrectly during reconstruction. A recent study by Carroll et al. delineates the neurologic complications from the anterior single-incision distal biceps tendon reconstruction. In all, only 1 of 50 patients suffered from a complication other than a nerve injury, and a large percentage suffered from a neurologic complication (48%), including a large percentage of LABCN palsies (38%).48 Other studies vary in their reporting of LABCN palsies as a complication after surgical reconstruction of the distal biceps; however, most authors find that it is a common complication. Utilizing a two-incision technique may be the best way to avoid this complication because LABCN injury is reported less frequently in the two-incision literature.31,33,34 PIN palsy and SRN palsy are infrequent complications of distal biceps tendon reconstruction. SRN palsy occurred in Carroll et al.’s review of neurologic complications at a rate of 4%.48 McKee et al. noted a 1.8% incidence of PIN palsy in their singleincision repair technique with suture anchors.39 However, a recent study reported that the rate of PIN/SRN palsy was near 9%.53 PIN palsy can occur secondary to a certain portion of the surgical technique utilized in cortical button fixation. Bain and colleagues conducted a cadaveric study that detailed a “safe zone” for guidewire placement, such that cortical buttons could be placed safely without injury to the PIN. They also advocated for handheld retractors around the radial tuberosity, rather than sharp retractors, to avoid injury to the radial nerve.23 The following recommendations can reduce the likelihood of neurologic injury when utilizing the single-incision technique. First, use of sharp retractors should be limited to the ulnar side of the radial tuberosity. Second, the lateral side of the radial

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tuberosity should be retracted with a handheld retractor to avoid PIN and SRN palsies. Finally, electrocautery should be limited to the use of the bipolar, especially when working near the radial tuberosity. Arcing can occur to the metallic handheld retractors, thus heating the areas around the nerves and causing thermal injury.

3.9.4.4   Heterotopic ossification HO is rare with the single-incision technique and has been historically associated with the two-incision technique because of the violation of the interosseous membrane. However, more contemporary researchers of the two-incision technique report its effectiveness and lack of significant HO formation compared with the single-incision surgery.5 Frequently, HO may occur in the setting of infection.50 HO may also be the culprit of a slowly developing PIN palsy.48 It is interesting to note that this complication may be under-recognized because of the lack of postoperative radiographs that are obtained beyond the initial office visit. Prevention of HO is a matter of debate. Unfortunately, the exact causes of HO are not clearly understood, but it is recognized that elbow trauma and extensive soft tissue dissection may play a role. Many surgeons utilize NSAIDs in the early period after distal biceps tendon reconstruction to help prevent HO. The use of radiation has not been reported for HO prophylaxis in distal biceps tendon reconstruction. The authors recommend avoiding extensive soft tissue dissection around the radial tuberosity and adjacent ulna, using sharp reamers/drill bits, and removing bone dust from the radial tuberosity if the single-incision technique is used. Finally, an NSAID such as indomethacin may be used for 1–4 weeks postoperation to help prevent HO formation.

3.10   Future trends There have been significant advances in the treatment of distal biceps repair over the last 2 decades. The Boyd and Anderson technique has been modified, and this classic technique has shown to be equivalent to single-incision techniques. The trend appears to be more aggressive early range of motion and strengthening. In addition, minimally invasive incisions appear to be on the rise as well.

3.11   Conclusion Distal biceps injuries are most commonly seen in middle-aged males in the dominant arm after an eccentric load to the flexed elbow. The diagnosis can often be made by physical exam alone. MRI is a valuable tool, especially in chronic tears, to determine the level of retraction. Acute repairs, performed through either a single or two-incision approach, have demonstrated good outcomes. Surgical repair is generally recommended unless the patient has medical contraindications to surgery. Complications are common with both single- and two-incision techniques, with most being transient

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nerve palsies. Biomechanical studies have demonstrated comparable results with various fixation techniques. Surgical reconstruction of chronic tears has resulted in good outcomes with slightly less strength than is seen in acute repairs. Postoperative rehabilitation protocols are trending toward early and more aggressive range of motion.

Disclosures The authors have no financial disclosures relative to this paper. Dr Metzler is a consultant for Smith & Nephew.

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Distal humerus fractures: open reduction and internal fixation

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R.M. Greiwe Commonwealth Orthopaedic Centers, Edgewood, KY, USA

4.1  Introduction Sir Astley Cooper first described distal humerus fractures in 1822 (Cooper, 1822). Later, French surgeon Malgaigne gave a detailed description of distal humerus fractures in his 1847 book Traeté des Fractures et des Luxations (Malgaigne, 1847). During that time and until the advent of radiographs, all elbow injuries including distal humerus fractures were treated conservatively: nonunions and malunions were typical. Reduction techniques for distal humerus fractures were utilized in Ancient Egypt and Greece, and early mobilization of fractures of the elbow was proposed during the middle ages by French royal surgeon Ambroise Paré (1510–1590). According to recent research, this idea was supported in the 1600s by German surgeon Lorenz Heister because issues with mobility had already been encountered after injury (Kozanek et al., 2014). Fractures of the distal humerus are uncommon injuries, accounting for only ­0.5–2% of all fractures (Zlotolow et al., 2006; Morrey, 2000; Charissoux et al., 2013; ­Court-Brown and Caesar, 2006). Historically, nonoperative treatment (i.e., “bag of bones”) was advocated as the best form of management because of a lack of adequate surgical techniques and implant-related issues. During the past several decades, operative management became widely accepted as the best treatment for these injuries, despite the complications associated with operative management. Distal humerus fractures are broadly categorized into those with intra-articular extension and those without. Intra-articular fractures are generally more challenging, at times requiring an olecranon osteotomy and extensive dissection. Difficulties exist when managing distal humeral fractures because of challenges in obtaining an anatomic reduction, related ulnar nerve issues, heterotopic ossification, comminution, osteopenia, nonunion, and the complex decision-making regarding whether to treat operatively with total elbow replacement or open reduction and internal fixation (ORIF). Success frequently depends on various factors, including quality of reduction, fracture type and severity, and patient compliance with physical therapy and lifting restrictions. Distal humerus fractures occur infrequently, but they represent 30% of all elbow fractures (Zlotolow et al., 2006). Most fractures of the distal humerus (50–70%) are intra-articular and generally related to a simple fall and osteoporosis (Charissoux et al., 2013; Robinson et al., 2003). Distal humeral fractures occur in a bimodal distribution, Shoulder and Elbow Trauma and its Complications. http://dx.doi.org/10.1016/B978-1-78242-450-5.00004-6 Copyright © 2016 Elsevier Ltd. All rights reserved.

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but women over the age of 65 are most commonly affected. Younger patients who sustain intra-articular fractures generally are involved in high-energy trauma (Galano et al., 2010). Recent research indicates that the overall incidence of distal humeral fractures is 5–30/100,000 and is increasing because of a more active older population with a longer lifespan (Palvanen et al., 2010; Robinson et al., 2003; Sheps, 2011). A recent study in Finland demonstrated that the rate of distal humerus fractures has tripled since 1970 (Palvanen et al., 2010). Compared with hip fractures associated with osteoporosis, distal humerus fractures generally occur to a more active patient who has a high level of autonomy, frequently living independently (Charissoux et al., 2013). Because of its increasing frequency, distal humeral fracture management is also increasing. The goals for the orthopedic surgeon treating these injuries should be to maintain function, decrease pain, and provide a stable ulnohumeral and radiocapitellar joint. Distal humerus fractures commonly occur through a fall or more significant force onto a flexed elbow, transmitting forces through the thin-walled olecranon/coronoid fossae, occasionally splitting down through the articular margin.

4.2  Anatomy and biomechanics To fully appreciate distal humeral fractures, the surgeon must have a sound understanding of the anatomy and biomechanics of the elbow. The elbow is made up of three articulations—ulnohumeral, radiocapitellar, and proximal radioulnar—surrounded by a fibrous joint capsule. There are three main static stabilizers to the elbow joint that include the bony architecture, the anterior bundle of the medial collateral ligament (MCL), and the lateral collateral ligament (LCL) complex. The dynamic stabilizers to the joint are the muscles that cross the elbow joint, including the brachialis, biceps, triceps, common flexor tendons, common extensor tendons, anconeus, and brachioradialis. The ulnohumeral joint has an axis of rotation that lies in 3–8° of external rotation and 4–8° of valgus in relation to the humeral shaft. The trochlea has 300° of articular cartilage and allows for the normal 140° arc of motion that is possible with elbow flexion and extension.

4.2.1  Neurovascular anatomy Several nerves and arteries lie in close proximity to the distal humerus and should be appropriately cared for during ORIF of the distal humerus. The radial nerve lies posterior to the humerus and exits the spiral groove posterior to the intermuscular septum. At an average point 10 cm proximal to the lateral epicondyle, but no closer than 7.5 cm, the nerve courses through the intermuscular septum and begins to track anteriorly (Gofton et al., 2003; Carlan et al., 2007; Galano et al., 2010). It is at this point that lateral plates may impinge the nerve when utilizing a parallel plating technique that will be described in detail later. The ulnar nerve travels anterior to the medial intermuscular septum in the arm and traverses this structure on its way to becoming a posterior structure. This orifice in the

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septum is called the arcade of Struthers and is located approximately 8 cm proximal to the medial epicondyle (Galano et al., 2010). The nerve stays just posterior to the septum and then runs directly into the groove posterior to the medial epicondyle. The nerve then splits the two heads of the flexor carpi ulnaris (ulnar and humeral) and again becomes an anterior structure. The ulnar nerve is injured in approximately 13–24% of intra-articular distal humerus fractures and should be carefully examined preoperatively for clinical and medicolegal reasons (Ruan et al., 2009; Kundel et al., 1996). The brachial artery and median nerve/anterior interosseous nerve are rarely injured with adult intra-articular distal humerus fractures. In pediatric injuries, which are outside of the scope of this chapter, the anterior interosseous nerve and brachial artery are more frequently injured because of the excessive posterior displacement of some Garland Type III supracondylar fractures (White et al., 2010).

4.2.2   Osteoarticular anatomy The elbow’s articular geometry is a highly congruent joint made up of the disk-like concave radial head with rim, the hemispherical capitellum, spool-like trochlea, and concave olecranon. The congruency of the elbow is critical and provides approximately 50% of elbow stability (Morrey and An, 1983). The radial head is covered with cartilage, including the concave disk-like inner surface and 280° of the rim (Miyasaka, 1999). The area not covered by cartilage is known as the “safe zone” and plates placed here will not interfere with pronation and supination. The radial head is variably offset from the neck axis such that the center of the convex radial head meets the capitellum in flexion and pronation. A deep groove and two convex facets form the cartilaginous anatomy of the trochlea. The olecranon’s greater sigmoid notch contains a sagittal ridge that runs the entire length of the notch. The ridge is flanked by two concavities that congruently meet the convex trochlear facets. This highly confluent and congruent joint is one of the primary restraints to dislocation of the elbow. It bears identifying some anatomic resemblance to the extensor mechanism of the patella and the femoral trochlea. The extensor mechanism of the elbow is much more constrained and is less easily dislocated than the patellofemoral joint, but its biomechanical role and similar anatomical features cannot easily be overlooked. The radiocapitellar joint is a hemispherical joint lateral to the ulnotrochlear joint that is most congruent in pronation and flexion. The round capitellum may be involved in capitellar shear fractures in association with distal humerus fractures (covered later in the chapter). The radiocapitellar joint is loaded most in extension and pronation (Morrey et al., 1988). The proximal radioulnar joint allows for free rotation of the radial head and provides a 90° arc of cartilage (lesser sigmoid notch) for radial head rotation (Figure 4.1—arthroscopic pictures of the elbow). The radial head has a corresponding 280° rim of articular cartilage that allows for smooth pronation and supination. After a distal humerus fracture, this area of the elbow should remain intact except for in rare, severe-injury patterns.

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(a)

(b)

RCL

Annular ligament

LUCL Crista supinatorum

Figure 4.1  Ligamentous anatomy of the elbow. (a) The medial elbow contains the ulnar collateral ligament (anterior band red arrow), posterior band (green arrow), and transverse ligament (black arrow). (b) The lateral elbow contains the LCL complex, which includes the lateral ulnar collateral ligament (LUCL), the annular ligament, and the radial collateral ligament (RCL).

4.2.3  Capsuloligamentous anatomy The capsule of the elbow attaches just proximal to the articular margin both anteriorly and posteriorly, above the respective coronoid, radial, and olecranon fossae. Laterally, the capsule becomes contiguous with the LCL and annular ligament. Medially, the capsule is contiguous with the MCL. Posteriorly, the capsule is tight in flexion; anteriorly, the capsule is tight in extension. The primary ligamentous stabilizers of the elbow are the LCL, MCL, and the anterior and posterior capsule. These structures are typically not injured after a distal humerus fracture unless they are iatrogenically injured. The MCL complex consists of an anterior band, posterior band, and a transverse ligament. The origin of the MCL is

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Figure 4.2  The sublime tubercle is located on the proximal ulna and is the anatomic insertion point for the MCL.

the anteroinferior aspect of the medial epicondyle and the insertion is located on the sublime tubercle (Figure 4.2). The anterior bundle is the strongest part of the ligament and is the main stabilizer to valgus stress on the elbow (Johnson, 2005). The LCL complex contains four main parts, including the radial collateral ligament, the lateral ulnar collateral ligament, the annular ligament, and the accessory collateral ligament (Figure 4.3). The origin of the LCL complex is the inferior surface of the lateral epicondyle. The insertion is a long crest of bone on the lateral ulna known as the crista supinatorum. The LCL provides significant stability to the elbow because of its resistance to varus and posterolateral forces. The annular ligament attaches to the anterior and posterior margins of the lesser sigmoid notch (O’Driscoll et al., 1991). The radial collateral ligament provides stability for the radial head and interdigitates with the annular ligament (Johnson, 2005). The lateral ulnar collateral ligament proceeds from the lateral epicondyle to the crista supinatorum, just lateral and slightly posterior to the radial head (O’Driscoll et al., 1991). The ligamentous structures are presumed to be intact after sustaining a distal humerus fracture. However, stability of the elbow should be monitored and tested to identify if any ligamentous injury has occurred after fracture fixation.

4.2.4   Elbow biomechanics The primary role of the elbow is to position the hand in space, so far as the shoulder and the length of the arm allow. In other words, as the elbow is able to variably flex, the hand may be positioned at any point in space to the extent the shoulder can place it there. The elbow is critical for activities of daily living such as eating, bathing, shaving, brushing one’s hair or teeth, and perineal care. Although normal range of motion is 0–140°, functional range of motion has been established by several studies to be approximately 30–130° (Boone and Azen, 1979; Morrey et al., 1981; Morrey and Chao, 1976). Therefore, the goal after distal humerus reconstruction is to achieve this range of motion or better. To understand the importance of the sagittal and coronal plane alignment after ORIF of the distal humerus, it is helpful to understand the flexion-extension axis of the elbow.

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C1

A1

A2

B1

B2

C2

A3

B3

C3

Figure 4.3  OTA/AO classification system.

The elbow is thought of as a trochleoginglymoid joint for its hinged (ginglymoid) and pivoting (trochoid) functions. During flexion and extension, the elbow acts as a loose hinge, and the flexion-extension axis changes during flexion and extension, pronation, and supination (Figure 4.4; Duck et al., 2003). The reason the elbow acts as a loose hinge rather than a pure hinge is unknown, but it may relate to hand positioning and alignment of the forearm or to equally balance joint forces when in supination or pronation.

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High “T”

“Y”

Lateral lambda

71

Low “T”

“H”

Medial lambda

Figure 4.4  Jupiter and Mehne classification system.

The ulnohumeral joint shares 43% of the load across the elbow, as compared with 57% across the radiocapitellar joint (Halls and Travill, 1964). Force transmission is greatest through the capitellum in relative extension (0–30°) and pronation (­Morrey et al., 1988). In the ulnohumeral joint, when the elbow is extended, the coronoid sees the primary load. When the elbow is flexed, the corresponding load is transmitted through the olecranon (Wake et al., 2004). Thus, peak pressure across the distal

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humerus is increased at terminal flexion and terminal extension, and contact pressures are less during the normal arc of motion.

4.3  Classification system In the modern era, after the invention of the roentgenogram, the first authors to classify distal humerus fractures were Helferich and Cotton (Helferich, 1897; C ­ otton, 1911). In 1969, Riseborough and Radin reported distal humerus fractures according to the shape of the fracture line in their report on intercondylar T-shaped fractures (Riseborough and Radin, 1969). Later, the Arbeitsgemeinschaft für Osteosynthesfragen (AO) group classified distal humerus fractures into A, B, and C types, according to the amount of intra-articular involvement (Ruedi, 2007). In this classification system, “A” refers to an extra-articular fracture, “B” designates a partial articular fracture, and “C” indicates an intra-articular fracture in which the articular surface is completely separated from the metaphysis. These are further subdivided based on the degree of comminution or to further define the fracture locale (Figure 4.5).

Figure 4.5  Preoperative photograph of a patient with a distal humerus fracture. Note the significant swelling, ecchymosis, and excoriations that may predispose this patient to wound complications. A discussion with the patient and family should be had to discuss this potential complication.

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This is currently the most prevalent fracture classification used in preoperative planning worldwide. In 1992, Jupiter and Mehne developed their classification scheme that derived itself from intraoperative observations of fracture patterns (Figure 4.6; Jupiter and Mehne, 1992). Critics to the above classification schemes have argued that they were not reliable or reproducible between observers, their reliability for the purposes of research and clinical decision-making was poor, and several fractures were not classifiable using their methods (Wainwright et al., 2000). Recently, Davies and Stanley tested a new classification scheme that combines the work of the above systems and identified that it was more reliable and reproducible than that of Riseborough and Radin, Jupiter and Mehne, and the AO group (Davies and Stanley, 2006). Dornberg et al. studied the inter- and intraobserver reliability of the AO classification when the addition of three-dimensional (3D) computed tomography (CT) was performed (Doornberg et al., 2006). It was noted that the reliability, but not the accuracy of the assessment, was improved with 3D CT. In other words, the interobserver reliability was similar, but the intraobserver reliability was improved. Therefore, when available, 3D CT scanning should be performed before surgical management such that the surgeon may fully appreciate all fracture planes.

Figure 4.6  The paratricipital approach. Ulnar nerve (green arrow) is protected and the triceps tendon (yellow arrow) is elevated to gain access to the distal humerus. This approach is used for extra-articular fractures and those amenable to indirect reduction.

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Figure 4.7  The olecranon osteotomy allows for maximal exposure to the distal humeral articular surface.

4.4  Preoperative evaluation As with any injury, understanding the mechanism is helpful in arriving at the diagnosis or determining underlying medical comorbidities. An older patient most often sustains a fall onto an outstretched arm. A history that includes a loss of consciousness or frequent falls should trigger a thorough evaluation by a primary care specialist, cardiologist, or neurologist. Ascertainment of the patient’s preinjury activity level, handedness, occupation, hobbies, and activity level is important and frequently influences the discussion regarding patient expectations. Presenting signs and symptoms vary, but a full orthopedic evaluation should be performed. Distal humerus fractures commonly occur from falls and may be associated with other injuries to the ipsilateral hip, ribs, and upper extremity. A careful and complete musculoskeletal evaluation should be performed. Pain is almost always present, especially with movement of the elbow. Inspection of the elbow typically reveals swelling and initially minor ecchymosis. Patients should be instructed that ecchymosis typically worsens and extends distally, involving the ipsilateral arm over the next 5–7 days. The dependent nature of the arm can result in significant swelling, particularly in patients with associated neurologic injury.

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(a)

(b)

Figure 4.8  (a) Ulnar nerve transposition protects the nerve and allows safe handling of the fracture fragments during the case. (b) A flexor-pronator-based fasciodermal sling (blue arrow) is created to maintain an anterior position to the nerve (red arrow).

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Palpation of the distal humerus will elicit pain; occasionally, crepitance will be felt with motion at the fracture fragments. A full neurovascular exam is an essential component when evaluating distal humerus fractures because of the proximity to the ulnar nerve. Ulnar nerve injury after distal humerus fractures is fairly common, especially with intra-articular fractures (Ruan et al., 2009; Kundel et al., 1996). Arterial injuries have also been reported, although rarely (Novak and Baratz, 2006; Robinson et al., 2003). A recent epidemiologic study over a 10-year period including 320 distal humerus fractures in adults revealed only 2 vascular injuries (Robinson et al., 2003). The incidence of brachial artery injury from blunt trauma is low, but it is also associated with a high rate of amputation and is more common with open injuries (Rozycki et al., 2003). Therefore, a complete examination is necessary, including evaluation of the radial, median, and ulnar nerves and the radial and ulnar arteries. Radiographic examination is a mandatory component of the evaluation of the distal humerus fracture and assists in determining appropriate operative treatment. An anteroposterior and lateral radiograph is adequate for most extra-articular fractures. If an intra-articular fracture is identified, then traction radiographs may assist in defining the fracture planes. In areas where CT is available, 3D CT scanning is very helpful in understanding the nuances of intra-articular fractures and preoperative planning (Doornberg et al., 2006).

4.4.1  Preoperative risk factors 4.4.1.1  Medical comorbidities Patients with significant medical comorbidities, including smoking or diabetes, should be counseled that they may have an increased risk of infection, delayed wound healing, and bone union issues. Furthermore, patients with alcohol or drug dependence may be noncompliant or have nutritional deficits that affect outcome. Attempts should be made through preoperative and postoperative discussions with such patients and caregivers to diminish noncompliance and improve nutritional deficiencies.

4.4.1.2  Injury to the central nervous system Patients with associated injuries to the central nervous system are at an extremely high risk of heterotopic ossification (Garland, 1991a,b; Garland et al., 1980; ­Hurvitz et al., 1992; Peterson et al., 1989). The presence of ectopic bone is a poor predictor for good outcomes after surgical management and may also require further surgery for removal of bone. Preventative strategies exist that diminish the chances for development of heterotopic ossification. These strategies are discussed in Chapter 14.

4.4.1.3  Fracture characteristics Patients with highly comminuted articular fragments and those with significant osteopenia may be better treated with total elbow arthroplasty (TEA). Other fracture characteristics play a role, including presence of an open fracture. In a recent study by Lawrence et al., the authors noted that wound complications after distal humerus fracture were more common after Gustilo-Anderson Grade III fractures

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(Lawrence et al., 2014). Of note, wound complications may be better tolerated after ORIF rather than elbow arthroplasty.

4.4.1.4   Age Age greater than 65 years is a relatively soft indication for TEA. Several studies have reported improved outcomes with TEA in patients older than 65 years of age (Frankle et al., 2003). However, it should be noted that bone quality and fracture pattern play a larger role in the decision-making process than age. Age alone may be a predictor after reviewing the recent literature, but each patient should be evaluated based on their own fracture characteristics and bone quality.

4.4.2   Patient expectations Proper patient education is a critically important piece to the preoperative consultation with the performing surgeon. In general, although results of operative management can result in a relatively painless joint, the patient should expect a long rehabilitation process and significant postoperative stiffness. The surgeon should ideally lay out the need for formal physical therapy along with the limitations necessary to improve healing and diminish postoperative complications. In addition, because ulnar neuropathy, nonunion, and hardware complications are common, a discussion regarding these potential issues may better inform the patient, allay fears, and decrease litigious behavior after treatment.

4.5  Surgical decision-making Nonsurgical management after distal humerus fractures should be reserved for patients with limited baseline function in the involved upper extremity (paralysis, ankylosis, etc.), those who are high-risk surgical candidates, or young patients with completely nondisplaced extra-articular fractures. Displaced, intra-articular distal humerus fractures are unsuccessfully treated without surgery because closed reduction cannot improve joint incongruity and prolonged immobilization almost universally results in significant stiffness. All others should be considered for operative management. Recent advances in surgical technique, implantable devices, operative approach, and postoperative rehabilitation have made surgical management the mainstay of treatment for almost all distal humerus fractures.

4.6  Technical considerations 4.6.1  Open reduction and internal fixation After the decision to perform ORIF, one must decide on plating technique (90/90 vs parallel plating), surgical approach, and what to do with the ulnar nerve. Several approaches have been described, and each has its own merits and drawbacks. With the exception of coronal shear fractures of the capitellum (which will

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be discussed later), all techniques use a posterior skin incision and work around or through the triceps to address the fracture. The described operative approaches include the Alonso-Llames approach (paratricipital; Ali et al., 2008; Alonso-Llames, 1972), the Bryan–Morrey approach (triceps reflecting; Ek et al., 2008), triceps reflecting anconeous pedicle (TRAP; Ozer et al., 2005), triceps splitting (Ziran, 2005), and olecranon osteotomy (Ring et al., 2004; Coles et al., 2006). The paratricipital approach avoids injury to the triceps by using medial and lateral windows to visualize the fracture planes. This approach is particularly useful for extra-articular fractures and those fractures that can be reduced indirectly (C1 and C2 fractures). The primary disadvantage to the approach is the lack of visualization of the articular surface. Despite this, because it can easily be converted to a TEA or an olecranon osteotomy, this is the preferred approach of many for Type A and Type C1 and C2 fractures. The triceps-reflecting approach (Bryan–Morrey) and TRAP approaches provide excellent exposure for distal humeral fracture management, and studies have demonstrated good outcomes after their use (Ozer et al., 2005; Ek et al., 2008). However, a significant disadvantage to these approaches is the risk for triceps failure because of poor tendon-to-bone healing. Despite this, there have been no head-to-head trials demonstrating worse outcomes with the triceps-reflecting and TRAP approaches compared with others for ORIF. The triceps-splitting approach is a common approach for fractures of the distal one-third of the humeral shaft, but it can also be used for intra-articular distal humerus fractures . In the latter situation, the proximal 1 cm of the olecranon may be removed to enhance visualization of the joint surface. The olecranon osteotomy approach is the workhorse approach for most intra-articular distal humerus fractures. This approach provides the best joint exposure of all of the approaches (Wilkinson and Stanley, 2001). A disadvantage to the approach is that conversion to TEA after ulnar osteotomy is challenging. In situations in which conversion to TEA is possible, it is advisable to potentially consider the triceps-reflecting approaches or simply the paratricipital approach. The olecranon osteotomy may be technically challenging, but several pearls improve its reconstruction. First, apex distal ulnar osteotomy should be performed through the bare area (∼2–3 cm distal to the olecranon tip). Second, the osteotomy should begin with an oscillating saw cutting parallel to the bone surface until the subchondral bone is felt, and then the procedure is completed using an osteotome so that the humeral cartilage is protected. The osteotomy is then fixed using a tension band, intramedullary screw, or ulnar plate. Although the osteotomy has proven to improve joint exposure, studies demonstrated equivalent functional outcomes with ulnar osteotomy over the triceps-splitting approach (Pajarinen and Bjorkenheim, 2002).

4.6.2  Plating technique Several controversies exist when considering plating methods for distal humerus fractures. Biomechanical evidence also supports the use of locked plating in distal humerus fractures over conventional plates, but only in comminuted fracture situations or in patients with poor bone quality (Korner et al., 2004). Most surgeons currently choose to utilize locking plates because of their enhanced stability profiles. Questions regarding

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type of plate fixation techniques have been a source of recent literature. Over time, dorsal plating has given way to parallel or perpendicular plating techniques. Currently, 180° plating techniques (parallel plating) are favored over 90°/90° plating (perpendicular plating) for osteoporotic or comminuted fractures of the distal humerus (Stoffel et al., 2008; Arnander et al., 2008; Schemitsch et al., 1994). Anatomically contoured locking plates are currently available from various implant manufacturers, and despite the high cost of these implants, clinical evidence does support their application. Two clinical case series on the results of locked plating have been reported and show excellent healing profiles with only one reported implant failure (Reising et al., 2009; Greiner et al., 2008). An ulnar nerve transposition or ulnar nerve release is generally chosen to protect the ulnar nerve from iatrogenic stretch and to decrease the risk of ulnar neuropathy from the injury. When ulnar nerve transposition is chosen, it is recommended to release the nerve proximally from the arcade of Struthers distally to the motor branch to the flexor carpi ulnaris, including Osborne’s fascia and the fascia of the flexor compartment. In doing so, the medial intermuscular septum should be resected so that a smooth transition zone can be made from posterior to the intermuscular septum to a subfascial sling anterior to the medial epicondyle. In general, most surgeons recommend that distal humerus fractures be treated with a precontoured, locked plate in a parallel-plating (180°) configuration. In rare cases of isolated condyle fractures and minimally displaced fractures, one plate or a cannulated screw option may be sufficient. Certainly, overprotecting the fracture is always recommended.

4.7  Principles of fixation Because of earlier reports of unsatisfactory results in 20–25% of patients with the standard AO/ASIF (Association for the study of internal fixation) techniques of 90°/90° plating (Gabel et al., 1987; Henley et al., 1987; John et al., 1994; Jupiter et al., 1985; Letsch et al., 1989), O’Driscoll outlined several principles that, in conjunction with locked plating, have improved the biomechanical stability of distal humerus fractures. The following principles have been developed and are now seen as the new standard for the management of these difficult fractures. The first principle of surgical treatment involves an anatomic articular surface reduction. The articular surface should be fixed provisionally with small, smooth Kirschner wires. In addition, headless compression screws may be needed to improve fixation of these small joint fragments. If possible, the Kirschner wires are not transitioned to headless screws until after the plates are applied and the larger screws are passed into the distal fragments. At times, these smaller screws may block an important large stabilizing screw from passing into the distal fragment. In general, the articular surface heals without difficulty, but the metaphyseal region is a common place for nonunion or delayed union. A second principle is appropriate alignment and healing of the metaphysis with the articular segment. In this area, it is important to have adequate bony contact and stability for healing. If bone loss has occurred in the metaphyseal region, then primary bone grafting or shortening of the metaphysis by up to 1 cm is appropriate.

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The third principle involves several parts and is predicated on the architectural stability of the distal humerus fixation as outlined by O’Driscoll. Eight objectives are described to encourage bony stability (Figure 4.9): (a)

(c)

(b)

(d)

Figure 4.9  Technical objectives during surgery include an anatomic reduction, passing as many screws as possible into the distal fragment, and application of locking plates. (a and b) Preoperative CT scan demonstrates a comminuted distal humerus fracture. (c and d) Postoperative radiographs demonstrate a reasonable execution of the technical objectives described. The patient made a near full recovery with excellent postoperative motion (5–140°) and returned to his job as a manual laborer.

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1. Every screw should pass through a plate. In the author’s opinion, this principle should be modified to allow for the placement of headless compression screws and other screws that stabilize the subchondral bone (rafting screws). 2. Each screw should engage a fragment on the opposite side that is also attached to a plate. This allows for interdigitating fixation and improved biomechanical stability. 3. As many screws as possible should be placed in the distal fragments. 4. Each screw should be as long as possible. 5. Each screw should engage as many articular fragments as possible. 6. The screws should lock together by interdigitation within the distal fragment, thereby creating a fixed-angle architecture that provides stability to the entire distal humerus. 7. Plates should be applied such that compression is achieved at the supracondylar level for both columns (Figure 4.10). 8. Plates used must be strong enough and stiff enough to resist bending or breaking before union occurs at the supracondylar level.

Although the practical application of each of the eight technical objectives is not always possible, they provide a helpful guideline for most surgeons during reconstruction of complex distal humerus fractures such that union and early stability can be achieved. The fourth principle of fracture management involves early, active motion and physical therapy. In general, patients should be encouraged to perform physical therapy within 1 week after ORIF, unless wound complications exist that preclude the movement of the elbow. Early physical therapy is an important tenet to treatment and helps diminish post-traumatic stiffness.

4.8  Surgical technique The patient is placed in the lateral decubitus position, all bony prominences are padded, and an axillary roll is placed. The involved extremity is prepped and draped, and the entire arm is placed over a bolster. A sterile tourniquet is utilized, and the incision is frequently taken up to the level of the tourniquet. The incision is such that it courses from approximately 8–10 cm proximal to the tip of the olecranon and approximately 4 cm distal to it. Around the tip of the ulna the incision is curved medially so that the incision does not lie directly on the olecranon itself. Dissection is taken down to the triceps fascia, and large, full-thickness flaps are taken medially and laterally so that the lateral border of the triceps is identified. The ulnar nerve is then exposed proximally and released from the arcade of Struthers to the first motor branch to the flexor carpi ulnaris. The nerve is handled with care, and a VessiLoop is placed around the nerve. The nerve frequently is transposed early in the operation so that it is not in jeopardy as work continues posteriorly. In general, the author prefers the paratricipital approach (Figure 4.6) for simple extra-articular fracture patterns and an olecranon osteotomy for more complex patterns (Figure 4.7). For the paratricipital approach, the triceps is isolated medially and laterally and a large Penrose drain is utilized to gain control of the triceps. Once the triceps is controlled, the fracture is reduced, aligned, and two plates are placed in parallel fashion.

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(a)

(b)

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Figure 4.10  (a) Anteroposterior and (b) lateral radiographs demonstrate parallel plating technique. This technique maximizes stability for intra-articular distal humerus fractures.

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The olecranon osteotomy is fairly technical, and some technical discussion should be had at this juncture. The olecranon is flat posteriorly and, generally speaking, should be osteotomized such that the saw blade is placed so that a perpendicular cut is made into the bare area. The osteotomy should be an acute angle of approximately 45° relative to the shaft. When the cut is at a flat angle, techniques utilized to reconstruct and compress the olecranon can result in rotation and improper positioning. When utilizing a cannulated screw method, the initial Steinman pin must be placed at a point that represents the middle of the bone from anterior to posterior at the level of the articular surface where the osteotomy cut is planned. If the pin is placed too close to the articular margin, then some distraction posteriorly will occur and the screw may impinge at the level of the joint. Other fixation methods should be applied before the osteotomy such that afterward the plate, screw, or tension band may be reapplied and the bone will anatomically align. After the osteotomy or planned joint exposure technique, the fracture must be assessed and appropriately aligned. At the level of the articular surface, it is critically important to obtain anatomic alignment of the joint surface. The use of Kirschner wires and headless compression screws may be utilized for this purpose. The anterior aspect of the joint should be realigned such that the anterior humeral line bisects the capitellum. The metaphysis is then reconstructed utilizing the fracture keys and lagged when possible. Kirschner wires may be utilized to stabilize the articular surface to the metaphysis so that a plate may be applied. Once the bone has been aligned properly, two parallel plates are applied on the medial and lateral columns. Typically, the medial plate is applied first, and the transposed nerve is carefully protected. Screws are placed into the lateral capitellum so that maximum stability can be obtained here. The lateral side of the elbow often sees significant distraction force with flexion because of the varus moments produced during flexion; therefore, fixation should enhance stability here. Next, a plate is placed on the lateral side and the objectives during fixation are maximized to enhance stability. Once architectural stability of the distal humerus is achieved, attention is turned to the repair of the ulnar osteotomy, if necessary. The repair may be performed with a plate, cannulated screw, headless screw, or tension band techniques.

4.8.1   Tension band The tension band technique is an appropriate fixation method and can be utilized quickly and effectively to reduce the osteotomy. The drawback of the technique is a high incidence of implant-related irritation and the biomechanical profile, which favors other techniques such as plating.

4.8.2   Cannulated screw The cannulated screw is the author’s preferred method because these implants offer excellent stability and their low profile minimizes the need for removal. The initial entry point can be a technical challenge, and an improper starting point will lead to a malreduction of the osteotomy. The starting point should be identified radiographically before placement of the starting guidewire to improve the quality of the reduction. An additional challenge is the significant torque that is placed on the distal ulna, which may

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cause malrotation of the ulna. In this situation, a counter torque may be placed on the ulna (such as a clamp) so that when compressing the osteotomy site, the ulna does not over-rotate and malreduce. In addition, a more angled V-shaped osteotomy cut (45° to the shaft) improves interdigitation of the fragments and may improve alignment.

4.8.3  Plate fixation Osteotomy fixation also may be performed using plate fixation. Advantages to plate fixation are the biomechanical properties of plate fixation, although plates can be irritating and compression across the osteotomy site can be technically challenging. Initial fixation may be obtained with Kirchner wires and then a dorsal plate is applied. Anatomic plates have an oblong screw that is applied first. A second screw (i.e., the “home run screw”) allows for compression across the osteotomy site. Final filling of distal nonlocking screws and proximal locking screws is then performed.

4.9  Surgical factors that affect outcome The most important factor involved in a good outcome after ORIF is proper reconstruction of the articular surface. Many times comminuted fractures can be difficult to reconstruct, and headless compression screws may be beneficial in these circumstances. When significant comminution exists or multiple fracture planes (including coronal shear fractures) are present, conversion to a TEA may be beneficial in certain patient populations (see Chapter 5). The most challenging aspect of reconstruction may be the alignment of the distal articular fragment in the coronal plane. It is common to see the distal fragment in too much extension, which would limit flexion after surgery. Proper lateral radiographs during surgery can assist in identifying whether the distal fragment is in extension. Helpful keys to the reduction found along the medial and lateral columns may assist in preventing extension at the fracture site. Overall, the use of periarticular precontoured locking plates has been found to benefit these fractures by providing adequate fixation in the distal fragment. This fixation is critical for aggressive postoperative rehabilitation. When reconstructing these fractures, after achieving appropriate alignment, the application of 180° plates (parallel plating) is biomechanically important. Please see Section 4.7 above regarding the principles of ORIF that can improve outcomes after ORIF of the distal humerus.

4.10  Coronal shear fractures Coronal shear fractures (Orthopaedic Trauma Association (OTA)/AO Type B3) may occur in isolation or as part of a complex distal humerus fracture, elbow dislocation, or radial head fracture. They are relatively rare and deserve special mention because the approaches and technical aspects of repair differ from standard distal humerus fractures (Figure 4.11; McKee et al., 1996). Coronal shear fractures involve an injury to the

Distal humerus fractures: open reduction and internal fixation

(a)

(b)

(c)

(d)

(e)

Figure 4.11  (a) Anteroposterior radiograph, (b) lateral radiograph, and (c) 3D CT scan demonstrating a coronal shear fracture. This patient was treated with ORIF with headless compression screws. (d and e) Postoperative radiographs at 6 weeks demonstrate anatomic restoration of the joint surface.

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capitellum, trochlea, or both, and they may be comminuted or simple fractures. Coronal shear fractures are frequently associated with fractures of the lateral epicondyle with LCL involvement. Because coronal shear fractures are so rare, much of the research performed on these injuries is retrospective. Coronal shear fractures were initially classified by Bryan and Morrey in 1985 and later modified by McKee et al. (1996). Type I fractures represent a coronal shear fracture of the capitellum, Type II fractures include all osteochondral lesions of the capitellum, Type III fractures represent a comminuted capitellar fracture, and Type IV fractures include those capitellar fractures with medial extension into the trochlea. The proper evaluation of coronal shear fractures includes a comprehensive orthopedic examination including neurovascular examination, radiographs, and a CT scan. Radiographs may be less obvious, but they demonstrate the pathognomonic “double-arc sign” that is characteristic of these injuries (McKee et al., 1996). It has also been demonstrated in multiple Level IV studies that defining the size and comminution of the coronal shear fracture can be difficult and that a preoperative CT scan is helpful for preoperative planning (Ashwood et al., 2010; Ruchelsman et al., 2008; Watts et al., 2007). The operative approach is different than for distal humeral fractures and includes a lateral extensor digitorum communis splitting approach that preserves the lateral ulnar collateral ligament. In general, even medial trochlear extension will be accessible via a lateral approach. If necessary, authors have advocated an olecranon osteotomy or a medial approach in this situation (Ring et al., 2003; Dubberley et al., 2006). Biomechanical evidence supports the placement of anterior to posterior headless compression screws, although multiple fixation methods are present in the literature. When the fracture pattern involves the lateral column, a lateral-based plate improves healing of the lateral epicondyle and its ligamentous attachments. Extremely complex and comminuted fracture patterns should even be considered for distal humeral hemiarthroplasty, although there are currently no distal humeral hemiarthroplasties approved for use in the United States. Historically, the treatment of capitellar fractures included excision or prolonged immobilization resulting in substantial instability or stiffness, respectively. However, more recently, treatment with ORIF and immediate motion has resulted in good to excellent results. A study by McKee et al. reported on six coronal shear fractures each managed with ORIF. All fractures united by 6 weeks and average flexion of 140° (range, 130–150°) and an average flexion contracture of 15° (range, 0–40°). All patients had a good or excellent functional result, according to the Mayo Elbow Performance Score (MEPS) (McKee et al., 1996). In 2006, Dubberley et al. reported on 28 fractures of the capitellum with or without fracture of the trochlea. These fractures were characterized by the presence or absence of posterior comminution. In this study, posterior comminution was found to be a negative predictor for success after ORIF. These patients had more complications, required more extensive surgery, and had worse outcomes compared with simple

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fractures. Average range of motion (19–139°) and MEPS score (91 ± 11) suggested good-to-excellent outcomes for most patients. Two of the most comminuted fractures did not unite and required conversion to TEA (Dubberley et al., 2006).

4.11   Postoperative rehabilitation Rehabilitation after ORIF of the distal humerus relies on the stability of the initial fixation. Fortunately, ligamentous stability is typically present and rehabilitation can progress based on the stability of the fracture. In general, patients are managed postoperatively in a posterior-based splint at 45–90° of flexion for the first 10 days. During this time period, edema and pain are controlled and the focus of rehabilitation should be maximizing hand and finger range of motion. Particular attention should be paid to padding the posterior portion of the olecranon so that pressure necrosis and skin breakdown can be prevented. Passive motion of the elbow is not necessary at this time. During the second time period from weeks 2 to 6, the fracture is healing and more aggressive measures may be taken to improve range of motion. Patients are placed in a brace, unlocked, so that the wound may be evaluated and range of motion can be pursued unimpeded. Aggressive passive stretching can be performed at the end range of motion by physical therapists. Moist, warm heat can be utilized to enhance range of motion at the extremes of motion. Radiographs should be obtained during this time period to examine for heterotopic ossification. If stiffness becomes problematic, then a static progressive elbow splint can improve range of motion. Applied force should be prolonged so that a lengthy stretch occurs. Continued work on edema and inflammation control should be another goal during this phase of rehabilitation. When the fracture has demonstrated adequate healing (typically around weeks 8–10), more aggressive range of motion and stretching can be instituted and patients are allowed out of the brace. Activities of daily living can also be instituted at this time. During this phase, patients may begin light weight-bearing and should be encouraged to begin functional use of the upper extremity.

4.12   Outcomes Outcomes after distal humerus fractures have evolved to significantly benefit the patient over the past 30 years. Whereas in the mid-1980s studies were undertaken to compare ORIF with nonsurgical treatment, nonsurgical management is now reserved for only the most infirm patients (Zagorski et al., 1986). It is clear that three particular advancements have improved the treatment of these fractures. First, principles of fixation determined by the AO group improved outcomes because treatment became more standardized with the development of better orthopedic implants (Kozanek et al., 2014). Second, improved plating techniques (parallel and

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90°/90°) after the principles of fixation according to O’Driscoll have reduced the number of hardware failures and nonunions (Stoffel et al., 2008; Schemitsch et al., 1994; O’Driscoll, 2005). Third, precontoured locking plates made their appearance in the early 2000s and added additional stability for elderly patients with poor bone quality and comminuted fractures (Korner et al., 2004; Reising et al., 2009; Greiner et al., 2008). Improved technology and surgical approaches have resulted in improved functional outcomes and excellent stability for most distal humerus fractures. Following the recommendations of the AO group, bicondylar plating was utilized and still resulted in poor outcomes in up to 20–25% of patients with complication rates in some studies reaching as high as 45% (Letsch et al., 1989; Jupiter et al., 1985; John et al., 1994; Holdsworth and Mossad, 1990; Henley et al., 1987; Gabel et al., 1987; Helfet and Schmeling, 1993). Failure of fixation occurred in 5 of the 88 fractures in the series of Letsch et al., 5 of the 33 patients in the series of Henley et al., and 3 of the 57 patients reported by Holdsworth and Mossad. Sanchez-Sotelo and colleagues felt they were able to improve union rates (97%) and failure of fixation (0%) by utilizing a principle-based approach to distal humeral fracture care. Still, complication rates (46%) and reoperation rates (28%) in this study were notably high (Sanchez-Sotelo et al., 2007). In a more recent study, Ducrot et al. reviewed the outcomes of 31 Type C fractures of the distal humerus and found that range of motion and function were very good. Average follow-up was 25 months, demonstrating 95% good to very good results using the MEPS and a functional arc of motion of 104° (Ducrot et al., 2013). Another recent study from Huang et al. demonstrated a 100% healing rate, a mean flexion-extension arc of 100°, and 76% good to excellent MEPS. Two patients required revision: one patient for fixation failure and one for a postoperative flexion contracture. Ek et al. demonstrated reasonable functional recovery after the retrospective review of nine patients using the Bryan–Morrey technique. The authors found that range of motion was good (median arc, 90°) after comminuted, OTA Type C injuries. The median postoperative Disabilities of Arm, Shoulder, and Hand score was 17.9, indicating mild residual impairment. Although it can be demonstrated from the above literature that functional outcomes and pain scores have improved over the past decades, it does little to solve the question of whether ORIF or TEA is the best form of treatment for comminuted Type C injuries in the elderly. Several recent studies have regarded TEA as the best surgical treatment for comminuted intra-articular fractures in elderly patients (McKee et al., 2009; Obremskey et al., 2003; Garcia et al., 2002; Kamineni and Morrey, 2004; Frankle et al., 2003) whereas others have claimed ORIF is the more appropriate treatment in this group (Huang et al., 2011). What appears to be clear is that outcomes can be good utilizing both TEA and ORIF for the treatment of distal humeral fractures in the elderly. Most importantly, patients who are elderly and sedentary or those who have significant fracture comminution should be considered for TEA. Other factors should also be included in the decision-making process, including surgeon experience and the possibility for wound and infection-related complications that may push the surgeon more toward ORIF.

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Outcomes after distal humeral ORIF have improved after advances in methods of fixation, approaches, and hardware development. Problems such as heterotopic ossification, wound complications, infection, ulnar neuropathy, stiffness, and occasional nonunion remain issues that plague ORIF and TEA. The next section will assist in the identification, management, and prevention of these complications.

4.13   Complications 4.13.1  Failure of fixation Failure of fixation has been significantly reduced through the advent of locking technology, bicondlyar plating, and a principle-based method to achieve fixation. Thus, when failure of fixation occurs, it generally occurs in a select patient population (osteoporotic, elderly patients with comminuted fractures) or it occurs because the above plating and technical principles were not achieved. If failure of fixation occurs because the fracture pattern and bone quality are the contributing factors, then the recommended next treatment would be a revision surgery for removal of hardware and TEA. However, if the surgeon was not able to achieve fixation because of technical considerations, a revision ORIF would be most appropriate.

4.13.2  Nonunion Patients experiencing continued discomfort at terminal flexion and extension more than 4 months after ORIF should be evaluated carefully for nonunion or delayed union. Radiographs may demonstrate “windshield-wipering” around the locking screws in the distal humerus whereas the proximal hardware is generally stable. The distal cancellous bone will typically heal, but the metaphyseal columns are the most common site for nonunion. Careful assessment with a CT scan can confirm cases that are less radiographically obvious. Every patient with previous surgery and suspicious clinical findings should be evaluated for an infectious cause, especially if the previous surgery was technically successful. An abnormal white blood cell count, erythrocyte sedimentation rate, or C-reactive protein level should increase the suspicion of infection. Aspiration of the elbow or nonunion site can be considered. Most importantly, a frozen section during surgery should be considered in the setting of nonunion with suspicion for infection. Most complex distal humeral nonunions will require an olecranon osteotomy. If the anatomy of the fracture is such, then many nonunions can be treated with a tricortical iliac crest bone graft for areas of large bone loss or simply cancellous bone for smaller areas.

4.13.3  Malunion When addressing this problem, identifying the exact location of the malunion is of primary importance. Malunions are most commonly found in the metaphyseal area, especially in the sagittal plane. In general, this occurs because surgeons are unable to fully correct the 30° of flexion in the distal articular surface. Most malunions are not

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severe enough to be surgically treated. However, intra-articular malunion cases are extremely complex and, unless a patient is young and joint destruction is minimal, a salvage operation such as TEA should be available. Extra-articular malunions can be corrected using an extra-articular osteotomy. Correction of the malunion may improve range of motion and decrease tardy ulnar nerve palsy rates, especially in the situation of a valgus malunion. Arthroscopic techniques to address malunion include bone contouring where the anterior or posterior humeral bone is contoured to accept the coronoid or olecranon, respectively. A capsulectomy can be performed at the same time to facilitate motion. Care should be taken to avoid taking too much bone, thus increasing the risk of future fracture.

4.13.4  Infection/wound complications Infection and wound complications after distal humeral fractures can be common, especially in elderly patients with poor peripheral vascular status or open fractures with significant soft tissue trauma. Identification of wound complications must occur early, and discussion with the patient and family should include the necessary treatment required if a deeper infection or hardware exposure develops. Should a wound complication occur over a well-vascularized bed, secondary closure with wet-to-dry dressing changes can occur. If marginal necrosis around the skin edges occurs, then it is best to wait and allow the area to demarcate before determining a plan of action. Obvious purulence should be irrigated immediately and the patient should be treated with intravenous antibiotics. A surrounding cellulitis may be treated with oral antibiotics and close follow-up. Open wounds without infection should be cleaned through local wound care and, if exposed hardware is present, then plans for removal of hardware should be made after fracture healing. Local or free flaps may be necessary when dealing with significant skin loss around the posterior aspect of the elbow because of the lack of blood supply here (Lawrence et al., 2014).

4.13.5  Ulnar neuropathy The decision to transpose the ulnar nerve after fracture fixation is still largely debated amongst traumatologists and elbow experts (Figure 4.8). Unfortunately, the literature on the topic is conflicting, with some authors suggesting ulnar nerve transposition and others suggesting in situ decompression. Ruan et al. prospectively randomized 29 patients with a distal humeral fracture to in situ decompression or ulnar nerve transposition. The results of their study demonstrated improved outcomes in the transposition group in which 12 of 15 patients recovered fully in the transposition group, but only 8 of 14 recovered completely in the decompression group (Ruan et al., 2009). Vasquez et al. retrospectively reviewed the results of two groups of patients with no preoperative ulnar nerve symptoms who underwent transposition and no transposition (Vazquez et al., 2010). They reported an incidence of 20% ulnar nerve complication rate and found no differences between the two groups. Chen et al. noted that patients did better after in situ release of the ulnar nerve (9% ulnar neuritis) versus transposition (33% ulnar nerve symptoms; p = 0.00003; Chen et al., 2010).

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Ulnar neuropathy rates immediately after distal humeral fracture surgery range from 0% to 30%, and it can be debilitating, but permanent rates of ulnar neuropathy are less (0–15%), indicating that most resolve (Webb, 2006; Huang et al., 2011; Doornberg et al., 2007; Sanchez-Sotelo et al., 2007). When ulnar neuropathy is present, it is best to wait to assess whether nerve sensory or sensorimotor function will return.

4.13.6  Heterotopic ossification Heterotopic ossification occurs in 0–21% of elbows after distal humerus ORIF (­Srinivasan et al., 2005; Theivendran et al., 2010; Athwal et al., 2009; Kundel et al., 1996; Sanchez-Sotelo et al., 2007). Patients with clinically relevant heterotopic ossification postoperatively demonstrate reduced motion, and heterotopic ossification may be identified on their postoperative radiographs. Prophylaxis against heterotopic ossification is another controversial topic in the treatment of distal humeral fractures. The major issue at hand is whether the risk of developing complications including nonunion from nonsteroidal anti-inflammatory drugs (NSAIDs) outweighs the benefits of preventing heterotopic ossification. Some authors recommend routine prophylaxis, whereas others recommend the situational use of prophylaxis. Risk factors identified to increase the risk of heterotopic ossification include central nervous system injury, delay in operative intervention, and surgery before definitive fixation (Kundel et al., 1996; Garland and O’Hollaren, 1982; Sanchez-Sotelo et al., 2007). Whether one decides to utilize NSAIDs all of the time or based on patient risk factors, the treatment of heterotopic ossification is sometimes necessary. Heterotopic ossification can be excised, either open or arthroscopically, depending on the location and experience of the surgeon. Chapter 14 will discuss the technical aspects of dealing with heterotopic ossification in more detail.

4.13.7  Elbow stiffness Elbow stiffness is a common complication that occurs after ORIF. All patients should be counseled regarding the loss of motion that occurs after ORIF. Elbow stiffness may be caused by various factors, including articular incongruity, capsular tightness, adhesions, heterotopic ossification, or hardware-related complications. Fortunately, strong initial fixation allows for early and aggressive range of motion after surgery. Further discussion regarding post-traumatic elbow stiffness will be discussed in Chapter 15. Upon identifying postoperative stiffness, it is critical to assess whether the patient is limited to a degree that surgical intervention is necessary. If so, then a careful assessment of the cause of elbow stiffness should be made so that the surgeon can appropriately address the source at the time of surgery. Many of the causes may be arthroscopically managed, but issues such as hardware-related impingement and heterotopic ossification may require open management.

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Prevention of postoperative stiffness may require extensive physical therapy and bracing that assists in improving motion. In the future, more research will be necessary to identify successful methods to prevent postoperative stiffness while preserving the healing process.

4.14  Future trends/additional sources of reference Several improvements in ORIF of the distal humerus have been achieved over the last four decades—namely improving rates of union and hardware failure. Several areas deserving of further research remain, including prevention of post-traumatic capsular stiffness, heterotopic ossification, ideal ulnar nerve management, and indications for TEA versus ORIF. In the future, well-designed prospective trials will assist in the decision-making process. Over the next several years, an increased understanding of the basic science involved in capsular stiffness and heterotopic ossification may yield significant medical and surgical advances that improve the quality of life and outcomes of patients after distal humerus fractures. Every effort has been made in this chapter to describe the most up-to-date techniques and treatment protocols for ORIF of the distal humerus. However, excellent resources are present in the literature with regard to surgical tips, technique, and decision-making. The research and writings by Jupiter and O’Driscoll have most recently helped define current management with ORIF of the distal humerus. Review articles by Galano et al. and Nauth et al. are also helpful papers that discuss the treatment of distal humerus fractures and their complications (Nauth et al., 2011; Galano et al., 2010).

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Carlan, D., Pratt, J., Patterson, J.M., Weiland, A.J., Boyer, M.I., Gelberman, R.H., 2007. The radial nerve in the brachium: an anatomic study in human cadavers. J. Hand Surg. Am. 32, 1177–1182. Charissoux, J.L., Vergnenegre, G., Pelissier, M., Fabre, T., Mansat, P., 2013. Epidemiology of distal humerus fractures in the elderly. Orthop. Traumatol. Surg. Res. 99, 765–769. Chen, R.C., Harris, D.J., Leduc, S., Borrelli Jr., J.J., Tornetta 3rd, P., Ricci, W.M., 2010. Is ulnar nerve transposition beneficial during open reduction internal fixation of distal humerus fractures? J. Orthop. Trauma 24, 391–394. Coles, C.P., Barei, D.P., Nork, S.E., Taitsman, L.A., Hanel, D.P., Bradford Henley, M., 2006. The olecranon osteotomy: a six-year experience in the treatment of intraarticular fractures of the distal humerus. J. Orthop. Trauma 20, 164–171. Cooper, A., 1822. Fractures of the external condyle of the humerus. In: Cooper, A.P. (Eds.), A Treatise on Dislocations and Fractures of the Joints. Longman, Hurst, London. Cotton, F.J., 1911. Dislocations and Joint Fractures. WB Saunders, Philadelphia, PA and London, UK. Court-Brown, C.M., Caesar, B., 2006. Epidemiology of adult fractures: a review. Injury 37, 691–697. Davies, M.B., Stanley, D., 2006. A clinically applicable fracture classification for distal humeral fractures. J. Shoulder Elbow Surg. 15, 602–608. Doornberg, J., Lindenhovius, A., Kloen, P., Van Dijk, C.N., Zurakowski, D., Ring, D., 2006. Two and three-dimensional computed tomography for the classification and management of distal humeral fractures. Evaluation of reliability and diagnostic accuracy. J. Bone Joint Surg. Am. 88, 1795–1801. Doornberg, J.N., Van Duijn, P.J., Linzel, D., Ring, D.C., Zurakowski, D., Marti, R.K., Kloen, P., 2007. Surgical treatment of intra-articular fractures of the distal part of the humerus. Functional outcome after twelve to thirty years. J. Bone Joint Surg. Am. 89, 1524–1532. Dubberley, J.H., Faber, K.J., Macdermid, J.C., Patterson, S.D., King, G.J., 2006. Outcome after open reduction and internal fixation of capitellar and trochlear fractures. J. Bone Joint Surg. Am. 88, 46–54. Duck, T.R., Dunning, C.E., King, G.J., Johnson, J.A., 2003. Variability and repeatability of the flexion axis at the ulnohumeral joint. J. Orthop. Res. 21, 399–404. Ducrot, G., Bonnomet, F., Adam, P., Ehlinger, M., 2013. Treatment of distal humerus fractures with LCP DHP locking plates in patients older than 65 years. Orthop. Traumatol. Surg. Res. 99, 145–154. Ek, E.T., Goldwasser, M., Bonomo, A.L., 2008. Functional outcome of complex intercondylar fractures of the distal humerus treated through a triceps-sparing approach. J. Shoulder Elbow Surg. 17, 441–446. Frankle, M.A., Herscovici Jr., D., Dipasquale, T.G., Vasey, M.B., Sanders, R.W., 2003. A comparison of open reduction and internal fixation and primary total elbow arthroplasty in the treatment of intraarticular distal humerus fractures in women older than age 65. J. Orthop. Trauma 17, 473–480. Gabel, G.T., Hanson, G., Bennett, J.B., Noble, P.C., Tullos, H.S., 1987. Intraarticular fractures of the distal humerus in the adult. Clin. Orthop. Relat. Res. 99–108. Galano, G.J., Ahmad, C.S., Levine, W.N., 2010. Current treatment strategies for bicolumnar distal humerus fractures. J. Am. Acad. Orthop. Surg. 18, 20–30. Garcia, J.A., Mykula, R., Stanley, D., 2002. Complex fractures of the distal humerus in the elderly. The role of total elbow replacement as primary treatment. J. Bone Joint Surg. Br. 84, 812–816.

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Garland, D.E., 1991a. A clinical perspective on common forms of acquired heterotopic ossification. Clin. Orthop. Relat. Res. 13–29. Garland, D.E., 1991b. Surgical approaches for resection of heterotopic ossification in traumatic brain-injured adults. Clin. Orthop. Relat. Res. 59–70. Garland, D.E., Blum, C.E., Waters, R.L., 1980. Periarticular heterotopic ossification in head-injured adults. Incidence and location. J. Bone Joint Surg. Am. 62, 1143–1146. Garland, D.E., O’Hollaren, R.M., 1982. Fractures and dislocations about the elbow in the head-injured adult. Clin. Orthop. Relat. Res. 38–41. Gofton, W.T., Macdermid, J.C., Patterson, S.D., Faber, K.J., King, G.J., 2003. Functional outcome of AO type C distal humeral fractures. J. Hand Surg. Am. 28, 294–308. Greiner, S., Haas, N.P., Bail, H.J., 2008. Outcome after open reduction and angular stable internal fixation for supra-intercondylar fractures of the distal humerus: preliminary results with the LCP distal humerus system. Arch. Orthop. Trauma Surg. 128, 723–729. Halls, A.A., Travill, A., 1964. Transmission of pressures across the elbow joint. Anat. Rec. 150, 243–247. Helferich, H., 1897. Atlas und Grundriss der Traumatischen Frakturen und Luxationen. Lehmann, Munich, Germany. Helfet, D.L., Schmeling, G.J., 1993. Bicondylar intraarticular fractures of the distal humerus in adults. Clin. Orthop. Relat. Res. 26–36. Henley, M.B., Bone, L.B., Parker, B., 1987. Operative management of intra-articular fractures of the distal humerus. J. Orthop. Trauma 1, 24–35. Holdsworth, B.J., Mossad, M.M., 1990. Fractures of the adult distal humerus. Elbow function after internal fixation. J. Bone Joint Surg. Br. 72, 362–365. Huang, J.I., Paczas, M., Hoyen, H.A., Vallier, H.A., 2011. Functional outcome after open reduction internal fixation of intra-articular fractures of the distal humerus in the elderly. J. Orthop. Trauma 25, 259–265. Hurvitz, E.A., Mandac, B.R., Davidoff, G., Johnson, J.H., Nelson, V.S., 1992. Risk factors for heterotopic ossification in children and adolescents with severe traumatic brain injury. Arch. Phys. Med. Rehabil. 73, 459–462. John, H., Rosso, R., Neff, U., Bodoky, A., Regazzoni, P., Harder, F., 1994. Operative treatment of distal humeral fractures in the elderly. J. Bone Joint Surg. Br. 76, 793–796. Johnson, J.A., King, G.J., 2005. Anatomy and biomechanics of the elbow. In: Williams, G.R., Yamaguchi, K., Ramsey, M.L. (Eds.), Shoulder and Elbow Arthroplasty. Lippincott ­Williams & Wilkins, Philadelphia, PA. Jupiter, J.B., Mehne, D.K., 1992. Fractures of the distal humerus. Orthopedics 15, 825–833. Jupiter, J.B., Neff, U., Holzach, P., Allgower, M., 1985. Intercondylar fractures of the humerus. An operative approach. J. Bone Joint Surg. Am. 67, 226–239. Kamineni, S., Morrey, B.F., 2004. Distal humeral fractures treated with noncustom total elbow replacement. J. Bone Joint Surg. Am. 86-A, 940–947. Korner, J., Diederichs, G., Arzdorf, M., Lill, H., Josten, C., Schneider, E., Linke, B., 2004. A biomechanical evaluation of methods of distal humerus fracture fixation using locking compression plates versus conventional reconstruction plates. J. Orthop. Trauma 18, 286–293. Kozanek, M., Bartonicek, J., Chase, S.M., Jupiter, J.B., 2014. Treatment of distal humerus fractures in adults: a historical perspective. J. Hand Surg. Am. 39, 2481–2485. Kundel, K., Braun, W., Wieberneit, J., Ruter, A., 1996. Intraarticular distal humerus fractures. Factors affecting functional outcome. Clin. Orthop. Relat. Res. 200–208. Lawrence, T.M., Ahmadi, S., Morrey, B.F., Sanchez-Sotelo, J., 2014. Wound complications after distal humerus fracture fixation: incidence, risk factors, and outcome. J. Shoulder Elbow Surg. 23, 258–264.

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Letsch, R., Schmit-Neuerburg, K.P., Sturmer, K.M., Walz, M., 1989. Intraarticular fractures of the distal humerus. Surgical treatment and results. Clin. Orthop. Relat. Res. 238–244. Malgaigne, J.F., 1847. Traite des Fractures et des Luxations. JB Bailliere, Paris, France. McKee, M.D., Jupiter, J.B., Bamberger, H.B., 1996. Coronal shear fractures of the distal end of the humerus. J. Bone Joint Surg. Am. 78, 49–54. McKee, M.D., Veillette, C.J., Hall, J.A., Schemitsch, E.H., Wild, L.M., Mccormack, R., Perey, B., Goetz, T., Zomar, M., Moon, K., Mandel, S., Petit, S., Guy, P., Leung, I., 2009. A multicenter, prospective, randomized, controlled trial of open reduction–internal fixation versus total elbow arthroplasty for displaced intra-articular distal humeral fractures in elderly patients. J. Shoulder Elbow Surg. 18, 3–12. Miyasaka, K.C., 1999. Anatomy of the elbow. Orthop. Clin. North Am. 30, 1–13. Morrey, B.F., 2000. Fractures of the distal humerus: role of elbow replacement. Orthop. Clin. North Am. 31, 145–154. Morrey, B.F., An, K.N., 1983. Articular and ligamentous contributions to the stability of the elbow joint. Am. J. Sports Med. 11, 315–319. Morrey, B.F., An, K.N., Stormont, T.J., 1988. Force transmission through the radial head. J. Bone Joint Surg. Am. 70, 250–256. Morrey, B.F., Askew, L.J., Chao, E.Y., 1981. A biomechanical study of normal functional elbow motion. J. Bone Joint Surg. Am. 63, 872–877. Morrey, B.F., Chao, E.Y., 1976. Passive motion of the elbow joint. J. Bone Joint Surg. Am. 58, 501–508. Nauth, A., Mckee, M.D., Ristevski, B., Hall, J., Schemitsch, E.H., 2011. Distal humeral fractures in adults. J. Bone Joint Surg. Am. 93, 686–700. Novak, V.P., Baratz, M.E., 2006. Anteromedial ecchymosis about the elbow in an adult with a distal humerus fracture. J. Hand Surg. Am. 31, 860–863. O’Driscoll, S.W., 2005. Optimizing stability in distal humeral fracture fixation. J. Shoulder Elbow Surg. 14, 186S–194S. O’Driscoll, S.W., Bell, D.F., Morrey, B.F., 1991. Posterolateral rotatory instability of the elbow. J. Bone Joint Surg. Am. 73, 440–446. Obremskey, W.T., Bhandari, M., Dirschl, D.R., Shemitsch, E., 2003. Internal fixation versus arthroplasty of comminuted fractures of the distal humerus. J. Orthop. Trauma 17, 463–465. Ozer, H., Solak, S., Turanli, S., Baltaci, G., Colakoglu, T., Bolukbasi, S., 2005. Intercondylar fractures of the distal humerus treated with the triceps-reflecting anconeus pedicle approach. Arch. Orthop. Trauma Surg. 125, 469–474. Pajarinen, J., Bjorkenheim, J.M., 2002. Operative treatment of type C intercondylar fractures of the distal humerus: results after a mean follow-up of 2 years in a series of 18 patients. J. Shoulder Elbow Surg. 11, 48–52. Palvanen, M., Kannus, P., Niemi, S., Parkkari, J., 2010. Secular trends in distal humeral fractures of elderly women: nationwide statistics in Finland between 1970 and 2007. Bone 46, 1355–1358. Peterson, S.L., Mani, M.M., Crawford, C.M., Neff, J.R., Hiebert, J.M., 1989. Postburn heterotopic ossification: insights for management decision making. J. Trauma 29, 365–369. Reising, K., Hauschild, O., Strohm, P.C., Suedkamp, N.P., 2009. Stabilisation of articular fractures of the distal humerus: early experience with a novel perpendicular plate system. Injury 40, 611–617. Ring, D., Gulotta, L., Chin, K., Jupiter, J.B., 2004. Olecranon osteotomy for exposure of fractures and nonunions of the distal humerus. J. Orthop. Trauma 18, 446–449. Ring, D., Jupiter, J.B., Gulotta, L., 2003. Articular fractures of the distal part of the humerus. J. Bone Joint Surg. Am. 85-A, 232–238.

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Riseborough, E.J., Radin, E.L., 1969. Intercondylar T fractures of the humerus in the adult. A comparison of operative and non-operative treatment in twenty-nine cases. J. Bone Joint Surg. Am. 51, 130–141. Robinson, C.M., Hill, R.M., Jacobs, N., Dall, G., Court-Brown, C.M., 2003. Adult distal humeral metaphyseal fractures: epidemiology and results of treatment. J. Orthop. Trauma 17, 38–47. Rozycki, G.S., Tremblay, L.N., Feliciano, D.V., McClelland, W.B., 2003. Blunt vascular trauma in the extremity: diagnosis, management, and outcome. J. Trauma 55, 814–824. Ruan, H.J., Liu, J.J., Fan, C.Y., Jiang, J., Zeng, B.F., 2009. Incidence, management, and prognosis of early ulnar nerve dysfunction in type C fractures of distal humerus. J. Trauma 67, 1397–1401. Ruchelsman, D.E., Tejwani, N.C., Kwon, Y.W., Egol, K.A., 2008. Open reduction and internal fixation of capitellar fractures with headless screws. J. Bone Joint Surg. Am. 90, 1321–1329. Ruedi, T.P., Buckley, R.E., Moran, C.G., 2007. Principles of Fracture Management. Thieme, New York, NY. Sanchez-Sotelo, J., Torchia, M.E., O’Driscoll, S.W., 2007. Complex distal humeral fractures: internal fixation with a principle-based parallel-plate technique. J. Bone Joint Surg. Am. 89, 961–969. Schemitsch, E.H., Tencer, A.F., Henley, M.B., 1994. Biomechanical evaluation of methods of internal fixation of the distal humerus. J. Orthop. Trauma 8, 468–475. Sheps, D.M., 2011. Population-based incidence of distal humeral fractures among adults in a Canadian urban center. Curr. Orthop. Pract. 22, 437–442. Srinivasan, K., Agarwal, M., Matthews, S.J., Giannoudis, P.V., 2005. Fractures of the distal humerus in the elderly: is internal fixation the treatment of choice? Clin. Orthop. Relat. Res. 222–230. Stoffel, K., Cunneen, S., Morgan, R., Nicholls, R., Stachowiak, G., 2008. Comparative stability of perpendicular versus parallel double-locking plating systems in osteoporotic comminuted distal humerus fractures. J. Orthop. Res. 26, 778–784. Theivendran, K., Duggan, P.J., Deshmukh, S.C., 2010. Surgical treatment of complex distal humeral fractures: functional outcome after internal fixation using precontoured anatomic plates. J. Shoulder Elbow Surg. 19, 524–532. Vazquez, O., Rutgers, M., Ring, D.C., Walsh, M., Egol, K.A., 2010. Fate of the ulnar nerve after operative fixation of distal humerus fractures. J. Orthop. Trauma 24, 395–399. Wainwright, A.M., Williams, J.R., Carr, A.J., 2000. Interobserver and intraobserver variation in classification systems for fractures of the distal humerus. J. Bone Joint Surg. Br. 82, 636–642. Wake, H., Hashizume, H., Nishida, K., Inoue, H., Nagayama, N., 2004. Biomechanical analysis of the mechanism of elbow fracture-dislocations by compression force. J. Orthop. Sci. 9, 44–50. Watts, A.C., Morris, A., Robinson, C.M., 2007. Fractures of the distal humeral articular surface. J. Bone Joint Surg. Br. 89, 510–515. Webb, L.W., 2006. Fractures of the distal humerus. In: Bucholz, R.W., Heckman, J.D., Court-Brown, C. (Eds.), Rockwood and Green’s Fractures in Adults, sixth ed. Lippincott Williams & Wilkins, Philadelphia, PA. White, L., Mehlman, C.T., Crawford, A.H., 2010. Perfused, pulseless, and puzzling: a systematic review of vascular injuries in pediatric supracondylar humerus fractures and results of a POSNA questionnaire. J. Pediatr. Orthop. 30, 328–335.

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Wilkinson, J.M., Stanley, D., 2001. Posterior surgical approaches to the elbow: a comparative anatomic study. J. Shoulder Elbow Surg. 10, 380–382. Zagorski, J.B., Jennings, J.J., Burkhalter, W.E., Uribe, J.W., 1986. Comminuted intraarticular fractures of the distal humeral condyles. Surgical vs. nonsurgical treatment. Clin. Orthop. Relat. Res. 197–204. Ziran, B.H., 2005. A true triceps-splitting approach for treatment of distal humerus fractures: a preliminary report. J. Trauma 58, 1306. Zlotolow, D.A., Catalano 3rd, L.W., Barron, O.A., Glickel, S.Z., 2006. Surgical exposures of the humerus. J. Am. Acad. Orthop. Surg. 14, 754–765.

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Arthroplasty for treatment of distal humerus fractures

5

B.M. Steen1, M.M. Hussey2, M.A. Frankle3 1Florida Orthopaedic Associates, DeLand, FL, USA; 2Arkansas Specialty Orthopaedics, Little Rock, AR, USA; 3Florida Orthopaedic Institute, Temple Terrace, FL, USA

5.1  Introduction Intra-articular fractures of the distal humerus pose a significant treatment challenge for the orthopedic surgeon. In young patients, open reduction and internal fixation (ORIF) with plates and screws remains the gold standard. Outcomes are related to the severity of injury and degree of articular involvement.1 In elderly patients, osteopenia and severe comminution make internal fixation difficult or perhaps impossible. In select instances, primary total elbow arthroplasty (TEA) can be utilized for acute reconstruction.

5.1.1   Demographics Distal humerus fractures occur predominantly in a bimodal age distribution. During the second decade of life, there is a high incidence of distal humerus fractures. These tend to be high-energy injuries related to motor vehicle collisions and falls from a height. A second peak in fracture occurrence is seen in elderly women during the seventh decade of life.1 These fractures tend to be low-energy injuries and are associated with osteopenia and significant articular comminution. Treatment goals in these two groups are different because of age, fracture type, and patient expectations. Treatment should be appropriately tailored to patient characteristics and the expected functional demands of the injured limb.

5.1.2   Fracture classification Multiple fracture classifications exist to describe distal humerus fractures. Initial classifications were descriptive in nature and divided distal humerus fractures into categories by the location of the horizontal fracture component and the presence of extension into the trochlea.2 The classification by Jupiter et al. expanded on the description of intra-articular fractures, further describing the shape of various fractures. They described six main fracture patterns based on the primary fracture lines to include high and low T fractures and Y, H, medial, and lateral lambda fractures.3 Likewise, the AO/OTA (Arbeitsgemeinschaft für Osteosynthesefragen/Orthopaedic Trauma Association) classification divides these fractures based on articular involvement and degree of comminution (Figure 5.1). In evaluating these classifications, Wainright et al. determined that use of the AO/OTA classification alone provided substantial intraobserver agreement.4 Despite this, no classification system is reproducible enough to be u­ tilized as a decision-making tool or outcome assessment tool. Shoulder and Elbow Trauma and its Complications. http://dx.doi.org/10.1016/B978-1-78242-450-5.00005-8 Copyright © 2016 Elsevier Ltd. All rights reserved.

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A A1

A2

A3

B1

B2

B3

C1

C2

C3

B

C

Figure 5.1  AO/OTA distal humerus fracture classification. Fractures are classified based on the articular involvement, location of primary fracture lines, and degree of comminution. Yamaguchi K, Williams GR, Ramsey ML, Galatz LM. Shoulder and elbow arthroplasty. ­Philadelphia, PA: Lippincott Williams & Wilkins; 2005.

5.1.3  Origin of elbow arthroplasty Modern TEA developed in response to failure of other procedures to treat the arthritic elbow. Interposition of material within the ulnohumeral joint has been reported as far back as 1893 by Schuller5 and was popularized in the 1920s by Putti.6 Early designs of metallic articulating implants had a high failure rate secondary to poor bone fixation and overconstraint of the joint. Dr Ralph Coonrad developed the first iteration of what we currently think of as the modern elbow replacement in 1971.7 His design was fixed to the bone with methacrylate cement and provided a limited amount of motion in the coronal plane. This design was further modified by Dr Bernard Morrey and is the foundation for current semiconstrained hinged elbow arthroplasties.8 Before 1990, the use of elbow arthroplasty for the treatment of fractures was ­primarily a salvage procedure for painful nonunions and malunions. In 1994, Kraay et al. published the first article reporting on the use of TEA for the treatment of acute fractures. The first case series reporting the treatment of acute distal humerus fractures in elderly patients with TEA was by Cobb and Morrey in 1997. Half of their patients had a fracture and pre-existing rheumatoid arthritis and the other half had no pre-existing rheumatoid arthritis. At a minimum of 2-year follow-up, they had revised only 1 patient for complications and 15 of 20 described there elbow as “excellent.”9

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5.1.3.1   Surgical decision-making Treatment of distal humerus fractures is complex, and selecting the appropriate treatment is based on surgeon-, fracture-, and patient-related factors. Assuming a surgeon is comfortable with the surgical technique, most would agree that TEA should be reserved for patients with severe articular comminution and low intercondylar fractures that have a high propensity for nonunion. Patient-related factors include age, medical comorbidities, reliance on upper extremities for weight bearing, presence of pre-existing elbow arthrosis, and ability to comply with postoperative restrictions. In most instances, ORIF is the preferred method of treatment secondary to the life-long restrictions placed upon TEA patients. Nevertheless, determining which patients will benefit most from acute TEA is difficult and should be determined on a case-by-case basis.

5.1.4  Advantages and disadvantages of TEA Acute TEA for treatment of distal humerus fractures offers several advantages. Fixation is immediate and allows for early active motion after wound healing. Patients obtain pain relief and recover motion sooner after TEA when compared with ORIF.10 After TEA, the risk of developing painful post-traumatic arthritis does not exist. The biggest disadvantage after TEA is the lifetime 5-lb weight restriction that stems from the significant forces placed across the implant–bone interface with dynamic loading of the joint. Elderly patients frequently require assistive aids for ambulation; therefore, they may not be compliant with their postoperative restrictions. Fortunately, elderly patients have fewer lifting demands and are good candidates if they do not require an assistive device. Other disadvantages of TEA for the treatment of acute distal humerus fractures include implant loosening, deep infection, wound-healing problems, polyethylene wear, and periprosthetic fracture. In reported series on TEA for the treatment of fracture, there is a low revision rate within the first few years of surgery, but concern for implant longevity exists. McKee et al. reported 3 revisions out of 25 patients who underwent acute TEA for fracture.10 Overall, this was significantly lower than the rate of reoperation for the internal fixation group; however, overall longevity of the implant was not addressed because long-term follow-up was not obtained. Frankle et al. had a similar experience with short-term follow-up in comparing internal fixation and TEA. Twenty-five percent of their patients who underwent internal fixation required revision to TEA, whereas none of the 12 patients who underwent acute TEA required a repeat operation.11 At an average of 7-year follow-up, Kamineni and Morrey reported revision in 5 of 49 patients and 5 other patients requiring reoperation.12

5.1.5   Arthroplasty options 5.1.5.1  Distal humerus hemiarthroplasty In cases of distal humerus fracture, the olecranon and radial head cartilage frequently remain uninjured. Ideally, isolated replacement of the distal humeral articular s­ urface would be performed. Distal humerus hemiarthroplasty (DHH) has been utilized

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for treatment of fractures, but the procedure has suffered from unacceptably high complication rates. Hohman et al. found that implant loosening, ulnar articular erosion, and instability can be encountered with this treatment option. In their series of seven patients with an average of 3 years follow-up, two patients required internal fixation in conjunction with DHH and two patients required ligament reconstruction in conjunction with DHH. Five of seven patients had at least one complication and four required reoperation at latest follow-up. All patients had evidence of progressive olecranon erosion over time, with all patients developing radiolucent lines; however, no patients had required revision to TEA at latest follow-up.13 Overall, hemiarthroplasty appears to be a reasonable option for treating irrepairable distal humerus fractures in young patients; however, there are many technical points that increase the likelihood of achieving a less than ideal outcome. Stability and function are dependent on adequate restoration of the osseous contour and ligamentous competence. Condylar fragments also need repair, and the soft-tissue envelope must be appropriately restored to obtain stability. The significant rate of olecranon erosion that occurs is also troubling and is likely multifactorial in nature. A loss of congruence between the native olecranon and prosthetic distal humerus and relative osteopenia may contribute to the rapid chondral erosion that has been reported. No DHH prostheses are currently approved for use in the United States.

5.1.5.2  Total elbow arthroplasty Most TEA systems provide the benefit of component linkage. Stability is no longer obtained from the native ligamentous structure; thus, ligament reconstruction and ­condyle preservation are not necessary to achieve an acceptable outcome. TEAs come in various designs based on the degree of constraint and whether or not the components are linked. These two concepts are not synonymous. It is possible to create a highly constrained unlinked device and, similarly, a less constrained linked device. Most current designs are semiconstrained and offer a linked or convertible articulation. Approximately 7–10° of varus-valgus motion is allowed before articulating at the limit maximum. When implants are correctly inserted, this freedom helps to reduce polyethylene wear and stress at the implant–bone interface. Conversely, with small errors during insertion or incomplete contracture release, the elbow may constantly articulate at the maximum limit, leading to edge loading of the bearing surface and increased force transmission at the implant–bone interface. There are currently several TEA designs on the market; however, no data exist directly comparing survivorship of the different implants. The Coonrad-Morrey prosthesis has the most significant body of literature supporting its use and success in the treatment of fractures, with revision rates range from 0% to 10% at 2- to 7-year follow-up.9,10,12–14

5.2  Evaluation and workup 5.2.1  Examination Every evaluation of the injured elbow should begin with a thorough history to include age, mechanism of injury, hand dominance, pre-existing arthritic conditions,

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occupation, history of falls, and smoking status. Also critical to consider in the elderly population is functional status, patient expectations, living situation, and any medical comorbidities because these may play a significant role in the treatment algorithm. A detailed physical examination should be performed to assess level of trauma sustained, presence of concomitant injuries, and degree of dysfunction of the injured extremity. The soft-tissue envelope about the elbow should be evaluated for ecchymoses, open wounds, abrasions, and presence of skin tenting. Closed injuries and Gustillo grade I open fractures can usually be treated primarily with arthroplasty. However, for Gustillo grade II or III open fractures, or if there are significant soft-­ tissue abrasions/contusions, definitive treatment should be delayed until the soft-tissue envelope has been stabilized. A complete baseline neurovascular examination of the affected extremity should be performed and documented. Distal radial and ulnar pulses should be palpated and compared to the uninjured arm. A thorough motor and sensory evaluation should be performed, particularly the ulnar nerve, because the injury or eventual treatment has shown increased rates of ulnar neuropraxia. The ability to perform active elbow extension should be evaluated to ensure a competent triceps mechanism. The ipsilateral shoulder and hand should be examined for associated injuries because the mechanism of injury often occurs on an outstretched upper extremity.

5.2.2   Imaging The radiographic assessment should begin with standard plain radiographs of the elbow, including anteroposterior (AP), oblique, and lateral views (Figure 5.2(a)), which will serve to evaluate details of the fracture pattern and whether or not a concomitant dislocation is present. Splint material should be removed before obtaining radiographs to improve the clarity of images. Radiographs of the shoulder and wrist should also be obtained if tenderness presents in these regions. Typically, the standard elbow series in combination with history and physical examination are sufficient to adequately formulate a treatment plan. However, if imaging quality is poor or if concern exists regarding the amount of intra-articular comminution and displacement, a computed tomography (CT) scan (Figure 5.2(b)) should be ordered to enhance preoperative decision-making and preparation. If institution capabilities permit, then a three-dimensional (3D) reconstruction may also prove valuable and has been shown to improve reliability of distal humeral fracture characterization (Figure 5.2(c)).14 If there is significant comminution that extends proximally, then obtaining comparison contralateral humerus radiographs can be obtained to help determine shortening and bone loss. Hughes et al. have shown that humeral shortening up to 2 cm can be accepted without significant loss of triceps extension strength.15 If more than 2 cm of humeral shortening is expected using standard implants, then a custom humeral prosthesis may be required, typically with an extended anterior flange. In addition, if hemiarthroplasty is being considered, plain radiographs of the uninjured elbow may be helpful for preoperative template sizing.

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Despite careful preoperative assessment and planning, intraoperative findings may reveal more comminution and articular cartilage disruption than could be appreciated from the imaging studies. In addition, significant osteopenia and poor bone quality may not be fully appreciated preoperatively and may preclude successful ORIF. Therefore, the decision to perform an arthroplasty might need to be made intraoperatively, particularly if the preoperative plan is for internal fixation. For example, McKee et al. had to intraoperatively convert 25% of their patients randomized for ORIF to TEA because stable fixation could not be achieved.10 Therefore, the surgeon should be prepared to convert to an arthroplasty if necessary and have these implants ready for use. When discussing treatment options with the patient, the possibility of elbow arthroplasty and the associated risks and outcomes should be preoperatively discussed with the patient.

Figure 5.2  Preoperative imaging. (a) AP elbow view demonstrating a comminuted distal humerus fracture with lateral column collapse. (b) Coronal-plane CT scan showing significant intra-articular comminution with extension into the trochlea. (c) 3D CT scan of same patient further characterizing fracture detail with a highly comminuted capitellum and lateral column.

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5.3  Surgical techniques 5.3.1  Setup and patient positioning The patient can be positioned in either the supine or lateral decubitus position for the surgical procedure. If using the supine position, then a bump should be placed under the ipsilateral scapula to facilitate bringing the arm across the chest. The arm is allowed to rest over a bolster with the elbow in flexion. The surgeon stands on the side of the injured extremity. If the lateral decubitus position is utilized, then the arm is draped over a post connected to the operating table. This position minimizes the need for another assistant, but it is less maneuverable than the supine position. The authors prefer to position patients in the lateral decubitus position with the arm draped free over a post (Figure 5.3(a)). The standard approach to the elbow for TEA is through a midline posterior skin incision. There have been various techniques described to manage the triceps mechanism. Bryan and Morrey described the triceps-reflecting approach, in which the triceps is reflected as a unit from medial to lateral off of the olecranon in continuity with the ulnar periosteum and forearm fascia.16 The triceps should then be meticulously reattached to the olecranon through drill holes at the end of the procedure. The advantage of this approach is improved visualization, whereas the disadvantages are the possible subluxation of the triceps laterally and resulting triceps weakness. Our preferred technique utilizes the paratricipital approach, in which the triceps insertion is preserved and the distal humerus is accessed through medial and lateral fascial incisions, releasing the medial and lateral soft tissues from the condyles.17 Visualization is facilitated by elevating the triceps off of the posterior humerus and excision of the fracture fragments. The obvious advantage of this approach is preserving the continuity of the triceps mechanism, eliminating the risk of triceps insufficiency and promoting (a)

(b)

Figure 5.3  Positioning and draping. (a) Lateral decubitus position with arm over a post connected to bed. (b) A tourniquet has been placed before draping high on the humerus to facilitate proximal exposure if necessary. The incision is curved slightly around the olecranon tip, avoiding the bony prominence. An iodophor adhesive drape is routinely utilized to provide antimicrobial activity throughout the procedure.

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faster rehabilitation. A disadvantage of this approach is difficulty visualizing the ulna for correct canal preparation and component positioning. To improve visualization, Kamineni et al. recommend reflecting approximately 20–25% of the medial triceps attachment from the olecranon.18 Alternatively, a triceps-splitting approach, which symmetrically releases the medial and lateral soft tissue, can be used. The advantage of this approach is excellent visualization of the humerus and ulna. The main disadvantage is the risk of extensor mechanism insufficiency. Shahane et al. described a modification of this approach that involves reflecting the medial 25% of the triceps and ulnar nerve as a single unit and the remaining 75% laterally.19 The advantage of this approach is leaving the ulnar nerve in its anatomic position and potentially reducing the risk of neuropraxia. Alternatively, a thin wafer of bone can be removed medially and laterally with the triceps insertion using an osteotome or microsagittal saw as described by Gschwend et al.20 This has the advantage of protecting the soft tissue and having bone-to-bone contact for healing. All bony prominences should be well padded throughout the case. The entire operative extremity to include the shoulder girdle should be prepped and draped, with a tourniquet placed high on the arm, facilitating proximal exposure if necessary. A standard 15- to 20-cm midline posterior incision is utilized, curved either medially or laterally to avoid placing the incision directly over the tip of the olecranon (Figure 5.3(b)). The skin and subcutaneous tissue are sharply dissected to the triceps fascia and then reflected medially and laterally as full-thickness flaps. The triceps tendon is exposed, as well as its distal extensor expansion as it blends into the forearm fascia. The ulnar nerve is identified, released, and mobilized from the cubital tunnel to a resting position anteriorly. A vessel loop is placed around the nerve for easier identification (Figure 5.4(a)). Medial and lateral fascial incisions are next made along the triceps border, and the triceps is elevated from the posterior humerus. Once the distal humerus is exposed, the fractured condyles are excised and the remaining soft-tissue constraints on the distal humerus are released to include the extensor/supinator and flexor/pronator complexes (Figure 5.4(b)). The forearm can then be pronated, dislocating the elbow and delivering the distal humerus through the medial window (Figure 5.4(c)). The loss of one or both condyles should not compromise fixation or function; however, their absence can make determining proper rotation and height of the humeral component difficult. Typically, no bone cuts are required on the humerus; however, the humeral cutting block can help ensure coplanar alignment. The humeral canal is next broached with increasingly larger rasps until a snug fit is obtained. The authors prefer to use the largest humeral component that will fit the canal. The anterior flange of the humeral component can assist with rotational alignment because it should sit flush with the anterior humeral cortex when the final implant is inserted. The first step in ulnar preparation is to remove the tip of the olecranon, which can be done with a microsagittal saw. The intramedullary canal is then entered at the base of the coronoid using a high-speed burr (Figure 5.5(a)).

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(a)

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(b)

(c)

Figure 5.4  Surgical exposure. (a) The ulnar nerve is identified and released from the cubital tunnel. (b) Fractured condyles and comminution are excised, with preservation for later bone grafting beneath the anterior flange. (c) Distal humerus exposure after mobilization of the triceps and pronation of forearm.

(a)

(b)

Figure 5.5  Ulnar preparation. (a) A high-speed burr can be used to gain entry into the ulnar canal, which is at the base of the coronoid. (b) Appropriate position of the ulnar component should place the center of rotation midway between the tips of the coronoid and olecranon.

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The trial rasp is then introduced and checked to ensure proper orientation. The rasp handle can typically be used to assess the orientation of the ulnar component. This step can be particularly difficult with this approach because the intact triceps can interfere with instrumentation. We utilize the largest rasp that fully sits as the size of the final implant. Final ulnar preparation is performed according to the specific implant manufacturer’s technique guide. Trial implants corresponding to the final rasp used are then inserted into the humerus and ulna in the appropriate orientation for a trial reduction. If present, then the olecranon fossa and humeral columns are useful for assessing proper humeral component seating. However, in some cases, substantial humeral bone loss may obliterate normal anatomic landmarks. In this situation, it is helpful to perform a trial reduction of the implants, allowing the soft tissue to reapproximate over the humerus and ulna. The elbow should be flexed to 90° and gentle axial traction applied in line with the humerus. This will provide a reasonable estimate of the correct depth to seat the humeral component, which can be marked on the humerus as a reference for final implantation. Remember that the humerus can be shortened up to 2 cm without significant alteration in function.15 Once trial components are positioned, the elbow is brought through a range of motion to assess for impingement. Any areas of bony impingement should be removed with a rongeur; otherwise, component malpositioning should be assessed. If soft-tissue restraints are limiting motion, they should be carefully released. Soft-tissue impingement can be difficult to correct unless the tissue can be resected; otherwise, if the limitation in motion is unacceptable, then the ­components may have to be repositioned. Once proper positioning is achieved and impingement-free motion is obtained, the final implants can be inserted. The canals are lavaged and dried while the cement is prepared. The authors add 2.4 g of tobramycin antibiotic and a few drops of methylene blue per each 40 g of cement (typically 80 g of cement are used). The methylene blue is used to improve cement visualization, which is helpful if a revision surgery requires cement removal. The cement is then vacuum-mixed and placed into a cement gun with a thin nozzle that will fit the humeral and ulnar canals. Cement restrictors are placed in the ulnar and humeral canals. The ulnar component is implanted first and positioned so that the center of the bearing is midway between the tips of the coronoid and olecranon (Figure 5.5(b)). Cement is next pressurized down the humeral canal while a bone graft is prepared from excised fracture fragments. This graft is placed between the anterior flange and anterior cortex of the humerus while the component is tapped down to the correct height. Once cement has cured, the components are coupled and the elbow is brought through a full range of motion to ensure that no impingement is present (Figure 5.6). If bony impingement is noted, then the bone can usually be trimmed away without compromising fixation. The tourniquet is deflated and adequate hemostasis is ensured. The ulnar nerve is transposed anteriorly into a subcutaneous soft-tissue envelope. A nonabsorbable suture is used to reapproximate the proximal flexors and extensors to the triceps expansion medially and laterally. The remainder of the wound is closed in standard fashion. Use of a drain is optional, but the authors do not routinely use them. The arm is then placed into a well-padded anterior splint in full extension.

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Figure 5.6  Final component placement with cement. As seen, the triceps tendon has been preserved throughout the case and will facilitate earlier rehabilitation.

The arm is postoperatively kept in strict elevation for 24 h to reduce edema. Intravenous antibiotics are typically given throughout the hospital stay, and oral antibiotics are possibly given up to 10 days postoperatively if there is sufficient risk for infection or problems with wound healing. The splint is typically removed in 2 days, after which a resting extension splint is made for the patient before discharge to reduce tension on the incision. This is worn until the sutures are removed and postoperative radiographs are obtained, typically approximately 10–14 days (Figure 5.7). Once the sutures have been removed, the patient is educated on gentle passive and active range-of-motion exercises to be performed each day. No restrictions on active elbow extension are necessary because the triceps was not detached. The extension splint is worn at night for approximately the first 4 weeks because flexion is usually the easiest to obtain in the authors’ experience. Formal physiotherapy is not routinely ordered, and adequate motion is achieved by simple range-of-motion exercises. The patient is encouraged to use the arm for light activities of daily living at 6 weeks and progressing as tolerated. A 2-lb repetitive and 10-lb single-event lifting restriction are placed on the patient for life and reinforced at every postoperative visit. The patient is seen annually for follow-up, with routine radiographs obtained to ensure stable fixation of the implants.

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Figure 5.7  Postoperative radiographs. (a) AP elbow radiograph with cement mantle seen. (b) Lateral radiograph with anterior humeral flange sitting flush on anterior cortex.

5.4  Outcomes Several studies have been performed over the past 15 years attempting to evaluate the outcomes of comminuted distal humerus fractures treated with TEA. These studies have focused on the elderly population, secondary to the technical difficulties associated with internal fixation of these complex intra-articular fractures in patients with osteoporotic bone, as well as the lifting limitations that have to be postoperatively placed on patients. Because of the low incidence of these injuries, most studies have been relatively small retrospective case series, reporting outcomes of a single institution. In 1997, Cobb and Morrey were the first to report outcomes of TEA for treatment of acute distal humeral fractures in the elderly. They retrospectively reviewed 20 patients with a mean age of 72 years and follow-up of 3 years. Rheumatoid arthritis was present in 10 elbows and influenced the choice of treatment according to the authors. The mean arc of motion was 25–130°. On the basis of the Mayo Elbow Performance Score (MEPS), 15 elbows had an excellent result and 5 had a good result, with no elbow demonstrating a fair or poor result. All patients were revision free except for one patient who sustained a periprosthetic fracture. Additional complications were seen in four patients, with ulnar neuropraxia in three and reflex sympathetic dystrophy in one. This landmark study brought to light the potential benefits of TEA for the treatment of these complex injuries in the elderly population.9

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In a follow-up study, Kamineni and Morrey reported their outcomes on a cohort of 48 patients with acute distal humerus fractures treated with TEA. With a mean patient age of 69 years and follow-up of 7 years, the mean arc of motion was 24°–131° and the mean MEPS was 93 of a possible 100 points. However, five patients required revision arthroplasty secondary to implant loosening or periprosthetic fracture, and five patients required reoperation because of wound-healing complications. Two patients had extension deficits related to posterior impingement from heterotopic ossification (HO). The mean age of patients requiring revision arthroplasty was 62 years, which was younger than the mean age of the entire cohort, emphasizing the demands that younger patients place on their implants.12 In a retrospective case series of 16 elderly patients treated with TEA for complex distal humeral fractures, Garcia et al. reported encouraging results for TEA when poor bone quality precluded stable ORIF. With a mean follow-up of 3 years, 68% reported no pain and 25% reported only mild pain. The mean arc of motion was 24°–125°, and the MEPS was 93 out of 100. No patients required revision, and 15 of 16 patients were satisfied with their result.21 The authors’ institution published the first study to specifically compare the outcomes of ORIF and semiconstrained TEA for the treatment of complex intra-articular distal humerus fractures in women older than 65 years of age with a mean follow-up of 46 months. Of the 12 patients treated with ORIF, there were 4 excellent, 4 good, 1 fair, and 3 poor results according to the MEPS. The three patients with poor results were eventually revised to a TEA. In the 12 patients treated with TEA, there were 11 excellent results and 1 good result, with no patients having fair or poor results. Three reoperations were required in this group, with one requiring reconnection of an uncoupled prosthesis and two requiring open debridement for hematoma and infection. Of note, the ORIF group was reconstructed with older technology (nonlocking and non-precontoured plates), which may have biased inferior results in this group.11 McKee et al. has performed the only prospective randomized controlled trial to date evaluating outcomes of ORIF versus TEA for treatment of intra-articular distal humeral fractures in elderly patients. Twenty patients were randomized to TEA and 20 patients to ORIF; however, 5 patients randomized to receive ORIF had to be converted intraoperatively to TEA because of an inability to obtain stable fixation. At 2 years follow-up, the TEA group demonstrated significantly better MEPS scores but no difference in Disabilities of Arm, Shoulder, and Hand scores. The mean arc of motion was 107° in the TEA group and 95° in the ORIF group, and reoperation was required in 12% in the TEA group and 27% in the ORIF group. However, these comparisons were not statistically different. Again, a confounding variable in the ORIF group included use of various types of plating systems. They also did not utilize newer locking plate technology, which could have skewed results.10 McKee et al. also sought to determine whether condylar resection had any detrimental effects on postoperative function. They found essentially no difference in strength and functional outcomes in patients who underwent condylar resection compared with fixation.22 Despite the encouraging results for TEA seen in these studies, enthusiasm should be tempered by the lack of long-term follow-up data for this treatment modality. ORIF should always be performed in the young population. It should also be considered

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even in the elderly population because studies have shown that when stable fixation and union are achieved in this patient population, their outcomes are equivalent to TEA in the short- and mid-term. With the application of newer plate technology, the outcomes and revision rates may improve in these patients. If stable fixation is intraoperatively deemed unachievable, then ORIF should be abandoned in favor of TEA.

5.5  Complications and their management Complications after treatment of distal humerus fractures are common regardless of treatment strategy. Complications do differ slightly between internal fixation and TEA. In the only randomized trial, McKee et al. found that 10 of 25 patients treated with TEA had at least 1 complication, and 3 of 25 patients required reoperation for their complication.10 In contrast, 8 of 15 ORIF patients had at least one complication, and 4 of 15 underwent reoperation (excluding 5 patients who had to intraoperatively be converted to TEA). This outlines the fact that although complications are common, most can be treated without surgical intervention. After TEA for treatment of distal humerus fractures, common complications include wound healing, ulnar neuropathy, HO, post-traumatic stiffness, and infection. Early component failure is uncommon, but implant loosening and periprosthetic fractures do occur with increased length of follow-up. Ulnar-sided loosening is twice as common as humeral loosening.23–26

5.5.1  Wound healing Wound complications can occur secondary to a traumatized soft-tissue envelope, the subcutaneous nature of the prosthesis, and/or the initiation of early motion after surgery. In all cases, immobilization in extension for a period of time is recommended to allow the soft-tissue envelope to heal. Priority should be given to tissue healing over motion because most patients will regain motion after TEA despite prolonged immobilization. Elevation of the limb in the early postoperative period can also help to reduce swelling and wound breakdown. The use of drains can be helpful to prevent tensile stress on the wound from postoperative hematoma. Minor wound breakdown can be conservatively managed with dressing changes and close follow-up. Motion should be discouraged until the wound is healed. Significant wound breakdown should be treated as analogous to early deep infection. The soft-tissue envelope should be opened, components washed, and the wound reclosed.

5.5.2  Neural complications By far, the most common neurologic complication associated with TEA is ulnar neuropraxia. Morrey et al. reported a 6% rate of ulnar nerve symptoms, with complete resolution occurring in all cases by 3 months.12 McKee et al. had to reoperate on a patient for persistent ulnar nerve symptoms after TEA for fracture.10 In addition, this patient had significant HO that required resection. All patients should undergo ulnar nerve transposition during TEA. Unfortunately, significant soft-tissue scarring and HO can lead to recurrent nerve compression in

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a delayed fashion. In cases in which ulnar nerve symptoms persist for more than 3 months, electromyography evaluation is useful. Persistent compression should be treated with ulnar nerve exploration and neurolysis.

5.5.3   Post-traumatic stiffness Stiffness occurs secondary to significant injury to the surrounding soft-tissue envelope. When compared with ORIF, TEA is not immune to development of stiffness and contracture. In McKee’s randomized trial, stiffness requiring re-intervention occurred nearly equally in the ORIF and TEA groups.10 Postoperative stiffness can be appropriately managed with capsular release. With regard to timing of reoperation, most authors tend to wait approximately 1 year before reoperation. This allows the soft-tissue envelope appropriate time for healing and recovery before secondary insult.

5.5.4   Heterotopic ossification HO is another cause for postoperative motion loss after any intervention for the treatment of distal humerus fractures. Development of HO is also related to soft-tissue injury related to the initial trauma. HO has been reported to occur in 16% of patients who undergo TEA for distal humerus fractures.10 Most cases are low Brooker grade with small islands or spicules of bone that do not significantly affect motion. In certain instances, significant HO can lead to unacceptable losses of motion and occasionally ulnar compression syndrome. In these instances, reoperation for resection of the HO is warranted. This is preferentially done once the HO has become radiographically mature. Currently, use of radiation treatment is not recommended to acutely prevent HO because wound-healing complications have been noted to occur at unacceptably high rates. However, there may be a role for the use of radiation treatment after delayed resection of HO.

5.5.5   Deep infection Infection communicating with prosthetic components is a troublesome problem after any arthroplasty. Management is similar to that for other prosthetic infections. If the infection is thought to be acute in nature, then treatment is focused on surgical debridement with component retention. Most authors advocate for retention of components if the patient has had symptoms for fewer than 2 weeks, no radiographic signs of loosening preoperatively, and the components are found to be well fixed intraoperatively. Thorough irrigation and debridement of any devitalized tissue is paramount, and all exchangeable parts should be replaced. In cases in which prosthetic loosening is present, implant resection is warranted. Patients can be treated with one-stage reimplantation or with staged reconstruction with antibiotic spacer placement followed by reimplantation. There is relatively little literature on appropriate treatment of chronic TEA infections, and choice of treatment should be left to the surgeon’s discretion on the basis of microbiology findings, infection severity, patient comorbidities, and soft-tissue envelope.

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5.5.6  Aseptic loosening After TEA for treatment of fracture, some patients have demonstrated early prosthetic loosening without infection. Reoperations have revealed significant bushing wear and metallic staining of the soft-tissue envelope. This is likely due to asymmetric loading at the implant linkage. Difficulty in judging rotational alignment after condylar resection and possibly the loss of secondary support from the forearm muscular sleeve as it inserts on the condyles may contribute to early bushing wear. There is a paucity of literature studying the concept of early bushing wear; however, condylar resection is commonly advocated. McKee et al. demonstrated no increase in weakness after condylar resection, but they did not address the late effects on implant survival.22 Aseptic loosening should be treated with revision of loose components. In cases in which a malrotation of components exist, this should be corrected during revision surgery. Humeral loosening should be addressed with the use of a revision length stem and increased length flange to ensure that rotational stability can be obtained. The cement mantle alone is not adequate to provide rotational stability to the humeral component. Increasing stem length, flange length, bone grafting behind the flange, and the addition of cerclage cables can enhance the strength of a revision construct. In cases of significant bone loss, structural allografts can also be used to regain osseous support of the implant. Occult infection should be ruled out with tissue specimen and culture in all cases of presumed aseptic loosening. Ulnar-sided loosening occurs more frequently, and it commonly results in periprosthetic fracture. In cases of ulnar loosening, stem length should be appropriately increased and the use of structural allograft struts and cerclage cables can be used to help augment the rigidity of the reconstruction.

5.6  Important points 5.6.1  Patient selection • Patient factors such as age, previous elbow disease, and expected postoperative activity level play an important role in deciding the most appropriate treatment plan. • When possible, ORIF should be the treatment of choice. In cases of severe osteopenia, extensive comminution, or low transcondylar fractures, TEA is a suitable treatment alternative.

5.6.2  Surgical technique • Avoid releasing the triceps. Various surgical approaches allow for the integrity of the triceps to be maintained. Excision of the condyle fragments provides ample room for prosthetic insertion. Medially, a small portion of the triceps may be released to help with ulnar exposure. Alternatively, a small longitudinal split in the distal triceps can be created to prepare and insert the ulnar component. This may allow increased ease in judging appropriate ulnar orientation. • In cases with condylar loss, the cutting guide can be used to help define the appropriate orientation of the humeral component. Alternatively, the posterior cortical line of the humerus can be used to estimate the correct flexion–extension axis of the humerus.

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5.6.3   Preventing complications • Healing of the soft-tissue envelope is of utmost importance after TEA for fracture. Immobilize patients until adequate healing of the soft-tissue envelope occurs. The authors r­ outinely immobilize patients for 2 weeks after surgery and longer if there is any question about wound integrity. • Pay attention to rotation and depth during component insertion. Trialing implants and ­providing an axial distraction force to the arm can help estimate the depth of insertion to ­recreate appropriate soft-tissue tension. Repair flexor and extensor musculature to bone when possible and to soft tissue when not. • Make sure to secure the anterior flange with a bone graft. This is important in resisting ­rotatory forces on the humerus over the life of the prosthesis.

5.7  Future directions 5.7.1   Improving outcomes TEA design has changed little over the last several decades. No designs currently exist to specifically address fracture-specific concerns. An ideal component would allow for stability with loss of the condyles, ease in recreating appropriate tension and alignment, improved bushing durability, and improved attachment to host bone. ­Current devices are offering cross-linked polyethylene components in an effort to reduce polyethylene wear. It is unclear whether this will have a significant effect on implant survivorship at this time. Recreating the normal anatomic center of the elbow likely plays a significant role in implant survival. In primary TEA, computer navigation has shown to significantly reduce malalignment errors during component implantation.27,28 Navigation may ­provide valuable benefit in fracture cases because of the distorted anatomy present with a fracture. Many current navigation systems depend on surface anatomy to ­estimate the appropriate center of rotation. In cases of fracture, epicondylar references are likely unavailable to aid in determining the center of rotation. Component fixation is another area in which significant improvement may occur over time. Hip and shoulder implants have evolved over time with the development of successful press-fit in-growth designs. Current elbow systems require prosthetic cementation for fixation. Although polymethyl methacrylate remains the most predictable method of securing an implant to bone, it is subject to fatigue failure over time. Development of in-growth stems may help prevent implant loosening from cement mantle fatigue. Currently, hemiarthroplasty has shown inferior results to linked TEA, even when epicondyles are retained. In certain fracture patterns, such as the low transcondylar pattern, a hemiarthroplasty prosthesis may be ideal. Instability and native ulnar wear currently are the two biggest obstacles to the routine use of hemiarthroplasty. The rate of ulnar erosion may be decreased if ulnohumeral congruency could be increased. This may be possible by increasing the various sizes and shapes of the trochlear prosthetic.

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5.8  Other resources and information The most complete and thorough encyclopedia on the elbow, distal humeral fractures, and elbow arthroplasty can be found in Morrey’s The Elbow and Its Disorders.29

References 1. Robinson CM, Hill RM, Jacobs N, Dall G, Court-Brown CM. Adult distal humeral metaphyseal fractures: epidemiology and results of treatment. J Orthop Trauma 2003;17(1):38–47. 2. Riseborough EJ, Radin EL. Intercondylar T fractures of the humerus in the adult. A comparison of operative and non-operative treatment in twenty-nine cases. J Bone Joint Surg Am 1969;51(1):130–41. 3. Jupiter JB, Mehne DK. Fractures of the distal humerus. Orthopedics 1992;15(7):825–33. 4. Wainwright AM, Williams JR, Carr AJ. Interobserver and intraobserver variation in classification systems for fractures of the distal humerus. J Bone Joint Surg Br 2000;82(5):636–42. 5. Schuller M. Chirungische mittheilungen uber die chronish rheumatischen gelenkentzundungen. Arch Klin Chir 1893;45:130. 6. Putti V. Arthroplasty. Am J Orthop Surg 1921;3:421. 7. Bryan RS. Total replacement of the elbow joint. Arch Surg 1977;112(9):1092–3. 8. Morrey BF, Bryan RS, Dobyns JH, Linscheid RL. Total elbow arthroplasty. A five-year experience at the Mayo Clinic. J Bone Joint Surg Am 1981;63(7):1050–63. 9. Cobb TK, Morrey BF. Total elbow arthroplasty as primary treatment for distal humeral fractures in elderly patients. J Bone Joint Surg Am 1997;79(6):826–32. 10. McKee MD, Veillette CJ, Hall JA, Schemitsch EH, Wild LM, McCormack R, et al. A multicenter, prospective, randomized, controlled trial of open reduction–internal fixation versus total elbow arthroplasty for displaced intra-articular distal humeral fractures in elderly patients. J Shoulder Elbow Surg 2009;18(1):3–12. 11. Frankle MA, Herscovici Jr D, DiPasquale TG, Vasey MB, Sanders RW. A comparison of open reduction and internal fixation and primary total elbow arthroplasty in the treatment of intraarticular distal humerus fractures in women older than age 65. J Orthop Trauma 2003;17(7):473–80. 12. Kamineni S, Morrey BF. Distal humeral fractures treated with noncustom total elbow replacement. J Bone Joint Surg Am 2004;86-A(5):940–7. 13. Hohman DW, Nodzo SR, Qvick LM, Duquin TR, Paterson PP. Hemiarthroplasty of the distal humerus for acute and chronic complex intra-articular injuries. J Shoulder Elbow Surg 2014;23(2):265–72. 14. Doornberg J, Lindenhovius A, Kloen P, van Dijk CN, Zurakowski D, Ring D. Two and three-dimensional computed tomography for the classification and management of distal humeral fractures. Evaluation of reliability and diagnostic accuracy. J Bone Joint Surg Am 2006;88(8):1795–801. 15. Hughes RE, Schneeberger AG, An KN, Morrey BF, O’Driscoll SW. Reduction of triceps muscle force after shortening of the distal humerus: a computational model. J Shoulder Elbow Surg 1997;6(5):444–8. 16. Bryan RS, Morrey BF. Extensive posterior exposure of the elbow. A triceps-sparing approach. Clin Orthop Relat Res 1982;166:188–92. 17. Alonso-Llames M. Bilaterotricipital approach to the elbow. Its application in the osteosynthesis of supracondylar fractures of the humerus in children. Acta Orthop Scand 1972;43(6):479–90.

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18. Kamineni S, Morrey BF. Distal humeral fractures treated with noncustom total elbow replacement. Surgical technique. J Bone Joint Surg Am 2005;87(Suppl. 1(Pt 1)):41–50. 19. Shahane SA, Stanley D. A posterior approach to the elbow joint. J Bone Joint Surg Br 1999;81(6):1020–2. 20. Gschwend N. Our operative approach to the elbow joint. Arch Orthop Trauma Surg 1981;98(2):143–6. 21. Garcia JA, Mykula R, Stanley D. Complex fractures of the distal humerus in the elderly. The role of total elbow replacement as primary treatment. J Bone Joint Surg Br 2002;84(6):812–6. 22. McKee MD, Pugh DM, Richards RR, Pedersen E, Jones C, Schemitsch EH. Effect of humeral condylar resection on strength and functional outcome after semiconstrained total elbow arthroplasty. J Bone Joint Surg Am 2003;85-A(5):802–7. 23. Gallo RA, Payatakes A, Sotereanos DG. Surgical options for the arthritic elbow. J Hand Surg Am 2008;33(5):746–59. 24. Lee BP, Adams RA, Morrey BF. Polyethylene wear after total elbow arthroplasty. J Bone Joint Surg Am 2005;87(5):1080–7. 25. Rispoli DM, Athwal GS, Morrey BF. Neurolysis of the ulnar nerve for neuropathy following total elbow replacement. J Bone Joint Surg Br 2008;90(10):1348–51. 26. Sanchez-Sotelo J, Morrey BF. Total elbow arthroplasty. J Am Acad Orthop Surg 2011; 19(2):121–5. 27. McDonald CP, Johnson JA, Peters TM, King GJ. Image-based navigation improves the positioning of the humeral component in total elbow arthroplasty. J Shoulder Elbow Surg 2010;19(4):533–43. 28. McDonald CP, Peters TM, Johnson JA, King GJ. Stem abutment affects alignment of the humeral component in computer-assisted elbow arthroplasty. J Shoulder Elbow Surg 2011;20(6):891–8. 29. Morrey BF, Sanchez-Sotelo J. The elbow and its disorders. 4th ed. Philadelphia, PA: ­Saunders; 2009.

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Fractures of the proximal forearm N. Kazemi1, R.M. Greiwe2 1Mount Sinai Medical Center, New York, NY, USA; 2Commonwealth Orthopaedic Centers, Edgewood, KY, USA

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6.1  Introduction Fractures about the elbow are broadly categorized to those that are proximal to the elbow joint (i.e., distal humerus fractures) and less commonly to ones that are distal to the elbow joint. Management of fractures of the proximal radius and ulna is difficult and complicated for several reasons. The anatomy of the proximal forearm is complex and involves three articulations: the ulnotrochlear, radiocapitellar, and the proximal radioulnar joints (PRUJ). The thin soft-tissue envelope about the elbow requires particular attention to minimize complications. The purpose of this chapter is to provide an overview of fractures of the proximal ulna and radial head/neck.

6.2  Anatomy The proximal ulna consists of the olecranon process posteriorly and the coronoid process anteriorly. The articulating surface of the proximal ulna is covered with cartilage, except for a bare area that separates the olecranon from the coronoid.1 The olecranon and the coronoid make up the greater sigmoid notch, which articulates with the trochlea. The greater sigmoid notch is angled 30° posteriorly relative to the shaft of the humerus, matching the similar anterior angulation of the distal humerus. This osseous geometry prevents anterior subluxation of the trochlea.2,3 The lesser sigmoid notch is located on the lateral aspect of the proximal ulna and articulates with the radial head. It is the site of attachment of the annular ligament. The olecranon acts as a posterior buttress, preventing anterior translation of the ulna, and is the site of triceps attachment. The proximal ulna has a physiologic angulation called the proximal ulna dorsal angulation (PUDA).4,5 Rouleau et al. first described the PUDA and found it to be present in approximately 96% of the population. The mean PUDA was reported to be 5.7° (range 0°–14°) and the apex of angulation was located, on average, 47 mm (range 34–78 mm) distal to the tip of the olecranon. The side-to-side correlation of the PUDA was reported to be high (r = 0.860), highlighting the importance of contralateral X-rays in complicated cases to restore anatomy.4 The coronoid is divided into the tip, body, and anteromedial and anterolateral facets.6 The tip and the anteromedial facet (AMF) protrude anteriorly and medially, respectively, from the proximal ulnar metaphysis and are susceptible to injury.7 The coronoid, along with the radial head, acts as an anterior buttress and is critical in elbow stability. The anterior elbow capsular insertion on the coronoid is located a few millimeters distal to the tip8; however, most coronoid tip fractures, even the very small ones, involve the capsular Shoulder and Elbow Trauma and its Complications. http://dx.doi.org/10.1016/B978-1-78242-450-5.00006-X Copyright © 2016 Elsevier Ltd. All rights reserved.

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(a)

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Posterior bundle Anterior bundle

Transverse ligament

(b)

Anterior capsule Radial collateral ligament Annular ligament

Posterior capsule Lateral ulnar collateral ligament

Figure 6.1  The ligamentous attachments of the medial and lateral side of the elbow. (a) The MCL consists of an anterior, posterior, and transverse bundle. (b) The lateral ligaments include the radial collateral ligament, annular ligament, and LUCL. Reprinted from Mathew PK, Athwal GS, King GJW. Terrible triad injury of the elbow: current concepts. JAAOS 2009;17:137–51.

insertion.9 The anterior band of the medial collateral ligament (MCL) inserts on the medial aspect of the coronoid at the sublime tubercle.8 The MCL consists of three parts: the anterior, posterior, and the transverse bundle (Figure 6.1). The anterior bundle is the most discrete component and the primary restraint of the elbow against valgus force.10 The posterior bundle is a thickening of the capsule rather than a distinct ligament.11 The transverse bundle connects the tip of the olecranon to the coronoid, and because it does not cross a joint, it is believed not to contribute to elbow stability.12 The lateral ligamentous complex of the elbow includes the lateral ulnar collateral ligament (LUCL), radial collateral ligament, annular ligament, and the accessory collateral ligament (Figure 6.1). The LUCL inserts on the lateral aspect of the proximal ulna at the crista supinatorum and plays a major role in providing varus and posterolateral stability to the elbow. The annular ligament circumferentially captures the radial head and inserts on the anterior and posterior margins of the lesser sigmoid notch. The radial collateral ligament inserts on the annular ligament and stabilizes the radial head. The accessory collateral ligament has attachments at the crista supinatorum and at the annular ligament.10,13,14 The quadrate ligament, important for stability of the PRUJ, is described as thickening of the elbow capsule at the inferior margin of the annular ligament attaching to the ulna.15 The radial head articular surface consists of a concave surface and a spherical rim. The concave surface articulates with the capitellum and is fully covered with articular cartilage. The spherical rim articulates with the lesser sigmoid notch and is covered with a 280° arc of articular cartilage.14 Anatomically, the radial head is not perfectly circular and has variable offset from the radial neck. The long axis of the radial head has been shown to be perpendicular to the lesser sigmoid notch with the forearm in neutral position. Restoration of this relationship is important during fixation or replacement of the radial head.16 The role of the radial head in stabilization of the elbow and forearm is twofold. First, it acts as a secondary valgus stabilizer of the elbow, offloading the MCL. Second, it acts as a load-sharing segment, along with the interosseous membrane, for loads across the wrist. Cadaveric studies have shown that the radial head is an important secondary stabilizer in MCL-deficient elbows.17

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The radiocapitellar joint, along with the interosseous membrane, the distal radioulnar joint, and the triangular fibrocartilage complex, acts as a continuum to resist proximal migration of the radius and provide for load transfer from the wrist to the elbow.18–20

6.3  Evaluation of patients with proximal forearm fractures Evaluation of a patient with a proximal forearm fracture should begin with a thorough history and physical examination. Examination of the soft-tissue envelope and a thorough neurovascular examination should always be performed. In higher energy trauma, there should be suspicion for neurovascular injuries. Compartment syndrome is rarely seen with proximal forearm fractures; however, it has been reported in the pediatric population.21 Range of motion evaluation is an essential component of the exam, especially in patients with radial head or neck fractures. Aspirating the elbow joint, with or without injection of anesthetic, can help evaluate range of motion, mechanical blocks, and presence of instability. Initial imaging should include anteroposterior (AP) and lateral radiographs of the elbow. On the lateral radiograph, the PUDA and radial head translation should be evaluated. Radial head translation is measured by the radiocapitellar ratio (RCR) as described by Rouloeu.22 This is defined as the minimal distance between the bisector of the radial head and the center of the capitellum divided by the diameter of the capitellum (Figure 6.2). An RCR value outside of the normal range of 1 mm posterior (−5%) to 3 mm anterior (13%) suggests a misalignment at the radiocapitellar joint. It has been shown that the PUDA and RCR are closely related and that a 5° malreduction at the PUDA leads to radial head subluxation.23 In complex cases, it may be beneficial to evaluate these measurements on the contralateral normal elbow radiographs so that they can be restored with reconstruction of the injured elbow. In comminuted fractures, the personality of the fracture and amount of displacement is difficult to assess with conventional radiographs. Computed tomography (CT) with three-dimensional (3D) reconstruction is of great value for preoperative planning in such cases.

6.4  Olecranon fractures Olecranon fractures account for approximately 10% of all upper extremity fractures in adults.24–26 In their epidemiologic study, Duckworth et al. reported 78 olecranon fractures among 6872 total fractures in 1 year. The mean age of patients with an olecranon fracture was 57 years. The mean age of male and female patients was 37 and 52 years, respectively. The most common mechanism of injury was a simple fall. An associated ipsilateral proximal radius fracture was present in 17% of patients, and 6.4% of injuries were open.27 Olecranon fractures result from either a direct blow or an indirect pull of the triceps tendon. With a direct force, the olecranon is driven into the distal humerus, generally

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resulting in a comminuted fracture pattern. Higher energy mechanisms result in transolecranon fracture-dislocations. An indirect avulsion type of injury results in a more simple transverse or short oblique fracture pattern.28

6.4.1  Classification system The most common classification system used for olecranon fractures is the Mayo classification first described by Morrey,29 which classifies olecranon fractures into three types: nondisplaced or minimally displaced fractures (Type I), displaced fractures

Figure 6.2  The RCR is defined (on the lateral view) as the minimal distance between the line that bisects the radial head and the center of the capitellum divided by the diameter of the capitellum. Reprinted from Rouleau DM, Sandman E, Riet RV et al. Management of fractures of the proximal forearm. JAAOS 2013;21:149–60.

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(Type II), and fractures associated with elbow instability (Type III). There are two modifiers that describe the absence (Subtype A) or presence (Subtype B) of comminution.

6.4.2   Treatment In rare occasions, olecranon fractures can be treated without surgery. The best candidates for nonoperative management are low-demand elderly patients with minimally displaced fractures.30 However, in patients with severe medical comorbidities, more displaced fractures may be considered for nonsurgical management. The elbow should be immobilized at a maximum amount of flexion that can be achieved without fracture gapping (generally between 45° and 90°). Patients should be followed weekly with radiographs until 4 weeks because these fractures have a tendency to displace without fixation. Weight bearing and active range of motion of the elbow should be avoided until bony union is achieved. Gallucci et al. presented their results with nonoperative treatment of displaced olecranon fractures in the elderly. They immobilized patients for approximately 5 days and allowed free range of motion as patients tolerated afterward. At a mean 16-month follow-up, the average pain score was 1/10, and the average arc of motion was 15°–140°. Twenty-two of 28 patients developed a nonunion, but no patients required surgical intervention. They concluded that nonoperative treatment of displaced olecranon fractures achieves good results with high satisfaction rates in the elderly.31 Transverse simple fractures proximal to the midpoint of the greater sigmoid notch or the bare area are considered stable and can be treated with a traditional tension-band wire (TBW) construct (Figure 6.3). TBW technique converts the posterior distraction force of the extensor mechanism to a dynamic compressive force at the articular surface.32 Two 0.062-in. (1.6 mm) Kirschner wires (K-wires), or a 7.3-mm partially

Figure 6.3  An 85 year-old woman who sustained a displaced relatively transverse olecranon fracture was treated with a tension band wire construct. Anteroposterior and lateral radiographs demonstrate good alignment following fixation.

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threaded intramedullary cancellous screw, are placed in the posterior olecranon crossing the fracture site. When using K-wires, they can be placed either intramedullary or obliquely to engage the anterior proximal ulnar cortex. It has been shown that engaging the anterior cortex avoids complications, such as pin migration.33–35 In a magnetic resonance imaging study, Prayson et al. demonstrated that the ulnar artery and the median nerve are at greatest risk when placing pins, but yet still located more than 10 mm from the anterior ulnar cortex. On the basis of this, they recommended that the tip of the K-wire should penetrate the anterior proximal ulnar cortex at least 15 mm distal to the tip of the coronoid and not be more than 10 mm proud.34 Therefore, before burying K-wires, they should be pulled back slightly so that when buried, they will not be excessively proud.36 One or two 18-gauge stainless steel wires are then used to create a double looped figure-of-eight TBW construct. Distally, the wire is passed through a predrilled 2-mm hole in the dorsal aspect of proximal ulna. Proximally, it runs deep to the triceps tendon. A 14- or 16-gauge needle or angiocatheter can be used to facilitate passage of wire deep to the triceps tendon. TBW constructs should not be used for unstable fracture patterns, including comminuted fractures or those extending distal to the greater sigmoid notch. They do not provide enough stability and may cause overcompression at the articular surface, causing joint incongruity. In these cases, anatomic reduction and rigid stabilization with plate fixation are required. This is performed using a direct posterior approach. Articular fragments should be anatomically reduced. There is often an intermediate fragment between the proximal and distal piece that plays an important role in restoration of the articular surface.37 This should be stabilized with a “home-run screw,” an intramedullary screw inserted into the plate from the tip of the olecranon, proximal to distal into the ulnar shaft. Care should be taken not to overcompress and narrow the trochlear notch in comminuted fractures. Some authors advocate fixation and bone grafting for complex comminuted fractures.38 It is important to avoid the urge to reduce the easily accessible posterior cortex first, indirectly reducing the articular surface. This may lead to malreduction of the joint despite anatomic reduction of the posterior cortex. Alternatively, a lateral approach can be used, making sure to protect the collateral ligaments. The proximal fragment can be reflected back to better access the joints. The articular fragments are then sequentially reduced and stabilized working from distal to proximal. The plate can be placed superficial to the triceps tendon or alternatively buried deep through a small longitudinal incision. One technical difficulty of plating olecranon fractures is the amount of fixation possible in the proximal fragment.39 The most proximal screw is often the only fixation available. The mechanism of failure for olecranon fractures is traditionally through the pull of the triceps tendon in a poorly fixed proximal fragment. In a cadaveric study, Wild et al. showed that suture augmentation of the plate construct with the triceps tendon would increase the ultimate load to failure by offloading the triceps tendon compared with plate fixation alone.39 The traditional AO (Arbeitsgemeinschaft für Osteosynthesefragen) technique for olecranon plating recommended a nonlocking, one-third tubular plate contoured to the proximal ulna.40–42 Precontoured plates with locking screws are increasingly used with the advent of locking technology. However, cadaveric studies have shown no

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difference in stiffness or load to failure between nonlocking and locking compression plates.43 When using a precontoured plate, the morphology of the proximal ulna and PUDA should be taken into consideration. Applying a stiff, straight plate to a proximal ulna with a high PUDA may result in a malunion.44 Very rarely, olecranon fractures with extensive comminution or bone loss may not be amenable to plate fixation. In such instances, the comminuted fragments are excised and the triceps tendon is advanced. Tendon-grasping sutures are placed in the triceps and passed through a bone tunnel in the distal piece. This technique should be reserved for elderly patients with low demand. The amount of olecranon that can be removed is a matter of debate. Gartsman et al. showed in a clinical study that up to 80% of the olecranon could be removed without significant functional loss.45 In a biomechanical study, An et al. showed that up to 50% of the olecranon could be excised without causing complete elbow instability.46 In a more recent cadaveric study, Bell et al. showed that resection of as little as 12.5% of the olecranon would cause significant changes in angular and rotational laxity of the elbow. However, they suggest that in the presence of other primary and secondary stabilizers of the elbow, up to 75% of the olecranon can be excised without causing gross instability.47

6.4.3   Rehabilitation Postoperative rehabilitation is specific to the surgeon and depends on the state of the soft tissue and the quality of fixation. The elbow is generally immobilized in relative extension (45°) for 1 week, allowing the soft tissue to heal. With adequate fixation and a cooperative patient, passive- and active-assisted range of motion can be started at week 1. Strengthening and weight bearing is reserved until radiographic and clinical evidence of bone healing. In patients with compromised soft tissue, a dynamic splint can be used to facilitate a gradual increase in elbow flexion.

6.4.4   Outcome Outcomes after olecranon fixation have historically been good. The literature available is mostly a collection of small case series. The Mayo Elbow Performance Score has been shown to be good to excellent in most patients. Karlsson et al. reported good-to-excellent results in 94% of patients in a group of 73 patients with an average follow-up of 19 years.48 The average range of motion after TBW fixation has been reported to be 116° ± 22° with an average loss of extension of 15° ± 17°.35 Results of plating have been shown to be similar to TBW fixation in multiple studies. The average arc of motion has been reported to be 13°–136° with an overall 94% good or excellent outcome.49

6.4.5   Complications Hardware prominence is the most common complication, and hardware removal is reported in 18–62% of patients.49–52 Hardware removal is more common after TBW fixation compared with plate fixation.53,54 Loss of elbow range of motion is another

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reported complication that may be seen in up to 75% of patients. An average of 10–15% of elbow range of motion may be lost compared with the contralateral side.28,55 Van der Linden reported an average arc of motion of 116° ± 22°, with an average extension loss of 15° ± 17° after TBW constructs in 78 patients.35 Buijze reported an average arc of motion of 13°–136° after plate fixation of 19 patients.49 Posttraumatic arthritis has been reported in 20–48% of patients.35,52 This has been associated with an articular step-off of more than 2 mm.56 Extra-articular malunion generally occurs at the metadiaphyseal junction. Patients may present with elbow stiffness and radial head subluxation, which may be confused with residual posterolateral instability. It is important to scrutinize the proximal ulnar reduction and the PUDA carefully in such situations. Treatment includes proximal ulnar corrective osteotomy as opposed to lateral elbow reconstruction.57,58 Intra-articular malunions will lead to rapid development of elbow arthritis requiring salvage procedures, hence the importance of anatomic reduction of the joint. Olecranon nonunions are uncommon and reported in 1% of cases, with higher energy fractures being more prone.59,60 The most common location is the metadiaphyseal junction. Management is challenging because of poor biology and quality of bone. Nonunion should be completely debrided and rigid fixation applied. Autograft is routinely used to enhance biology. Off-label use of bone morphogenic protein (BMP) has been reported in the literature. Argintar et al. reported that fracture defects less than 4 cm and the presence of vascularized soft tissue were good prognostic factors for the success of using BMP.61 Rotini et al. recommended rigid fixation and structural bone graft for proximal ulnar nonunions. They reported superior outcomes when nonunions were greater than 5 cm distal to the tip of the olecranon. In addition, they recommend that asymptomatic nonunions with greater than 90° arc of motion of the elbow would not benefit from surgical intervention. Infection after open reduction and internal fixation (ORIF) of olecranon fractures is a challenging problem. The soft tissue about the elbow is thin, and any superficial infection could rapidly become deep. Therefore, there should be a low threshold for surgical intervention when there is suspicion of infection. Oral antibiotics are generally not acceptable for the management of infection with any presence of drainage. Some authors recommend irrigation and debridement, with or without application of an external fixator, followed by 6–12 weeks of antibiotics. This should then be followed by an additional 12 weeks of antibiotic “holiday” before reconstructive efforts.62 In a study of 499 isolated olecranon fractures, Snoddy et al. found that there was a higher rate of infection in patients treated with a TBW construct.54 Heterotopic ossification (HO) is an uncommon complication reported in less than 1% of patients.63 Bauer et al. found that delay to surgery more than 8 days and delay to mobilization more than 15 days were associated with increased risk of developing HO. There is currently no role for indomethacin or radiation for HO prevention.63

6.4.6  Coronoid fractures Coronoid fractures are generally caused by axial compression of the trochlea on the coronoid process. Isolated fractures are rare and are often associated with other

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soft-tissue injuries about the elbow.64 They have been reported to be present as an associated injury in approximately 2–15% of elbow dislocations.65 Doornberg and colleagues studied four coronoid fracture patterns associated with specific traumatic elbow instability mechanisms. These include transverse coronoid fractures associated with valgus posterolateral rotatory instability, AMF fractures associated with varus posteromedial instability, and larger coronoid base fractures associated with either a posterior or anterior transolecranon fracture-dislocation.9 The posterolateral rotatory mechanism is the most common cause of elbow dislocation and is caused by a supination force on an outstretched axially compressed arm. The body causes a valgus and posterolateral rotation force around a planted elbow, tearing the stabilizing ligaments of the elbow from lateral to medial direction with the anterior band of the MCL being the last ligament to fail.66 The resultant coronoid fracture is generally small and transversely oriented.67 The coronoid and the radial head can both be fractured with this injury, resulting in the so-called terrible triad of the elbow.68 A fall on an outstretched hand may also cause a varus posteromedial rotatory injury pattern.69 The lateral collateral ligament is typically avulsed from the lateral epicondyle and the varus force fractures the AMF of the coronoid. In rare cases, the lateral collateral ligament stays intact and the olecranon fails instead. If the MCL fails, the elbow completely dislocates and the AMF fracture is generally small. However, more commonly, the medial ligamentous complex stays intact or is partially disrupted. The force causes joint subluxation as opposed to dislocation and the associated AMF fracture piece is larger. The radial head is generally not injured (Figure 6.4). Transolecranon fracture-dislocations occur because of traumatic injuries to the greater sigmoid notch either through an anterior or posterior force. The coronoid is generally fractured at the base and can be accessed through the olecranon fracture.67,69

6.4.7   Classification system Regan and Morrey described the initial classification system used for coronoid fractures,70 which was based on the size of the coronoid piece. Type I was a coronoid tip avulsion. Type II involved 50% of the coronoid process or less and Type III involved more than 50% of coronoid process. Each type was subcategorized into A and B on the basis of the absence (A) or presence (B) of elbow instability.70 The transverse coronoid process fracture after a terrible triad injury can involve anywhere from 19% to 59% of the coronoid.67 O’Driscoll later proposed a new classification system that was based on the anatomic location of the fracture.69 They divide the coronoid process into three main segments: tip, AMF, and the base. Coronoid tip fractures are subdivided into Subtype I, being a 2-mm or smaller tip piece, and Subtype II, being larger than 2 mm. AMF fractures are subdivided into three subtypes. Subtype I involves the anteromedial rim, Subtype II involves the anteromedial rim and the tip, and Subtype III is a combination of Subtype II and a fracture of the sublime tubercle. Coronoid base fractures are subdivided into two subtypes: Subtype I involves the coronoid base and Subtype II involves the olecranon (transolecranon) and the coronoid base (Figure 6.5).

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Figure 6.4  Anteromedial coronoid fracture. (a) A 48-year-old man sustained a fall. In addition to a Type V acromioclavicular separation, he also sustained an AMF fracture of the coronoid. (b) Postoperative images demonstrating fixation of the AMF fracture fixed through a Hotchkiss over-the-top approach. (c) AP view of the medial coronoid fracture following ORIF. (d) Lateral view demonstrating reconstruction of the coronoid.

6.4.8  Treatment Treatment of coronoid fractures is based on the pattern of injury. The injury is infrequently seen in isolation, and an assessment of elbow stability is made. When the elbow is deemed stable, nonsurgical management is preferred. Transverse fractures are generally a result of valgus posterolateral force and are associated with an elbow dislocation and radial head fracture (the so-called terrible triad). The average size of the transverse coronoid fracture is 39% of the coronoid height.7 Decisions regarding

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Subtype 1 ≤2 mm Subtype 2 >2 mm

(a) Tip AM facet Subtype 1 Subtype 2 Subtype 3 Sublime tubercle

(b)

Subtype 1

Subtype 2

(c) Figure 6.5  Coronoid fracture illustration according to the O’Driscoll classification. (a) Type I and (b) Type II. Type II Subtypes 1, 2, and 3 correspond to progressive severity of AMF fractures. (c) Type III, Type III Subtype 1 (coronoid base and olecranon). (a and b) Axial views of the proximal elbow demonstrating the radial neck and radial head (inset dotted line) and an axial view of the joint surface just distal to the joint. Reprinted from Rouleau DM, Sandman E, Riet RV et al. Management of fractures of the proximal forearm. JAAOS 2013;21:149–60.

fixation should be made intraoperatively after an assessment of elbow stability. In situations in which the MCL is also injured, the coronoid fracture should be managed surgically because the elbow is unstable. The fracture can be exposed through a lateral approach using the commonly present capsuloligamentous tear. If there is no traumatic rent, then the common extensor tendon should be split. It is important to stay anterior to the center of the capitellum to avoid iatrogenic injury to the lateral ligamentous complex of the elbow. The LUCL has frequently been avulsed at the humeral origin

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because of the traumatic dislocation and the ligament can be identified by peering underneath the avulsed tissue. Access to the coronoid is obtained through the traumatic injury to the radial head. The preferred treatment for coronoid tip fractures is suture fixation through the anterior capsule, capturing the coronoid fragment. The suture is passed through bone tunnels and tied on the dorsal ulnar cortex over a bone bridge. Screw fixation can be used for larger fragments, but augmentation with sutures is recommended because screws alone may not be enough to protect against the axial loads across the coronoid.7 When associated with complete elbow dislocation, AMF fractures are usually too small to be fixed with screws or plates. These are commonly O’Driscoll Type II, Subtype I or II fractures.69 In such cases, suture fixation through a medial approach is recommended. When associated with elbow subluxation as opposed to complete dislocation, AMF fractures are typically large enough for plate fixation, but they may be fixed with headless compression screws. Through a medial approach, a plate can be used to buttress the AMF piece and prevent displacement. When utilizing the medial approach, the ulnar nerve should be released in situ. Some surgeons perform routine transposition; however, this is not required. Several intervals have been described for the medial elbow dissection.69,71,72 For small fractures anterior to the sublime tubercle, the Hotchkiss over-the-top approach can be used.71 When using this technique, which was originally described for elbow contracture release, the flexor-pronator mass is split and the anterior half along with the brachialis are elevated off of the medial epicondyle. For more medial fractures involving the sublime tubercle, the flexor carpi ulnaris (FCU)-splitting approach can be used. This technique uses the natural split between the two heads of the FCU.7,69 In a cadaveric study, Huh et al. demonstrated that the FCU-splitting approach provides superior exposure to the anteromedial coronoid compared with the Hotchkiss over-the-top approach.73 For larger fracture fragments involving the coronoid base, the entire flexor-pronator mass can be elevated off of the ulna as described by Taylor.72 This technique requires extensive dissection and is less commonly used. Coronoid base fractures usually result from anterior or posterior transolecranon fracture-dislocations. Anterior transolecranon fracture-dislocations produce large coronoid base fragments that can be fixed with dorsal plates and screws. The coronoid base reduction can be assessed through the olecranon fracture or via a separate medial approach. Posterior transolecranon fracture-dislocations are more complex and are often associated with osteoporosis. There may be multiple separate fragments, including an anteromedial, central, tip, and a lesser sigmoid notch fragment. Transverse tip fragments are fixed using drill tunnels with suture. A medial plate can be used in addition to a dorsal plate for additional fixation. If the surgeon believes that the final construct is not reliable, then a hinged external fixator should be used for additional stability.

6.4.9  Rehabilitation Rehabilitation after coronoid fixation should be personalized based on the reliability of fixation. In the setting of a compliant patient and reliable fixation, passive elbow exercises can be started immediately after surgery. Active exercises begin soon thereafter.

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When fixation is less reliable, the elbow should be immobilized for 3–4 weeks. Active elbow exercises are generally avoided until 6 weeks. Shoulder abduction produces a varus force at the elbow and should be avoided for at least 4 weeks.

6.4.10  Complications Ulnar nerve palsy may occur after coronoid fixation. This is partly because of dissection and handling of the nerve during surgery and partly because of sequelae of trauma (swelling, scarring, callus formation, contractures). Development of ulnar nerve palsy usually causes a setback in patient’s rehabilitation, including diminished elbow motion and increased pain.74 In the instance of a setback after initial good rehabilitation, it is important to carefully evaluate for developing ulnar nerve palsy or an underlying infection. Elbow stiffness is a common complication after traumatic elbow injuries and could be due to various causes, including excessive scar formation, instability, hardware impingement, ulnar neuropathy, and HO. Management generally involves surgical treatment of the underlying cause. In the case of HO, resection can be performed as soon as the bone is mature and scar is mobile, usually by 4 months.7 Slight joint incongruity, not subluxation or dislocation, is common after surgical treatment of coronoid fractures. This is treated with active elbow exercises and avoidance of varus stress with abduction.7 In the setting of residual subluxation or dislocation, surgical intervention generally with a hinged external fixator is necessary. Other complications include arthritis and infection of the elbow. Elbow arthrosis is directly related to the quality of reduction and elbow stability. Studies have demonstrated that superior outcome is achieved in the setting of a stable elbow as opposed to an unstable elbow.68,75 Infections after coronoid fixation are uncommon. The implant is generally kept in place and the infection is treated with serial debridements and intravenous antibiotics.7 Recurrent instability may stem from inadequate fixation, nonunion, or ligamentous laxity. Treatment depends on the underlying cause of the instability and may require ligament reconstruction, revision of fixation, and possible bone grafting. A hinged external fixator is usually necessary.

6.5  Radial head and neck fractures Radial head fractures (Figure 6.6) account for approximately 4% of all fractures, more than 30% of fractures about the elbow, and more than 50% of proximal forearm fractures.76–78 The average age of patients sustaining this fracture is 40 years, and the gender distribution is roughly equal. The incidence is reported between 25% and 39% per 100,000 adults per year.76,78–81 Most fractures (90%) are stable and not associated with instability or other fractures.78,80,82 Radial neck fractures are approximately half as common as radial head fractures. Their incidence increases with increasing age and complex fracture patterns.76,78,80 Mason described the original classification for radial head fractures.83 He described Type I as nondisplaced fractures, Type II as displaced partial head fractures, and Type III

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Figure 6.6  Radial head fracture: 38-year-old gentleman who fell. (a) Initial radiographs demonstrated a depressed fracture of the radial head. (b) Postoperative radiographs demonstrate an adequate reduction of the joint surface with two headless compression screws. (c) AP view 3 months s/p ORIF radial head with headless compression screws demonstrating an anatomic reconstruction of the joint surface. (d) Lateral view demonstrating a healed radial head fracture at 3 months.

as displaced fractures involving the entire head. There have been several modifications to Mason’s classification since 1954. Johnston added Type IV to Mason’s classification as radial head fractures associated with elbow instability.84 Broberg and Morrey set criteria for being considered a Mason Type II (partial head) fracture. They suggested that the fragment must be larger than 30% of the articular surface and be

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displaced at least 2 mm to be considered a Type II fracture.85 Hotchkiss modified the Mason classification on the basis of treatment.86 He described Type I fractures as nondisplaced, minimally displaced (2 mm) fractures of the radial head or neck without comminution, with or without block in elbow motion, which are amenable to ORIF. Type III fractures were described as displaced fractures that are not amenable to internal fixation and should be either excised or replaced with a prosthesis. The first step in the management of radial head and neck fractures is to determine whether the injury is stable or unstable. Most fractures are stable nondisplaced or minimally displaced fractures of the radial neck or the anterolateral portion of the radial head.27,78,87 This anterolateral area is the nonarticular portion of the radial head and is prone to fractures because it is weaker than the surrounding subchondral bone.88 The key to appropriate management is identifying fracture patterns associated with instability. The common instability patterns seen with radial head and neck fractures are in the setting of posterior elbow dislocations,85,89 terrible triad injuries,68,89 MCL injuries, capitellar fractures, Essex-Lopresti lesions,90,91 and Monteggia injuries.92

6.5.1   Stable injuries Nondisplaced or minimally displaced radial head fractures not associated with the instability patterns stated above are considered stable fractures. These injuries are nonoperatively treated unless there is a mechanical block to elbow motion. Some authors have advocated elbow aspiration with or without anesthetic injection for pain relief and assessment of block in range of motion.93–95 In a prospective randomized study, Chalidis et al. demonstrated no difference in terms of pain relief or elbow function between patients receiving aspiration alone and those receiving aspiration and bupivacaine injection.94 In the acute setting, there may be difficulty differentiating between loss of elbow motion due to pain and an actual mechanical block despite aspiration and injection. In inconclusive situations, an examination under anesthesia may be necessary to evaluate for instability or a block to motion. Treatment of stable radial head fractures should focus on avoidance of elbow stiffness. The authors generally place patients in a sling and ace wrap and advocate early elbow range of motion. Randomized trials have shown no difference between a brief period of immobilization followed by mobilization and immediate mobilization.96 Unsworth-White et al. demonstrated that 2 weeks of immobilization in 90° of flexion followed by mobilization would result in loss of terminal extension when compared with immediate mobilization.97 Operative intervention is only indicated when there is mechanical block to motion, which is rare.27,86,98,99 Long-term studies have demonstrated excellent outcomes with nonoperative treatment of these injuries.100,101 Akesson presented 49 patients with Mason Type II fractures treated with early mobilization. Forty of 49 (82%) had no subjective complaints at a mean follow-up of 19 years and there were minimal clinical differences between the injured and uninjured elbow in terms of range of motion. Six patients had unsatisfactory outcomes and underwent radial head excision.100 Herbertsson

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presented 100 patients with Mason Type II and III fractures with good outcome in 84 (84%) patients at a mean follow-up of 19 years. Of the 100 patients, 78 had nonoperative treatment, 19 had radial head excision, 2 had ORIF, and 1 had MCL repair. However, the study is limited because the authors did not stratify outcomes based on treatment.101

6.5.2  Unstable injuries Unstable radial head/neck injuries generally result from higher energy mechanisms and, as mentioned earlier, are associated with other injuries such as elbow dislocations, Essex-Lopresti lesions, and Monteggia injuries (Figure 6.7). Features indicative of an unstable injury include gross displacement, periosteal disruption, metaphyseal bone loss, radiocapitellar malalignment, and block to elbow or forearm motion. Unstable injuries to the radial head will be covered in more detail in Chapters 2 and 9.102 The literature on treatment of unstable radial head fractures is not conclusive. For the most part, they require surgical treatment in addition to treatment of associated bony or ligamentous pathology. In a systematic review, Struijs et al. concluded that there is insufficient evidence to draw a definitive conclusion on the optimal treatment of Mason Type II–IV radial head fractures.103 It has been shown that unstable radial head fractures may be treated nonsurgically as long as patients accept late consequences, such as delayed surgery.104–106 However, operative treatment is generally recommended for unstable radial head fractures. Options for surgical treatment of radial head fractures include ORIF and replacement. Some authors advocate excision as a treatment for some fractures. However, recent biomechanical studies highlight the importance of the radial head as a secondary stabilizer of the elbow. Therefore, excision in the setting of elbow or forearm instability should not be performed.85,105–107 This treatment will lead to proximal radius migration, positive ulnar variance, and residual elbow instability.108–110 Some authors have reported good outcomes with radial head excision for Mason Type III fractures.111,112 If this is being considered, then the push–pull test should demonstrate less than 2–4 mm of movement of the proximal radius.113 Ikeda et al. presented 28 patients with Mason Type III fractures and compared radial head excision in 15 with ORIF in 13. Sixteen patients had associated elbow dislocations, 5 had coronoid fractures, and 1 had a capitellar fracture. At mean follow-up of 3 and 10 years, patients who had ORIF demonstrated better function.114 The goal of ORIF is to obtain a stable construct and to restore the joint congruity. Small (1.5 or 2.4 mm) headless screws can be used for fixation.115–117 Bioabsorbable implants or small-threaded wires may be useful for fixation of very small fragments.118 Once the articular surface is restored, the reconstructed radial head fragment can be fixed to the proximal radial neck using a plate and screw construct if necessary. Any hardware on the radial neck and head should be placed in the so-called “safe zone.” Various methods have been described to identify the safe zone: 1. The lateral aspect of the radial head that corresponds to the area in between the radial styloid and Lister’s tubercle with the arm in neutral rotation. 2. The lateral aspect of the radial head with the forearm in neutral rotation. 3. The most posterior aspect of the radial head with the forearm in full supination.119–121

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Figure 6.7  A comminuted unstable radial head injury associated with a Monteggia fracturedislocation. (a) Preoperative radiographs of a 38-year-old patient who was undercut while playing soccer. (b) Postoperative radiographs demonstrate stable radial head alignment. (c) Lateral view of ORIF, radial head replacement and lateral ligament reconstruction following Type IV Monteggia fracture. The radial head is well-located (d) AP view demonstrating healing of the proximal ulna fracture and adequate alignment of the radiocapitellar joint.

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Several authors have reported good outcomes after internal fixation of partially displaced radial head fractures.115,116,122–124 On the contrary, internal fixation of displaced whole-head (Mason Type III) fractures has been associated with poor outcomes.82,108,125–127 Ring et al. recommended that ORIF be performed for minimally comminuted fractures with less than three articular fragments.125 Fixation of fractures with more than three articular fragments and significant comminution may lead to failure of fixation, nonunion, osteonecrosis, and unpredictable motion.125,126,128 Comminuted radial head fractures involving more than 30% of the articular surface for which satisfactory ORIF is not possible should be treated with radial head replacement. This has been shown to offer more predictable outcomes.128–136 In the setting of elbow or forearm instability, there should be a low threshold to replace the radial head to reconstitute stability. Overstuffing of the joint should be avoided when performing radial head arthroplasty. The proximal edge of the prosthesis should sit less than 1 mm proximal to the corner of the lesser sigmoid notch.137–139 Various prosthetic implant designs are available and intend to replicate the native anatomy of the proximal radius. To expose the radial head, we utilize the extensor digitorum communis (EDC)splitting approach or the interval between the EDC and the extensor carpi radialis brevis.86,98 This is a more anterior exposure as compared with the traditional Kocher interval between the extensor carpi ulnaris and anconeus. In addition to providing excellent exposure, there is a lower chance of injuring the LUCL. The key is to stay anterior to the center of the capitellum. Dissection more distally around the radial neck warrants identification and protection of the posterior interosseous nerve (PIN). It has been shown that pronating the forearm moves the PIN away from the surgical field.140

6.5.3  Rehabilitation Postoperative rehabilitation depends on associated injuries, stability of surgical repair, and patient compliance. Patients are generally immobilized in a splint for the first 10–14 days to allow for wound healing. The elbow is immobilized in supination with medial-sided elbow injuries and in pronation with lateral-sided injuries.141,142 Shoulder abduction causes varus stress across the elbow joint and should be avoided in lateral elbow injuries. Active and active-assisted range of motion is usually started after the first postoperative visit. In general, patients are given a brace that allows for active range of motion and can simultaneously block motion at terminal extension for added stability.

6.6  Summary Proximal forearm fractures are complex injuries. Complications after these injuries can be devastating, and revision surgery is generally challenging. Appropriate treatment requires careful patient examination, thorough evaluation of imaging, and adequate preoperative

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planning. Operative intervention should focus on restoring the bony and ligamentous anatomy and on concentrically reducing the elbow. In general, rehabilitation is optimized when tailored to the patient, injury pattern, and stability of fixation.

6.7  Future trends Most of the literature of proximal forearm fractures involves retrospective reviews. Future work should focus on large prospective trials evaluating areas such as treatment of small AMF fractures, benefit of prophylactic ulnar nerve neurolysis when treating AMF fractures, ORIF versus radial head replacement, and outcome of various replacement prostheses for radial head fractures.

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131. Dotzis A, Cochu G, Mabit C, et al. Comminuted fractures of the radial head treated by the Judet floating radial head prosthesis. J Bone Jt Surg Br 2006;88:760–4. 132. Grewal R, MacDermid JC, Faber KJ, et al. Comminuted radial head fractures treated with a modular metallic radial head arthroplasty. Study of outcomes. J Bone Jt Surg Am 2006;88:2192–200. 133. Moro JK, Werier J, MacDermid JC, et al. Arthroplasty with a metal radial head for unreconstructible fractures of the radial head. J Bone Jt Surg Am 2001;83:1201–11. 134. Smets S, Govaers K, Jansen N, et al. The floating radial head prosthesis for comminuted radial head fractures: a multicentric study. Acta Orthop Belg 2000;66:353–8. 135. Popovic N, Gillet P, Rodriguez A, et al. Fracture of the radial head with associated elbow dislocation: results of treatment using a floating radial head prosthesis. J Orthop Trauma 2000;14:171–7. 136. Johnson JA, Beingessner DM, Gordon KD, et al. Kinematics and stability of the fractured and implant-reconstructed radial head. J Shoulder Elb Surg 2005;14(1 Suppl. S): 195S–201S. 137. Van Riet RP, Van Glabbeek F, Verborgt O, et al. Capitellar erosion caused by a metal radial head prosthesis: a case report. J Bone Jt Surg Am 2004;86:1061–4. 138. Van Glabbeek F, Van Riet RP, Baumfeld JA, et al. Detrimental effects of over stuffing or understuffing with a radial head replacement in the medial collateral ligament deficient elbow. J Bone Jt Surg Am 2004;86:2629–35. 139. Van Riet RP, Sanchez-Sotelo J, Moreey BF. Failure of metal radial head replacement. J Bone Jt Surg Br 2010;92:661–7. 140. Diliberti T, Botte MJ, Abrams RA. Anatomical considerations regarding the posterior interosseous nerve during posterolateral approaches to the proximal part of the radius. J Bone Jt Surg Am 2000;82:809–13. 141. Dunning CE, Zarzour ZD, Patterson SD, et al. Muscle forces and pronation stabilize the lateral ligament deficient elbow. Clin Orthop Relat Res 2001;388:118–24. 142. Armstrong AD, Dunning CE, Faber KJ, et al. Rehabilitation of the medial collateral ligament-deficient elbow: an in vitro biomechanical study. J Hand Surg Am 2000;25:1051–7.

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Fractures of the proximal radius and ulna: coronoid fractures

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J.D. Wyrick, A.W. Jimenez University of Cincinnati, Cincinnati, OH, USA

7.1  Introduction The coronoid process, along with the radial head, plays an important role in elbow stability. Fractures involving the coronoid often result in elbow instability, which may lead to pain, poor function, and ultimately arthritis. The anteromedial (AM) facet of the coronoid is the primary restraint to varus stresses and, when fractured, can result in varus instability. The coronoid and radial head are both important anterior buttresses preventing posterior instability. The fracture patterns of coronoid fractures are now well documented to occur with specific mechanisms. Understanding these patterns and mechanisms will guide the surgeon as to which structures need repair to restore stability. Fractures of the coronoid need to be carefully clinically and radiographically evaluated to determine appropriate management. Fractures associated with elbow instability should be approached surgically to restore stability, permit early range of motion (ROM), and prevent the long-term sequelae of a painful stiff elbow.

7.2  Anatomy The osseous anatomy of the elbow is constrained; therefore, it imparts significant stability based purely on its design. The greater sigmoid notch is composed of the anterior coronoid process and the posterior olecranon process, separated by a bare area. The medial aspect of the coronoid is widened and forms the AM facet. Doornberg et al. (2007) demonstrated using three-dimensional (3D) computed tomography (CT) scans that approximately 60% of the AM facet is unsupported by metaphyseal bone, explaining why it is prone to fracture with varus stress (Figure 7.1). The sublime tubercle on the medial aspect of the coronoid serves as the attachment site of the anterior bundle of the medial collateral ligament (MCL; Figure 7.2). The tip of the coronoid, which is often fractured in a “terrible triad” injury, remains attached to the anterior capsule of the elbow as the capsule attaches 4–5 mm distal to the tip, as can be noted during arthroscopy (Cohen, 2004; Dyer and Ring, 2010). The coronoid has been divided into an AM facet, anterolateral facet, and the body or base. The brachialis inserts distal to the capsule along the base of the coronoid (Cage et al., 1995). Shoulder and Elbow Trauma and its Complications. http://dx.doi.org/10.1016/B978-1-78242-450-5.00007-1 Copyright © 2016 Elsevier Ltd. All rights reserved.

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Figure 7.1  The sigmoid notch with the coronoid separated from the olecranon by a bare area. Note the unsupported AM facet. AM, anteromedial facet; CT, coronoid tip; BA, bare area; OT, olecranon tip; RH, radial head.

(a)

(b) Posterior bundle Anterior bundle

Transverse ligament

Anterior capsule Radial collateral ligament Annular ligament

Posterior capsule Lateral ulnar collateral ligament

Figure 7.2  Ligamentous structures of the elbow: (a) medial side and (b) lateral side. Reprinted with permission from Tashjian and Katarincic (2006).

7.3  Imaging Coronoid fractures may be subtle on plain radiographs, especially if they occur in isolation. Standard anteroposterior (AP) and lateral radiographs of the elbow should be obtained. If a dislocation has occurred, then radiographs of the elbow need to be performed again after reduction to ensure a concentric reduction has been obtained as well as to assist in the identification of the origin of any fracture fragments. Coronoid tip fractures are often confused with radial head fragments on the lateral radiograph.

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Figure 7.3  Imaging of a terrible triad injury. (a) Postreduction lateral radiograph with radial head and coronoid fractures. (b and c) 3D CT scans showing better definition of coronoid and radial head fractures.

It is helpful to assess the size of the coronoid fragment on the lateral radiograph because larger fragments are associated with increased instability. Radiographs are difficult to interpret when a radial head fracture is also present, which is often the case; therefore, a CT scan should be obtained (Figure 7.3). The fracture size and pattern is readily appreciated from the CT, and 3D reconstructions can be extremely helpful, especially for identifying AM facet fractures. The AP radiograph needs to be inspected closely for widening of the lateral joint space. With an AM facet fracture, widening of the radiocapitellar and the lateral trochlea coronoid joint space can be seen with narrowing between the AM facet and medial trochlea. This can also be performed as a stress radiograph with an AP view obtained with varus stress applied to the elbow (Steinmann, 2008; Budoff, 2012; Figure 7.4). Sanchez-Sotelo et al. (2005) has described a “double crescent” sign on the lateral radiograph representing the depressed AM facet fragment.

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Figure 7.4  AP radiograph with varus stress to the elbow, which demonstrates gapping of the radiocapitellar joint and compression of the medial ulnohumeral joint with displacement of the AM facet.

7.4  Mechanisms of injury and fracture patterns The use of CT scans in the evaluation and classification of coronoid fracture patterns has led to the association of specific fracture patterns to mechanisms of injury. Tip fractures are associated with valgus posterolateral rotatory (VPLR) injuries, AM facet fractures with varus posteromedial (VPM) rotatory injuries, and basilar fractures with axial loading and resultant transolecranon fracture-dislocations (O’Driscoll et al., 2003; Doornberg and Ring, 2006a; Mellema et al., 2014).

7.4.1  Coronoid tip fractures Coronoid tip fractures result from a shearing injury due to a VPLR stress to the elbow. The mechanism occurs during a fall on the outstretched arm, when the hand is planted and the body rotates internally relative to the forearm. This causes a ­valgus and posterolateral force across the elbow, resulting in a rupture of the lateral collateral ligament (LCL) complex. The radial head typically fractures from the valgus load and then rolls posterior to the capitelleum. As the coronoid resists this posterior force, the tip is fractured from the shearing mechanism (O’Driscoll et al., 2003; Mathew et al., 2009). This is the mechanism responsible for the terrible triad injury, a term referring to an elbow dislocation with associated radial head and coronoid fractures.

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7.4.2  AM facet fractures Fractures of the AM facet have been associated with a VPM force across the elbow. It is proposed to occur when a person catches themselves from a backward fall, the hand is planted, and the body rotates externally relative to the forearm. The varus force ruptures the LCL complex and drives the AM facet into the medial trochlea, fracturing the AM facet. As the force continues, the elbow posteriorly dislocates. Increasing force also results in extension of the fracture involving larger portions of the coronoid. It is also common for the tip to be involved. If the fracture extends to involve the sublime tubercle, then increasing instability of the elbow results from the loss of the MCL attachment. The radial head is usually not fractured in this injury pattern (O’Driscoll et al., 2003; Doornberg and Ring, 2006b).

7.4.3   Basilar fractures Coronoid fractures involving the base of the coronoid with a resultant large portion of the coronoid involved are usually the result of an axial load to the posterior surface of the proximal ulna with the elbow flexed. The distal humerus is driven into the sigmoid notch resulting in a pilon-type fracture (Figure 7.5). There are two main fracture patterns occurring with this mechanism: the anterior transolecranon fracture-dislocation and the posterior transolecranon fracture-dislocation (Doornberg and Ring, 2006a). The anterior transolecranon fracture-dislocation is not a Monteggia injury because the relationship of the proximal radioulnar joint remains intact. The forearm displaces anteriorly and the olecranon is displaced posteriorly by the pull of the triceps. The radial head is typically not fractured. The coronoid fragment is often a large fragment with the MCL still attached to the sublime tubercle, which remains intact with the fragment. Higher energy injuries may result in comminution of the coronoid with injury to the ligamentous attachments.

Figure 7.5  Lateral radiograph of an axial load injury demonstrating an anterior transolecranon fracture-dislocation with a large basilar coronoid fragment.

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Posterior transolecranon fracture-dislocations can be considered a variant of a ­Monteggia lesion (Jupiter et al., 1991). There is apex posterior angulation of the ­fracture, and the radial head is often injured. A higher incidence of ligament injury is present in this fracture pattern with up to 60% having avulsion of the LCL c­ omplex from the lateral epicondyle in a series by Doornberg and Ring (2006a). They also reported more variability in the coronoid fracture with involvement of the tip and AM facet in some injuries (Mellema et al., 2014). These injuries are often complex and occur frequently in the elderly population, making internal fixation challenging.

7.5  Classification The original classification of coronoid fractures by Regan and Morrey (1989) was based on plain radiographs. The lack of CT imaging and the small number of operated fractures at the time resulted in an oversimplified classification system compared with more recent literature (Mellema et al., 2014; Adams et al., 2012). Using CT data, it is now apparent that coronoid fractures occur in more complex patterns than simple transverse fractures. The Regan and Morrey classification divided fractures into three types, each of which was then subdivided into A and B subtypes, indicating the presence (A) or absence (B) of an associated dislocation. The classification is based on the height of the fracture on a lateral radiograph (Figure 7.6). Type I fractures are tip fractures considered to be small avulsion injuries. Type II fractures involve less than 50% and Type III fractures more than 50% of the coronoid. The O’Driscoll classification system is a comprehensive classification that better defines the fracture patterns and is correlated with the fracture mechanism (O’Driscoll et al., 2003; Figure 7.7). This knowledge has led to improved injury pattern recognition that guides the physician in the treatment of these complex injuries. The classification divides the fractures into three main types with subtypes. Type I fractures are transverse tip fractures and are subdivided into Subtype 1, which

Figure 7.6  Regan and Morey classification of coronoid fractures. Type I fractures involve only the tip of the coronoid, Type II fractures involve less than 50% of the coronoid, and Type III fractures involve more than 50% of the coronoid. Reprinted with permission from Doornberg and Ring (2006a).

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Figure 7.7  O’Driscoll classification of coronoid fractures: (1) coronoid tip fractures, (2) fractures of the AM facet, and (3) body or basal fractures. Reprinted from Doornberg and Ring (2006a).

involves less than 2 mm of the coronoid height, and Subtype 2, with greater than 2 mm of the coronoid height. Type I fractures are shearing injuries, most commonly secondary to terrible triad complex dislocations. Type II fractures involve the AM facet and are subdivided into three subtypes. Subtype 1 is limited to the AM rim without significant extension into the tip or sublime tubercle. Subtype 2 includes the AM rim with extension into the tip. Subtype 3 includes the AM rim with extension to involve the sublime tubercle, with or without extension into the tip. Type II fractures are associated with a VPM injury, which most often results in instability with subluxation rather than frank dislocation. Type III fractures are basilar fractures that correspond to the Type III Regan and Morrey classification, involving more than 50% of the coronoid. They have been subdivided into Subtype 1, which only involves the coronoid, and Subtype 2, which has an associated olecranon fracture. The vast majority of Type III fractures are associated with anterior and posterior transolecranon fracture-dislocations, with posterior being much more common than anterior. The O’Driscoll classification has been corroborated in multiple studies, supporting the association of fracture patterns with specific mechanisms of injury (Sanchez-Sotelo et al., 2005; Adams et al., 2009; Doornberg and Ring, 2006a; ­Mellema et al., 2014). Understanding this relationship allows the clinician to assess the injury more accurately and formulate a plan to address specific injuries known to be associated with the injury pattern.

7.6  Biomechanics The importance of the bony architecture to elbow stability has been demonstrated from the earliest studies on elbow biomechanics (Morrey and An, 1983; Morrey et al., 1991). Because these fractures rarely occur in isolation without ligamentous injury, it is necessary to examine elbow stability in the context of multiple structures being injured. Biomechanical studies based on the patterns of injury help guide the clinician in the treatment of these complex injuries.

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In the VPLR injury pattern, the coronoid is typically fractured in a transverse or tip fracture pattern. This usually occurs in combination with a radial head fracture, creating the terrible triad injury. A major question and area of controversy is when to fix the coronoid fracture. Some authors recommend always repairing the coronoid because the outcomes are unpredictable and the degree of soft-tissue injury leading to recurrent instability is difficult to assess (Mathew et al., 2009; Ebrahimzadeh et al., 2010; ­Forthman et al., 2007). Beingessner et al. (2007) studied the effect of repairing tip fractures in a model with a repaired LCL complex and radial head arthroplasty, with or without an intact MCL. They found the tip fracture had no effect on valgus stress testing, and the MCL-deficient elbows had increased valgus laxity with and without tip fracture repair. In a simulated model of Regan and Morrey Types I, II, and III coronoid fractures, Closkey et al. (2000) demonstrated that it takes greater than 50% fracture of the coronoid process to cause posterior displacement when axially loaded. The medial and lateral ligaments were intact; therefore, it does not relate well to a clinical situation. Jeon et al. (2012) similarly showed that removal of less than 42% of the coronoid did not result in instability if the radial head and collateral ligaments were intact. Excision of the radial head resulted in instability. Fractures of greater than 50% of the coronoid, Regan and Morrey Type III, resulted in instability, even with intact radial head and collateral ligaments. It should be noted that fractures of more than 50% include the sublime tubercle, thus creating an MCL-deficient elbow. Schneeberger et al. (2004) designed a very elegant terrible triad model testing for posterolateral rotatory instability with multiple injury combinations, including excision of 30%, 50%, and 70% of the coronoid. These injuries were combined with and without radial head excision and replacement and with and without collateral ligament detachment. All elbows dislocated with any variation of coronoid fracture combined with radial head excision, even with intact ligaments. Only a fracture of 30% could be stabilized with radial head replacement alone. Fractures involving more than 50% of the coronoid required radial head replacement and reconstruction of the coronoid to restore stability. From a biomechanical perspective, it is recommended that coronoid fractures of more than 30% of the height be repaired in terrible triad injuries. Coronoid fractures associated with terrible triad injuries can be of any size, but the average size is 35% (Doornberg and Ring, 2006a; Doornberg et al., 2006). Studies examining the VPM injury pattern have also noted an effect of increasing fracture size with increasing instability. Hull et al. (2005) tested the effect of incremental removal of the coronoid on varus stability. By measuring the load to cause varus displacement, they found that decreased load began after removal of 40% of coronoid height and an excision of 50% or greater resulted in statistically significant decreased loads to cause varus instability. This study also corroborated that elbows are more stable in flexion compared with extension. Pollock et al. (2009) studied the effect of varying sizes of AM facet fractures combined with LCL complex injuries. This provides a good model for clinically relevant VPM injuries and correlates with the O’Driscoll coronoid fracture classification system. The three subtypes of the O’Driscoll Type II fractures were simulated. Subtypes 1 (AM rim) and 2 (AM rim and tip) were created, involving either a 2.5-mm fragment or 5-mm fragment. A Subtype 3 fracture was also studied using a 5-mm fragment.

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These groups were all studied with and without repair of the LCL. Increasing varus instability was noted with increasing size and extent of the fracture. Larger fractures (5 mm) of Subtypes 1, 2, and 3 had significant varus instability even after repair of the LCL complex, suggesting that internal fixation of these fractures should be performed in addition to LCL repair. Subtype 3 fractures had severe varus and valgus instability because of involvement of the sublime tubercle. Unfortunately, these biomechanical studies do not address whether the LCL complex needs to be repaired if secure fixation of the AM facet can be obtained.

7.7  Management Management is again directed by the pattern of injury associated with the fracture pattern (Mellema et al., 2014). Preoperative CT scans with 3D reconstruction views are extremely helpful in surgical planning. Nonoperative management is based on elbow stability. Type I tip fractures must be small and nondisplaced, as confirmed by CT scan. The associated radial head fracture must likewise be small and nondisplaced with no block of motion. Most importantly, the elbow must be stable to ROM, extending to at least 30° before becoming unstable (Mathew et al., 2009; Chan et al., 2014). Type II AM facet fractures are associated with early arthritis secondary to elbow instability; therefore, operative treatment is typically indicated (Sanchez-Sotelo et al., 2005; Doornberg and Ring, 2006b). If the coronoid fracture is small and nondisplaced by CT scan, and the elbow shows no signs of instability, then nonoperative management may be considered. A varus stress AP radiograph should be obtained to confirm that no widening of the radiocapitellar joint exists, which indicates instability and the need for surgery (Steinmann, 2008; Budoff, 2012). Moon et al. (2013) reported on three patients with Type II fractures treated nonoperatively. They demonstrated no significant varus instability with a stress radiograph. Patients were immobilized for 4 weeks while avoiding shoulder abduction. Excellent ROM without arthritis was present at 2 years follow-up. Type III fractures are associated with unstable fracture patterns, and nonoperative treatment is reserved for patients considered high risk for surgery.

7.7.1  Type I fractures—VPLR injury These fractures are transverse tip fractures associated with terrible triad injuries from a VPLR injury. This injury pattern requires treatment of the multiple components of the injury, including the LCL complex, radial head, and coronoid fracture as described in the protocol by Pugh et al. (2004). Repair of the MCL and/or application of an external fixator are typically unnecessary. The management of this injury is discussed in more detail in Chapter 2. The surgical technique addresses the deep structures first, then progressing to the more superficial. The coronoid is typically repaired first, followed by the radial head fracture, then the LCL complex, and finally the medial side is approached if necessary. The surgical incision can be either lateral or a midline universal posterior incision. The muscular interval is through an extensor digitorum communis (EDC) split as described

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Figure 7.8  Repair of the coronoid: (a) suture-lasso technique, (b) use of anterior cruciate ligament guide to create transosseous drill holes. Reprinted from Mathew et al. (2009).

by Hotchkiss (1997) or through the traumatic rent if present. Elevating the anterior common extensor origin and brachialis allows for more exposure of the coronoid and radial head (Hotchkiss, 1997; Desloges et al., 2014). The coronoid is typically small, making internal fixation difficult. A suture-lasso technique has been utilized with good success and has been shown to be superior to lag screws and suture anchors (Pugh et al., 2004; Garrigues, 2011; Figure 7.8). If the radial head is irreparable, then it is useful to excise the head at this time, allowing for improved exposure of the coronoid. Drill holes for passing a #2 nonabsorbable suture are drilled from posterior to anterior in the proximal ulna. An anterior cruciate ligament drill guide can be useful in placing the holes through the base of the coronoid fracture. If the coronoid fragment is large enough, then holes can be made in the fragment and the sutures passed through it and the anterior capsule. Alternatively, the sutures can just be passed around the fragment, capturing the capsule. The sutures are passed through the drill holes exiting posteriorly and tied at the end of the procedure, after addressing the radial head and LCL complex. The radial head is addressed next, either with ORIF or replacement. Results have not proven one technique better than the other (Watters et al., 2014; Leigh and Ball, 2012). Indications used for radial head replacement include more than three fragments, impacted or comminuted neck fracture, and older patients (Pugh et al., 2004). If radial head replacement is chosen, then care must be taken to correctly size the radial head implant so that the head sits at the level of the coronoid and does not extend proximally. The LCL complex is repaired next using a #2 or #5 nonabsorbable braided suture as a grasping suture. The extensor origin is often avulsed from the lateral epicondyle and can be repaired with the same suture. The author’s preference is to repair the complex to the lateral epicondyle through transosseous drill holes, although the successful

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Figure 7.9  Terrible triad injury with irreparable radial head fracture. (a) Prereduction injury film. (b) Postoperative radiograph with radial head replacement and suture-lasso repair of coronoid with suture tied over a mini-plate over posterior ulna.

use of suture anchors has been described. Once the lateral structures are repaired, the coronoid suture is tied over the posterior ulna with the elbow flexed (Figure 7.9). The elbow is then tested by ranging from flexion to extension while observing under a lateral fluoroscopic view. If the elbow cannot be extended to at least 30° before subluxation is noted, then further treatment is required. The choices at this point, if the coronoid has been adequately addressed, include exploration and repair of the MCL, application of a static or hinged external fixator, or cross-pinning of the joint (Pugh et al., 2004; Mathew et al., 2009; Ring et al., 2014). The usefulness of exploring the MCL is not confirmed. Forthman et al. (2007) reported on a series of 34 patients treated successfully without repair of the MCL. Successful outcomes have also been reported in a series of terrible triad patients with Regan and Morrey Type I and II fractures in which the coronoid was not repaired (Papatheodorou et al., 2014). However, most authors recommend repair of the coronoid fracture unless it is a very small tip fracture (Mathew et al., 2009; Ebrahimzadeh et al., 2010; Forthman et al., 2007).

7.7.2  Type II fractures—VPM rotatory injury The surgical approach for AM facet fractures is typically through a posterior midline incision, allowing access medially to repair the fracture and laterally to repair the LCL complex. The incision can be made with the arm across the patient’s chest and the arm can then be brought down to lie on a hand table after the skin flap is elevated. The medial side is approached first. The ulnar nerve is identified and released but need not be transposed unless a more extensile exposure is chosen. Three intervals in the flexor-pronator origin have been described for exposure of the coronoid fracture: the Hotchkiss over-the-top, the flexor carpi ulnaris (FCU)-splitting, and the Taylor and Scham posterior approach (Ring and Doornberg, 2007; Hotchkiss, 2000; Taylor and Scham, 1969). Each approach is positioned successively more posterior on the flexor-pronator origin. The Hotchkiss over-the-top splits the flexor-pronator origin approximately 1 cm anterior to the FCU-split and elevates the flexor carpi radialis

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Figure 7.10  Medial elbow exposures. (a) Flexor-pronator origin with line showing the FCU splitting approach. (b) Hotchkiss over-the-top approach between FCU and PL. FCU, flexor carpi ulnaris; PL, palmaris longus; FCR, flexor carpi radialis (Hotchkiss, 2000).

(FCR) and pronator teres origins off of the medial epicondyle and medial supracondylar ridge of the distal humerus. The exposure can be carried further anterior and lateral by elevating the brachialis off of the anterior joint capsule (Figure 7.10). The FCU-split uses the anatomic split in the FCU where the ulnar nerve travels. Again, as in the Hotchkiss over-the-top, the flexor-pronator origin anterior to this is elevated. These are the two most common approaches. The over-the-top provides better access to the tip of the coronoid, allowing adequate access to capture the tip fragments in fractures that extend anteriorly. The FCU-split allows for better access

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to the sublime tubercle and base of the coronoid compared with the Hotchkiss overthe-top (Huh et al., 2013). Review of preoperative CT scans is helpful in planning the best approach. The Taylor and Scham approach elevates the entire flexor-pronator origin and would be most useful for O’Driscoll Type III basilar fractures. Care must be taken to protect the ulnar nerve in any approach, but the nerve will require more dissection and mobilization in the FCU-split and Taylor and Scham approaches. Elevating the muscles must be performed carefully so as not to injure the MCL attachment to the sublime tubercle. It is helpful to begin the deeper dissection more distally in the muscle, elevating it distally from the ulna and working proximally to the sublime tubercle. As the dissection nears the sublime tubercle, it becomes more difficult to distinguish the tendinous origin from the fibers of the ligament (Steinmann, 2008; Figure 7.11). Fixation is performed with implants in the 2.0- to 2.4-mm size range. These fractures are typically comminuted, making internal fixation with only lag screws tenuous. Lag screws combined with buttress plating using a T-shaped plate work well. Small anterior tip fragments may require additional suture-lasso fixation (Figure 7.12). After fixation of the fracture, the LCL complex requires repair. It may be argued that repair of the LCL complex is not necessary if the bony injury is stabilized. No biomechanical studies have yet addressed this. In addition, AM facet fractures are typically comminuted and fixation is performed with small implants, leading to concern regarding stability. Repair of the LCL complex is straightforward, and the current recommendation is to repair it. The lateral skin flap is raised, and an EDC-splitting approach anterior to the lateral ulnar collateral ligament (LUCL) is developed. The LCL complex is repaired using a transosseous suture through the lateral epicondyle, as described above for terrible triad injuries.

7.7.3  Type III fractures—axial loading injuries Because these fractures usually have a transolecranon component, they are approached surgically through a posterior incision. The coronoid is accessed through the olecranon fracture. The olecranon may be mobilized by elevating the extensor carpi ulnaris muscle laterally and FCU medially, taking care to protect the ulnar nerve. If comminution extends anteriorly, then more extensive exposure can be attained by mobilizing the ulnar nerve and elevating the flexor-pronator origin, as described in Section 7.7.2. The MCL attachment to the sublime tubercle is typically intact, and care should be taken to preserve it. The LUCL attachment is also typically intact; however, there are reports of it being injured, either by avulsion from the lateral epicondyle or from fracture of the crista supinatoris (Ebrahimzadeh et al., 2010; Ring and Jupiter, 1998; Athwal et al., 2014). The goal of surgery is to restore the shape of the trochlear notch and stabilize it with secure fixation (Doornberg et al., 2004). After exposure, the first goal is to reduce and provisionally fix the coronoid component, either to the shaft fragment or, if less comminuted, to the olecranon fragment. When there is a great deal of comminution, pinning the olecranon to the trochlea stabilizes that fragment so that the coronoid and shaft can then be reduced to the fragment. Provisional fixation may be obtained with K-wires and

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Figure 7.11  VPM fracture dislocation. (a) AP radiograph demonstrating dislocation. (b) Postreduction radiograph showing loss of ulnohumeral joint space and displaced AM facet fracture. (c and d) 3D CT views showing coronoid fracture involving tip and AM facet. (e) AP and (f) lateral radiographs after open reduction and internal fixation with mini-fragment plate and screws.

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Figure 7.12  Coronoid fracture. (a) Intraoperative fluoroscopic view with varus stress demonstrating a widened radiocapitellar joint space and displaced AM facet. (b) 3D CT demonstrating large transverse fracture fragment and separate AM facet fragment. (c) Medial exposure through Hotchkiss approach. UN, ulnar nerve; PL, palmaris longus; MCL, medial collateral ligament; FCU, flexor carpi ulnaris. (d) Intraoperative view after open reduction and internal fixation. AM, anteromedial facet; C, coronoid base; ME, medial epicondyle. (e) Postoperative lateral radiograph.

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definitive fixation with plate and screws. Provisional fixation with 2.0- and 2.4-mm fragment plates placed medially or laterally can be extremely helpful in comminuted fractures. Many vendors now have anatomic proximal ulna plates that use a combination of 2.7- and 3.5-mm screws. The smaller 2.7-mm screws are very useful in the comminuted fragments. A stable fixation construct is a “home-run screw” from the tip of the olecranon to the anterior cortex of the coronoid. Screws can then be directed anteriorly and posteriorly through the plate into the tip of the coronoid, with additional screws directed into the proximal tip of the olecranon (Figure 7.13). Additional fixation using small screws or sutures may be required to repair separate AM fragments. Upon completion of fracture fixation, stability of the elbow should be assessed utilizing lateral fluoroscopic imaging to observe the arc of motion. If instability is noted while in extension, then the etiology must be identified. Possible causes include an unstable coronoid tip fragment or an LCL complex injury, with or without a radial head fracture. Once these injuries have either been ruled out or repaired, and instability remains, the next option is to either place an external

Figure 7.13  Posterior transolecranon fracture-dislocation. (a) Lateral radiograph demonstrating Type III coronoid and transolecranon fractures and posterior dislocation of the radial head. (b) After open reduction and internal fixation with posterior anatomic plating of the ulna and screw fixation of the radial head fracture.

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fixator (static or hinged) or cross-pin the elbow joint. It is common for a posterior transolecranon injury to occur in the elderly population, making internal fixation tenuous because of poor bone quality. Protecting the internal fixation is another reason to temporarily span the elbow with an external fixator (Ring and Jupiter, 1998; Ring et al., 1997, 1998). The external fixator or cross-pins are only needed for 3–4 weeks, at which point the pins are removed under general anesthesia and the elbow is ranged under fluoroscopy (Ring et al., 2014).

7.7.4   Postoperative management The elbow is splinted in the position of stability, typically flexion, for no more than 7 days. For most injuries that have stable repairs, ROM is started within the first few days. If there is concern regarding stability, then it is preferable to immobilize the elbow longer to maintain reduction and address stiffness later by doing a capsular release (Budoff, 2012). For Type II injuries, it is important to avoid varus stress, which stresses the LCL complex repair and the AM facet fracture. The patient must avoid shoulder abduction for the first 4 weeks. For terrible triad injuries, the patient must avoid supination and extension forces. They are instructed regarding ROM exercises with the forearm in pronation while using a hinged brace that blocks the terminal 30°–45° of extension. Active motion exercises that avoid varus stress have been shown to improve the subluxation or gapping sometimes noted on postoperative lateral radiographs (Duckworth et al., 2008; Ebrahimzadeh et al., 2010). These are especially beneficial when performed with the patient supine and performed overhead against gravity (Mathew et al., 2009). Static progressive splinting is a useful adjunct, which can be started after week 4.

7.8  Outcomes Before the recognition and understanding of the terrible triad injury pattern, poor outcomes were frequently reported (Ring et al., 2002a,b). The development of protocols that emphasized repair of the coronoid, repair or replacement of the radial head, and repair of the LCL complex resulted in improved stability and outcomes in a challenging injury (Pugh et al., 2004; Mathew et al., 2009). More recent studies report successful outcomes in at least 80% using the Mayo Elbow Performance Score and the system of Broberg and Morrey compared with a 35% success rate previously reported (Pugh et al., 2004; Forthman et al., 2007; Ring et al., 2002a). With the recent recognition of the Type II VPM injury pattern and its uncommon occurrence, few studies are available. Doornberg and Ring (2006b) reported on 18 patients with AM facet fractures. Nine were felt to have had adequate surgical treatment of the injury and nine inadequate. Seven of the nine receiving adequate treatment were rated excellent or good using the system of Broberg and Morrey. Of the nine inadequately treated patients, seven had persistent instability, with three reporting excellent outcomes, five fair, and one poor. Good outcomes should be expected with proper recognition and treatment of this injury.

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Multiple studies have demonstrated consistently good outcomes with Type III fractures provided that the trochlear notch can be securely restored with particular attention to stable fixation of the coronoid (Ring et al., 1997; Ring and Jupiter, 1998; Jupiter et al., 1991; Doornberg et al., 2004). A report of long-term outcomes with average follow-up of 18 years included 20 patients—10 anterior and 10 posterior transolecranon fracture-dislocations. The average flexion-extension arc of motion was 124°. ­Outcomes according to the Mayo Elbow Performance Score were 13 excellent, 4 good, 2 fair, and 1 poor; however, 70% of patients had radiographic evidence of arthrosis (Lindenhovius et al., 2008).

7.9  Complications Potential complications include recurrent instability, stiffness, heterotopic ossification, malunion, nonunion, infection, ulnar neuropathy, and arthrosis. Recurrent instability occurs more commonly after a terrible triad injury. Treatment is directed to the original goals of surgery: repairing the coronoid, repairing or replacing the radial head, and repairing or reconstructing the LUCL. A hinged external fixator can be very helpful in cases of persistent instability. Heterotopic ossification is common after elbow trauma and, unfortunately, prophylactic treatment with radiation is associated with a high incidence of nonunion (Hamid, 2010). Heterotopic ossification, when associated with elbow stiffness, requires excision, which is usually performed at 4 months or later after injury. This allows the ossification to mature (Ring et al., 2006). Stiffness is best managed proactively by starting early ROM exercises. This requires a stable elbow joint. If there is potential instability, then an overhead active exercise program can often still be performed (Mathew et al., 2009). However, it is better to have a stiff and stable elbow joint than an unstable and painful one. Contracture release and capsulectomy may be performed later to improve motion. Dynamic and static progressive splinting may be started after 4 weeks and is helpful early after contracture release. Ulnar neuropathy is problematic and common, being present in 25% in one series (Lindenhovius et al., 2008). Caution must be taken to protect the nerve during medial exposures. Ulnar neuropathy is also associated with elbow stiffness, and the nerve should be released or transposed after elbow contracture release (Ring, 2006).

7.10  Future directions The contribution of the coronoid to elbow stability has been emphasized in this chapter. There are situations in which the coronoid is difficult to repair, either as the result of extreme comminution or delayed presentation. Reconstruction of the coronoid has been described using various grafts, including the tip of the olecranon, the radial head, costochondral and iliac crest autografts, and allografts (Moritomo et al., 1998; Van Riet et al., 2005; Chung et al., 2007; Silveira et al., 2005; Ring et al., 2012). The results have been mixed in this complex population, with problems related to matching the contour with a

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cartilaginous surface and poor incorporation of allografts. A 3D CT study comparing the best matching shape between radial head and olecranon grafts with the native coronoid demonstrated a better match between the olecranon and coronoid tip (Kataoka et al., 2014). The radial head was a better match for the AM facet. Coronoid prostheses have demonstrated comparable function to the native coronoid in laboratory studies using an unstable elbow model with a 40% coronoid deficiency (Gray et al., 2013; Alolabi et al., 2012). Although these results are promising, future studies are needed to evaluate performance in a clinical setting.

References Adams, J.E., et al., 2012. Fractures of the coronoid: morphology based upon computer tomography scanning. Journal of Shoulder and Elbow Surgery 21 (6), 782–788. Available at: http://dx.doi.org/10.1016/j.jse.2012.01.008. Adams, J.E., et al., 2009. Management and outcome of 103 acute fractures of the coronoid process of the ulna. The Journal of Bone and Joint Surgery. British Volume 91, 632–635. Alolabi, B., et al., 2012. Reconstruction of the coronoid using an extended prosthesis: an in vitro biomechanical study. Journal of Shoulder and Elbow Surgery 21 (7), 969–976. Available at: http://dx.doi.org/10.1016/j.jse.2011.04.014. Athwal, G.S., et al., 2014. Crista supinatoris fractures of the proximal part of the ulna. The Journal of Bone and Joint Surgery. American Volume 96 (4), 326–331. Available at: http://www.ncbi.nlm.nih.gov/pubmed/24553889. Beingessner, D.M., et al., 2007. The effect of suture fixation of type I coronoid fractures on the kinematics and stability of the elbow with and without medial collateral ligament repair. Journal of Shoulder and Elbow Surgery 16, 213–217. Budoff, J.E., 2012. Coronoid fractures. Journal of Hand Surgery 37 (11), 2418–2423. Available at: http://dx.doi.org/10.1016/j.jhsa.2012.09.002. Cage, D.J., et al., 1995. Soft tissue attachments of the ulnar coronoid process. An anatomic study with radiographic correlation. Clinical Orthopaedics and Related Research 320, 154–158. Available at: http://www.ncbi.nlm.nih.gov/pubmed/7586820 (accessed 08.04.15.). Chan, K., et al., 2014. Can we treat select terrible triad injuries nonoperatively? Clinical Orthopaedics and Related Research 472 (7), 2092–2099. Chung, C.-H., et al., 2007. Reconstruction of the coronoid process with iliac crest bone graft in complex fracture-dislocation of elbow. Archives of Orthopaedic and Trauma Surgery 127 (1), 33–37. Available at: http://www.ncbi.nlm.nih.gov/pubmed/16896743 (accessed 27.04.15.). Closkey, R.F., et al., 2000. The role of the coronoid process in elbow stability. A biomechanical analysis of axial loading. The Journal of Bone and Joint Surgery. American Volume 82-A (12), 1749–1753. Cohen, M.S., 2004. Fractures of the coronoid process. Hand Clinics 20 (4), 443–453. Available at: http://www.ncbi.nlm.nih.gov/pubmed/15539099 (accessed 26.04.15.). Desloges, W., et al., 2014. Objective analysis of lateral elbow exposure with the extensor digitorum communis split compared with the kocher interval. The Journal of Bone and Joint Surgery. American Volume 96 (5), 387–393. Available at: http://www.ncbi. nlm.nih.gov/pubmed/24599200. Doornberg, J., Ring, D., Jupiter, J.B., 2004. Effective treatment of fracture-dislocations of the olecranon requires a stable trochlear notch. Clinical Orthopaedics and Related Research 429, 292–300.

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Doornberg, J.N., et al., 2007. The anteromedial facet of the coronoid process of the ulna. ­Journal of Shoulder and Elbow Surgery 16 (3), 667–670. Doornberg, J.N., Duijn, J.Van, Ring, D., 2006. Coronoid fracture height in terrible-triad injuries. Journal of Hand Surgery American Volume 31 (5), 794–797. Doornberg, J.N., Ring, D., 2006a. Coronoid fracture patterns. Journal of Hand Surgery 31, 45–52. Doornberg, J.N., Ring, D.C., 2006b. Fracture of the anteromedial facet of the coronoid process. The Journal of Bone and Joint Surgery. American Volume 88 (10), 2216–2224. Available at: http://www.ncbi.nlm.nih.gov/pubmed/17015599 (accessed 26.04.15.). Duckworth, A.D., et al., 2008. Residual subluxation of the elbow after dislocation or fracture-dislocation: treatment with active elbow exercises and avoidance of varus stress. ­Journal of Shoulder and Elbow Surgery 17 (2), 276–280. Dyer, G., Ring, D., 2010. My approach to the terrible triad injury. Operative Techniques in Orthopaedics 20 (1), 11–16. Available at: http://dx.doi.org/10.1053/j.oto.2009.09.015. Ebrahimzadeh, M.H., Amadzadeh-Chabock, H., Ring, D., 2010. Traumatic elbow instability. Journal of Hand Surgery 35 (7), 1220–1225. Available at: http://dx.doi.org/ 10.1016/j.jhsa.2010.05.002. Forthman, C., Henket, M., Ring, D.C., 2007. Elbow dislocation with intra-articular fracture: the results of operative treatment without repair of the medial collateral ligament. Journal of Hand Surgery 32 (8), 1200–1209. Garrigues, G.E., 2011. Fixation of the coronoid process in elbow fracture-dislocations. The Journal of Bone and Joint Surgery 93, 1873. Gray, A.B., et al., 2013. The effect of a coronoid prosthesis on restoring stability to the coronoid-deficient elbow: a biomechanical study. Journal of Hand Surgery 38 (9), 1753–1761. Available at: http://dx.doi.org/10.1016/j.jhsa.2013.05.004. Hamid, N., 2010. Radiation therapy for heterotopic ossification prophylaxis acutely after elbow trauma: a prospective randomized study. Journal fur Mineralstoffwechsel 17 (4), 163. Hotchkiss, R., 1997. Displaced fractures of the radial head: internal fixation or excision? The Journal of the American Academy of Orthopaedic Surgeons 5 (1), 1–10. Available at: http://www.ncbi.nlm.nih.gov/pubmed/10797202. Hotchkiss, R.N., Kasparyan, N.G., 2000. The medial “Over the top” approach to the elbow. Techniques in Orthopaedics 15, 105–112. Huh, J., et al., 2013. Medial elbow exposure for coronoid fractures: FCU-split versus overthe-top. Journal of Orthopaedic Trauma 27 (12), 730–734. Available at: http://www.ncbi. nlm.nih.gov/pubmed/23412510. Hull, J.R., et al., 2005. Role of the coronoid process in varus osteoarticular stability of the elbow. Journal of Shoulder and Elbow Surgery/American Shoulder and Elbow Surgeons…[et al.] 14 (4), 441–446. Available at: http://www.ncbi.nlm.nih.gov/pubmed/16015247 (accessed 26.03.15.). Jeon, I.H., et al., 2012. The contribution of the coronoid and radial head to the stability of the elbow. Journal of Bone and Joint Surgery. British Volume 94-B (1), 86–92. Jupiter, J.B., et al., 1991. The posterior Monteggia lesion. Journal of Orthopaedic Trauma 5 (4), 395–402. Available at: http://www.ncbi.nlm.nih.gov/pubmed/1761999 (accessed 26.04.15.). Kataoka, T., et al., 2014. Three-dimensional suitability assessment of three types of osteochondral autograft for ulnar coronoid process reconstruction. Journal of Shoulder and Elbow Surgery 23 (2), 143–150. Available at: http://dx.doi.org/10.1016/j.jse.2013.10.004. Leigh, W.B., Ball, C.M., 2012. Radial head reconstruction versus replacement in the treatment of terrible triad injuries of the elbow. Journal of Shoulder and Elbow Surgery 21 (10), 1336–1341. Available at: http://dx.doi.org/10.1016/j.jse.2012.03.005.

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Lindenhovius, A.L.C., et al., 2008. Long-term outcome of operatively treated fracture-dislocations of the olecranon. Journal of Orthopaedic Trauma 22 (5), 325–331. Mathew, P.K., Athwal, G.S., King, G.J.W., 2009. Terrible triad injury of the elbow: current concepts. The Journal of the American Academy of Orthopaedic Surgeons 17 (3), 137–151. Mellema, J.J., et al., 2014. Distribution of coronoid fracture lines by specific patterns of traumatic elbow instability. Journal of Hand Surgery 39 (10), 2041–2046. Available at: http://dx.doi.org/10.1016/j.jhsa.2014.06.123. Moon, J.G., et al., 2013. Non surgically managed anteromedial coronoid fractures in posteromedial rotatory instability: three cases with 2 years follow-up. Archives of Orthopaedic and Trauma Surgery 133, 1665–1668. Moritomo, H., et al., 1998. Reconstruction of the coronoid for chronic dislocation of the elbow. Use of a graft from the olecranon in two cases. The Journal of Bone and Joint Surgery. British Volume 80 (3), 490–492. Available at: http://www.ncbi.nlm.nih.gov/pubmed/9619943 (accessed 27.04.15.). Morrey, B.F., An, K.N., 1983. Articular and ligamentous contributions to the stability of the elbow joint. The American Journal of Sports Medicine 11 (5), 315–319. Available at: http://www.ncbi.nlm.nih.gov/pubmed/6638246 (accessed 08.04.15.). Morrey, B.F., Tanaka, S., An, K.N., 1991. Valgus stability of the elbow. A definition of primary and secondary constraints. Clinical Orthopaedics and Related Research 265, 187–195. Available at: http://www.ncbi.nlm.nih.gov/pubmed/2009657 (accessed 17.03.15.). O’Driscoll, S.W., et al., 2003. Difficult elbow fractures: pearls and pitfalls. Instructional Course Lectures 52, 113–134. Available at: http://www.ncbi.nlm.nih.gov/pubmed/12690844 (accessed 08.04.15.). Papatheodorou, L.K., et al., 2014. Terrible triad injuries of the elbow: does the coronoid always need to be fixed? Clinical Orthopaedics and Related Research 472 (7), 2084–2091. Pollock, J.W., et al., 2009. The effect of anteromedial facet fractures of the coronoid and lateral collateral ligament injury on elbow stability and kinematics. The Journal of Bone and Joint Surgery. American Volume 91, 1448–1458. Pugh, D.M.W., et al., 2004. Standard surgical protocol to treat elbow dislocations with radial head and coronoid fractures. The Journal of Bone and Joint Surgery. American Volume 86-A (6), 1122–1130. Available at: http://jbjs.org/content/86/6/1122.abstract (accessed 08.04.15.). Regan, W., Morrey, B., 1989. Fractures of the coronoid process of the ulna. The Journal of Bone and Joint Surgery. American Volume 71 (9), 1348–1354. Available at: http://www.ncbi.nlm.nih.gov/pubmed/2793888 (accessed 26.04.15.). Ring, D., et al., 2006. Elbow capsulectomy for posttraumatic elbow stiffness. The Journal of Hand Surgery 31 (8), 1264–1271. Available at: http://www.ncbi.nlm.nih.gov/pubmed/17027785 (accessed 27.04.15.). Ring, D., 2006. Fractures of the coronoid process of the ulna. Journal of Hand Surgery 31, 1679–1689. Ring, D., et al., 1997. Transolecranon fracture-dislocation of the elbow. Journal of Orthopaedic Trauma 11 (8), 545–550. Ring, D., Bruinsma, W.E., Jupiter, J.B., 2014. Complications of hinged external fixation compared with cross-pinning of the elbow for acute and subacute instability. Clinical Orthopaedics and Related Research 472 (7), 2044–2048. Ring, D., Doornberg, J.N., 2007. Fracture of the anteromedial facet of the coronoid process. Surgical technique. The Journal of Bone and Joint Surgery. American Volume 89 (Suppl. 2 (Part 2)), 267–283.

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Ring, D., Guss, D., Jupiter, J.B., 2012. Reconstruction of the coronoid process using a fragment of discarded radial head. Journal of Hand Surgery 37 (3), 570–574. Available at: http://dx.doi.org/10.1016/j.jhsa.2011.12.016. Ring, D., Jupiter, J.B., 1998. Fracture-dislocation of the elbow. The Journal of Bone and Joint Surgery. American Volume 80 (4), 566–580. Available at: http://www.ncbi.nlm.nih. gov/pubmed/9563387 (accessed 10.04.15.). Ring, D., Jupiter, J.B., Simpson, N.S., 1998. Monteggia fractures in adults. The Journal of Bone and Joint Surgery. American Volume 80 (12), 1733–1744. Available at: http://www.ncbi.nlm.nih.gov/pubmed/9875931 (accessed 27.04.15.). Ring, D., Jupiter, J.B., Zilberfarb, J., 2002a. Posterior dislocation of the elbow with fractures of the radial head and coronoid. The Journal of Bone and Joint Surgery. American Volume 84-A (4), 547–551. Ring, D., Quintero, J., Jupiter, J.B., 2002b. Open reduction and internal fixation of fractures of the radial head. The Journal of Bone and Joint Surgery. American Volume 84-A (10), 1811–1815. Available at: http://jbjs.org/content/84/10/1811.abstract (accessed 26.04.15.). Sanchez-Sotelo, J., O’Driscoll, S.W., Morrey, B.F., 2005. Medial oblique compression fracture of the coronoid process of the ulna. Journal of Shoulder and Elbow Surgery 14, 60–64. Schneeberger, A.G., Sadowski, M.M., Jacob, H.a C., 2004. Coronoid process and radial head as posterolateral rotatory stabilizers of the elbow. The Journal of Bone and Joint Surgery. American Volume 86-A, 975–982. Silveira, G.H., Bain, G.I., Eng, K., 2005. Reconstruction of coronoid process using costochondral graft in a case of chronic posteromedial rotatory instability of the elbow. Journal of Shoulder and Elbow Surgery/American Shoulder and Elbow Surgeons…[et al.] 22 (5), e14–18. Available at: http://www.ncbi.nlm.nih.gov/pubmed/23523307 (accessed 27.04.15.). Steinmann, S.P., 2008. Coronoid process fracture. The Journal of the American Academy of Orthopaedic Surgeons 16 (9), 519–529. Tashjian, R.Z., Katarincic, J.A., 2006. Complex elbow instability. Journal of the American Academy of Orthopedic Surgeons 14, 278–286. Taylor, T.K., Scham, S.M., 1969. A posteromedial approach to the proximal end of the ulna for the internal fixation of olecranon fractures. The Journal of Trauma 9 (7), 594–602. Available at: http://www.ncbi.nlm.nih.gov/pubmed/5793927 (accessed 26.04.15.). Van Riet, R.P., Morrey, B.F., O’Driscoll, S.W., 2005. Use of osteochondral bone graft in coronoid fractures. Journal of Shoulder and Elbow Surgery/American Shoulder and Elbow Surgeons…[et al.] 14 (5), 519–523. Available at: http://www.ncbi. nlm.nih.gov/pubmed/16194745 (accessed 27.04.15.). Watters, T.S., et al., 2014. Fixation versus replacement of radial head in terrible triad: is there a difference in elbow stability and prognosis? Clinical Orthopaedics and Related Research 472 (7), 2128–2135.

Olecranon fractures G.N. Lervick Minnesota Orthopedic Sports Medicine Institute (MOSMI), Twin Cities Orthopedics, Edina, MN, USA

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8.1  Introduction Similar to most skeletal injuries, olecranon fractures involve a range of severity from simple, nondisplaced fractures to more complex injury patterns involving fracture-­ dislocations of the elbow. By definition, they are intra-articular injuries that require anatomic restoration of the articular surface. When surgical treatment is warranted, several methods of internal fixation may be utilized and include tension-band wiring, intramedullary screw fixation, plate fixation (locking and/or nonlocking constructs), intramedullary nailing, and (rarely) fragment excision with triceps advancement. The goal of surgical fixation is to permit early motion to combat stiffness of the elbow joint. In general, good results are achievable in most surgically treated cases.

8.2  Anatomy The anatomy of the elbow is inherently complex. The bony architecture of the elbow provides for a relatively high degree of constraint and stability. As a result, recurrent instability of the elbow in the absence of associated bony injury is relatively rare. However, understanding any bony injury pattern also requires a working knowledge of the associated ligamentous and periarticular soft-tissue anatomy. The olecranon articulates with the trochlea of the humerus and thereby prevents anterior translation of the ulna with respect to the distal humerus. The articular portions of the olecranon and coronoid process are covered by hyaline cartilage. There is often a bare area devoid of cartilage, midway between the olecranon and the coronoid process, termed the semilunar notch. The coronoid process stabilizes the humerus against distal translation on the proximal ulna. Fractures involving the coronoid may result in instability of the elbow and indicate a relatively higher severity injury pattern. The primary tendinous anatomy of the olecranon is the triceps mechanism. The triceps tendon inserts into the posterior third of the olecranon and proximal ulna, blending through a broad expansion with the aponeurosis of the anconeus muscle and the common extensor origin. The periosteum of the olecranon is intimately associated with the triceps tendon. The brachialis muscle and tendon insert broadly on the midportion of the anterior coronoid and the proximal ulnar metaphysis. The ligamentous anatomy of the elbow is another important consideration. In addition to the radial head, the anterior band of the ulnar collateral ligament (UCL) is a Shoulder and Elbow Trauma and its Complications. http://dx.doi.org/10.1016/B978-1-78242-450-5.00008-3 Copyright © 2016 Elsevier Ltd. All rights reserved.

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primarily valgus stabilizer. Varus stability is provided primarily by the lateral collateral ligament complex, which includes the lateral ulnar collateral ligament (LUCL). Injury to the LUCL may also result in posterolateral rotatory instability (PLRI) and represents a complex instability pattern. Knowledge of the ligamentous anatomy becomes important when treating these more complex bone and soft-tissue injury patterns that may involve fracture of the olecranon. The ulnar nerve is situated on the posterior and medial aspect of the elbow. Along its distal course, it moves anteriorly to join the ulnar artery. The intimate association of this neurovascular bundle with the proximal ulna should be considered during surgical treatment because it is at risk with anterior cortical penetration by Kirschner wires (K-wires) used during tension-band wiring or with overpenetration during drilling with plate and/or intramedullary fixation.

8.3  Fracture anatomy/classification Application of the pertinent fracture anatomy of the olecranon has led to the development of several classification schemes. Although numerous systems have been described, there is not universal consensus regarding the optimal method. The main advantage of using a classification system is to consistently describe the pattern of injury. All of the described methods attempt to guide treatment and help in categorizing prognosis. Some systems have also incorporated associated injuries to the radial head and supracondylar humerus, once again reflecting a more significant injury pattern (which likely affects prognosis). A frequently cited method is the Mayo classification of olecranon fractures (Figure 8.1). This is a scheme that is based on the degree of fracture displacement, comminution, and resultant elbow joint stability. Type I fractures are nondisplaced and have little or no comminution. Type II fractures are displaced, but the elbow joint remains stable. In this injury type, an adequate amount of the anterior joint surface exists, and the associated anterior portion of the UCL remains intact; as a result, the joint remains stable despite the bony injury. Type III fractures are typically comminuted and may have an associated radial head fracture. Such injuries lead to frank elbow instability and often involve a relatively larger portion of the olecranon. Type II and Type III fractures are subclassified as noncomminuted (Subtype A) and comminuted (Subtype B). Schatzker also described a classification system focused on the mechanical considerations of an olecranon fracture, particularly as it relates to the type of surgical fixation required. Six types are described: Type A is a simple transverse fracture; Type B is a complex transverse fracture with impaction of the central portion of the articular surface; Type C is a simple oblique fracture; Type D is a comminuted fracture; Type E is an oblique fracture distal to the midpoint of the trochlear notch; and Type F is a fracture of the olecranon with associated radial head fracture, which is often associated with a rupture of the UCL. Finally, olecranon fractures are also included in the comprehensive Arbeitsgemeinschaft für osteosynthesfragen (AO) classification system of fractures (Figure 8.2). The AO system divides fractures of the proximal radius and ulna into three major

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TYPE I Undisplaced

TYPE Il Displaced – Stable

A – Noncomminuted

B – Comminuted

A – Noncomminuted

B – Comminuted

TYPE Ill Unstable

Figure 8.1  The Mayo classification of olecranon fractures. With permission from Elsevier publication, Baecher N, Edwards S. Olecranon fractures: current concepts. J Hand Surg 2013;38A:593–604.

categories. Type A fractures are extra-articular and involve the metaphysis of either the radius or the ulna. Type B fractures are intra-articular injuries to either the radius or the ulna, with Type B1 being an intra-articular fracture of the olecranon alone. Type C fractures are intra-articular injuries of both the radial head and the olecranon. The Orthopaedic Trauma Association (OTA) classification system for olecranon fractures is based upon the AO system, both are probably best suited for description in research. None of the existing classification systems has gained complete or universal acceptance, and all have inherent pros and cons. However, it is important to develop a familiarity with the existing classification systems so as to best understand the given pattern of injury and to help guide treatment and discuss prognosis with the patient. When describing the injury and making treatment recommendations, the Mayo system is highly practical and straightforward, and it seems to have the most popularity.

8.4  Epidemiology In adults, approximately 10% of all upper extremity fractures involve the olecranon. Simple displaced transverse fractures are the most common. In a review of 100 consecutive fractures at the Mayo Clinic, 12 were nondisplaced (Type I), 82 were displaced

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A1

A2

A3

B1

B2

B3

C1

C2

C3

Figure 8.2  The AO classification of olecranon fractures. With permission from Elsevier publication, Baecher N, Edwards S. Olecranon fractures: current concepts. J Hand Surg 2013;38A:593–604.

with a stable elbow joint (Type II), and 6 were displaced with an unstable elbow joint (Type III). Other series have demonstrated similar findings. A report of an orthopedic trauma database (6872 patients) included 78 patients with olecranon fractures with a mean age of 50 years. Men tended to suffer the injuries at younger ages than women, but overall there was no sex predominance. Sixty-seven percent of subjects sustained the injuries from ground-level falls, 17% had associated proximal radial fractures, and 6% were open injuries.

8.5  Initial evaluation Olecranon fractures are typically isolated injuries. Coexisting injuries typically will involve other areas of the same upper extremity. As a result, a thorough evaluation of the entire affected extremity, from the shoulder girdle to the wrist, is indicated. When an olecranon fracture has occurred, the elbow will typically demonstrate soft-tissue swelling and an effusion. Because of the immediate subcutaneous position

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of the olecranon, the fracture may be readily suggested even on physical examination because a defect or gap in the area of the fracture may be palpable. In addition, the subcutaneous position also makes careful inspection of the skin important. In particular, recognition of even small puncture sites through the skin with leakage of bloody fluid (fracture hematoma) should be carefully investigated because they may suggest an open fracture. Appropriate assessment of the distal neurovascular function of the limb should be documented, including median, radial, and ulnar nerve function as well as radial pulses. Standard anteroposterior (AP) and lateral radiographs of the elbow are sufficient for evaluation of most isolated olecranon fractures. In the setting of an acute injury, assistance with limb positioning may be necessary to ensure that true orthogonal radiographs are obtained. In injuries with suspected areas of comminution that could affect surgical fixation or technique, such as articular impaction or associated radial head or coronoid injury, the use of computed tomography (CT) may be helpful. The advent of three-dimensional (3D) reconstruction techniques has become particularly valuable in surgical planning in these more challenging cases.

8.6  Treatment The goals of olecranon fracture treatment are to anatomically realign the articular surface, preserve motor strength, restore stability of the joint (when necessary), and promote the ability to allow early range of motion (ROM) exercise. In most instances, this is achieved with operative techniques involving internal fixation. However, in certain selected situations, nonsurgical management may be considered.

8.6.1   Nonoperative treatment Nondisplaced fractures in which the elbow extensor mechanism is intact may be nonoperatively treated. Controversy exists about the amount of acceptable articular displacement. Although immobilization in full extension may improve fracture reduction, it may result in diminished flexion. Immobilization of the elbow in 45–90° of flexion for approximately 3 weeks has been recommended for nondisplaced fractures. This may either be done with simple splinting or with brief application of either a cast or fracture brace. Our preference is to use a hinged elbow brace (Ossur, Inc., Reykjavik, Iceland; Figure 8.3) that can be either locked or unlocked to allow desired ranges of movement. ROM may be progressed gradually, typically limiting flexion to 90–110° until there is radiographic evidence of fracture healing. At 6 weeks from the time of initial injury, a progression to full active ROM and gradual strengthening and conditioning is allowed. Return to a normal activity profile is allowed between 8 and 12 weeks provided that radiographs show no signs of malalignment or inadequate consolidation. In general, relatively few fractures are amenable to this form of treatment. In addition, close radiographic follow-up is mandatory to ensure adequate bony healing and that the fracture has not lost

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Figure 8.3  (a–c) Preoperative lateral radiograph of a 38-year-old female with a displaced, simple transverse olecranon fracture with a relatively small proximal segment. AP and lateral postoperative radiographs (6 months) demonstrating complete fracture union after intramedullary compressive screw fixation and nonabsorbable suture augmentation.

alignment as the healing process has taken place. We recommend radiographs at 2-week intervals during the initial 6 weeks of treatment, particularly as ROM is begun, to optimize outcome. Alternatively, in patients who are elderly and relatively sedentary in their activity expectations, or who have medical comorbidities contraindicating surgical intervention, even displaced fractures may be nonsurgically managed. In such situations, a brief period of immobilization (either with bracing or splinting), followed by gentle active assisted ROM exercises, may be a reasonable form of treatment. A recent study demonstrated a 91% rate of patient satisfaction, 72% with good or excellent functional results, and reasonable objective outcome scores. No patients required treatment for symptomatic nonunion at a mean follow-up of 6 years after injury.

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8.6.2   Operative treatment 8.6.2.1   Biomechanics The biomechanics of olecranon fracture fixation has historically been an area of keen research interest. All types of currently considered surgical reconstruction, including tension-band wiring, intramedullary screw fixation, plate fixation (nonlocking and locking), and intramedullary nailing, have been studied in the laboratory. The optimal method of fixation continues to be debated. Tension-band wiring, as described in the AO manual, was designed to convert the tensile distraction force of the triceps (posterior ulna) into a compressive force at the articular surface. However, biomechanical studies have failed to confirm that this actually occurs. Initial descriptions of the technique centered on intramedullary K-wire placement with associated tension cables. Over time, most authors have recommended that placement of K-wires be bicortical and anterior to the long axis of the ulna on the basis of improved biomechanics and reduction of fracture gap formation in vitro. A significant point of interest has been determining which fracture types are amenable to tension-band wiring as opposed to plate fixation. In general, existing data suggest that simple transverse and relatively simple oblique fracture patterns are the best indication for tension-band techniques. These types of fractures are also a good application of intramedullary compression screw fixation, with or without associated tensioning cable(s). Cadaveric studies have indicated in more extensive fracture patterns, or those with higher levels of comminution (nonsimple patterns), that either plate fixation or intramedullary nailing provides a more rigid construct and should be favored.

8.6.2.2   Surgical technique Many authors advocate supine patient positioning, with the arm draped across the chest or with use of an arm holder. In contrast, the authors’ preference has been a semilateral position of the patient with use of a beanbag and appropriate padding of potential pressure points. A padded bolster or simple pillows can typically be secured to support the operative arm during the procedure. Alternatively, a prone position could also provide similar adequate exposure. Either general or regional anesthesia (or some combination) may be utilized. Adequate fluoroscopic visualization is critical to obtaining adequate fracture reduction and sound fixation. The authors prefer using a large C-arm brought from the patient’s head, aligned parallel to the surgical table. The authors typically invert the C-arm so that it is above the patient and provides little interference to the surgical team. The lateral view is the most critical, and virtually all fracture patterns can be reduced and provisionally fixed using this view. Once adequate initial reduction and fixation is achieved, simple rotation of the arm allows for adequate AP assessment and visualization of fixation. A tourniquet is applied high on the upper arm. The authors prefer the use of a sterile tourniquet to allow for adequate exposure depending on body habitus. The olecranon is approached through a posterior, laterally favored curvilinear incision that attempts to reduce scarring directly over the olecranon tip and the underlying fixation.

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During the exposure on the medial side of the ulna, the muscular origin of the flexor digitorum profundus, flexor digitorum superficialis, and deep head of the pronator teres may be elevated if necessary. The location of the ulnar nerve can usually be identified by palpation and avoided during the operation. The authors do not routinely isolate or transpose the ulnar nerve. The fracture site is cleared of hematoma, and the periosteum is elevated approximately 2 mm from the edges of the fracture. The fracture is then reduced and held with either a tenaculum or provisional K-wire(s). Placement of a small oblique drill hole in the ulnar shaft distal to the fracture may aid in anchoring the distal tine of the tenaculum. Because of the congruence of the ulnohumeral joint, reduction of the fracture anatomy using the matching anatomy of the distal humerus as a template typically results in excellent positioning. More careful attention to the anatomy and provisional reduction is required in cases involving associated elbow instability and/or fracture comminution. As mentioned previously, fixation options include tension-band wire fixation with K-wires or in combination with an intramedullary screw, intramedullary screw fixation alone, plate fixation, or intramedullary nailing. Separate interfragmentary compression screws may be required for certain fracture patterns. Rarely, excision of the fragments and advancement of the triceps may be indicated. After internal fixation is completed, the elbow should be taken through full ROM to confirm stability and guide postoperative rehabilitation. Pronation and supination should be examined to confirm that there is no blockage due to malpositioned hardware.

8.6.3  Tension-band wiring In general, current evidence suggests a trend away from tension banding toward more rigid surgical constructs, such as plate and screw fixation. The perceived shift in treatment preference is primarily due to the lack of evidence that tension banding actually converts posterior tension forces to articular compression and the demonstration of similar rates of hardware removal. However, some surgeons still prefer this technique, and an awareness of it remains warranted. Several technical tips are helpful in achieving optimal results with the tension-band wire technique. K-wires (0.062) are utilized because their ends can be easily bent. Although some surgeons have historically preferred to place the K-wires in the intramedullary canal, most now prefer to place the wires bicortically, engaging the anterior cortex and thereby providing greater resistance to wire migration. The proximal end of the wire should be buried beneath the fibers of the triceps to prevent wire migration. If the anterior cortex is engaged, then care should be taken to avoid overpenetration of the wires because neurovascular damage, restriction of forearm rotation, and the development of heterotopic ossification (HO) have been reported. In general, wires should be placed with no more than 10 mm of the tip protruding, and they should be placed at least 15 mm distal to the coronoid process. Full pronosupination should be confirmed after the wires have been inserted. The length of the wire should be noted at the point where it engages the second cortex. Once the wire penetrates the far cortex, it should be partially backed out and bent 180° at the previously measured position.

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The excess wire should then be cut off. The fibers of the triceps tendon should be split sharply with a scalpel at the site of the K-wires to allow for the cut and bent ends to be impacted against the cortex. If the ends are not impacted, but are rather left superficial to the triceps fibers, then postoperative elbow extension may cause the K-wire to back out, and fixation may be compromised. Care should be taken when impacting the K-wires because they have the potential to advance up to 10 mm distally during this process. An intravenous catheter may assist in passing an 18-gauge wire beneath the fibers of the triceps. The needle and plastic cannula are inserted deep to the triceps tendon, adjacent to the bone, beneath the two K-wires. The insertion needle is removed, leaving the plastic cannula in place. The 18-gauge wire can then be inserted into the end of the plastic cannula, and both cannula and wire are pulled back, passing the wire deep to the triceps fibers. The wire is then passed through a transverse drill hole (typically 2–2.5 mm) placed distal to the fracture. Two twisted knots are placed in the wire, one radial and one ulnar, and each is tightened to produce symmetric tension at the fracture site. The ends of the twisted wires are then cut and bent down against the cortex to prevent subcutaneous irritation. Most authors still prefer 18-gauge wire for fixation when using this technique. However, a braided suture may also be used in an effort to minimize soft-tissue irritation. There is cadaveric biomechanical evidence that 18-gauge wire and braided suture are similar in terms of fracture stability. However, no clinical data exist confirming this. After fixation, the elbow should be examined to confirm full ROM, including pronation and supination, and to confirm fixation stability. If there is any question regarding the adequacy of fracture reduction or fixation using orthogonal fluoroscopy, then intraoperative plain radiography should be used. It is critical that the tension-band wire is properly looped proximally around the K-wires because the wire may occasionally be passed dorsal to one or both of the wires and therefore engage only the triceps tendon. Although it has been classically felt that tension banding may have a lower profile than plating, hardware removal rates of 65–80% are similar to those observed with plating. Excellent or good results have been demonstrated in a very high percentage of cases with appropriate indications. Most data suggest that simple transverse or short oblique fractures are the most acceptable for this fixation method. An interfragmentary lag screw may be useful when there is an oblique fracture plane. A study of 78 patients treated with tension banding demonstrated a union rate of 98.7% and a relatively low rate of complications. Clinical outcomes using this technique have been similar to other methods. In one series, the average ROM was 15–120°.

8.6.4  Intramedullary screw fixation The use of a single large-diameter intramedullary cancellous screw has also been advocated. As with tension-band fixation, relatively simple fracture patterns are most amenable to this method (Figure 8.3). Some authors recommend supplementation of intramedullary screw fixation with a tension-band wire around the screw head because this may minimize the potential for fixation loss with isolated screw fixation.

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An important technical aspect is frontal plane anatomy. There is approximately 4° of valgus angulation of the ulnar shaft with respect to the sigmoid notch. When using this technique, care must be exercised to properly place the screw along the intramedullary shaft axis and thus avoid displacement of the fracture. The use of both finger palpation and AP plane fluoroscopy can be very helpful in this regard. The authors prefer the use of noncannulated 6.5- or 7.3-mm AO cancellous screws with long thread length (typically 32 mm) to obtain adequate purchase and compression in the intramedullary canal. Depending upon bone quality, a washer may be utilized to augment compression and prevent screw cutout. There are biomechanical studies that demonstrate that a single 7.3-mm intramedullary screw, with or without tension-band wiring, may be better than K-wire tension banding with regard to articular surface compression and gap resistance. As yet, there are no clinical studies that confirm the superiority of this technique over traditional tension banding with smooth wires. Current peer-reviewed data suggest this technique is highly successful with appropriate indications. As mentioned previously, relatively simple fracture patterns, such as those amenable to tension-band fixation, are also the best indication for intramedullary fixation. Potential complications have included inadequate reduction and/or loss of fixation.

8.6.5  Plate fixation Plate fixation is most commonly recommended for comminuted fracture patterns that are not amenable to tension-band wire or intramedullary fixation. This typically includes oblique fractures distal to the midpoint of the trochlear notch, fractures that involve the coronoid process, and those associated with Monteggia fracture-dislocations of the elbow. Such fracture patterns are considered unstable. Oblique fractures may be treated with one or two interfragmentary compression screws in addition to plate fixation to resist torsional forces. However, plating is also becoming more popular for stable fracture patterns. The reason for this appears to be twofold: (1) increased awareness of the biomechanical limitations of tension banding and (2) clinical outcome studies that suggest the need for hardware removal to be no greater with internal plate fixation as opposed to tension-banding techniques. Various plate types, including one-third tubular, dynamic compression, and pelvic reconstruction, have historically been utilized for fixation of comminuted olecranon fractures. In more recent years, several different custom olecranon plates have been designed that optimize fixation and have lowered the risk of fixation failure (Figure 8.4(a–e)). Such plates have also included the potential for locking constructs when desired by the surgeon. Depending upon the type of plate (and in particular, its proximal design), appropriate management of the triceps is necessary. Most plates are applied directly to bone via a precise longitudinal split of the triceps at its insertion, whereas others are designed to fit directly over the triceps tendon insertion itself. Although numerous precontoured plating options exist, there does not appear to be a clear or distinct clinical or biomechanical advantage of any one device over another. An important technical note regarding plate fixation is that in severely comminuted or unstable fractures, care must be taken not to narrow the olecranon-to-coronoid

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(a)

(b)

(c)

(d)

(e)

Figure 8.4  (a, b) Preoperative AP and lateral radiographs of a 52-year-old male patient with slightly displaced, comminuted olecranon fracture. (c) Preoperative sagittal CT section evaluating articular surface. (d and e) Intraoperative orthogonal fluoroscopic views. Note: Views were obtained as outlined in text, with rotation of arm allowing AP view. (f and g) One-year postoperative AP/lateral radiograph of same patient. Patient achieved typical functional result, with slight loss of terminal extension and otherwise return to full functional activity profile.

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(f)

(g)

Figure 8.4 Continued.

distance. Because there is no cartilage in the midportion of the sigmoid notch, aligning the remaining articular surfaces in comminuted fractures may result in narrowing of the olecranon-to-coronoid distance. In these difficult cases, every effort should be made to meticulously restore the congruency of the articular surface. The dorsal cortical fragments may serve as a guide to reconstruct the correct anatomic alignment. However, as mentioned previously, reducing these fractures in layers, with or without accessory or provisional fixation of articular fragments (0.045 K-wires or small screws), may be necessary or helpful (Figure 8.5). In addition, use of distraction techniques may aid in reduction and provisional stabilization. Once adequate articular reduction has been achieved, definitive plate fixation may then be placed. Bone graft may be utilized to support the articular surface after elevation of depressed fragments. In particular, avoidance of excessive articular surface compression is necessary to prevent malreduction. Close scrutiny of intraoperative fluoroscopy during this portion of the procedure is required. In situations in which fracture instability heightens concern for this complication, locking plate technology may assist in maintaining articular surface distance. In rare situations, some fractures with irreducible intercalary fragments may be treated with fragment excision and advancement of the proximal ulnar segment. If considering this method, the proximal ulnar fragment should be carefully contoured to reapproximate the proper radius of articular curvature. An additional concern regarding plate fixation is when the proximal fragment is of particularly small size. Small fragments are at risk for splitting in the sagittal plane and can complicate initial fixation. In such situations, reinforcement with augmenting sutures through the triceps tendon may be helpful. Biomechanical investigation suggests such augmentation may increase the ultimate load to failure compared with plating alone. Plate fixation has been demonstrated to be superior to tension-band fixation in terms of anatomic articular restoration, regardless of fracture type. Additional studies have suggested high rates of success with plate fixation, even in the setting of more complex

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(a)

(b)

Figure 8.5  (a and b) Example of fixation of intercalary articular fragment with small screws before definitive application of a dorsal plate. With permission from Elsevier publication, Baecher N, Edwards S. Olecranon fractures: current concepts. J Hand Surg 2013;38A:593–604.

fracture types such as Monteggia fracture-dislocations. As a result, plate fixation has been particularly recommended in the setting of fracture patterns that extend into the meta-diaphyseal junction or if the coronoid process is involved. However, as plate technology continues to evolve, many authors now advocate for the routine use of internal plating as the preferred treatment method, even in simple (stable) fracture patterns. The initially described AO technique for plating unstable olecranon fractures utilized an intraoperatively contoured one-third tubular nonlocking plate applied to the proximal ulna. More recently, precontoured plates with varying locking screw configurations have become popular. It remains unclear whether locking screw technology leads to better clinical outcome. In cadaveric biomechanical studies, similar stiffness and load to failure have been demonstrated between nonlocking and locked plating. In addition, there appears to be little biomechanical difference among the various

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currently available precontoured designs. Precontoured plate usage (and selection) should be done with consideration of the morphology of the proximal ulna. In particular, recognition of the normal proximal ulnar dorsal angulation, which averages 5.7° (range 0–14°), is necessary. In situations in which the ulna normally has some degree of proximal dorsal angulation, application of a straight plate may alter anatomic alignment at the radiocapitellar and proximal radioulnar joint and result in malunion. Several studies have shown similar results with plate fixation as compared with tension banding, although patient selection (fracture type) may be slightly different. In 19 patients with comminuted olecranon fractures, locked plating resulted in a 100% union rate at a mean time of 4 months and a mean arc of motion from 13° to 136°. Ninety-four percent of patients had an outcome rated good or excellent. However, 19% of the patients had an extension deficit of more than 30°, and 56% elected hardware removal within 2 years of the index procedure. A prospective randomized study directly compared plate fixation with tension banding for Mayo Type IIA fractures. In this study, plate fixation resulted in a lower complication rate and higher clinical outcome scores, although elbow ROM was equivalent in the two treatment groups. Relatively similar results have been demonstrated in patient groups with slightly higher injury severity. In 25 patients with either Mayo Type II or III fractures undergoing plate fixation, there were no cases of nonunion, 88% had good or excellent results, and patient satisfaction was high. Mean Disabilities of Arm, Shoulder, and Hand and 36-item Short Form (SF-36) scores were similar to normative general population data. Twenty percent of subjects elected plate removal. An investigation of comminuted and/or complex olecranon fractures treated with contoured plating demonstrated a 100% union rate, with an average time to union of 15 weeks. Patients achieved an average ROM of 14–125°, and 78.6% were rated good or excellent. The slightly lower clinical outcome scores in this report were intuitively expected given the higher injury severity studied.

8.6.6  Intramedullary nailing Intramedullary nails are a relatively recent technical option in the management of olecranon fractures. The main theoretical advantage of this technique is minimization of soft-tissue irritation (and need for subsequent hardware removal). In addition, there is evidence that intramedullary nailing may result in less gapping at the fracture site than tension banding when early ROM is instituted. Further clinical investigation is required to determine the optimal indication of this method of fixation. It is interesting to note that some authors have discussed this technique in a broadened indication of treating nondisplaced fractures, thereby allowing earlier ROM without concern for loss of fracture alignment. Future study will likely determine the efficacy in this clinical situation. Most intramedullary devices designed for proximal ulnar fractures are intended for simple, transverse injury patterns. However, one multiplanar, locked intramedullary nail (OlecraNail, Mylad Orthopedic Solutions, Doylestown, PA) is potentially suitable for unstable, comminuted fractures (Figure 8.6). This nail has a fixed-angle design and

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Figure 8.6  (a) A multiplanar locked intramedullary proximal ulnar nail. (b) Radiograph of an intramedullary nail used to rigidly fix an olecranon fracture. With permission from Elsevier publication, Baecher N, Edwards S. Olecranon fractures: furrent foncepts. J Hand Surg 2013;38A:593–604.

offers rigid stability in all planes. Similar to the existing locking plates, this particular nail has a fixed-angle design and rigidly stabilizes bone fragments in all planes. In a cadaveric biomechanical study, intramedullary nailing and locked plating demonstrated similar fracture stability under cyclic loading. In addition, there was evidence that nailing held fracture fragments stable under higher maximal loading conditions. It remains unclear whether this is of clinical importance, although this finding may suggest potential benefit where limited load bearing is necessary in the postoperative period. Potential patient groups that would benefit from this include elderly or polytrauma patients. If used in more complex fracture patterns, then strict adherence to techniques of articular surface reduction and restoration is required (similar to that outlined in Plate fixation).

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In a study of 18 patients with unstable proximal ulnar fractures treated with locked intramedullary nailing, subjects achieved ROM within 10° of the contralateral elbow, minimal pain, and a high level of return to function. No subsequent hardware removals were necessary at minimum follow-up of 1 year. Another investigation reported 93% good or excellent results in patients. However, this study included simple and comminuted fractures.

8.6.7  Excision of fragment and triceps advancement Excision of the fracture fragment and reattachment of the triceps tendon may be indicated in a select group of elderly patients with osteoporotic bone. In general, consideration is given for this technique when the olecranon fracture fragments involve less than 50% of the joint surface and are too small or too comminuted for successful internal fixation. The integrity of the medial collateral ligament, the interosseous membrane, and the distal radioulnar joint must be established before consideration is given to excision; otherwise, instability will likely result. The triceps tendon is reattached with nonabsorbable sutures that are passed through drill holes in the proximal ulna, much like the technique utilized in primary triceps tendon repair. Some authors recommend that the triceps be reattached adjacent to the remaining articular surface, creating a sling for the trochlea. This technical measure results in a smooth, congruent transition from the triceps tendon to the articular cartilage of the olecranon. However, it also decreases the moment arm and may result in some measure of extensor weakness. As a result, others advocate that reattachment be performed at the posterior portion of the ulna to maximize its mechanical advantage. We are unaware of any clinical data comparing these two technical variables. Some debate has existed regarding the amount of the proximal ulna that can be safely excised without compromising stability of the elbow. Although some clinical studies suggest upward of 75–80% of the joint surface may be removed, in vitro biomechanical data suggest that no more than 50% of the trochlear notch be removed so as to avoid instability. As a result, most authors have proposed this amount be the cutoff for consideration of this technique. Although data exist suggesting that partial olecranon excision may result in a lower complication and reoperation rate when compared with internal fixation, most authors still consider this a technique of last resort. In general, excision is reserved for those unusual cases in which open reduction seems unlikely to be successful. Open reduction and internal fixation should still be attempted in most cases because it allows for bone-to-bone healing and anatomic restoration. If internal fixation fails, then excision and triceps advancement can still be performed as a salvage procedure. Overall, relatively low complication rates have been reported with this procedure.

8.7  Rehabilitation Most authors agree that appropriate postoperative rehabilitation is a crucial component of achieving a successful clinical outcome. However, virtually no data exist regarding the optimal protocol for maximizing clinical outcome. In general, a customized

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Figure 8.7  Example of a hinged, articulating elbow brace (Össur, Inc., Reykjavik, Iceland). The brace may either be unlocked or allowed to articulate with desired limitations of either flexion and/or extension.

regimen that takes into account fracture pattern, associated injuries, condition of the soft tissues, fixation method, and patient characteristics such as bone quality is most likely to promote a good outcome. In the immediate postoperative period, the elbow is typically splinted at or near full extension to decrease tension across the fracture site. We prefer the use of a hinged elbow brace (Össur, Inc., Reykjavik, Iceland; Figure 8.7) that can be applied in locked fashion and used in the initial postoperative phase as a splint. This can be applied in a desired position of either full extension or slight elbow flexion. This also allows for straightforward assessment of the bandage; in situations in which wound drainage and/or the need for frequent dressing changes are noted, this can be accomplished relatively easily by removing the brace. A well-padded, sterile bandage is applied and covered with a compressive elastic wrap to assist with swelling control. This is typically kept in place for the initial 48–72 h to promote early soft-tissue stabilization. Changing the bandage to a lighter and less restrictive dressing may be done as early as 48–72 h after surgery; however, this may be delayed in situations in which bone quality or fracture stability could be compromised with earlier movement. In situations in which the fracture pattern is inherently stable and fixation subjectively good, the authors prefer to initiate dressing change and range of movement early at 2–3 days after surgery. In contrast, more unstable fracture patterns, compromised or at

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risk soft-tissue anatomy, and/or less rigid fixation may dictate delaying movement and dressing changes anywhere from 7 to 10 days after surgery. The timing of initiation of range of movement is the primary variable at the surgeon’s discretion. Once this decision is made, the types of movements allowed are similar for all methods of fracture fixation. However, the magnitude of ROM allowed will vary depending upon fracture pattern, associated injury (in particular concomitant instability considerations), and the quality of fixation. Gentle passive ROM in the early phases of healing results in less distraction at the fracture site; therefore, it is generally preferred. We recommend a protocol that focuses on early gravity-assisted (passive) elbow extension and active assisted elbow flexion to a predetermined limit. In most instances, elbow extension to full (0° or beyond) is allowed unless the intraoperative assessment of elbow stability dictates otherwise. Although limiting the amount of flexion theoretically decreases tension on the surgical repair, the timing or extent to which this can be tolerated for any given fracture is unknown. In general, the authors limit flexion to approximately 90–100° for the first 2–3 weeks, but allow 10° weekly increases, attempting to attain a goal of 115–125° of flexion at week 6 postoperatively. Unassisted active ROM is prohibited in the first 6 weeks postoperatively, although active assisted pronosupination is recommended with the elbow at approximately 90° flexion unless associated soft-tissue injury patterns (e.g., PLRI or Monteggia variants) dictate otherwise. When tension banding has been performed, the initiation of ROM exercises may be delayed until 10–14 days after surgery. However, the authors have typically not delayed motion if stable compression, such as with an intramedullary screw, has been achieved at the time of surgery and bone quality is good. If triceps advancement is performed, then initiation of movement is also delayed slightly, and rehabilitation is then progressed otherwise in very similar fashion to that previously outlined. In the less common scenario in which stability of either the ulnohumeral joint and/or radiocapitellar joint must be maintained, as in the case of more complex fracture dislocation patterns, we recommend close radiographic surveillance during the period of time when rehabilitation is being gradually progressed. In particular, consideration should be given for radiographs at regular 2-week intervals during the first 6–8 weeks after surgery. This helps to ensure that ROM exercises can be safely progressed, maintaining adequate goals for movement while ensuring congruent joint stability. The authors err on the side of promoting bone healing and joint alignment and consider treating a stiff but congruent joint in a more delayed fashion as opposed to non- or malunions brought on by overly aggressive early rehabilitation protocols. The authors typically reserve functional strengthening until 6–8 weeks from the time of surgery. Criteria for progression into this phase of rehabilitation are radiographic evidence of adequate bone healing and the presence of a stable and congruent elbow joint. In addition, the presence or absence of other concomitant injuries (e.g., polytrauma) or other soft-tissue considerations may affect the timing and rate at which the strengthening progression is allowed. In most instances, allowance of activities as tolerated is begun at roughly 12 weeks after surgery if the radiographic evaluation remains sound.

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8.8  Complications 8.8.1   Hardware removal Symptomatic hardware remains the most common complication after surgical treatment of olecranon fractures. A survey-based study suggests that treating surgeons are often unaware of the extent to which these implants affect patients. In fact, patients commonly undergo hardware removal with someone other than the initial treating surgeon. In this study, the rate of patient-reported implant removal was 65%. Although initially thought to be less bothersome, tension banding has not shown lower rates of implant removal than plate fixation. In both cases, removal rates between 20% and 100% have been reported. Intramedullary nailing has demonstrated the lowest rate of hardware removal after olecranon fracture treatment. The authors have also found the need for hardware removal to be relatively unusual after intramedullary screw placement for simple, transverse fractures. However, clinical data to support this are lacking.

8.8.2   Stiffness Appropriate counseling of patients suffering an olecranon fracture is an important element of treatment. Mild reduction in functional ROM is relatively common after treatment, whether surgical or nonsurgical. In particular, the potential for loss of terminal extension should be discussed. On average, a loss of 10–15% of ROM has been reported and occurs in up to 75% of cases. It should be noted that delayed improvement in ROM has been reported over the course of ongoing follow-up. As a result, continued efforts at ROM exercise seem warranted for up to 8–12 months after initiation of treatment.

8.8.3   Arthrosis The incidence of post-traumatic arthrosis after treatment of an olecranon fracture may approach 20%. As expected, associated risk factors for the development of arthrosis appear to be higher initial injury severity (based on magnitude of displacement) and persistence of articular incongruity. At medium-term follow-up, most cases of subsequent arthrosis are relatively mild. Further long-term follow-up is required to determine the rate and/or magnitude of arthritic progression over time in these cases. Current data are lacking in this regard.

8.8.4   Ulnar neuritis Ulnar neuritis is relatively uncommon, having been reported in 2–12% of cases. Nonsurgical management is initially recommended, unless significant concerns exist that an iatrogenic event, such as laceration or penetration, may have occurred at the time of surgery. Consideration should be given for electrodiagnostic evaluation with electromyography and/or nerve conduction studies. These are not typically of value until 14–21 days have elapsed from either the time of surgery or the time when the

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neurologic evaluation changed. In situations in which concerns for hardware placement, fracture reduction, and/or joint instability exist with strong electrodiagnostic evidence of more complete nerve injury, surgical exploration and possible neurolysis should be considered. We tend to favor neurolysis with combined nerve transposition, although others prefer in situ techniques. Objective improvement in ulnar nerve function has been demonstrated up to 20 months after surgery, and most often simple observation with reassurance is indicated.

8.8.5  Heterotopic ossification Although commonly a concern with surgical and nonsurgical management of elbow fractures, HO is an uncommon occurrence in the setting of an isolated olecranon fracture. In a large study of 786 fractures involving the elbow, only 1 of 221 olecranon fractures developed HO (