Download - Complex elbow injuries involving radial head
Complex elbow injuries involving the radial head
Adam C WattsConsultant Elbow and Upper Limb Surgeon, Wrightington Hospital
Visiting Professor, Manchester University
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Fracture Dislocations
Recognisable patterns of injury
Management plan based on anatomical principles
Consider “hidden” injury
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Elbow fracture dislocations
1.Posterior rotatorya.pronation lateral rotation
b.pronation medial rotation
2.Trans-olecranona.extension
b.flexion
3.Longitudinal
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Elbow fracture dislocations
1.Posterior rotatorya.pronation lateral rotation
b.pronation medial rotation
2.Trans-olecranona.extension
b.flexion
3.Longitudinal
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Elbow fracture dislocations
1.Posterior rotatorya.pronation lateral rotation
b.pronation medial rotation
2.Trans-olecranona.extension
b.flexion
3.Longitudinal
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www.wrightington.com
Elbow fracture dislocations
1.Posterior rotatorya.pronation lateral rotation
b.pronation medial rotation
2.Trans-olecranona.extension
b.flexion
3.Longitudinal
4
www.wrightington.com
Elbow fracture dislocations
1.Posterior rotatorya.pronation lateral rotation
b.pronation medial rotation
2.Trans-olecranona.extension
b.flexion
3.Longitudinal
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Terrible Triad algorithm
Restore coronoid
Restore radial head
Restore lateral soft tissue restraints
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Terrible Triad algorithm
Restore coronoid
Restore radial head
Restore lateral soft tissue restraints
Restore medial soft tissue if still unstable
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Terrible Triad algorithm
Restore coronoid
Restore radial head
Restore lateral soft tissue restraints
Restore medial soft tissue if still unstable
Apply hinged ex-fix
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Does the coronoid need to be fixed?
Cohort study of 14 consecutive patients (Level 4)
2 Regan-Morrey type I, 12 type 2
No coronoid fixation - Min f/u 24 months
Mean arc of motion 123°
DASH 14
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Fix or Replace?
No difference in ROM (Level 4)
ORIF more likely to be unstable
33% risk of arthrosis with arthroplasty
Equivalent re-operation rates
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Transolecranon Monteggia Fracture Dislocations
Proximal ulna fracture with dislocation of radial head from radiocapitellar joint and proximal radioulnar joint
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Jupiter Classification of Type II Fractures
IIa Coronoid level
IIb Metaphyseal/Diaphyseal junction
IIc Distal to coronoid
IId Fracture extending to distal 1/2 ulna
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Ring Classification
Type IApex anterior diaphyseal ulna fracture with anterolateral dislocation of radiocapitellar and PRUJ
Type IIMetaphyseal buckle fractures with anterolateral radiocapitellar dislocation (paediatric only)
Type IIIApex posterior ulna fractures with posterior dislocation radiocapitellar joint
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Aims of treatment
Restoration of normal ulna alignment
Restoration of elbow stability
coronoid buttressradial headlateral ligament complex
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Ligament Augmentation and Reconstruction System (LARS)
Polyester rope
Ultimate stress 2600N
Residual Strain at 2500N = 1.5%
Stiffness = 209N/mm (cf 129 native IOM)
No damage after 5 million cycles
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Experience to date
15 Procedures (chronic injuries) min follow-up 18
months
1 persistent axial instability - revised to OBF
No other recurrent proximal migration
Mean DASH improved 77 to 41/100
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Elbow fracture dislocations
1.Posterior rotatorya.pronation lateral rotation
b.pronation medial rotation
2.Trans-olecranona.extension
b.flexion
3.Longitudinal
55
www.wrightington.com
Elbow fracture dislocations
1.Posterior rotatorya.pronation lateral rotation
b.pronation medial rotation
2.Trans-olecranona.extension
b.flexion
3.Longitudinal
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Terrible Triad
www.wrightington.com
Elbow fracture dislocations
1.Posterior rotatorya.pronation lateral rotation
b.pronation medial rotation
2.Trans-olecranona.extension
b.flexion
3.Longitudinal
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Terrible TriadPMRI
www.wrightington.com
Elbow fracture dislocations
1.Posterior rotatorya.pronation lateral rotation
b.pronation medial rotation
2.Trans-olecranona.extension
b.flexion
3.Longitudinal
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Terrible TriadPMRI
Ring Type 1
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Elbow fracture dislocations
1.Posterior rotatorya.pronation lateral rotation
b.pronation medial rotation
2.Trans-olecranona.extension
b.flexion
3.Longitudinal
55
Terrible TriadPMRI
Ring Type 1Ring Type 3
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Elbow fracture dislocations
1.Posterior rotatorya.pronation lateral rotation
b.pronation medial rotation
2.Trans-olecranona.extension
b.flexion
3.Longitudinal
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Terrible TriadPMRI
Ring Type 1Ring Type 3
Essex-Lopresti