Management

Acute Elbow Dislocation Management

Elbow Dislocation Lateral

 

1.  Reduction under IV / conscious sedation

- assistant applies traction in slight flexion

- second person corrects lateral displacement by manipulating olecranon medially

- flexion to 90o

 

2.  Post reduction assess stability

- stable if can extend to within 30 - 40o without instability

- if unstable, pronate forearm and see if can extend to within 30 - 40o (MCL intact)

- if unstable pronated with elbow < 45o extended, elbow will need surgery

 

3.  Confirm concentric reduction

- 2 view check x-rays mandatory

 

4.  Stable elbow

- manage in POP 90o 2 weeks

- weekly check xray

- then begin ROM exercises

 

Elbow ROM Brace

 

Management Problems

 

A. Simple Elbow Dislocation

 

B.  Complex Elbow Dislocation

- radial head fracture

- coronoid process fracture

- Terrible Triad (MCL / coronoid / radial head)

- olecranon fracture +/- radial head +/- coronoid

- capitellar fractures

 

Note

- difficult problem

- need to prepared at all times to

- ORIF / replace radial head

- repair / reconstruct LCL

- ORIF / suture coronoid

- repair MCL

- apply external fixator

 

1.  Simple Elbow Dislocation

 

A.  Stable Simple Elbow Dislocation

 

 Simple Elbow DislocationElbow Simple Dislocation Reduced

 

Management

 

Reduce

 

Assess Stability 

- OT if unstable > 45o in pronation

 

X-ray weekly

 

Mobilise 2 - 3 weeks

 

If FFD at 6/52 > 40o

- night extension splint

- turnbuckle elbow extension splints

 

Josefsson et al 1987 JBJS AM

- randomised 30 patients with elbow dislocations

- non-operative group 2 weeks in plaster at 90°

- operative group had ruptures of both collaterals / most had avulsions from the humeral epicondyles

- no difference in outcome between the two groups regardless of initial stability

- loss of extension was commonest complication

- seen 50% more in operative group

 

B.  Unstable simple elbow dislocation

 

Uncommon but not rare

- may be intact medially

- avulsed LCL and CEO

 

Algorithm

 

1.  Kocher approach & Reconstruct / Repair LCL + CEO

- lateral ulna collateral ligament is usually avulsed from lateral condyle

- centre of rotation is centre of capitellum

- place suture anchor

- repair anconeus and ECU over top

- +/- reconstruct / augment with slip Palmaris if required

- ROM brace

 

2.  Elbow still unstable / address MCL

- usually avulsed from medial epicondyle 

- usually can do direct repair / suture anchors

- mid-substance probably have to reconstruct with Palmaris

 

Medial approach centred on medial epicondyle

- locate, mobilise and protect ulna nerve

- proximally between brachialis and triceps

- distally between pronator teres and brachialis

- can reflect PT

- protect median nerve distally

 

C.  Chronic Simple Elbow dislocation

 

Missed injury / delayed presentation

- open reduction

- removal scar tissue

- repair / reconstruction LCL

- +/- hinged external fixation

 

2.  Dislocation with Radial Head Fracture

 

Manage as per radial head classification

 

Hotchkiss Modified Mason class (R&G)

 

Type I

 

Non / minimally (<2mm) displaced fracture of head 

- forearm rotation (pronation/supination) is limited only by acute pain and swelling 

- diagnose by LA injection and full pronation and supination

 

Non operative treatment

 

Type II

 

Displaced fracture of the head or neck 

- > 2mm and amenable to fixation

 

Motion may be mechanically limited with or without significant joint incongruity 

 

CT Radial Head FractureRadial Head ORIF

 

Management

- Kocher approach

- ORIF

- LCL repair / reconstruction

 

Type III

 

Severely comminuted fracture of the radial head and neck 

- not reconstructable 

- Titanium replacement

 

Radial Head Replacement

 

Ashwood et al JBJS Am 2004

- 16 patients titanium monoblock radial head

- 81% G/E at 2 years

 

Radial Neck Fracture

 

Morrey et al J Orthop Trauma

- concern regarding loss of rotation with plating

- prefer to ORIF with oblique screws or radial head replacement

 

3.  Dislocation with Coronoid Fracture

 

Elbow Dislocation Large Coronoid Fragment

 

The coronoid is the most important portion of ulno-humeral articulation

 

Reasons

- provides anterior buttress

- attachment of capsule and brachialis

- anterior band of the MCL attaches to it

 

Manage as per Regan and Morrey Classification

- ORIF / repair type I / II

 

Regan and Morrey Classification

 

Type I 

- stable as nothing attaches to tip 

- shear fracture, not avulsion fracture

 

Type II 

- 50% coronoid

- elbow usually unstable / ORIF or suture

 

Type III

- > 50%

- uncommon

- can be comminuted

- ORIF or suture

 

Elbow Dislocation Large Coronoid Fragment 2

 

Approach

 

Universal posterior approach

- single posterior skin incision

- elevate flaps laterally and medially as required

- lateral approach to repair ulna LCL

- medial approach to repair coronoid

 

Medial approach

- isolate and protect ulna nerve  

- elevation of ulna origin of flexor pronator group anterior to FCU

- important if fracture is medial

 

Fixation

 

1.  Screw / buttress plate

 

Coronoid Buttress Plate APCoronoid Buttress Plate Lateral

 

2.  Sutures through capsule / Lasso repair 

- tie over drill holes through olecranon / endobutton

 

3.  Reconstruct with radial head, iliac crest, or allograft

 

Note:  Acknowledged by world class names as being difficult

 

4.  Dislocation + Terrible Triad

 

Complex Elbow Dislocation APComplex Elbow Dislocation Lateral

 

Definition

- radial head fracture + coronoid fracture + MCL

 

Surgical Algorigthm

 

Universal Posterior Approach

 

1.  Type 2 radial head

- Kocher approach

- ORIF

- repair / reconstruct ulna LCL

- reassess stability

- if unstable, additional medial approach

- isolate and protect ulna nerve

- if type II / III coronoid elevate CFO and ORIF / suture

- repair / reconstruct MCL

- assess stability

- rarely may require external fixator

 

2.  Type 3 radial head

- Kocher approach

- excise radial head

- attempt ORIF / suture coronoid process through this gap

- unless large anteromedial fracture which is best treated with anteromedial buttress plate

- replace radial head

- repair / reconstruct LCL

- reassess stability

- may then need medial approach and MCL repair / reconstruction

- reassess stability

- may need hinged external fixator

 

5.  Dislocation with Olecranon Fracture +/- Coronoid Fracture +/- Radial Head Fracture

 

Elbow Dislocation Fracture Olecranon and Radial HeadElbow Dislocation ORIF Olecranon Replace Radial Heal LCL repairElbow Dislocation ORIF Olecranon Replace Radial Heal LCL repair

 

A.  Anterior / Trans Olecranon Fracture Dislocations

 

Less common, better outcomes because

- coronoid fragment usually larger / easier to ORIF

- collaterals often intact

- radial head often intact

 

Management

- universal posterior approach

- ORIF / suture coronoid through olecranon fracture

- TBW or plate for olecranon fracture

- can repair coronoid with lag screw from olecranon plate

- Kocher approach

- ORIF / replace radial head

- repair / reconstruct LCL

- reassess stability

- +/- repair reconstruct MCL

 

B.  Posterior Monteggia Fracture

 

Elbow Dislocation Posterior Monteggia

 

More common, worse outcome because

- LCL more likely to be ruptured as well

- coronoid more likely to be comminuted

- radial head fracture

 

Management

- ORIF coronoid through olecranon fracture

- ORIF olecranon (often plate as distal to centre of rotation of elbow)

- +/- ORIF /replace radial head

- +/- repair / reconstruct LCL

- +/- hinged fixator

 

6. Other

 

Dislocation with distal radius fracture

 

Dislocated Elbow Fracture wristDislocated Elbow Fractured Wrist