Goal
1. Obtain and maintain a concentric reduction
2. Achieve a painless and functional ROM
Acute Elbow Dislocation Management
1. Reduction under conscious sedation
Traction / countertraction
- use thumbs to correct lateral displacement / push olecranon medially
- flexion to 90o
Youtube elbow dislocation reduction technique video
Youtube elbow dislocation reduction technique video 2
Youtube elbow dislocation reduction technique video 3
2. Assess stability post reduction
Elbow stable if can extend to within 30 - 40o without redislocation
- 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 on xray
4. Stable elbow
- manage in POP 90o 2 weeks
- weekly check xray
- then begin ROM exercises
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
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
Management
- Kocher approach
- ORIF
- LCL repair / reconstruction
Type III
Severely comminuted fracture of the radial head and neck
- not reconstructable
- Titanium 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
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
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
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
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
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
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
External rotator
Indications
1. Persistent instability despite ORIF and LCL repair
2. Gross acute instability, not suitable for surgery
3. Delayed treatment > 4 weeks
Compass hinge / S&N
Set up
- two incomplete rings proximal and distal
- hinge in centre
- can be used actively or passively
- adjustment wheel is medial (to use with other hand)
- rings posterior, open anteriorly
- rings compatible with ilizarov equipment
- hinge can also be adjusted in the varus valgus plane
- do so that distal ring is perpendicular to plane of ulna
Key is distal humeral axis
- imagine axis is in spool at end of humerus
- open laterally to identify capitellum
- open medially to identify trochlea
- confirm centre of rotation on lateral
A. Insert medial and lateral 3.5 mm pins partially
- place external fixator over pins but this can be difficult
- adjust pins so hinge slides easily over them
- insert pins 2mm
B. Insert a single pin through axis of rotation
- slightly easier to apply the external hinge over the pin
- may not have to open the medial side as much
- only slight to identify and protect the ulna nerve
Medial Humeral half pin
- posterior to ulna nerve
- ensure proximal ring is perpendicular to humerus
- use two hole rancho cube with centering sleeve
- drop off undersurface off ring
- insert 5mm pin (drill, measure, insert HA pin by hand)
- need bicortical fixation
Lateral humeral pin
- anterior to radial nerve
- 2 hole post with single hole rancho
- allows angulation of pin from proximal to distal
- also angle posterior to anterior
Ulna pins
- 4mm pins into subcutaneous border
- must reduce elbow first and hold reduced whilst inserting pins
- ring must be perpendicular to ulna
- usually put elbow in 90 degrees of flexion
- proximal pin off proximal side of ring wth rancho cube
- bicortical usually into coronoid
- check is stable reduction
- insert second +/- third pin distally