Elbow

Arthrodesis

Indications

 

Very few

- young labourer with severe disabling elbow pain

- trial in POP at 90o for 6 weeks

 

Poor function

- adjacent joints cannot compensate for loss of function

 

Contraindications

 

RA

- high failure rate especially flail elbow with poor bone stock

 

Arthroplasty

Indications

 

RA 

- very good results

- 97% 10 year survival Coonrad-Morrey prosthesis

 

Other Dx 

- OA / post-traumatic arthritis / nonunion

- tend to have worse survival than RA

 

Haemophilia

- elbow joint commonly involved

- 90% of haemophiliacs

 

Acute unreconstructable fracture > 60

 

Contra-indications

 

Sepsis

 

Poor soft tissue cover skin triceps

 

Under 60 years

 

Charcot Joint

 

Implant Types

 

1. Fully Constrained 

- have highest failure

 

2. Semi- constrained 

 

Coonrad-Morrey TER

- sloppy hinge

- allow some varus-valgus

 

3. Unconstrained 

 

Design

- stems on ulna & humerus to prevent loosening

- poly / metal bearing

- require MCL & LCL for stability

 

Technique Latitude Total Elbow Replacement

 

Total Elbow Latitude RATotal Elbow Latitude RA

 

Design

- can covert unlinked to linked simply at end of case or at later revision by adding anterior O piece

- unconstrained / semiconstrained

- anterior humeral flange with bone graft important for longetivity

 

Lateral position

- arm over bolster

 

Posterior Approach

- full thickness skin flaps

- identify and protect ulna nerve with vessiloops

 

Total Elbow Ulna Nerve

 

Triceps Options

 

A. Split in midline

- feathered off bone medially and laterally

- left attached distally

 

B.  Bryan-Morrey

- triceps elevated from subperiosteally

- from ulna to radial side

- periosteum left attached on radial side

 

C.  Triceps sparing

- elevate triceps tendon medially and laterally

- identify and protect ulna and radial nerve medially and laterally

- divide collaterals from humerus and dislocate elbow to medial aspect of triceps

 

Distal Humerus

- elevate and tag LCL / MCL for later repair

- elevate anterior capsule off humerus

 

Dislocate Elbow

 

Prepare humerus

 

1.  Size capitellum and trochlea with spool

- judge off distal humerus

- insert into olecranon and over radial head

 

2.  Stabilise centre of rotation

- most important

- centre of capitellum to medial epicondyle of trochlea (just distal and anterior to it)

- pass pin through

 

3.  Resect olecranon fossa, find entry to IM canal

- pass IM guide

 

4.  Attach resection jig to rotation and IM pins

5.  Drill holes made to establish area to resect with saw

6.  Need to leave medial column (some trochlea) and lateral column (some capitellum)

7.  Trial

 

Prepare ulna and radius

 

1.  Broach IM canal of ulna

2.  Pass IM jig, centre on ulna

- EM points towards ulna styloid

- fixed in position with 3 pins

3.  Use jig to 

- resect radial head

- burr prepares ulna lateral to medial

4.  Trial

 

Humeral / ulna and radius prosthesis inserted

- simplex cement

- cement restrictors

 

Closure

- collateral ligaments reattached through humeral prosthesis

- closure triceps over drain with Ethibond

 

Post op

- POP 1 - 2 weeks till wound healed

 

Results

 

Morrey et al JBJS Am 1998

- TER in rheumatoid arthritis

- followed for 10 years

- 92% survival rate

- 10% incidence of serious complication requiring re-operation

- infection / aseptic loosening / fracture / triceps avulsion / loosening

 

Morrey et al JBJS Am 2010

- TER in post traumatic arthritis

- 69 patients followed for 9 years

- 19% failure rate

- infection < 5 years, bushing failure 5-10 years, then component loosening

- most patients with failure < 60 years

 

Complications

 

Infection

 

Total Elbow Replacement InfectionTotal Elbow Joint Infected 2Infected TER

 

Incidence

- 4-5%

- most common cause of failure

 

Risk factors for infection

- previous surgery

- previous infection

- stage IV RA

- drainage post-op

- re-operation for any reason

- poor skin

 

Prevention

- Bier's block and IV antibiotics at beginning of case

- POP for 2 weeks post op to achieve wound healing

 

Management

 

Often follows superficial infection or bursitis

- need aggressive treatment of any superficial infection

- can often salvage joint with early debridement and washout

 

If signs of bony infection / loosening 

- 2 stage revision

- resection arthroplasty

 

Total Elbow Replacement Cement SpacerTotal Elbow Replacement Cement Spacer 2

 

Intraoperative fracture

 

Instability

 

More common in unconstrained

- 6%

 

Transient neuropraxia

- 5%

 

Triceps failure

- 2%

 

Loosening

 

Revision TER

 

Total elbow loose humeral component

 

 

 

 

Arthroscopy

Indications

 

1. Removal Loose body

 

Elbow scope Loose Body

 

2. Excison of osteophytes

- coronoid

- olecranon

- aiming to improve ROM / prevent impingement

 

Elbow Stiffness Posterior ImpingementElbow Stiffness Posterior Debridement

 

3. Elbow Stiffness Capsular Release

- capsular contraction can limit range

- anterior capsulotomy

- risk to median nerve anteriorly

 

4. Management OCD lesions

 

Elbow scope Radial Head OCDElbow OCD

 

5.  Synovectomy

- RA, haemophilia

- usually results in marked blood loss

- leave portals open to allow for drainage to prevent haemarthrosis and stiffness

 

6.  Washout sepsis

 

7. Excision of Radial Head

- useful combined with synovectomy in RA

- can excise head and 2-3mm of neck

- to ensure stability should keep annular ligament

 

Contra-indications

 

Abnormal elbow scarring

Extensive HO

Previous ulna nerve transposition

 

Technique

 

Equipment

 

4mm scope 

2.7mm wrist scope

 

Position

 

A.  Patient lateral

- hip supports

- arm over L shaped bolster

 

Elbow Lateral Decubitus

 

B.  Patient supine

- anterior portals and arthroscopy with arm on arm board

- posterior portals and arthroscopy with arm bent over patient

 

Landmarks

 

Outline surface markings with a pen

- epicondyles, radial head, olecranon

- medial and lateral supracondylar ridge

- draw ulna nerve

 

PIN landmarks

- anterior to radial head

- posterior to mobile wad

 

Anterior elbow arthroscopy

 

Lateral portals

 

A.  Proximal Anterolateral portal

 

Uses

- intial viewing portal

 

Technique

- 1-2 cm proximal to lateral epicondyle

- just anterior to lateral intermuscular septum

- onto anterior humerus

- walk down into joint

- insufflate with 20 mls

- incision in skin

- same technique to insert portal

 

Issues

- radial nerve

- moved further away by insufflation

- most dangerous portal

- do first before swelling obscures anatomy

 

Elbow Arthroscopy Anterior Compartment

 

B.  Anterolateral Portal

 

Uses

- working portal

- microfracture capitellar OCD

 

Technique

- just in front of lateral epicondyle / anterior to radial head

- in sulcus between radial head and capitellum

- PIN most in danger here

- avoid distal / anterior placement

 

Elbow Arthroscopy AnterolateralElbow Scope Anterolateral Portal

 

Medial Portals

 

Proximal Anteromedial Portal 

 

Anatomy

- 2cm proximal to the medial epicondyle

- just anterior to humerus / medial intermuscular septum

- ulna nerve behing medial epicondyle

- median nerve and brachial artery anterior

 

Technique

- insert needle under vision

- incision in skin

- pass haemostat under vision

 

Elbow Scope Anterolateral Portal

 

Uses

- removal of loose body

- visualise chondral surfaces ulnohumeral and radiocapitellar

 

Anteromedial portal

 

Anatomy

- 2cm anterior and 2cm distal to medial epicondyle

 

Posterior elbow arthroscopy

 

Indication

 

Posterior loose bodies

Olecranon tip / fossa impingement

Retrograde capitellum OCD drilling

 

Danger

- ulnar nerve when debriding medially

 

Portals

 

Posterocentral portal

- 3 cm proximal to tip olecranon

- in midline

 

Posterolateral portals

 

Technique

- 2 - 3 cm proximal to tip olecranon

- in line lateral edge of triceps

 

Soft spot portal

 

Anconeus triangle

- olecranon tip / radial head / lateral epicondyle

- through skin, anconeus, capsule

 

Danger

- posterior cutaneous nerve

 

Uses

- retrograde drilling of capitellum

 

Elbow Arthroscopy Posterior CompartmentElbow Arthroscopy Medial CompartmentElbow Arthroscopy PosterolateralElbow Arthroscopy Posterolateral 2

 

Complications

 

Nerve injuries

 

All nerves at risk especially PIN

 

Always

- no LA

- minimise tourniquet time

- minimise pump pressure to 40

 

If PIN palsy post op

- need to explore

- usually cut

- very difficult to defend medicolegally

- only do elbow arthroscopy if trained in it and have done cadaver course

 

Vascular injury

 

Haemarthrosis

 

Stiffness

 

Infection

 

 

 

 

Capitellar OCD

Epidemiology

 

Adolescents & young adults

 

Usually between 12 - 21 years 

 

Throwing athletes / gymnasts

 

Little Leaguer's Elbow

- combination of capitellar OCD and MCL injury

- a repetitive throwing injury / seen in pitchers

 

Aetiology

 

1.  Trauma & Overuse

 

Common throwing sports / gymnastics

- dominant limb predominates

- repetitive overuse

- valgus overload on radiocapitellar joint 

- fatigue failure of the subchondral area 

- overlying cartilage fails under shear stress & separates

 

Capitellum loaded more heavily

- less able to take load than radial head articular surface

- especially if have some slight eccentric loading which can occur in throwing athlete or gymnast

 

2.  Ischaemia

 

Predominant blood supply to capitellum from posterior vessels

- histopathology shows osteonecrosis

 

Pappas Classification   

 

Category 1  - patients < 13 years of age 

Category 2  - 13 years to adulthood 

Category 3  - adults 

 

Found better prognosis with younger patients 

- especially with open capitellar growth plate

- respond better to non operative treatment

 

Symptoms

 

Dominant arm / history of over-use

 

Pain activity related

 

Limited range

- very common presentation

 

Clicking, grinding, catching, locking

- ? Loose bodies

 

Examination

 

Tender over lateral aspect elbow

 

Loss of extension

 

Radio-capitellar compression test

- active supination and pronation with arm fully extended

 

Examine MCL

 

Iwase's Classification Xray

 

Grade 1

- localised flattening and translucency

 

Capitellar OCDElbow OCD

 

Grade 2

 

A:  Small fragment without sclerosis

B:  Small fragment with sclerosis

 

Elbow OCD Type 2BElbow OCD Type 2B CT

 

Grade 3

- in situ loose body

 

DDx

 

Panner's disease / osteochondrosis

- child 4 - 8 years old

- entire capitellum involved

- not sure if is earlier spectrum of same disease

 

MRI

 

Fluid interface denotes detachment / instability

 

Capitellar OCD MRI

 

Management

 

Non Operative

 

Indications

 

Stable lesion

- intact cartilage

- nil detachment / no synovial fluid behind OCD

 

Option

 

Protected ROM

- hinged brace

- attempt to reduce axial load

- nil sports until full ROM

- 3-6 months

 

Results

 

Mihara et al Am J Sports Med 2009

- 39 baseball players mean age 13 years

- cessation of throwing, weights, push ups

- healing of lesion in 16/17 patients with open growth plates

- healing of lesion in 11/22 with closed growth plates

- 25/30 early stage lesions healed

- only 1/9 advanced stage lesions healed (Grade 2A and Grade 3)

- suggest early surgical intervention in advanced OCD

- recommend surgical intervention if no sign of healingin 3-6 months

 

Operative

 

Indications

 

1.  Failure non operative treatment

2.  Loose bodies

3.  Instability / displacement

 

Large / salvageable fragments

 

A.  Stable / Drill in situ

 

Elbow OCD InsituElbow OCD Retrograde Drilling

 

Arthroscopic technique

- anterograge via anterolateral portal if possible

- retrograde via ACL jig / posterolateral portal with elbow flexed

 

B.  Unstable / Fixation

 

Arthroscopic technique

- via soft spot portal

 

Takahara et al JBJS Am 2007

- demonstrated fragment fixation or reconstruction better than removal

- fragment fixation with bone graft

 

Small / unsalvageable Fragments

 

A. Arthroscopic Debridement

 

Elbow Scope Capitellar OCDElbow Scope OCD Debridement

 

Schoch et al Arthroscopy 2010

- arthroscopic debridement in 13 patients

- follow up average 3 years

- symptomatic relief

- 6/13 had to cease some sport

 

B.  Microfracture

 

Elbow Scope OCDElbow scope OCD Microfracture

 

C.  Abrasion

 

Elbow OCDElbow OCD Abrasion

 

Large Chondral Defects

 

A.  Mosaicplasty

 

Ovesen et al J Should Elbow Surg 2011

- 10 patients treated with mosaicplasty

- average age 21

- incorporation in all patients

- significant improvement in Mayo elbow scores

 

B.  MACI

 

Coronoid Process Fracture

BackgroundClassification Coronoid Fractures

 

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

 

Reasons

1.  Provides anterior buttress

2.  Anterior capsule and brachialis attach to coronoid

2.  Anterior band of the MCL attaches to it

- distally and medially on sublime tubercle

 

Instability rises and prognosis deteriorates according to the amount of coronoid process that is fractured

 

Fracture patterns

 

Transverse

Anteromedial facet fragment

 

Mechanism

 

Most commonly associated with elbow dislocations

Anteromedial facet fractures may be caused by varus / rotational force

 

Regan and Morrey Classification

 

Coronoid Process Classification

 

Type I 

- usually stable

- shear fracture not avulsion fracture

- may rarely cause residual instability in elbow dislocation

 

Coronoid Fracture Type 1Coronoid Fracture Type 1 CT

 

Type II 

- 50% coronoid

- elbow usually unstable

- lose attachment of capsule

- ORIF screws or sutures

- any ? about stability use hinged fixator

 

Coronoid Fracture Type 2

 

Type III

- > 50% coronoid

- Uncommon

- unstable as lose capsule +/- MCL with anteromedial fragment

- ORIF with screw / sutures / anteromedial buttress plate

- again may need hinged fixator

 

Type 3 Coronoid FractureCoronoid Fracture Type 3

 

Operative Management

 

Surgical approach

 

1.  Universal posterior approach

- if performing surgery for complex dislocation

- allows medial and lateral access to joint

 

2.  Lateral approach through radial head

- if excising radial head, then replacing

 

3.  Medial approach

- isolate and protect ulna nerve  

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

- important if fracture is anteromedial

 

4.  Approach through fractured olecranon

 

Options

 

Type 1

- capsular suture repair

 

Type 2 / 3

A.  Screws (AP or PA)

B.  Pass sutures through capsule and tie over drill holes in ulna

 

Anteromedial fragment

- medial approach / buttress plate

 

Coronoid Process Buttress Plate

 

Unrepairable / unstable

- reconstruct with radial head, iliac crest, or allograft

 

Cubitus Varus

Incidence

 

Occurs 10% of supracondylar humeral fractures

- varus malunion

 

Lateral condyle fracture

- AVN trochlea

 

Elbow Cubitus Varus

 

Growth arrest of medial aspect physis

- rare

- post traumatic

 

Effects

 

Usually little functional defect

 

Cosmetic problem

- appearance can be unacceptable to parents and child

 

NHx

 

Does not correct with time

 

Operative Management

 

1.  Lateral closing wedge osteotomy of the supracondylar region 

- perform at skeletal maturity

- metaphyseal not diaphyseal

- preserve medial cortex

- beware abnormal position of radial nerve (passes through callous)

- 1mm of wedge for each degree

- fixation with plate

 

2.  Complex Osteotomies

- posterior approach

- bilateral plates

- for severe deformities

 

Elbow post distal Osteotomy

 

3.  Young patient / open physis

- guided growth

- application lateral 8 plate

 

 

 

Dislocation

Anatomy Pathology

EpidemiologyElbow Dislocation LateralComplex Elbow Dislocation AP

 

6 /100 000

- second most common dislocation after shoulder

 

Mechanism

 

FOOSH

 

Goal

 

1.  Obtain and maintain a concentric reduction 

2.  Achieve a painless and functional ROM

 

Associated Injuries

 

20% neuropraxia (ulna nerve / AIN)

 

Classification

 

Final position of Ulna Relative to Humerus

 

Posterior

Posterolateral

 

Degree

 

1.  Complete 

 

2.  Subluxed / Perched (Drop sign)

- < 10 % patients

 

Simple / Complex

 

25-50% associated with fracture

 

Timing

 

Acute / Chronic / Recurrent

 

Bony Anatomy

 

Ulnohumeral Joint

 

Trochlea and ulna highly conformed

- trochlea covered by cartilage in arc 300o

- trochlea separated from the capitellum by groove in which rim of radial head articulates

- trochlea 6o valgus which creates carrying angle

 

Radiocapitellar Joint

 

60% of load at elbow

- concave radial head with capitellum

- posteromedial 2/3 articulates with sigmoid notch ulna

- anterolateral 1/3 has no cartilage /  safe zone

 

Anterior part of radial head fractures normally

- part of spectrum in dislocation

- radial head important secondary stabiliser, especially when MCL deficient

 

Radial head and neck form an angle of 15o with the shaft

 

Distal Humerus

 

Tilted anteriorly 30o in lateral plane

- 5o internally in transverse plane

- 6o of valgus in front plane

 

Elbow Valgus Carrying angleElbow Trochela Anterior Angulation

 

Centre of rotation

- trochlea

- centre of rotation offset anteriorly from humeral shaft

 

Elbow Centre of Rotation

 

LCL

 

LCL anatomy elbow

 

Action

- Varus Stability

 

LCL has 4 Components

 

1. Annular Ligament

- anterior edge supinator crest to posterior edge

 

2. Radial Collateral Ligament

- CEO to annular ligament

- fan-shaped

 

3. Lateral Ulna Collateral Ligament 

 

Most important restraint to PL instability

- CEO to supinator crest

 

Must protect in Kocher approach

- in line with edge of anconeus, deep to it

- must protect in surgical approach between anconeus and ECU

 

4.  Accessory Collateral Ligament

- from crest to diffusely over annular ligament

 

MCL

 

Elbow MCL

 

Action

- primary restraint to valgus stability

- especially in flexion

- this is the position in the throwing athlete

- in extension radial-capitellar joint important

 

3 parts

 

1. Anterior band

- CFO to sublime tubercle

- most important

 

2. Transverse band

- olecranon - sublime

- groove for ulna nerve

 

3. Posterior band

- CFO to olecranon

 

Constraints to Elbow Instability 

 

Primary Static

 

1.  Ulnohumeral articulation

- olecranon and coronoid

 

2.  MCL 

 

3.  LCL

 

Secondary Static

 

1.  Radio-capitellar joint

 

2.  CFO / EFO

 

3.  Capsule

 

Dynamic Stabilisers

 

Anconeus - PLR stability

 

Triceps / Brachialis / Biceps

 

Pathoanatomy / Horii circle

 

Begins on the lateral side, progresses to the medial side in three stages

- anterior band of MCL is the last torn

 

Stage 1

 

Damage to LCL

- Posterolateral Rotatory Subluxation

- this can reduce spontaneously

 

Stage 2

 

Damage to anterior and posterior capsule

- posterior capsule quite insignificant

- anterior important

 

Coronoid appears perched on trochlea

- incomplete PL dislocation

- concave medial edge of ulna on trochlea

- can be easily reduced or even by patient

 

Stage 3

 

Medial disruption

 

Stage 3A

 

Anterior band of MCL intact

- postero-lateral dislocation

- pivots about this anterior band

- often seen with radial head and coronoid fracture

 

Reduce with traction, varus and pronation

 

Maintain stability with hand pronated

- stability provided by anterior MCL

 

Stage 3B

 

Entire MCL disrupted

- varus / valgus / rotatory instability present after reduction

 

Need to be flexed > 30 - 40o to be stable

 

Stage 3C

 

Unstable at 90o

 

Entire distal humerus stripped / CFO / CEO

- reduction maintained only with flexion > 90o

 

Hinged External Fixator

External fixator elbow 1External Fixator Elbow 2

 

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

 

Compass Hinge Lateral XrayCompass Hinge AP Xray

 

Compass HInge Medial ClinicalCompass Hinge Clinical

 

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

 

Compass Hinge Centre of Rotation

 

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

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

 

 

Distal Biceps Tendon Rupture

Epidemiology

 

Dominant arm of middle aged men

- between 40 and 60

 

Aetiology

 

Sudden dramatic event

- sporting / weightlifting injury

- resisting heavy extension load

 

Pathology

 

Degenerative changes seen on histology

 

Types

 

Complete

- retracted / rupture of lacertus fibrosis

- minimally retracted

 

Partial

- small - partial tears of some fibres

- large - near complete avulsion of biceps tendon from radial tuberosity

 

NHx

 

Complete tears / non operative management

- 30% loss of flexion strength

- 50% loss of supination strength

 

Examination

 

Distal Biceps Rupture

 

Acute onset pain / distal swelling / bruising

 

Biceps muscle may bulge proximally

- not always seen as lacertus fibrosis may be intact

 

Hook test

- attempt to hook finger about biceps tendon

- unable to palpate biceps tendon

 

O'Driscoll et al Am J Sports Med 2007

- Hook test negative in partial tears

- but 9/12 painful with this test

 

Biceps Tendon Hook Test

 

Weakness

- supination > flexion

 

Distal Biceps Rupture 1Distal Biceps Rupture 2Distal Biceps Rupture 3

 

X-ray

 

May see bony avulsion from radial tuberosity

 

MRI

 

Confirm diagnosis

 

A.  Complete tear / retracted

- relatively easy to diagnose

 

Distal Biceps Rupture MRI

 

B.  Partial tear

 

Best evaluated on the axial view

- absence of low signal intensity biceps tendon insertion onto tuberosity

- present of soft tissue oedema

 

MRI Biceps Partial TearBiceps Partial tear

 

Festa et al J Hand Surg Am 2010

- MRI 100% sensitive for full thickness tears

- MRI only 59.1% sensitive for partial tears

 

Management

 

Non-operative

 

Indication for complete tears

 

Elderly patients who do not require full strength and endurance

 

Usually lose one grade power with distal avulsion

- decreased strength and endurance 

- supination and flexion

- i.e. labourer might have difficult with inserting screws

 

Operative

 

Indication

 

Young active patients with recent rupture 

- may be more difficult with chronic tears

 

Options

 

Two incision Boyd and Anderson

- anterior incision to retrieve tendon

- posterior incision to attach tendon to radial tuberosity

- associated with radioulnar synostosis

- less risk of inadvertant PIN injury

 

One incision

- single anterior incision

- use suture anchors / endobutton to fix to tuberosity through this incision

- theoretical higher risk PIN injury

- endobutton fixation 2 - 3 x higher strength than suture anchors

 

Operative Technique:  One incision technique with endobutton

 

Set up

- supine, arm board, tourniquet

 

Incision

- longitudinal medially / transverse across cubital fossa / longitudinal mobile wad

- S shaped

 

Find biceps tendon

- proximally above brachialis

- Allis clamp

- mobilise by blunt dissection

- deliver into wound

 

Distal Biceps Repair IncisionDistal Biceps Tendon with EndobuttonDistal Biceps Repair Final

 

Fixation with no 2 Ethibond / Fibre wire

- Krackow suture

- enter lateral aspect tendon proximally

- suture down to distal aspect

- pass around middle two holes of endobutton

- back up medial aspect and tie

- leave 2 mm space between endobutton and distal end of tendon

- allows space for dorsal cortex of radius

 

Insert passing sutures and flipping sutures in lateral holes

- no 2 ethibond to pull through

- 1 vicryl to flip

- different colours to help you tell which is which

 

Dissect down to radial tuberosity

- find and protect LCNFA

- under cephalic vein

- mobile wad laterally with radial nerve

- blunt dissect down to radial tuberosity

 

Prepare radial tuberosity

- forearm fully supinated

- make trough for tendon with burr

- avoid lateral retractors which can inadvertantly injure PIN

 

Pass guide wire through dorsal cortex 

- aim distal and medial

- pass cannulated 4.5 endobutton reamer

- pass beath needle with sutures

- pass and flip endobutton

- check II

 

Distal Biceps Endobutton RepairDistal Biceps Endobutton Repair

 

Post op

- splint for 2 weeks

- then active assist ROM

- no heavy lifting for 8/52

 

Results

 

Greenberg et al J Should Elbow Surg 2003

- endobutton technique

- patients had 97% flexion strength

- 82% supination strength

 

Khan et al Arthroscopy 2008

- suture anchor repair in 17 patients

- 5 degee loss of extension and rotation

- strength 80% other side

 

John et al JSES 2007

- suture anchor repair in 53 patients

- 46 excellent results, 7 good

- HO in 2 patients

 

Chavan et al Am J Sports Med 2008

- systematic review

- endobutton strongest

- increased complications in two-incision techniques

 

Mazzocca et al Am J Sports Med 2007

- biomechanical study

- endobutton (440N) stronger than suture anchors (380N) or bone tunnel (300)

 

Lo et al Arthroscopy 2011

- 11 mm to PIN if aim directly across long axis of radius

- increases to 16 mm if aim 30 degrees to the ulna side

- aiming distally 45 degrees and radially decreased this to 2 mm

 

2 incision Boyd and Anderson Technique

 

Technique

 

Anterior Henry approach as before

 

Passed curved haemostat 

- maximally pronate forearm

- hug border of radius

- avoid periosteum of ulna to prevent synostosis

- palpate tip dorsally in extensor mass

- dissect down to radius

 

Thompson's approach

- line from lateral epicondyle to lister's tubercle

- between EDC and ECRB

- expose supinator

- find and protect PIN

- subperiosteally detach supinator

 

Repair

- performed through bone tunnels

 

Results

 

Greewal et al JBJS Am 2012

- single incision (anchors) v double incision (drill holes)

- RCT 91 patients

- double incision 10% stronger flexion strength

- increased transient neuropraxis LCNF in single incision

- ASES / DASH scores same in each group

- 4 re-ruptures due to lack of complicance

 

Partial Tears

 

Management Options

 

Bain et al Sports Med Arthrosc 2008

- non operative treatment < 50%

- operative treatment for > 50%

 

Surgical Treatment of a Partial Tear

 

Biceps ApproachBiceps Partial TearBiceps Partial Tear 2Biceps Partial Tear 3

 

Repair with suture anchors

 

Biceps Suture Anchor Repair

 

Chronic Tears

 

> 3 weeks old

- harder to repair

- associated with higher complication rates

- have to repair in significant position of flexion

 

Options if flexion > 70o required for fixation

1.  Semitendinosus graft

2.  Fixation to brachialis

- restores flexion strength

- doesn't restore supination strength

 

Complications

 

Infection

Rerupture

Injury LCNFA

Injury PIN

Loss of extension

- more common with chronic injuries

Distal Humerus Fractures

EpidemiologyDistal Humeral Fracture

 

2 groups

- young patient with high velocity injury

- older patient with comminuted, osteoporotic fracture

 

In the second group fixation can be very difficult

 

Anatomy

 

Hinged Joint

- trochlea axis is centre of rotation

- 40o anterior angulation in sagittal plane

- trochlea 3-8o externally rotated

- 4 - 8o valgus

- medial and lateral columns

 

Elbow Lateral NormalElbow Lateral Normal 40 degree anterior angulation

 

Elbow AP NormalElbow Normal AP 4 degrees valgus

 

CT scan

 

Aids preoperative planning

- identify capitellar fracture

- identify if trochlea deficiencies which might need bone grafting

- aid diagnosis / reconstruction intr-articular extension

 

Muller's Classification

 

Type A: Extra-articular fracture

 

Distal Humerus Fracture

 

Type B: Uni-condylar fracture

- lateral /  medial

 

Elbow Medial Condyle FractureElbow Lateral Condyle Fracture

 

Type C: Bi-condylar fracture

 

Distal Humeral Fracture APDistal Humeral Fracture BicondylarDistal Humeral Fracture

 

Operative Management

 

Timing

 

Within 24 hours or at 5 - 7 days

- minimises inflammation

- minimises risk HO

 

Options

 

1.  ORIF

 

2.  Distal humeral replacement / osteoporotic and highly comminuted fractures

 

Kalogrianitis et al J Should Elbow Surg 2008

- 9 patients mean age 37

- highly comminuted, osteoporotic, non reconstructable fractures

- no deep infections

- ROM 15 - 120o

 

McKee et al JSES 2009

- RCT 42 patients > 65 years of age

- ORIF vTEA

- 5 ORIF patients converted to TEA intraop

- better outcomes and decreased reoperation rate with TEA

 

Impression

- good treatment if unable to ORIF

- high level of skills required

- can replace distal humerus only if ligaments and proximal ulna preserved

- otherwise must replace ulna +/- linked prosthesis

 

3.  "Bag of bones" treatment

- patient elderly and not operative candidate

- intial rest in plaster

- then mobilisation

- surprisingly good ROM and function

 

Distal Humerus Non Operative

 

Approach

 

Extra-articular fracture

 

Distal Humerus Extraarticular ORIF

 

1.  Mobilise triceps either side of humerus 

- reduce distal fragment and hold with K wires

- application 2 x perpendicular plates

 

2.  Bryan - Morrey Triceps sparing posteromedial approach

- find and protect ulna nerve

- elevate triceps aponeurosis medial to lateral off ulna

- leave one side of periosteum intact

 

3.  Split triceps

- feather with osteotome off ulna medial and laterally

 

Intra-articular fracture

 

Need to visualise distal humerus to get anatomical reduction

- olecraonon blocks visualisation

- Chevron Osteotomy

 

Technique for Intra-articular fracture

 

Distal Humerus ORIF APDistal Humerus ORIF Lateral

 

Position

- lateral decubitus with bolsters

- arm over bolster

- tourniquet

- may need to prep and drape iliac crest for bone graft

 

Elbow Lateral Decubitus

 

Posterior approach

- midline posterior incision is used

- deviate radial side of olecranon (prevents painful incision)

- ulnar nerve identified / mobilised / vessiloops / protected

 

Chevron Olecranon Osteotomy

 

Chevron Osteotomy

 

Technique

- predrill proximal ulna with 3.2 mm bit 

- partially tapped for 6.5 mm cancellous screw

- cut with oscillating saw, apex distal

- homan retractors each side to protect structures

- attempt to make in bare area of central olecranon

- 3 cm from tip olecranon

- complete with osteotome so can interdigitate fracture and not saw away segment of articular cartilage

- take fragment and retract proximally, taking triceps with it to expose distal humerus

- radial nerve 14 cm proximal to lateral epicondyle

- wrap in wet sponge, clip with artery to drapes

 

Restoration of Articular Anatomy

- Anatomic reduction of the condyles / distal articular surface

- ORIF with cannulated 4.0 mm partially threaded screws

- reduce fragment onto distal humerus

- fix with K wires in medial and lateral columns

- check with II

 

Pre-contoured locking plates

- posterolateral and medial

- ensure not of equal length to decrease stress risers proximally

- can get variants of posteriorlateral plate to fix coronal plane fracture of capitellum (AP screws in PL plate)

- fix with locking screws

- ensure not in olecranon or coronoid fossa  

 

Assess ROM

- no block to motion

- good stability

 

Check II

 

Assess ulna nerve 

- ensure not impinging on medial plate   

- may need to consider anterior transposition  

 

ORIF olecranon

- 6.5 mm screw + washer, then wire tension band

- may need plate if screw does not get good bite

- can use K wires and TBW

 

Post op 

 

POP backslab 2/52 for wound healing

Range if stable with physio / active assist

- avoid PROM (HO)

 

Results

 

G/E 75%

 

Complications

 

ROM

- loss of 10 - 20o extension common

 

Humeral non union

 

Olecranon osteotomy non union

- 5%

- bone graft and plate

 

Ulna nerve palsy

- keep in mind the need to perform anterior transposition in original OT

- treat with neurolysis + transposition

 

Painful Hardware

- most common

- re-fracture risk if remove both plates

 

Adult Lateral Condyle Fracture

 

Elbow Lateral Condyle FractureElbow Lateral Condyle Fracture 2

 

Definition

 

Fracture of lateral condyle

- involve capitulum alone

- may extend medially to involve the lateral portion of trochlea

 

Management Options

 

These fractures are typically displaced and require surgical treatment

- Kocher approach and ORIF with compression screws

- Posterior approach and posterolateral plate

 

Adult Medial Condyle Fracture

 

Elbow Medial Condyle Fracture

 

Anatomy

 

Medial epicondyle is common origin of several flexor muscles of hand and wrist

When medial epicondyle is fractured, flexor muscles pull fragment distally

 

Management

 

1.  Medial approach

- find and protect ulna nerve

- ORIF with screws

 

2.  Posterior approach

- find and protect ulna nerve

- application of medial plate / ORIF with screws

- ensure at end no encroachment of  plate on nerve or might need anterior transposition

 

Transcondylar Fracture

 

Definition

 

Type of supracondylar fractures that occurs within joint capsule

- very distal / often very comminuted

- most commonly occurs with osteoporotic bone

 

Treatment

 

Non-displaced fractures are treated with splinting or percutaneous pinning

 

Displaced fracture

- consider ORIF

- may need to consider primary hemiarthroplasty / elbow replacement

 

Capitellar Fracture

 

Uncommon fracture which is difficult to diagnose if fracture fragment is small

 

Elbow Capitellar FractureCapitellar Fracture CT SagittalCapitellar Fracture CT Axial

 

Type I

- Hans Steinthal fracture

- fracture of the capitellum in the coronal plane

- involves large part of the osseous portion of capitulum

- fracture hinges anteriorly between radial head and radial fossa producing a block to flexion

 

Management

 

If closed reduction is obtained, then reduction is usually stable with elbow flexion

 

Open reduction

- Kocher approach

- one or two headless compression screws

- front to back

- buried

 

Capitellar Fracture ORIF0001Capitellar Fracture ORIF0002

 

Type II

- Kocher Lorenz fracture               

- affects primarily articular cartilage and very little underlying bone

- these usually cause few subsequent joint problems

 

Management

- healing potential is minimal & excision is recommended

Epicondylitis

Lateral Epicondylitis / Tennis Elbow

Incidence

 

Lateral : Medial 9:1

 

Epidemiology

 

4th & 5th decades

- M = F

- 75% dominant arm 

 

50% of regular tennis players

- especially > 2 hrs / week

 

Aetiology

 

Insertion pathology / Enthesopathy

 

Over-extension of the elbow with supination / pronation

 

Anatomy

 

Lateral epicondyle

- anconeus from posterior face

- ECRB and EDC from anterior face (CEO)

- ECRL and BR from lateral supracondylar ridge

 

Differentiate ECRB from ECRL

- ECRB tendinous insertion onto lateral epicondyle

- ECRL still muscular at this point (arises more proximally)

 

LCL

- apex of lateral epicondyle

 

PIN

- radial nerve between brachialis and BR

- divides at level of radial head

- enters supinator at this level (radial tunnel)

 

DDx

 

1.  OCD capitellum / radial head

2.  Radial tunnel / supinator / PIN syndrome

3.  PLRI

4.  OA, RA

5.  Referred Pain / C6-7 radiculopathy

6.  Enthesopathy

7.  Annular ligament tears

 

Risk factors

 

Tennis

- poor technique

- poor grip

- hard court surfaces

- strings too taut

 

Occupational

- plumbers

- painters

 

Pathophysiology

 

Starts as micro-tear in ECRB 

 

Histology

 

Angiofibrotic hyperplasia

- marked fibroblast proliferation

- extensive vascular hyperplasia

- disorganised collagen production

- may go on to dystrophic calcification

 

Disruption of parallel orientation of collagen fibres 

- invasion of fibroblasts and vascular granulation type tissue

- without an acute or chronic inflammatory component

 

History

 

History of overuse

Pain lateral elbow

Backhand in tennis main problem

 

Examination

 

Localised Swelling

 

ROM

- few degrees loss of extension = CEO

- >15-20° loss is intra-articular pathology

 

Tender ECRB

- 5 mm distal and anterior to CEO

 

Test

- pain with resisted wrist dorsiflexion with elbow extended

 

Examine for Stability - PLRI

Examine Supination / Pronation - radiocapitellar OA

Examine C spine

 

DDx

 

Radial Tunnel Syndrome

- tenderness 3-4 cm distal to lateral epicondyle

- pain with resisted thumb / IF and supination

 

Xray

 

Usually normal

25% soft tissue calcification

 

Tennis Elbow CalcificationTennis Elbow Bone Spur

 

NCS 

 

Normal

 

MRI

 

Will demonstrate tears and oedema on T2

 

Elbow MRI Lateral Epicondylitis

 

Management

 

Non Operative

 

Timing

 

6-9 months

- successful ~ 75- 85%

 

Rest Phase

 

Complete rest lasting for 3-6/52

-  avoid precipitating factors

 

NSAIDs

- oral or topical

 

Brace

- wrist in extension

- cock up wrist splint

 

Forearm tennis band

- limit muscle expansion

- may create new force direction

 

HCLA injection

- find patient's maximum tenderness deep to fascia 

- repeat 2-3 times over 6-12 months

- peri not intra-tendinous

- must then rest the tendon for it to work long term

- risks of local skin depigmentation and CEO rupture

 

Conditioning Phase

 

Once pain settled

- Extensor origin stretching 

- Wrist extension exercises (1lb increments)

- eccentric muscle training

- ART (active release technique)

- Activity modification / change racquet and stroke

 

Tyler et al J Should Elbow Surg 2010

- RCT using eccentric muscle training

- significant improvement in outcome

 

Adjuctive Therapy

 

1.  Shock wave lithotripsy

 

Meta-analysis of RCT

- minimal effect comparted with placebo

 

2.  Autologous Blood / PRP Injections

 

Peerbooms et al Am J Sports Med 2010

- RCT autologous blood v corticosteroid

- superior outomes with plasma cell injections at one year

 

3.  Botox Injections

 

Improvements compared with placebo

Inferior to corticosterioid

 

Operative Management

 

Indication 

 

Failure of good non-operative management

- > 6 - 12/12

 

Options

- open debridement

- percutaneous tenotomy

- arthroscopic

- radiofrequency microtenotomy

 

Open debridement

 

3 cm incision 

- centred on CEO

- ECRB is deep and posterior to ECRL

- ECRL muscular at this point

 

Surgical dissection

- Detach ECRB

- Debride degenerative tissue

- Decorticate underlying CEO

- +/- reattach ECRB

 

Tennis Elbow ReleaseTennis Elbow Release 2

 

Tennis Elbow Release 3Tennis Elbow 4

 

Modifications

- Z lengthen

- denervate sensory nerves to epicondyle

- combine with decompression PIN

- cover with anconeus flap in chronic or recurrent cases

 

Post-op

- splint 10 days

- gentle ROM to 6/52

- then strengthening exercises

 

Arthroscopic Release

 

Arthroscopic Tennis Elbow Release 1Arthroscopic Tennis Elbow Release 2Arthroscopic Tennis Elbow Release 3

 

Complications

 

Instability

- inadvertant release LCL

 

Neuroma

- posterior cutaneous nerve forearm

- runs 1.5 cm anterior to lateral epicondyle on BR fascia

 

HO

- rare, but can be devastating

 

Results

 

Dunn et al Am J Sports Med 2008

- retrospective study of 92 elbows over 12 years

- open release

- 84% good to excellent results

 

Baker et al Am J Sports Med 2008

- 42 patients with arthroscopic resection followed up for 10 years average

- 87% patient satisfaction

 

Dunkow et al JBJS Br 2004

- RCT open v percutaneous tenotomy

- earlier return to work and faster recovery

 

Meknas et al Am J Sports Med 2008

- RCT of open release v microfrequency tenotomy

- no difference in pain relief

- better grip strength at 12 weeks

Medial Epicondylitis / Golfers Elbow

Incidence

 

10% of elbow tendonitis

 

Aetiology

 

Overuse injury

- poor swing in golf

- poor throwing technique

- overuse of topspin in tennis

- occupational (repetitive hammering / screwing)

 

Some patients also have lateral epicondylitis

 

Examination

 

Tenderness CFO

 

Stimulate pain

- flexion of WJ with fingers resisting

- resisted pronation 

- resisted ulna deviation

 

May have ulna nerve symptoms

 

Xray

 

Rule out OA / OCD elbow

 

DDx

 

MCL insufficiency

- must differentiate from MCL instability

- if release CFO in setting of MCL laxity will have frank instability post-op

 

Management

 

Non-Operative Management

 

As per tennis elbow

 

Operative Management

 

Surgical Release

 

Medial incision

- identify and protect ulna nerve

- release of CFO

- protection of MCL

- debridement of scar and bony prominence

- drill holes into epicondyle

- reattachment of CFO

- + / - Ulnar nerve decompression

 

Post op

- splint

- no resisted wrist flexion / pronation 6 - 8 weeks

- no sport for 4 - 6 months

 

Results

 

Segal 1992

- small series 

- 11 of 16 good results with operative release

 

Vangness JBJS Br 1991

- 35 operative cases

- felt the underlying pathology was a tear in the CFO

- incomplete healing

- treatment as described above

- 34/35 good or excellent results

- 1 patient could not return to sport

 

 

 

Forearm Fractures

Anatomy

 

Radial bow radius

- important for rotation

 

Interosseous membrane

- Z pattern

- proximal radius to distal ulna

 

Mechanism

 

Direct blow

- ulna / night stick

 

Ulna Fracture Night Stick

 

Indirect

 

Monteggia

- Proximal 1/3 ulna fracture with radial head dislocation

 

Elbow Monteggia FractureElbow Monteggia Fracture ORIF

 

Monteggia Variant

- proximal 1/3 ulna fracture with radial head / neck fracture

 

Monteggia Variant APMonteggia Variant Lateral

 

Galleazzi

- distal 1/3 radial fracture with DRUJ disruption

 

Galleazzi APGalleazzi LateralGalleazzi Xray APGalleazzi Xray Lateral

 

Associated Injuries

 

Ulna can be compound

Compartment Syndrome

 

Compound Ulna

 

X-ray

 

Joint above and below

 

Elbow

- always assess radial capitellar line on two views

 

DRUJ disruption

- widened space between R & U

- radial shortening > 5 mm

- ulna styloid fracture

 

Classification

 

Isolated single bone

 

Both bone

 

Fracture of one bone with ligament rupture

- Galleazzi, Monteggia

 

Fractures of bone bones with ligament rupture

 

Non operative Management

 

Indications

 

Ulna

- < 10o angulation

 

Ulna Fracture Undisplaced

 

Radius

- completely undisplaced

- maintenance radial bow

 

Operative Management

 

Options

 

Intramedullary fixation

- children (good remodelling potential)

- prophylaxis to prevent pathological fracture

 

Ulna Intramedullary Wire

 

External Fixation

- severe injury / compound

 

Plate fixation

 

Ulna Plating

 

Goals

 

Anatomical reduction with absolute stability

- length

- rotation

- radial bow (need to bend plate for long fractures)

 

Approach

 

Forearm Fractures Plate LateralForearm Fractures Plate AP

 

Ulna

- approach between ECU / FCU

 

Radius

 

Distal

- between FCR and radial artery

 

Proximally

- between BR and pronator teres

- supinate forearm

- elevate supinator from ulna to radial

 

Galleazzi

 

Incident DRUJ instability

- up to 50% if fracture radius < 7.5 cm to distal articular surface

- < 5% if > 7.5 cm

 

Galleazzi ORIF 1Galleazzi ORIF 2

 

Plate distal radius

- assess DRUJ stability

- if stable, early ROM

- unstable, splint in supination

- if still unstable, ensure that radius is anatomical

- may have to repair TFCC / ORIF ulnar styloid

- if still unstable, may rarely have to K wire ulna to radius

 

Galleazzi ORIF APGalleazzi ORIF Lateral

 

Complications

 

Nonunion

- 2%

- exclude infection

 

Radial Fracture Non Union CTUlna Non Union

 

Malunion

 

Problem

- > 10o angulation leads to loss of ROM

 

Management

- osteotomy

 

Radial Fracture Malunion Radial Fracture Malunion 2Radial Osteotomy Radial Osteotomy Lateral

 

Infection

 

Management

 

Initial

- excise non union 

- debridement

- ABx cement spacer + external fixator

- eliminate infection

 

Obtain union

- BG and plate

 

Compartment syndrome

- don't close fascia

- good haemostasis

 

Synostosis

 

Risk factors

- fractures at same level / Monteggia

- proximal fractures

- open fractures

- head injuries

- bone grafting

- ORIF through single incision

- delayed surgery > 2 weeks

 

Management

 

Excision

- usually posterior approach

- elevate ECU from ulna

- exposes synostosis and radius

- application of bone wax to bone after debridement

- +/- irradiation / indomethacin especially in head injured patients

- worst results with proximal synostosis

 

MCL Insufficiency

AetiologyTommy John Surgery

 

Throwing injury

- seen in the throwing athlete

- repetitive microtrauma / valgus stress

- develop laxity

 

History

 

Initially

- lose velocity / accuracy

 

Develop medial pain

 

40% ulna nerve symptoms

 

Examination

 

Pain on palpation of anterior bundle MCL

 

CFO muscle bulk covers insertion in full extension

- reveal UCL with flexion

 

Jobes test

 

Valgus stress with elbow flexed 25o to unlock olecranon

- forearm pronated to prevent false positives due to lateral side laxity

- problem is shoulder ER

 

Modification

- lie patient prone

- apply valgus stress

 

Elbow MCL Test ProneElbow MCL Test Prone 2

 

Milker test

- shoulder ER

- thumb pointing out

- extend arm whilst placing valgus strain

 

MIlkers Sign 1Milkers Sign 2

 

Anatomy

 

Elbow MCL Anatomy

 

X-rays

 

40% calcification MCL

 

Stress view

- > 3mm difference from opposite side

 

MRI

 

Nearly all throwing athletes / pitchers will have abnormalities

- don't decide surgery on basis of MRI findings

 

Management

 

Non Operative

 

RICE

NSAIDS

 

Physio      

- may be muscle imbalance in throwers 

- overactivity of EDC and ECRB aggravates valgus

- physio to balance flexors and extensors 

- radial deviators vs Ulna deviators

- if doesn't settle consider reconstruction

 

Really amounts to 6/12 rest

- problem for professional athletes

 

Operative

 

Tommy John Surgery

 

Named after famous American baseball pitcher

- first to have this surgery

 

Options

 

1.  Repair

- not often able to be done

- perhaps in acute tear

 

2.  Reconstruction with free graft

+ / - transpose ulnar nerve anteriorly out of the way

- many techniques described

 

UCL reconstruction

 

Tommy John Surgery

 

Numerus techniques described

 

Palmaris longus / gracilis graft

 

Ulna tunnel

- proximal ulna at level coronoid tubercle

- AP

 

Humeral tunnel

- medial epicondyle

- Y shaped

- no posterior cortical penetration to avoid injury ulna nerve

 

Figure of 8

- tension at 30o

- suture both limbs together to improve tension

 

Post-Op

 

Immobilise for 10/7

ROM brace for 4/52

 

No throwing for 6/12

No sport for 12/12

 

Results

 

Jimmy Andrews et al Am J Sports Med 2010

- modification Jobe technique + subcutaneous ulna nerve transfer

- 942 patients followed up for 2 years minimum

- 83% returned to previous level of sport

- returned to throwing at 4 - 5 months

- return to full sport at 12 months

 

Posterior Elbow Impingement

 

Symptoms

 

Cause posteromedial pain

- probably related to subtle UCL instability

 

May be protective

 

Examination

 

Pain posteromedially with full extension

 

CT

 

Identify posterior olecranon osteophytes

 

Management

 

Arthroscopic Resection

 

Maximum 2 - 3 mm

- if remove too much arthroscopically

- high incidence of UCL tear

- probably protective

Myositis Ossificans

 

Elbow Myositis OssificansElbow Myositis Ossificans

 

DDx

 

Parosteal OS

- bone is not continuous with cortex in MO

 

Aetiology

 

3% incidence in elbow joint trauma to some degree

 

Head + elbow joint trauma > 90%

 

Pathogenesis

 

Ectopic bone may ossify ligaments and capsule

- does not respect anatomical boundaries

- can completely envelope ulna nerve

- may form radio-ulnar synostosis

 

Usually in brachialis

 

Xray

 

Elbow HO

 

CT

 

Show mature trabeculation

Define anatomical location

 

Elbow CT Posterior HOElbow CT HO Anterior

 

Surgery

 

Timing

 

Gartland 

- negative Alk Phos and negative bone scan do not rule out recurrence after excision

- recommends do not resect till about 18/12

- well defined trabeculae on x-ray

 

Excision must be coupled with prophylaxis

 

Prophylaxis

 

Indomethacin

- 25 mg tds for 2 - 6 weeks

 

Radiotherapy

- 700 Gray single dose post operatively

 

Prognosis

 

A poor neurological recovery and spasticity associated with recurrence

 

Approach 

 

Depends on site of ectopic bone

 

Options

- posterolateral

- anterolateral

- medial

 

Elbow HO Excision PreopElbow HO Excision Post op

 

Complications

 

Recurrence

 

Nerve injury

 

Beware post operative instability

 

Elbow Post HO Excision

 

 

Olecranon Fracture

Definition

 

Intra-articular proximal ulna fracture

 

Anatomy

 

Articulates with trochlea

- may have a central bare area

 

Triceps insertion

- via broad aponeurosis which blends with anconeus and CEO

 

Management

 

Non operative Management

 

Undisplaced fracture

- need to ensure triceps mechanism is intact

- Long arm POP 3/52 in 90o flexion

 

Operative Management

 

Indications

 

1.  Disruption of extensor mechanism

- any displaced fracture

2.  Articular incongruity

 

Options

 

TBW

Plate

Excision fragment / triceps advancement

 

TBW Technique

 

Elbow Olecranon FractureOlecranon Fracture AP TBWOlecranon TBW Lateral

 

Goal

- convert the tensile distraction force of triceps into a compressive force at the articular surface

 

Options

- bi-cortical K wires

- intra-medullary k wires

- intramedullary screw

 

Contraindication

- fracture distal to centre of rotation / midpoint of trochlea notch

- highly comminuted fractures

- oblique fractures

- best to use plate in these situations

 

Technique

- lateral decubitus over bolster

- curvilinear incision to avoid prominence of olecranon

- clean and washout haematoma

- reduction (extend elbow to defunction triceps / place bone forcep)

- 2 x IM k wires (no need to bite anterior cortex / risk nerve injury)

- drill hole in ulna, pass 20 gauge wire

- form figure of 8 wire about wires, can pass under triceps

- twist via 2 knots

- bury end of K wires under triceps

 

Screw / TBW

 

Beware bow of proximal ulna

- may cause medial shift

- avoid long screw

 

Plate

 

Olecranon Fracture Lateral

 

Indication

- fracture distal to centre of rotation

 

Main problem is hardware prominence

- precontoured low profile

- proximal hooks to grip triceps

- beware over compression articular surface in comminuted fractures

 

Olecranon Plate

 

Excision fragment / triceps advancement

 

Indications

- elderly

- osteoporotic

- < 50% articular surface

- non reconstructable

 

 

 

 

Osteoarthritis

Epidemiology

 

Relatively rare

 

Average age 50

 

Men 4:1 Women

 

Usually dominant arm

 

Aetiology

 

Primary

- associated with strenuous manual labour

 

Secondary

- trauma

- OCD

- synovial chondromatosis

- valgus extension overload / MCL insufficiency

 

Pathology

 

Begins radiocapitellar joint

 

Progresses to ulnohumeral joint

 

Forces across joint about 1/2 body weight

- increased in strenuous work

- small cross sectional area

- increases contact stresses

 

Clinically

 

Often have end range pain

- minimal in mid range

- pain when olecranon and coronoid osteophytes impinge

 

X-ray

 

May have well preserved radiocapitellar and ulnohumeral joints

 

Osteophytes olecranon and coronoid

 

Elbow OA LateralElbow OA AP

 

CT

 

Useful in defining antomy pre operation / identification loose bodies

 

Elbow Arthritis CT

 

Elbow Loose Bodies CTElbow Loose Bodies CT 2

 

MRI

 

Useful in detecting early chondral damage

 

MRI Radiocapitellar OAMRI Ulna Trochlea OA

 

Arthroscopy

 

Capitellar Chondral InjuryRadial Head Chondral DamageUlna Chondral Damage

 

DDx

 

Inflammatory arthritis / RA

- minimal osteophytes

- severely arthritic joint spaces

- have pain throughout range of motion

 

Management

 

Non operative

 

Analgesia

HCLA

 

Operative

 

1.  Open procedures

 

A.  Open capsular releases

- for stiffness

- releases as required

 

See Elbow / Stiffness

 

B.  OK procedure

- removal of coronoid and olecranon osteophytes

 

See Elbow / Stiffness

 

2.  Arthroscopic Osteochondroplasty and Releases

 

Anterior joint

- remove loose bodies

- resect coronoid osteophytes

- anterior capsular release to improve extension

- +/- radial head resection

 

Posterior joint

- remove loose bodies

- resect olecranon osteophytes

 

See Elbow / Arthroscopy

 

3.  Total elbow arthroplasty

 

Indications

- > 65

- sedentary

 

Results

 

? reduced long term survival compared to RA

 

Bjord-Tilde et al J Should Elbow Surg 2009

- Norwegian Joint Registry

- 469 RA revision rates 7% at 5 years and 15% at 10 years

- OA numbers small (24) with 5% revision rate at 5 years, 10 year not available

 

Posterolateral Rotatory Instability

Definition

 

Radius rotates externally in relation to the ulna

- posterior displacement of the radial head relative to the capitellum

- in flexion

 

Posterolateral rotatory Instability

 

Anatomy LCL

 

LCL Elbow

 

Pathology

 

1.  Laxity or tear of ulna LCL

- posterior dislocation / subluxation / perching

- most common cause

 

2.  Torn CEO

- dynamic restraint

 

3.  Depressed fracture of radial head / malunion coronoid fractures

- leading to loss of secondary restraint

 

Mechanism

 

Dislocation occurs with a valgus ER force pivoting the elbow on the intact MCL

 

Aetiology

 

Trauma

- acute LCL tear after dislocation

 

Iatrogenic

- tennis elbow release

- Kocher approach

 

Ligamentous laxity

 

Long standing cubitus varus

 

History

 

Posterolateral elbow pain

 

Describe clunk on full extension

 

Patient may be able to demonstrate instability

 

Examination

 

Test combines external rotation / supination with valgus and axial loading

 

1.  O'Driscoll Pivot Shift Test

 

Best with patient anaesthetised

- can sublux joint

 

If patient awake, only get pain and apprehension

 

Patient supine

- examiner at head of bed

- GHJ full flexed with hand over head

- elbow resembles knee in this position

- forearm supinated

- elbow fully extended

 

Valgus stress with axial load & slowly flex joint

- at 40o the radial head is subluxed maximally posterolaterally

- radial head becomes prominent as it dislocates

- patient feels apprehension as the radial head subluxes

- past 40o flexion the radial head reduces

 

Positive

- prominent radial head (dislocates)

- pivot

- pain  (apprehension)

- maximum subluxation is at 40o flexion but with increased flexion reduces with snap

 

2.  Table Top Test

 

Push up on table with forearms in supination

- gives supination

- relieved by thumb pressing on radial head

 

X-ray

 

Usually normal

- may be slight widening of radiohumeral joint

- radial head may appear slightly posterior

 

MRI

 

Difficult to distinguish lateral complex

 

Management

 

NHx

 

Does not improve with time

- usually requires surgery if very symptomatic

 

Options

 

1. Repair 

2. Imbricate

3. Reinforce/Reconstruct with PL graft

 

Reconstruction

 

Kocher approach between Anconeus & ECU

- drill holes x 2 base sublime tubercle

- drill holes x 2 at lateral epicondyle (isometric point)

- palmaris graft in figure of 8

- tighten with elbow at 30 - 40o of flexion

 

Post op

- hold flexed 2/52

- then allow ROM in hinged brace

 

Results

 

O'Driscoll et al JBJS Br 2005

- retrospective review of 44 cases

- some direct repair, some autograft reconstruction

- 86% satisfaction

- better outcomes in reconstruction group

 

Radial Head & Neck Fractures

Radial Head Fracture

 

Mechanism

 

FOOSH

- axial load with a valgus force

 

Biomechanics

 

1.  Provides Valgus stability

- especially if MCL deficient

 

2.  Longitudinal stability

- aided by interosseous membrane

 

3.  Load Transfer

- 60% of load at elbow

- with radial head excision, load is transferred to ulno-humeral joint

- increase risk of OA

 

Hotchkiss modification of Mason Classification

 

Type I

 

Undisplaced fracture

- intra-articular displacement < 2mm

- no mechanical limit forearm rotation

- if in doubt, inject LA into radiocapitellar joint / soft spot

- ensure no mechanical block to rotation

 

Radial Head Mason 1Radial Head Fracture Mason 1

 

Type II

 

Displacement > 2mm

- motion mechanically limited

- reconstructable

 

Radial Head Fracture Type 2Radial Head Fracture Type 2 CTRadial Head Fracture Mason 2

 

Type III

 

Severely comminuted fracture of the radial head and neck

- not reconstructable

- requires excision for movement

 

Type IV

 

Associated with elbow dislocation

 

Complicated Radial Head Fracture

 

1.  Elbow Dislocation

 

2.  Essex Lopresti

 

Fracture Radial Head + Disruption DRUJ / Interosseous membrane

- dorsal dislocation of DRUJ

- ORIF / replacement radial head

- supinate DRUJ to reduce +/- TFCC repair +/- K wire

 

Surgical Options

 

1.  ORIF

 

Radial Head ORIF

 

Kocher approach

- between anconeus and ECU

- dissect muscles off capsule

- protect ulna collateral ligament under anterior edge of anconeus

- pronate forearm to protect PIN

- divide capsule in line with incision, create anterior and posterior flaps

 

Safe Zone for implants

- posterolateral portion of cartilage

- yellow and thinner

- non articulating

- 90o arc between radial styloid and lister's

 

ORIF 

- headless compression screws

 

Complications

 

AVN 

- soft tissue stripping

 

Non union 

- same reasons

- 10%

 

Results

 

Ring et al JBJS Am 2002

- results of ORIF Type III radial head

- overall 54% poor results

- good results with 2 or 3 fragments

- poor results with 4 results

  

2.  Excision

 

Indication

- elderly patient

 

Contra-indication

- MCL or interosseous membrane disrupted

 

Complications

- reduced strength

- proximal radial translation

- DRUJ instability and pain

- valgus instability elbow

- arthrosis (deceased SA, increased contact stresses)

 

3.  Replacement

 

Radial Head Replacement LateralRadial Head Replacement APRadial Head Replacement Monoblock

 

Options

 

1.  Silastic 

- less resistant to compressive forces

- can get synovitis

- good as temporary spacer

- can cut out later

 

2.  Titanium

- monoblock / modular / bipolar

 

Technique Modular Titanium Radial Head

 

Radial Head Replacement

 

Excise radial head

- insert trial broaches into neck

- small or large diameter, standard or long

- insert trial head size and thickness

- check xray

- ensure not overstuffed

- put through range

- prepare real implant on operating table

- have to insert head and neck as one piece

 

Radial Head Replacement Lysis APRadial Head Replacement Lysis Lateral

 

Results

 

Grewal JBJS Am 2006

- modular radial head

- 26 patients followed prosectively for 2 years

- no revisions

- mild OA in 19%

 

Burhart et al J Should Elbow Surg 2010

- bipolar radial head

- 17 patients followed up for between 6 and 10 years

- 2 dislocations, 8 had evidence capitellar OA

- no loosening

- 16/17 good or excellent results Mayo elbow scores

 

Complications

 

1.  Aseptic loosening

2.  Overstuffing

3.  Capitellar OA

4.  Malpositioning

 

Radial Head Poorly Positioned

 

Radial neck fracture

 

Radial Neck Fracture

 

Indications for surgery

- > 30o angulated

 

Approach

- Z incision annular ligament

- elevate supinator with arm pronated

 

Options

 

1. T plate in safe zone

- distal limit is bicipital tuberosity

- pre-contoured low profile plates

- may need to lag articular surface first

- check ROM intra-operatively

- plates often bulky and may limit ROM

 

Radial Neck Plate

 

2.  Fix with headless compression screws

- proximal to distal

- cross fracture site

 

Radial Neck Fracture ORIF Screws APRadial Neck Fracture ORIF Screws Lateral

 

3.  Retrograde Intramedullary Wire

 

4.  Radial Head Replacement

Rheumatoid Elbow

Elbow Rheumatoid ArthritisElbow Rheumatoid Arthritis 2

 

Epidemiology

 

50% rheumatoid patients have elbow pathology

- 80% also have shoulder pathology

- 90% hand and wrist

 

Always consider entire upper limb

 

Pathology

 

Synovitis

- swelling and pain

- may develop FFD due to holding in flexed position

 

Annular ligament may rupture

- anterior displacement of radial head

- due to pull of biceps

 

Collateral ligaments may rupture

- ML instability

 

Ulna nerve neuropathy

- synovitis

- rheumatoid nodule

 

Cartilage and bone destruction

- severe cartilage damage

- instability

- bony destruction

 

Management

 

Non Operative

 

SMART / DMART / Immunological medications

 

HCLA

 

Splints

 

Turnbuckle braces

- night time

- for loss of extension

 

Operative

 

1.  Synovectomy +/- radial head excision

 

Indications

- minimal OA

- significant synovitis

- young patient

 

Radial head excision

- to improve rotation

 

Contra-indications

 

Elbow instability

- can worsen

- may develop progressive valgus

 

Options

 

1.  Open

 

A. Extended Kocher

- limited access to posterior olecranon

- limited access to medial side

 

B.  Universal Posterior approach

 

2.  Arthroscopic

 

Results

 

Maenpaa et al J Shoulder Elbow Surg 2003

- 103 synovectomies open synovectomies via Kocker approach

- 5 year survival (reoperation / TER) 77%

- best with early OA
- no improvement in ROM but good pain relief

 

2.  Arthrodesis / Resection arthroplasty

 

Salvage only

 

3.  Interposition arthroplasty

 

Results inferior to arthroplasty

 

4.  Arthroplasty

 

A.  Non constrained

 

Need ST stability and balancing

- there is an incidence of postoperative instability (7 - 19%)

- good ROM

- need stems to prevent loosening (high failure rate of resurfacing)

 

Ewald et al JBJS Am 1993

- 202 follow up for 6 years

- 1.5% revision 

 

B.  Constrained

 

Higher early rates of failure

- 22% 4 year revision rate

 

C.  Semi constrained

 

Morrey JBJS Am 1998

- Coonrad - Morrey prosthesis

- 97% minimally painful at 10 years

 

Coonrad-Morrey

- anterior flange on humeral prosthesis very important to survival

 

Latitude prosthesis

- unconstrained can be converted to constrained

 

Total Elbow Replacement RA LatitudeTotal Elbow Replacement RA Latitude

 

 

 

 

 

Stiffness

Functional range

 

30- 130o - Flexion / Extension

50o each - Pronation / Supination

 

Aetiology

 

Extrinsic

- skin / subcutaneous tissue

- capsule (anterior / posterior)

- collateral ligament contracture

- muscle contracture

- HO

 

Intrinsic

- articular deformity / malunion

- articular adhesions

- impinging osteophytes (olecranon / coranoid)

- impinging fibrosis (olecranon / coranoid)

- loose bodies

 

Mixed

 

History

 

Decreased flexion / extension

- ulno-humeral joint

 

Decreased pronation / supination

- radio-capitellar joint

 

Pain

- post-traumatic elbow stiffness is usually not painful

- indicates chondral damage

 

Examination

 

Active v passive ROM

 

Management

 

Non-operative

 

Options

 

Physio

- graduated active assisted stretching 

 

Dynamic hinged elbow splint 

- often poorly tolerated

 

Static progressive 

- turnbuckle splint

 

Operative Treatment

 

Options

 

MUA

- not recommended

- may worsen stiffness

- due to haematoma or articular damage

 

1.  Arthroscopic Release

2.  Open Release

3.  OK Procedure

4.  Interposition arthroplasty

5.  Total Elbow Arthroplasty

 

1.  Arthroscopy 

 

Used increasingly to treat stiffness

 

Relative Contra-indications

- previous ulna nerve transposition

- severe soft tissue contractures

- bridging HO

 

Technique

- remove scar tissue / loose bodies

- remove olecranon / coronoid osteophytes

- radial head resection

- resect bony malunions

- can perform modified O-K procedure

 

Case

 

Post elbow fracture malunion / posterior impingement / FFD 40o

 

Elbow Malunion LateralElbow Malunion MRI

 

Elbow Malunion ImpingementElbow Malunion Impingement

 

Elbow Malunion Partial DebridementElbow Malunion Post Debridement

 

Elbow Malunion PreopElbow Malunion Post Op

 

2.  Open Soft tissue releases 

 

Approach

 

Universal posterior approach

- arm over patient held by assistant

 

Lateral interval

- to distal humeral elevating BR and ECRL

- distally between ECRB and EDC

 

Medial interval

- find and protect ulna nerve

- between triceps and brachialis proximally

- detach pronator teres distally

 

Technique Morrey

 

A.  Muscle releases

- brachialis released from humerus

- triceps released from humerus

 

B.  Capsulotomy / capsulectomy

- anteriorly elevate brachialis off capsule

 

C.  Excision of HO

 

D.  Removal of osteophytes

- coronoid / olecranon 

 

E.  Debridement of osteochondral flaps / loose bodies

 

F.  +/- Release of collateral ligaments

- preserve anterior band of MCL 

- ligament reconstruction & hinged elbow fixator if becomes unstable

 

G.  Radial head debridement / excision 

- especially if blocking supination / pronation

 

Results

 

Increases of 30 - 40o

 

3.  OK procedure

 

Elbow OK Procedure APElbow OK Procedure Lateral

 

Definition

 

Outerbridge - Kashiwagi procedure

- debridement athroplasty

 

Technique

 

Posterior approach 

- triceps split

 

Excision of posterior capsule

 

Excision of tip of olecranon

 

Access to anterior compartment via olecranon fossa

- 1 cm diameter hole

- use burr

- need to minimise bone dust

 

Debridement of coranoid and radial head

 

Removal of loose bodies

 

Results 

 

4.  Interposition Arthroplasty

 

Indication

- stiff elbow joint

- damage to >50% of ulno-humeral articular surface

- failure to achieve good range of motion following soft tissue release

 

Technique

 

Kocher Approach

 

Detach lateral ligament from humerus

 

Refashion ulno-humeral surface

- may be necessary in fracture or extensive malunion 

- create congruent surfaces for flexion / extension

 

Strip of fascia lata 

- fashioned and attached to anterior humerus

- fascia passed around end of humerus to cloth front and back

- then doubled on itself and attached to anterior ulna

- articular surface is fascia on fascia

 

Lateral ligament is then reattached

 

+/- hinged external fixation with distraction

 

5.  Total elbow replacement (arthroplasty)

 

Results

- 70% satisfaction

- less successful than RA

- some improvement in range (20o)