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Introduction
  • A traumatic injury pattern of the elbow characterized by 
    • elbow dislocation (often associated with posterolateral dislocation or LCL injury )
    • radial head or neck fracture
    • coronoid fracture
  • Pathophysiology
    • mechanism
      • fall on extended arm that results in a combination of 
        • valgus, axial, and posterolateral rotatory forces  
          • produces posterolateral dislocation
    • pathoanatomy
      • structures of elbow fail from lateral to medial
        • LCL disrupted first
        • anterior capsule injured next
        • possible MCL disruption
  • Prognosis
    • historically poor outcomes secondary to
      • persistent instability
      • stiffness
      • arthrosis
Anatomy
  • Radial head
    • a primary restraint to posterolateral rotatory instability (PLRI)
    • secondary valgus stabilizer
    • forearm in neutral rotation, lateral portion of articular margin devoid of cartilage
      • roughly between radial styloid and listers tubercle
  • Coronoid process 
    • provides an anterior and varus buttress to ulnohumeral joint
    • resists posterior subluxation beyond 30 deg of flexion
    • fracture fragment always has some anterior capsule attached
      • useful in repair
  • Medial collateral ligament 
    • three components
      • anterior bundle
        • most important to stability, restraint to valgus and posteromedial rotatory instability
          • inserts on sublime tubercle (anteromedial facet of coronoid) 
          • specifically inserts 18.4mm dorsal to tip of coronoid process
      • posterior bundle
      • transverse ligament 
  • Lateral collateral ligament  
    • inserts on supinator crest distal to lesser sigmoid notch
    • the primary restraint to posterolateral rotatory instability
    • four components
      • lateral ulnar collateral ligament (most important for stability)
      • radial collateral ligament
      • annular ligament
      • accessory collateral ligament
    • when injured is usually avulsed off of the lateral epicondyle
Presentation
  • Symptoms
    • patients complain of pain, clicking and locking with elbow in extension
  • Physical exam
    • possible varus / valgus instability patterns
    • distal radial ulnar joint must be evaluated for possible Essex-Lopresti injury 
Imaging
  • Radiographs   
    • evaluate for concentricity of ulnohumeral and radiocapitellar joints
    • line drawn through center of radial neck should intersect the center of the capitellum regardless of radiographic projection
    • evaluate lateral radiograph for coronoid fracture
    • need prereduction and postredcution films
    • consider PA and lateral films of wrist and forearm when indicated
  • CT
    • often utilized for better evaluation of coronoid fracture
    • 3D imaging for determining fracture line propagation
Treatment
  • Nonoperative
    • immobilize in 90 deg of flexion for 7-10 days
      • indications (rare)
        • ulnohumeral and radiocapitellar joints must be concentrically reduced
        • radial head fx must not meet surgical indications 
        • coronoid fx must be small 
        • elbow should be sufficiently stable to allow early ROM
      • technique
        • one week of immobilization followed by progressive ROM
        • active motion initiated with resting splint at 90 degrees, avoiding terminal extension
        • static progressive extension splinting at night after 4-6 weeks
        • strengthening protocol after 6 weeks
  • Operative
    • ORIF versus radial head arthroplasty, LCL reconsutrction, coronoid ORIF, possible MCL reconstruction
      • indications
        • terrible triad elbow injury that includes an unstable radial head fracture, a type III coronoid fracture, and an associated elbow dislocation  
        • coronoid avulsion fractures involving less than 10% of the coronoid do not confer elbow stability in cadaveric studies and therefore do not require repair  
          • should instability persist after addressing the radial head and the LCL complex in the presence of a small coronoid avulsion fracture, the next best step is MCL reconstruction
Techniques
  • ORIF vs replacement of radial head, coronoid ORIF, LCL reconstruction, and possible MCL reconstruction 
    • approach
      • posterior skin incision advantageous
        • allows access to both medial and lateral aspect of elbow
        • lower risk of injury to cutaneous nerves
        • more cosmetic
    • technique
      • radial head ORIF vs. arthroplasty
        • radial head ORIF indicated if non comminuted fractures that involve < 40% articular surface 
          • 1.5, 2.0, or 2.4mm countersunk screws 
          • plate if necessary; 2.0 plates cause minimal loss of motion even when placed on radial neck
          • plate position should be posterolateral 
            • safe zone: 90-110 arc from radial styloid to Lister's tubercle with arm in neutral rotation 
        • radial head arthroplasty indicated for comminuted radial head fxs 
          • implant should articulate 2mm distal to the tip of the coronoid process
          • radial head resection without replacement is NOT indicated in presence of Essex-Lopresti lesion or in ligamentously injured elbows
          • if <25% head damaged or fragments not reconstructable and nonarticulating, can excise fractured portion if elbow stable (rarely indicated)
      • coronoid ORIF
        • can be fixed through radial head defect laterally
        • sutures, suture anchors, screws, or rarely plate fixation. 
          • suture passed through 2 drill holes
          • posterior to anterior lag screws if fragment large
          • basal coronoid fxs (rare) fixed with anteromedial or medial plate on proximal ulna
      • LCL repair 
        • usually avulsed from origin on lateral epicondyle
        • reattach with suture anchors or transosseous sutures 
          • must be reattached at center of capitellar curvature on lateral epicondyle
        • if MCL is intact, LCL is repaired with forearm in pronation
        • if MCL injured, LCL is repaired with forearm in supination to avoid medial gapping due to overtightening
        • repairs are performed with elbow at 90 degrees of flexion
      • MCL repair
        • indicated if instability on exam after LCL and fracture fixation, especially with extension beyond 30 degrees
    • postoperative
      • elbow fixators - hinged or static
        • consider when instability is noted after complete bone and soft tissue repair
      • immobilization
        • immobilize elbow in flexion with forearm pronation to provide stability against posterior subluxation q
        • if both MCL and LCL were repaired, splint in flexion and neutral rotation
Complications
  • Instability
    • more common following type I or II coronoid fractures
  • Failure of internal fixation
    • most common following repair of radial neck fractures
      • poor vascularity leading to osteonecrosis and nonunion
  • Post-traumatic stiffness 
    • very common complication
    • initiate early ROM to prevent
  • Heterotopic ossification
    • consider prophylaxis in pts with head injury or in setting of revision surgery
  • Post-traumatic arthritis
    • due to chondral damage at time of injury and/or residual instability
 

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