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Introduction
  • Epidemiology
    • bimodal distribution
      • high energy injuries in the young
      • low energy falls in the elderly
  • Pathophysiology
    • mechanism
      • direct blow
        • usually results in comminuted fracture
      • indirect blow
        • fall onto outstretched upper extremity
        • usually results in transverse or oblique fracture
Anatomy
  • Osteology
    • together with coronoid process, forms the greater sigmoid (semilunar) notch
    • greater sigmoid notch articulates with trochlea
      • provides flexion-extension movement
      • adds to stability of elbow joint
  • Muscles
    • triceps
      • inserts onto posterior, proximal ulna
      • blends with periosteum
      • innervated by radial nerve (C7)
    • anconeus 
      • inserts on lateral aspect of olecranon
      • innervate by radial nerve (C7)
Classification
 
Mayo Classification
  • Based on comminution, displacement, fracture-dislocation

 
Colton Classification
Nondisplaced - Displacement does not increase with elbow flexion
Avulsion (displaced)

Oblique and Transverse (displaced)

Comminuted (displaced)

Fracture dislocation
 
Schatzker Classification
Type A Simple transverse fracture  
Type B Transverse impacted fracture  
Type C Oblique fracture  
Type D Comminuted fracture  
Type E More distal fracture, extra-articular  
Type F Fracture-dislocation  
 
AO Classification
Type A Extra-articular
Type B Intra-articular
Type C Intra-articular fractures of both the radial head and olecranon
 
Presentation
  • Symptoms
    • pain well localized to posterior elbow
  • Physical exam
    • palpable defect
      • indicates displaced fracture or severe comminution
    • inability to extend elbow
      • indicates discontinuity of triceps (extensor) mechanism
Imaging
  • Radiographs
    • recommended views
      • AP/lateral radiographs
        • true lateral essential for determination of fracture pattern
    • additional views
      • radiocapitellar may be helpful for
        • radial head fracture
        • capitellar shear fracture
  • CT
    • may be useful for preoperative planning in comminuted fractures
Treatment
  • Nonoperative
    • immobilization
      • indications
        • nondisplaced fractures
        • displaced fracture is low demand, elderly individuals 
      • technique
        • immobilization in 45-90 degrees of flexion initially
        • begin motion at 1 week
  • Operative
    • tension band technique 
      • indications
        • transverse fracture with no comminution
      • outcomes
        • excellent results with appropriate indications
    • intramedullary fixation   
      • indications
        • transverse fracture with no comminution (same as tension band technique)
    • plate and screw fixation 
      • indications    
        • comminuted fractures
        • Monteggia fractures
        • fracture-dislocations 
        • oblique fractures that extend distal to coronoid
    • excision and triceps advancement
      • indications
        • elderly patients with osteoporotic bone
        • fracture must involve <50% of joint surface
        • nonunions
      • outcomes
        • salvage procedure that leads to decreased extension strength
        • may result in instability if ligamentous injury is not diagnosed before operation
Surgical Techniques
  • Tension band technique  
    • technique
      • converts distraction force of triceps into a compressive force
      • engaging anterior cortex of ulna with Kirschner wires may prevent wire migration
      • avoid overpenetration of wires through anterior cortex
        • may injury anterior interosseous nerve (AIN)  
        • may lead to decreased forearm rotation 
      • use 18-gauge wire in figure-of-eight fashion through drill holes in ulna
    • cons
      • high % of second surgeries for hardware removal (40-80%) q
      • does not provide axial stability in comminuted fractures 
  • Intramedullary fixation 
    • technique
      • can be combined with tension banding
      • intramedullary screw must engage distal intramedullary canal
  • Plate and screw fixation post
    • technique
      • place plate on dorsal (tension) side
      • oblique fractures benefit from lag screws in addition to plate fixation
      • one-third tubular plates may not provide sufficient strength in comminuted fractures
      • may advance distal triceps tendon over plate to avoid hardware prominence
    • pros
      • more stable than tension band technique
    • cons
      • 20% need second surgery for plate removal
  • Excision and triceps advancement 
    • technique
      • triceps tendon reattached with nonabsorbable sutures passed through drill holes in proximal ulna
Complications
  • Symptomatic hardware
    • most frequent reported complication
  • Stiffness
    • occurs in ~50% of patients
    • usually doesn't alter functional capabilities
  • Heterotopic ossification
    • more common with associated head injury
  • Posttraumatic arthritis
  • Nonunion
    • rare
  • Ulnar nerve symptoms
  • Anterior interosseous nerve injury
  • Loss of extension strength
 

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