69 G.Bentley(ed.),EuropeanInstructionalLectures.

EuropeanInstructionalLectures10,
DOI:10.1007/978-3-642-11832-67,2010EFORT
Operative Strategy for Fracture-Dislocation
of the Elbow
KonradMader
Introduction
TheelbowjointisoneoIthemostinherentlystablearticula-
tionsoItheskeleton|49|.Wheninadditiontothedisloca-
tion oI the joint at least one oI the osseous or articular
componentstructuresthatcontributetothestabilityoIthe
elbowisdisrupted,theinjuryistermed'Iracture-dislocation
oItheelbowandtheriskoIrecurrentorchronicinstability
andthedevelopmentoIpost-traumtaticarthritisoItheelbow
areincreased|2,1113,17,18|.TreatmentoItheseinjuries
ischallengingduetodiIfcultiesinapplyingaccuratedefni-
tionsoIthepatternsoItheinjury,inevaluatingthespecifc
roles oI the component structures that contribute to the
instabilityoItheelbowandthelackoIastandardizedratio-
naleIortheoperativetreatment.SoIttissueinjuryincluding
openwoundsandvascularornervecompromiseaddtothe
complexityoItheinjury.InrecentyearsinvestigativeeIIorts
wereputintothedefnitionoIthecomponentsthatcontribute
to the stability oI the elbow and the concept oI operative
fxationoItheosseousandligamentouslesions(i.e.,articular
IragmentsoIthedistalhumerus|7,20,31,32,35,36|,the
radialhead|33,41|,thecoronoidprocess|3,14,15,21,34,
59, 6164, 72, 75|, the olecranon |16, 42, 50, 51, 65, 70|
the collateral ligaments |18, 54, 76| and combinations oI
theselesions|19,28,29,37,38,4345,58,60,67,68,78|
in order to reconstitute elbow stability. In addition to this
morerecentlythedevelopmentanduseoIthetrans-articular
external fxator with motion capacity oI the elbow has
extensivelybroadenedthetherapeuticspectrumoItreating
complex elbow trauma and partially changed therapeutic
pathways|6,10,2227,39,40,4648,52,55,57,66,69,
71,77|.ThepurposeoIthislectureistoanalysethe current
literatureandownprospectivedatainordertoestablishand
discuss a strategy in the treatment Iracture-dislocations oI
theelbow(Fig.1).
Diagnostic Tools
Conventional Imaging
Any elbow trauma is assessed initially using standard
antero-posterior(AP)andlateralradiographs,whichgives
an idea oI the type and personality oI injury involved
(Fig.2).TheAPistakenwiththeelbowextendedandthe
Iorearmsupinated(whenpossible)withthepatientseated
or supine, the beam is directed perpendicular to the mid-
pointoItheelbowjoint.TheIeaturesdemonstratedonthis
view should include the distal humerus, epicondyles, tro-
chlea, capitellum, radial head including proximal radius
and olecranon. The lateral view is taken with the patient
seatediIpossible,theshoulderabductedto90,sothatthe
shoulder is level with the flm and the elbow is fexed at
90.InthispositiontheIorearmisplacedinsupinationand
thebeamisdirectedperpendiculartothehumeralepicon-
dylescenteredontheelbowjoint.Onthisviewtheepicon-
dyles should be superimposed, the olecranon should be
seen in profle, and the radial head superimposed on the
coronoid process. Relationships that should be checked
include the radiocapiteller line, which should bisect the
radial head and the capitellum, and the anterior humeral
line,whichshouldrunthroughthemiddlethirdoIthecapi-
tellum.AthoroughassessmentoItheinitialradiographsat
thisstageshouldincludethesoIttissueenvelope,anterior
andposteriorIatpads,corticalcontinuity,jointcongruency,
and bony alignment. Coonrad et al. proposed the 'drop
sign,whichisanincreaseinulno-humeraldistanceonthe
lateral X-ray-flm. This objective and static radiographi-
cally-measurableincreaseinulno-humeraldistancecanbe
K.Mader
OrtopediskAvdeling,
SeksjonTraumekirurgi/Hndkirurgi,
FordeSentralsjukehuset,6807Forde,Norway
e-mail:konrad.maderhelse-Iorde.no
70 K. Mader
viewed as warning sign Ior the presence oI ligamentous
instability|9|.Aradialhead-capitellumviewcanbeobtained
by having the patient positioned Ior a lateral elbow view
andthenanglingthebeam45medialtolateralandcentred
2.5cm.inIeriortotheepicondylaraxis.Thisviewgivesan
unrestricted view oI the radial head. CareIul analysis oI
thesethreeconventionalX-rayswillgiveinIormationabout
the bony lesions involved and any existing dislocation or
subluxation oI the elbow joint. Repeat AP and lateral
X-raysaIterreductionandcastinginawell-paddedupper
arm cast (in 100 oI fexion) are required and again cau-
tiouslyanalysedIoranypersistingsubluxationoIthejoint.
Jointincongruityorasymmetry(i.e.,rotatorysubluxation)
ora'dropsignshouldbecautiouslyevaluated.
Computed Tomography
ComputedtomographyisthetooloIchoicetoevaluatethe
type and extent oI bony Iragmentation and presence/
absenceanddirectionoIanypersistentdislocation/sublux-
ationoItheelbowjoint(Fig.3ae).Helicalscanningwith
two-dimensionalreconstructioncanbedonequicklywith
thearmrestedinthecast.The'Supermanposition(with
the arms overhead) produces the best image quality, but
scanscanbedonewiththeelbowattheside(givingsome
morevolumearteIacts).ItisuseIultostartwiththeoriginal
transversesections,IollowedbytheanalysisoItheIrontal
and sagittal reconstruction images and fnally the three-
dimensionalreconstruction.Thetransverseplaneisusedto
evaluate the proximal radio-ulnar joint and the distal
Fig. 2 Antero-posteriorandlateralX-rayoIaIracture-dislocation
oI the leIt elbow in a 30-year-old male patient: note the com-
poundIractureoItheproximalulna,theventralsubluxationoI
thedistalhumerus,theinvolvementoItheradialhead/neckand
thecoronoidprocess
Fig. 1 TreatmentalgorithmoIunstableelbowdislocation
UNSTABLE ELBOWFRACTURE DISLOCATION
Closed reduction, cast 100
Evaluation of X-rays, CT
Radial head/ neck:
Try to refix
(on table reconstruction)
safety corridor
(plates) threaded wires
(radial head replacement)
Coronoid:
Anteriomedial facet:
refixation
Reduction in flexion:
extension limit
(ex fix)
or refixation
Olecranon:
Refix coronoid-
bearing key-
fragment(s)
Maintain COD
Angle stable plating
Ligaments, soft tissues,
instability:
Reattach bony ligament
avulsion
No direct ligament repair
HINGED ELBOWFIXATOR
71 Operative Strategy for Fracture-Dislocation of the Elbow
a b
c d
e
Fig. 3 CTscansoIthesamepatient;()transversescandepicting
the involvement oI the coronoid process; () transverse scan
showingtheventraldislocationoIthedistalhumerusandthecom-
pounddestructionoItheproximalulna;()sagittalreconstruction
showinginvolvementoItheradialneck;()sagittalreconstruction
showingtheextentoItheulnardestruction;()sagittalreconstruc-
tionwithsubluxationoIthehumerus
72 K. Mader
humerus, olecranon, coronoid and radial head including
thepatternoIarticularIragmentation.ThecoronalorIron-
tal plane provides an image similar to the standard PA
radiograph and will provide better bone detail and intra-
articularIragmentation.Thesagittalplanewillgiveaclear
view oI ventral or dorsal dislocation oI the humero-ulnar
joint and the dislodgement oI Iragments oI the coronoid
processandtheradialhead.
Evidence-Based Medicine?
Forallreaderswiththeinterestinevidence-basedorthope-
dicsmedicine,randomizedtrialsandthemeta-analysisoI
themedicalliteraturethereissadnews:randomizedstudies
andameta-analysisoItreatmentconceptsattheelbowdo
only exist in the treatment oI chronic epicondylitis. The
digestionoI250scientifcpapersonIracture-dislocationoI
theelbowwasasourtourthroughLevelIII(case-control
studies),IV(casestudies)andpredominantlyLevelVstud-
ies(expertopinion).Firstprospectiveprotocolsandaran-
domizedcontrolledtrialcomparingtheoutcomeoIpatients
treatedwithreductionandearlyphysiotherapyvs.hinged-
fxationinunstableelbowdislocationsareunderway.
Injury Mechanism
Fracture-dislocationoItheelbowmainlyoccursinthejoints
between the humerus and ulna and primarily is caused by
compression, shearing, and avulsion Iorces. Radial head
andneckIracturesareproducedbycompressionorshearing
Iorce.OlecranonandcoronoidprocessIractures,accompa-
nied by dislocation, are also caused by compression or
shearing Iorce. The most common type oI Iracture oI the
olecranonismadebytractionIorceorpullingoIthetriceps
muscle.ConcurrentIracturesoIbothcondylesareproduced
mainlybyavulsionorshearingIorces.Almostalldisloca-
tionsoItheelbowareaccompaniedbyruptureoIcollateral
ligamentsoravulsionIracturesoIthemedialorlateralepi-
condyle.BecausetheincidenceoIcoronoid,olecranon,and
condyleIracturesseemstoincreasestotheamountoIcom-
pressionIorce,thecurrentbiomechanicalstudiesIocussing
on Iracture-dislocations resulting Irom experimental com-
pression Iorce |1, 4, 5|. Amis and Miller, in a cadaveric
study, demonstrated a fexion-extension 'arc oI injury,
whichrelatesIracturetypestoelbowpositionatthemoment
oIimpact|1|.RadialheadandcoronoidIracturesIollowed
impactalongtheIorearmupto80fexion.OlecranonIrac-
tures occurred by direct impact around 90 fexion. Distal
humeralIracturesmostlyoccurredabove110fexion.
Fracture Fixation
Duringthelastdecade,inAmericaandEuropestandardsur-
gicalprotocolstotreatcomplexelbowIracture-dislocations
haveevolved|16,26,28,29,34,38,39,44,45|.Thesepro-
videguidanceinreconstructingbothligamentousandbony
components. Recent advances in Iracture fxation oI the
radialhead|41|,olecranon|42|,theintroductionoIangle-
stableplatingsystemsinIracturesoIthedistalhumerusand
olecranon|73|,andthestrategicuseoIhingedexternalfxa-
tionhaveIurtherbroadenedthetherapeuticspectrum.
Surgical Approaches
Surgicalapproachestotheelbowcanbeclassifedaccord-
ing to the aspect oI the joint exposed, as anterior, lateral,
medial, posterior and global |56|. The aim oI a surgical
approachtotheelbowistoprovideanadequateextensile
exposurewithpreservationoItheneurovascularstructures.
Modern surgical approaches to the elbow began with the
lateralapproachtotheelbowdescribedasearlyas1911by
Kocher. Subsequently, many authors have described
approaches to the elbow with the intention oI providing
improved visualization, primarily oI the anterior elbow,
withoutcompromisingthesurgicaloutcome|38,56|.Henry
described the generally Iollowed principle oI 'extensile
exposure.ThemajorityoItheseexposureuseinternervous
orintermuscularintervals.ThereIore,itisapre-requisiteto
beIamiliarwiththesurgicalanatomyoIthemajornerves
and their cutaneous branches, the muscles and the medial
and lateral ligament complex |25, 56, 74|. When a dorsal
approach is mandatory, olecranon osteotomy should be
avoidedaccordingtoMcKeeetal.|8,37|.
Coronoid Process
Coronoid Iractures oI the ulna are relatively uncommon
yetcriticalinjuriestorecognize|59|.Theydefnitelyplay
animportantroleinelbowinstability.Historicrecommen-
dationsaretofxalllargecoronoidIractureIragments,as
wellassmallIractureIragmentsassociatedwithinstabil-
ity.Thecoronoidprocessactsasabonybuttresstoprevent
posterior dislocation and has three soIt tissue insertions
which lend stability as well: the anterior joint capsule oI
theelbow,thebrachialismuscleandthemedialulnarcol-
lateral ligament. II the elbow is unstable, management
usuallyconsistsoIacombinationoIbonyandsoIt-tissue
repairsoItenincludingcoronoidprocessrepair|3,15,59|.
LossoImotionisthemostcommoncomplicationoIthese
73 Operative Strategy for Fracture-Dislocation of the Elbow
injuries.Thecurrentrecommendationistorepairvirtually
all coronoid Iractures associated with instability |72|.
Recent biomechanical and clinical investigations have
emphasizedtheimportanceoIthecoronoidprocessinthe
stability oI the ulno-humeral articulation. Recently,
Doornberg and Ring indicated the importance oI the
antero-medial Iacet oI the coronoid as a distinct type oI
coronoid Iracture resulting Irom a varus postero-medial
rotational injury Iorce resulting in complex instability
|14|. They concluded that antero-medial Iractures oI the
coronoid are associated with either subluxation or com-
pletedislocationoItheelbowinmostpatients.Inorderto
detect this very unstable sub-set oI coronoid Iractures
again a CT scan is mandatory |1416|. Usually there
aretwoormoreIragments,whichmakestablere-fxation
ademandingprocedurewithpossiblecomplicationssuch
as heterotopic ossifcation and secondary dislocation
(Fig. 4ad). Although most experts recommend open
reductionanddirectorindirectfxationoIcoronoidIrag-
ments|14,19,21,34,61,69,75|thereisanewconcept,
whenusinghingedexternalfxation,tolimitextensionto
30 Ior a period oI 23 weeks and thereby indirectly to
createstability.Thepersonalexperiencewith85consecu-
tivecaseswillbediscussedinthelecture.
a b c
d
Fig. 4 Fracture dislocation oI the right elbow in a 35-year-old
man:()lateralX-raydemonstratingacomplexcoronoidIracture;
() sagittal CT reconstruction showing basal multi-Iragmented
coronoid Iracture pattern. () 3-D CT reconstruction depicting
twodistinctiveIragments,oIwhichoneisanantero-medialIacet
Iragment; () X-ray control 3 months post-operatively aIter
openreductionandinternalfxationoIthecoronoidwithhelpoI
an ulnar osteotomy showing severe heterotopic ossifcation
(IlahiIV)ontheulnarsideleadingtocompleteankylosisoIthe
joint|30|
74 K. Mader
Radial Head
'IIindoubt,resectwastheolddogmaregardingthetreat-
ment oI Iractures oI the radial head. Patients with commi-
nuted radial head Iractures and those with associated
soIt-tissueinjuriesoItheelbowhaveapooroutcomeiIthe
radialheadissimplyresected.Complicationsincludesubse-
quentdistalradio-ulnarpain,weaknessandinstabilityoIthe
elbow,cubitusvalgusandulnarneuritis|33,41|.TheroleoI
theradialheadasanimportantstabiliseroItheIorearmand
elbow is now better understood |58, 62|. It should not be
resected without careIul consideration |62, 63|. The treat-
ment oI Mason type-III Iractures and those with associated
ligamentousdamageordislocation(MasontypeIV)ischal-
lenging. Several methods oI reconstruction have been
describedandprostheticreplacementoItheradialheadisrec-
ommendedIorcomminutedIractures,especiallyiIthemedial
collateralligamentisdisrupted|58,60,62|.Therearesome
concerns about the non-anatomical shape oI the prostheses
whichmaycauseloosening,subsequentdegenerativechanges
a
c
d
b
Fig. 5 Twenty-three-year-old patient with complex Iracture-
dislocationoItherightelbowwithacomminutedIractureoIthe
proximalradius;()X-raysinacastaIterreduction;()Scout
CT scan showing the 'superman position. () exemplary CT
scansshowingtheextentoItheradialheaddestruction;()3-D
reconstructionoIthebonyinjury.()conventionalanteroposte-
riorX-ray5weeksaItertheinjuryaIterORIFoItheradialhead
andapplicationoIanhingedexternalfxator;()higherresolu-
tion demonstrating reconstruction oI the radial head with fne
threadedscrews
75 Operative Strategy for Fracture-Dislocation of the Elbow
andinstabilityoItheelbow.Wealwaystrytoreconstructthe
radialhead,evenasan'on-tablereconstruction,asitwillbe
themajorradialstabilizeraIterbonyhealing.IIthereissevere
comminutionoItheradialheadandneck,aIterreconstruction
a hinged fxator is mandatory in order to unload the radial
head.Nexttopre-Iormedplates,intheso-called'saIe-zone
headlessmini-IragmentscrewswithfnethreadsareuseIulin
reconstructingtheradialhead(Fig.5aI)|40,41|.
The Terrible Triad
The 'terrible triad injury (radial head Iracture, coronoid
Iractureandulnarligamentdisruption)hasahistoryoIcom-
plicatedoutcomesasthesurgeonattemptstomaximizeIunc-
tionalrange-oI-motiongoalswhilemaintainingstability|78|.
Several investigators have displayed standardized surgical
protocols relying on stable reconstruction oI the bony ele-
mentsandextensiveligamentrepair|19,34,38,39,62,63|.
While most American colleagues rely on the protocol oI
reconstruction/replacementoItheradialheadwithcoronoid
and ligament repair, the integrative use oI hinged external
fxationischallengingthis|23,24,26,57,69|.
Trans-Olecranon Dislocation
Trans-olecranon Iracture-dislocation oI the elbow occurs
when a high-energy direct blow is applied to the dorsal
aspect oI the Iorearm with the elbow in mid-fexion and
causes an olecranon Iracture associated with an anterior
dislocationoItheIorearmwithrespecttothedistalhumerus
|50,51|.ThetrochleaappearstohaveIracturedthroughthe
olecranon process as the Iorearm is displaced anteriorly.
The trans-olecranon Iracture-dislocation is diIIerent Irom
the anterior Monteggia, Bado one lesion, because in the
Iormer,thereisalossoIstabilityintheulno-humeraljoint
buttheradio-ulnarrelationshipispreserved.Thecapsule-
ligamentous restraints, in particular the annular ligament,
remainintact.MostoItheIailuresoItheulno-humeraljoint
e
f
Fig. 5 continued)
76 K. Mader
arearesultoIthebonydisruptionratherthantheligamen-
touscomponent.Theosseousinjurycanbeasimple,non-
comminuted,transverse,orobliqueIractureoItheolecranon,
butismorecommonlyacomplexandcomminutedIracture
involvingthetrochlearnotchand,sometimes,thecoronoid
process as well. This lesion, oIten caused by high-energy
trauma,canresultinacomplexskeletaldisruptioninclud-
inganavulsionorshearIracture.Itbecamequiteclearthat
this injury represents an intrinsically-unstable bony lesion
thatrequiresgoodpre-operativeplanningandstableinter-
nal fxation with complete restoration oI articular congru-
ence and the coronoid buttress. This allows early active
mobilization, which is critical to obtain good long-term
results.IIthereisadditionalsoIttissueinjuryorseverebone
loss, maintenance oI the coronoid-olecranon tip distance
(COD)isoIutmostimportanceinordertoavoidpost-trau-
matic stiIIness. Again a hinged mono-lateral fxator is a
suitabletooltocontrolthesoIttissuesandallowearlymobi-
lization|50,51,55,65,66|.
The Role of Hinged External Fixation
Ithasbecomeveryclearinrecentyears,thathingedexternal
fxationwithmotioncapacityisanimportanttoolinthetreat-
mentoIsevereIracture-dislocationoItheelbow|6,10,2227,
39,40,4648,52,55,57,66,69,71,77|.Severalbiomechani-
calandclinicalstudieshavedemonstrated,thatstablemove-
mentinanearlyphysiologicrangeoImotionispossible,that
anexternalfxatorwithadequatestabilityminimizesvarusor
valgus load aIter bony stabilization and with severed liga-
ments,andthatitshouldbeusedinasituationoIpersistent
instability/subluxationincomplexelbowIracture-dislocations
|24,53,55|.InrecentreviewstheroleoIhingedexternalfxa-
tionhasexpandedIromusingitasa'lasthelptouseearlyin
thetreatmentprotocol.Nowhingedfxationhasbecomesuch
anintegratedpartinthetreatmentprotocolinsomecentresin
Europe,thatitistheadvanceinthetreatmentoItheseinjuries.
Asshowninthetreatmentalgorithm(Fig.1),astructureduse
oIhingedfxationwillactuallychangecommonprotocolsoI
ligament reconstruction and the treatment oI 'terrible triad
injuries.Asuitablehingedexternalfxator(withappropriate
biomechanical Ieatures) as an integral part in the treatment
protocolchallengesactualtreatmentalgorithms|24,55,69|.
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