The principles of the operative technique are to (1) restore coronoid
stability through fracture fixation (type-II or III
fractures7) or
through anterior capsular repair (a type-I fracture), (2) restore radial head
stability through fracture fixation or replacement with a metal prosthesis,
(3) restore lateral stability through repair of the lateral collateral
ligament complex and associated so-called secondary constraints such as the
common extensor origin and/or the posterolateral capsule, (4) repair the
medial collateral ligament in patients with residual posterior instability,
and (5) apply a hinged external fixator when conventional repair does not
establish sufficient joint stability to allow early motion. The general
approach is to repair the damaged structures sequentially from deep to
superficial, as seen from the lateral approach (coronoid to anterior capsule
to radial head to lateral ligament complex to common extensor
origin)8.
CRITICAL CONCEPTSINDICATIONS:Failure to obtain a congruent reduction of the ulnohumeral or
radiocapitellar jointsFailure to maintain a congruent reduction of the ulnohumeral or
radiocapitellar jointsFailure to maintain congruent reduction of the elbow joint through a
functional (20° to 130°) range of motionRestriction of forearm rotation due to displaced radial head fragmentsAssociated open woundsAssociated injuries in the ipsilateral upper extremity that require
operative interventionAssociated neurologic (relative indication) or vascular (absolute
indication) injuriesCONTRAINDICATIONS:Medical contraindication to surgery.Noncompliant patient.The elbow joint is stable following closed reduction through a functional
(30° to 130°) range of motion with minimally displaced fractures. This
patient is a candidate for closed treatment and close observation. This
represents <5% of patients with this type of injury.PITFALLS:Fixing the radial head and/or the lateral collateral ligament prior to
repair of the coronoid or anterior capsule eliminates exposure of the coronoid
and makes repair impossible without a separate medial approach.Resecting the radial head alone without replacement
(Fig. 12). The radial head is
a critical secondary stabilizer of the elbow in this situation. Replacement
with a metallic (rather than Silastic), modular radial head (so that the head
and stem size can be adjusted independently) is preferred.Transarticular fixation of the joint is a reasonable salvage procedure if,
despite the surgeon's best efforts, elbow stability cannot be restored with
conventional care. However, this should be a temporary solution: a pin of
sufficient size so that it will not break should be used, and the patient
should be referred promptly to a surgeon with skill in advanced techniques
such as hinged fixation.Failing to repair the lateral collateral ligament complex. The ligament is
usually avulsed from the lateral aspect of the distal end of the humerus and
can be reattached with sutures through drill-holes in the bone or suture
anchors. This is an integral part of the repair and emphasizes the laterally
based surgical strategy (as opposed to the more traditional medial approach to
elbow instability). A medial approach alone is insufficient to restore
stability in this setting.Prolonged immobilization (more than three weeks) following surgical repair
may produce a reasonable radiograph but usually produces a very stiff elbow
that requires further surgical intervention. The goal of surgery should be to
restore sufficient stability so that early motion can be allowed. This
enhances functional outcome, improves the range of motion, and allows the
dynamic stabilizers of the elbow (the flexor-pronator mass and the common
extensor origin) to assist in stabilizing the joint.AUTHOR UPDATE:Fixation of the coronoid fragment can be accomplished with the use of the
drill-guide found on most anterior cruciate ligament reconstruction sets. The
drill-guide tip can be placed on the coronoid fragment and an appropriately
sized guidewire from a cannulated screw set is inserted through the
drill-guide to provisionally fix the coronoid. This allows precise placement
of the cannulated screw or screws and eliminates multiple passes with the
guidewire into the small coronoid fragment. Larger coronoid fragments can be
fixed with the use of recently introduced plates designed specifically for the
coronoid. However, the use of these plates requires a direct medial approach
to the coronoid.
CRITICAL CONCEPTS
INDICATIONS:
Failure to obtain a congruent reduction of the ulnohumeral or
radiocapitellar jointsFailure to maintain a congruent reduction of the ulnohumeral or
radiocapitellar jointsFailure to maintain congruent reduction of the elbow joint through a
functional (20° to 130°) range of motionRestriction of forearm rotation due to displaced radial head fragmentsAssociated open woundsAssociated injuries in the ipsilateral upper extremity that require
operative interventionAssociated neurologic (relative indication) or vascular (absolute
indication) injuries
Failure to obtain a congruent reduction of the ulnohumeral or
radiocapitellar joints
Failure to maintain a congruent reduction of the ulnohumeral or
radiocapitellar joints
Failure to maintain congruent reduction of the elbow joint through a
functional (20° to 130°) range of motion
Restriction of forearm rotation due to displaced radial head fragments
Associated open wounds
Associated injuries in the ipsilateral upper extremity that require
operative intervention
Associated neurologic (relative indication) or vascular (absolute
indication) injuries
CONTRAINDICATIONS:
Medical contraindication to surgery.Noncompliant patient.The elbow joint is stable following closed reduction through a functional
(30° to 130°) range of motion with minimally displaced fractures. This
patient is a candidate for closed treatment and close observation. This
represents <5% of patients with this type of injury.
Medical contraindication to surgery.
Noncompliant patient.
The elbow joint is stable following closed reduction through a functional
(30° to 130°) range of motion with minimally displaced fractures. This
patient is a candidate for closed treatment and close observation. This
represents <5% of patients with this type of injury.
PITFALLS:
Fixing the radial head and/or the lateral collateral ligament prior to
repair of the coronoid or anterior capsule eliminates exposure of the coronoid
and makes repair impossible without a separate medial approach.Resecting the radial head alone without replacement
(Fig. 12). The radial head is
a critical secondary stabilizer of the elbow in this situation. Replacement
with a metallic (rather than Silastic), modular radial head (so that the head
and stem size can be adjusted independently) is preferred.Transarticular fixation of the joint is a reasonable salvage procedure if,
despite the surgeon's best efforts, elbow stability cannot be restored with
conventional care. However, this should be a temporary solution: a pin of
sufficient size so that it will not break should be used, and the patient
should be referred promptly to a surgeon with skill in advanced techniques
such as hinged fixation.Failing to repair the lateral collateral ligament complex. The ligament is
usually avulsed from the lateral aspect of the distal end of the humerus and
can be reattached with sutures through drill-holes in the bone or suture
anchors. This is an integral part of the repair and emphasizes the laterally
based surgical strategy (as opposed to the more traditional medial approach to
elbow instability). A medial approach alone is insufficient to restore
stability in this setting.Prolonged immobilization (more than three weeks) following surgical repair
may produce a reasonable radiograph but usually produces a very stiff elbow
that requires further surgical intervention. The goal of surgery should be to
restore sufficient stability so that early motion can be allowed. This
enhances functional outcome, improves the range of motion, and allows the
dynamic stabilizers of the elbow (the flexor-pronator mass and the common
extensor origin) to assist in stabilizing the joint.
Fixing the radial head and/or the lateral collateral ligament prior to
repair of the coronoid or anterior capsule eliminates exposure of the coronoid
and makes repair impossible without a separate medial approach.
Resecting the radial head alone without replacement
(Fig. 12). The radial head is
a critical secondary stabilizer of the elbow in this situation. Replacement
with a metallic (rather than Silastic), modular radial head (so that the head
and stem size can be adjusted independently) is preferred.
Transarticular fixation of the joint is a reasonable salvage procedure if,
despite the surgeon's best efforts, elbow stability cannot be restored with
conventional care. However, this should be a temporary solution: a pin of
sufficient size so that it will not break should be used, and the patient
should be referred promptly to a surgeon with skill in advanced techniques
such as hinged fixation.
Failing to repair the lateral collateral ligament complex. The ligament is
usually avulsed from the lateral aspect of the distal end of the humerus and
can be reattached with sutures through drill-holes in the bone or suture
anchors. This is an integral part of the repair and emphasizes the laterally
based surgical strategy (as opposed to the more traditional medial approach to
elbow instability). A medial approach alone is insufficient to restore
stability in this setting.
Prolonged immobilization (more than three weeks) following surgical repair
may produce a reasonable radiograph but usually produces a very stiff elbow
that requires further surgical intervention. The goal of surgery should be to
restore sufficient stability so that early motion can be allowed. This
enhances functional outcome, improves the range of motion, and allows the
dynamic stabilizers of the elbow (the flexor-pronator mass and the common
extensor origin) to assist in stabilizing the joint.
AUTHOR UPDATE:
Fixation of the coronoid fragment can be accomplished with the use of the
drill-guide found on most anterior cruciate ligament reconstruction sets. The
drill-guide tip can be placed on the coronoid fragment and an appropriately
sized guidewire from a cannulated screw set is inserted through the
drill-guide to provisionally fix the coronoid. This allows precise placement
of the cannulated screw or screws and eliminates multiple passes with the
guidewire into the small coronoid fragment. Larger coronoid fragments can be
fixed with the use of recently introduced plates designed specifically for the
coronoid. However, the use of these plates requires a direct medial approach
to the coronoid.
The surgical approach can be either a direct lateral incision (and, if
necessary, a separate medial approach) or a posterior incision with
subcutaneous dissection laterally and, if required, medially. Since the
majority of the damaged structures can be dealt with from the lateral side,
this is our preferred approach, for which the patient is placed in the supine
position with the arm on a hand table. Alternatively, if a posterior approach
is chosen, the patient is placed in a lateral position with the affected side
up and the arm lying over a bolster, draped free. This position is used if we
anticipate placing a hinged external fixator or performing a separate medial
approach.
The typical patterns of lateral soft-tissue injury have been previously
described. The most common injury is an avulsion of the lateral collateral
ligament complex from the humerus, leaving a typical "bare spot"
on the posterolateral aspect of the lateral condyle (Figs.
1 and
2)9.
Care is taken to work through any soft-tissue disruption created by the trauma
(with proximal and distal surgical extension as required), preserving intact
structures as much as possible (Fig.
3). The detached lateral ligament complex is tagged for later
repair. Approximately 60% of patients also have a disruption of all or part of
the common extensor origin; this is also tagged for later repair.
The deepest structure, the coronoid, is addressed first: visualization is
dramatically improved by resection of the radial head if there is an
irreparable fracture, which is seen in approximately 60% of patients
(Fig. 4). If a large fragment
(a type-II or III coronoid fracture) is found, we perform an open reduction
and place one or two small-fragment (3.0 or 3.5-mm) lag screws from the
posterior surface of the ulna to fix the coronoid fracture fragment. In
comminuted fractures, we attempt to fix the largest fragment possible, which
is typically the articular portion, as this restores the anterior buttress of
the coronoid and prevents posterior subluxation of the elbow joint. Cannulated
screws are very useful in this regard, as the guidewire of the screw can be
precisely placed in the coronoid fragment (Figs.
5,
6, and
7,
7). Type-I coronoid fractures
are too small to be fixed with screws, so they can be repaired by placing
lasso-type sutures around the fragment and the attached anterior capsule and
tying those sutures to the base of the coronoid through drill-holes made with
an eyed Kirschner wire (Fig.
8).
The radial head fracture is then evaluated. Generally, the primary goal is
to fix the fracture if there are one or two fracture fragments of the head.
The fracture fragments are reduced and held with a small reduction forceps,
and then they are temporarily fixed with small Kirschner wires. Definitive
fixation is then performed with small fragment screws countersunk below the
articular surface of the head (Fig.
9). We find Herbert screws particularly useful in this regard
(Figs. 10-A, 10-B, and
10-C). If fracture comminution
(three or more fragments), impaction, cartilage damage, or an associated
radial neck fracture indicates that a stable anatomic reduction is not
feasible, the radial head is excised pending later replacement. Minor
fragments (<25% of the head) that are too small or damaged to fix are
débrided, and the residual intact radial head is left in situ. If
prosthetic replacement is necessary, we use a metal (rather than a silicone)
implant because of its better mechanical properties and clinical
results10. Also, a
modular prosthesis that allows independent alteration of the head diameter and
height and the stem size is preferable since this allows the surgeon to
exactly recreate the dimensions of the native radial head. Trial components
are implanted, and then the elbow is put through a range of motion to
determine the size that best restores joint stability. The definitive
components are then inserted.
Once the intra-articular work is completed, detachment of the lateral
ligament complex from the humerus is repaired with nonabsorbable sutures
placed either through drill-holes in the bone or with suture anchors
(Figs. 11-A and 11-B). The
most important suture is the stitch placed in the center of rotation of the
elbow laterally, located at the center of the capitellar circumference in the
lateral condyle. Midsubstance tears of the lateral collateral ligament are
occasionally seen and are repaired with number-1 or 2 nonabsorbable suture. We
use local tissue only, and it is not usually necessary (in primary cases) to
use tendon grafts or to perform ligament augmentations.
Prior to definitive closure, the elbow is examined for stability. The goal
is concentric reduction with no observed posterior or posterolateral
subluxation or dislocation through an arc of flexion-extension from 20° to
130°11.
Residual instability, if present, is typically seen in extension and/or
supination. Valgus instability alone is usually well tolerated postoperatively
and is not an indication for further surgical
intervention12.
However, residual posterior or posterolateral instability is not acceptable.
If this is evident, it is prudent first to check the quality of the reduction
and fixation of the coronoid fracture and radial head and the placement of the
lateral ligament repair sutures. If these appear satisfactory, then there are
two options: perform a repair of the medial structures (the medial collateral
ligament and, if disrupted, the flexor pronator mass) or apply a hinged
external fixator to the
elbow5. As our
experience with this injury pattern has grown, the use of a hinged fixator has
decreased except for cases involving revision. A standard subcutaneous and
skin closure is then performed, and the elbow is immobilized in a well-padded
posterior splint in the most stable position, which is typically flexion
(90°) and full pronation. Drains are not used.
The splint is left in place for one to ten days, depending on the stability
achieved and other associated injuries. In general, in an awake, alert patient
with an isolated injury and good intraoperative stability, range-of-motion
exercises are started on the first postoperative day. Patients are allowed
active and active-assisted exercises to allow the recruitment of muscle groups
(the flexor-pronator mass and common extensor origin) that act as dynamic
stabilizers of the elbow. Full forearm rotation is allowed with the elbow at
90° of flexion. Unrestricted shoulder and wrist exercises are encouraged.
We avoid the terminal 30° of extension (typically the most unstable
position) for four weeks postoperatively. We do not routinely use casts or
splints.