AOT Elbow Forearm book sample chapters

2.1

Distal humerus—introduction

2

Humerus, distal

2.1

Distal humerus—introduction Jesse B Jupiter

15

2.2

Apophyseal avulsion fracture of the medial epicondyle (13-A1.2) Jesse B Jupiter

31

2.3

Supracondylar fracture (13-A2) with extension into the humeral shaft (12-B1) and proximal ulnar fracture (21-B1) Michael Plecko

37

2.4

Extraarticular, metaphyseal simple, transverse, transcondylar fracture (13-A2.3) Daniel A Rikli

45

2.5

Extraarticular, multifragmentary fracture with intact wedge (13-A2.1) Jesse B Jupiter

51

2.6

Extraarticular, multifragmentary metaphyseal fracture (13-A3.3) Christoph Sommer

57

2.7

Partial articular fracture, sagittal lateral condyle (13-B1.1) Reto H Babst

63

2.8

Partial articular fracture, sagittal lateral condyle, transtrochlear (13-B1.2), collateral ligament intact Jesse B Jupiter

69

2.9

Partial articular fracture, sagittal medial condyle, transtrochlear multifragmentary (13-B2.3) Daniel A Rikli

77

2.10

Partial articular fracture, sagittal medial condyle, transtrochlear multifragmentary (13-B2.3) Jesse B Jupiter, David C Ring

81

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2

Humerus, distal

2.11

Partial articular, complete frontal fracture of the capitellum (13-B3.1) Tak-Wing Lau, Frankie Leung

87

2.12

Partial articular, frontal fracture of the trochlea, simple (13-B3.2) David C Ring

95

2.13

Partial articular, frontal fracture of the trochlea, fragmented (13-B3.2) David C Ring

101

2.14

Partial articular, frontal fracture of capitellum and trochlea (13-B3.3) Jesse B Jupiter

107

2.15

Complete articular fracture, articular and metaphyseal simple (13-C1.1), with slight displacement Sean E Nork

115

Complete articular fracture, articular and metaphyseal simple (13-C1.2), with marked displacement Sean E Nork

123

Complete articular fracture, articular and metaphyseal simple (13-C1.3), with T-shaped epiphyseal fracture Reto H Babst

131

Complete articular fracture, articular and metaphyseal simple (13-C1.3), with T-shaped epiphyseal fracture Sean E Nork

137

Complete articular fracture, articular simple, metaphyseal multifragmentary (13-C2.1), with displacement Reto H Babst

145

2.16

2.17

2.18

2.19

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2.1

Distal humerus—introduction

2.20

Complete articular fracture, articular simple, metaphyseal multifragmentary (13-C2.1) Frankie Leung, Tak-Wing Lau

2.21

Complete articular fracture, articular simple, metaphyseal multifragmentary (13-C2.2), with fragmented wedge Sean E Nork

151

157

2.22

Complete articular fracture, articular simple, metaphyseal multifragmentary (13-C2.3) Peter Kloen, David L Helfet

165

2.23

Open, complete articular fracture, articular simple, metaphyseal multifragmentary (13-C2.3) Reto H Babst

173

2.24

Complete articular fracture, articular multifragmentary, metaphyseal simple (13-C3.1) Sean E Nork

177

2.25

Complete articular fracture, articular and metaphyseal multifragmentary (13-C3.3) Sean E Nork, Daphne Beingessner, Douglas P Hanel,

185

2.26

Complete articular fracture, articular multifragmentary, metaphyseal complex (13-C3.3) Daniel A Rikli

191

2.27

Complete articular fracture, articular multifragmentary, metaphyseal complex (13-C3.3) Sean E Nork

195

2.28

Open, displaced, complete articular fracture (13-C3.2) in a polytraumatized patient Michael Schütz

203

2.29

Open, complete articular fracture, multifragmentary (13-C3.2), with multifragmented proximal ulna fracture Reto H Babst

209

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2

Humerus, distal

2.30

Intraarticular nonunion Thomas P Rüedi

217

2.31

Supracondylar nonunion Jesse B Jupiter

223

2.32

Supracondylar osteotomy Diego L Fernandez

229

2.33

Infected nonunion of an articular fracture Jesse B Jupiter

233

2.34

Posttraumatic arthrosis Diego L Fernandez

237

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3

Radius and ulna, proximal

3.1

Fracture dislocations of the elbow ………………………………………………………………………… 247 Jesse B Jupiter

3.2

Extraarticular fracture of the proximal ulna, metaphyseal simple, radius intact (21-A1.2) ……… 259 Jesse B Jupiter

3.3

Extraarticular, simple fracture of the radial neck, ulna intact (21-A2.2) Daniel A Rikli

3.4

Extraarticular, multifragmentary fracture of the radial neck, ulna intact (21-A2.3)………………… 273 Jesse B Jupiter, Ufuk Nalbantoǧlu

3.5

Articular olecranon fracture, radius intact (21-B1.2) …………………………………………………… 281 Michael Schütz

3.6

Unifocal, multifragmentary, articular olecranon fracture, radius intact (21-B1.1) ………………… 285 Sean E Nork

3.7

Articular, open fracture of olecranon (21-B1.3), simple fracture of ulna shaft (22-A1.2), anterior dislocation of radial head ………………………………………………………………………… 293 Michael Plecko

3.8

Bifocal olecranon fracture, radius intact (21-B1.2) ……………………………………………………… 297 Michael Schütz, Stefan Greiner, Norbert P Haas

3.9

Articular fracture of the coronoid process, radius intact (21-B1.1) …………………………………… 305 Jesse B Jupiter, David C Ring

3.10

Articular, bifocal multifragmentary fracture of the proximal ulna, radius intact (21-B1.3) ……… 313 Jesse B Jupiter

3.11

Articular fracture of the radial head, luna intact (21-B2.1) …………………………………………… 319 Jesse B Jupiter, Ufuk Nalbantoǧlu

3.12

Articular, multifragmentary fracture of the radial head, ulna intact (21-B2.3), depression of forearm ……………………………………………………………………………………… 327 Christoph Sommer

3.13

Articular, multifragmentary fracture of the radial head, ulna intact (21-B2.3) ……………………… 333 Reto H Babst

…………………………… 267

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3

Radius and ulna, proximal

3.14

Articular, simple fracture of the radial head, extraarticular fracture of the proximal ulna (21-B3.2) ……………………………………………………………………………………… 339 Jesse B Jupiter, David C Ring

3.15

Articular, multifragmentary fracture of the radial head, extraarticular fracture of the proximal ulna (21-B3.3)……………………………………………………………………………………… 345 Michael Schütz, Norbert P Haas

3.16

Articular, simple fracture of the radial head and the coronoid process (21-C1.2), with elbow dislocation ("terrible triad") ………………………………………………………………… 349 David C Ring

3.17

Articular, multifragmentary fracture of the radial head, simple fracture of the olecranon (21-C2.1) ………………………………………………………………………………………… 355 Daniel A Rikli

3.18

Articular, simple fracture of the radial head, multifragmentary fracture of the proximal ulna (21-C2.1) ……………………………………………………………………………………… 359 Michael Plecko

3.19

Articular, multifagmentary fracture of the radial head, simple fracture of the coronoid process (21-C2.3) ………………………………………………………………………………… 367 Reto H Babst

3.20

Extraarticular fracture of the proximal ulna (21-A1.2), with pseudarthrosis ………………………… 371 Christoph Sommer

3.21

Malunited fracture of the radial neck with clinical signs of painful subluxation during loaded supination …………………………………………………………………………………… 375 Reto H Babst

3.22

Complex malunion of the proximal radial shaft associated with intraarticular malunion of the radial head …………………………………………………………………………………………… 381 Diego L Fernandez

3.23

Old, unreduced Monteggia fracture in a child with persistent radial head dislocation and malunion of the proximal ulna ……………………………………………………………………… 391 Diego L Fernandez

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Author

3.5 1

Michael Schütz

Articular olecranon fracture, radius intact (21-B1.2) Case description

46-year-old female fell and sustained a bifocal olecranon fracture. There were no other injuries.

Fig 3.5-1a–b Preoperative x-rays. a AP view. b Lateral view.

Indication

a

b

According to the principles of articular fracture management, a stable osteosynthesis permitting early functional treatment with or without a splint should be achieved. Due to an intermediate intraarticular fragment, plate osteosynthesis was performed instead of K-wire or cerclage fi xation.

Preoperative planning Equipment • LCP metaphyseal plate 3.5, 6 holes • 3.5 mm locking head screws • 3.5 mm cortex screws • 1.25 and 1.6 mm K-wires

90°

(Size of system, instruments, and implants can vary according to anatomy.)

Patient preparation and positioning Antibiotic prophylaxis: single dose 2nd generation cephalosporin.

Thrombosis prophylaxis: low-molecular weight heparin.

Fig 3.5-2 Prone position, arm on an arm table, pneumatic tourniquet (sterile or unsterile), radiography and image intensifi cation.

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3

2

Radius and ulna, proximal

Surgical approach

Fig 3.5-3

A straight dorsal incision is made under tourniquet control.

3

a

Reduction and fixation

b

Fig 3.5-4a–i a The articular fracture zone is exposed. b–d The intermediate fracture fragment is reduced, under

vision, in correct alignment to the distal joint fragment, and temporarily fixed with two K-wires. The K-wires must be inserted so that they will not interfere with the planned position of the plate.

c

d

The proximal main fragment is then reduced anatomically onto the distal fragment with the help of the pointed reduction forceps. The complete reduction is stabilized with 1.6 mm K-wires.

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3.5

3

Articular olecranon fracture, radius intact (21-B1.2)

Reduction and fixation

(cont)

e

f

g

Fig 3.5-4a–i (cont) The 6-hole metaphyseal LCP is bent anatomically at its e

f

h

i

g h–i

proximal end to encompass the olecranon. To achieve close bone plate contact, the triceps attachment is split and the plate is positioned. The plate is held in the desired position with two K-wires inserted through the two trocars.

The fi rst screw is a 3.5 mm cortex lag screw, positioned subchondrally as proximally as possible. This step is monitored by image intensification. Another 3.5 mm cortex screw is inserted into the shaft. The intermediate metaphyseal fragment is fi xed with a 3.5 mm cortex lag screw oriented towards the olecranon.

Four locking head screws are inserted for fi nal fi xation.

Clinical testing of the range of motion and radiological control ends the operation.

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3

4

Radius and ulna, proximal

Rehabilitation

A posterior upper arm splint was applied until wound healing had occurred.

Physical therapy started on postoperative day 2, initially with passive movement and later with active movement.

Implant removal

Implant removal may be necessary due to the very thin softtissue coverage and the probability of irritation.

5

Pitfalls –

6

Pearls +

Reduction and fi xation

Reduction and fi xation

If cortex screws and locking head screws are both being inserted into the same plate, there is a risk that the fi xation techniques will interfere with each other, which may lead to implant loosening.

It is highly recommended that all cortex (conventional) screws be inserted before inserting the locking head screws.

Rehabilitation

Rehabilitation

Prolonging physiotherapy may lead to elbow stiffness, and aggressive therapy may lead to fi xation failure (radial head).

A careful balance between early physical therapy to prevent elbow stiffness (especially pronation and supination), and gentle mobilization must be found.

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Author

3.6 1

Sean E Nork

Unifocal, multifragmentary, articular olecranon fracture, radius intact (21-B1.1) Case description

A 28-year-old male sustained a monotrauma resulting in a closed fracture of the left elbow after a fall from a ladder.

Fig 3.6-1a–b

Preoperative x-rays.

b

a

Indication This young patient presented with a displaced intraarticular fracture of the elbow. In addition, the extensor mechanism of the elbow has been disrupted. In order to maximize the functional recovery of the

elbow, operative treatment is required. This allows early motion to minimize joint stiffness, and anatomical reconstruction of the articular surface to minimize arthritis.

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3

Indication

Radius and ulna, proximal

(cont) Fig 3.6-2 Principle of bridge plating.

A bridge plate can be likened to locked intramedullary nail fi xation of a comminuted shaft fracture. In multifragmentary fractures of the olecranon, anatomical reconstruction of the articular surface itself is the primary goal. Intermediate, nonarticular fragments do not need to be reduced anatomically. Cancellous bone graft can be used to support the articular fragments and fi ll defects.

Directly manipulate only the articular fragments. Excessive manipulation of intermediate fragments risks disturbing their blood supply. If the soft-tissue attachments are preserved, and the fragments are relatively well aligned, healing is predictable. Alignment of the main fragments can usually be achieved indirectly utilizing traction and soft-tissue tension.

Mechanical stability, provided by the bridging plate, is adequate for indirect healing (callus formation).

Preoperative planning Traction x-rays are useful in understanding the fracture pattern. These allow for the identifi cation of intraarticular and metaphyseal comminution. In this case, there were two major fracture fragments of the articular surface. The major articular fragment included the olecranon process. The intercalary fragment contained a segment of the articular surface. The distal oblique nature of the fracture made tension band wiring much less reliable.

Plate fi xation should be used for this fracture.

Equipment • Anatomically-contoured proximal ulna plates for the proximal ulna are potentially advantageous. These allow fi xation around the tip of the olecranon with screw fi xation from the plate proximally to the intact ulnar diaphysis distally.

• Straight plates 2.0 to assist with reduction and maintenance of the intercalary fracture fragments.

• 2.4, 2.7, and 3.5 mm cortex screws • 1.5, 1.8, and 2.0 mm K-wires • Pointed reduction clamps (large and small) • Dental picks • Locking compression plates can be considered especially if there is associated osteopenia or open wounds.

(Size of system, instruments, and implants can vary according to anatomy.)

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3.6

Unifocal, multifragmentary, articular olecranon fracture, radius intact (21-B1.1)

Preoperative planning Equipment

a

d

(cont)

(cont)

b

e

Fig 3.6-3a–e Use a dynamic compression plate (DCP) (1), reconstruction plate (2), limited-contact dynamic compression plate (LC-DCP) (3), or locking compression plate (LCP) (4). The reconstruction plate is the least durable and should be used cautiously as a bridged plate.

c

1 2 3 4 5

DCP Reconstruction plate LC-DCP LCP Proximal ulna prebent plate

Choose the length of the plate so that at least three screws can be inserted in the most proximal fragment and three in the diaphysis.

If the fracture is very proximal or in osteoporotic bone, a preshaped olecranon LCP with locking head screws can be used to allow better fi xation.

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3

Radius and ulna, proximal

Preoperative planning

(cont)

Patient preparation and positioning Antibiotic prophylaxis: single dose 1st generation cephalosporin.

Thrombosis prophylaxis: low-molecular weight heparin.

The patient is positioned in a lateral position with 90° of fl exion of the affected elbow. A radiolucent arm board is used. This allows unimpeded fl uoroscopic imaging in the AP and lateral planes by positioning the C-arm parallel to the patient’s body. Alternatively, prone positioning can be used to present the elbow in a similar position. Positioning and imaging is often easier in the prone position, but potentially increases the anesthetic risks.

Both positions (lateral and prone) allow the surgeon to either sit or stand while facing the dorsal surface of the distal humerus.

90°

a

90°

b

c

288

Fig 3.6-4a–c a Lateral position. b C-arm with the patient positioned in a lateral position. c Prone position.

3.6

2

Unifocal, multifragmentary, articular olecranon fracture, radius intact (21-B1.1)

Surgical approach

An extensile dorsal incision avoiding the tip of the olecranon is used. Full thickness skin flaps are created medially and laterally, exposing the fascia of the dorsal triceps and anconeus proximally, and the proximal ulna distally. Exposure and mobilization of the ulnar nerve should be considered, given the need for proximal and medial exposure. The majority of the reduction can be performed based on the dorsal cortical realignment.

Fig 3.6-5 A straight dorsal incision is made under tourniquet control.

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3

3

Radius and ulna, proximal

Reduction and fixation Fig 3.6-6a–b Intraoperative fluoroscopic views showing the reduction and implant positions.

b

a

The intercalary fragment can be first reduced anatomically to the distal ulna, given the large cortical read. They can then be stabilized with a 2.4 mm lag screw from dorsal to palmar, effectively converting the injury into a two-piece fracture. Drill holes placed from medial to lateral and from lateral to medial in the ulnar diaphysis distal to the fracture allow medial and lateral clamp placements. The olecranon process fragment is then symmetrically compressed to the diaphyseal segment.

Usually, this is initially accomplished most easily in extension, followed by flexion to avoid the commonly observed extension malreduction. A small (2.0 mm) plate can be placed medially

to hold the reduction and to provide an additional point of fixation into the intercalary fragment. A dorsal plate that wraps around the olecranon process can then be placed. A small vertical and longitudinal split in the triceps insertion is necessary to allow proximal plate placement directly onto the bone. Two points of proximal fixation can be obtained with screws placed through the plate. The most proximal screw can be placed through the plate as a lag screw; the distal exit point should be ulnar to avoid interference with forearm rotation. Distally, two points of fixation are adequate.

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3.6

4

Unifocal, multifragmentary, articular olecranon fracture, radius intact (21-B1.1)

Rehabilitation

Splinting in extension, including night splinting, should initially be considered until physical therapy is initiated. This patient was advised not to weight bear until the bone graft had incorporated and there was radiographic evidence of healing.

Physical therapy was begun on the 2nd postoperative day, with active and passive range-of-motion exercises.

Medication: Analgesia was administered as required.

b

d Fig 3.6-7a–d a–b Immediate postoperative c–d

a

x-rays.

X-rays after 4 months showing uneventful healing.

c

Implant removal

Implant removal is usually not required if the implants are positioned appropriately. However, if symptomatic, the plates can be removed after fracture healing has occurred. Because

primary bone healing has priority, plate removal should be delayed for at least 12–18 months postoperatively.

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3

5

Radius and ulna, proximal

Pitfalls –

6

Pearls +

Equipment

Equipment

A plate that does not wrap around the olecranon process must rely on short screws to fi x the proximal segment.

The dorsal plate must be of adequate strength to resist the proximal bending forces that occur with rehabilitation.

An LC-DCP can be contoured to fit the proximal ulna, including the bend around the tip of the olecranon.

A large Weber clamp (pointed reduction clamp) can be modified by straightening one of the two tines which can then be placed into a transverse drill hole in the ulna, distal to the fracture. The curved tine can be placed on the proximal olecranon segment, lateral to the anticipated plate location.

Precontoured plates have a bend that incorporates the ulna bow, enabling an improved fit.

Surgical approach

Surgical approach

In the acutely injured extremity, the subcutaneous dorsal border of the olecranon may not be easily palpated.

Care must be taken to identify the interval between the anconeus and flexor carpi ulnaris muscles.

The incision should avoid the skin overlying the olecranon tip to decrease future discomfort.

Reduction and fi xation

Reduction and fi xation

The proximal radioulnar joint must be avoided during screw fi xation.

Smaller lag screws (2.0 and 2.4 mm) have the advantage of securing intercalary and comminuted fragments yet allowing plate placement given the low-profi le cruciate screw heads.

Rehabilitation

Rehabilitation

Premature weight-bearing and aggressive physical activities prior to healing may compromise the fi xation.

Early mobilization with active and passive elbow rangeof-motion exercises is recommended. Weight bearing is restricted until there is evidence of healing.

Adequate exposure of the medial and lateral articular surfaces of the olecranon helps to ensure an accurate articular reduction.

Terminal extension loss despite aggressive rehabilitation occurs frequently. Consideration should be given to splinting the elbow in extension during the immediate postoperative period.

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Author

Michael Plecko

3.7 Articular, open fracture of olecranon (21-B1.3), simple fracture of ulna shaft (22-A1.2), anterior dislocation of radial head 1

Case description

A 79-year-old male fell from a ladder and suffered a Gustilo type I open, multifragmentary fracture of the proximal ulna with anterior dislocation of the radial head and an undisplaced simple fracture of the ulnar shaft. His right dominant arm was affected. Additionally, he had a severe thorax trauma with multiple rib fractures and a hematopneumothorax.

Fig 3.7-1a–b Preoperative x-rays. a AP view of the right elbow. b Lateral view.

a

b

Indication

Preoperative planning

Segmental fracture of the ulna 21-B1, multifragmentary Gustilo type I open fracture of the proximal ulna, anterior dislocation of the radial head, and additional simple undisplaced 22-A1 fracture at the shaft of the ulna.

After stabilizing the patient’s general condition, open reduction and internal fixation with additional reduction of the radial head had to be performed within the first 48 hours.

Equipment • LCP olecranon plate 3.5, 8 holes • 3.5 mm self-tapping locking head screws • 3.5 mm locking head screws • 3.5 mm cortex screws • 2.4 mm cortex screw • K-wire (Size of system, instruments, and implants can vary according to anatomy.)

Patient preparation and positioning Antibiotics: 24 hours cephalosporin intravenous.

Thrombosis prophylaxis: none

Fig 3.7-2 Supine position with towel roll at the level of the rib cage with the injured arm placed on it. Sterile tourniquet.

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3

2

Radius and ulna, proximal

Surgical approach Fig 3.7-3a–b Posterior

approach to the ulna. Excision of blood clot and of the olecranon bursa. Preparation of the ulnar nerve and marking the nerve with a vessel loop.

a

3

a

b

Reduction and fixation

b

Fig 3.7-4a–c a–b Anatomical reduction of the olecranon fracture with a pointed reduction forceps and

temporary fixation with a K-wire. Positioning of an 8-hole LCP olecranon plate and temporary fixation of the proximal end of the plate by insertion of a K-wire through the threaded drill sleeve. The drill sleeve is correctly positioned with the help of an aiming block.

The first screw to be introduced through the plate is a cortex screw to fix the coronoid process. The second screw, a 3.5 mm locking head screw, is inserted into the shaft fragment. The cortical fragment on the radial side is fixed with a plate-independent 2.4 mm cortex screw using the compression method.

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3.7

3

Articular, open fracture of olecranon (21-B1.3), simple fracture of ulna shaft (22-A1.2), anterior dislocation of radial head

Reduction and fixation

(cont)

c Fig 3.7-4a–c (cont) c The fi xation of the plate is fi nalized with four locking

head screws in the proximal fragment, two in the intermediate shaft fragment, and three in the distal shaft fragment.

4

a

b

Fig 3.7-5a–b

The lateral postoperative x-ray shows an additional undisplaced shaft fracture of the ulna. This fracture was not clearly seen in the preoperative x-rays.

The radial head is reduced. a AP view. b Lateral view.

Rehabilitation

Functional treatment was started on postoperative day 1 with active and passive motion of the elbow joint and the forearm.

a Fig 3.7-6a–b

b

Range of motion 12 days postoperatively.

a

bb

Fig 3.7-7a–b X-rays taken 6 months postoperatively showed bone consolidation of both fractures with the radial head in correct alignment. a AP view. b Lateral view.

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3

4

Radius and ulna, proximal

Rehabilitation

(cont)

a

b

c

d

Fig 3.7-8a–d

Six months postoperatively the patient was pain free, had only slightly functional restrictions, and equal strength on both sides. a–b Range of motion: flexion/extension 0/5/140. c–d Range of motion: pronation/supination 70/0/70.

5

Pitfalls –

6

Pearls +

Equipment

Anatomical preshaped plates are helpful in complex fracture situations.

Reduction and fi xation

Reduction and fi xation

In this case, the undisplaced additional ulnar shaft fracture was not clearly seen on the preoperative x-rays.

The special, anatomically preshaped LCP olecranon plate 3.5 with the combination hole allows stable fi xation of this segmental fracture by two different methods: the compression method for the olecranon fracture and splinting method for the undisplaced shaft fracture.

Correct reduction and fi xation of the multifragmentary olecranon fracture is the precondition for the reduction of the displaced radial head.

Angular stable plating of the proximal ulna also leads to higher stability in multifragmentary fracture situations.

This permits an early active rehabilitation program.

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Authors

3.8 1

Michael Schütz, Stefan Greiner, Norbert P Haas

Bifocal olecranon fracture, radius intact (21-B1.2) Case description

A 72-year-old female sustained a monotrauma, closed fracture injury to the right elbow.

Fig 3.8-1a–b Preoperative x-rays. a AP view. b Lateral view.

a

b

Indication The patient presented with an articular fracture of the olecranon with at least two fracture lines. An impression of the articular surface was evident on the mid fragment. In consideration of the patient’s age

at the time of injury, operative treatment was deemed necessary to restore the joint surface and preserve the elbow range of motion and function.

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3

Indication

Radius and ulna, proximal

(cont)

a Fig 3.8-2a–b Tension band principle. a The tension band converts tensile forces into compression forces.

There must be no comminution on the side opposite the plate.

Note the contact of the articular surface in this fracture.

b

b

The following criteria must be fulfi lled for a plate to act as a tension band: • The fractured bone must be eccentrically loaded.

• The plate must be placed on the tension side.

• The plate must be able to withstand the tensile forces.

• The bone must be able to withstand the compressive force which results from the conversion of distraction forces by the plate.

• There must be a bony buttress opposite to the plate to prevent cyclic bending. The articular surface needs to have contact, as illustrated here.

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3.8

Bifocal olecranon fracture, radius intact (21-B1.2)

Preoperative planning Fig 3.8-3 The patient is placed in a face-down position with the injured arm fl exed at 90° over a roll and freely mobile.

Equipment • LCP 3.5, 7-hole • 3.5 mm self-tapping locking head screws • 2.0 mm K-wires • 2 mm cortex screws (Size of system, instruments, and implants can vary according to anatomy.)

Patient preparation and positioning Antibiotics: Agmentan 2.2 g intravenous combination compound of amoxicillin (penicillin) and clavulanacid.

Thrombosis prophylaxis: low-molecular weight heparin.

2

Surgical approach

A posterior approach is initially taken. A skin incision is started approximately 2 cm above the tip of the olecranon at the dorsal aspect of the humerus, curving the olecranon radially, and ending approximately 5 cm distal of the tip of the olecranon following the ulnar edge. The triceps tendon is left intact and the subcutaneous tissue is dissected just to the periosteum.

Fig 3.8-4

Posterior approach.

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3

3

Radius and ulna, proximal

Reduction and fixation

The fracture is exposed and the borders are cleaned carefully with a curette. The joint is reduced by traction and the collapsed joint surface gently elevated to restore congruity. Temporary fixation is achieved by the insertion of two 2.0 mm K-wires.

The middle fragment is fixed with a 2.0 mm cortex ulnoradial screw. After visualization of the plate position by C-arm in two planes, a 7-hole LCP 3.5 is flexed approximately 60° between the first and second screw hole and adjusted to fit on the proximal ulnar rim. If necessary, the triceps tendon is split at

a

its insertion on the olecranon to allow positioning of the plate.

A cortex screw is placed from the tip of the olecranon through the first plate hole in the direction of the coronoid, just under the articular surface. A monocortical self-tapping locking head screw is placed in the second plate hole. Two holes above the fracture are left empty. Finally, two bicortical and one monocortical self-tapping locking head screws are placed in the plate distally.

b

Fig 3.8-5a–e a Through a posterior incision directly reduce the fracture

with the help of pointed reduction forceps. Temporarily hold the reduction with one or two K-wires. Insert the K-wires in a position where they do not interfere with the planned plate and screws. Control reduction with direct visualization of the sigmoid notch and the posterior cortex of the olecranon and confirm with C-arm fluoroscopic control.

b

The middle fragment is fixed with a 2.0 mm cortex ulnoradial screw. A 7-hole LCP 3.5 is flexed and adjusted to fit on the proximal ulnar rim.

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3.8

3

c

Bifocal olecranon fracture, radius intact (21-B1.2)

Reduction and fixation

(cont)

d Fig 3.8-5a–e (cont) c To achieve close bone plate contact, split the triceps

e

attachment before positioning the plate. Anchor the plate with two screws to the tip of the olecranon. Make sure that the screws do not protrude into the joint. d If cortex screws are used, insert three screws bicortically into the distal fragment. Make sure to maintain the contour and width of the greater sigmoid notch. e An alternative in very proximal ulna fractures can be the use of a one-third tubular hook plate. Cut the screw hole on one end of the plate and bend it to form a bifid hook.

The hook engages in the proximal fragment, where it can be additionally fixed with one or two scrws. Apply the plate underneath the triceps brachii tendon and make sure that the tip does not impinge on the olecranon fossa.

Note: The one-third tubular plate is thin and may fail under bending loads. Thus it should be used only as a tension band with good bone support.

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3

3

Radius and ulna, proximal

Reduction and fixation

(cont) Fig 3.8-6a–b

a

4

Postoperative x-rays after 1 week.

b

Rehabilitation

The limb was protected by a dorsal splint of the elbow in 90° flexion and neutral rotation until wound consolidation. Early range of motion was started on the first postoperative day, allowing full range of motion in extension, flexion, pronation, and supination. The patient was advised to limit weight bearing in extension or flexion for 4 weeks. An increase of activity was dependent on the follow-up x-rays and clinical examinations.

a

b

Fig 3.8-7a–b

AP and lateral x-rays 1.5 months postoperatively.

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3.8

4

Bifocal olecranon fracture, radius intact (21-B1.2)

Rehabilitation

a Fig 3.8-8a–b

(cont)

b

AP and lateral x-rays 2.5 months postoperatively.

a Fig 3.8-9a–b

b

AP and lateral x-rays 12.5 months postoperatively.

Implant removal

Implant removal may prove necessary later because of mechanical irritation by the superficial subcutaneous position of the plate. However, implant removal should not be performed earlier than 12 months postoperatively.

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3

5

Radius and ulna, proximal

Pitfalls –

6

Pearls +

Equipment

Equipment

Problems may occur if the length of the plate is too short and, consequently, too few screws are placed in the distal fragment.

Conversely, if the length of the plate is too long proximally, impingement in the olecranon fossa with limitation of extension may occur.

The contoured LCP is optimal for more complex fractures.

Reduction and fi xation

With osteoporotic bone, the LCP is optimal.

Surgical approach

The skin incision crossing the tip of the olecranon may lead to skin irritation or contracture. a

Reduction and fi xation

Inadequate anchorage of the self-locking screws may hinder stable fi xation.

b Fig 3.8-10a–b a Depending on the fracture configuration,

interfragmentary compression can be achieved by inserting a lag screw through the plate. b Reduction of a large coronoid component of multifragmentary proximal ulna fractures can often be done through the fracture site. Provisional or defi nitive fi xation can be placed at that time, but sometimes it helps to use a screw through a posterior plate for fi xation, as shown here. Insert this as a lag screw, as perpendicularly as possible to the fracture plane at the base of the coronoid. Smaller diameter screws may be better.

Rehabilitation

Rehabilitation

Delayed rehabilitation may lead to immobilization of the elbow, causing a limitation of the active range of motion and joint contracture.

With contused skin envelope, delay mobilization for 3–5 days.

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Author

3.22 1

Diego L Fernandez

Complex malunion of the proximal radial shaft associated with intraarticular malunion of the radial head

Case description

A 38-year-old male sustained a proximal forearm fracture as a result of a fall from a mountain bike. Three years previously a midshaft fracture of the same right forearm had been treated with open reduction and internal fixation.

a

b

Fig 3.22-1a–b Initial x-rays revealed a multifragmentary fracture of the proximal radius associated with an intraarticular fracture of the radial head, and an oblique fracture of the proximal ulna. A malunion of the proximal third of the radius was present as a result of the previous fracture, as well as a broken screw in the midshaft of the ulna.

a

b

Fig 3.22-2a–b The patient was initially treated in another institution with plate fixation of the proximal ulna fracture, and the proximal radial fracture left untreated. To control shortening of the radius, a distal transfixation of the radius and ulna was performed with a percutaneous K-wire. A long arm cast was applied for 6 weeks.

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3

1

Radius and ulna, proximal

Case description

(cont)

Two years following treatment, and after having had the plate on the ulna removed, the patient presented with an intraarticular malunion of the radial head and a complex malunion of the proximal and midshaft of the radius, with complete loss of forearm rotation in a neutral position.

a

b

Fig 3.22-3a–b X-rays revealed a double angulated malunion of the proximal shaft of the radius, massive reduction of the interosseous space, and intraarticular incongruity both in the radiocapitellar joint and in the proximal radioulnar joint.

a

b

Fig 3.22-4a–b Preoperative x-rays of the contralateral side.

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3.22

Complex malunion of the proximal radial shaft associated with intraarticular malunion of the radial head

Indication

a

Due to complete loss of forearm rotation, the patient had to compensate for the loss of pronation with shoulder abduction that resulted in painful fi bromyalgic contracture of the shoulder girdle.

A corrective osteotomy, interosseous membrane release, and radial head replacement was indicated to improve forearm rotation, especially pronation.

An alternative procedure would have been a pronation osteotomy of the radius at the midshaft level to place the hand in a more functional position; however, this would not have dealt with the progressive degenerative changes in the lateral compartment of the elbow.

b

c

Fig 3.22-5a–d a–b Preoperative, completely blocked, forearm rotation on the right side. c–d Flexion/extension of the elbow is well preserved.

d

Preoperative planning Preoperative planning using comparative x-rays of both forearms taken in a standardized fashion, including both the elbow and wrist joint (see Fig 3.22-3, Fig 3.22-4) as well as comparative x-rays of both elbows ( Fig 3.22-6).

a

b

c

d

Fig 3.22-6a–d Comparative x-rays of both elbows in order to plan the correct size of the radial head implant. The double angulation of the proximal radial shaft is well appreciated ( b) while widening and incongruity of the radial head is seen in (a).

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3

Radius and ulna, proximal

Preoperative planning

(cont) Fig 3.22-7 Preoperative drawings.

A double transverse osteotomy of the proximal shaft at the level of the deformity is shown. The most proximal is 8 cm from the radiocapitellar joint, and the most distal 5 cm distal to the fi rst osteotomy. The level of resection of the radial head is also shown.

Both osteotomies are realigned with a 10-hole LCDCP 3.5. Notice the use of cancellous bone grafts at both osteotomy levels taken from the resected radial head. A Judet-type bipolar radial head prosthesis has also been planned. An optional interposition with a pedicle fl ap of the brachioradialis muscle drawn.

Equipment • LC-DCP 3.5 • Metallic angle templates • Radial head prosthesis instrumentation • Fluoroscan (mini C-arm) (Size of system, instruments, and implants can vary according to anatomy.)

Patient preparation and positioning The patient is placed in a supine position, with the affected arm resting on a hand table, a nonsterile pneumatic tourniquet in place.

Antibiotic prophylaxis is preferred since the patient has had previous surgery, and an operation time of more than 2 hours is expected.

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3.22

2

Complex malunion of the proximal radial shaft associated with intraarticular malunion of the radial head

Surgical approach

a

b Fig 3.22-8a–c a The proximal part of a palmar Henry approach to the

c

whole radius is preferred. A longitudinal incision on the medial border of the brachioradialis muscle (mobile wad) is utilized. b The brachioradialis and the superficial branch of the radial nerve are separated radially while the flexor tendons and the radial artery are retracted towards the ulnar side, exposing the supinator muscle and the pronator teres muscles in the proximal part of the incision. c The supinator is detached from the proximal radial shaft close to the insertion of the biceps tendon and reflected laterally, thus protecting the posterior interosseous nerve. In the proximal part of the incision the anterior elbow capsule may be opened, exposing the radial head, the capitellum and the sigmoid notch of the proximal radioulnar joint. In this case, resection of the radial head and prosthetic replacement is performed through this approach.

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3

3

Radius and ulna, proximal

Reduction and fixation

Supinator muscle

Superficial radial nerve Brachioradialis

Fig 3.22-9 Exposed malunion of the proximal radius including the radial head and the capitellum in the proximal area. Note the retracted and separated supinator muscle towards the ulna, while the brachioradialis and the superficial radial nerve are retracted laterally. The lateral antebrachiocutaneous nerve is held with a rubber band.

Fig 3.22-10

The point of fibrous contact of the malunited proximal radius shaft with the ulna is shown here (arrow), creating a radioulnar synchondrosis.

Ulna

Radius

According to the preoperative plan, the transverse osteotomy sites of the radial resection, the proximal osteotomy, and the distal osteotomy are marked with an osteotome.

a

b

Fig 3.22-11a–b The radial head is resected. a Note degenerative changes at the level of the capitellum. b Sagittal cut of the resected head shows important incongruence and depressed central fragments.

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3.22

3

Complex malunion of the proximal radial shaft associated with intraarticular malunion of the radial head

Reduction and fixation

(cont)

After resection of the radial head, the distal osteotomies are performed and the contracted interosseous membrane released at the level of the synchondrosis. Next, a 10-hole LC-DCP 3.5 is slightly curved to adapt to the anatomy of the proximal radius and is provisionally applied distally, in the middle fragment, and in the proximal fragment with three unicortical screws. Reduction of both osteotomies following minimal wedge resection is improved using bone reduction clamps between the fragments and the plate. The rest of the screws is then inserted, except those in the proximal fragment. A

unicortical screw is left, and the proximal radius then prepared with awls for reception of a cemented Judet prosthesis shaft.

The test prosthesis is inserted with the small test head, and the stability of the prosthesis with passive motion of the elbow and pronation/supination movements is checked. The definitive Judet prosthesis is subsequently cemented with CMW cement.

Prior to polymerization of the cement, the two remaining screws in the proximal fragment are inserted tangential to the prosthesis shaft.

Fig 3.22-12a–d a–b Immediate postoperative x-rays

c–d a

b

c

d

showing the reconstruction of the proximal radius with the prosthesis, and the double osteotomies.

Note good realignment and a maintenance of the radius length without incongruity at the level of the distal radioulnar joint.

Note that the osteotomies are fi xed with three unicortical screws in each main fragment.

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3

4

Radius and ulna, proximal

Rehabilitation

In this case, a forearm U-splint including the elbow (sugar tong splint) was applied for 12 days, at which time the sutures were removed. Thereafter, the patient was started on active and passive range-of-motion exercises, with particular emphasis on pronation and supination exercises, as preoperative forearm

a Fig 3.22-13a–b

b

X-rays 3 months postoperatively showed an uneventful bony healing of both osteotomies, stable implants, and a well-centered prosthesis with good radiocapitellar congruency.

rotation had been totally blocked in a neutral position. At 3 months there was a significant improvement of pronation to 60°, while supination remained limited to approximately 15°.

Elbow function was not limited.

a

b

Fig 3.22-14a–b

X-rays 3 years postoperatively showed complete remodeling of both proximal and distal osteotomies, and a stable Judet prosthesis.

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3.22

4

Complex malunion of the proximal radial shaft associated with intraarticular malunion of the radial head

Rehabilitation

(cont) Fig 3.22-15a–d

Function was maintained 3 years postoperatively with restoration of a functional arc of forearm rotation.

c a

b

d

Implant removal

Implant removal was absolutely contraindicated because of the high risk of iatrogenic lesion to the posterior interosseous nerve.

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3

5

Radius and ulna, proximal

Pitfalls –

6

Pearls +

Equipment

Equipment

Lack of proper implants, particularly the different choices of radial head prostheses, may contribute to operative difficulties.

The varying plates and prostheses to accommodate the preoperative plan should be readily available.

Surgical approach

Surgical approach

An incision that does not provide adequate exposure of the proximal radioulnar joint and the posterior interosseous nerve may hinder the planned complex reconstruction or lead to iatrogenic damage of the nerve.

A Henry approach, including anterior elbow arthrotomy, is strongly recommended.

Reduction and fi xation

Reduction and fi xation

The use of a plate of insufficient length when bridging a double osteotomy must be avoided because of the high risk of instability and delayed union or nonunion. The jamming of screws with the shaft of the radial head prosthesis must also be avoided.

The osteotomy is performed with minimal soft-tissue stripping and continuous irrigation. The osteotomized fragments should be indirectly reduced to a well premolded plate.

Rehabilitation

Rehabilitation

Forceful manipulation in the early stages may lead to prosthesis dislocation.

Rehabilitation should be progressive. If there is tendency for contracture, a dynamic forearm rotation splint may be indicated for 8 weeks postoperatively.

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Author

3.23 1

Diego L Fernandez

Old, unreduced Monteggia fracture in a child with persistent radial head dislocation and malunion of the proximal ulna

Case description

An 8-year-old boy sustained a Monteggia fracture of his right forearm after a fall from a tree. The radial dislocation had not

been noticed by the treating physician, and the fracture was stabilized in a long arm cast for 6 weeks.

b

a

c

Fig 3.23-1a–c X-rays and clinical appearance of the child’s forearm immediately after the injury. The x-rays revealed an anterior dislocation of the radial head, with the proximal ulna showing an anterior angulation of 20°.

a

b

Fig 3.23-2a–b

X-rays at 6 weeks following cast removal reveal an exuberant periosteal callus around the ulna fracture, while the radial head was still anteriorly dislocated.

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3

1

Radius and ulna, proximal

Case description

(cont)

One year postinjury, the child complained of limited forearm rotation and painful elbow flexion. A clinical exam revealed a pronation/supination arc of 60-0-40, while flexion and extension of the elbow was 120-0-0.

Fig 3.23-3a–b

X-rays 1 year postinjury reveal a remodeled callus, a persistent anterior angulation of the ulna of 10°, and a completely anteriorly dislocated radial head.

Indication

a

b

If the radial head is not reduced, rotation of the forearm will not be improved, and since there is no load transfer through the radial head, a convex “mushroom-type” remodeling of the radial head will ensue. This will make later reduction and restoration of a congruent radiocapitellar joint impossible. Open reduction of the radial head and correction of the ulnar malunion as well as capsular reefi ng is necessary. Creation of an annular ligament with a free tendon graft is not necessary if a capsular flap created from the elongated remnants of the annular ligament is securely reefed to the proximal ulna.

Preoperative planning The osteotomy of the ulna requires no sophisticated preoperative planning since it will spontaneously open dorsally to a degree in which the radial head is stable and congruent with the capitellum and sigmoid notch.

Patient preparation and positioning The patient is placed in a supine position with the affected arm resting on a hand table, with a pneumatic tourniquet in place.

The elbow is semifl exed, with a rolled towel underneath.

Antibiotic prophylaxis: single shot 2nd generation cephalosporin.

Equipment • Small fragment set • 6-hole LC-DCP 3.5 • K-wires • Fluoroscan (Size of system, instruments, and implants can vary according to anatomy.)

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3.23

2

Old, unreduced Monteggia fracture in a child with persistent radial head dislocation and malunion of the proximal ulna

Surgical approach

a

Extensor carpi ulnaris

1

Flexor carpi radialis

3 4

2

5 6 c 1 2 3 4 5 6

b

d

Brachioradialis Extensor carpi radialis longus Capsule Extensor digitorum communis Extensor digiti quinti Extensor carpi ulnaris

e

Fig 3.23-4a–e A posterolateral longitudinal incision, centered on the proximal subcutaneous border of the ulna, is extended proximally over the elbow and slightly curved to the lateral aspect of the midarm. a The proximal ulnar shaft is exposed between the extensor carpi ulnaris and flexor carpi radialis. b–c The anterolateral exposure of the elbow joint is performed by elevating the common origin of the extensor carpi ulnaris, extensor digitorum communis, extensor carpi radialis brevis and longus, and brachioradialis from their

d

e

insertions in the lateral aspect of the humerus and at the level of the lateral epicondyle. The anterior bow of the malunited ulna is also shown in these pictures.

Elevation of the anterolateral elbow capsule. Note that the radial nerve has been exposed on the medial border of the brachioradialis, and is held with a rubber band.

The dislocated radial head is then exposed by resection of the scar tissue of the originally torn annular ligament.

This tissue has to be partially resected to allow for reduction of the chronic dislocation.

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3

3

Radius and ulna, proximal

Reduction and fixation

a

b

c

d

Fig 3.23-5a–d A transverse osteotomy of the ulna is then a

b

c–d

performed at the point of maximal deformity, protecting the soft tissues with Hohmann retractors.

The radial head dislocation is reduced with digital pressure from anterior to posterior until it is congruent with the capitellum.

As reduction is obtained, the osteotomized ulna will open dorsally, in this case to approximately 10° (see also preoperative planning). The reduced radial head is pinned

with an axial 1.6 mm K-wire through the capitellum, and the osteotomy plated with a DCP or LC-DCP 3.5. The capsular strip providing a new annular ligament is sutured dorsally to the periosteum of the proximal ulna. Finally, the detached lateral capsule and insertion of the common extensors are adapted with nonabsorbable sutures to the periosteum of the lateral humerus over a suction drainage. A long arm cast is applied for a period of 6 weeks.

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3.23

4

Old, unreduced Monteggia fracture in a child with persistent radial head dislocation and malunion of the proximal ulna

Rehabilitation

At 6 weeks, the cast and percutaneous K-wire used to stabilize the radiocapitellar joint were removed, and progressive range-of-motion exercises of the elbow were initiated under supervision of a physical therapist. Following removal of the K-wire, x-rays were taken to check the stability of the radial

head. Another x-ray examination of the osteotomy and the elbow was recommended 2 weeks after initiating the cast-free postoperative treatment.

Complete remodeling of the osteotomy was performed 1 year postoperatively.

c

a Fig 3.23-6a–b

b

Stable radiocapitellar

joint.

a

b

d

Fig 3.23-7a–d A functional result, with an adequate flexion/extension of the elbow and free pronation/supination.

Implant removal

Implant removal is recommended in children because of exuberant bony growth over the plate, and because the

location of the plate on the subcutaneous border of the ulna may cause irritation.

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3

5

Radius and ulna, proximal

Pitfalls –

6

Pearls +

Surgical approach

Surgical approach

The radial nerve may be inadvertently damaged (possible iatrogenic lesion) while exposing the anteriorly dislocated radial head.

The joint must be safely exposed without damaging the lateral physical growth plate of the capitellum during capsular detachment. The radial nerve must be exposed and protected.

Reduction and fi xation

Reduction and fi xation

Failure to obtain an anatomical reduction of the radial head with anterior subluxation may be due to insufficient mobilization of the osteotomized ulnar fragments.

Avoid multiple drilling of the radial head in the reduced position, instead perform a single shot K-wire fi xation using the fluoroscope.

Iatrogenic lesions may occur to the epiphyseal plate of both the capitellum and the radial head.

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