- dislocations of the elbow associated with fracture are termed complex;
- comprimise 49% of elbow dislocations;
- most of these fractures are inherently unstable and require surgery;
- prolonged elbow immobilization produces poor results.
- surgery must achieve sufficient stability to allow early ROM;
- when dislocation is assoc w/ fracture, first reduce dislocation;
- gentle closed reduction of elbow is recommended, usually under GEA, w/ early return to protected motion.
- repeated manipulations should be avoided;
- transarticular pin fixation;
- in some cases there will be persistent subluxation following closed reduction of unstable dislocations;
- in these cases, consider temporary transarticular fixation with a threaded Steiman pin;
- pins are directed through the olecranon process into the distal humerus, exiting through the posterior cortex;
- typically, the arm is immobilized in a long arm cast for 3 weeks, before pin removal;
- ref: Unstable elbow dislocations and fracture-dislocation: Temporary trans-articular fixation. KE Cramer. et al. (12th Annual
Meeting of the OTA);
- Dislocation + Medial Epicondyle Frx:
- following closed reduction, the medial epicondyle fracture is classified with regard to displacement;
- if it displaced < 5 mm and does not move w/ gentle valgus stress test, then continued closed treatment is indicated;
- ORIF of frx is indicated for displacement > 10 mm, severe valgus instability (suggested by positiv gravity stress test),
associated ulnar nerve symptoms, or incarceration of frag w/in ulnohumeral joint;
- Dislocation + Coronoid Process Frx:
- frx is due to avulsion by brachialis when elbow is hyperextened;
- type I: avulsion of the tip of the coronoid process;
- type II: involving less than 50% of the process
- for above types closed reduction and early motion is recommended;
- type III: frag involving > 50% of process
- assoc w/ high redislocation rate & requires ORIF
- there may be an associated valgus instability since MCL inserts onto the fracture fragment;
- brachialis attaches to the coronoid and will be partially detached w/ low fractures;
- Reconstruction of the coronoid process with a radial head fragment.
- Coronoid Process and Radial Head as Posterolateral Rotatory Stabilizers of the Elbow.
- Surgical Approaches:
- Posterolateral Approach
- Posterior approach:
- hinged fixators
- hinged fixator should always be considered with complex elbow dislocation, since it ensures early active ROM;
- essential to achieve perfect concentric reduction of joint at the time of fixator application, since slight incongruity during the
postop period will not allow mobilization;
- ref: Good functional recovery of complex elbow dislocations treated with hinged external fixation: a multicenter prospective study.
- proximal translation of radius (see Essex Lopresti Frx);
- it is important to have adequate views of the wrist early on inorder to follow proximal radial translation later on;
- heterotopic ossfication
- whether or not all patients with complex elbow frx dislocations should receive prophylaxis is a matter of controversy
The lateral ligament is injured preferentially in posterolateral dislocation of the elbow joint. Correlation analysis with MRI between ligament injuries and associated fractures
Current concepts review. Fracture-dislocation of the elbow.