1. Clinical Algorithm for Fracture/Dislocation of the Elbow
I am going to talk about traumatic elbow instability and present a clinical algorithm for the management of fractures/dislocation of the elbow
Relatively common
2nd only to shoulder dislocations
annual incidence: 6/100,000
Christian Veillette M.D., M.Sc., FRCSC
Assistant Professor, University of Toronto
Shoulder & Elbow Reconstructive Surgery
Toronto Western Hospital University Health Network

2. Elbow Stability Dependent upon: Soft tissue Bony congruity
We know that elbow stability is roughly dependent on soft tissue and bony congruity in a 50:50 ratio
There have been a number of fairly complex biomechanical studies all of which show that those two elements make up roughly half of the components of elbow stability
So soft tissue and bone congruity are the two things we are looking for

3. Bony structures Bony congruity: Coronoid process Radial head
If we look at bony congruity, the two most important structures are the coronoid process and the radial head
In every picture you see of an elbow fracture/dislocation, or elbow dislocation have the same general pattern where the elbow wants to go out in a posterior fashion
Look at the muscle force in vectors across the elbow, basically the elbow wants to dislocate or subluxate in a posterior fashion. So there will be a common theme in almost all the radiographs you see here is the elbow sliding out the back.
The two bony structures that prevent that from happening, as you see in the slide here are the coronoid process and radial head
Falling trauma is a posterolateral instability pattern not a valgus instability pattern

4. Soft tissue structures
Medial (ulnar) collateral ligament
Medial epicondyle to tubercle on medial aspect of coronoid
Anterior band most important
If you look at the soft tissues for many years most of our attention was focussed on the MCL.
The focus of most sports literature on this subject is reconstruction of the MCL in throwers and that dominated our thinking on elbow instability for a long time
The MCL is important but not nearly as important as the lateral based structures at least in the trauma setting
One thing I will point out about the MCL is where it attaches, the base of the coronoid here
If you lose a significant chunk of your coronoid its like a double whammy because you have also lost the attachment of your MCL and that can have a significant negative affect on the stability of your elbow

5. Soft tissue structures
Lateral (ulnar) collateral ligament
Lateral epicondyle to tubercle of supinator crest on lateral side of ulna
Posterior bundle most important
Common injury in elbow dislocation
Resists varus and posterolateral rotational stress
The lateral soft tissue structures we have come to recognize are the most important in the development of posttraumatic instability of the elbow
Dr. O’Driscoll and Morrey are the ones that have popularized this kind of thinking
In the lateral collateral ligament complex, it is not really a single band or fiber that you see in other areas, but it is sort of a thickening of the capsule on the lateral side, and it runs from the lateral epicondyle to the supinator crest on the lateral side of the ulna
Most common injury in elbow dislocations
If you look at it pictorally here, you can see that this is what it looks like when you get in there. But the most important bands are right here.
Holds the elbow and joint and prevents the ulnar and radius from rocking off in a posterolateral fashion

6. Lateral collateral ligament complex

7. Mechanism of Injury Fall on outstretched hand with shoulder abducted
“Elbow Subluxation and Dislocation, A Spectrum of Instability”, O’Driscoll, et al
Fall on outstretched hand with shoulder abducted
Axial load produced at the elbow as it flexes
The body internally rotates on the hand
Ext rotation (hypersupination) & valgus moments are applied to the elbow

8. Mechanism of Injury-Circle Concept/Stages
Elbow Subluxation and Dislocation, A Spectrum of Instability”, O’Driscoll, et al
Stage 1
LUCL disruption
Stage 2
LUCL + RCL + ant/post capsule disrupted
Stage 3
Stage 2 + MCL disruption
MCL disruption – partial (3A) or complete (3B)

9. Algorithm for Elbow Fracture/Dislocation
No Fracture
Fracture
Concentric
Stable
Non-concentric
Not stable
Concentric
Stable
I general in the algorithm for the treatment of an elbow fracture dislocation, if there is no fracture ie. A simple elbow dislocation the vast majority following closed reduction will be concentric and stable and benefit from early motion
And the thickness of the arrows here illustrates where the numbers tend to go in this pattern
Occassionally an elbow dislocation with no associated fracture will not be stable or not be concentric and you need to repair it.
On the other hand once you get into the fracture dislocations of the elbow, so that you have associated fracture, they become a complex elbow injuries. Most of those are going to require fixation because they do not tend to be concentric and stable once you reduce them.
If you are lucky, the fracture is small and minimally displaced you may be able to get away without an operation to allow early motion
In general, simple elbow dislocations are going to go down this path, and complex elbow dislocations are going to go down this path.
Early motion
Operative repair
Early motion

10. Concentric/Stable Concentric Radial head lines up with capitellum
Ulnohumeral joint concentric
Stable
Elbow stays reduced for ROM from minimum 30 to 130o
Not only in extremes of flexion
What do I mean by concentric or stability>
Basically, you want your radial head to line up with the capitellum on every view, it should do that on every view regardless of the angle taken
And you want your ulnohumeral joint to be concentric, and that is kind of difficult to tell sometimes on radiographs
By stabililty you want a concentric reduction through a functional arc of motion of the elbow which is from 30 to 130 degrees
It does not mean putting the elbow in 130 degrees of flexion because that is the only way you can keep it stable

11. Simple dislocation – Treatment?
What about simple dislocations? The vast majority are posterior from a fall on an outstretched hand and they will do well with nonoperative treatment
There is actually a good randomized trial looking at this. And so the question was asked, do these simple elbow dislocations require surgery, because most of them have both ligaments torn

12. Do simple elbow dislocations require surgery?
In general little role for surgery with uncomplicated elbow dislocation
Josefsson, JBJS, 1987
“Surgical vs. Nonsurgical treatment of ligamentous injuries of the elbow joint following dislocation of the elbow joint: A prospective randomized study”
No significant advantage in operative group
This is one of the papers that gives us pretty good footing to recommend nonoperative treatment for these injuries. If you splint them for 5-7 days and then move them early in a controlled fashion the vast majority do well.
Immediate reduction of the dislocation
forearm in supination to clear the coronoid under the trochlea
longitudinal traction and direct pressure over olecranon
Repeat films to assess for fracture

13. Simple Elbow Dislocation
Treatment
No more than 7-10 days of cast immobilization
Early active use and exercises
Melhoff and colleagues
Protzman and colleagues

14. Simple Elbow Dislocation
Treatment
Treat slight subluxation with early active motion
Avoidance of varus stress
Melhoff and colleagues
Protzman and colleagues

15. Open repair for simple dislocation
Anterior dislocation
Open injuries
Severe displacement

16. Open dislocation/Severe displacement

17. Non-concentric reduction

19. Avulsion from lateral condyle
The typical injury pattern you see on the lateral side is avulsion from the lateral condyle - barespot
Important to know so that you can operate thru the avulsed tissue and not create a surgical insult next to it.
Looked at these different injury patterns
Mckee et all JSES 2003 Pathoanatomy of lateral ligament disruption in complex elbow instability
Mckee et al. JSES 2003 Pathoanatomy of lateral ligament disruption in complex elbow instability

20. Elbow fracture-dislocations
Definition
Dislocation of the elbow
Intra-articular fracture
But how should this be classified? There is NO dislocation.
Few teaching points about the general principles we have talked about already
Elbow fracture dislocation is a huge topic you could probably spend a whole day course on it. So I am going to try and just hit the highlights and use the Terrible triad of the elbow as an example of what to do and what not to do.
The terrible triad is the classic elbow fracture dislocation

21. Definition The variety of injuries can seem overwhelming
Traumatic Elbow Instability
Combination of fractures and ligament injuries that destabilize the elbow
The variety of injuries can seem overwhelming

22. Patterns of Traumatic Elbow Instability With Fracture
Dislocation+
radial
head fracture
Anterior
Terrible
Triad
Posterior
Posteromedial
Varus
Rotational
Instability
Dislocation
Olecranon Fracture-
Dislocations
But most injuries can be classified into one of 5 common injury patterns with a few exceptions.

23. Dislocation vs. Disruption

24. Dislocation vs. Disruption

25. Dislocation vs. Disruption

26. Dislocation vs. Disruption
In disruption injuries, where the articular surfaces remain apposed, the ligaments often remain at least partially intact

27. Patterns of Traumatic Elbow Instability With Fracture
Dislocation+
radial
head fracture
Anterior
Terrible
Triad
Posterior
Posteromedial
Varus
Rotational
Instability
Dislocation
Olecranon Fracture-
Dislocations
Dislocation Injuries
Disruption Injuries

28. Terrible Triad of the Elbow
Elbow dislocation + coronoid # + radial head #
Results of conventional treatment – Terrible!
Regan, Morrey – type III coronoid # - 20% good
Heim (AO group) – 8/11 poor
Josefsson – 4/4 poor
Adler, Shaftan - 10% of cases but 50% of bad results
Ring (JBJS 2002) - 7/11 poor
Elbow dislocation with fracture of both the coronoid and the radial head
Right away you know that the lateral and probably the medial soft tissues are gone, two boney structures that hold the elbow in joint are both gone
And this is why in the literature in the past this injury has had such terrible results

29. Technical errors in terrible-triad injury
Example of what not to do
Patient with terrible triad of the elbow and you can see that there have been a number of mistake made
They did attempt to fix the coronoid but they missed
That radial head was simply excised
The two structures that are needed to prevent the elbow from sliding out the back are both gone
And the only thing that was intact was the olecranon and they cut that off to do the approach
Technical errors resulted in early postoperative posterior dislocation in this patient with a terrible triad-type injury treated with a transolecranon approach (which is not routinely recommended). The radial head was excised and was not replaced, and the fixation of the coronoid fragment (arrow) was unsuccessful. This type of revision, where prior surgery may have disrupted tissues and/or structures vital for stability, may require a hinged external fixator to obtain and maintain concentric joint reduction and allow early motion.
McKee M. D. et.al. J Bone Joint Surg 2005:87:22-32

30. Terrible Triad Two university affiliated centers – 41 patients
With more consistent surgical technique you could get better results with this injury

31. Standard surgical protocol
Fix sequentially from inside to outside
Fix coronoid or repair anterior capsule
Fix or replace the radial head (metallic, modular)
Repair the LCL/CEO
Repair the MCL
Apply a hinged fixator (revision)

32. Surgical technique 1) Radial head fracture ORIF - 12 Replacement - 23
Excision - 6
2) Coronoid fracture
ORIF - 18
Capsule repair - 23
3) Soft tissue repair
LCL/CEO - 41
MCL - 6
4) Hinged external fixator - 9

35. Terrible Triad

36. Coronoid fixation

37. Coronoid fixation

38. Lateral collateral ligament repair
J Am Acad Orthop Surg, Vol 17, No 3, March 2009,

39. Results Mean f/u 14 months Mean flexion-extension arc 109o
Mean forearm rotation arc 127o
Mean Mayo elbow score 89
19 excellent, 14 good, 7 fair, 1 poor

40. J Am Acad Orthop Surg, Vol 17, No 3, March 2009, 137-151.

41. Summary The LCL is more important than the MCL
The ligaments will heal if you keep the elbow concentric, even when treated late
Active motion adds to stability (avoid varus stress)
Even small coronoid fractures can be a problem

42. Summary Recognition of the fracture/ fracture pattern
Restoration of ulnohumeral stability
Fixation of olecranon/coronoid fractures
Restoration of radiohumeral stability
ORIF or replacement of radial head
Lateral collateral ligament repair
+/- MCL repair
Early motion

43. Thank You