Olecranon Fractures and Radial Head Fractures

1
Olecranon Fractures and Radial Head Fractures

• John T. Capo, MD
• Original Authors Andrew H. Schmidt, MD, Gregory
  J. Schmeling, MD
• and David C. Templeman, MD March 2004
• New Author John T. Capo, MD, Revised October
  2006

2
Elbow Anatomy

• Three distinct joints
• humeral(trochlea) ulnar
• humeral(capitellar) radial
• proximal radial-ulnar(PRUJ)

3
Factors Responsible for Elbow Stability Bony
Anatomy

• Normal muscle forces drive elbow posteriorly
• Brachialis base coronoid
• Biceps radial tuberosity
• Resist AP forces
• Coronoid process
• Radial Head

4
Factors Responsible for Elbow Stability Bony
Anatomy

• Varus/Valgus
• Radial Head
• Trochlea
• Medial coronoid facet

5
MCL
LCL
Ligamentous Stability
6
Surgical Anatomy

• Articular cartilage
• Sigmoid notch of ulna bare spot centrally
• Coronoid process preserve height
• As high as radial head on lateral view
• Tip subtends angle of 30º from ulnar shaft
• Twice as high as olecranon tip
• Beware of narrowing sigmoid fossa when treating
  comminuted fractures.

7
Olecranon Fractures
8
Mechanism of Injury

• Acute Tension overload Tension applied by the
  triceps with flexion of the elbow.
• Direct Trauma
• Chronic overload stress fracture, osteopenia,
  pediatric injuries.

9
Evaluation

• Check integrity of skin
• Check extension of elbow
• Evaluate neurovascular status, especially ulnar
  nerve
• X-rays in three views (AP, Lateral, Oblique
  -shows radial head in profile)

10
Imaging
Oblique View (sometimes helpful)
AP View
Lateral View
11
Classification

• Numerous classifications
• Colton
• Morrey
• Schatzker
• AO/ASIF
• OTA

• Criteria
• Displacement
• Direction of fracture
• Degree of comminution
• Percent involvement
• Associated injuries

12
Mayo Clinic Classification

• Type I Nondisplaced 12
• Type II Displaced/ elbow stable 82
• Type III Elbow unstable 6
• Both types II and III subdivided into
• A noncomminuted
• B comminuted

Morrey BF, JBJS 77A 718-21, 1995
13
Treatment Objectives

• Restoration of the articular surface.
• Restoration and preservation of the elbow
  extensor mechanism.
• Restoration of elbow motion and prevention of
  stiffness
• Goal is to begin early ROM
• Prevention of complications.

14
Treatment Methods

• Nonoperative
• Rarely used
• Non-displaced with intact elbow extension
• Operative
• Open reduction and internal fixation
• Tension band wire with pins or intramedullary
  screws
• Plate
• Excision of olecranon and triceps repair
• Comminuted, unreconstructable fractures
• Elderly patients

15
Nonoperative Treatment

• Nondisplaced fractures
• Long arm cast - complicated by stiffness
• Long-arm splint for 7-10 days followed by
  functional bracing for 4-6 weeks
• complicated by loss of reduction

16
Indications for Surgery

• Disruption of extensor mechanism
• Unable to actively extend elbow
• Articular incongruity
• Any displaced fracture

17
Olecranon Excision

• Elderly patients
• those with osteoporosis
• involving lt50 of joint
• Reattach triceps anteriorly
• At joint surface
• No difference in isometric strength but fewer
  complications in the excision group
• Gartsman et al, JBJS 63A718, 1981-

18
ORIF Surgical Technique

• Evaluate comminution of dorsal cortex
• If intact tension band wire appropriate
• If comminuted, plate appropriate
• Evaluate orientation of fracture line
• Transverse tension band wire
• Oblique, complex ? plate

19
Positioning

• Arm position
• Supine with arm across chest.
• Lateral or prone also may be used.
• Supine with arm on hand table
• Tourniquet
• Regional or general anesthesia
• Posterior approach

20
Tension Band Wire

• For most simple, transverse, non-comminuted
  fractures
• Use 18- or 20-gauge steel wire or small braided
  cable.
• Be sure wires cross over dorsal cortex.
• May use with either parallel K-wires or an
  intramedullary screw.

21
Tension Band Wire
Place K-wires across fracture -engage anterior
cortex
Pass Tension wire deep to tendon with angiocath
two knots over dorsal cortex
Reduce fracture -hold with tenaculum
From Hak and Golladay, JAAOS, 8266-75, 2000
22
Case Example - Transverse Fracture
23
(No Transcript)
24
Intramedullary Screw ?

• Need to add tension band wire
• Long/large screw required
• 6.5mm cancellous
• 85-110 mm long

25
Anatomy of the Proximal Ulna

• Beware of the bow of the proximal ulna, which may
  cause a medial shift of the tip of the olecranon
  if a long screw is used.

From Hak and Golladay, JAAOS, 8266-75, 2000
26
Plate Fixation

• Used for comminuted fractures, fractures with
  shaft extension, or oblique fracture line
• DCP
• 3.5 Recon plate
• Screw placement crucial for stability

27
Complex Olecranon Fracture
As fracture becomes more distal and oblique- more
amenable to plate fixation
28
Plate Fixation
Courtesy Fred Behrens, MD
29
Coronoid Fractures
30
CORONOID PROCESSAnatomy

• Anterior aspect of the greater sigmoid notch
• articulates with trochlear
• brachialis insertion
• Laterally,
• lesser semilunar notch articulates with radial
  head
• Medially,
• attachment of anterior fibers of MCL
• Resist posterior elbow subluxation

Courtesy Virak Tan, MD
31
CORONOID PROCESSFracture

• Isolated fracture is UNCOMMON
• Usually occurs in association with other elbow
  injuries
• dislocation (10 have coronoid fx)
• olecranon fx (5 have coronoid fx)
• Mechanism
• similar to elbow dislocation
• axial load with elbow in slight flexion

32
CORONOID FRACTUREClassification Morrey

• Type I tip
• Type II 50
• Type III gt 50
• IIIB also w/ olecranon

33
(No Transcript)
34
A
B
A gt B
Coronoid Height should be at least 2X olecranon
tip height
35
CORONOID FRACTURETreatment

• Type I
• according to concurrent pathology (usually early
  motion)
• Type II
• early motion, unless unstable
• internal fixation

36
CORONOID FRACTURES

• Medial coronoid facet
• MCL attachment
• Posterior medial varus rotatory instability
• can lead to arthrosis

Courtesy Virak Tan, MD
37
CORONOID FRACTURETreatment- medial facet

• Anatomic reduction critical

38
CORONOID FRACTURETreatment

• Type III
• internal fixation
• Screw from below
• Plate from above
• reconstruction with bone graft ( tip of
  olecranon)
• /- hinged external fixation

39
CORONOID FRACTURE

• Usually occurs in association with other elbow
  injuries
• Approach
• Lateral if radial head out
• Medial over the top
• Preserve UCL
• Indirect posterior

40
Proximal Ulna with Distal Shaft Extension
41
Plate Location

• No mechanical difference between posterior or
  lateral placement -King et al, J Shoulder Elbow
  Surg 5437, 1996
• Less problems with plate prominence when placed
  laterally
• Also can get bicortical screw purchase

42
Indirect Reduction-sometimes useful
ex fix distractor push-pull fix plate
proximally first
43
Case Example - Comminuted Fracture Involving the
Coronoid Process
44
Dorsal plate Screw through plate to fix the
coronoid process DC Plate needed for bending
stresses
45
Outcomes Olecranon Fractures

• Union 76-98
• 19 point scale painfunctionROMx-ray
• IM screw TBW 17.7
• IM screw 17.2
• TB-wire 16.7

Murphy DF et al., Clin Orthop 224215, 1987
46
Proximal Plating

• 73 Good /Excellent
• 24 Monteggia
• 13 Complex
• LCDCP
• Simpson, Injury 27

47
Combined Proximal Ulna Fractures

• Complex fractures
• Olecranon
• shaft
• coronoid
• Must combine different fixation techniques

48
(No Transcript)
49
Displacement of Fragments
50
How to hold and repair coronoid fragment?
51
Temporarily pin through distal humerus.
52
(No Transcript)
53
Lag through ulnar shaft, then close book
54
Use DC Plate recon can bend
55
Complications
56
Potential Complications

• Hardware symptoms in 22 - 80
• 34-66 require hardware removal
• Hardware failure 1-5
• Infection 0-6
• Pin migration 15
• Ulnar neuritis 2-12
• Heterotopic ossification 2-13

57
Complications

• Macko Szabo JBJS1985
• 16/20 Prominent K- Wires
• 4 skin breakdown 1 infection
• 2 loss off reduction
• Danzinger OTA
• 62 of 34 with complications

58
Radial Head Fractures
59
Radial Head Importance
Radiocapitellar joint
60
Radial Head Importance
Buttress to axial migration of the radius
61
Radial Head Importance
Resists posterior dislocation of the elbow
62
Valgus stability
63
Valgus Elbow Stability

• The radial head is a secondary restraint to
  valgus forces
• function by shifting the center of varus-valgus
  rotation laterally, so that the moment arm and
  forces on the medial ligaments are smaller.
• Radial head is more critical when there is injury
  to both the ligamentous and muscle-tendon units
  about the elbow.

64
Radial Head Importance
Resists post-lateral rotatory instability (PLRI)
65
Mechanism of Injury

• Usually occurs in a fall.
• Axial load to the elbow with combined valgus
  force.
• Can be combined with high energy injuries
• Elbow dislocation
• Coronoid fracture
• Collateral ligament injuries

66
Physical Exam

• Neurovascular
• Evaluated elbow stability
• valgus stress 30 degrees flexion, forearm
  pronated
• PLRI valgus, supination, axial load
• AP stability with progressive extension
• Axial stability in OR
• elbow flexed, push on fisted hand, check proximal
  migration of radial shaft
• Tenaculum on shaft pull proximally
• Evaluate distal radio-ulnar joint stability
• Measure forearm rotation
• Mechanical block?

67
Imaging

• Plain X-ray
• AP
• Lateral
• Oblique Coyle view
• MRI
• Ligamentous injury
• skeletally immature patient.

68
Classification
Mason
69
Modified Mason Classification

• Type I nondisplaced
• No block to forearm rotation, displacement lt 2mm
• Type II displaced
• Internal fixation possible
• Type III displaced, severely comminuted
• Judged to be irreparable
• Usually requires excision to allow elbow movement

Hotchkiss R, JAAOS 51, 1997
70
Simplified Classification

• Fixation unnecessary
• Fixation required and possible
• -ORIF
• Unreconstructable
• -Arthroplasty
• -Excision (rare)

71
RH Fractures Treatment Algorithm
(20)
Arthroplasty/ Excise
excision
72
Difficulties with ORIFof Radial Head

• Angulation and offset of radial head
• Cancellous bone in head-poor screw purchase
• Comminuting worse than expected

73
Is ORIF worth the effort?

• Boulas Morrey, 1998 ORIF best functional
  results
• Pomianowski, Morrey et al 2001
• Biomechanically native radial head functions best
• Arthroplasty restores stability but not identical
  to RH

74
Does ORIF produce good Results?

• Ring Jupiter JBJS 2003
• Poor functional results with gt3 fragments
• Older Plates
• King, Evans, Kellam, 1991
• Mason II 100 good/excellent results
• Mason III 33 G/E results
• Excellent results anatomic reduction, stable
  fixation, early ROM

75
Surgical Technique
76
Identify capitellum first
77
Keep LUCL ligament origin intact
Stay above equator of Radial Head
78
(No Transcript)
79
3.5 4.0 cm
Post Interosseus Nerve
80
Radial Head Fractures-Simple Partial Articular
81
IF screws
82
Good ROM
83
Head Neck complete articular
84
Comminution often worse than anticipated
85
Fixation into the head difficult
86
Radial Head Fixation - Safe Zone
From Hotchkiss R, JAAOS 51, 1997
87
Radial Head Fixation

• Small Kirschner wires used provisionally
• Use small screws to fix head fragments
• 1.3 to 2.4 mm headed screws
• Bury head with countersink
• Headless compression screws
• May have to remove head fragments and fix on back
  table

88
Radial Head Fixation

• Secure radial head to neck with small plates
• Locking preferred
• Radial head specific plates
• Blade or small Hand set plates
• Keep hardware in Safe Zone
• 100 arc centered on the dorsal aspect of the
  neutrally rotated forearm.
• Check forearm rotation intraoperatively.

89
ORIF Goals
-multiple screws into head -low profile to avoid
impingement -IF screw -begin early ROM
90
Case Example

• 32 y.o. male, Fell from roof
• Left elbow injury
• NV intact
• Closed injury
• Moderate swelling

91
(No Transcript)
92
(No Transcript)
93
(No Transcript)
94
CT Scan
95
Problems

• 1. Radial head fracture
• 2. Coronoid fracture
• 3. Fragments in joint
• 4. Collateral ligaments
• 5. Humeral ulnar joint not reduced

96
-Approach -Fix the coronoid? What
technique? -Radial head fix/replace? -How do you
repair collateral ligaments Drill holes or
suture anchors Sequence of events
97
Sequence

• Lateral approach
• Piece together RH on back table
• Fix head to plate
• Weave sutures thru LCL
• Suture anchor in coronoid base, run sutures in
  capsule over coronoid

98
Sequence

• Reduce elbow in flexion
• Tie coronoid sutures
• Fix rad head to shaft
• Tie LCL sutures to lat epicondyle

99
(No Transcript)
100
(No Transcript)
101
(No Transcript)
102
Unreconstructable Fractures
103
Arthroplasty
104
New Modular Components
105
Metallic MODULAR RADIAL HEAD
106
Radial Head Arthroplasty

• Metallic not silicone
• Non-cemented- head self centers on capitellum
• Modular avoid head/shaft mismatch
• Must preserve or repair LCL
• Use especially if other areas of instability
• DONT OVERSTUFF THE JOINT

107
Excision of Head

• If entire head is comminuted and all ligamentous
  are intact
• 1. no axial instability
• 2. no post instability
• 3. no valgus instability
• 4. no PLRI

Very rare!
108
Acute Instability with Posterior Elbow
Dislocation

• Restoration of radial head function required.
• Internal fixation should be performed when
  possible, along with repair of the lateral
  ligaments.
• If repair is not possible, prosthetic replacement
  with a metallic spacer should be considered.

109
Essex - Lopresti Lesion

• Defined as longitudinal disruption of forearm
  interosseous ligament, usually combined with
  radial head fx and/or dislocation plus distal
  radioulnar joint injury
• Difficult to diagnose
• Treatment requires restoring stability of both
  elbow and DRUJ components of injury.
• Radial head excision in this injury will result
  in disabling proximal migration of the radius.

110
Injury to Interosseous Ligament

• Perform repair of radial head and/or neck.
• Make sure DRUJ and PRUJ are reduced
• Start early protected rotation

111
Complications

• Improperly placed hardware
• Late removal and capsular release
• Loss of fixation
• Late radial head excision if soft-tissues healed
• Posterior interosseous nerve injury
• Elbow stiffness
• Capsular release

112
Outcomes
113
Outcomes after Excision are Controversial

• There are recent papers reporting long-term
  outcomes after radial head excision that give
  conflicting results

114
Resection of the Radial Head after Mason Type-III
Fractures

• 21 patients reviewed after 16-30 years
• 17 of 21 (81) excellent results.
• Only 1 fair result.

Ikeda and Oka, Acta Orthop Scand 71191, 2000
115
Results of Acute Excision of the Radial Head
inFracture Dislocations

• 10 cases
• Follow-up 4.6 years
• Results
• 4 excellent, 5 good, 1 fair
• Degenerative changes present in 8 of 10
• Although early results satisfactory, the
  incidence of degenerative changes worrisome.

Sanchez-Sotelo J et al., J Orthop Trauma 14354,
2000
116
The Functional Outcome with Metallic Radial Head
Implants in the Treatment of Unstable Elbow
Fractures

• 20 patients evaluated after mean 12 years (6-29
  years)
• All had radial head fxs with elbow dislocation
  and associated injuries to MCL, coronoid, or
  proximal ulna.
• Results 12 excellent, 4 good, 2 fair, 2 poor.

Harrington IJ et al., J Trauma 5046, 2001
117
Conclusions

• Difficult fractures
• Can radial head be fixed? (gt3 frags)
• Newer plates helpful
• Crucial to evaluate other bony and ligamentous
  structures
• Excision is rarely done

If you would like to volunteer as an author for
the Resident Slide Project or recommend updates
to any of the following slides, please send an
e-mail to ota_at_aaos.org
Return to Upper Extremity Index
E-mail OTA about Questions/Comments