Introduction |
- Epidemiology
- bimodal distribution
- high energy injuries in the young
- low energy falls in the elderly
- Pathophysiology
- mechanism
- direct blow
- usually results in comminuted fracture
- indirect blow
- fall onto outstretched upper extremity
- usually results in transverse or oblique fracture
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Anatomy |
- Osteology
- together with coronoid process, forms the greater sigmoid (semilunar) notch
- greater sigmoid notch articulates with trochlea
- provides flexion-extension movement
- adds to stability of elbow joint
- Muscles
- triceps
- inserts onto posterior, proximal ulna
- blends with periosteum
- innervated by radial nerve (C7)
- anconeus
- inserts on lateral aspect of olecranon
- innervate by radial nerve (C7)
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Classification |
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Mayo Classification |
- Based on comminution, displacement, fracture-dislocation
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Colton Classification |
Nondisplaced - Displacement does not increase with elbow flexion |
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Avulsion (displaced) |
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Oblique and Transverse (displaced) |
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Comminuted (displaced) |
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Fracture dislocation |
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Schatzker Classification |
Type A |
Simple transverse fracture |
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Type B |
Transverse impacted fracture |
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Type C |
Oblique fracture |
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Type D |
Comminuted fracture |
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Type E |
More distal fracture, extra-articular |
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Type F |
Fracture-dislocation |
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AO Classification |
Type A |
Extra-articular |
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Type B |
Intra-articular |
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Type C |
Intra-articular fractures of both the radial head and olecranon |
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Presentation |
- Symptoms
- pain well localized to posterior elbow
- Physical exam
- palpable defect
- indicates displaced fracture or severe comminution
- inability to extend elbow
- indicates discontinuity of triceps (extensor) mechanism
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Imaging |
- Radiographs
- recommended views
- AP/lateral radiographs
- true lateral essential for determination of fracture pattern
- additional views
- radiocapitellar may be helpful for
- radial head fracture
- capitellar shear fracture
- CT
- may be useful for preoperative planning in comminuted fractures
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Treatment |
- Nonoperative
- immobilization
- indications
- nondisplaced fractures
- displaced fracture is low demand, elderly individuals
- technique
- immobilization in 45-90 degrees of flexion initially
- Operative
- tension band technique
- indications
- transverse fracture with no comminution
- outcomes
- excellent results with appropriate indications
- intramedullary fixation
- indications
- transverse fracture with no comminution (same as tension band technique)
- plate and screw fixation
- indications
- comminuted fractures
- Monteggia fractures
- fracture-dislocations
- oblique fractures that extend distal to coronoid
- excision and triceps advancement
- indications
- elderly patients with osteoporotic bone
- fracture must involve <50% of joint surface
- nonunions
- outcomes
- salvage procedure that leads to decreased extension strength
- may result in instability if ligamentous injury is not diagnosed before operation
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Surgical Techniques |
- Tension band technique
- technique
- converts distraction force of triceps into a compressive force
- engaging anterior cortex of ulna with Kirschner wires may prevent wire migration
- avoid overpenetration of wires through anterior cortex
- may injury anterior interosseous nerve (AIN)
- may lead to decreased forearm rotation
- use 18-gauge wire in figure-of-eight fashion through drill holes in ulna
- cons
- high % of second surgeries for hardware removal (40-80%)
- does not provide axial stability in comminuted fractures
- Intramedullary fixation
- technique
- can be combined with tension banding
- intramedullary screw must engage distal intramedullary canal
- Plate and screw fixation
- technique
- place plate on dorsal (tension) side
- oblique fractures benefit from lag screws in addition to plate fixation
- one-third tubular plates may not provide sufficient strength in comminuted fractures
- may advance distal triceps tendon over plate to avoid hardware prominence
- pros
- more stable than tension band technique
- cons
- 20% need second surgery for plate removal
- Excision and triceps advancement
- technique
- triceps tendon reattached with nonabsorbable sutures passed through drill holes in proximal ulna
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Complications |
- Symptomatic hardware
- most frequent reported complication
- Stiffness
- occurs in ~50% of patients
- usually doesn't alter functional capabilities
- Heterotopic ossification
- more common with associated head injury
- Posttraumatic arthritis
- Nonunion
- Ulnar nerve symptoms
- Anterior interosseous nerve injury
- Loss of extension strength
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