Elbow Reconstruction – Understanding Failure (PART 2)

Continuing on last post on elbow reconstruction, today we’re going to talk about the contingency plan i.e. when the surgeon attempted to reconstruct column, but failed to achieve intra-articular fragment reduction.

Clinical Presentation

• 29 year old female
• Thinly built
• Road traffic accident with injury to the left elbow
• Trauma to the skin (abrasion) overlying the fracture
• Closed fracture without any neurovascular deficit
• Co-morbidities – None

Investigations

• X-ray of the suspected region- pelvis/chest/spine screening/limbs
• X-ray of affected region- anteroposterior/ lateral/ traction views (author preference)
• CT scan of elbow (cost constraint)- gold standard
• Blood workup for surgical fitness

What should have been done?

• Author’s preferred method- discussed in one of earlier discussion on distal humerus fractures.
• Simple plan
  • Olecranon osteotomy
  • Intercondylar partially threaded cancellous screw (lag effect)
  • Temporary column fixation
  • Medial column single screw fixation
  • Lateral column fixation by 3.5 mm LCP/Lateral Distal humerus plate

Fixation Issues

• No compression in between two condylar articular fragments
• Medial column not restored
• Anterior angulation of distal humerus not maintained
• Lateral distal fragment- capitullum is fixed in rotation
• Short screw length
• Slab application (length) is not appropriate for such injuries

Why does one land in such issues?

• Pre-op formulate a plan to fix such complex trauma case
• Follow the plan, ensure each step is correctly addressed
• Back-up plan should be there in case difficulty/ problem in original plan (author would have to drop idea of single medial screw and go for medial plate due to comminution)
• Critical analysis of the postop case to ensure adequate results in next case

Last Case Discussion

• Pre-op & contingency plan
• Importance of exposure and different methods
• C-arm visualization
• Patient expectancy from injury
• Strongest bone lies along medial and lateral columns and therefore the implant should be placed here
• Intra-articular anatomical reduction and fixation by lag screw placed from medial to lateral direction
• With normal 40° anterior angulation of the condyles and humeral shaft restored, lateral plate is positioned posteriorly & medial plate in saggital plane along the medial border.
• Screws in the distal fragment need to be as long as possible,engaging as many fracture fragments as possible, ensuring screw tip is not impinging into the joint
• Medial and lateral column screws should “interdigitate“ such that they have hold on opposite column fracture fragment 
• Check ROM and fracture fixation stability on the OT table before closure