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

Elbow Reconstruction in Trauma Cases – PART 1

Today, we’re going to talk about Elbow Reconstruction in trauma cases. The main principle which we have to keep in mind when reconstructing the elbow is- stable internal fixation of articular surface & also stable internal fixation of the articular segment to the metaphysis & diaphyseal fragments.

Clinical Presentation

• 34 year old male
• History of RTA
• Presented on the day of Injury
• Pain and swelling over left elbow with abrasion and bleeding from the wound
• Difficulty in elbow movement
• 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
• Additional test as required for co-morbidities if any

Clinical Evaluation

• Soft tissue envelope
• Neurological status distal to injury
• Vascular status distal to injury

Goal and Principle of Surgical Fixation

Goal of treatment

To achieve stable fixation, union of fracture fragments with restoration of function of elbow.

Principles of fixation

• Anatomical reduction of intra-articular fragments
• Preservation of blood supply
• Stable fixation
• Early and safe mobilization

Importance of Surgical Plan

• Surgeon needs to pre-formulate a surgical fixation plan and the necessary approach for adequate exposure.
• In addition to the above planning, a backup/contingency plan also needs to be formulated in such complex trauma cases.

Surgical Issues

• Principle of stable fixation constitute
  • Stable internal fixation of articular surface
  • Stable internal fixation of the articular segment to the metaphysis and diaphyseal fragment

• The surgeon although was able to achieve reduction of the intra-articular fragment, the distal construct was fixed in translation to the proximal construct.
• Different exposures gives good to complete visualization of articular surface
• Choose the exposure depending upon
  • Surgical experience
  • Type of implant
  • Patient factors- skin condition/age/fracture pattern
  • Future need of elbow arthroplasty

• Author’s preference
• Olecranon osteotomy (fixation with TBW/ Long screw+ SS wire)
• Byran-Morrey Approach (Triceps-sparing postero-medial approach)
  • Midline incision
  • Ulnar nerve identified, mobilized and latex loop placed
  • Medial edge of triceps and distal forearm fascia elevated as single unit off olecranon and reflected laterally
  • Resection of extra-articular tip of olecranon(better visualization, later helps during ROM exercises)

Adequate Visualization on C-arm During Surgery

At 90° flexion: The olecranon overlaps only a small part of the medial joint surface

• If elbow flexion is increased to 110°- free and complete joint surface is seen on lateral radiograph
• It is therefore important to have proper patient positioning allowing elbow movement and facilitate radiography.

Pre-op Counselling

What patients may expect?

• Loss of 15-25° of flexion and extension
• Maintain most of supination and pronation
• Decrease in muscle strength (triceps)
• Implant impingement (especially olecranon fixation implant)
• Complications associated with the procedure