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Nonunion and Malunion of Distal Humerus Fractures

Introduction Nonunion and malunion are two of the most common and challenging complications of distal humerus fractures. Newer internal fixation principles and techniques have improved our ability to achieve stable fixation of complex distal humerus fractures (see Chapter 44, Chapter 45, Chapter 46, Chapter 47 ). However, some fractures will fail to unite, leaving the patient with an unstable, dysfunctional, and often painful upper extremity requiring…

Persistent Elbow Instability

Introduction The osseous and soft tissue constraints of the elbow create a stable articulation with four functional degrees of freedom: flexion, extension, supination, and pronation. Varus and valgus freedom is negligible for functional purposes. The added degrees of freedom afforded by rotation, as well as the obligatory varus stress on the elbow that accompanies shoulder abduction, make instability of this joint more complex than that seen…

Hinged External Fixators of the Elbow

Introduction Interest in and use of external fixators has waxed and waned over the years. I continue to use this device to allow motion and simultaneously (1) maintain a reduced and balanced ulnohumeral joint, (2) protect repaired or reconstructed collateral ligaments, and (3) lessen force across the joint. Rationale and Options The mechanics and anatomic landmarks for the application of various fixator devices have been well…

Distal Humerus Fractures: Shear Fractures of the Humeral Articular Surface

Introduction Isolated fracture of the capitellum is discussed in detail in Chapter 46 . Fractures primarily involving the articular surface of the capitellum and trochlea are often shearing in nature and involve fracture of the lateral epicondyle and impaction of the posterior lateral column and the posterior and medial trochlea. On occasion, the injury can extend to the medial column and result in fracture of the…

Distal Humerus Fractures: Isolated Fracture of the Capitellum

Introduction The capitellar fracture of the humerus is a relatively uncommon injury but can result in significant functional impairment if not appropriately treated. Since its first description in 1841 by Cooper, the fracture has been recognized as an articular fracture of the lateral part of the humerus without metaphyseal extension to the column above the olecranon fossa. Our current understanding of this fracture has recognized a…

Distal Humerus Fractures: Fractures of the Columns With Articular Involvement

Introduction Distal humerus fractures represent a very challenging injury. For years, these injuries were universally treated using relatively unstable internal fixation (wires or unstable plate constructs), which led to a substantial rate of poor outcomes secondary to nonunion, stiffness, or posttraumatic arthritis. The outcome of these injuries has been greatly improved by 1 better understanding of these injuries, facilitated by more widespread use of computed tomography…

Low Transcondylar Fractures of the Distal Humerus

General Considerations Introduction Distal humerus fractures in adults consist of a variety of fracture patterns involving a specific anatomic region. As a result of pattern variation, different surgical procedures must be considered for optimal results. Controversy exists regarding the surgical approach, plate fixation configuration, whether to do internal fixation or elbow replacement, and soft tissue management. The patient's age, bone quality, fracture comminution, comorbidities, and expectations…

Coronoid Fractures

Introduction Fractures of the coronoid process of the ulna occur on the injury spectrum of complex elbow instability (see Chapter 36 ). Thus, associated bone and ligament injuries are the rule with coronoid fractures, and many of the topics contained herein overlap with those in Chapters 36 and 49 . When the coronoid is fractured, the complexity of both surgical decision making and operative treatment is…

Olecranon Fractures and Monteggia Fractures

Introduction The subcutaneous location of the olecranon makes it vulnerable to trauma. Isolated fractures of the olecranon comprise approximately 10% of fractures about the elbow, with an estimated incidence of 1.08 per 10,000 person-years. Most result from low-energy trauma such as a fall from a height of less than 2 m, a direct blow to the elbow, or forced hyperextension. A fall on a partially flexed elbow…

Essex-Lopresti Injuries

Introduction Forearm instability is a complex and debilitating condition. The term Essex-Lopresti injury refers to injuries consisting of fracture of the radial head with longitudinal disruption of the interosseous membrane (IOM) and distal radioulnar joint (DRUJ). This instability has been termed longitudinal radioulnar dissociation (LRUD), and DRUJ disruption also may involve injury to the triangular fibrocartilage complex (TFCC). These injuries were first described in 1946 by…

Radial Head Fracture : Management of Complications After Treatment

Unfortunately, a number of patients treated for a radial head fracture according to the principles described in previous chapters will not do well and may require further surgery. Management of these patients will be different depending on the nature of the complication developed, the presence of associated injuries or conditions, and the patient's anticipated demands and activity level. In this chapter, we will review a few…

Prosthetic Radial Head Replacement

Introduction In general, the management of type I fractures is well understood and accepted. Controversy does surround the type II and type III fracture due to increased complexity from treatment of associated injuries. Our treatment logic is described in Chapter 37 ( Fig. 39.1 ). The essential role of implant replacement is when the head cannot be fixed and there are associated injuries dictating a stable…

Radial Head Fracture: Open Reduction and Internal Fixation

Introduction Surgical treatment of displaced radial head fractures has evolved from excision of fracture fragments or the entire head of the radius, to several techniques of open reduction and internal fixation (ORIF), and modern types of radial head replacement. The first documented case of an ORIF of a radial head fracture was performed in 1909. Initially, ORIF was used sporadically, largely because of the perception that…

Radial Head Fracture: General Considerations, Conservative Treatment, and Radial Head Resection

Introduction Historical Review The first description of a radial head fracture may be attributed to Beard, who, in 1834, noted the presence of this injury at autopsy. By 1880, Bruns found 21 cases in the literature, but only one of them was a clinical case; the others were anatomic findings. In 1891, Hoffa described two types of radial head fractures, displaced and undisplaced, and he recommended…

Complex Elbow Instability: General Principles

Introduction Injury to the elbow joint may cause damage to the stabilizing elements such as bony structures or ligaments. Profound knowledge of these stabilizing elements is the basis of adequate treatment and success to restore a stable and functioning elbow joint. Definition Complex instability of the elbow is defined as instability caused by a traumatic injury to the articular surface and to the ligamentous structures. The…

Simple Elbow Dislocation

Introduction The term simple elbow dislocation is applied to those injuries resulting in loss of congruity between the distal humerus and the proximal forearm (ulna and radius) without associated bony injuries. The structures disrupted include the elbow capsule, lateral collateral ligament complex, and oftentimes the medial collateral ligament, with various degrees of damage to the common flexor and/or common extensor groups. Ligamentous injuries may occur in…

Elbow Stiffness in Children and Adolescents

Introduction Elbow trauma is one of the most common types of injury in the pediatric and adolescent population. While treating elbow injuries, the orthopedist may also be faced with managing a posttraumatic elbow contracture. Elbow stiffness after injury is less common in patients under 18 years of age. However, it is not uncommon after certain injuries. Elbow contractures develop in 3% to 6% of children following…

Osteochondritis Dissecans

Introduction Osteochondral lesions may be the source of elbow pain, swelling, and loss of motion in children or adolescents. The typical presentation is an adolescent gymnast or overhead throwing athlete (e.g., baseball pitcher). The dominant arm is usually involved but may be bilateral in approximately 5% to 20%. It is important to distinguish between osteochondrosis of the capitellum, or Panner disease, and osteochondritis dissecans (OCD). The…

Pediatric Elbow Dislocations

Introduction The development and maturation of the elbow is complex in children. Many cartilaginous structures are incompletely ossified until late in skeletal development and are weaker in tensile strength in comparison to the surrounding ligamentous and muscular attachments. Thus, isolated elbow dislocations are uncommon in children, accounting for approximately 3% to 6% of all elbow injuries in children. Up until 2 years of age, any malalignment…

Olecranon and Monteggia Fractures in Children

Introduction Fractures of the proximal ulna are thought to be relatively uncommon in children, accounting for approximately 5% of elbow fractures. The true incidence may be higher because many are missed. Monteggia fractures may be undiagnosed 50% of the time, even at children's hospitals. Olecranon fractures, particularly sleeve fractures, may also be missed due to the late ossification of the olecranon. The first ossification center in…