Management of complex elbow instability
Tóm tắt
Complex elbow instability is a challenging injury even for expert elbow surgeons. The preoperative radiographs should be carefully evaluated to recognize all lesions that may occur in complex elbow instabilities. Recognizing all the possible lesions is critical to achieve an optimal outcome. The most common types of injuries are as follows: (1) radial head fractures associated with lateral and medial collateral ligaments lesions (with or without elbow dislocation); (2) Coronoid fractures and lateral collateral ligament lesion (with or without elbow dislocation); (3) Terrible Triad; (4) Transolecranon fracture-dislocation; (5) Monteggia-like-lesions; and (6) Humeral Shear fractures associated with lateral and medial collateral ligaments lesions (with or without elbow dislocation). A correct evaluation includes X-rays, CT scan with 2D and 3D reconstruction and stability test under fluoroscopy. The treatment is always surgical and is challenging, and outcomes are not predictable. The goals of treatment are (1) to perform a stable osteosynthesis of all fractures, (2) to obtain concentric and stable reduction of the elbow and (3) to allow early motion. The proximal ulna must be anatomically reduced and fixed; the radial head must be repaired or replaced, and the coronoid fractures must be repaired or reconstructed. With respect of soft tissue lesions, the LUCL must be reattached with suture anchors or trans-osseous suture. The next critical step is the intra-operative assessment of elbow stability. If the elbow remains unstable, MCL repair and/or application of hinged external fixator must be considered. The most recent clinical and experimental studies have significantly expanded our knowledge of elbow instability and its management. Definite treatment protocols may improve the clinical results of such complex injuries.
Tài liệu tham khảo
Morrey BF, An KN (1983) Articular and ligamentous contributions to the stability of the elbow joint. Am J Sports Med 11(5):315–319
Morrey BF, Tanaka S, An KN (1991) Valgus stability of the elbow. A definition of primary and secondary constraints. Clin Orthop Relat Res 265:187–195
Ring D, Jupiter JB (1998) Fracture-dislocation of the elbow. J Bone Joint Surg Am 80(4):566–580
O’Driscoll SW, Jupiter JB, King GJ, Hotchkiss RN, Morrey BF (2001) The unstable elbow. Instr Course Lect 50:89–102
Ring D, Jupiter JB, Simpson NS (1998) Monteggia fractures in adults. J Bone Joint Surg Am 80(12):1733–1744
Biyani A, Olscamp AJ, Ebraheim NA (2000) Complications in the management of complex monteggia-equivalent fractures in adults. Am J Orthop 29(2):115–118
Strauss EJ, Tejwani NC, Preston CF, Egol KA (2006) The posterior Monteggia lesion with associated ulnohumeral instability. J Bone Joint Surg Br 88(1):84–89
Eathiraju S, Mudgal CS, Jupiter JB (2007) Monteggia fracture-dislocations. Hand Clin 23(2):165–177
Konrad GG, Kundel K, Kreuz PC, Oberst M, Sudkamp NP (2007) Monteggia fractures in adults: long-term results and prognostic factors. J Bone Joint Surg Br 89(3):354–360
Egol KA, Immerman I, Paksima N, Tejwani N, Koval KJ (2007) Fracture-dislocation of the elbow functional outcome following treatment with a standardized protocol. Bull NYU Hosp Jt Dis 65(4):263–270
Tashjian RZ, Katarincic JA (2006) Complex elbow instability. J Am Acad Orthop Surg 14(5):278–286
Celli A, Nicoli E (2004) Fractures of the radial head associated with dislocation of the elbow. Chir Organi Mov 89(1):7–19
Sotereanos DG, Darlis NA, Wright TW, Goitz RJ, King GJ (2007) Unstable fracture-dislocations of the elbow. Instr Course Lect 56:369–376
Morrey BF (1993) Radial head fracture. In: Morrey BF (ed) The elbow, 2nd edn. WB Saunders, Philadelphia, pp 383–404
Van Riet RP, Morrey BF, O’Driscoll SW, Van Glabbeek F (2005) Associated injuries complicating radial head fractures: a demographic study. Clin Orthop Relat Res 441:351–355
Morrey BF (1995) Current concepts in the treatment of fractures of the radial head, the olecranon, and the coronoid. Instr Course Lect 44:175–185
Nalbantoglu U, Gereli A, Kocaoglu B, Aktas S, Turkmen M (2008) Capitellar cartilage injuries concomitant with radial head fractures. J Hand Surg Am 33(9):1602–1607
O’Driscoll SW, Bell DF, Morrey BF (1991) Posterolateral rotatory instability of the elbow. J Bone Joint Surg Am 73(3):440–446
Søjbjerg JO, Ovesen J, Nielsen S (1987) Experimental elbow instability after transection of the medial collateral ligament. Clin Orthop Relat Res 218:186–190
Hotchkiss RN, Weiland AJ (1987) Valgus stability of the elbow. J Orthop Res 5(3):372–377
Schneeberger AG, Sadowski MM, Jacob HA (2004) Coronoid process and radial head as posterolateral rotatory stabilizers of the elbow. J Bone Joint Surg Am 86-A(5):975–982
Hotchkiss RN (1997) Displaced fractures of the radial head: internal fixation or excision? J Am Acad Orthop Surg 5(1):1–10
Smith GR, Hotchkiss RN (1996) Radial head and neck fractures: anatomic guidelines for proper placement of internal fixation. J Shoulder Elbow Surg 5(2 Pt 1):113–117
Ring D, Quintero J, Jupiter JB (2002) Open reduction and internal fixation of fractures of the radial head. J Bone Joint Surg Am 84-A(10):1811–1815
Ring D (2008) Displaced, unstable fractures of the radial head: fixation vs. replacement–what is the evidence? Injury 39(12):1329–1337
Morrey BF, Chao EY, Hui FC (1979) Biomechanical study of the elbow following excision of the radial head. J Bone Joint Surg Am 61(1):63–68
Herbertsson P, Josefsson PO, Hasserius R, Besjakov J, Nyqvist F, Karlsson MK (2004) Fractures of the radial head and neck treated with radial head excision. J Bone Joint Surg Am 86-A(9):1925–1930
Pilato G, De Pietri M, Vernieri W, Bini A (2004) The surgical treatment of fractures of the radial head: a comparison between osteosynthesis and capitellectomy. Chir Organi Mov 89(3):213–222
Ikeda M, Sugiyama K, Kang C, Takagaki T, Oka Y (2005) Comminuted fractures of the radial head. Comparison of resection and internal fixation. J Bone Joint Surg Am 87(1):76–84
Lindenhovius AL, Felsch Q, Doornberg JN, Ring D, Kloen P (2007) Open reduction and internal fixation compared with excision for unstable displaced fractures of the radial head. J Hand Surg Am 32(5):630–636
Kocher T (1911) Textbook of operative surgery, 3rd edn. A. and C. Black, London
Nielsen D, Nowinski RJ, Bamberger HB (2002) Indications, alternatives, and complications of external fixation about the elbow. Hand Clin 18(1):87–97
Tan V, Daluiski A, Capo J, Hotchkiss R (2005) Hinged elbow external fixators: indications and uses. J Am Acad Orthop Surg 13(8):503–514
Adams JE, Hoskin TL, Morrey BF, Steinmann SP (2009) Management and outcome of 103 acute fractures of the coronoid process of the ulna. J Bone Joint Surg Br 91(5):632–635
Sanchez-Sotelo J, O’Driscoll SW, Morrey BF (2006) Anteromedial fracture of the coronoid process of the ulna. J Shoulder Elbow Surg 15(5):e5–e8
Ring D (2006) Fractures of the coronoid process of the ulna. J Hand Surg Am 31(10):1679–1689
Regan W, Morrey B (1989) Fractures of the coronoid process of the ulna. J Bone Joint Surg Am 71(9):1348–1354
Cohen MS, Hastings H 2nd (1998) Acute elbow dislocation: evaluation and management. J Am Acad Orthop Surg 6(1):15–23
O’Driscoll SW, Jupiter JB, Cohen MS, Ring D, McKee MD (2003) Difficult elbow fractures: pearls and pitfalls. Instr Course Lect 52:113–134
Doornberg JN, Ring DC (2006) Fracture of the anteromedial facet of the coronoid process. J Bone Joint Surg Am 88(10):2216–2224
Pollock JW, Brownhill J, Ferreira L, McDonald CP, Johnson J, King G (2009) The effect of anteromedial facet fractures of the coronoid and lateral collateral ligament injury on elbow stability and kinematics. J Bone Joint Surg Am 91(6):1448–1458
Hotchkiss RN, Kasparyon G (2000) The medial “Over the top” approach to the elbow. Tech Orthop 15(2):105–112
McKee MD, Schemitsch EH, Sala MJ, O’driscoll SW (2003) The pathoanatomy of lateral ligamentous disruption in complex elbow instability. J Shoulder Elbow Surg 12(4):391–396
Hotchkiss RN (1996) Fractures and dislocations of the elbow. In: Rockwood CA Jr, Green DP, Bucholz RW, Heckman JD (eds) Rockwood and green’s fractures in adults, vol 1, 4th edn. Philadelphia, Lippincot-Raven, pp 929–1024
Pugh DM, Wild LM, Schemitsch EH, King GJ, McKee MD (2004) Standard surgical protocol to treat elbow dislocations with radial head and coronoid fractures. J Bone Joint Surg Am 86-A(6):1122–1130
Ring D, Jupiter JB, Zilberfarb J (2002) Posterior dislocation of the elbow with fractures of the radial head and coronoid. J Bone Joint Surg Am 84-A(4):547–551
Zeiders GJ, Patel MK (2008) Management of unstable elbows following complex fracture-dislocations—the “terrible triad” injury. J Bone Joint Surg Am 90(Suppl 4):75–84
Mathew PK, Athwal GS, King GJ (2009) Terrible triad injury of the elbow: current concepts. J Am Acad Orthop Surg 17(3):137–151
Harrington IJ, Tountas AA (1981) Replacement of the radial head in the treatment of unstable elbow fractures. Injury 12(5):405–412
Pomianowski S, Morrey BF, Neale PG, Park MJ, O’Driscoll SW, An KN (2001) ontribution of monoblock and bipolar radial head prostheses to valgus stability of the elbow. J Bone Joint Surg Am 83-A(12):1829–1834
Loreto CA, Rollo G, Comitini V, Rotini R (2005) The metal prosthesis in radial head fracture: indications and preliminary results. Chir Organi Mov 90(3):253–270
Doornberg JN, Parisien R, van Duijn PJ, Ring D (2007) Radial head arthroplasty with a modular metal spacer to treat acute traumatic elbow instability. J Bone Joint Surg Am 89(5):1075–1080
Biga N, Thomine JM (1974) Trans-olecranal dislocations of the elbow. Rev Chir Orthop Reparatrice Appar Mot 60(7):557–567
Ring D, Jupiter JB, Sanders RW, Mast J, Simpson NS (1997) Transolecranon fracture-dislocation of the elbow. J Orthop Trauma 11(8):545–550
Mouhsine E, Akiki A, Castagna A, Cikes A, Wettstein M, Borens O, Garofalo R (2007) Transolecranon anterior fracture dislocation. J Shoulder Elbow Surg 16(3):352–357 Epub 2006 Dec 22
Doornberg J, Ring D, Jupiter JB (2004) Effective treatment of fracture-dislocations of the olecranon requires a stable trochlear notch. Clin Orthop Relat Res 429:292–300
Monteggia GB (1814) Istruzioni Chirurgiche. Maspero, Milano
Bado JL (1967) The Monteggia lesion. Clin Orthop 50:71–86
Jupiter JB, Leibovic SJ, Ribbans W, WIlk RM (1991) The posterior Monteggia lesion. J Orthop Trauma 5:395–402
Edwards GS Jr, Jupiter JB (1988) Radial head fractures with acute distal radioulnar dislocation. Essex-Lopresti revisited. Clin Orthop Relat Res 234:61–69
Bock GW, Cohen MS, Resnick D (1992) Fracture-dislocation of the elbow with inferior radioulnar dislocation: a variant of the Essex-Lopresti injury. Skeletal Radiol 21(5):315–317
Malik AK, Pettit P, Compson J (2005) Distal radioulnar joint dislocation in association with elbow injuries. Injury 36(2):324–329
Giannicola G, Sacchetti FM, Greco A, Gregori G, Postacchini F (in press) Open reduction and internal fixation combined with hinged elbow fixator in capitellum and trochlea fractures. A retrospective study in 15 patients followed for 29 months. Acta Orthop