Injury, 7, 143-l
143
59
Fracture-dislocations D. Scharplatz Kantonsspital,
of the elbow
and M. Allgiiwer Bade
Summary
This paper presents a series of 105 cases of fracturedislocation of the elbow joint. All these fractures differ in mechanism, age of patient and method of treatment, so problems arise in classification. Causes can be grouped together more easily than the principles of treatment. The cases are classified into 2 major groups and 10 subgroups. Single fracture types are analysed and the optimal type of treatment is studied. As with all joint fractures, adequate reconstruction is obligatory to remove all steps in the articular cartilage, and rigid fixation is mandatory except for the radial head, where excision is indicated. The different fracture types and their relevant operations are illustrated with examples. INTRODUCTION Definition FRACTURE-DISLOCATIONSof the elbow include all fractures with total or partial displacement of the articular surface, which adds up to a large group. As with all joint fractures, adequate reconstruction is obligatory to remove all steps in the articular cartilage, and rigid fixation is mandatory except for the radial head, for which excision is indicated. We differentiate between 2 major groups of fractures according to the direction of the acting forces (Table Z) as follows (AllgGwer, 1973): 1. Pure axial forces. 2. Forces leading to valgus or varus displacement. Methods of treatment To allow the joint to be exercised early, the available methods include tension wiring, lag-screw fixation and internal fixation by plate and screws. No external support is then needed after operation, apart from an optional splint which can be removed for daily exercise beginning on the first or second postoperative day (Miller et al., 1969).
Case series We present 105 cases (90 per cent from the University Clinic in Basle) of the fracture types shown in Tables Z and ZZ which were assembled, analysed and followed up. The fractures occurred from 1969 to 1972 inclusive, the A0 principles were used and the cases were reviewed at 1 year using the individual A0 punch-card records. Follow-up was continued yearly up to 4 years in the earlier cases. At each year the punch-card information was brought up to date and further radiographs taken. The examining doctor looked for inadequate function and abnormal movement, including flexion and extension as well as pronation and supination. The results are discussed under the individual fracture types. FRACTURE
TYPES
Fracture-dislocations axial forces
produced
by
Transverse fractures of the olecranon (Figs. 1 and 2) Cause
Direct blow while the biceps is contracted. Treatment
A figure-of-eight tension wire was usually applied, but in 10 patients this was supplemented by axial Kirschner wires. Operations
Single figure-of-eight tension wire Double figure-of-eight tension wire Figure-of-eight wire and axial wires Plate on the proximal part of the ulna Tension band, axial wires and screw Axial wires only Total
4 16 9 1 1 1 32
Approaches
A posterior
approach
is possible
with the patient
Injury: the British Journal of Accident Surgery Vol. ~/NO. 2
144 Tab/e 1. Fracture-dislocations
produced
by axial forces
Type of fracture
Transverse Cornminuted
fracture
Cause
of olecranon
fracture
of olecranon
Transverse or cornminuted fracture of olecranon with anterior dislocation of radius and ulna Transverse or cornminuted fracture of olecranon with anterior dislocation of radial head (atypical Monteggia) Fracture of ulnar shaft with anterior dislocation of radial head (Monteggia) Fracture of coronoid process with posterior dislocation
Table //. Fracture-dislocations
Direct blow while contracted As above
Tension wire (single or double) Tension wire (double, with additional Kirschner wire) Reposition and tension wire (double)
As above
Tension banding (double) and reconstruction of the radio-ulnar joint
Direct injury and anterior shearing force
Plate to proximal ulna and reconstruction of radio-ulnar
Thrust in long axis of limb
With a small fragment : reposition and splintage for 3 weeks In complete avulsion : reposition and lag screw
joint
and lateral forces
Type of fracture
Marginal fracture of radial head with distraction of distal radio-ulnar joint (Essex-Lopresti) Fractures of medial epicondyle with displacement radialwards Medial condyle fracture type I (through the condylar notch) Fracture of medial condyle type II (between trochlea and capitulum) Y-fractures with angulation of distal fragment Cornminuted fracture of lower end of humerus
biceps
Triceps contraction and forward shearing force
due to transverse
Fracture of lateral epicondyle, displaced ulnarwards Fracture of lateral epicondyle with rotation of fragment Fracture of lateral condyle type I (capitulum completely or partially broken) Fracture of lateral condyle type II (capitulum and half trochlea) Marginal fracture of radial head
Treatment
Cause
Adduction (leading avulsion) As above Abduction
Treatment
to
In children (often), Kirschner wire In adults (rare), lag screw Kirschner wire, lag screw
(contusion)
If possible, lag screw; if not excision of fragment
As above
Lag screws transverse
As above
In children : reconstruction In adults : resection of the head Try to achieve same length of ulna and radius (no primary resection of head) In children, Kirschner wire In adults, lag screw Lag screw transversely
As above
Abduction
(avulsion)
Adduction
(contusion)
As above
Transverse
Complex
forces
Complex
forces
lying prone or supine. In the prone position the advantage is that the arm lies in the right position without assistance. Reduction of the fracture is, however, more difficult and the position may worry the anaesthetist. We prefer the supine position, therefore, and place the arm across the chest under slight
or oblique
or oblique
lag screws
Principle : reconstruction of surface of joint Principle : fixation of metaphysis to diaphysis with screws or 2 thirdtubular plates
traction. pleased,
Reduction is easier, the but the assistant has a harder
Technique
of tension
anaesthetist job.
is
wiring
Exact reduction is achieved verse hole is drilled through
by a single hook, a transthe crest of the ulna distal
Scharplatz
and AllgGwer : Fracture-dislocations
and 1.2-mm wire is passed through it. The ends of the wire are crossed over and anchored behind the proximal fragment through the tendon of the tricens. The ends are twisted tightly, the twist bent over, nipped short and buried. -
to the fracture,
145
of the Elbow After-treatment
Table III shows the functional results as well as the postoperative management and complications. Movement was usually begun immediately after the internal fixation, without a period of immobilization. In older or unreliable patients a removable back slab was applied between periods of daily physiotherapy. Complications
Two patients developed pseudarthrosis and one suffered from a postoperative infection. One 71-yearold patient with an unstable double tension wire developed a pseudarthrosis and required a lag screw
A
Fig. 1. A 71-year-old lady before treatment. A, Anteroposterior
view; B, lateral view.
Fixation with a double tension wire. A, Anteroposterior
view; B, lateral view.
Fig. 2.
146
Injury: the British Journal of Accident Surgery Vol. ~/NO. 2
after 3 months. Thirteen months after this he had an extension loss of 20”. A 20-year-old Italian patient developed a pseudarthrosis after fixation with a tension wire and axial Kirschner wires. At 18 months a cancellous bone graft was applied and stability secured, which resulted in rapid consolidation.
Table ///. Transverse fracture of the olecranon
operation. Of the 24 patients reviewed, the metal was removed from 16; the remaining 8 patients still had their metal, usually because of their age. Follow-up
(Table IV)
Of 32 transverse
fractures of the olecranon, 24 were
: treatment Functional results
Single figure-of-eight tension wire Double figure-of-eight tension
wire Figure-of-eight
Postoperative treatment
4
3
1
-
4
16
13
3
-
14
2
-
9 1
7 1
2
-
8 0
1 1
-
1 1 32
24
1
-
-
-
wire and axial
wire Plate on the olecranon Tension band, axial wires and screw Axial wires only
Total
The case of postoperative infection developed in a 74-year-old patient after fixation with a double tension wire. Drainage led to resolution of the infection in 2 months, after which a new internal fixation was performed with a 5-hole plate. This resulted in bony consolidation without complication. Removal of the metal
Metal was removed between 3 and 15 months after
Tab/e IV. Transverse fracture of the olecranon
-
-
0 0 26
1 1
7
1 -
1 1
5
reviewed at l-4 years. Of the remaining 8, 4 patients had died, 1 was in an old people’s home (and though she was immobilized, the elbow function was full), 2 had gone abroad and 1 could not be traced. A standard method of review and clinical examination was employed in every case and the information entered in the A0 punch-cards. The complications above, which had been recorded before the end of the year, do not appear on the table.
: follow-up Symptoms
X-rays
Clinical examination
Treatment
Single figure-of-eight tension wire 4 Double figure-of-eight tension wire 11 Figure-of-eight wire and axial wire 6 Plate to the proximal ulna 1 Tension band, axial wires and screw 1 Axial wires only 1 Total 24
3 8 5 1 0 1 18
1 2 1
1
1 5
1
2 9 3 1 1 16
1 2
1 2 1
3 7 3
4
1 14
1 1 3 1
3
1 1 4
6
4
Scharplatz
and Allgijwer:
Fracture-dislocations
A sub-group of transverse fractures, the oblique fractures, consisted of 4 cases. These were fixed as follows : Tension wire 1 2 Cancellous screws Tension wire and screw 1 Table Ill. cont.
-
-
2
-
-
-
0
Cause
A direct blow when the triceps is tense. Treatment (Fig. 3)
These were all treated with tension wires as follows: Double tension wire 4 Tension wire and Kirschner wires 3 Tension wire and screw 3 The treatment is summarized in Table V. Complications
Complications
-
147
of the Elbow
-
4
-
14 1
8 1
-
1 1 29
1
2
There were two complications. One patient with a pseudarthrosis at 3 months was treated with a cancellous screw combined with a tension wire. Though he was doing well on discharge from hospital, he did not return for follow-up. In another patient the tension wire became untwisted on day 13 and a fresh tension wire was required, after which he developed no further complication. Eight patients were available for review at 1 year, from 4 of whom the metal had already been removed. Table VI shows the results. Transverse or cornminuted fractures of the olecranon with anterior dislocations of the radius and ulna Cause
Triceps contraction
and a forward shearing force.
Approach
There were no complications in these cases. Three patients were reviewed at 1 year and had good results. The fourth was in a mental hospital and was said to have no limitation of movement. Cornminuted fractures of the olecranon The cases from the Surgical University Clinic of
Basle were older patients with an average age of 73 years, except for one of 18.
Table IV. cont.
Postero-ulnar,
skirting the olecranon.
Follow-up
There was one patient aged 29 who had united with a plate on the proximal part of the ulna. There was no complication and the metal was still in place at the first year review. At this time, he had a full range of movement and X-rays showed bony consolidation. Transverse or cornminuted fracture of the olecranon with anterior dislocation of the radial head
This is the atypical Monteggia fracture (Fig. 4).
Limitation of movement
Cause
Triceps contraction
and anterior shearing force.
Approach
Dorso-ulnar, with incision of the extensor mass to expose the ulna (avoiding the deep radial nerve) until the radio-ulnar joint is reached. 3 8 4 1 0
1 2 1
1 1
1 1
2
2
1 1
1
1
17
5
2
Cases
There were 3 patients, 2 women of 62 and 69 and 1 man of 50. These were treated as follows : Double tension wiring 1 Tension wire and Kirschner wire 1 Tension wire, cancellous screw, cerclage wire resection of the radial head 1
148
Injury: the British Journal of Accident
Surgery Vol. ~/NO. 2
cases, comprising 3 women and 1 man. The ages were between 41 and 70 years (average age 59).
Complications
The patients with the simple double wire and the tension wire and Kirschner wire recovered normally. The patient with the complex fixation developed a varus deformity and pseudarthrosis, and required a further operation at 84 months. After the application of a cancellous bone graft, the fracture was fixed with a plate. At review she had slight pain, callus was visible on the X-ray films and extension and flexion lacked 30” together, with a limitation of pronation and supination of 25”.
Approach
Fracture of the ulnar shaft with anterior dislocation of the radial head This is the Monteggia fracture. There were
They all had plate fixation of the ulna and reduction of the dislocated radio-ulnar joint, with refixation of the annular ligament. None had complications or later disabilities.
Cause
Direct injuries and anterior shearing forces. Postero-ulnar and entry through the extensor compartment to the ulna (avoiding the deep radial branch) until the radio-ulnar joint is reached. Treatment
4
Fig. 3. A, Cornminuted
fracture of the olecranon before treatment.
Table
fractures
V. Comminuted
B, Figure-of-eight
double tension wire.
: treatment
of the olecranon
Functional
Postoperative
results
treatment
Treatment
Double tension wire Tension wire and Kirschner Tension wire and screw Total
wire
4 3 3 10
3 1 2 6
1 2 1 4
0
4 3 1 8
2 2
0
Scharplatz and Allgker:
Fracture-dislocations
Fracture of the coronoid posterior dislocation
of the Elbow
149
process with
Cause
A thrust in the long axis of the limb. Approach
Dorso-ulnar with entry through the external compartment to the ulna (avoiding the deep radial branch) until the radio-ulnar joint is reached. Cases
The 2 cases were women of 25 and 69. One was treated by a tension wire and a screw, and the other by a tension wire and a Kirschner wire. The first patient developed a pseudarthrosis. She had no further treatment but at review had slight pain and an extension loss of 30”, a flexion loss of 20”, pronation and supination were reduced by 20”.
C Fig. 4. A typical monteggia
tion; B, after operation;
fracture. A, Before fixaC, appearance after 63 weeks.
Fracture-dislocation due to transverse and lateral forces Fracture of the lateral epicondyle, displaced ulnarwards There was one case of this type, a boy of 10.
Table V. cont. Complications
Cause
Adduction
with avulsion.
Approach
1
1
1
1
4 1 3 8
Dorso-radial. Treatment
The avulsed epicondyle was fixed back with a wire and a plaster back slab applied for 14 days. At 4 weeks
Injury: the British Journal of Accident Surgery Vol. ~/NO. 2
150 Table VI. Comminuted fractures of the olecranon
: follow-up
Symptoms
Double tension wire Tension wire and Kirschner wire Tension wire and screw
Total
3
2
2
1
3 8
3 6
1
1
the wire was removed and there was already full movement. He has not been reviewed since. Fracture of the lateral condyle with rotation of the fragment The single patient was a woman of 39 who had fallen on to the right hand (Figs 5, 6 and 7).
Fig. 5. A 39-year-old woman before treatment.
1 1
1
1
1
2 4
1 2
with avulsion.
Approach
Dorso-radial.
Clinical examination
2
2
2
3 5
1 1
1
2
1
a lag screw. The patient went home in a bandage at 3 days and there was no complication. The screw was removed at 3 months, and the wound healed primarily. On examination at 19 months there was good movement and the patient had 10” of limitation in flexion and extension, and 20” of limitation in pronation and supination.
A, Anteroposterior
Cause
Adduction
X-rays
view; B, lateral view.
Fracture of the lateral condyle type I In these cases the capitulum was completely or partially broken. The patients were 2 men of 68 and 31, and 2 boys of 5 and 6 years.
Treatment
Cause
The avulsed fragment was fixed back in position with
Abduction (contusion).
Scharplatz and AllgBwer: Fracture-dislocations
151
of the Elbow 6 weeks, from the 6-year-old
boy at 15 months (for unrelated reasons) and at 12 months from the man of 31. Three patients were reviewed at 4, 12 and 15 months and had no loss of function.
Table VI. cont. Limitation of movement
Fracture of lateral condyle type II This type of fracture involves the capitulum and half the trochlea. The 4 patients were a boy of 7 years and 3 adults aged from 41 to 78. 3 1 1 5
Cause 1 2 3
1 2 3
1
1
Abduction
1
1
Approach
(contusion).
A long dorso-radial incision, elevating the medial skin until the ulnar nerve is exposed. Approach
Dorso-radial. Treatment
Treatment was related to the patient’s age. The children and younger man were treated with wires only and the older man with wires and lag screw. After operation the children and older man were
Treatment
The boy was treated with wires only, but each adult with wires and a lag screw. Follow-up
At 4 months the boy had good consolidation, full function and the wires were removed. The patient of 78 was reviewed at 1 year and had 20” of limited
Fig. 6. The same case (39-year-old woman). Fixation with a lag screw. A, Anteroposterior
view; B, lateral view.
given removable back slabs, while the younger man had a simple bandage.
extension and flexion at both elbows. The 2 other patients, being foreign visitors, were lost to follow-up.
Metal removal
Marginal fracture of radial head There were 5 patients; average age was 24.6.
The wires were removed from the 5-year-old boy at
152
Injury:
Cause
the British Journal
of Accident
Vol. ~/NO. 2
Treatment
Abduction
(contusion).
The head of the radius was fixed with a transiixion wire. A removable plaster back slab was given. The metal was removed at 19 months, and there was painless, full function.
Approach
Dorso-radial.
A Fig. 7.
Surgery
B
(39-year-old woman.) Results after removal of the metal. A, Anteroposterior
Treatment
view; B, lateral view.
Fractured medial epicondyle displacement radialwards
with
All these fractures were fixed with one or more cortical screws. In one patient of 20,2 screws failed to give rigid fixation and after 5 weeks he was tied with 3 screws. One patient had the screws removed at 1 month, and another at 4 months. The cases without reconstruction are not considered.
There were 5 boys and 2 girls aged between 13 and 17, in all of whom, therefore, bone growth had not yet ceased.
Follow-up
Abduction (avulsion).
One patient was lost to follow-up, but the others had full function, including the patient who had a reoperation.
Approach
Cause
Dorso-ulnar.
Marginal fracture of the radial head with distraction of the distal radio-ulnar joint This is the Essex-Lopresti fracture. The single patient was aged 38.
The details of treatment are shown in Table VII. The wires were removed after an average period of 8 weeks.
Cause
Follow-up
Abduction
(contusion).
Approach
Dorso-radial.
Treatment
Apart from a boy of 15 and a girl of 14, all cases were reviewed at 12 and 18 months. A 16-year-old boy had 5” lack of extension, but all the others had full ranges and full function of the elbow.
Scharplatz
and Allgijwer:
Fracture-dislocations
of the Elbow
153
Medial condyle fracture type I (through the condylar notch)
Cause Adduction
There was one patient, an English tourist of 27, who had been injured in a traffic accident several weeks before and had been treated conservatively.
Approac,, Dorso-ulnar
(contusion).
exposing the ulnar nerve.
The old fracture was refixed with multiple wires and screws and supported in a removable plaster back slab. She recovered without complication and the
A
B
Fig. 8. Fracture of medial condyle, type II, before treatment.
A
A, Anteroposterior
view; B, lateral view.
B
Fig. 9. The same type of fracture. Fixation with lag screws, refixation of the olecranon osteotomy. posterior view; B, lateral view.
A, Antero-
154
Injury: the British Journal of Accident
X-rays she sent us after good bony consolidation.
removal
of the metal
showed
Fracture of medial condyle type II (between trochlea and capitulum)
In 1 patient the condyles were refixed with lag screws, and in the 47-year-old patient the refixation was done by a ‘I-hole T-plate and lag screws. The T-plate was removed at 8 months, and the screws from the older patient at 14 months.
Adduction (contusion). Approach with
mid-forearm. Exposure of the ulnar nerve. Exposure of the joint either by retraction of the incised tendon of triceps or by osteotomy of the olecranon which is reconstructed finally with a tension wire procedure. Treatment
Cause
Dorso-ulnar
Surgery Vol. ~/NO. 2
exposure of the ulnar nerve.
Cases
Operation details
There were 2 patients (aged 58 and 80), both fixed with screws (Figs. 8 and 9). The patient aged 80 had a removable back slab after operation. The metal was not removed in either case before 1 year.
The older patient had an open Y-fracture of the humerus. The reduction was adequate and the fixation rigid. He was provided with a removable back slab, but the younger man had a simple bandage.
Tab/e V//. Fractures
of the medial
epicondyle
with displacement
radialwards:
treatment
Postoperative treatment
Functional results
Kirschner
wire
Lag screws Total
5 2 7
5 2 7
1 1
Follow-up
Complications
The 5%year-old patient was reviewed at 5 years. The metal had not been removed, but he had a clear uninfected non-union. He only complained of a mild painless limitation of function, but X-ray showed a varus deviation of 8, with slight lateral displacement. The fracture line was still visible, there was bone dystrophy and incongruent bone surfaces. There was a loss of 20” of both extension and flexion. The patient could do no work because of mental disease, unrelated to the fracture, and the disability was assessed at 30 per cent. The patient of 80 died 6 months after the accident.
The man of 39 had a persistently healed spontaneously.
Y-fractures with angulation of the distal fragment The 2 cases were men of 39 and 47 (Figs. 10, 11 and 12).
Cornminuted the humerus
Cause
Approach
Complex forces.
As in the previous case.
4 2 6
warm arm, but it
Follow-up
Both patients were examined at the time of metal removal, and the man with the T-plate had full supination and pronation but lacked 10” of extension. The patient who had screws only complained of definite pain at 14 months, slight swelling, loss of 30” of extension and 35” of flexion, and 25” limitation of both pronation and supination. The muscle power in this arm was reduced. fracture of the lower end of
Cause
Complex forces.
Approach
Cases
Long dorsal incision, skirting the olecranon radially and extending from the mid-upper arm to the
There were 20 patients of whom 3 were under 20, and the ages ranged from 9 to 82 years (Figs. 13 and 14,
Scharplatz
and AllgBwer:
Fracture-dislocations
155
of the Elbow
p. 157). They were treated as follows: Fixation with plate and screw. Fixation with screws only. An 80” children’s condylar plate, screws and Kirschner wires. Table VIII shows the operation and treatment details. There were only 2 early complications out of these 20 cases: 1 pseudarthrosis and 1 infection. Follow-up
The children with screws and Kirschner wires or Kirschner wires alone had very good results, the 65-year-old man with the 80” condylar plate died shortly afterwards by suicide, and the 58-year-old lady with a screw fixation had osteoporosis and slight atrophy on review. The remaining 11 cases included 6 patients without limitation of joint function, and of
Table VU. cont. Complications ,n
61
the 5 patients with limited joint function, 3 had no actual disability. The results were graded by the patients themselves as very good in 9 cases, good in 4 and reasonable in 2 (Table IX).
DISCUSSION In this paper, the various fracture-dislocations of the elbow joint are described and analysed. As all these fractures differ in mechanism, age of patient and methods of treatment, problems arise in classification. Causative factors can be grouped together more easily than the principles of treatment. The treatment is really related to the fracture site and 2 options are open: 1. Resection of the fragment, as in the radial head and sometimes in small olecranon fragments (Heim, 1973). 2. Exact anatomical reduction with fixation of the fragments to the shaft. The indications for open operation can be summarized thus. In adults operation is always indicated. Children’s fractures should, if possible, be managed conservatively (Blount, 1957). Fractured epicondyles always need operation, but care must be taken at the growth zones. All types of fracture can be approached posteriorly with the patient either prone or supine. The prone position has the advantage that the arm lies in the right position without the help of an assistant, but manipulation to reduce the fracture is more difficult and problems may
B
A Fig. 10. Y-fracture
before treatment. A, Anteroposterior
view; B, lateral view.
156
Injury:
the British Journal
Fig. 11. Fixation with transverse lag screw and two oblique screws, eight tension wire. A, Anteroposterior view; B, lateral view.
and fixation
of Accident
of the osteotomy
A
Fig. 12. Results
after removal
Surgery
B
of the metal
at 62 weeks.
A, Anteroposterior
view;
B, lateral
view.
Vol. ~/NO. 2
by figure-of-
Scharplatz and
Allgtjwer
Fig. 13. Comminuted
:
Fracture-dislocations
of the Elbow
fracture of lower end of humerus. A, Before treatment;
B, after fixation.
A Fig. 14. Result after removal of the metal. A, Anteroposterior
view; B, lateral view.
158
Injury: the British Journal of Accident Surgery Vol. ~/NO. 2
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143
59
Fracture-dislocations D. Scharplatz Kantonsspital,
of the elbow
and M. Allgiiwer Bade
Summary
This paper presents a series of 105 cases of fracturedislocation of the elbow joint. All these fractures differ in mechanism, age of patient and method of treatment, so problems arise in classification. Causes can be grouped together more easily than the principles of treatment. The cases are classified into 2 major groups and 10 subgroups. Single fracture types are analysed and the optimal type of treatment is studied. As with all joint fractures, adequate reconstruction is obligatory to remove all steps in the articular cartilage, and rigid fixation is mandatory except for the radial head, where excision is indicated. The different fracture types and their relevant operations are illustrated with examples. INTRODUCTION Definition FRACTURE-DISLOCATIONSof the elbow include all fractures with total or partial displacement of the articular surface, which adds up to a large group. As with all joint fractures, adequate reconstruction is obligatory to remove all steps in the articular cartilage, and rigid fixation is mandatory except for the radial head, for which excision is indicated. We differentiate between 2 major groups of fractures according to the direction of the acting forces (Table Z) as follows (AllgGwer, 1973): 1. Pure axial forces. 2. Forces leading to valgus or varus displacement. Methods of treatment To allow the joint to be exercised early, the available methods include tension wiring, lag-screw fixation and internal fixation by plate and screws. No external support is then needed after operation, apart from an optional splint which can be removed for daily exercise beginning on the first or second postoperative day (Miller et al., 1969).
Case series We present 105 cases (90 per cent from the University Clinic in Basle) of the fracture types shown in Tables Z and ZZ which were assembled, analysed and followed up. The fractures occurred from 1969 to 1972 inclusive, the A0 principles were used and the cases were reviewed at 1 year using the individual A0 punch-card records. Follow-up was continued yearly up to 4 years in the earlier cases. At each year the punch-card information was brought up to date and further radiographs taken. The examining doctor looked for inadequate function and abnormal movement, including flexion and extension as well as pronation and supination. The results are discussed under the individual fracture types. FRACTURE
TYPES
Fracture-dislocations axial forces
produced
by
Transverse fractures of the olecranon (Figs. 1 and 2) Cause
Direct blow while the biceps is contracted. Treatment
A figure-of-eight tension wire was usually applied, but in 10 patients this was supplemented by axial Kirschner wires. Operations
Single figure-of-eight tension wire Double figure-of-eight tension wire Figure-of-eight wire and axial wires Plate on the proximal part of the ulna Tension band, axial wires and screw Axial wires only Total
4 16 9 1 1 1 32
Approaches
A posterior
approach
is possible
with the patient
Injury: the British Journal of Accident Surgery Vol. ~/NO. 2
144 Tab/e 1. Fracture-dislocations
produced
by axial forces
Type of fracture
Transverse Cornminuted
fracture
Cause
of olecranon
fracture
of olecranon
Transverse or cornminuted fracture of olecranon with anterior dislocation of radius and ulna Transverse or cornminuted fracture of olecranon with anterior dislocation of radial head (atypical Monteggia) Fracture of ulnar shaft with anterior dislocation of radial head (Monteggia) Fracture of coronoid process with posterior dislocation
Table //. Fracture-dislocations
Direct blow while contracted As above
Tension wire (single or double) Tension wire (double, with additional Kirschner wire) Reposition and tension wire (double)
As above
Tension banding (double) and reconstruction of the radio-ulnar joint
Direct injury and anterior shearing force
Plate to proximal ulna and reconstruction of radio-ulnar
Thrust in long axis of limb
With a small fragment : reposition and splintage for 3 weeks In complete avulsion : reposition and lag screw
joint
and lateral forces
Type of fracture
Marginal fracture of radial head with distraction of distal radio-ulnar joint (Essex-Lopresti) Fractures of medial epicondyle with displacement radialwards Medial condyle fracture type I (through the condylar notch) Fracture of medial condyle type II (between trochlea and capitulum) Y-fractures with angulation of distal fragment Cornminuted fracture of lower end of humerus
biceps
Triceps contraction and forward shearing force
due to transverse
Fracture of lateral epicondyle, displaced ulnarwards Fracture of lateral epicondyle with rotation of fragment Fracture of lateral condyle type I (capitulum completely or partially broken) Fracture of lateral condyle type II (capitulum and half trochlea) Marginal fracture of radial head
Treatment
Cause
Adduction (leading avulsion) As above Abduction
Treatment
to
In children (often), Kirschner wire In adults (rare), lag screw Kirschner wire, lag screw
(contusion)
If possible, lag screw; if not excision of fragment
As above
Lag screws transverse
As above
In children : reconstruction In adults : resection of the head Try to achieve same length of ulna and radius (no primary resection of head) In children, Kirschner wire In adults, lag screw Lag screw transversely
As above
Abduction
(avulsion)
Adduction
(contusion)
As above
Transverse
Complex
forces
Complex
forces
lying prone or supine. In the prone position the advantage is that the arm lies in the right position without assistance. Reduction of the fracture is, however, more difficult and the position may worry the anaesthetist. We prefer the supine position, therefore, and place the arm across the chest under slight
or oblique
or oblique
lag screws
Principle : reconstruction of surface of joint Principle : fixation of metaphysis to diaphysis with screws or 2 thirdtubular plates
traction. pleased,
Reduction is easier, the but the assistant has a harder
Technique
of tension
anaesthetist job.
is
wiring
Exact reduction is achieved verse hole is drilled through
by a single hook, a transthe crest of the ulna distal
Scharplatz
and AllgGwer : Fracture-dislocations
and 1.2-mm wire is passed through it. The ends of the wire are crossed over and anchored behind the proximal fragment through the tendon of the tricens. The ends are twisted tightly, the twist bent over, nipped short and buried. -
to the fracture,
145
of the Elbow After-treatment
Table III shows the functional results as well as the postoperative management and complications. Movement was usually begun immediately after the internal fixation, without a period of immobilization. In older or unreliable patients a removable back slab was applied between periods of daily physiotherapy. Complications
Two patients developed pseudarthrosis and one suffered from a postoperative infection. One 71-yearold patient with an unstable double tension wire developed a pseudarthrosis and required a lag screw
A
Fig. 1. A 71-year-old lady before treatment. A, Anteroposterior
view; B, lateral view.
Fixation with a double tension wire. A, Anteroposterior
view; B, lateral view.
Fig. 2.
146
Injury: the British Journal of Accident Surgery Vol. ~/NO. 2
after 3 months. Thirteen months after this he had an extension loss of 20”. A 20-year-old Italian patient developed a pseudarthrosis after fixation with a tension wire and axial Kirschner wires. At 18 months a cancellous bone graft was applied and stability secured, which resulted in rapid consolidation.
Table ///. Transverse fracture of the olecranon
operation. Of the 24 patients reviewed, the metal was removed from 16; the remaining 8 patients still had their metal, usually because of their age. Follow-up
(Table IV)
Of 32 transverse
fractures of the olecranon, 24 were
: treatment Functional results
Single figure-of-eight tension wire Double figure-of-eight tension
wire Figure-of-eight
Postoperative treatment
4
3
1
-
4
16
13
3
-
14
2
-
9 1
7 1
2
-
8 0
1 1
-
1 1 32
24
1
-
-
-
wire and axial
wire Plate on the olecranon Tension band, axial wires and screw Axial wires only
Total
The case of postoperative infection developed in a 74-year-old patient after fixation with a double tension wire. Drainage led to resolution of the infection in 2 months, after which a new internal fixation was performed with a 5-hole plate. This resulted in bony consolidation without complication. Removal of the metal
Metal was removed between 3 and 15 months after
Tab/e IV. Transverse fracture of the olecranon
-
-
0 0 26
1 1
7
1 -
1 1
5
reviewed at l-4 years. Of the remaining 8, 4 patients had died, 1 was in an old people’s home (and though she was immobilized, the elbow function was full), 2 had gone abroad and 1 could not be traced. A standard method of review and clinical examination was employed in every case and the information entered in the A0 punch-cards. The complications above, which had been recorded before the end of the year, do not appear on the table.
: follow-up Symptoms
X-rays
Clinical examination
Treatment
Single figure-of-eight tension wire 4 Double figure-of-eight tension wire 11 Figure-of-eight wire and axial wire 6 Plate to the proximal ulna 1 Tension band, axial wires and screw 1 Axial wires only 1 Total 24
3 8 5 1 0 1 18
1 2 1
1
1 5
1
2 9 3 1 1 16
1 2
1 2 1
3 7 3
4
1 14
1 1 3 1
3
1 1 4
6
4
Scharplatz
and Allgijwer:
Fracture-dislocations
A sub-group of transverse fractures, the oblique fractures, consisted of 4 cases. These were fixed as follows : Tension wire 1 2 Cancellous screws Tension wire and screw 1 Table Ill. cont.
-
-
2
-
-
-
0
Cause
A direct blow when the triceps is tense. Treatment (Fig. 3)
These were all treated with tension wires as follows: Double tension wire 4 Tension wire and Kirschner wires 3 Tension wire and screw 3 The treatment is summarized in Table V. Complications
Complications
-
147
of the Elbow
-
4
-
14 1
8 1
-
1 1 29
1
2
There were two complications. One patient with a pseudarthrosis at 3 months was treated with a cancellous screw combined with a tension wire. Though he was doing well on discharge from hospital, he did not return for follow-up. In another patient the tension wire became untwisted on day 13 and a fresh tension wire was required, after which he developed no further complication. Eight patients were available for review at 1 year, from 4 of whom the metal had already been removed. Table VI shows the results. Transverse or cornminuted fractures of the olecranon with anterior dislocations of the radius and ulna Cause
Triceps contraction
and a forward shearing force.
Approach
There were no complications in these cases. Three patients were reviewed at 1 year and had good results. The fourth was in a mental hospital and was said to have no limitation of movement. Cornminuted fractures of the olecranon The cases from the Surgical University Clinic of
Basle were older patients with an average age of 73 years, except for one of 18.
Table IV. cont.
Postero-ulnar,
skirting the olecranon.
Follow-up
There was one patient aged 29 who had united with a plate on the proximal part of the ulna. There was no complication and the metal was still in place at the first year review. At this time, he had a full range of movement and X-rays showed bony consolidation. Transverse or cornminuted fracture of the olecranon with anterior dislocation of the radial head
This is the atypical Monteggia fracture (Fig. 4).
Limitation of movement
Cause
Triceps contraction
and anterior shearing force.
Approach
Dorso-ulnar, with incision of the extensor mass to expose the ulna (avoiding the deep radial nerve) until the radio-ulnar joint is reached. 3 8 4 1 0
1 2 1
1 1
1 1
2
2
1 1
1
1
17
5
2
Cases
There were 3 patients, 2 women of 62 and 69 and 1 man of 50. These were treated as follows : Double tension wiring 1 Tension wire and Kirschner wire 1 Tension wire, cancellous screw, cerclage wire resection of the radial head 1
148
Injury: the British Journal of Accident
Surgery Vol. ~/NO. 2
cases, comprising 3 women and 1 man. The ages were between 41 and 70 years (average age 59).
Complications
The patients with the simple double wire and the tension wire and Kirschner wire recovered normally. The patient with the complex fixation developed a varus deformity and pseudarthrosis, and required a further operation at 84 months. After the application of a cancellous bone graft, the fracture was fixed with a plate. At review she had slight pain, callus was visible on the X-ray films and extension and flexion lacked 30” together, with a limitation of pronation and supination of 25”.
Approach
Fracture of the ulnar shaft with anterior dislocation of the radial head This is the Monteggia fracture. There were
They all had plate fixation of the ulna and reduction of the dislocated radio-ulnar joint, with refixation of the annular ligament. None had complications or later disabilities.
Cause
Direct injuries and anterior shearing forces. Postero-ulnar and entry through the extensor compartment to the ulna (avoiding the deep radial branch) until the radio-ulnar joint is reached. Treatment
4
Fig. 3. A, Cornminuted
fracture of the olecranon before treatment.
Table
fractures
V. Comminuted
B, Figure-of-eight
double tension wire.
: treatment
of the olecranon
Functional
Postoperative
results
treatment
Treatment
Double tension wire Tension wire and Kirschner Tension wire and screw Total
wire
4 3 3 10
3 1 2 6
1 2 1 4
0
4 3 1 8
2 2
0
Scharplatz and Allgker:
Fracture-dislocations
Fracture of the coronoid posterior dislocation
of the Elbow
149
process with
Cause
A thrust in the long axis of the limb. Approach
Dorso-ulnar with entry through the external compartment to the ulna (avoiding the deep radial branch) until the radio-ulnar joint is reached. Cases
The 2 cases were women of 25 and 69. One was treated by a tension wire and a screw, and the other by a tension wire and a Kirschner wire. The first patient developed a pseudarthrosis. She had no further treatment but at review had slight pain and an extension loss of 30”, a flexion loss of 20”, pronation and supination were reduced by 20”.
C Fig. 4. A typical monteggia
tion; B, after operation;
fracture. A, Before fixaC, appearance after 63 weeks.
Fracture-dislocation due to transverse and lateral forces Fracture of the lateral epicondyle, displaced ulnarwards There was one case of this type, a boy of 10.
Table V. cont. Complications
Cause
Adduction
with avulsion.
Approach
1
1
1
1
4 1 3 8
Dorso-radial. Treatment
The avulsed epicondyle was fixed back with a wire and a plaster back slab applied for 14 days. At 4 weeks
Injury: the British Journal of Accident Surgery Vol. ~/NO. 2
150 Table VI. Comminuted fractures of the olecranon
: follow-up
Symptoms
Double tension wire Tension wire and Kirschner wire Tension wire and screw
Total
3
2
2
1
3 8
3 6
1
1
the wire was removed and there was already full movement. He has not been reviewed since. Fracture of the lateral condyle with rotation of the fragment The single patient was a woman of 39 who had fallen on to the right hand (Figs 5, 6 and 7).
Fig. 5. A 39-year-old woman before treatment.
1 1
1
1
1
2 4
1 2
with avulsion.
Approach
Dorso-radial.
Clinical examination
2
2
2
3 5
1 1
1
2
1
a lag screw. The patient went home in a bandage at 3 days and there was no complication. The screw was removed at 3 months, and the wound healed primarily. On examination at 19 months there was good movement and the patient had 10” of limitation in flexion and extension, and 20” of limitation in pronation and supination.
A, Anteroposterior
Cause
Adduction
X-rays
view; B, lateral view.
Fracture of the lateral condyle type I In these cases the capitulum was completely or partially broken. The patients were 2 men of 68 and 31, and 2 boys of 5 and 6 years.
Treatment
Cause
The avulsed fragment was fixed back in position with
Abduction (contusion).
Scharplatz and AllgBwer: Fracture-dislocations
151
of the Elbow 6 weeks, from the 6-year-old
boy at 15 months (for unrelated reasons) and at 12 months from the man of 31. Three patients were reviewed at 4, 12 and 15 months and had no loss of function.
Table VI. cont. Limitation of movement
Fracture of lateral condyle type II This type of fracture involves the capitulum and half the trochlea. The 4 patients were a boy of 7 years and 3 adults aged from 41 to 78. 3 1 1 5
Cause 1 2 3
1 2 3
1
1
Abduction
1
1
Approach
(contusion).
A long dorso-radial incision, elevating the medial skin until the ulnar nerve is exposed. Approach
Dorso-radial. Treatment
Treatment was related to the patient’s age. The children and younger man were treated with wires only and the older man with wires and lag screw. After operation the children and older man were
Treatment
The boy was treated with wires only, but each adult with wires and a lag screw. Follow-up
At 4 months the boy had good consolidation, full function and the wires were removed. The patient of 78 was reviewed at 1 year and had 20” of limited
Fig. 6. The same case (39-year-old woman). Fixation with a lag screw. A, Anteroposterior
view; B, lateral view.
given removable back slabs, while the younger man had a simple bandage.
extension and flexion at both elbows. The 2 other patients, being foreign visitors, were lost to follow-up.
Metal removal
Marginal fracture of radial head There were 5 patients; average age was 24.6.
The wires were removed from the 5-year-old boy at
152
Injury:
Cause
the British Journal
of Accident
Vol. ~/NO. 2
Treatment
Abduction
(contusion).
The head of the radius was fixed with a transiixion wire. A removable plaster back slab was given. The metal was removed at 19 months, and there was painless, full function.
Approach
Dorso-radial.
A Fig. 7.
Surgery
B
(39-year-old woman.) Results after removal of the metal. A, Anteroposterior
Treatment
view; B, lateral view.
Fractured medial epicondyle displacement radialwards
with
All these fractures were fixed with one or more cortical screws. In one patient of 20,2 screws failed to give rigid fixation and after 5 weeks he was tied with 3 screws. One patient had the screws removed at 1 month, and another at 4 months. The cases without reconstruction are not considered.
There were 5 boys and 2 girls aged between 13 and 17, in all of whom, therefore, bone growth had not yet ceased.
Follow-up
Abduction (avulsion).
One patient was lost to follow-up, but the others had full function, including the patient who had a reoperation.
Approach
Cause
Dorso-ulnar.
Marginal fracture of the radial head with distraction of the distal radio-ulnar joint This is the Essex-Lopresti fracture. The single patient was aged 38.
The details of treatment are shown in Table VII. The wires were removed after an average period of 8 weeks.
Cause
Follow-up
Abduction
(contusion).
Approach
Dorso-radial.
Treatment
Apart from a boy of 15 and a girl of 14, all cases were reviewed at 12 and 18 months. A 16-year-old boy had 5” lack of extension, but all the others had full ranges and full function of the elbow.
Scharplatz
and Allgijwer:
Fracture-dislocations
of the Elbow
153
Medial condyle fracture type I (through the condylar notch)
Cause Adduction
There was one patient, an English tourist of 27, who had been injured in a traffic accident several weeks before and had been treated conservatively.
Approac,, Dorso-ulnar
(contusion).
exposing the ulnar nerve.
The old fracture was refixed with multiple wires and screws and supported in a removable plaster back slab. She recovered without complication and the
A
B
Fig. 8. Fracture of medial condyle, type II, before treatment.
A
A, Anteroposterior
view; B, lateral view.
B
Fig. 9. The same type of fracture. Fixation with lag screws, refixation of the olecranon osteotomy. posterior view; B, lateral view.
A, Antero-
154
Injury: the British Journal of Accident
X-rays she sent us after good bony consolidation.
removal
of the metal
showed
Fracture of medial condyle type II (between trochlea and capitulum)
In 1 patient the condyles were refixed with lag screws, and in the 47-year-old patient the refixation was done by a ‘I-hole T-plate and lag screws. The T-plate was removed at 8 months, and the screws from the older patient at 14 months.
Adduction (contusion). Approach with
mid-forearm. Exposure of the ulnar nerve. Exposure of the joint either by retraction of the incised tendon of triceps or by osteotomy of the olecranon which is reconstructed finally with a tension wire procedure. Treatment
Cause
Dorso-ulnar
Surgery Vol. ~/NO. 2
exposure of the ulnar nerve.
Cases
Operation details
There were 2 patients (aged 58 and 80), both fixed with screws (Figs. 8 and 9). The patient aged 80 had a removable back slab after operation. The metal was not removed in either case before 1 year.
The older patient had an open Y-fracture of the humerus. The reduction was adequate and the fixation rigid. He was provided with a removable back slab, but the younger man had a simple bandage.
Tab/e V//. Fractures
of the medial
epicondyle
with displacement
radialwards:
treatment
Postoperative treatment
Functional results
Kirschner
wire
Lag screws Total
5 2 7
5 2 7
1 1
Follow-up
Complications
The 5%year-old patient was reviewed at 5 years. The metal had not been removed, but he had a clear uninfected non-union. He only complained of a mild painless limitation of function, but X-ray showed a varus deviation of 8, with slight lateral displacement. The fracture line was still visible, there was bone dystrophy and incongruent bone surfaces. There was a loss of 20” of both extension and flexion. The patient could do no work because of mental disease, unrelated to the fracture, and the disability was assessed at 30 per cent. The patient of 80 died 6 months after the accident.
The man of 39 had a persistently healed spontaneously.
Y-fractures with angulation of the distal fragment The 2 cases were men of 39 and 47 (Figs. 10, 11 and 12).
Cornminuted the humerus
Cause
Approach
Complex forces.
As in the previous case.
4 2 6
warm arm, but it
Follow-up
Both patients were examined at the time of metal removal, and the man with the T-plate had full supination and pronation but lacked 10” of extension. The patient who had screws only complained of definite pain at 14 months, slight swelling, loss of 30” of extension and 35” of flexion, and 25” limitation of both pronation and supination. The muscle power in this arm was reduced. fracture of the lower end of
Cause
Complex forces.
Approach
Cases
Long dorsal incision, skirting the olecranon radially and extending from the mid-upper arm to the
There were 20 patients of whom 3 were under 20, and the ages ranged from 9 to 82 years (Figs. 13 and 14,
Scharplatz
and AllgBwer:
Fracture-dislocations
155
of the Elbow
p. 157). They were treated as follows: Fixation with plate and screw. Fixation with screws only. An 80” children’s condylar plate, screws and Kirschner wires. Table VIII shows the operation and treatment details. There were only 2 early complications out of these 20 cases: 1 pseudarthrosis and 1 infection. Follow-up
The children with screws and Kirschner wires or Kirschner wires alone had very good results, the 65-year-old man with the 80” condylar plate died shortly afterwards by suicide, and the 58-year-old lady with a screw fixation had osteoporosis and slight atrophy on review. The remaining 11 cases included 6 patients without limitation of joint function, and of
Table VU. cont. Complications ,n
61
the 5 patients with limited joint function, 3 had no actual disability. The results were graded by the patients themselves as very good in 9 cases, good in 4 and reasonable in 2 (Table IX).
DISCUSSION In this paper, the various fracture-dislocations of the elbow joint are described and analysed. As all these fractures differ in mechanism, age of patient and methods of treatment, problems arise in classification. Causative factors can be grouped together more easily than the principles of treatment. The treatment is really related to the fracture site and 2 options are open: 1. Resection of the fragment, as in the radial head and sometimes in small olecranon fragments (Heim, 1973). 2. Exact anatomical reduction with fixation of the fragments to the shaft. The indications for open operation can be summarized thus. In adults operation is always indicated. Children’s fractures should, if possible, be managed conservatively (Blount, 1957). Fractured epicondyles always need operation, but care must be taken at the growth zones. All types of fracture can be approached posteriorly with the patient either prone or supine. The prone position has the advantage that the arm lies in the right position without the help of an assistant, but manipulation to reduce the fracture is more difficult and problems may
B
A Fig. 10. Y-fracture
before treatment. A, Anteroposterior
view; B, lateral view.
156
Injury:
the British Journal
Fig. 11. Fixation with transverse lag screw and two oblique screws, eight tension wire. A, Anteroposterior view; B, lateral view.
and fixation
of Accident
of the osteotomy
A
Fig. 12. Results
after removal
Surgery
B
of the metal
at 62 weeks.
A, Anteroposterior
view;
B, lateral
view.
Vol. ~/NO. 2
by figure-of-
Scharplatz and
Allgtjwer
Fig. 13. Comminuted
:
Fracture-dislocations
of the Elbow
fracture of lower end of humerus. A, Before treatment;
B, after fixation.
A Fig. 14. Result after removal of the metal. A, Anteroposterior
view; B, lateral view.
158
Injury: the British Journal of Accident Surgery Vol. ~/NO. 2
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