OlecranonFracturesandRadialHeadFractures鷹嘴尺骨.ppt

1、Olecranon Fractures and Radial Head Fractures,Andrew H. Schmidt, MD Gregory J. Schmeling, MD David C. Templeman, MDCreated March 2004,Anatomy of the Olecranon and Radial Head,Surgical Anatomy,Articular cartilage Sigmoid notch of ulna: bare spot Coronoid process Note angle of k-wires to engage anteri

2、or cortex Beware of narrowing sigmoid fossa when treating comminuted fractures.,Olecranon Fractures,Mechanism of Injury,Acute Tension overload: Tension applied by the triceps with flexion of the elbow. Direct Trauma Chronic overload: stress fracture, osteopenia, pediatric injuries.,Evaluation,Check

3、integrity of skin Check extension of elbow Evaluate neurovascular status, especially ulnar nerve X-rays in three views (AP, Lat, Oblique),Imaging,AP View,Lateral View,Oblique View,Factors Responsible for Elbow Stability,Valgus = Medial collateral ligament and radial head Varus = Lateral collateral l

4、igament Coronoid process Sigmoid Fossa of the olecranon,Classification,Numerous classifications: Colton Morrey Schatzker AO/ASIF OTA,Criteria Displacement Direction of fracture Degree of comminution Percent involvement Associated injuries,Type I: Nondisplaced 12% Type II: Displaced/ elbow stable 82%

5、 Type III: Elbow unstable 6% Both types II and III subdivided into: A: noncomminuted B: comminuted,Mayo Clinic Classification,Morrey BF, JBJS 77A: 718-21, 1995,Treatment Objectives,Restoration of the articular surface. Restoration and preservation of the elbow extensor mechanism. Restoration of elbo

6、w motion and prevention of stiffness. Prevention of complications.,Treatment Methods,Nonoperative Operative Excision of olecranon and triceps repair Open reduction and internal fixation Tension band wire with pins or intramedullary screws Plate,Indications for Surgery,Disruption of extensor mechanis

7、m (any displaced fracture) Articular incongruity,Nonoperative Treatment,Nondisplaced fractures Long arm cast - complicated by stiffness Long-arm splint for 7-10 days followed by functional bracing for 4-6 weeks - complicated by loss of reduction,Olecranon Excision,Appropriate for elderly patients an

8、d those with osteoporosis, involving 50% of joint (70%) Reattach triceps anteriorly. No difference in isometric strength but fewer complications in the excision group (Gartsman et al, JBJS 63A:718, 1981),Surgical Techniques,Preop Planning,Evaluate comminution of dorsal cortex If intact: tension band

9、 wire appropriate If comminuted, plate appropriate Evaluate orientation of fracture line Transverse: tension band wire Oblique, complex: plate,Positioning,Supine with arm across chest. Lateral or prone also may be used. Tourniquet Regional or general anesthesia Posterior approach,Tension Band Wire,U

10、sed for most simple, noncomminuted fractures,Tension Band Wire,Use 18- or 20-gauge steel wire or small braided cable. Be sure wires cross over dorsal cortex. May use with either parallel K-wires or an intramedullary screw. With screw techniques, beware of bowing of the canal that may shift the fract

11、ure,Tension Band Wire,A. Vertical split in triceps tendon,B. Bury end of K-wire deep to tendon,C. Pass Tension band wire deep to tendon with angiocatheter,From Hak and Golladay, JAAOS, 8:266-75, 2000,Intramedullary Screw ?,Appropriate for oblique fracture plane Add tension band wire,Anatomy of the P

12、roximal Ulna,Beware of the bow of the proximal ulna, which may cause a medial shift of the tip of the olecranon if a long screw is used.,Anatomy of the Proximal Ulna,Beware of the bow of the proximal ulna, which may cause a medial shift of the tip of the olecranon if a long screw is used.,From Hak a

13、nd Golladay, JAAOS, 8:266-75, 2000,Biomechanics ofTension Band Wires,Location of distal transverse hole for wire Controversial - theoretical biomechanical analysis suggests that anterior placement of the hole relative to the k-wires is best (Rowland and Burkhart, CORR 277:238, 1992) Biomechanical te

14、sting and clinical experience suggests that it doesnt seem to matter. A “figure-of-8 wire” and medullary screw seems to be the strongest construct and is comparable to a plate.,Case Example - Transverse Fracture,Plate Fixation,Used for comminuted fractures or fractures with shaft extension: Semitubu

15、lar DCP 3.5 Recon plate,Ulnar Shaft Extension,Plate location,No mechanical difference between posterior or lateral placement (King et al, J Shoulder Elbow Surg 5:437, 1996) Less problems with plate prominence when placed laterally,Indirect Reduction,Case Example - Comminuted fracture involving the c

16、oronoid process,Dorsal plate necessary in order to fix the coronoid process,Case Example - Comminuted olecranon fracture,Lateral plate used to lessen plate prominence,Outcomes,Union 76-98 % 19 point scale = pain+function+ROM+x-ray IM screw & TBW 17.7 IM screw 17.2 TB-wire 16.7,Murphy DF et al., Clin

17、 Orthop 224:215, 1987,Proximal Plating,73% Good /Excellent 24 Monteggia 13 Complex LCDCP Simpson, Injury 27,Complications,Potential Complications,Hardware symptoms in 22 - 80% 34-66% require hardware removal Hardware failure 1-5% Infection 0-6% Pin migration 15% Ulnar neuritis 2-12% Heterotopic ossi

18、fication 2-13%,Complications,Macko 1 infection 2 loss off reduction Danzinger OTA 62% of 34 with complications,Tension Band Wire - Backing Out,K-wires deep to bone Tension band wire deep to triceps,Radial Head Fractures,Function of the Radial Head,Controversial - in the absence of other injuries, ra

19、dial head excision does not seem to compromise elbow function. Two potential roles of the radial head: Resist valgus forces Transfer of load from wrist to radiocapitellar joint during gripping activities.,Valgus Elbow Stability,The radial head is a secondary restraint to valgus forces, and seems to

20、function by shifting the center of varus-valgus rotation laterally, so that the moment arm and forces on the medial ligaments are smaller. Clinically, the radial head is most important when there is injury to both the ligamentous and muscle-tendon units about the elbow.,Longitudinal Stability,The ra

21、dial head acts in concert with the interosseous ligament of the forearm to provide longitudinal stability. Proximal migration of the radius can occur after radial head excision.,Clinical Implications,Radial head preservation is necessary when there is valgus instability associated with elbow disloca

22、tion, or when there is longitudinal instability if the forearm due to interosseous ligament injury. Options are internal fixation versus radial head excision and prosthetic replacement.,Mechanism of Injury,Usually occurs in a fall. Axial load to the elbow with combined valgus force.,Evaluation,Neuro

23、vascular Evaluated elbow stability, especially to valgus stress (assess at both 30 and 90 degrees flexion with forearm pronated) Evaluate distal radio-ulnar joint stability Measure forearm rotation. Pain and crepitus over radial neck/head,Imaging,AP View,Lateral View,Oblique View,Other Imaging Techn

24、iques,MRI and ultrasound helpful, especially in the skeletally immature patient.,Modified Mason Classification,Type I: nondisplaced No block to forearm rotation, displacement 2mm Type II: displaced Internal fixation possible Type III: displaced, severely comminuted Judged to be irreparable Usually r

25、equires excision to allow elbow movement,Hotchkiss R, JAAOS 5:1, 1997,Treatment Recommendations,Isolated Radial Head/Neck Fracture,Minimally displaced: start early ROM Displaced: perform excision of the radial head.,Photo: David Lhowe, M.D.,Outcomes after Excision are Controversial,There are recent

26、papers reporting long-term outcomes after radial head excision that give conflicting results:,Resection of the radial head after Mason type-III fractures ,21 patients reviewed after 16-30 years 17 of 21 (81%) excellent results. Only 1 fair result.,Ikeda and Oka, Acta Orthop Scand 71:191, 2000,Functi

27、on after early radial head excision for fracture ,15 patients reviewed after mean 10 year follow-up (range 3-18 years) All patients had reduced power and and 67% had pain.,Ikeda and Oka, Acta Orthop Scand 71:191, 2000,Results of acute excision of the radial head in fracture dislocations,10 cases Fol

28、low-up 4.6 years Results: 4 excellent, 5 good, 1 fair Degenerative changes present in 8 of 10 Although early results satisfactory, the incidence of degenerative changes worrisome.,Sanchez-Sotelo J et al., J Orthop Trauma 14:354, 2000,Acute Instability with Posterior Elbow Dislocation,Restoration of

29、radial head function required. Internal fixation should be performed when possible, along with repair of the lateral ligaments. If repair is not possible, prosthetic replacement with a metallic spacer should be considered.,Injury to Interosseous Ligament,Perform repair of radial head and/or neck. Ma

30、y protect with an external fixator if needed during healing.,Surgical Techniques,Lateral incision Deep dissection anterior to the posterolateral ligaments. Expose anterior surface of lateral epicondyle, expose joint by elevating capsule. Expose radial neck by carefully elevating the supinator muscle

31、 with the arm pronated to protect the posterior interosseous nerve.,Internal Fixation,3 steps: Repair radial head Secure radial head to the radial neck Avoid impingement of plates during forearm rotation.,Photos: David Lhowe, M.D.,Radial Head Fixation - Safe Zone,From Hotchkiss R, JAAOS 5:1, 1997,Ra

32、dial Head Fixation,Small Kirschner wires used provisionally. Use “mini-fragment” screws (1.5 to 2.7 mm). Secure radial head to neck with 2.0 or 2.7 L-shaped plates or mini blade plates Remember the “Safe Zone” = arc of 100 degrees centered on the equator of the neutrally rotated forearm. Check forea

33、rm rotation intraoperatively.,Complications,Primarily related to improperly placed hardware or loss of fixation. Late excision of the radial head may be necessary after other soft tissues have healed. Posterior interosseous nerve injury - treat with radial nerve splint. Elbow stiffness - loss of extension common. Best treatment is avoidance by allowing early exercise.,Outcomes,“Surgical management of radial head fractures”, Parasa and Maffulli, J R Coll Surg Edin 46:76, 2001 Retrospective study of 29 patients Best