Standard surgical protocol to treat elbow dislocations with radial head and coronoid fractures. Surgical technique.

BACKGROUND: The results of elbow dislocations with associated radial head and coronoid fractures are often poor because of recurrent instability and stiffness from prolonged immobilization. We managed these injuries with a standard surgical protocol, postulating that early intervention, stable fixation, and repair would provide sufficient stability to allow motion at seven to ten days postoperatively and enhance functional outcome. METHODS: We retrospectively reviewed the results of this treatment performed, at two university-affiliated teaching hospitals, in thirty-six consecutive patients (thirty-six elbows) with an elbow dislocation and an associated fracture of both the radial head and the coronoid process. Our surgical protocol included fixation or replacement of the radial head, fixation of the coronoid fracture if possible, repair of associated capsular and lateral ligamentous injuries, and in selected cases repair of the medial collateral ligament and/or adjuvant-hinged external fixation. Patients were evaluated both radiographically and with a clinical examination at the time of the latest follow-up. RESULTS: At a mean of thirty-four months postoperatively, the flexion-extension arc of the elbow averaged 112 degrees +/- 11 degrees and forearm rotation averaged 136 degrees +/- 16 degrees . The mean Mayo Elbow Performance Score was 88 points (range, 45 to 100 points), which corresponded to fifteen excellent results, thirteen good results, seven fair results, and one poor result. Concentric stability was restored to thirty-four elbows. Eight patients had complications requiring a reoperation: two had a synostosis; one, recurrent instability; four, hardware removal and elbow release; and one, a wound infection. CONCLUSIONS: Use of our surgical protocol for elbow dislocations with associated radial head and coronoid fractures restored sufficient elbow stability to allow early motion postoperatively, enhancing the functional outcome. We recommend early operative repair with a standard protocol for these injuries.

Effect of humeral condylar resection on strength and functional outcome after semiconstrained total elbow arthroplasty.

BACKGROUND: Under certain conditions it is standard practice to excise ununited humeral condyles during insertion of a semiconstrained total elbow prosthesis. Since the osseous origins of the common extensors and flexor-pronator muscles are lost, it has been postulated that this excision has a negative effect on strength. We are not aware of any previous study in which this issue has been investigated with use of standardized, objective testing of muscle strength. METHODS: We used objective testing to determine the effect of condylar resection on the muscle strength of the elbow, forearm, wrist, and hand in thirty-two patients who had undergone total elbow arthroplasty. To eliminate bias, the normal, contralateral limb served as the control, and all strength values are given as a percentage of the normal side. The humeral condyles were intact in sixteen patients and had been resected in the other sixteen. Patient demographics were similar in the two groups. RESULTS: There were no significant differences between the two groups with regard to strength of pronation (103% of the normal side in the group with intact condyles compared with 89% in the group with resection of the condyles; p = 0.40), supination (68% compared with 89%; p = 0.49), wrist flexion (66% compared with 56%; p = 0.46), wrist extension (75% compared with 65%; p = 0.40), or grip strength (83% compared with 72%; p = 0.40). There was also no difference between the two groups with regard to the Mayo Elbow Performance Score (79 points in the group with intact condyles compared with 77 points in the group with resection of the condyles; p = 0.67). CONCLUSIONS: Condylar resection has a minimal, clinically irrelevant effect on forearm, wrist, and hand strength and no effect on the Mayo Elbow Performance Score following total elbow arthroplasty. Thus, the findings of our study support the practice of condylar resection, which simplifies total elbow arthroplasty for many conditions.

Standard surgical protocol to treat elbow dislocations with radial head and coronoid fractures.

BACKGROUND: The results of elbow dislocations with associated radial head and coronoid fractures are often poor because of recurrent instability and stiffness from prolonged immobilization. We managed these injuries with a standard surgical protocol, postulating that early intervention, stable fixation, and repair would provide sufficient stability to allow motion at seven to ten days postoperatively and enhance functional outcome. METHODS: We retrospectively reviewed the results of this treatment performed, at two university-affiliated teaching hospitals, in thirty-six consecutive patients (thirty-six elbows) with an elbow dislocation and an associated fracture of both the radial head and the coronoid process. Our surgical protocol included fixation or replacement of the radial head, fixation of the coronoid fracture if possible, repair of associated capsular and lateral ligamentous injuries, and in selected cases repair of the medial collateral ligament and/or adjuvant hinged external fixation. Patients were evaluated both radiographically and with a clinical examination at the time of the latest follow-up. RESULTS: At a mean of thirty-four months postoperatively, the flexion-extension arc of the elbow averaged 112 degrees +/- 11 degrees and forearm rotation averaged 136 degrees +/- 16 degrees. The mean Mayo Elbow Performance Score was 88 points (range, 45 to 100 points), which corresponded to fifteen excellent results, thirteen good results, seven fair results, and one poor result. Concentric stability was restored to thirty-four elbows. Eight patients had complications requiring a reoperation: two had a synostosis; one, recurrent instability; four, hardware removal and elbow release; and one, a wound infection. CONCLUSIONS: Use of our surgical protocol for elbow dislocations with associated radial head and coronoid fractures restored sufficient elbow stability to allow early motion postoperatively, enhancing the functional outcome. We recommend early operative repair with a standard protocol for these injuries.

Advances in the management of humeral nonunion.

Approximately 10% of all long-bone fractures occur in the humerus. Although primary treatment usually is successful, humeral nonunion can lead to marked morbidity and functional limitation. Complications include joint contractures of the shoulder and elbow, especially with periarticular pseudarthrosis. Marked osteopenia or bone loss, or both, often occur after fracture and after failure to achieve union. Retained implants often break, impeding fixation and requiring removal. Soft-tissue deficits and incisions from the original injury or prior surgeries also may complicate reconstruction, as can intra-articular fractures and associated nerve palsies. Successful surgical management of humeral nonunion requires stable internal fixation that allows early joint motion and uses autogenous bone graft to promote healing. Contracture release and early joint motion are necessary to optimize function. Shoulder hemiarthroplasty and semiconstrained total elbow arthroplasty are viable options for irreversible joint damage. Advances in preoperative evaluation and surgical reconstruction have improved functional outcomes.