肘关节骨折英文版.ppt

Management of Adult Elbow FractureDislocations,The Second Affiliated Hospital of Bengbu Medical College,ZHONG CHUAN-ZHANG,Adult elbow fracture dislocations present a significant challenge to the treating surgeon and are associated with,a high complication rate,.An important goal of treatment is to preserve or restore functional use of the elbow.,Dislocations of the elbow may be simple orcomplex,with simple dislocations representing a,purely soft tissue injury,of the elbow resulting inthe dislocation.,Complex dislocations are associated with a combination of fractures and soft tissue injuries,and for this reason may also be termed,fracture dislocations,.,The most commonly used classification for,radial head fractures,was initially described by,Mason in 1954,further modified,by Broberg and Morrey in 1987,and finally Hotchkiss in 1997.,Although the full details of the modified Mason classification are presented in Table 1,generally,type 1 represents nondisplaced fractures,type 2 is a displaced(2 mm)fractures,and type 3 is reserved for severely comminuted radial head fractures.,Coronoid fractures,are described using the,Regan and Morrey classification,where type 1 involves the tip of the coronoid process,type 2 is a fracture of less than 50%of the coronoid height,and type 3 fractures include greater than 50%ofthe coronoid.,Olecranon fractures,are most commonly classified with the Schatzker,Mayo,or AO classification system.,The,Schatzker classification,describes the pattern and location(intra/extraarticular)and is organized by mechanicalconstruct needed for fixation.,The,Mayo classification,simplifies the fracture pattern into type 1 nondisplaced stable fractures,type 2 displaced stable fractures,and unstable type 3 fractures,which are commonly comminuted.,Posterior elbow dislocation.(A)Lateral and(B)AP views of a posteriorly dislocated elbow.Visualization and assessment of small periarticular fractures is difficult on plain film imaging;however,CT images,clearly demonstrate fractures of the(C)coronoid and(D)lateral epicondyle.,Radial head fractures:,posterior elbow dislocations with associated isolated fracture of the radial head are rare injuries and,a relative indication for surgical fixation,.These injuries can be managed in,a long arm cast,although conservative management may be associated with,joint arthrosis and blocks to forearm rotation.,When operative fixation is chosen,open reduction and internal fixation,or,acute radial head replacement,are recommendedbecause radial head excision in the presence of a traumatic elbow dislocation is contraindicated due to the risk of,proximal migration,.,Elbow dislocation with a radial head fracture and a concomitant coronoid fracture(Fig.3)is nearly always an,indication for surgery.,Postoperative(F)lateral and(G)posteroanterior radiographsshowing radial head replacement and,suture anchors,at the LUCL origin maintaining a stable reduction.The coronoid was fixed with a suture lasso placed through the capsular attachments and,tied at the base of the ulna through 2 drill holes.,Coronoid fracture:,elbow dislocation with isolated fracture of the coronoid is rare and surgical intervention is,to some extent,based on the,size and location of the coronoid fragment,.Some investigators conservatively manage isolated fractures involving less than 10%of the coronoid height with a long arm cast.Surgical fixation is indicated for elbow dislocations withfractures greater than 10%of coronoid height as well as the well-known,terrible triad injury of simultaneous elbow dislocation with coronoid and radial head fractures,(Fig.3).,Olecranon fracture,:,anterior transolecranon fracture,dislocation necessitates operative intervention.The ulnar articular surface must be,anatomically restored,and any associated injuries to the coronoid,distal humerus,or radial head addressed at the time of fixation.,Unlike a Monteggia fracture dislocation,the,proximal,radioulnar joint,is not compromised with these injuries(Fig.4).,Postoperative radiograph demonstrate fixation of the olecranon with a proximal ulna plate,LUCL repair with,suture anchors,and MUCLrepair of bony avulsion with a,screw,and washer and fixation of the coronoid.,Preoperative neurologic deficits must be carefully noted.,All dislocations should be,reduced and splinted,at 90 until operative intervention.,Preoperative Planning,Patient Positioning,The posterolateral(Kocher)approach,The posterolateral(Kocher)approach occurs between the,extensor carpi ulnaris(ECU),and the,anconeus,which provides direct access to the joint capsule;however,there is increased risk of injury to the,LUCL,.,Direct lateral(Kaplan)approach,Regardless of the interval chosen,dissection should be carried out with the elbow in pronation to reduce risk of injury to the,posterior interosseous nerve,(PIN).,The Hotchkiss over-the-top approach,Also shown is the planned medial c(solid line)and the course of the ulnar nerve(dotted line).FCR,flexor carpi radialis;PL,palmaris longus;PT,pronator teres,Surgical Procedure,Most commonly,the injuries are addressed in an inside-out fashion,addressing any injury to the,coronoid first,then progressing to the radial head,olecranon,lateral,soft tissues,and finally the,medial,soft tissue structures.,Coronoid,Suture fixation of the olecranon.Suture fixation of coronoid fracture through 2 drill holes created at the ulnar border with suture capturing the coronoid fragment through its soft tissue attachments.,Types 2 and 3 fractures often require a,medialsided approach,because they are commonly fixed with formal open reduction and internal fixation.,The screw should be placed in the,posterior to anterior,direction to achieve greater fixation strength and to reduce the risk of injury to,anterior neurovascular structures,.,Radial head,and neck,Fracture extension into the neck that necessitates more proximal dissection should prompt identification and isolation of the,PIN,to,avoid iatrogenic injury,.If a few large fragments exist and bone is healthy enough to achieve secure fixation,headless compression screws,may be used.,Fracture extension into the neck is treated with a buttress plate,again placed in the,safe zone,of the proximal radius to avoid impingement(Fig.14).It is important to restore,anatomic alignment and lengthto avoid future instability.,Lateral soft tissues,Posterior fracture dislocations of the elbow invariably have some degree of soft tissue damage to the lateral elbow and are the,most common cause of injury to the LCL,.Due to the critical role of the LCL as the primary lateral,elbow stabilizer,soft tissue repair is mandatory at the time of surgery because failure to address this injury is a,significant cause for recurrent instability,.,Surgical repair with,suture anchors or bone tunnels placed,at the origin of the LCL at the bare areaon the epicondyle.The LCL may be reapproximated with its neighboring capsule,fascia,andmuscular structures.Some investigators advocate repair with the elbow in,supination,to,prevent overtensioning,of the ligament complex.,Complications,Heterotopic ossification,Recurrent joint instability,Ulnar neuropathy,Elbow stiffness/contractures,Posttraumatic osteoarthritis,Summary,The authors begin with,evaluation,of the coronoid,followed by the radial head,lateral soft tissues,and finally the medial soft tissue structures.,If,instability,persists after addressing the coronoid and lateral structures,the authors commonly apply,a hinged elbow-spanning external fixator,for 4 to 6 weeks.,Thanks for attention,