Handout Cover Sheet

Session Letter/Number: 430

Session Title: Elbow Trauma Gone Bad
Session Type: ICL 2-Hour
Location: Room 31C
Session Date & Time: Friday, March 17, 2017, 11:00 AM - 12:30 PM

INSTRUCTORS WHO CONTRIBUTED TO THIS HANDOUT:

Moderator:
Emilie V. Cheung, MD
Faculty:
April D. Armstrong, MD
Robert Z. Tashjian, MD

The Academy reserves any and all of its rights to materials presented at the Annual
Meeting. Reproductions of any kind, by any person or entity, without prior written permission
from the Academy are strictly prohibited.
 ICL 430: Elbow Trauma Gone Bad

AAOS 2017 San Diego

Friday,  March  17,  2017

Objectives:

1. Become familiar with instability patterns, (posterolateral rotatory instability and

posteromedial varus instability) associated with elbow trauma
2. How to best prevent and treat soft tissue complications such as wound healing, nerve
injury, and posttraumatic elbow stiffness
3. How to salvage failed elbow fixation with current non-arthroplasty and arthroplasty
options

Description:

Complications ensuing from elbow trauma can be challenging to manage. We will discuss
current understanding on recognizing and treating instability patterns. Critical concepts
regarding soft tissue complications such as stiffness, wound healing, nerve injury, revision ORIF,
arthroplasty, with an emphasis on case-based discussions.

Outline

I. Introduction- Emilie Cheung

II. Missed instability patterns in the elbow, how to recognize and treat—
Robert Tashjian (20 minutes)
a. Posterolateral rotatory instability- the most common pattern of elbow instability
b. Posteromedial instability- associated with anteromedial facet of coronoid
c. Missed instability
i. Salvage: bony reconstruction, ligamentous, external fixation

III. Non-arthroplasty options- Salvage of Nonunion/Malunions: (Coronoid, Distal

humerus, Radial head, Olecranon )------
(20 minutes)
a. Arthroscopic
b. Interposition arthroplasty
c. Revision ORIF of malunions/nonunions
 IV. How do we address the stiff elbow and soft tissue concerns-- April Armstrong (20
minutes)
a. Review pertinent ligamentous and neurovascular anatomy
b. Lateral column approach
c. Medial approaches: Hotchkiss, FCU split, the posterior bundle of MCL
d. Combined approaches
e. H.O. resection techniques and pearls

Q&A 10 minutes

V. Arthroplasty options
Emilie Cheung (20 minutes)
a. Total elbow arthroplasty
i. Track record
b. Radial capitellar arthroplasty
c. Distal humeral hemiarthroplasty

VI. Soft tissue concerns-

a. Wound complications- prevention and treatment
b. Ulnar nerve- what’s the latest
c. Vascular and nerve anatomy review

Q&A, and Case presentations, diasters. Emilie Cheung MD (15 minutes)

 
 1

Elbow Trauma Gone Bad - ICL AAOS 2017

STIFF ELBOW AFTER TRAUMA

April Armstrong, MD, FRCSC

Why does the elbow lose motion?

1. Elbow has high degree of congruity and complexity of the articular
joint
2. The sensitivity of the tissue, particularly the capsule, to trauma
• Dr Morrey, 2005

Things to consider when dealing with a stiff elbow joint after trauma:

RULE OUT INFECTION!!

The motion
• Measure with a goniometer
• Pain at rest is concerning for infection
• Motion through the arc is typically not painful, if it is painful
then consider articular joint involvement and the patient may
not respond as well to the surgical release if they continue to
have pain and may need to consider an interposition (provided
ligaments are intact)
• May have pain at the extremes of motion where there is bony
impingement
• Elbow flexion contracture less than 100/110 degrees – need to deal
with the ulnar nerve
• Is it a hard or soft endfeel ie, kissing bone lesions or capsular
contracture
• Do they have motor function to move the elbow after it is released?
Any spasticity issues or pathologic increased muscle tone?
• Functional arc of motion is 30 – 130 degrees, 50 degrees
pronation/supination but can be individualized based on the patients
needs
The joint
• It is reduced/congruent?
• Is there any articular malunion?
• Bone likes to sit in 3 fossae
1. radial fossa
2. coronoid fossa
3. olecranon fossa
• The coronoid and olecranon tips have osteophytes that extend
medially and laterally and can impinge along the columns of the
coronoid and olecranon fossae
 2

• The olecranon fossa is oval and not circular

• Not uncommon to have articular adhesions so be careful if
manipulating since you can injure the cartilage
The soft tissues
• Any lacerations or other injury to tendon or muscle bellies?
• Burned skin does not stretch very well and so get help from your
plastics colleagues
• Is the elbow quiet?
• Were the medial or lateral collateral ligaments involved at index
injury?
• Was the lateral collateral ligament repaired?
• Was the LCL repaired to its anatomic insertion – if not then it can
restrict motion depending on where it was repaired
• You should preserve the anterior bundle of the MCL and the lateral
ulnar collateral ligament to maintain stability
• Loss of flexion needs posterior capsule released, loss of extension
needs anterior capsule released
• The posterior bundle of the MCL restricts flexion range of motion and
needs to be released
• Is the elbow contracted in extension?
• You can have problems with posterior soft tissue tension when
flexing elbow after motion restored
Heterotopic bone
• Is it restricting motion?
• In post-traumatic elbow it can be anywhere and don’t miss the bone
in the medial and lateral elbow gutters along the ulnohumeral joint
• CT scan is very helpful to map out the HO pattern and 3D
reconstructions can help but sometimes not as helpful as 2D imaging
• Did the patient have a head injury – you may want to discuss with the
neurosurgical colleagues about recovery period and may have
difficulty with compliance with therapy
• Prophylaxis – NSAIDS/radiation?
The ulnar nerve
• Can be encased in HO bone – kerrison punch very helpful
• I typically transpose subcutaneously since it is usually scarred to the
cubital tunnel and I need to move it to release the posterior bundle of
the MCL
The radial nerve
• Lies anterolateral on the capsule, capsule is closer to the joint since
you loose joint volume with a contracture
The median nerve
• Protected by the brachialis
 3

Treatment options

• Arthroscopy
• If soft tissue contracture only, minimal bone
involvement, flexion ROM >110 degrees
• Open release
• Medial, lateral, combined
• Arthroplasty
• Interposition, joint replacement

Surgery Decision Tree (Non-articular contractures)

Soft tissue contracture only

Flexion >110 °
Yes

Arthroscopic Release or No
Lateral incision with
lateral column approach

Open Release

Soft tissue contracture only Soft tissue and bone involved Soft tissue and bone involved
Flexion < 110 ° Flexion > 110° Flexion < 110 °

Posterior midline incision
Medial approach
Ulnar nerve transposition
Release of posterior MCL
Lateral or posterior midline incision Posterior midline incision
Lateral column approach Medial approach
Ulnar nerve transposition
Release of Posterior MCL
Medial approach
if needed
Lateral column
approach if needed
 4

My Core Steps for open contracture release

• Posterior midline incision (used most often – allows medial or lateral

approach, you don’t have to elevate to one side if not needed)
• Ulnar nerve transposition and release of posterior MCL if flexion
<110°
• Preserve anterior bundle of MCL and Lateral ulnar collateral ligament
• Anterior release
o Anterior capsule release/excision
o Elevate brachialis off humerus
o Bony work – coronoid fossa, radial fossa, coronoid tip
extending medially and laterally
o Check that have soft endfeel with flexion and that radial head
and coronoid tip no longer impinge in the fossae
• Posterior release
o Posterior capsular release/excision
o Bony work – olecranon fossa, tip of olecranon extending
medially and laterally
o Follow medial and lateral gutters of the ulnohumeral joint –
these can be filled with HO bone and even though the bone
may not seem like a lot it can really be restrictive, axial views
of the CT scan I have found are very useful

Radioulnar Synostosis
• Need advanced imaging to understand reason
• Rehabilitation is more challenging

Rehabilitation
• Anterior splint with arm in extension
– Hang overnight
– Edema control
– Protects posterior wound
– Extension is hardest to keep
• Continuous regional block
– Full AAROM POD #1 – patient driven every hour on the hour, others
have used CPM but I have not been doing this
– Wean off block during POD#1
• Splints
– Night time extension splint
– Cuff and collar or simple sling during day if needed or nothing

Tips and Pearls for HO excision

• HO can be anywhere
o CT scan helps in post-traumatic cases
• Cob to elevated soft tissues
 5

o Find HO and native bone plane

o Osteotome in the plane
• Kerrison rongeur from spine set to unroof the bone from ulnar nerve
• Try to remove as a ‘block’ of bone
• If joint is otherwise normal patient has potential to do well!

Other pearls

• Results not as good

– Articular involvement from injury
– ? Bony malalignment
• Hardware out last!!

References

1. Streubel PN, Cohen MS.Open surgical release for contractures of the elbow.J Am
Acad Orthop Surg. 2015 Jun;23(6):328-38.
2. Koh KH, Lim TK, Lee HI, Park MJ.Surgical release of elbow stiffness after internal
fixation of intercondylar fracture of the distal humerus.J Shoulder Elbow Surg. 2013
Feb;22(2):268-74.
3. Charalambous CP, Morrey BF.Posttraumatic elbow stiffness.
J Bone Joint Surg Am. 2012 Aug 1;94(15):1428-37.
4. Williams BG, Sotereanos DG, Baratz ME, Jarrett CD, Venouziou AI, Miller MC.The
contracted elbow: is ulnar nerve release necessary?J Shoulder Elbow Surg. 2012
Dec;21(12):1632-6.
5. Lindenhovius AL, van de Luijtgaarden K, Ring D, Jupiter J.
Open elbow contracture release: postoperative management with and without
continuous passive motion.J Hand Surg Am. 2009 May-Jun;34(5):858-65.
6. Lindenhovius AL, Linzel DS, Doornberg JN, Ring DC, Jupiter JB.
Comparison of elbow contracture release in elbows with and without heterotopic
ossification restricting motion.J Shoulder Elbow Surg. 2007 Sep-Oct;16(5):621-5.
7. Ring D, Adey L, Zurakowski D, Jupiter JB.Elbow capsulectomy for posttraumatic
elbow stiffness. J Hand Surg Am. 2006 Oct;31(8):1264-71.
8. Tan V, Daluiski A, Simic P, Hotchkiss RN.Outcome of open release for post-
traumatic elbow stiffness.J Trauma. 2006 Sep;61(3):673-8.
10. Dávila SA, Johnston-Jones K.Mana ging the stiff elbow: operative, nonoperative,
and postoperative techniques.J Hand Ther. 2006 Apr-Jun;19(2):268-81. Review.
11. Jupiter JB, O'Driscoll SW, Cohen MS.The assessment and management of the stiff
elbow.Instr Course Lect. 2003;52:93-111. Review.
Missed instability patterns in the elbow, how to recognize and treat: PLRI, PMRI,
Missed dislocations with ligament and bone defects
ICL – Elbow Trauma Gone Bad

Robert Z. Tashjian, MD
Associate Professor, Department of Orthopaedics
University of Utah School of Medicine

Posterolateral Rotatory Instability (PLRI)

I. Background
o Condition where radial head AND ulna rotate externally on the distal humerus leading to
posterior displacement and subluxation of the radial head relative to the capitellum
o Radius and ulna move as a unit since proximal radioulnar joint remains intact
o First described by O’Driscoll in 1991 (O’Driscoll et al. JBJS 1991)
o Overall incidence is rare yet considered most common form of chronic elbow instability
o Instability typically occurs from an elbow dislocation with failure to heal of the lateral
ligamentous structures. May be secondary to other mechanisms of LCL injury.
o Typically complaints of clicking, mechanical symptoms, instability
o Lateral ulnar collateral ligament (LUCL) insufficiency considered primary etiology
although now most recognize that secondary stabilizer insufficiency is also required to
result in PLRI
o Treatment includes nonoperative (avoidance, bracing) although with limited success;
Surgical reconstruction of LUCL preferred with multiple techniques described
o Outcomes are reproducible and durable to prevent instability
II. Anatomy
-Primary restraints to PLRI are the lateral ligament complex, the radial head and coronoid
process and the lateral extensor musculature
a. Lateral ligament complex
1. Primary restraint of PLRI – prevents external rotation of radius and ulna relative to
humerus (O’Driscoll JBJS Am 1991).
2. Components –
• Annular ligament – anterior margin of sigmoid notch to supinator crest
• Radial collateral ligament – lateral epicondyle to annaular ligament
• Lateral Ulnar Collateral Ligament – lateral epicondyle to supinator crest
(originally described as primary ligament component to restrain PLRI).
Original anatomic description by Morrey et al. Clin Orthop Rel Res 1985.
3. Anatomically appears to be a continuous ligamentous sheet (Imantani et al J Shoulder
Elbow Surg 1999)
• Isolated sectioning of LUCL ligament alone will not lead to PLRI –
requires 2 of 3 components of LCL complex to be injured to result in
PLRI (Dunning et al JBJS Am 2001)
• Arthroscopic sectioning study showed that both the radial collateral and
LUCL need to be cut to cause significant PLRI; full PLRI instability only
when muscle cut as well (McAdams J Shoulder Elbow Surg 2005)
4. Isometry
 Radial collateral ligament is isometric; LUCL is not; LUCL is loose in extension
and tight in flexion; LUCL is most isometric 2 mm anterior to lateral epicondyle.
(Moritomo et al JBJS 2007)

5. Injury may occur due to trauma (dislocation), chronic attenuation or iatrogenic causes
• Trauma – dislocations cause disruption of the LUCL in all cases
(Josefsson 1987); typically will heal – failure to heal may lead to chronic
instability
o Most common injury of LCL complex is avulsion off the lateral
epicondyle (52%) followed by midsubstance rupture (29%) in
series of patients with simple or complex dislocations. (McKee
et al. J Shoulder Elbow Surg 2003)
o May occur with radial head excision in cases of trauma (Hall et
al JBJS Am 2005)
• Chronic attenuation –
o Long-standing cubitus varus (O’Driscoll JBJS AM 2001, Beuerlin
JBJS Am 2004); longstanding overuse; generalized hyperlaxity
• Iatrogenic -
o Lateral epicondylitis release (open or scope)(Kalainov JBJS
2005); open approaches to lateral elbow and radial head; serial
steroid injections
b. Radial head, capitellum and coronoid –
1. Radial Head – Provides osseous congruency with capitellum and tightens LCL complex
Improving stability
• Jensen et al J Shoulder Elbow 2005 – Biomechanically showed increased
varus and external rotatory laxity after isolated excision of radial head
• Deutch et al. J Shoulder Elbow Surg 2003 – radial head excision resulted
in 45% increase in pathologic forearm external rotation with intact
ligaments
• Schneeberger AG et al. JBJS 2004 – Excision of radial head with intact
ligaments increased posterolateral rotatory laxity which was restored
with radial replacement
• Hall et al JBJS 2005 – Clinical series of PLRI in patients after radial head
resection
2. Capitellum –
• Loss of height would lead to slackening of LCL and possible PLRI
• Sabo et al. J Shoulder Elbow Surg 2011 – Biomechanical study showing
capitellum excision leads to increased ulnar external rotation which is
corrected with replacement
3. Coronoid process –
• May play additive role with radial head in PLRI stabilization
• Schneeberger AG et al. JBJS 2004 – 30% coronoid resection plus radial
head resection led to dislocation of elbow where radial head resection
alone led to increased posterolateral rotatory laxity alone without
dislocation; Elbow stability restored with radial head replacement
although elbows lacking > 50% of coronoid could not restore elbow
stability with radial head replacement alone despite intact ligaments
 •Deutch et al J Shoulder Elbow Surg 2003 – 50% coronoid resection
increased pathologic forearm rotation 28%
• Okazaki et al. J Hand Surg Am 2007 – 3 patient case report of
insufficient coronoid process after fx leading to PLRI
c. Common extensor origin
1. Important static secondary stabilizers crossing the lateral elbow
2. Possible dynamic stabilizers
3. Extensor disruption commonly occurs with dislocations or fracture-dislocations;
Occurred in 66% of cases. (McKee et al. J Shoulder Elbow Surg 2003)
4. May be violated as part of surgical approach and may lead to instability if not fully
repaired or reattached
5. Cohen et al. JBJS 1997 – sectioning studies provide evidence that extensor muscle
origins provide stability through fascial bands and intermuscular septa

III. Clinical Presentation

• Diagnosis primarily made based upon history and physical examination with only
utilizing imaging as supplemental
a. Presentation and History
a. Injury Mechanism
i. Typically full elbow dislocation in past or surgical treatment on the lateral
side of the elbow
b. Symptoms
i. Lateral elbow pain
ii. Mechanical symptoms – lateral clicking, popping, snapping
iii. Aggravated by activities including pushing up from a chair with the axial
loading of the externally rotated forearm with a valgus moment

IV. Physical Examination

a. Prior skin incisions of lateral elbow exposures should be identified; Identify generalized
hyperlaxity
b. Range of motion and stability
a. Typically full range of motion or can have slight contracture due to long-term pain
limitations; Varus/valgus stress testing may show slight varus laxity but often normal
c. Special Testing
a. Goals of testing to place elbow in position of maximal instability with forearm
external rotation, axial and valgus loading and elbow extension
i. Attempt to reproduce symptoms of instability
b. Specific Test
i. Pivot Shift Test (O’Driscoll JBJS Am 1991)– patient supine, limb overhead;
with forearm supinated, valgus and axial loading applied the elbow is flexed
from full extension – at 40 degrees the dislocated/subluxed radial head
reduces with clunk; can start in flexed position and extend as well; often
requires general anesthetic
ii. Posterolateral rotatory drawer test (O’Driscoll JBJS Am 2000) - Patient
supine, arm overhead; elbow flexed 30 degrees; AP force applied to forearm
in external rotation; Aim is to sublux the forearm away from humerus on
lateral side pivoting on MCL; Analogous to Lachman test for ACL injury of
knee
 iii. Table-top relocation test (Regan et al J Shoulder Elbow Surg 2006) (Arvind et
al J Shoulder Elbow Surg 2006) Patient performs press-up on table edge
using one arm with forearm in supination; apprehension at 40 degrees of
flexion starting at full flexion; repeated with thumb pressure over radial
head and positive if pressure on radial head relieves apprehension.
iv. Chair sign (Regan et al. J Shoulder Elbow Surg 2006) – Patient seated with
elbows flexed to 90 degrees, forearms supinated and arms abducted;
patient tries to rise from chair pushing up with arms; positive if
apprehension or radial head dislocation occurs with elbow extension.
V. Imaging
a. Plain radiographs
• Avulsion fracture of origins or insertion of LCL
• Presence of injury to radial head, capitellum, coronoid process
o Impression fractures on the posterior aspect of capitellum
• Drop sign (Coonrad RW et al. J Shoulder Elbow Surg 2005)– widening of
ulnohumeral joint on lateral film greater than 4 mm of unstressed elbow
c. MRI
• Controversial reliability of MRI to document LCL injury
o Terada et al. J Shoulder Elbow Surg 2004 – 20 normal asymptomatic
elbows; 50% able to identify LUCL; 50% ambiguous; MRI poor to be
able to detect even normal LUCL
o Potter et al. Radiology 1997 – 100% sensitive to detect injured LUCL
o Carrino et al. Radiology 2001 – Able to diagnose 38% to 88% of
injured LUCL in cadavers
VI. Surgical Treatment
• Options include repair of LCL complex, re-tensioning the ligaments or
reconstruction
• Nonoperative management has a limited role to bracing and activity
modification. Typically patients that need to put their elbow in a position at
risk will have symptoms
a. Osseous deformity correction –
a. Radial head replacement and coronoid reconstruction will be required if significant
defects are present.
b. In cubitus varus, distal humeral osteotomy will often be required to correct
instability. Osteotomy alone may result in a stable elbow with LCL reefing or
transfer medial tricep tendon. Osteotomy with LUCL reconstruction can also be
performed to increase reliability of stable elbow. Reconstruction alone has been
described but may result in recurrent instability with graft failure. (O’Driscoll JBJS
AM 2001, Beuerlin JBJS Am 2004)
b. Ligament Repair
a. In the setting of acute dislocations that remain persistently unstable then may
consider this an option; reasonable option out to about 6 weeks post injury
c. Ligament Re-tensioning
a. Limited data – Arthrscopic re-tensioning has been described with reasonable results
but a treatment option only for extremely experienced elbow arthroscopists (Savoie
FH et al. Hand Clin 2009;25:323—9)
d. Ligament Reconstruction
a. Mainstay of surgical reconstruction for chronic PLRI
b. Graft choices varied – allograft and autograft; Palmaris, plantaris, Achilles, Triceps
tendon, semitendinosus or gracilis
c. Alternative reconstruction options – Split anconeus fascia transfer (Chebli CA,
Murthi AM. Murthi AM. Open ASES Meeting, Chicago, March 2006)
d. Distal graft fixation for reconstruction – typically 2 holes; suture anchors also
described
e. Proximal graft fixation for reconstruction - 3 tunnel technique (Nestor et al JBJS Am
1992); 1 tunnel docking technique (Jones et al J Shoulder Elbow Surg 2011)
f. Tensioning techniques – Yoke; docking, anterior reefing
g. Single strand reconstruction restores varus and posterolateral rotatory stability with
ulnar tunnel placed either distally at the supinator crest at the radial head/neck
junction or proximally at the proximal aspect of the sigmoid notch. (King GJW et al.
J Shoulder Elbow Surg 2002)
h. Surgical Technique of LUCL reconstruction utilizing a tendon graft
i. Split semitendinosus allograft my preferred graft; Mayo clinic staff now uses
allograft plantaris
ii. Long lateral incision over Kocher’s interval extending 5- 6 cm proximal to
lateral epicondyle and 5 to 6 cm distal; just posterior to lateral epicondyle
to avoid cutaneous nerves;
iii. Develop Kocher’s interval distal to lateral epicondyle retracting anconeus
posteriorly to expose entire proximal lateral ulnar shaft including supinator
crest; reflect ECU anteriorly off lateral epicondyle exposing lateral capsule
and attenuated ligaments from the midline of radial head posteriorly
iv. Incise radiohumeral capsule slightly anteriorly so this can be reefed
anteriorly at the completion of the case; allows visualization of joint
v. Identify supinator crest – place one 3 mm burr hole in the ulna at the radial
head/neck junction just posterior to the supinator crest and then a second
ulna tunnel 1.25 cm proximal and posterior to the first making sure to stay
out of the radiohumeral joint; Connect both tunnels with curved curette and
place a passing #0 ethibond suture. (Nestor et al. JBJS Am 1992)
vi. Optimal location of the distal ulnar tunnel - located with proximal wall of
tunnel 16 mm to 20 mm distal to radial head articular surface (Goren et al
AJSM 2010)
vii. Utilize the ethibond to identify isometric origin of LUCL on lateral
epicondyle by taking elbow through flexion and extension showing minimal
change in suture slack (Nestor et al. JBJS Am 1992)
viii. Optimal location of humeral tunnel – Most posterior/distal wall of the
humeral tunnel should be located at 3:00 position of the lateral epicondyle
(Goren et al AJSM 2010). Therefore, should place humeral tunnel slightly
anterior and superior to achieve this location of the posterior/distal wall.
ix. LUCL is tight in flexion and slack in extension therefore placing humeral
tunnel anteriorly should help tighten the ligament in extension
x. Drill single 4 mm burr tunnel approximate 1.5 cm deep in the humerus at
isometric point; drill 2 small holes proximal to the burr hole with a 2 mm
drill bit on either side of the lateral supracondylar ridge into the burr hole;
place a single #0 ethibond through each drill hole into the burr hole as
passing stitches
 xi. Prepare graft; split semi-tendinosis – place whip stitch at either end and use
passing suture in ulna tunnel to pass graft first in ulna tunnels; align both
ends of graft proximally at the entrance of humeral tunnel and trim graft to
allow about 5 mm of each limb of graft to be seated into humeral tunnel;
place a #2 Fiberwire stitch in a Krackow fashion in each limb of graft; pass
both tails of anterior limb stitch through the anterior 2 mm drill hole and
the other 2 tails of the posterior graft limb stitch through the posterior drill
hole.
xii. Hold arm in 30 degrees of extension and full pronation; dock graft into
tunnel and tie 2 Fiberwire stitches through each drill hole over lateral
supracondylar ridge; confirm capsule is between graft and radial head to
avoid graft abrasion; Prior to tying graft, consider reefing capsule anteriorly
with remaining ligaments; IF still slack in graft after docking consider reefing
graft anteriorly to underlying capsule/ligaments. Make sure when
tightening the graft that the ligament is tight in extension – anterior reefing
of the graft may improve this.
xiii. Close ECU/anconeous fascia;
xiv. Postoperative Rehabiliation – Splint at 90 degrees of flexion for 1 week in
mild pronation. Out of splint at 1 week and start ROM exercises using a
hinged brace. Lock brace to 30 degree extension limit for first 2 weeks then
to full extension. Brace is used from 1 week postoperative to 12 weeks
postoperative. From 1 to 6 weeks no lifting more than 1 lb. At 6 weeks,
allow 5 to 10 lb lifting. At 3 months allow 20 lb lifting and start
strengthening of the forearm and arm flexors, extensors. At 4.5 months
return to most activities except heavy lifting. Return to all activities at 6
months postoperative.
VII. Outcomes
a. Nestor et al JBJS Am 1992
• 7 patients underwent LUCL reconstruction with palmaris and 5 hole technique;
3 patients had imbrications of RCL; 1 patient underwent LUCL reconstruction
with lateral 1/3 rd triceps tendon
• Stability obtained in 10 patients with 7 excellent results; one failure in a LUCL
with Palmaris reconstruction
b. Sanchez-Sotelo JBJS Br 2005
• 12 direct repairs; 33 ligament reconstructions; surgery restored stability in
all but 5; average 6 year follow-up; MEPS was 85 on average; 32 good or
excellent and 7 fair and 5 poor; Better results with posttraumatic etiology,
patients with subjective instability and those having a reconstruction with
graft. Conclusion that reconstruction with graft is more predictable than
repair.
c. Olsen et al JBJS Br 2003
• 18 patients; triceps tendon graft from ipsilateral elbow; bone tunnels in humerus
and anchors in ulna; mean 44 month f/u; no recurrent dislocations; stable in 14 and
3 had minor limitation of movement; 13 no/slight pain; 15 returned to normal level
of activity; 17 satisfied; 1 failure
d. Lee et al J Shoulder and Elbow Surg 2003
 • 10 patients; 6 graft reconstructions and 4 LCL repairs; no patient had residual
instability; G or E in 8 and fair in 2; All excellent results had a reconstruction; All
patients were satisfied; Reconstructions were better than repairs.
e. Jones KJ et al. J Shoulder Elbow Surg 2011
• LUCL reconstruction with docking technique proximally and palmaris autografts; 8
patients; mean follow-up of 7 years; 6 patients complete resolution of instability;
25% reported occasional instability; MEPS 87.5; All patients satisfied

Varus Posteromedial Rotatory Instability (PMRI) – Anteromedial Facet Fractures of the Coronoid

I. Background
o The coronoid process plays a critical role in maintaining stability of the elbow joint.
o Historically, fractures of the coronoid process were defined by their overall size based
on the classification system described by Regan and Morrey.
o Several recent classification systems have been created to define fractures of the
coronoid process by their location and their associated injury patterns
o O’Driscoll et al created the coronoid fracture classification system
 Type II fractures, which involve the anteromedial facet, include three subtypes.
• Subtype 1 fractures involve the rim.
• Subtype 2 fractures involve the rim and tip.
• Subtype 3 fractures involve the rim and sublime tubercle.
o Adams et al classified coronoid fractures based on CT scans.
 The authors reported that oblique anteromedial fractures, which are equivalent
to O’Driscoll type II fractures, accounted for 17% of coronoid process injuries.
 The authors also reported on a newly described oblique anterolateral fracture
pattern, which accounted for 7% of coronoid process injuries and did not often
require surgical fixation.
 Conversely, anteromedial facet fractures often require surgical treatment to
avoid the development of early rapid arthritis.
o Aggressive surgical fixation for most coronoid process injuries has been supported
biomechanically and suggested clinically
o Recent studies have recognized that not all anteromedial facet fractures require surgical
repair
II. Pathophysiology
- Varus PMRI of the elbow results from a fall backward onto both hands, in which there was
axial loading of the arm with pronating and varus forces.
- Varus PMRI will result in a rupture of the LCL complex, and the trochlea will fracture the
anteromedial facet of the coronoid.
- Doornberg et al reported that 58% of the anteromedial facet is unsupported by the proximal
ulna, which places it at risk for fracture in the mechanism of injury already mentioned.
- The radial head is typically preserved without injury.
- The MCL can be injured as well with this injury pattern.
- Rhyou et al reported concomitant repair of the MCL in 3 of 18 cases while Park et al
reported injury in 6 of 11 cases of which 3 cases required surgical repair due to residual
instability after LCL repair and coronoid fracture fixation.
- The treatment strategy for anteromedial facet injuries potentially includes nonsurgical
treatment, LCL repair only, anteromedial facet repair only or both LCL and anteromedial
facet repair.
 - The surgical indications for anteromedial facet injuries continue to evolve as clinical
information on their outcomes becomes available.
III. Evaluation
- The history should query patients on the dislocation as well as the position of the hands and
arms at the time of the injury.
- Ap and lateral radiographs of the elbow and wrist should be performed
- Radiographs must be carefully reviewed because anteromedial facet injuries often may be
very subtle.
- The medial joint space often is narrowed or incongruent on AP radiographs.
- The fracture may be difficult to see on lateral radiographs
o Sanchez-Sotelo et al described a double-crescent sign in the setting of a
depressed fracture.
- Three-dimensional CT reconstructions with the radius and humerus subtracted are
critical to evaluate coronoid process injuries
o The ulna can be rotated to view the articular surface from proximal to distal,
which allows for classification of the injury based on the O’Driscoll
classification system
o The fracture should be evaluated for displacement as well as the subtype
classification.
- Varus stress radiographs also may be obtained to evaluate for medial joint space
collapse and lateral joint space widening.
- On physical examination, the patient should be placed in the supine position and
brought through a full range of elbow flexion and extension to offload the LCL.
o The patient should be queried about symptoms of instability or grinding, both
of which are indications for surgical repair.
IV. Treatment - Indications
- Because this injury pattern has been recognized only in the past 10 years and it is, overall,
much less common than other forms of complex elbow instability, studies on the outcomes
of clinical care for patients who underwent treatment for cornoid process injuries are
limited.
- Because of these limited data, the indications for nonsurgical and surgical treatment of
coronoid process injuries are still evolving.
o Initially, all injuries were believed to require surgical fixation of both the LCL and
the anteromedial facet fracture.
o As knowledge of cornoid process injuries improved, the treatment algorithm, which
is based on fracture pattern, size, and location; stress radiographs; and clinical
symptoms, has been refined
- All patients should initially be treated with closed reduction and splinting, after which the
elbow should be reexamined.
- Varus stress radiographs with the forearm placed in pronation should be obtained in the
setting of an anteromedial facet fracture that has minimal displacement with no static
collapse of the medial ulnohumeral joint space seen on AP radiographs.
o If no medial collapse of the ulnohumeral joint space, no lateral gapping, and a firm
end point are seen, the patient can be considered for nonsurgical treatment.
o Passive elbow flexion and extension should be evaluated with the patient placed in
the supine position.
 o If no crepitus or feelings of instability exist and stress radiographs are negative,
nonsurgical treatment can be considered.
o If nonsurgical treatment is selected, flexion and extension overhead exercises with
the patient in the supine position as well as passive supination and pronation with
the elbow positioned 90° of elbow flexion should begin 1 week after injury.
o A sling should be worn for 6 weeks to protect the elbow between physical therapy
sessions.
o Radiographs should be obtained every week for the first 3 weeks as well as 6 weeks
after injury to confirm maintenance of alignment and no collapse.
o Six weeks after injury, the sling should be discontinued, and progression stretching
may be performed, with strengthening initiated 3 months after injury.
o Patients may return to activities as tolerated 4 to 5 months after injury.
- Surgery is recommended if substantial displacement with subluxation is seen on radiographs
or if positive varus stress or clinical symptoms of grinding or instability with supine overhead
elbow flexion and extension are apparent.
- Surgery may include LCL repair only, anteromedial facet repair only, or both.
o Park et al treated patients who had O’Driscoll type II subtype 1 fractures with LCL
repair only and patients who had O’Driscoll type II subtype 2 and subtype 3
fractures with LCL repair and buttress plating.
o Rhyou et al recommended treatment based on fracture fragment size (articular
height as defined by Pollack et al.)
 If the fragment was smaller than or equal to 5 mm, the authors did not
repair the fracture.
 If the fragment was larger than 6 mm and not comminuted, the authors
repaired the facture via a medial approach.
 If varus stress testing under fluoroscopy with the forearm positioned in
pronation revealed a firm end point with a congruent medial ulnohumeral
joint, the authors did not repair the LCL.
 If loss of congruency occurred, the authors repaired the LCL.
 This treatment algorithm allowed some patients who had very small
fractures and a stable elbow to undergo nonsurgical treatment.
o Nonsurgical treatment can be considered for slightly larger fragments if no grinding
or instability exists during overhead passive flexion and extension with the patient
placed in the supine position

IV. Treatment – Surgical Technique

- A variety of medial approaches may be used to surgically repair cornoid process
fractures.
- Surgical techniques include an over-the-top approach, which uses a 50:50 flexor-
pronator split anterior to the ulnar nerve; a through-the-bed approach to the ulnar
nerve, which splits the two heads of the FCU; and a slightly posterior approach with
take-down of the ulnar head of FCU (the Taylor-Scham approach)
o Only a very small number of fractures, many of which can be treated
nonsurgically, can be repaired via the over-the-top approach with the use of
suture fixation; therefore, the over-the-top approach is uncommonly used.
o The mainstays of fixation include the FCU-splitting and the Taylor-Scham
approaches.
 o Many surgeons prefer the FCU-splitting approach; however, the incidence of
ulnar neuropathy is approximately 10% in patients who undergo surgical
treatment with this exposure.
o Working through the FCU often requires extensive dissection of the ulnar
nerve and may place a substantial amount of traction on the nerve.
o Although the Taylor-Scham approach may require take-down of the FCU, the
entire FCU and the transposed ulnar nerve can be elevated anteriorly to
eliminate all traction during fixation.
- Internal fixation can be achieved using suture, screws, or a buttress plate.
o Small 2.0- or 2.4-mm T- or L-shaped plates can be used as a buttress.
o If the fracture is small, suture fixation passed through dorsal drill holes may
be a reasonable alternative.
- Extensive knowledge of joint anatomy is required to prevent intra-articular
penetration or penetration of the lesser sigmoid notch if screw fixation is performed,
either alone or through a plate.
o In general, screw trajectory should be distal and dorsal, and preoperative
planning should be performed to prevent joint penetration.
- The UCL often is attached to the fracture fragment in an O’Driscoll type II subtype 3
fracture and is still attached to the sublime tubercle in O’Driscoll type II subtype 1 or
subtype 2 fractures; therefore, it should be protected
- Dissection of the FCU muscle off the proximal ulna in a distal to proximal direction
during exposure will prevent inadvertent injury to the anterior band of the UCL.
- LCL repair should be performed to the lateral epicondylar isometric point with the
use of bone tunnels or suture anchors.

IV. Outcomes
- Overall, limited data exist on the outcomes for patients who undergo surgical
treatment for anteromedial facet fractures in the setting of varus PMRI
- Doornberg and Ring reported on a series of 18 patients who had anteromedial facet
fractures, 15 of whom were treated surgically, and 3 of whom were treated
nonsurgically.
o The coronoid was fixed with a plate in nine patients, a screw in one patient,
and sutures in one patient. The coronoid was not repaired in the remaining
seven patients.
o At mean follow-up of 26 months, the authors reported that six patients had
malalignment of the fracture and varus subluxation, which was caused by a
lack of fixation in four patients and a loss of fixation in two patients.
o All six of the patients with malalignment and varus subluxation had fair or
poor results.
o The remaining 12 patients had good or excellent outcomes. There was a 17%
incidence of ulnar neuropathy in patients who underwent repair via the FCU-
splitting approach. The three patients who were treated nonsurgically had
maintenance of alignment of the fracture and had excellent results based on
the rating system described by Broberg and Morrey. The authors
recommended that surgical fixation of anteromedial facet fractures to prevent
 malalignment, except in patients who have very small fractures with no
subluxation and no radiocapitellar joint opening with varus stress.

- Rhyou et al reported on 18 patients who had anteromedial facet coronoid fractures

and PMRI
o The authors repaired only fractures that were larger than 5 mm in size
(articular height as defined by Pollock et al and repaired the LCL only if an
incongruent medial ulnohumeral joint was present during varus stress in
pronation as seen under fluoroscopy.
o The authors reported 2 patients who had O’Driscoll type II subtype 1
fractures, 14 patients who had O’Driscoll type II subtype 2 fractures, and 2
patients who had O’Driscoll type II subtype 3 fractures.
o Seven patients were treated with ORIF only, four patients were treated with
LCL repair only, six patients were treated with LCL repair and ORIF, and one
patient was managed nonsurgically. ORIF included the use of cannulated
screws in two patients, Kirschner wires with tension-band wiring in seven
patients, and a buttress plate in two patients.
o The UCL was repaired in three patients.
o The mean MEPS was 98 (range, 85 to 100) at a mean follow-up of 37 months.
o There was no difference in outcomes between the subtypes.
o The authors provided a treatment algorithm that defined the size of the small
fractures with no subluxation that were previously described by Doornberg
and Ring.
- Park et al reviewed 11 patients with isolated anteromedial facet fractures who were
treated with ORIF.
o The authors treated patients who had O’Driscoll type II subtype 1 fractures
with LCL repair only and patients who had O’Driscoll type II subtype 2 and 3
fractures with LCL repair and ORIF.
o Three patients required MCL repair.
o At a mean follow-up of 31 months, the mean range of motion was 128°, and
the mean MEPS was 89.
o Ten patients had good or excellent results.
o Two of 11 patients complained of postoperative ulnar neuropathic symptoms.
One patient already had symptoms at the time of surgery. The one patient
with preoperative symptoms had an ulnar nerve exploration at the time of
surgery and the nerve was anteriorly transposed in the subcutaneous area.
This patient had full recovery by 3 months postoperative. The other patient
with new onset ulnar neuritis still had mild numbness in the ulnar nerve
distribution at 25 months postoperative. All eleven patients in this series were
treated with the FCU-splitting approach.
V. PMRI conclusions
- Overall, the surgical repair of varus PMRI can lead to excellent outcomes.
- Surgical repair typically consists of LCL repair with ORIF of the fracture.
- Small fractures (<6 mm in height) may be considered for nonsurgical management.
- Similarly, the LCL often does not require repair if the elbow is stable to varus stress in
pronation as seen under fluoroscopy.
 - Larger fractures also may be considered for nonsurgical management if minimal
displacement, no static subluxation, a negative varus stress test, and no sensation of
instability or grinding with supine overhead flexion and extension is present after injury.
- If surgery is required, a medial approach with buttress plate fixation will typically lead to
reasonable outcomes.
o The FCU-splitting approach has a 10% to 15% incidence of postoperative ulnar
neuropathy; therefore, an alternate approach, including the Taylor-Scham
approach, which limits traction on the nerve, should be considered if exposure is
difficult during an FCU-splitting approach

Missed Instability
I. Background
a. Missed or neglected elbow dislocations are fortunately uncommon. Can be a result of
an incomplete examination or lack of obtaining radiographs
b. Chronic elbow dislocations can also result of surgically repaired simple or complex
dislocations with failure of fixation or ligament repair leading to persistent subluxation
or dislocations
i. Causes of failure
1. Bony stabilizers insufficient
a. Inadequate bony fixation due to poor methods of internal
fixation
b. Poor bone quality due to size, comminution or osteoporosis
leading to early failure of appropriate methods of fixation
c. Failure of healing fracture fixation
i. Age
ii. Smoking
iii. Comorbidities
iv. Osteoporosis
2. Ligament stabilizers insufficient
a. Failure to repair ligament injuries
b. Failure of ligament repair techniques due to fixation failure
c. Failure to heal of ligament repairs
i. Lack of postoperative protect
1. Splint, brace, sling
2. Protected therapy
3. External fixation
ii. Lack of fixation of other stabilizers (i.e bony)
d. Failure to reconstruct chronic ligament injuries
3. Cartilage loss
a. Acute – Large osteochondral injuries requiring repair or
reconstruction
i. Trochlear – Consider large allograft reconstruction vs
arthroplasty
ii. Posterior capitellar – Osborne-Cottrell lesion requiring
fixation or grafting
b. Chronic
i. Loss of articular congruity resulting in persistent
instability despite treatment of bony and ligamentous
 stabilizers - Salvage options – interposition, fusion,
arthroplasty

II. Bony insufficiency

a. Radial Head
i. Biomechanics
1. The radial head is an important secondary stabilizer that provides
approximately 30% of valgus stability
2. The radial head also is a primary restraint to PLRI
3. Schneeberger et al reported that isolated radial head excision in cadaver
models with intact ligaments led to increased rotatory laxity.
a. The authors reported that radial head excision and excision of
30% of a coronoid fracture in cadaver models with intact
ligaments resulted in ulnohumeral subluxation rather than just
posterolateral rotatory laxity
b. Radial head replacement corrected subluxation; however,
posterolateral rotatory displacement still existed, and coronoid
fixation was required to stabilize the elbow.
c. Restoration of both the radial head and the coronoid was
required to restore stability in cadaver models that had
substantial (>30%) fractures
4. Complete restoration of the radial head with either repair or
replacement is required to restore elbow stability
5. If repair is not possible, then replacement should be strongly considered
because excision may lead to poor outcomes

ii. ORIF/Excision – often impossible in these situations due to chronicity

1. Fragment excision is a reasonable treatment option for patients who
have small, nonreparable fragments (<25% to 30%) that do not
articulate with the lesser sigmoid notch if stability of the elbow is
achieved after coronoid and LCL repair
2. The anterolateral head, which is typically injured in patients who have
fracture-dislocations, is critical for stability; therefore, care must be
taken during excision because even a small amount of bone loss may
lead to instability.
iii. Replacement
1. Radial head arthroplasty is indicated for patients who have comminuted
Mason type III fractures, surgical neck fractures with substantial neck
comminution, and partial radial head fractures with several fragments
that do not allow for fixation.
2. Overstuffing should be avoided because it will substantially limit elbow
range of motion, specifically flexion, as well as result in pain and
capitellar erosion
3. The diameter of the implant should be slightly undersized using the
minimum, rather than the maximum, diameter of the head.
4. The best guide for radial head height involves matching the proximal
articular surface of the radial head arthroplasty with the lateral edge of
the coronoid at its junction with the lesser sigmoid notch.
 5. Doornberg et al reported that the radial head is, on average, 0.9
mm more proximal than the lateral edge of the coronoid process.
Severe overlengthening (>6 mm) is apparent on radiographs in
patients who have medial ulnohumeral joint incongruity. To avoid
overlengthening, the articular surface should be even with the
lateral edge of the coronoid.
6. Chronic cases can lead to posterior subluxation of the proximal radial
shaft that might not allow restoration of radiocapitellar alignment –
consider bipolar implant

b. Coronoid
i. The coronoid process has been biomechanically shown to be an important
stabilizer to varus, posteromedial rotatory, posterolateral rotatory and axial
forces
ii. Poor results have been reported in cases of complex dislocations where
coronoid process fractures have not been repaired
iii. Consequently, repair should be attempted for most fractures that are larger
than 10% of coronoid process after a fracture dislocation
iv. Irreparable coronoid fractures due to severe comminution or cases where the
coronoid fragments have been excised pose a difficult problem
v. Treatment options for irreparable fractures
1. Hinged external fixation has been reported as a salvage procedure for
unreconstructable coronoid fractures in order to maintain elbow
stability
2. Other authors have reported reconstruction of the coronoid process
with a variety of grafts including both autograft (radial head, iliac crest,
proximal olecranon) and allograft
a. Van Riet et al reported on 6 patients who underwent allograft (3
cases) and autograft (3 cases using radial head) reconstruction
i. At a mean of 64 months postoperative, the authors
reported 1 excellent, 2 good, 1 fair and 1 poor result
using the Mayo Elbow Performance Score and that
results were unpredictable using this technique
b. Esser et al and Chen et al also reported on graft reconstructions
utilizing autograft radial head
c. Moritomo et al reported 2 cases of using the ipsilateral
olecranon tip as a graft source for coronoid reconstruction using
an anterior approach
i. Both elbows were stable at minimum of 1 year follow-
up with a pain free flexion arc from 30° to 120°.
d. Kohls-Gatzoulis et al and Chung et al each reported on using a
iliac crest autograft to reconstruct a coronoid with good results
at a minimum of 1 year
3. Results of graft reconstructions vary significantly. Despite this variability
from a very limited group of case reports, the technique is a reasonable
alternative for a difficult clinical problem
vi. Variety of fixation techniques for large coronoid graft reconstructions
1. AP screws, PA Screws, Suture
III. Ligamentous Insufficiency
a. Consider ligament repair laterally and/or medially – Reconstruction likely needed if
longer than 6 weeks post injury; may consider repair in any case as based on Daluiski et
al although most would perform reconstruction if over 6 weeks from injury
i. Daluiski et al – Reported primary repair of ligaments with success in 34 patients
even in chronic setting > 30 days after injury;
b. Combined medial and lateral ligament insufficiency
i. Single ligament graft reconstruction
1. Van Riet et al - drilling 2 ulnar tunnels; gracilis autograft; posterior
midline approach; reported single and double loop techniques
2. Finkbone PR, O’Sriscoll SW – “Box loop” reconstruction
a. Donar tendon is passed through the humerus and ulnar an dtied
back to itself
b. Fourteen cases with mean follow-up of 64 months. Nine
patients returned to the clinic and were evaluated. 5 patients
phone follow-up
c. Average follow-up time 64 months. 7 elbows were normal and
4 greatly improved, 2 improved and 1 worse.
ii. Separate reconstructions – medial and lateral

IV. Cartilage loss

a. Osborne-Cottrell lesions
i. Osteochondral fracture in the posterolateral margin of the capitellum is a cause
of persistent lateral instability
ii. Jeon et al – 5 patients with chronic PLRI with osteochonfral fracture; all had
deficient radiocapitellar articulation in extension; Excision of fragment and
ligament reconstruction failed in 1 or 3 cases; consider osteochondral grafting
V. Capsular contracture
a. Medial or lateral open release on all cases
VI. Ulnar nerve
a. Ulnar nerve subcutaneous transposition on all cases
VII. External fixation
a. Methods
i. Static external fixation
1. Advantages and disadvantages
2. Method of application
ii. Dynamic hinge external fixator
1. Advantages and disadvantages
a. Advantages
i. Allows motion at the same time as providing stability
ii. Allows maintenance of stability with persistent
irreparable bony or ligamentous insufficiency; The soft
tissues heal in a directed mode and lead to re-
establishment of the ligament apparatus.
b. Disadvantages
i. Need exact identification of flexion extension axis
 1. Passes through the center of the arcs formed by
the trochlear sulcus and the capitellum; axis is
internally rotated 3 to 8 degrees with regard to
the plane of the epicondyles and forms a82 to
86 degree angle with the axis of the humerus
2. Malalignment of 5 degrees cause a 4 fold
increase in energy expenditure
ii. Cumbersome
iii. Difficult to apply; long learning curve – if not placed
exactly can drive elbow into unstable position
iv. Axis pin can interfere with ligament reconstruction
2. Dynamic
a. Compass hinge –
i. Ring D, Hannouche D, Jupiter J Hand Surg Am
2004;29:470-80
1. 13 patients with ulnohumeral instability after fx
dislocation treated with hinged fixator, cornoid
reconstruction, radial head repair or
replacement and collateral ligament
reconstruction or repair; surgery performed at
average of 8 weeks after injury
a. at 57 months, stability restored in all;
DASH 15, MEPS 84; 10 good or
excellent; ROM 99 flexion extension

b. DJD II
i. Panpandrea, Morrey, O’Driscoll JSES 2007;16:68-77
1. 21 patients with chronic instability after
coronoid fracture dislocation assessed at a
minimum of 2 years after reconstruction
2. 13/21 patients had a successful outcome – only
1 of 7 with delay greater than 7 weeks was
considered a success
3. 19 fractured RH, 11 of which were originally
treated with RH excision
4. 16 patients with coronoid fx dislocation treated
with hinge; 12/16 considered successful; only
50% remained reduced with use of fixator
5. 71% complication rate
6. Delay beyond 7 – 8 weeks led to uniformly
unsuccessful results
7. Conclusions – persistent instability after
fracture dislocation of the elbow is a situation
to be prevented because reconstruction is
unpredictable.
c. DJD II and Orthofix
i. Sorensen et al JSES 2011;20:1300-9.
 1. 20 patients with persistent instability after fx
dislocation treated at a mean of 11 weeks after
injury. Evaluated 17 elbows at a mean of 44
months postop; all had hinge fixator and
reconstruction of static stabilizers
2. 10/17 elbows had a good or excellent result; 96
degree ROM; MEPS 74; Patients treated within
6 weeks after trauma had better scores (MEPS
81 vs 62); no recurrent dislocations;
3. 41% complication rate
d. Orthofix–
i. Ruch et al Injury 2001-
1. 5 patients treated with hinge ex fix at 6 weeks
or greater post injury
a. repair or reconstruct all bony and
ligamentous injuries
b. flexion arc 84, congruent joint in all,
DASH 23
c.
e. Unilateral self centering fixator (not available yet)–
i. Bigazzi et al – New external fixator designed with a gear
to freely align itself withteh center of the elbow
rotation during passive flexion extension
1. 7 patients; no cases of misalignment, loss of
fixation, pin loosening or instability

3. Static
a. Place 2 humeral pins and 2 ulnar pins; humeral pins can be
placed directly posteriorly through the triceps to avoid the
radial nerve - Radial nerve is directly posterior at level of the
deltoid tuberosity; 11 to 14 cm proximal to the lateral
epicondyle the nerve moves from posterior to anterior
therefore direct posterior placement is safe 10 cm to the lateral
epicondyle; ulnar pins placed on dorsal subcutaneous border
b. Leave fixator in place for 4 to 6 weeks; remove and initiate
therapy protected by a hinged brace
4. Severe bone deficiency not reconstructable utilizing coronoid grafting
techniques; radial head insufficiency not allowing replacement due to
persistent subluxation of the proximal radial shaft; tenuous bony or
ligamentous fixation

VIII. Algorithm for Missed instability with combined injuries (authors preferred techinique)
a. Posterior midline approach
b. Ulnar nerve transposition
c. Lateral approaches – Kaplan and Kocher intervals extended proximally
d. Medial approach – through bed of the ulnar nerve
 e. Coronoid reconstruction – if radial head absent – approach laterally through lateral
window; repair or reconstruct with olecranon tip or allograft radial head; if RH intact –
approach medially with Taylor Schamm approach
f. Radial head replacement or repair
g. Box-loop ligament reconstruction
h. IF stability not restored due to failure to restore RH, Coronoid or ligament
reconstruction – static ex fix; if self centering hinge becomes available would consider in
this situation

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