Green CH-19

Section 2 •  Elbow

of the elbow are addressed, an external fixator is applied to maintain the reduction. Ideally, fixation of all of the injuries will be secure enough to start earlier rehabilitation. However, extensive repairs or swell- ing may require a delay in the initiation of therapy. Wound healing and infection prevention is the highest priority, then joint stability, and finally ROM after complex elbow repairs. Stabilization surgery can be done through a posterior inci- sion with full-thickness skin and subcutaneous flaps raised to allow access to the lateral and medial sides of the joint. Alternatively, separate direct lateral and medial incisions can be used. The laterally based incision requires less soft-tissue dissection and may lead to less wound healing problems than a posterior incision. The potential need for future additional surgery is also a consideration when planning the surgical approach. A lateral incision may be preferred if future surgical contracture release is planned, while a posterior incision would be preferred for later elbow replacement. Complex Instability: Fracture Dislocations Complex instability falls into two main catagories, terrible triad injuries and VPRI. Terrible triad injuries involve frac- tures in addition to the ligamentous injuries, as described for simple elbow dislocations. Surgery is recommended when the fractures of the coronoid or radial head would require intervention on their own. Surgery is also recommended if the joint is not congruently reduced or the elbow demonstrates clinical instability at greater than 45 ° of flexion. Surgery to address terrible triad injuries requires repair of types II and III coronoid fractures, radial head repair or replace- ment, and repair or reconstruction of the LCL. MCL repair often may be required to stabilize the elbow as well as applica- tion of an external fixator. Management of coronoid fractures can be difficult especially if there is comminution. Although the coronoid is most easily accessed from the medial side it can also be reached from the lateral side if a radial head replacement is required. Coronoid fractures can be fixed with a variety of techniques, including screws, small plates and screws, and tran- sosseous sutures. The decision for a single posterior incision or separate lateral and medial incisions is based on surgeon prefer- ence. These injuries often include extensive soft-tissue injuries, and swelling can be a problem. Wound healing problems can be a major complication of surgery for these injuries. VPRI may include subtle injuries and require operative intervention when the trochlea is not congruent and/or the radial capitellar joint is gapped on an anterioposterior elbow radiograph. Computed tomography (CT) is used to assess the joint alignment in suspected cases, as these injuries are often difficult to assess with plain radiographs. The coronoid frac- ture is addressed through a medial approach to the elbow by elevating the flexor carpi ulnaris muscle (FCU) anteriorly. The ulna nerve is identified and protected during this approach. The LCL requires a separate lateral approach to repair or reconstruct the ligament. If fixation is tenuous, an external fixation will be applied to offload the repaired joint and liga- ments, and protect the reduction.

Lateral (radial) collateral ligament

Annular ligament

Accessory lateral collateral ligament

Articular capsule

Lateral ulnar collateral ligament Figure 19.1  Illustration of the medial elbow ligamentous com- plex. (Reproduced with permission from Gramstad G: Anatomy of the shoulder, arm, and elbow, in Boyer MI, ed: AAOS Comprehen- sive Orthopaedic Review 2. Rosemont, IL, American Academy of Orthopaedic Surgeons, 2014.) A small number of patients will continue to have radio- graphic findings of instability at 7 to 14 days or clinical findings of instability at 14 days, thus will be considered for surgical stabilization. In the majority of these cases, the LCL and common extensor origin are found torn away from the lat- eral epicondyle, and can be anatomically repaired either with sutures through bone tunnels or with suture anchors. If the LCL is torn midsubstance, a ligament reconstruction with a tendon graft may be required (Figure 19.3). Uncommonly, the MCL will also require repair or reconstruction after the lateral repair. If the elbow continues to have instability after both sides

Anterior band

Posterior band

Transverse band

Figure 19.2  Illustration of the lateral elbow ligamentous com- plex. (Reproduced with permission from Gramstad G: Anatomy of the shoulder, arm, and elbow, in Boyer MI, ed: AAOS Comprehen- sive Orthopaedic Review 2. Rosemont, IL, American Academy of Orthopaedic Surgeons, 2014.)

178 Postoperative Orthopaedic Rehabilitation

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