FRACTURES AND DISLOCATIONS OF THE ELBOW AND FOREARM

In spite of the fact that surgical techniques for the
treatment of fractures of the distal humerus have advanced
substantially over the past 20 years and now are quite sophisticated,
the rate of complications remains quite high (21,69,83,86,87,91,92 and 93,116,124,169).
Such complications include nonanatomic reduction of articular surfaces,
malunion, nonunion, residual stiffness of the elbow, heterotopic
ossification, posttraumatic osteoarthrosis, and generalized functional
disability. These injuries are being treated more often now with
coexisting multiple injuries or in an extremity with complex
ipsilateral open injuries, which previously may have led to amputation.
In the very elderly, osteopenia often compromises internal fixation,
and total elbow arthroplasty is a reasonable alternative (32).

Elbow and forearm fractures continue to present major
problems to orthopaedic traumatologists because of the high occurrence
of comminution, the large and complex articular surfaces involved, the
close proximity of important nerves and vessels, and the poor
soft-tissue coverage. In spite of the best treatment, the result may be
poor because of the magnitude of the original injury. In the vast
majority of fractures, ideal treatment consists of early open reduction
with replacement of any lost bone, and rigid anatomic fixation of the
joint surfaces and adjoining metaphyseal bone, with early aggressive
active range-of-motion and strengthening exercises (69,94,169).
As with all intraarticular fractures, good technique requires careful
preoperative planning, adequate exposure of the joint and fracture,
biomechanically sound internal fixation, and protection of
neurovascular structures. Flexibility on the part of the surgeon and
the availability of a wide range of plates and screws are necessary (2,20,87,93,122,130,171,172).

Comminuted elbow fractures in which the bone is
osteopenic and the patient is over 70 years old can be nearly
impossible to fix. Primary total elbow arthroplasty is a reasonable
alternative in these patients, particularly if they have coexisting
arthrosis or rheumatoid arthritis. Cobb et al. (32)
performed arthroplasty in 21 elbows in 20 consecutive patients, whom
they followed for a mean duration of 3.3 years with a minimum follow-up
of 2 years. Fifteen elbows had an excellent result, five had a good
result, and one was not ratable. Of these, one required revision for a
fracture of the ulnar component sustained in a fall.

The elbow joint consists of three articulations: the
radial-capitellar, the trochlear-olecranon, and the proximal
radial-ulnar. The distal humerus consists of two divergent osseous
columns, one lateral and one medial, which flare and are separated by
the thin or absent bone of the olecranon fossa, and are connected
together distally by the trochlea. The end of the lateral column
becomes the capitellum. The lateral column is in approximately 20° of
valgus relative to the midline of the humeral shaft, whereas the medial
column is at a 40° to 45° angle. Viewed from a lateral perspective, the
capitellum is tilted 30° to 40° anteriorly, and the trochlea 10° to 20°
(Fig. 16.1). The articulation between the
trochlear notch of the olecranon and the trochlea is the most important
joint of the elbow because it provides the flexion–extension arc of
elbow motion as well as approximately half of the intrinsic stability
of the elbow (83). Reconstruction of the normal
shape of the trochlea is therefore critical to restoration of good
motion and stability in the elbow. Because the majority of
intraarticular fractures split through the narrow waist of the trochlea
with some comminution, there is a tendency during internal fixation to
narrow the trochlea. Avoid this, however, because it creates a
noncongruous elbow, which will interfere with motion and lead to
osteoarthrosis.

The anatomic shape of the elbow joint, in particular the ulnar–humeral articulation, is such that the trochlear

notch of the olecranon surrounds almost 100° of the trochlea, making the elbow one of the most stable joints in the body (119,138).
The olecranon, in its articulation with the trochlea, contributes
significantly to anterior–posterior stability, as well as varus,
valgus, and rotatory stability. Resection of increasingly larger
amounts of the proximal end of the olecranon leads to a linear decrease
in the stability of the elbow. Resection of only 25% of the olecranon
process decreases the resistance of the elbow to valgus load by 50%.
The coronoid process plays an important role, in that it resists
posterior displacement of the elbow joint, particularly in flexion, and
the anterior band of the medial collateral ligament attaches near the
base of the coronoid process; therefore, large fractures involving the
coronoid process may result in incompetence of this ligament. In spite
of its small size, the radial head contributes to stability and the
transmission of longitudinal force across the elbow joint. The load
borne by the radial–capitellar joint is maximal when the forearm is
pronated and the elbow extended and loaded longitudinally. The
continuity of the radial head is most important when there is
associated ligament instability in the elbow and in particular when
there is incompetence in the intraosseous membrane and distal radial
ulnar joint of the forearm (an Essex-Lopresti lesion).

Restoration of a T- or Y-type comminuted intraarticular
fracture of the distal humerus requires reconstruction of an
equilateral triangle consisting of the lateral column, the medial
column, and the trochlea. Fortunately, even in the elderly, the
cortical bone of the medial and lateral columns usually provides good
purchase for bone screws. In a biomechanical study of internal fixation
of the distal humerus, Helfet and Hotchkiss (61)
found that double-plate construction with the two plates at right
angles, a medial plate on the medial column and a posterior plate on
the lateral column, provided the strongest fixation regardless of
whether the plate was a one-third tubular or a 3.5 mm reconstruction
plate. Schemitsch et al. (154) looked at plates
of two designs placed in five different configurations. They found that
when cortical contact was present, dual plates placed medially and
laterally—whether at 90° to each other or in the same plane—provided
equivalent rigidity. When a cortical gap was present, however, they
found that the combination of an anatomically designed lateral buttress
J-plate and a medial reconstruction plate gave the greatest rigidity.
In practice, 3.5 mm reconstruction plates or their equivalent,
particularly in titanium, give the best opportunity to obtain a close
fit of the plates to the complex surfaces of the distal humerus, and
when placed posteriorly on the lateral condyle and medially on the
medial condyle, they provide the strongest construct. Interfragmentary
screw fixation from the capitellum through the trochlea usually ensures
good stability of the articular surface. Reestablishment of good bone
contact throughout the construct, using tricortical bone graft from the
iliac crest if necessary, substantially improves fixation and chances
for union.

Olecranon osteotomy, if used for exposure, is another
source of complications if the fixation fails. The biomechanically
soundest technique appears to be a chevron

type
osteotomy through the nonarticular portion of the olecranon, predrilled
and fixed with interfragmentary screw fixation augmented by a tension
band wire.

The Association for the Study of Internal Fixation (AO-ASIF) classification (Fig. 16.2)
is the most commonly used scheme for determining treatment and clinical
research. The Orthopaedic Trauma Association and the International
Society for Fracture Repair recently expanded the AO classification (125)
to provide a more detailed breakdown to enhance the accuracy of
clinical reports. Their system, however, contains 38 separate fractures
of the distal humerus. Jupiter and Mehne (86)
divide distal humerus fractures into three major groups: extracapsular,
transcolumnar, and intraarticular, which includes single- and
bicolumnar fractures and articular fractures involving the capitellum
and the trochlea (21,86) (Table 16.1).

High T-fractures are those that divide both columns
proximal to the olecranon fossa, whereas low T-fractures traverse the
olecranon fossa just proximal to the trochlea. The latter may be the
most common fracture pattern in the elderly, and they are difficult to
treat because of the small distal fragment. Y- or T-fractures begin in
the center of the trochlea, probably due to the olecranon trochlear
ridge being impacted into the trochlea, which causes a fracture line to
propagate vertically from the trochlear notch and then split to cross
each column obliquely. An H-fracture is a bicolumnar fracture with a
fracture of the medial column around the medial epicondyle and a split
of the lateral column into a T or Y pattern, producing a

free-floating
trochlear fragment. In a medial lambda fracture, the proximal fracture
line exits medially and the lateral fracture line extends distally to
the level of the lateral epicondyle. In a lateral lambda fracture, the
fracture is high on the lateral column and exits near the medial
epicondyle with the intraarticular component next to the capitellum. A
particularly difficult fracture is a shear fracture in the frontal
plane involving the anterior portion of the capitellum and lateral half
of the trochlea. This results in the characteristic double-arc sign
seen on the lateral radiograph of Figure 16.3.

Postoperatively, after elbow fixation, elevate the
entire extremity above the level of the heart. Observe carefully for
excessive swelling and compartment syndrome. Once swelling has abated
and the drain has been removed, remove the bulky compression dressing,
apply a supportive brace, and begin active range-of-motion exercises.
Set fixed limits on the brace if necessary, according to an examination
under anesthesia.

Allow the patient to rest with the elbow in extension
and work on the range of motion from that position. Discontinue the
braces as soon as feasible. If the patient has

difficulty
gaining range of motion, use dynamic flexion and extension splints on
alternating nights. Avoid resistive exercises and any heavy use of the
extremity until fracture healing has occurred, which is generally in
10–14 weeks.

McKee et al. (101) reported
surprisingly good results in the treatment of shear fractures of the
distal articular surfaces of the humerus in six patients. All united
without evidence of osteonecrosis. Functional outcomes were good, with
an average flexion contracture of 15° with further flexion to 141°. In
T-type bicondylar fractures, Helfet and Schmeling (62) reported an average of 75% excellent to good results.

Nondisplaced olecranon fractures that are stable and
have an intact triceps aponeurosis are generally grouped separately.
With this injury, the patient can extend the injured elbow against
gravity without causing displacement of the fragments. If there is a
question about stability, examine under fluoroscopy to document it.

Displaced olecranon fractures are classified according
to the fracture line and degree of comminution. A modification of
Colton’s classification (34) separates these into four types (Fig. 16.11):

The AO classification (122) has been modified recently by the Orthopaedic Trauma Association (125) into eight types.

Morrey (117) has not found any
of the previous classifications to be useful to him for clinical
decision making; therefore, he proposed the Mayo classification:

Prayson et al. (132) compared
four different methods of tension band wiring. They compared a
monofilament wire in a traditional figure-eight loop with K-wires
inserted from the tip of the olecranon into the anterior cortex or
intramedullary, to similar constructs using cables in both

figure-eight
and circular loops. They found that insertion of the K-wires from the
tip of the olecranon into the anterior cortex and the use of cable
provided superior fixation to intramedullary K-wires and monofilament
wire. In a prospective randomized study, Hume and Wiss (74)
compared tension band wiring to plate fixation. Although plate fixation
required longer operative time, it did not have an increased
complication rate, and the clinical results were superior to tension
band wire. Postoperative loss of reduction occurred in 53% of patients
fixed with tension band wires and in only 5% after plating. With
plates, good clinical results were 26% more common, and good
radiographic results were 39% more common.

Nondisplaced olecranon fractures may be managed by
maintaining the elbow in a semiflexed position (to 90° of flexion, if
tolerated) with a cast or splint. Obtain repeat radiographs at 5–7 days
to ensure maintenance of reduction. Early, protected range of motion
may begin at about 1 week. Rarely, one encounters an undisplaced
fracture in a person in whom nonunion or displacement is not tolerable,
such as in a professional throwing athlete. A tension band wiring can
be applied with minimal exposure, which allows more aggressive early
rehabilitation with minimal risk of displacement.

Treatment of displaced olecranon fractures (Colton types
II–IV and Mayo types II–III) has been the topic of a significant amount
of research and discussion through the years. Alternative methods
include open reduction and internal fixation or fragment excision, and
reconstruction of the triceps mechanism (49,70,77,176). I favor anatomic reduction with internal fixation when possible, with early mobilization.

In Colton type I (avulsion) fractures, tension band
wiring of the intraarticular fracture restores the continuity of the
extensor mechanism and allows early range of motion. For the
extraarticular fragment, treatment depends on fragment size and patient
age. In the young person with a significant bony fragment, open
reduction and internal fixation allows bone-to-bone healing. If the
patient is older or the fragment size is limited, excision and
reattachment of the triceps mechanism is preferred.

For Colton type II (transverse or oblique) fractures,
internal fixation options include tension band wiring with associated
K-wires or a screw (or screws) (79), and
intrafragmentary compression screws with or without neutralization
plating. I prefer a tension band wire with K-wires or a single screw of
appropriate size. This method transforms tension forces into
compressing forces across the fracture site (176).
Active elbow flexion increases compression and stability because of the
tension band construct. Plate fixation plus an interfragmentary
compression screw is more stable than a tension band wire but requires
more exposure (74).

For Colton type III fractures (fracture–subluxations),
those that propagate from the distal third of the olecranon are
potentially unstable. The biceps and brachial muscles may cause
anterior subluxation of the radial head and displacement of the distal
fragment of the ulna. This adds a compressive force to the posterior
surface of the olecranon, making tension band wiring less effective (71).
Therefore, I recommend rigid internal fixation with interfragmentary
compression screws augmented by a neutralization plate. In some cases,
a reverse obliquity of the fracture line may result in a proximal
fragment too small for plate fixation. In this case, use an
intramedullary compression screw to prevent anterior subluxation (Fig. 16.12). Failure to recognize

this specific fracture pattern may result in unsatisfactory fixation.

Because of the high energy that causes Colton type IV
(comminuted) injury, the fracture is frequently complex and is usually
a challenge to reduce and fix (Fig. 16.13). If
the fracture extends beyond the coronoid process, length must be
restored. Fractures of the coronoid process must be adequately reduced
and fixed to preserve stability (117). Reconstruct the joint surface using interfragmentary screw compression wherever possible. Bone graft is

frequently needed. Then contour a 3.5 to 3.7 mm reconstruction plate to
fit along the posterior–lateral cortex to buttress the fragments and
help neutralize the deforming forces (Fig. 16.13C, Fig. 16.13D). A semitubular plate is usually too weak (152). Other possibilities for fixation include tension band wiring and the use of modified plates such as the hook plate (173).
Tension band wiring alone is often unstable, allowing telescoping of
the fragments with loss of articular congruity. Treatment of these
difficult fractures must be individualized, with fixation based on the
fracture pattern.

In most elbows, immediate active motion through nearly a
full range of motion is possible. Patients must avoid any lifting or
heavy use of the elbow until it is healed. This is a problem in
multiply injured patients who spend the majority of their time in bed,
because they tend to use their upper extremities to move themselves
about the bed. Warn patients to avoid this. Where the fracture is
comminuted or the bone osteoporotic and fixation marginal, determine
the safe range of motion intraoperatively and apply a postoperative
brace, setting the limits of the brace in the safe zone and allowing
the patient early active motion. Once the fracture is healed, which is
usually in 6–10 weeks, a full rehabilitation program is possible.

A well-accepted and commonly used classification of the Monteggia lesion is that of Bado (Fig. 16.15) (9,10,134).
The categories have in common a dislocation of the radial–humeral joint
associated with a fracture of the ulna or with lesions at the wrist.
Four types of fracture–dislocations are described, based on the
direction of the radial head dislocation. A series of equivalent
injuries is also described with respect to the mechanism of injury and
treatment:

Bado also described equivalent lesions for type 1:

Type 2 equivalents (Fig. 16.15C)
are epiphyseal fractures of the dislocated radial head or fractures of
the neck of the radius. Bado described no equivalents for Monteggia
lesion types 3 and 4.

Compared to other forearm fractures, the Monteggia
fracture dislocation is more likely to result in disability and
permanent stiffness of the elbow (15,19,134,140).
To the surgeon, this lesion is possibly the most challenging forearm
injury. To enhance the chances of obtaining a satisfactory result, the
following are needed:

However, even with the most meticulous attention to these details, poor function may result.

The preceding principles can be applied to the
skeletally mature patient, for whom it is generally accepted that
operative intervention is indicated. However, the Monteggia lesion in
children has been successfully treated by closed reduction and casting.
Open treatment in a child with this injury is the exception.

Immobilize in a long-arm cast with moderate to full
supination for about 2–3 weeks. For type 1, 3, and 4 lesions, maintain
flexion at 90°. Position type 2 lesions at 70° of flexion. After
removal of the cast, begin active motion. Avoid extremes of motion to
prevent recurrent radial head subluxation. A motion restricting brace
may be helpful.

Type I fractures require no treatment other than
symptomatic, although careful evaluation of the elbow to look for major
ligamentous injury is essential.

In type II fractures, if the ulnar humeral joint is unstable, fixation is indicated (Fig. 16.17).
If fixation is not possible, the elbow may be stabilized with the
distraction external fixator without fixation of the fragment.

In type III fractures, open reduction and internal
fixation are indicated if the fracture is not too comminuted and
therefore unfixable. Loss of fixation or redisplacement of these is
common; therefore, Regan and Morrey (135)
neutralize the deforming forces across the elbow with a distraction
hinge external fixator. In comminuted fractures, they do not excise the
bone fragments, as this can lead to chronic elbow instability, but
stabilize them with #5 nonresorbable sutures to the shaft of the ulna
using the distraction device to provide stability. Early motion in all
of these fractures is important.

Using these indications, Regan and Morrey (135)
were able to obtain satisfactory results in 90% of patients with type I
fractures and 67% with type II, but only 25% for type III, showing the
difficulty of these fractures.

The most widely used and accepted classification of radial head fractures is Mason’s (97):

About 10% of all radial head fractures occur in
association with an elbow dislocation. This may result in altered
treatment and prognosis; thus others have designated this as a type IV
injury (Fig. 16.18D).

The Orthopaedic Trauma Association and the International Society for Fracture Repair classification system (125)
provides a much more detailed classification, which includes fractures
of both the head and neck, both as isolated injuries and in combination
with fractures of the ulna. Because all clinical studies published to
date use the Mason classification, I use it here.

The goal of treatment is to maintain good elbow function
and thus to retain adequate motion and joint stability. To evaluate
function acutely, aspirate the elbow and then instill local anesthetic
into the elbow joint. This affords two benefits. First, it decompresses
the joint and relieves pain (68). Second, once
the elbow becomes relatively painless, it is possible to determine
whether there is a bony block to motion or not. This procedure is
important in all radial head fractures in which closed treatment is
being considered.

Much controversy exists concerning the advantages and
disadvantages of radial head excision. Advocates feel that it allows
early motion and less morbidity for most type II and III fractures (77).
Others have disputed this mode of therapy, noting complications of
subluxation of the distal radioulnar joint, elbow pain, and cubitus
valgus deformity following excision (25,45,110,114,138).
Since the radial head has a role as a significant stabilizer of the
elbow, recommendations for early excision have probably been
overstated. Proponents of saving the head in all fracture types note
that late excision is still a viable option that has been shown to give
good results (18,117,118,126,179).

To preserve stability of the elbow and prevent proximal
radial migration, prosthetic replacement with silicone rubber has been
proposed (60,120,121,161).
I no longer use silicone implants because they are unstable and lead to
silicone synovitis. This view is supported by others (112).
Certainly, the routine use of a prosthesis in the treatment of radial
head fractures is not favored. Situations in which its use may be
indicated are fractures associated with elbow or distal radioulnar
instability, for which a rigid stable replacement such as a metallic
head or allograft might be useful. We have used both at the University
of California Davis Medical Center, but our experience and that of
others is limited, and effectiveness is not yet proven (82,162).

Because of the failure of other methods to obtain
consistent, reliably satisfactory results in Mason type II, III, and IV
fractures, I recommend reconstruction of the radial head and neck with
anatomic restoration of the radiohumeral joint, despite its technical
difficulty. Current indications for open reduction and internal
fixation are as follows:

Small and minifragment screws can be used to reconstruct
the radial head, and miniplates can be used on the neck. Try to place
fixation where it will not encounter the proximal radioulnar joint
(sigmoid notch). Countersinking the screw head is necessary if it is
placed within the articular circumference. An alternative method of
fixation is the Herbert differential pitch bone screw, which allows for
placement beneath the articular surface (98). Absorbable pins may be used as well (127).
Long-term studies evaluating operative reconstruction of these injuries
are needed before there will be widespread acceptance (117). Treatment is based on the fracture type.

Treat Mason type I undisplaced radial head fractures by
aspiration and evaluation for any block to motion. If there is no bony
block to motion, then begin early active range of motion after pain has
subsided. Initial splinting provides comfort while allowing full
pronation and supination. Take frequent follow-up radiographs to check
for displacement.

Type II fractures are most controversial. If the
fracture pattern is amenable to internal fixation, I favor anatomic
restoration (Fig. 16.19). Otherwise, nonoperative treatment is advocated, again with aspiration and evaluation of motion (53). If problems persist, perform late excision.

Type III comminuted fractures in most elbows are best
treated with complete excision within 48 hours after fracture. The
elbow will be stable to valgus stress if the medial collateral ligament
is intact. There appears to be no advantage to removal of just the
displaced fragments. If examination under anesthesia in type III
injuries reveals satisfactory motion, pursue nonoperative treatment,
with late excision of the radial head if the result is not
satisfactory. However, late excision of the radial head after type III
fractures does not give nearly as good results as it does after type II
fractures (4,117). With
the increasing sophistication of mini-fragment fixation systems, more
surgeons are attempting to reconstruct and internally fix these
fractures (45,120,147). For stable elbows, Morrey (117)
advocates excision, and I agree. In complex fractures with instability
of the elbow or an Essex-Lopresti lesion, however, treatment is
exceedingly difficult. Fixation of the radial

head and neck with a miniplate and screw system may be essential to a stable elbow.

Treat type IV fractures, with a posterior dislocation of
the elbow together with a radial head fracture, by initial reduction of
the dislocation and then treatment of the radial head according to the
principles just described. Preservation of the radial head in these
injuries is important to maintain stability and thus is highly
recommended (25,81,117,179).
When extirpation of the head is unavoidable, consider repair of the
torn ligaments or use of a distraction external fixation or a temporary
radial head prosthesis.

Early motion is essential for a good result. Having
determined the safe and stable range of motion under anesthesia prior
to wound closure, apply a motion-limiting brace and begin active motion
as soon as the patient’s pain and soft-tissue swelling are controlled.
Dynamic splinting after 6 weeks may be helpful in gaining range of
motion, as previously described. Avoid resistive exercises or heavy use
of the elbow until fracture union has occurred.

The usual cause of elbow dislocation is a fall on the
outstretched arm. Motor-vehicle accidents are also a common cause of
elbow dislocation, frequently with associated systemic injury. These
are often higher-energy injuries, and the mechanism may involve axial
compressive loading on a slightly flexed elbow. In most cases, a
posterolateral dislocation occurs with tearing of the radial collateral
ligament and lateral capsule (157). Associated
fractures are more likely to occur in higher-energy injuries. With
hyperextension of the elbow, the capsular constraints are torn and the
humerus is driven through the capsule anteriorly, tearing the
brachialis muscle. The anterior portion of the medial collateral
ligament appears to be the primary stabilizer in resisting valgus
stress and is a pivot point that allows the radius and ulna to
dislocate posteriorly when the lateral ligamentous constraints are torn
(Fig. 16.20) (72,157).
The final position is usually posterolateral, but depending on the
resultant force vector, straight posterior or posteromedial dislocation
may occur.

Other directions of elbow dislocation are distinctively
uncommon. The rare anterior dislocation occurs with extreme
hyperextension and may be associated with extensive tearing of the
brachialis musculature, or neurovascular injury. Straight lateral
dislocations are also rare and are associated with extensive tearing of
the medial ligamentous restraints. The reverse is true for the uncommon
medial dislocation or subluxation. Divergent dislocations are rare
high-energy injuries associated with extensive soft-tissue injury to
the interosseus membrane, joint capsule, and collateral and annular
ligaments (Fig. 16.21). Usually, this strong
musculoligamentous complex binds the radius and ulna securely, so that
both bones dislocate together in a linear fashion. Therefore, isolated
dislocation of either bone is uncommon, although dislocation of the

radial head is frequently associated with fractures of the proximal ulna (139) (i.e., Monteggia type 1 injury) (Fig. 16.22).
In children, the ulnar fracture can be subtle, consisting only of mild
ulnar bowing in association with a dislocation of the radial head,
which is usually anterior but uncommonly may be posterior or lateral.
Occasionally, the radial head remains dislocated after attempted
reduction of an elbow dislocation. Congenital or developmental
dislocation of the radial head with superimposed acute trauma may
present difficulty in diagnosis. These conditions are usually
bilateral, and radiographic evaluation of the opposite elbow is helpful
in securing the diagnosis.

Displaced radial head fractures are uncommonly
associated with dislocation of the distal radioulnar joint
(Essex-Lopresti injury). This injury has been discussed previously with
radial head fractures.

Modification of Hamilton and Stimson’s long-established classification is shown in Figure 16.23 (105).
This system includes uncommon varieties of dislocation. However, from a
practical standpoint, approximately 90% of elbow dislocations
encountered are posterior or posterolateral (Fig. 16.24).

The conscious patient has severe pain. The elbow is
swollen and usually held in slight flexion, often supported by the
uninjured hand. The forearm is foreshortened, and the olecranon and
radial head are prominent posteriorly in the typical dislocation.
Neurovascular function is usually intact but needs to be accurately
assessed. With rare anterior dislocation, neurovascular injury may be
present. Crepitus or extensive ecchymosis implies a fracture
dislocation. Soft-tissue abrasions about the elbow may exist, although
open dislocation is uncommon.

Radiographs in two planes reveal the type of
dislocation. They should be scrutinized carefully for associated
periarticular fracture, especially of the radial head, coronoid process
of the ulna, or medial epicondyle (Fig. 16.25).
The latter fracture is seen more commonly in children and is the most
likely culprit in irreducible elbow dislocation. When fracture of the
medial epicondyle accompanies elbow dislocation, it usually reduces
with elbow relocation. Occasionally, it is incarcerated in the joint,
preventing reduction and requiring surgical treatment. In the unlikely
event that physical examination suggests a vascular injury, obtain an
arteriogram promptly.

Reduce the elbow as soon as possible using closed
manipulation. Closed reduction usually is not difficult. Most elbow
dislocations can be reduced in the emergency room under conscious
sedation. Various methods of reduction have been described. All
techniques involve correcting any lateral or medial displacement. Figure 16.26
depicts a method in which the arm hangs off the end of a well-padded
table and the patient is prone and relaxed. With the elbow flexed at
90°, apply gentle but firm traction on the forearm while grasping the
distal humerus with your opposite hand, and apply thumb pressure on the
posteriorly displaced olecranon. Some physicians advise mild
hyperextension to diminish impingement of the coronoid process, but
this is usually not necessary. After reduction, gently flex and extend
the elbow to ensure that reduction is complete and to ascertain
stability. Confirm reduction on radiographs.

Reduce anterior dislocations by slight flexion and
posterior displacement of the forearm, accompanied by gentle traction.
The rare divergent dislocation usually requires separate reductions of
the ulna and then of the radius. Gross instability or residual
subluxation may require open reduction and repair of the annular
ligament and capsuloligamentous complex.

Most elbow dislocations unaccompanied by major
periarticular fracture are not difficult to reduce. Inability to reduce
an elbow dislocation promptly requires careful reevaluation of
radiographs and physical findings to ascertain the impediment. The most
frequent indications for operative intervention are irreducible
dislocation, associated fractures, incongruous joint after reduction,
gross instability or neurovascular injury, and unreduced (chronic)
dislocations (44).

The classification of forearm fractures is simple and
straightforward. It is based on the level of the fracture(s), from
proximal to distal; the bone(s) that are involved; the degree of
displacement, angulation, and rotation; the presence or absence of
overriding, segmentation, or comminution; and whether the fracture is
open or closed. The Orthopaedic Trauma Association and the
International Society for Fracture Repair system (125) classifies shaft fractures into 36 types; these are not clinically useful, although they are used in clinical investigation.

Fractures of the ulnar shaft that commence at about the
level of the coronoid process, extending to about midshaft, and that
occur in conjunction with dislocation of the radial head are known as
Monteggia fractures and have been discussed previously in this chapter (1,9,10,15,19,40,133,134,151,158).

Fractures of the proximal third of the radius are
characterized by rotational problems; these are discussed later in this
chapter.

Midshaft fractures of the radius or ulna, or both,
present with varying configurations, depending on the mechanism by
which the injury was inflicted and the degree of violence involved (37).
The fractures are typically transverse or short oblique if they are
simple. Alternatively, in high-energy injuries, they may exhibit
extensive comminution or segmentation, with significant soft-tissue
involvement.

Fractures of the lower half of the ulna are known as
“nightstick fractures,” an obvious reference to the mechanism of
injury. Fractures of the radius with disruption of the distal
radioulnar joint are termed Galeazzi or Piedmont fractures (90,108,109,113).

Perform clinical and radiologic evaluation, together
with careful attention to the condition of the soft tissues. Often the
deformity of the forearm with fractures of one or both bones will be
evident immediately. Refrain from excessive manipulation to avoid
further damage to soft tissues. Note any evidence of neurologic or
vascular compromise. Check the patient periodically to confirm the
continuing integrity of circulatory and neurologic function.

Radiographs must include x-ray views in two orthogonal
planes of the entire forearm, including both the elbow and the wrist
joints. Fractures of the radius and ulna can be complicated by subtle
injuries to these joints. Radial–ulnar disassociation with rupture of
the central band of the intraosseous ligament can be difficult to
detect and is often diagnosed late (166,170).
Especially when fractures of the proximal radius and/or radial head and
neck show shortening, look for evidence of proximal subluxation of the
radius at the distal radioulnar joint. Comparison films to the opposite
normal side may be necessary. On clinical examination, more pain than
would be expected and tenderness at the distal radioulnar joint should
suggest this injury.

The ulna, which is relatively straight, has a stable
articulation with the distal humerus at the elbow and runs virtually
subcutaneously distally to the ulnar styloid at the wrist. The radius
is bowed along its length from the widened distal end, which
articulates with the carpus, to just distal to the bicipital tuberosity
(at the insertion of the biceps tendon). There, it angles at about 13°
opposite to the bow to articulate with the capitellum. The radius and
ulna form a joint at the distal end, where the strutlike radius sweeps
and rotates around the relatively fixed distal ulna with motions of
pronation and supination.

In treating fractures in the forearm, the radial bow and
proper interosseous space must be maintained for normal motion to be
achieved. Schemitsch and Richards (153), as
discussed previously, showed that restoration of the radial bow is
related in a directly linear fashion to the quality of the outcome.
Normal rotation of the forearm requires a normal bow in the radius. The
normal maximum radial bow, measured by the distance between the radius
in the ulna across the interosseous membrane, is 15 mm. To get 80% of
normal range of motion, this bow must be within 1.5 mm. The same
relationship is related to grip strength. Both the amount of bow and
the location are important.

Moore et al. (113) demonstrated
the importance of the interosseous ligament to the axial stability of
the distal radioulnar joint in cadavers. They showed that osteotomy of
the radius allows axial movement of the radius of 3 mm and division of
the triangular fibrocartilage increases the movement to 6 mm, whereas
division of the central band of the interosseous membrane produced more
than 10 mm of proximal migration of the radius. In mechanical tests of
cadaver intraosseous membranes, Wallace et al. (170)
demonstrated elongation of about 10 mm of the central band before
failure. In a preliminary study, they demonstrated that ultrasound may
be of value in detecting tears of the interosseous membrane.

Markolf et al. (96) showed that
when the elbow is in valgus alignment with contact of the radial head
against the capitellum, the main pathway for load transmission from the
hand to the elbow is through the radius. When the hand was loaded, with
the forearm in neutral rotation, the mean force in the proximal
ulnar–humeral joint was only 12%, whereas when the elbow was in varus
alignment and the forearm in neutral rotation, 93% of the force was
transferred via the interosseous membrane through the ulna. It is
evident that transfer of a load from the wrist through the radius and
ulna to the elbow is complex and

dependent
on the anatomy of the wrist, the soft-tissue attachments between the
radius and the ulna, and the position of the forearm. Radial–ulnar
load-sharing changes significantly when the distal end of the radius is
shortened by as little as 2 mm, emphasizing the need for anatomic
reduction.

The forces of muscle groups originating or inserting at
different levels of the radius and ulna are associated with various
deformities after fixation. For example, a fracture in the proximal
third of the radius, occurring between the supinator insertion and the
pronator teres insertion, results in supination of the proximal
fragment and pronation and angulation of the distal radius. In addition
to supination, the biceps brachii tends to flex the proximal radial
segment. If the fracture occurs distal to the insertion of the pronator
teres, both fragments are likely to be found in neutral rotation (Fig. 16.28).

Distally, the insertion of the pronator quadratus
pronates the distal radial fragment. In the presence of an intact
radius, fractures of the ulnar shaft are comparatively less affected.
Muscles attaching to the proximal ulna are resisted by the stability of
the elbow joint. The radial head, of course, is not restricted by that
joint. Distally the ulna has little mobility and relatively weak muscle
attachments, so it is not often displaced.

Fractures of one or both bones of the forearm, if
essentially undisplaced and stable, may be successfully treated by
closed methods (14,33,35,36,149,150).
This requires meticulous attention to molding of the plaster to
maintain the necessary relationships among the radius, ulna, and
interosseous membrane. The fracture must be evaluated weekly to ensure
that no loss of position has occurred. The technique for closed
treatment is well outlined in an excellent book by Charnley (31). See Chapter 10
for additional information on application of upper extremity casts.
Isolated ulnar shaft fractures with less than 10° of angulation can be
treated with casts or braces (149,150).

Sarmiento et al. (150) treated
287 isolated fractures of the ulnar shaft with prefabricated functional
braces resulting in a 99% union rate and good to excellent functional
results in 96% of the cases.

Only in children does the salubrious effect of growth and remodeling offer an alternative to the otherwise mandatory

surgical treatment of displaced or unstable forearm fractures, assuming
that adequate alignment and proper rotation of the fragments can be
obtained and maintained by closed methods. Angulation in the plane of
joint motion is most likely to improve with growth and remodeling.
However, rotational deformities and loss of normal interosseous space
cannot be expected to improve with growth and remodeling, even in very
young patients. The cut-off ages are in the range of 10–12 years in
girls and 12–14 years in boys. At these ages, surgical treatment must
strongly be considered for displaced fractures of the forearm.

All displaced, unstable fractures of the radius and ulna in adults are best treated with internal fixation (6,7,20,22,38,42,43,54,59,65,66,78,89,107,111,122,123,131,141,148,153,155,159,160,163,164,166),
including isolated fractures of the ulna with angulation greater than
10°, Monteggia fracture–dislocations, and Galeazzi fractures.

Open fractures warrant immediate irrigation,
debridement, administration of antibiotics, and stabilization of the
fracture by internal or external fixation (see Chapter 12).
Compartment syndrome, which must be treated by fasciotomy, also
warrants stabilization of fracture fragments by internal or external
fixation.

Fractures are best internally fixed as soon after injury
as practical, preferably before the onset of swelling. With delay,
fracture blisters secondary to swelling can develop. Ruptured fracture
blisters or abrasions that are more than 6–8 hours old may be
contraindications for surgery. At least 7–10 days may be required for
abraded skin and fracture blisters to heal and for swelling to subside.

Chapman et al. (29) have shown
that immediate fixation of open fractures of the forearm of all grades
can be done with minimal risk of infection if thorough irrigation and
debridement are done. Only 1 of 49 open fractures plated primarily
became infected, and that resolved with treatment.

Plan the surgical approaches for the treatment of
forearm fractures after considering the level of the fracture
(especially important in radius injuries), the protection afforded any
neurovascular structures that may be encountered, and the best means of
providing efficient exposure with minimal soft-tissue damage. Open
wounds may require a modification of the “ideal” surgical approach.

Four basic exposures are recommended:

Approach ulnar fractures with the patient lying supine
or partially turned toward the side contralateral to the fracture. In
this way, the arm can be pronated across the chest to facilitate access
by the surgeon and the assistant.

Approach very proximal radial fractures through either a volar antecubital incision or a dorsolateral approach (63).
The dorsolateral approach provides an excellent extensile approach to
the radius from the elbow to the wrist. The key to the exposure is the
identification and meticulous reflection of the posterior interosseous
nerve along with the supinator muscle off the proximal third of the
radius. Exposure of the middle third presents no problems. The distal
third of the radius is usually approached volarly, but the dorsal
approach is useful as well.

The specific approaches are thoroughly discussed in Chapter 1 and in the classic book by Henry (63).

Bagby (11,12 and 13), Danis (39), and others (5,47,48,65,76,107,128,129,168,177)
established the principles used today in plate fixation of forearm
fractures. The most appropriate treatment for unstable fractures of the
bones of the forearm is open reduction and internal fixation using
plates and screws. Anderson et al. (5,6 and 7)
used the 4.5 mm, round-holed, narrow plate in their series and
established the efficiency of plate fixation of the forearm bones in
North America. These plates are rather large for the forearm and have a
22% incidence of refracture of the bone after plate removal. The 3.5 mm
AO-ASIF dynamic compression plate; its more recent version, the low
contact dynamic compression (LCDC) plate; and similar plates such as
the Alta reconstruction titanium plate are now the most commonly used
plates in adults and have made it possible to apply these techniques to
even small-boned patients such as adolescents and most women.

In a series of 129 fractures of the radius and ulna fixed with the AO 3.5 mm plate, Chapman et al. (29)
had a union rate of 98.5%, with 92% excellent or satisfactory
functional results, and no refractures after removal of the 3.5 mm
plates. Newer, equivalent-size titanium plates are now available that
are stronger yet more flexible than stainless-steel plates.

Jones et al. (80) in a
laboratory study compared the stability of LCDC plates and fluted
intramedullary rods for the fixation of fractures of the radius and
ulna. They showed that the intact ulna is more important than the
radius to forearm stability in bending and torsion. Therefore, if the
radius is fractured but the ulna remains intact, medullary nailing will
produce constructs with greater stiffness, particularly in torsion,
than if the ulna is fractured and the radius is intact. In the case of
fractures of both bones, they found that nails resulted in
significantly less stiffness in torsion as well as in distraction and
compression as compared

to plates. Torsional stiffness with intramedullary nails was 2% of intact specimens, whereas with plates it was 83%.

Rush (143), Sage (144,145 and 146), and others (95,156)
popularized intramedullary nailing of forearm fractures in the late
1950s and the 1960s. Medullary nailing was attractive at the time
because closed treatment of displaced forearm fractures in adults was
not achieving acceptable levels of function and the principles of plate
fixation and the smaller stronger plates had not yet been popularized
by the AO group. In addition, the percutaneous techniques of
intramedullary nailing that avoided open incisions was appealing
because infection rates in open internal fixation at that time were
higher than they are now. As pointed out in the previous discussion on
the biomechanics of internal fixation, plates offer superior stability
to nail designs currently available. Nailing with smooth nonlocking
nails such as rush rods often requires additional immobilization in a
long-arm cast, which interferes with restoration of forearm motion.
Other problems of intramedullary nailing include the following:

More recent locking nail designs such as the ForeSight nail (Smith and Nephew, Memphis, TN), the Lefèvre nail (42),
and others offer improved fixation due to their proximal and distal
cross-locking capability. These designs (e.g., the Sage nail) often
have fluted cross sections, and this offers additional fixation. There
is little published on these newer nails, nor is a prospective
randomized study comparing plates to nails available; therefore, their
effectiveness remains unproven at present.

Kundel et al. (92) showed 52%
excellent to good late results in 77 intraarticular fractures of the
distal humerus treated by open reduction and internal fixation. Nerve
injuries resulting from the fracture occurred in 26 patients, and 49%
had heterotopic bone formation; the results were less favorable in
patients with open fractures and those with multiple injuries. Helfet
and Schmeling (62) reported an incidence of
only 4% of heterotopic ossification, 4% infection, 7% ulnar nerve
palsy, 5% failure of fixation, and 2% nonunion. This rate of
complications is what would be expected with today’s modern techniques.
Neither of these authors mention postoperative stiffness, which in my
experience is the primary reason patients have poor outcomes (50,167).

Early failure of internal fixation of all upper
extremity fractures is most commonly due to inadequate fixation, poor
patient cooperation, or poor-quality bone (17,67,73,106,136,159).
The nature and magnitude of the original injury, because of
comminution, may also lead to failure, but the devascularization
associated with comminution and severe soft-tissue injuries is more
likely to lead to infection or to failure of union. In the absence of
infection, the most common causes of failure in the reconstruction of
supracondylar fractures of the humerus are poor preoperative planning
and failure to follow the principles outlined in this chapter. This can
lead to the use of inadequate appliances, or to failure to achieve
sufficient stability in the fracture site that early rehabilitation can
be tolerated without failure. Fortunately, reconstruction of nonunions
and intraarticular malunions of the distal humerus is surprisingly
successful, with final functional arcs of motion averaging 100° (83,84,85,103) (see Chapter 27 for more details).

Common errors in the plate fixation of bones in the
forearm are failure to choose a plate of adequate length; using plates
that are too small, such as one-third tubular plates; and failure to
eliminate micromotion in the fracture site. Interfragmentary
compression with screws should always be done, if feasible.

As discussed previously, the need for bone grafting forearm fractures after plate fixation is debatable (29,177).
In fractures with bone loss or substantial comminution, or where there
has been significant soft-tissue stripping, I believe that bone
grafting is prudent. Collagraft (Zimmer, Warsaw, IN) (28)
has been shown in forearm fractures to be equal in efficacy to
autologous cancellous bone graft. This eliminates the morbidity of
taking an iliac crest graft. On the other hand, securing a small amount
of cancellous bone through a stab incision on top of the iliac crest
incurs minimal morbidity. Fortunately, with good technique, union rates
of 97% to 98% can be expected. Most nonunions respond well to repeat
plate fixation and bone grafting (see Chapter 27).

Neuropathy in the ulnar nerve at the elbow can be caused
by the original injury, operative manipulation of the nerve, inadequate
release of the soft tissues around the nerve in a transfer, and
postoperative fibrosis around the nerve. The best approach is to avoid
any additional ulnar neuropathy by gentle neurolysis of the nerve and
well-executed anterior transfer. Ulnar nerve neurolysis and
transposition during reconstruction after failure of primary treatment
of elbow fractures has a reasonable chance of providing good pain
relief, improvement in sensation,

and even improvement in hand strength and dexterity (102).

Injury of the median nerve most commonly occurs at the
elbow and may coexist with injury of the brachial artery. In fractures,
there may be direct contusion or stretching of the nerve over displaced
fragments, and in dislocations the nerve can slip around the medial
condyle and be stretched across the back of the trochlea. Trapping of
the nerve in the trochlear sulcus with compression is possible. In the
vast majority of cases, the injury is a neuropraxia, which responds to
reduction of the elbow and observation. The posterior interosseous
branch of the radial nerve is vulnerable in type I Monteggia fractures
because of anterior dislocation of the radial head (175).
The vast majority of these recover with nonoperative care. In closed
injuries, exploration of any of these nerves around the elbow and the
forearm is rarely indicated. If recovery is not seen by the time the
fracture heals, then nerve conduction and electromyographic and nerve
conduction studies are indicated to determine the nature of the lesion
and the need for surgical exploration.

Vascular injuries are uncommon. In fractures of the
distal humerus and with injuries around the elbow, any evidence of
impaired circulation, unless it returns to normal immediately after a
closed reduction, merits an arteriogram. With a disruption of the
brachial artery, the collateral supply about the elbow often prevents
loss of limb, but poor circulation can lead to long-term pain and
dysfunction. Obtain vascular surgery consultation if there is any
question of whether a brachial artery exploration and repair are
indicated.

Compartment syndrome is uncommon after pure elbow
dislocations but is more common after high-energy displaced fractures
of the distal humerus, elbow, and forearm. At the time of irrigation
and debridement of open fractures about the elbow and in the forearm,
it is usually fairly easy to do an open or semipercutaneous fasciotomy
of the deep fascia of the compartment in which you are operating. This
prophylactic procedure adds little morbidity and may prevent an
occasional compartment syndrome. After internal fixation of elbow and
forearm injuries, do not close the deep fascia, because closure can
precipitate a compartment syndrome. Postoperatively monitor patients
carefully for signs of compartment syndrome, measure intracompartmental
pressures when there is any question, and proceed with fasciotomy when
the diagnosis is made. In the forearm, fasciotomy usually requires
release from proximal to the lacertus fibrosis to the midpalm,
including release of the carpal tunnel (see Chapter 13).

Heterotopic ossification (HO) about the elbow is
actually unusual in the absence of associated predisposing causes such
as head injury, high-energy trauma, or thermal injury (88,99,138,165) (Fig. 16.39) (see Chapter 124).
Prophylactic treatment with diphosphonate, nonsteroidal
anti-inflammatory agents such as indomethacin, and low-dose radiation
therapy have been advocated and used with success in total hip
replacement and other disorders. I have no experience with using
prophylaxis for HO around the elbow. The treatment consists of
resection of the heterotopic bone after full maturation, usually in
combination with a soft-tissue release of the elbow to gain range of
motion (99) (see Chapter 27).

Radius–ulnar synostosis is most common following
fractures of both bones at the same level, particularly when plate
fixation of both bones is performed and the hematoma between the bones
communicates (88). Minimize the risk of
synostosis by limiting dissection so that the hematoma between the two
fractures does not communicate, by not placing bone graft in the
interosseous space, and by beginning early pronation and supination.
Maturation of a synostosis usually requires 12 or more months. Although
attempts to surgically remove a synostosis early may result in a
recurrence, Jupiter and Ring (88) showed
slightly improved results when resection was performed before 12 months
in 17 limbs treated by resection and interposition fat graft (see Chapter 27).

Persistent dislocation of the elbow after injury is
usually due to a fracture of the coronoid process with displacement,
severe comminution that precludes fixation, or failure of fixation
(discussed in more detail in Chapter 27). Use of a functional external fixator in unstable elbows may avoid this complication. Moritomo et al. (114)
have described successful reconstruction of the coronoid process for
chronic dislocation of the elbow using a graft from the olecranon in
two cases.

Infection after internal fixation of upper extremity
fractures, even in the presence of open fractures, is unusual, with
infection rates generally below 2% (29). When
acute infection occurs early after plate fixation and the plate is
stable, irrigation and debridement of the wound, combined with
administration of intravenous antibiotics, usually results in
resolution of infection. An antibiotic bead pouch may be helpful.
Low-grade persistent infection can often be managed by appropriate
antibiotic coverage until the fractures are healed. Plate removal at
that point usually results in resolution of the infection. Major
infections, particularly when there is loose fixation, usually require
removal of the implants and conversion to external fixation (see Chapter 135).

Lindsey et al. (94) have
demonstrated that retention of diaphyseal plates, with a mean follow-up
of more than 8 years, results in no significant change in forearm bone
density and grip strength. Mih et al. (107)
compared 62 patients who had their forearm plates removed at an average
of 19 months after insertion, to 113 patients who retained their
forearm plates. The complication rate was much higher in those in whom
the plates were removed, including seven refractures through screw
holes or through the original fracture site. They recommended against
routine removal of forearm plates. Factors that predispose to
refracture are the degree of initial displacement and comminution, the
use of large screws (implants using screws larger than 3.5–3.7 mm in
diameter are rarely necessary), premature removal of the plate, and
lack of postremoval protection (29,67,142).
To avoid this complication, I use titanium plating systems with screws
3.7 mm in diameter or smaller, and I do not remove these plates unless
they are symptomatic or the patient desires removal. In some athletes,
such as football linemen, for whom there is substantial risk of trauma
to the forearm, removal may be indicated to avoid the stress riser at
the end of the plate, but avoidance of refracture may require skipping
a playing season.