Arthroscopic Management of Elbow Fractures and Dislocations

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ARTHROSCOPIC MANAGEMENT OF ELBOW FRACTURES & DISLOCATIONS Felix H. Savoie III M.D., Michael O’Brien M.D.

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S1060-1872(14)00012-4 http://dx.doi.org/10.1053/j.otsm.2014.02.011 YOTSM50437

To appear in: Oper Tech Sports Med

Cite this article as: Felix H. Savoie III M.D., Michael O’Brien M.D., ARTHROSCOPIC MANAGEMENT OF ELBOW FRACTURES & DISLOCATIONS, Oper Tech Sports Med , http://dx.doi.org/10.1053/j.otsm.2014.02.011 This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting galley proof before it is published in its final citable form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.

ARTHROSCOPIC MANAGEMENT OF ELBOW FRACTURES & DISLOCATIONS

Lead Author: Felix H Savoie, III, M.D. Second Author: Michael O’Brien, .M.D. ABSTRACT Arthroscopic techniques continue to evolve. One area of increasing interest involves the management of acute fractures and ligamentous injuries of the elbow. The complicated soft tissue and complex joint arrangement of the elbow make it an intriguing joint for acute arthroscopic management. We present techniques for the management of radial head fractures, coronoid fractures and lateral ligament injuries.

INTRODUCTION: Arthroscopic techniques are having a dramatic impact in the arenas of trauma and fracture management. Specifically in the elbow, the arthroscope has proven beneficial in the management of many different intra-articular and peri-articular fractures and fracture dislocations. However, as with any traumatic injury, if there is any concern regarding the anatomy, specifically the neurovascular structures, then open or arthroscopic exposure and protection should be accomplished as the initial part of the procedure. Similarly, the use of retractors during the procedure to protect essential structures should be considered mandatory in elbow arthroscopy for fractures and dislocations.

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HISTORY AND PHYSICAL EXAMINATION: The history of the injury should be the first focus of the evaluating physician. The amount of energy that produced the injury will have a significant effect on associated damage. History of prior injuries and associated medical conditions should also be noted. Initial physical exam should focus on observation of deformity and neurovascular status. The initial evaluation of motion and stability will often be limited due to pain, soft tissue swelling and hemarthrosis. Once the initial exam and radiographs are obtained, one can consider aspiration of the hemarthrosis followed by an intra-articular infusion of xylocaine or bupivacaine which may provide sufficient analgesia to facilitate the assessment of motion and stability

IMAGING: Imaging may be limited due to the inability of patients to tolerate positioning of the injured joint for adequate assessment. As with the physical exam, aspiration and infiltration of the joint with an anesthetic may facilitate positioning for optimal radiographs. However, more advanced imaging is also quite useful to determine the best management option in these traumatic situations. Magnetic resonance imaging (MRI) will provide further detail regarding ligament integrity in the setting of coronoid fractures and elbow dislocations. Computed tomography (CT) scan with 3D reconstruction can not only help with discerning the fracture patterns but also can be used to help determine screw length pre-operatively.

INDICATIONS/CONTRAINDICATIONS:

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Arthroscopic management of elbow fractures is a rapidly evolving indication for the use of elbow arthroscopy in the identification and treatment of intra-articular pathology. The technique provides for a minimally invasive surgical exposure, minimizing further soft tissue trauma in a region notorious for wound complications. Arthroscopic debridement of fibrinous and osseous debris is advantageous to post-operative elbow range of motion. Visualization of fracture fragments and chondral injuries is often superior to open approaches and minimizes the requirements for intraoperative fluoroscopy. Identification of intra-articular pathology not evident on pre-operative imaging allows for appropriate treatment measures and a more accurate prognosis. Elbow arthroscopy can be used in combination with indirect reduction techniques to maximize articular congruity, or can be used for direct arthroscopic reduction with fixation devices passed into the joint. Absolute contraindications to arthroscopic treatment of acute elbow fractures include infection, neurovascular injuries, poly-trauma, and severely osteoporotic bone in which fixation will be inadequate. Relative contraindications include severe soft tissue swelling, and severely displaced intra-articular fractures in which altered anatomic landmarks and orientation compromise safe arthroscopic access. Open nerve exploration may be necessary in patients with previous ulnar nerve transposition. Arthroscopic treatment of open fractures is controversial, but may facilitate irrigation and debridement and minimize further soft tissue injury in select cases. Open exploration of the posterior interosseous nerve is recommended for radial head fractures when fracture fragments penetrate the capsule and brachialis muscle anteriorly. Injury to the nerve is possible with arthroscopic extraction of fracture fragments from this location due to the close proximity or even entanglement with the nerve. Open removal

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of these fragments is essential to eliminate nerve entrapment in scar tissue that could result in shearing and traction injuries during the rehabilitation process.

SURGICAL TECHNIQUES: Basic Principles The techniques have been previously described [1-3]. We prefer the prone position for fracture management with a small bump under the upper arm. The shoulder can be internally or externally rotated to allow open access to either side of the elbow. A fluoroscopy device must be available to provide satisfactory images of the fracture and its fixation. The forearm and hand should be wrapped with compressive wrapping material to restrict swelling and fluid extravasation. Intravenous prophylactic antibiotics are routinely administered pre-operatively. The location of the nerves and vessels should be carefully marked prior to beginning the arthroscopy. Allowances must be made for displacement due to the deformity from the fracture. Prior to beginning arthroscopy, it is helpful to “pin” the mobile fracture fragment with a small Kirschner wire (K-wire) that can be used to assist with reduction and also sometimes allow placement of a cannulated screw over the wire. This also allows the surgeon to get a “feel “for the fracture in terms of mobility and reducibility.

Equipment Most procedures can be accomplished with the 4.0 mm 30 degree arthroscopic camera. A 70 degree arthroscope can be useful to provide pan-articular visualization of the capitellum or radial head from a posterior portal when instrumentation is required from

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the soft spot portal. It is essential to have switching sticks, interchangeable cannulas and blunt freer type dissectors for retractors to protect the neurovascular structures. A 3.5 mm full-radius arthroscopic shaver is useful for removal of organized fracture hematoma and debris. Various implants can be used for fixation, contingent on the fracture configuration discussed in detail below. Either a small drain or an incisional wound vac, i.e., negative-pressure wound therapy (NPWT), over each of the punctures can be used in the initial post-operative phase to reduce swelling and improve wound healing. Portals along the lateral side should be closed with suture to minimize prolonged drainage, which is a frequent minor complication.

Radial Head Fractures Radial head fractures are the most common type of elbow fractures in adults, and offer an excellent opportunity for arthroscopic evaluation and management. Displaced two-part radial head fractures can be visualized through a proximal anteromedial or posterolateral portal to assess the degree of articular incongruity, fracture fragment stability, and any impingement to forearm rotation. Instrumentation is usually best achieved via direct lateral and soft spot portals. The fracture is visualized from the proximal anteromedial portal (Figure 1-A). The fragments are debrided and then reduced using a probe/grasper in the anterior lateral portal. A spinal needle may be placed over the radial head to determine the best angle for instrumentation and a K-wire placed across the fracture site (Figure 1-B) from the soft spot portal. Definitive fixation can then be performed using absorbable pins or cannulated screws (Figure 1-C). Herbert-Whipple screws (Zimmer,

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Inc, Warsaw, IN) and headless variable pitch screws (e.g. Acutrak screws, Acumed, LLC, Hillsboro, OR) are advantageous in providing secure fixation with compression to allow early motion, while being buried beneath the articular surface to avoid impingement. Reduction and stability of the fixation can be directly assessed during full rotation of the elbow. Rolla et al [4] have reported preliminary results in six patients who underwent arthroscopic reduction internal fixation for radial head fractures classified as Mason [5] Type II (3), Type III (2), and Type IV (1). All patients returned to their pre-injury level of function within 6 months. Michels et al [6] have presented longer term results of an arthroscopic technique for treatment of Mason Type II radial head fractures in fourteen patients. The Mayo Elbow Performance (MEP) scores were excellent for eleven and good for the other three patients at mean follow-up of 5 years and 6 months. The procedure was refined to the use of only a midlateral viewing portal and an anterolateral working portal. A potential advantage of the arthroscopic technique was the observation that a single screw was usually sufficient to obtain stability. The authors concluded that the capsular dissection required in an open technique may increase fracture fragment instability resulting in the requirement for additional fixation. Dawson and Inostroza [7] have published a case report in which they describe a technique of arthroscopic reduction and percutaneous pinning to treat an angulated radial neck fracture, an entity encountered in the developing elbow, most commonly between 9 and 13 years of age. The fracture is reduced through an anterolateral portal with a hemostatic forceps, while a K-wire is percutaneously inserted to obtain fixation of the

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radial head to the diaphysis. A cast is applied for three weeks, and the K-wire is then removed. In some cases of fractures managed non-operatively, delayed radial head excision is an effective option. Broberg and Morrey [8] and Menth-Chiari [9,10] documented significant relief of pain and recovery of motion after late resection of the radial head after non-operative treatment of Mason Type II and III fractures in a review of 21 patients.

Coronoid Fractures Operative intervention of coronoid process fractures is recommended for Regan and Morrey [11] Type III fractures, and any type that interfere with joint motion. The most simple technique involves visualization of the fragment via a proximal anterior lateral portal (Figure 2-A). The fragment is then manipulated by a probe placed via an anteromedial. The fragment is anatomically reduced, and a K-wire is inserted into the fracture bed posteriorly (Figure 2-B). Furthermore, the fracture fragment is reduced to the fracture bed, and the K-wire is inserted through the fragment and into the stable base. As with the radial head, the wire should be held by a grasper to prevent accidental withdrawal while the fixation screw is inserted (Figure 2-C) [12]. Fragments too small for screw fixation can be stabilized with the application of suture anchors placed within the base of the fracture. A hinged brace or external fixator may be necessary to maintain joint stability, and offload the repair until adequate healing has occurred. Lui et al [13] have described successful arthroscopic outcomes in two athletes with Type I coronoid fractures who failed initial conservative management. Treatment consisted of

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excision of loose bodies in one, and excision of a fibrous nonunion in the other. Adams et al [16,17] reported their experience with arthroscopic-assisted reduction and fixation of four Type II and three Type III coronoid fractures. Cannulated screw fixation was achieved antegrade over pins placed using an anterior cruciate ligament (ACL) guide system. The authors note that all five of the available patients for follow-up at an average 2 years and 8 months obtained MEP scores of 100%.

Capitellar and Coronal Shear Fractures Type I and II capitellar fractures are also amenable to arthroscopic repair. The fracture can be visualized with the arthroscope in the proximal anterior-medial portal (Figure 3A). An anterior lateral portal is established, and with a varus stress test, the fragment is manipulated using a probe or grasper into an anatomic reduction (Figure 3-B). A K-wire is then inserted to stabilize the fragment [14]. As with coronoid fractures, a guide may be utilized to assist with direction of the wire over which a screw may be placed (Figure 3C). Osteo-chondral defects not repairable should be arthroscopically debrided [15]. Hausman et al. [18] retrospectively reviewed their results of arthroscopically-assisted treatment of six pediatric lateral condyle fractures. Standard anteromedial and anterolateral portals were used. The fracture fragment was reduced under direct visualization with the assistance of percutaneous 0.062 K-wire joysticks, including a Kwire placed transversely through the axis of the capitellum to facilitate rotational control of the reduction. The K-wire fixation was maintained for 4 weeks post-operatively in a long arm cast. Although the mean follow-up was only 32 weeks, all patients had achieved

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full active range of motion with no radiographic evidence of nonunion or malunion. Perez Carro et al [19] described similar results in their series of 4 patients.

Intercondylar and Supracondylar Fractures Intercondylar and supracondylar fractures generally require open reduction with plate fixation. Of the three AO Group, C classification sub-types, only the C1 type is amenable to arthroscopically-assisted reduction with percutaneous fixation as previously described (Figure 4-A, 4-B). Kirschner wires are drilled from a medial to lateral direction to reduce and provisionally secure each condyle together. Wires are then drilled proximally into each column to secure this construct to the distal humerus. Arthroscopic evaluation must confirm anatomic reduction both anteriorly and posteriorly prior to definitive screw fixation (Figure 4-C). Single column screw fixation limits this technique to individuals with bone quality sufficient enough to allow for early protected motion. Visualization can be augmented with an arthroscopic triceps reflection, if necessary. A retractor strategically placed through a superior portal can be used to lift the triceps to facilitate the exposure.

COMBINATION INJURIES: In some cases of fracture dislocation, arthroscopy may be used for some or all of the procedure. In these cases, the entire team has to be prepared to work efficiently to prevent complications. The initial radiographs (Figure 5-A) will only reveal a small part of the damage. The pattern of fixation is usually diagnostic with hematoma clean up (Figure 5-

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B) followed by radial head fixation (Figure 5-C), coronoid fixation (Figure 5-D) and then lateral ligament repair (Figure 5-E, 5-F) using the same techniques as previously listed.

Recurrent Elbow Instability In some cases of lateral elbow instability, arthroscopic stabilization may be useful. The indications are symptomatic subluxation or dislocation of the elbow that has failed nonoperative management. In the initial visualization anteriorly, one will see the lax annular ligament displaced inferiorly from its usual location around the radial head (Figure 6-A). The arthroscope is placed into the posterior central portal, and one can notice the gapping on the lateral side of the ulnohumeral articulation (Figure 6-B) as well as the ability to “drive through” the ulnohumeral articulation to the medial side (Figure 6-C). Visualization along the lateral side of the humerus will show the absence of the normal attachment of the radial ulnohumeral ligament (RUHL) complex to the humerus (Figure 6-D). The ligaments are then repaired by placing an anchor into the most anterior attachment site (Figure 6-E) and sequentially retrieving the 4 or 6 sutures under and through the lateral ligament complex using both shuttling (Figure 6-F) and retrograde (Figure 6-G) techniques. The final view from both posterior (Figure 6-H) and anterior (Figure 6-I) should show restoration of the normal ligament complex. Results of repair of posterolateral instability have been previously published by the authors with satisfactory results [20].

Complications

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Results of arthroscopic fracture management have generally been satisfactory, with few reported complications. However, the majority of articles have been written by very experienced arthroscopists, who have taken extraordinary precautions to prevent problems. Elbow arthroscopy has a higher reported complication rate than any other joint, with an overall rate of major and minor complications approximating 10% in the reported literature. Moreover, the wound complication rate is substantial in the acutely traumatized elbow. It is essential to be familiar with the deformed anatomy inherent in these fractures and to use retractors to protect the soft tissues. Each case should have a time limit set preoperatively after which the elbow must be opened or the procedure halted.

CONCLUSIONS: The use of arthroscopy has many possibilities in the traumatic setting. Adherence to basic principles of both arthroscopy and fracture management, with protection of the neurovascular structures should allow this tool to be utilized to maximum effectiveness, speeding recovery and improving results.

SUGGESTED READING: Adams, J. E., Merten, S. M., and Steinmann, S. P.: Arthroscopic-assisted treatment of coronoid fractures. Arthroscopy, 23(10): 1060-5, 2007. Broberg, M. A., and Morrey, B. F.: Results of delayed excision of the radial head after fracture. J Bone Joint Surg Am, 68(5): 669-74, 1986.

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Bryan, R. S., and Morrey, B. F.: Fractures of the distal humerus. In The elbow and its disorders, pp. 302-309. Edited by Morrey, B. F., 302-309, Philadelphia, W.B. Saunders, 1985. Closkey, R. F.; Goode, J. R.; Kirschenbaum, D.; and Cody, R. P.: The role of the coronoid process in elbow stability. A biomechanical analysis of axial loading. J Bone Joint Surg Am, 82-A(12): 1749-53, 2000. Dawson, F. A., and Inostroza, F.: Arthroscopic reduction and percutaneous fixation of a radial neck fracture in a child. Arthroscopy, 20 Suppl 2: 90-3, 2004. Feldman, M. D.: Arthroscopic excision of Type II capitellar fractures. Arthroscopy, 13(6): 743-8, 1997. Hardy, P.; Menguy, F.; and Guillot, S.: Arthroscopic treatment of capitellum fracture of the humerus. Arthroscopy, 18(4): 422-6, 2002. Hausman, M. R.; Qureshi, S.; Goldstein, R.; Langford, J.; Klug, R. A.; Radomisli, T. E.; and Parsons, B. O.: Arthroscopically-assisted treatment of pediatric lateral humeral condyle fractures. J Pediatr Orthop, 27(7): 739-42, 2007. Khalfayan, E. E.; Culp, R. W.; and Alexander, A. H.: Mason Type II radial head fractures: operative versus nonoperative treatment. J Orthop Trauma, 6(3): 283-9, 1992. Liu, S. H.; Henry, M.; and Bowen, R.: Complications of Type I coronoid fractures in competitive athletes: report of two cases and review of the literature. J Shoulder Elbow Surg, 5(3): 223-7, 1996. Mason, M. L.: Some observations on fractures of the head of the radius with a review of one hundred cases. Br J Surg, 42(172): 123-32, 1954.

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Menth-Chiari, W. A.; Poehling, G. G.; and Ruch, D. S.: Arthroscopic resection of the radial head. Arthroscopy, 15(2): 226-30, 1999. Menth-Chiari, W. A.; Ruch, D. S.; and Poehling, G. G.: Arthroscopic excision of the radial head: Clinical outcome in 12 patients with post-traumatic arthritis after fracture of the radial head or rheumatoid arthritis. Arthroscopy, 17(9): 918-23, 2001. Michels, F.; Pouliart, N.; and Handelberg, F.: Arthroscopic management of Mason Type 2 radial head fractures. Knee Surg Sports Traumatol Arthrosc, 15(10): 1244-50, 2007. Milch, H.: Fractures and Fracture Dislocations of the Humeral Condyles. J Trauma, 4: 592-607, 1964. Perez Carro, L.; Golano, P.; and Vega, J.: Arthroscopic-assisted reduction and percutaneous external fixation of lateral condyle fractures of the humerus. Arthroscopy, 23(10): 1131 e1-4, 2007. Regan, W., and Morrey, B.: Fractures of the coronoid process of the ulna. J Bone Joint Surg Am, 71(9): 1348-54, 1989. Rolla, P. R.; Surace, M. F.; Bini, A.; and Pilato, G.: Arthroscopic treatment of fractures of the radial head. Arthroscopy, 22(2): 233 e1-233 e6, 2006. Schneeberger, A. G.; Sadowski, M. M.; and Jacob, H. A.: Coronoid process and radial head as posterolateral rotatory stabilizers of the elbow. J Bone Joint Surg Am, 86-A (5): 975-82, 2004. Brown, T. D.; Peden, J. P.; Savoie, F. H.; and Field, L. D.: Arthroscopic Reduction Internal Fixation of Elbow Fractures. In Minimally Invasive Shoulder and Elbow Surgery,

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pp. 375-383. Edited by Levine, W. N.; Blaine, T. A.; and Ahmad, C. S., 375-383, Informa Healthcare USA, Inc., 2007. Holt, M. S.; Savoie, F. H., 3rd; Field, L. D.; and Ramsey, J. R.: Arthroscopic management of elbow trauma. Hand Clin, 20(4): 485-95, 2004. Moskal, M. J.; Savoie, F. H., 3rd; and Field, L. D.: Elbow arthroscopy in trauma and reconstruction. Orthop Clin North Am, 30(1): 163-77, 1999. Savoie, F. H.; Peden, J. P.; and Field, L. D.: Arthroscopic Reduction and Internal Fixation of Elbow Fractures. In Advanced Reconstruction Elbow, pp. 85-92. Edited by Yamaguchi, K.; King, G. J. W.; McKee, M. D.; and O'Driscoll, S. W., 85-92, American Academy of Orthopaedic Surgeons, 2007.

FIGURE LEGEND: Figure 1: The arthroscopic management of radial head fractures: A) Identification and debridement of the fracture. B) The fracture is held reduced while a spinal needle is inserted over the radial head and a parallel wire is inserted inferior to the spinal needle marking the path to stabilize the fracture. C) Final view of the stabilized radial head fracture.

Figure 2: The arthroscopic management of coronoid fractures: A) The fracture is visualized via a proximal anterior lateral portal. B) A wire is inserted from posterior and seen to exit in the center of the fracture bed. C) The fragment is reduced, the wire advanced into the fragment and a screw inserted over the wire to maintain reduction of the fracture.

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Figure 3: The arthroscopic management of capitellar fractures: A) The fracture is identified by visualizing from a proximal anterior medial portal. B) The fracture is reduced, and fixation is inserted from posterior while observing from anterior and radiographic confirmation obtained. C) As with coronoid fractures, a guide may be utilized to assist with direction of the wire over which a screw may be placed . Figure 4: The arthroscopic management of selected distal humerus fractures: A) The fracture is identified from an anterior portal. B) Debridement of the fracture can usually be accomplished via a posterior central portal, as long as one knows the exact location of the ulnar nerve. C) Percutaneous screw fixation allows adequate stabilization in these select cases. D) The final view of the fracture site after arthroscopic stabilization is complete

Figure 5: Arthroscopic management of a “terrible triad “injury with fractures of the coronoid and radial head, along with avulsion of the entire radial ulnohumeral ligament complex: A) Radiographs of the fracture dislocation are of less than optimal quality. CT scan provided exact information as to fracture pattern and length of screws necessary for fixation. B) The anterior hematoma and capsular injury is carefully removed while a retractor protects the anterior neurovascular structures. C) Final view of the radial head fixation with 2 cannulated screws. D) Final view of the coronoid fracture fixation with a single cannulated screw. E) This view from the posterior central portal looking down the lateral gutter demonstrates the complete

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avulsion of the lateral ligament complex. F) The lateral ligament complex seen in Figure 5-E is now repaired. G) The post-operative radiographs demonstrate satisfactory placement of the arthroscopically guided screws in the radial head and coronoid process, as well as anatomic reduction of the elbow joint from the arthroscopic lateral ligament repair

Figure 6: The arthroscopic management of recurrent lateral instability of the elbow: A) Anterior view of the lax annular ligament. B) Posterior view of the olecranon sitting separated from the humerus due to the ligament injury. C) The arthroscopic “drive through” sign showing the gap between the humerus and ulna due to the insufficiency of the lateral ligaments. D) The normal site of the humeral attachment of the radial ulnohumeral ligament (RUHL) complex showing no normal tissue. E) An anchor is inserted into the normal origin site of the RUHL complex in preparation for repair. F) Sutures are retrieved under the annular ligament and through the ligament complex, in this case, using a spinal needle and a shuttling suture to achieve anatomic placement. G) Sutures from the anchor may also be retrieved using a retrograde retriever. H) Once all sutures are passed and tied, the ulna should be reduced to the humerus when visualized from the posterior portal. I) Confirmation of adequate repair can be established by viewing anteriorly again and seeing the annular ligament in its normal position.

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