Trauma 101: Orthopedics Study Tool

Indication

Undisplaced or minimally displaced isolated fractures with no mechanical block to rotation and a stable elbow.

Implant design notes

No implant. Sling for a few days only; aspiration of a tense haemarthrosis with local anaesthetic can relieve pain and allow assessment of rotation.

Approach

Non-operative, with active motion from the outset.

Steps overview

1. Assess passive pronation and supination for a mechanical block, using intra-articular local anaesthetic if pain prevents assessment
2. Test valgus stability and palpate the wrist and forearm for a concomitant interosseous injury
3. Provide a sling for comfort for a few days at most
4. Start active flexion, extension and rotation immediately
5. Review at two weeks to confirm improving arc and no instability
6. Warn about a possible mild permanent extension deficit

Notes

A persisting mechanical block after aspiration and local anaesthetic changes the plan; document rotation carefully in the notes.

Indication

Displaced fractures with a mechanical block or a large single fragment amenable to stable fixation, particularly in the young or when the head is needed for stability.

Implant design notes

Small or mini-fragment screws, countersunk below the articular cartilage, or a low-profile plate placed within the non-articulating safe zone of the radial head so it does not impinge on the proximal radioulnar joint through rotation.

Approach

Lateral approach through the interval between extensor carpi ulnaris and anconeus, keeping dissection anterior to the mid-axis to protect the lateral collateral ligament and staying proximal to protect the posterior interosseous nerve.

Steps overview

1. Supine with the arm across the chest or on a hand table; tourniquet applied
2. Develop the lateral interval, incising the capsule anterior to the ligament complex
3. Keep the forearm pronated during exposure to move the posterior interosseous nerve away
4. Reduce the fragment anatomically under direct vision
5. Fix with countersunk screws or a plate within the safe zone
6. Take the elbow through full rotation to exclude impingement of the implant
7. Repair the capsule and the lateral collateral complex if violated, then mobilise early

Notes

Comminution into more than three fragments fixes poorly and predicts failure — replacement is often the better choice. The posterior interosseous nerve is the structure at risk with distal dissection.

Indication

Unreconstructable comminuted fractures, especially with associated elbow instability such as in a terrible-triad injury or an Essex-Lopresti pattern.

Implant design notes

Metallic monoblock or modular implant sized to the excised head, restoring the lateral column length. Overstuffing the joint causes pain, capitellar wear and loss of motion; the implant should sit just proximal to the lesser sigmoid notch level.

Approach

Lateral approach as above; the fragments themselves are reassembled on the table to judge the correct diameter and height.

Steps overview

1. Expose laterally and remove all head fragments, keeping them for sizing
2. Reassemble the fragments to determine diameter and thickness
3. Prepare the neck and canal, then trial the implant
4. Check the radiocapitellar relationship and the ulnohumeral joint for overstuffing on a true anteroposterior view
5. Address the coronoid and the lateral collateral ligament and, if still unstable, the medial ligament
6. Insert the definitive implant and test stability through a full arc
7. Repair the ligaments and start protected early motion

Notes

Excision without replacement in an unstable elbow or with a disrupted interosseous membrane leads to proximal radial migration, wrist pain and valgus instability. Replacement is preferred whenever the head is a needed stabiliser.