With elbow dislocations, recognize the terrible triad: elbow
dislocation, radial head fracture, and coronoid fracture. The terrible triad is
not a simple elbow dislocation; it is a complex elbow dislocation. In addition
to these three injuries of the elbow, there is always a tear of the lateral
ulnar collateral ligament. The treatment usually is reduction and splinting of
the elbow.
This cannot be the definitive treatment; it is the initial
treatment. If no surgery is done, you will have recurrent dislocation of the
elbow. You need to do surgery for reduction and fixation of the fractures and
also to restore the elbow stability. This injury is unstable. Simple reduction
and splinting is not going to work for this injury. You have to recognize the terrible
triad which means surgery. There are multiple types of elbow dislocation based
on the position of the olecranon relative to the humerus. The most common type
of elbow dislocation is the posterolateral type. There are two basic types of
elbow dislocations: simple and complex. Simple elbow dislocations have no
fracture seen, and are usually a ligamentous injury. Complex elbow dislocations
have associated fractures in addition to the ligamentous injury. With any elbow
dislocation, you need to check the shoulder and the wrist for injuries and
fractures because it can occur in up to 15%. When you have a simple dislocation
of the elbow, you need to reduce it and then check the range of stability of
the elbow. If you find that the elbow is stable with range of motion, then you
will do a short period of immobilization with a posterior splint for
approximately one week with the elbow in about 90 degrees of flexion. Then start
active range of motion of the elbow. Recurrence of the dislocation is rare
(less than 1%). If you keep the elbow immobilized more than 3 weeks, there will
be severe stiffness of the elbow. Surgery should be done if the dislocation is
irreducible, if there is associated fracture, or if you are unable to maintain
stability of the elbow. After immobilization and early range of motion of the
elbow, you will see the patient and do follow up x-rays to check joint
congruity and to make sure that the elbow reduction is maintained. To treat the
terrible triad, you should initially do a closed reduction. Open reduction and
internal fixation of the coronoid (if possible), of the radial head or excise
the radial head with radial head arthroplasty if the radial head is
unreconstructable. In addition, you will do lateral ulnar collateral ligament (LUCL)
repair. Never excise the radial head alone in this situation. For an elbow
dislocation with olecranon fracture, do open reduction and plate fixation.
K-wires and tension band is not strong enough to hold the fracture and
stabilize the elbow at the same time. For an elbow dislocation with a radial
head fracture, do fixation or replacement of the radial head (never do excision
of the radial head alone in this situation). The LUCL is the most important
lesion in recurrence or persistence of instability of the elbow following
simple elbow dislocation.
The injury progresses from lateral to medial. The lateral
collateral ligament fails first, and it avulses proximally at the lateral
epicondyle. The medial collateral ligament (MCL) fails last. In varus
posteromedial rotary instability, there is an elbow injury plus LUCL tear, plus
coronoid fracture which involves the medial facet of the coronoid. Treatment for
chronic dislocation is open reduction capsular releases with hinge external
fixation and early range of motion. Loss of terminal extension is a
complication of elbow dislocation. Usually for decreased range of motion of the
elbow, you will do static progressive splinting between 6-10 weeks. No manipulation
of the elbow is done, which is different from the knee after total knee
replacement, where you can do manipulation up to three months. With heterotopic
ossification, do excision. Remove the myositis and excise the posterior part of
the MCL to allow more flexion. To be functional, the range of motion of the
elbow should be between 30-130 degrees. Some physicians suggest that if the
flexion is less than 100, you will do release of the posterior bundle of the
MCL in addition to release of the ulnar nerve. If you want more flexion of the elbow,
excise the posterior part of the MCL.
Patellar fractures can involve different topic, and I am
going to try and highlight the important points related to patellar fractures.
The medial patellofemoral ligament is the primary stabilizer of the patella, so
when the patella dislocates, you will have an injury to that ligament and also
an injury to the medial patellar facet articulation cartilage or an
osteochondral fragment. In addition to the medial patellar facet injury, you
will get a lateral femoral condyle injury. Bipartite patella occurs in about 8%
of the population. It could be bilateral in about 50%, and it usually occurs in
the superolateral aspect of the patella. You should observe it and not fix it.
It is not an acute fracture that may need excision or lateral retinacular
release. It can occur in children between 8-10 years old. It is a rare
condition. The patient will be unable to do straight leg raising, so you
suspect that the extensor mechanism is injured. The patient may have a high
riding patella on x-ray with a palpable gap when you examine the patient. The
x-ray may show small flecks of bone as the patellar tendon avulses with a
portion of the distal pole of the patella. Sometimes the bony injury is so
small that the condition can be missed. You should have a high index of suspicion.
You may need to get an MRI to confirm diagnosis. The treatment is usually ORIF
if the fracture is displaced.
The patella is a large sesamoid bone. The quadriceps muscle
is inserted at the proximal pole and the distal pole gives attachment to the
patellar tendon. The patella is triangular in shape. The proximal 3/4 of the
patella is covered with cartilage, however the distal 25% of the patella is not
covered with cartilage. The patella increases the power of the extensor
mechanism by about 50% because it displaces the extensor mechanism anteriorly,
and that will increase the moment arm.
Transverse fractures of the patella can be non-displaced or
displaced. The patella can be pulled apart by the attached quadriceps tendon.
The patient will be unable to do active extension of the knee. Upper or lower
pole fractures of the patella are fractures at the site of attachment of the
patellar tendon. Comminuted fractures of the patella can be non-displaced or
displaced. Comminuted fractures have multiple pieces, are very unstable, and
are difficult to fix. Vertical fractures of the patella are the most common,
and they are stable and nondisplaced. Osteochondral fractures are small fractures of the patella usually associated with acute dislocation of
the patella.
In examination, you may feel a palpable gap. The area of the
knee is usually swollen. The patient will be unable to do straight leg raise.
The lateral view of the knee is the best view to see the fracture. 2-3 mm of
displacement will probably mean that the patient will need surgery.
If you think that the patient’s extensor mechanism is
intact, and the patient is able to do straight leg raise, and the fracture is
nondisplaced or minimally displaced, it is usually a transverse fracture in
this situation, then immobilize the knee straight in a hinged knee brace for
4-6 weeks with weight bearing as tolerated. Sometimes the patient cannot move
the knee because of the pan and injection of lidocaine inside the knee can help
to assess the integrity of the extensor mechanism. If the patient has a total
knee with 2mm displacement of the patella, and the extensor mechanism is
intact, then the patient will be treated conservatively in a brace or in a knee
immobilizer (no surgery).
Indication for surgery is a displaced patellar fracture and
the inability to do straight leg raising.
First, preserve the patella (if
possible). The tension band fixation technique is the gold standard for the
treatment of displaced patellar fractures (the fracture is usually a transverse
fracture), and the tension band technique is the one that gives us the most
complications. The first step in the tension band technique is to reduce the
fracture with reduction clamps. Next, at least two K-wires are placed across
the fracture. An anterior tension band is applied, organized in a Figure-8
pattern. You need to put the Figure-8 tension band wire close to the patella
superiorly and not far away from the patella because that may cause construct
instability and fracture displacement. A second wire may be placed
circumferentially around the patella. Bending the K-wires from both ends may
decrease migration of the wires and decrease the complications. The wire that
is bent at both ends may be difficult to remove. Tension band fixation technique
may be done with K-wires or also with cannulated screws (through the cannulated
screws, you place the wires). It does not matter if you have an open or closed
fracture, you treat it the same way. When you place K-wires, it means
symptomatic hardware and thus a secondary reoperation. It was found that the
longitudinal screws and the tension band wires are a more superior fixation.
The tension band construct when performed correctly will provide absolute
stability and will convert the tension forces from the muscle pull into
compression forces at the articular surface. You want to have anatomic
reduction and stable fixation; don’t judge the reduction by what you see at the
surface of the fracture. Try to see and feel the joint if you can. Check the
x-rays carefully. The surface of the patella may be well reduced, however, the
joint may be distracted or displaced. If you tighten the cerclage wire
aggressively, you may have a good looking surface, but you may have a
distracted join. After you fix the patella, you will do a range of motion of
the knee before closure and give the patient a hinged knee brace, locked into
extension with weight-bearing as tolerated. Weight-bearing is controversial.
Some people start weight-bearing early, and some people start weight-bearing
after 4-6 weeks. A can may be helpful to the patient. You will begin active
flexion at 2-3 weeks (patient will lie prone, flexing and extending the knee).
When the patient is prone, it avoids active knee extension and avoids excessive
stress on the fracture site. At 6 weeks, you can unlock the brace and start
moving the knee, gradually increasing the flexion.
If the patellar fracture is comminuted, you can use the
peripatellar circumferential wire loop fixation, which is commonly used as an
addition to other methods of fixation. You can also use a plate fixation
utilizing a low profile implant and providing stable fixation. This technique
is becoming more popular.
You can also excise the patella partially or completely. In
a partial patellectomy, the distal pole is extra-articular, and if it is
severely comminuted and less than 40% of the patella, then you can excise it
(in general, you would like to preserve the patella). If you can’t preserve the
patella and ORIF is not possible, then do partial patellectomy and preserve the
largest piece. Partial patellectomy may be necessary, but open reduction and
internal fixation (if possible) is associated with a better outcome. You will
do the partial patellectomy in several comminuted inferior pole fractures. You
will do medial and lateral retinacular repair, and a poor outcome may occur
with removal of more than 40% of the patella. Total patellectomy will be done
when the fractured patella cannot be fixed. Total patellectomy can cause
extensor lag and loss of the extensor strength. The quadriceps torque is
reduced by about 50%.
Symptomatic hardware and knee pain is the most common
complication after patellar fracture fixation, especially if you use the
tension band technique. It requires implant removal in about 50% of the time.
This complication will include the hardware migration. Failure after patellar
fracture fixation occurs in about 20% of the time due to increasing age,
fixation with wires, technical errors and noncompliance.
Lumbar spinal stenosis is a narrowing of the spinal canal
and narrowing of the intervertebral foramen (nerve root canal).
There are two
types of lumbar spinal stenosis- central and lateral. Hypertrophy of the facet
joints, hypertrophy of the ligamentum flavum, disc degeneration, or arthritis
are all examples of conditions which constrict the nerve root canals causing
compression of the spinal nerves and sciatica. Patients will have back pain
that is better with flexion, or leaning forward like over a grocery cart. The
pain will be worse with extension of the back. Leaning forward increases the
foramen size by about 12%. Leaning backwards reduces the foramen size by about
20%. Neurological exam is normal in about 50% of the patients.
Central canal
stenosis is responsible for giving neurogenic claudication. Patients may have
leg pain, back pain, buttock pain, weakness, cramps of the calf, and a heavy
sensation. Patients will exhibit grocery cart sign (flexion of the back). The patient
history is key for making the diagnosis of spinal stenosis. Lateral recess
stenosis will give radicular symptoms. It can occur in the nerve root canal.
Neural foraminal stenosis occurs in the intervertebral foramen. Physicians
should look for other conditions such as hip problems, metastatic tumors, or
vascular conditions. You should always examine the pulses. Neurogenic
claudication and vascular claudication may coexist. Walking is bad for both
neurogenic and vascular claudication. Sitting will relieve the symptoms in both
neurogenic and vascular claudication. Stopping and standing is good for the
vascular claudication but still causes symptoms for lumbar spinal stenosis.
Using a stationary bicycle will relieve symptoms of lumbar spinal stenosis, however
it will aggravate the symptoms in vascular claudication. In vascular
claudication, pain starts within the calf and leg. In neurogenic claudication,
pain starts proximally and then spreads distally. It seems like postural
changes of the spine will make the neurogenic claudication worse, however this
will not affect the vascular claudication. Vascular claudication will be
affected by muscle movement or muscle function, such as walking of riding a
bicycle. In neurogenic claudication, leaning over while riding the bicycle will
relieve the symptoms in the same way as the shopping cart sign. Spinal stenosis
can be treated operatively. In central canal stenosis, you should do a
decompression by laminectomy. In lateral recess stenosis, you should do a
medial facetectomy. You should add fusion for instability or if more than 50%
of the bilateral facets are removed. You should look at the x-rays or the MRI.
If there is a slip of the vertebrae, do a fusion in addition to the
laminectomy. The risk of pseudoarthrosis is increased 500% by smoking.
Depression and other comorbidities can affect the outcome. In two years,
patients who are treated with surgery are better in pain and function than the
patient who is treated conservatively. The most common reason for failed surgery
is recurrence of the disease (residual foraminal stenosis). Walking is bad
without the aid of a shopping cart. Leaning over the shopping cart will relieve
the symptoms. If you have a patient with lower back pain and gait disturbance
(hyperflexia), then you have an upper motor neuron lesion. Think about the
cervical spine. You need to get an MRI of the cervical spine after you examine
the patient. Think of cervical spine myelopathy because lumbar stenosis does
not give these findings. Patient with spinal stenosis, spondylolisthesis, or
facet disease will have pain with extension of the lumbar spine. Pain with
lumbar spine flexion will suggest a disc related disorder.
Ankylosing Spondylitis is an inflammatory condition that
affects young adults, occurs more in males, and affects the spine, sacroiliac
joints, and large joints (ex. Hip). Ankylosing means “rigid” or fusion.
Spondy
means “spine”. Spondylitis is inflammation of the spine. The patient may have
inflammation followed by fusion of the spine and the sacroiliac joints. Other large
joints (ex. Hip) may be affected, so the patient may complain of morning
stiffness, low back pain, and maybe hip pain. The pain associated with
Ankylosing Spondylitis gets better with exercises and not with rest. There is a
difference between Reheumatoid arthritis and Ankylosing Spondylitis. Rheumatoid
arthritis affects the synovial lining of joints and affects predominantly the
cervical spine. Ankylosing Spondylitis affects ligaments, tendons, discs, and
some joints, but it will affect the entire axial spine. Ankylosing Spondylitis
is part of the seronegative spondyloarthropathy. This means that the rheumatoid
factor is negative. Although the rheumatoid factor is negative, the HLA-B27 is
positive. Ankylosing Spondylitis is a systemic problem that involves the immune
system. It is almost like rheumatoid arthritis, but with a negative rheumatoid
factor. Risk Factors of Ankylosing Spondylitis would include a young male with
a positive family history + HLA-B27 gene positive. The HLA-B27 is part of the
immune system. It is an antigen that will be on the surface of the cell.
HLA-B27 probably has the same amino acid sequence as the protein produced by
bacteria (klebsiella pneumonia), by food, or by other things. When the immune
system identifies this protein and it goes through the blood stream, then these
T-cells can recognize that antigen that protein is on the surface of cells
(HLA-B27). Then the T-cells recruit other cells to attack it. Everything that
contains HLA-B27 (tendons, ligaments, joints, etc) will be attacked because
they think it is a bad protein.
The protein produced by the bacteria for
example or by the HLA-B27 have the same sequence and the immune system cannot
tell the difference between both of them so it is an autoimmune disease. These patient
will have fusion of the spine. The spine will not have any free movement. The patient
will complain of gradual stiffening of the spine and limited chest wall
expansion. Less than 2 cm of chest wall expansion is more diagnostic than the
HLA-B27 blood test. Ankylosing Spondylitis is a difficult condition to diagnose
and there will be a “Bamboo Spine” seen on the x-ray. There will be sacroiliac joint
involvement which is a characteristic for Ankylosing Spondylitis. There will
also be fusion of the SI joint. There may be systemic autoimmune disease that
will cause fever and malaise. There will be uveitis (redness and inflammation
of the eye). There will be aorta inflammation that may lead to aortic aneurysm
if the aorta is dilated or aortic regurgitation. The patient may have
depression. When you do the blood test, it will be HLA-B27 positive. The sedimentation
rate and CRP could be high. Treatment of Ankylosing Spondylitis uses things
that decrease inflammation such as anti-inflammatory medications, physical
therapy to improve flexibility and strength of the spine and joints, or TNF
alpha blocking agents.
This cannot be the definitive treatment; it is the initial
treatment. If no surgery is done, you will have recurrent dislocation of the
elbow. You need to do surgery for reduction and fixation of the fractures and
also to restore the elbow stability. This injury is unstable. Simple reduction
and splinting is not going to work for this injury. You have to recognize the terrible
triad which means surgery. There are multiple types of elbow dislocation based
on the position of the olecranon relative to the humerus. The most common type
of elbow dislocation is the posterolateral type. There are two basic types of
elbow dislocations: simple and complex. Simple elbow dislocations have no
fracture seen, and are usually a ligamentous injury. Complex elbow dislocations
have associated fractures in addition to the ligamentous injury. With any elbow
dislocation, you need to check the shoulder and the wrist for injuries and
fractures because it can occur in up to 15%. When you have a simple dislocation
of the elbow, you need to reduce it and then check the range of stability of
the elbow. If you find that the elbow is stable with range of motion, then you
will do a short period of immobilization with a posterior splint for
approximately one week with the elbow in about 90 degrees of flexion. Then start
active range of motion of the elbow. Recurrence of the dislocation is rare
(less than 1%). If you keep the elbow immobilized more than 3 weeks, there will
be severe stiffness of the elbow. Surgery should be done if the dislocation is
irreducible, if there is associated fracture, or if you are unable to maintain
stability of the elbow. After immobilization and early range of motion of the
elbow, you will see the patient and do follow up x-rays to check joint
congruity and to make sure that the elbow reduction is maintained. To treat the
terrible triad, you should initially do a closed reduction. Open reduction and
internal fixation of the coronoid (if possible), of the radial head or excise
the radial head with radial head arthroplasty if the radial head is
unreconstructable. In addition, you will do lateral ulnar collateral ligament (LUCL)
repair. Never excise the radial head alone in this situation. For an elbow
dislocation with olecranon fracture, do open reduction and plate fixation.
K-wires and tension band is not strong enough to hold the fracture and
stabilize the elbow at the same time. For an elbow dislocation with a radial
head fracture, do fixation or replacement of the radial head (never do excision
of the radial head alone in this situation). The LUCL is the most important
lesion in recurrence or persistence of instability of the elbow following
simple elbow dislocation. 
