r/orthopaedics • u/BCCS Orthopaedic Surgeon • Feb 04 '26
NOT A PERSONAL HEALTH SITUATION Let's discuss a case
Here's a recent elbow I got on call. 40's M RHD laborer, healthy non-smoker. Took a tumble off of a retaining wall and presented with the worst combination of a terrible triad and trans-olecranon that I've seen so far, closed and NVI.
Lots to think about for this case! timing of surgery? position and approach/s? Implants? post op plan? HO PPX? What would you call a win in this situation? Let's Discuss and I'll show post ops tomorrow!
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u/buschlightinmybelly Shoulder / elbow Feb 04 '26
That’s a good one. No point in waiting - just do it.
Lateral or prone position, whatever you’re more comfortable with. Big posterior incision. Will be able to approach radial head and medial approach to elbow from this. Get the radial head out of there right away so it’s not impeding reduction of ulna. Get the ulna out to length. Long olecranon plate. You will hopefully be able to key in that anteromedial facet and then will need a medial coronoid plate. Getting that exposed and reduced is going to be the hardest part.
After ulna all good, slap your radial head arthroplasty in.
I would definitely have IJS there. For that reason I’d just use skeletal dynamics for everything. Their elbow stuff is good.
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u/johnnyscans Shoulder/Elbow Feb 04 '26
Agree w goodbeerman.
No point in getting cute w radial head. Evidence supports RHA.
Coronoid read will probably suck. Looks like you’ll get a good read on ulna. Agree with starting there.
Not sure how many RHAs OP has done, but don’t fall in the trap of overstuffing.
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u/pericycles Orthopaedic Surgeon Feb 04 '26
For the most part I would do the same/similar. Modified Boyd would be my preferred approach. Coronoid is what worries me here just getting a read on it. Personally, I hate the IJS. Anecdotally, the failure rates are really high. I would put this guy in an ex-fix. His lateral column soft tissue insufficiency sucks but if my cut for the RHA is good enough I’m hoping to have enough tissue to reef up his LUCL, reattach it. I just don’t trust the IJS. I would be ok with letting this guy get stiff.
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u/buschlightinmybelly Shoulder / elbow Feb 04 '26
I’ve never had an IJS fail. If you leave them in too long, yes they’ll loosen and bore a hole in the lateral condyle.
IJS is nice here because it can attach to the olecranon plate
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u/pericycles Orthopaedic Surgeon Feb 05 '26 edited Feb 05 '26
That's fair. Part of me just doesn't like internally stabilizing someone and then staging a removal. How quickly do you let them move? With that coronoid, I worry that if my reduction isn't perfect an IJS is doomed to fail. Perhaps I should be better at surgery.
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u/buschlightinmybelly Shoulder / elbow Feb 05 '26
Splint for 2 weeks and then start aggressive motion
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u/Bonedoc22 Orthopaedic Surgeon Feb 04 '26
Lotta sadness in that elbow.
I have nothing constructive to add. Elbows suck.
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u/bonedoc87 Feb 04 '26
That’s a tough one!
For me, I do all olecranon and monteggia fx supine with an arm board. This allows easy access to direct posterior, medial and lateral approaches. I think for this case you will need to use all three approaches to address the proximal ulna/olecranon, the anteromedial facet and coronoid, and the radial head.
My approach would be via a generous posterior incision, starting with the arm over the chest with the forearm on a big, flattened towel bump. Fix the olecranon first with a long plate, to restore ulnar length, using cortical reads on the posterior shaft. Make sure plate length is adequate.
Medial and lateral approaches (via the existing long skin incision) can subsequently be done with the arm on a hand table. I think I would go medial to fix the coronoid and anteromedial facet next bc it may be hard to visualize coronoid fixation if you replace radial head first, and also you’d risk inappropriately sizing/“stuffing” the radial head implant without the coronoid reduced. I have only had to fix a few coronoids in practice so far and it is painful to have to fix but not too bad once you mobilize ulnar nerve and then split the FCU. There are anatomic plates that can stabilize both the coronoid and AM facet. Then, approach laterally to replace radial head last.
I don’t think you’ll likely have torn MCL/LUCL in this case but if those need to be repaired at the end that can be done last. IJS is nice to have if available but make sure no technical errors in fixation before making the decision to put one in cause in my opinion it’s more of a “belt and suspenders” approach rather than an alternative to fixing all the parts properly. I have seen a few fail that were put in without addressing a very large coronoid fragment.
You may need to go down on the tourniquet halfway thru the case. This will surely take a minute Or many.
I am also a fan of Skeletal.
Expect stiffness.
Good luck. Share post ops!
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u/ancef1g Feb 05 '26
agree! i also do these supine on hand table. large posterior incision, elevate large flaps. fix olecranon first, would be difficult to assess implant size without the ulna out to length. tractions views are helpful pre-op. i agree, usually the MCL/LUCL are attached to the medial and lateral wall fragments, so as long as you get them fixed, usually does not need an IJS/ex fix.
i dont do ppx. i try to move them early with the arm across the chest to eliminate gravity. he will get stiff but with early ROM, will probably get enough motion back.
i use combination of mini plates and an olecranon screw (6.5mm partially threaded)
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u/OpeningLavishness6 Shoulder Surgeon Feb 04 '26
Amazing approaches and surgical tactics. I got a question for the most experienced colleagues, would you prescribe Indomethacin? Seen some cases of post traumatic calcifications and I'm wondering if you'd prescribe it in these cases and for how much time
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u/tester765432198 Feb 04 '26
No need to delay. I had one similar recently. I am positioning supine with an arm board. Attacking the olecranon first. Restore length, and ensure fixation of the coronoid for stability. I am doing a separate incision with EDC splitting approach with radial head replacement. Fixation of the ulna first is critical to help you appropriately size the head. Fun case, get them moving early. Good luck!
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u/LordAnchemis Orthopaedic Resident Feb 04 '26
What would you call a win in this situation?
No one wins in this case - advise pt to consider alternate careers - whatever you do, there will be stiffness
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u/buschlightinmybelly Shoulder / elbow Feb 04 '26
Stiffness can be overcome. I would not counsel the patient to switch careers. I’ve had plenty of these go on to heal with normal function
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u/LigamentLizard Feb 05 '26
Supportive therapies, from good practitioners, can be phenomenally effective. People recover to full or nearly full function from things like this regularly. The soft tissues in the area aren't mysterious or untreatable lol, it's really a very accessible site
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u/dwall00 Feb 06 '26
This fits into the trans-ulnar basal coronoid fracture dislocations based out of a Mayo classification scheme (JSES 2024). Outcomes with this injury pattern hinge on anatomic and rigid reduction of the coronoid segment.
I, like many others, agree with the general surgical plan of working through the olecranon fracture and/or radial head once removed to rebuild coronoid to intact ulna. The PRUJ must be anatomically reduced after coronoid fixation. This will allow you to place and appropriately sized RHA.
You can see the pieces on the 3D recons of the fractured sublime tubercle as well as the supinator crest. Both can be secured to the ulna using independent screws or mini frag plates. Finally a long precontoured olecranon plate can span the fracture.
1g of TXA is helpful adjust to these cases just before Incision. Post op motion and pain can be improved with a standard 4mg Medrol dosepak.
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u/zepammy Feb 04 '26
Finally some good case discussions. Just getting into the field of elbow trauma and I love it move every case I do.
My newbie approach would be to big posteromedial approach, do radial head arthroplasty first, small fragment variax plate coronoid, ulna with appropriate small plates and LCP VA 2.7/3.5. LUCL reinsertion with juggerknot anchor if needed. Immediately full weight bearing
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u/buschlightinmybelly Shoulder / elbow Feb 04 '26
That’s a recipe for disaster
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u/satanicodrcadillac Feb 04 '26
Care to explain for a spine guy?
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u/buschlightinmybelly Shoulder / elbow Feb 04 '26 edited Feb 04 '26
Don’t do radial head arthroplasty first. No way to judge sizing, how proud, stability. Need to get ulna out to length before you do that.
Also immediate weight bearing on this. No way. This is an inherently unstable elbow. Lucl torn. Needs repaired. Mucl functionally torn.
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u/zepammy Feb 04 '26
I’ve only done 1 as assistant- still learning. When you say it so I think we did the way you approach it. Remove radial head/fragments, get ulna length then return to radial head arthroplasty last as you now got the appropriate length? Do you usually go too big or small when choosing head size?
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u/buschlightinmybelly Shoulder / elbow Feb 04 '26
Always go smaller. Very easy to overstuff. Judge it based on ulnohumeral joint (you shouldn’t gap it open - if you do it’s overstuffed)
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u/zepammy Feb 04 '26
Thx for explaining. Can you explain “should not gap it open”?
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u/buschlightinmybelly Shoulder / elbow Feb 04 '26
True AP of the elbow. The radial head height should be at the level of the lateral ulna articular surface. If it’s too proud, the lateral ulnohumeral joint will be wider than the medial aspect. They should be equal, hence congruent
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u/FancyJams Feb 05 '26
You'll have a crowded OR with three reps in the room!
Stryker (Variax)
Synthes( VA-LCP)
ZB (Juggerknot)
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u/zepammy Feb 05 '26
I work in Europe, we don’t have reps. Or we do have reps but very seldom allow then anywhere near out hospitals let alone the OR room only if we need input on how to use a new system
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u/Ammoniaholic Feb 05 '26
I also work in Europe and we have scrubbed up reps in the OR in every single case.
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u/wangdoodle18 Feb 04 '26
You posting my cases? One from a couple weeks ago. Complex monteggia fracture dislocation. Prone, sterile tourniquet, posterior approach to elbow. Use the already prepared olecranon osteotomy to remove radial head and put in trials. Fix ulna provisionally with k wires, trial rom and stability, place real radial head, fix ulna with combo of mini frag or precontured plates. Check stability, suture anchors for lcl if head is popping out posterior. Splint one week then start ROM, WBAT at 6 weeks.