Very few

- young labourer with severe disabling elbow pain

- trial in POP at 90o for 6 weeks


Poor function

- adjacent joints cannot compensate for loss of function





- high failure rate especially flail elbow with poor bone stock






- very good results

- 97% 10 year survival Coonrad-Morrey prosthesis


Other Dx 

- OA / post-traumatic arthritis / nonunion

- tend to have worse survival than RA



- elbow joint commonly involved

- 90% of haemophiliacs


Acute unreconstructable fracture > 60






Poor soft tissue cover skin triceps


Under 60 years


Charcot Joint


Implant Types


1. Fully Constrained 

- have highest failure


2. Semi- constrained 


Coonrad-Morrey TER

- sloppy hinge

- allow some varus-valgus


3. Unconstrained 



- stems on ulna & humerus to prevent loosening

- poly / metal bearing

- require MCL & LCL for stability


Technique Latitude Total Elbow Replacement


Total Elbow Latitude RATotal Elbow Latitude RA



- can covert unlinked to linked simply at end of case or at later revision by adding anterior O piece

- unconstrained / semiconstrained

- anterior humeral flange with bone graft important for longetivity


Lateral position

- arm over bolster


Posterior Approach

- full thickness skin flaps

- identify and protect ulna nerve with vessiloops


Total Elbow Ulna Nerve


Triceps Options


A. Split in midline

- feathered off bone medially and laterally

- left attached distally


B.  Bryan-Morrey

- triceps elevated from subperiosteally

- from ulna to radial side

- periosteum left attached on radial side


C.  Triceps sparing

- elevate triceps tendon medially and laterally

- identify and protect ulna and radial nerve medially and laterally

- divide collaterals from humerus and dislocate elbow to medial aspect of triceps


Distal Humerus

- elevate and tag LCL / MCL for later repair

- elevate anterior capsule off humerus


Dislocate Elbow


Prepare humerus


1.  Size capitellum and trochlea with spool

- judge off distal humerus

- insert into olecranon and over radial head


2.  Stabilise centre of rotation

- most important

- centre of capitellum to medial epicondyle of trochlea (just distal and anterior to it)

- pass pin through


3.  Resect olecranon fossa, find entry to IM canal

- pass IM guide


4.  Attach resection jig to rotation and IM pins

5.  Drill holes made to establish area to resect with saw

6.  Need to leave medial column (some trochlea) and lateral column (some capitellum)

7.  Trial


Prepare ulna and radius


1.  Broach IM canal of ulna

2.  Pass IM jig, centre on ulna

- EM points towards ulna styloid

- fixed in position with 3 pins

3.  Use jig to 

- resect radial head

- burr prepares ulna lateral to medial

4.  Trial


Humeral / ulna and radius prosthesis inserted

- simplex cement

- cement restrictors



- collateral ligaments reattached through humeral prosthesis

- closure triceps over drain with Ethibond


Post op

- POP 1 - 2 weeks till wound healed




Morrey et al JBJS Am 1998

- TER in rheumatoid arthritis

- followed for 10 years

- 92% survival rate

- 10% incidence of serious complication requiring re-operation

- infection / aseptic loosening / fracture / triceps avulsion / loosening


Morrey et al JBJS Am 2010

- TER in post traumatic arthritis

- 69 patients followed for 9 years

- 19% failure rate

- infection < 5 years, bushing failure 5-10 years, then component loosening

- most patients with failure < 60 years






Total Elbow Replacement InfectionTotal Elbow Joint Infected 2Infected TER



- 4-5%

- most common cause of failure


Risk factors for infection

- previous surgery

- previous infection

- stage IV RA

- drainage post-op

- re-operation for any reason

- poor skin



- Bier's block and IV antibiotics at beginning of case

- POP for 2 weeks post op to achieve wound healing




Often follows superficial infection or bursitis

- need aggressive treatment of any superficial infection

- can often salvage joint with early debridement and washout


If signs of bony infection / loosening 

- 2 stage revision

- resection arthroplasty


Total Elbow Replacement Cement SpacerTotal Elbow Replacement Cement Spacer 2


Intraoperative fracture




More common in unconstrained

- 6%


Transient neuropraxia

- 5%


Triceps failure

- 2%




Revision TER


Total elbow loose humeral component








1. Removal Loose body


Elbow scope Loose Body


2. Excison of osteophytes

- coronoid

- olecranon

- aiming to improve ROM / prevent impingement


Elbow Stiffness Posterior ImpingementElbow Stiffness Posterior Debridement


3. Elbow Stiffness Capsular Release

- capsular contraction can limit range

- anterior capsulotomy

- risk to median nerve anteriorly


4. Management OCD lesions


Elbow scope Radial Head OCDElbow OCD


5.  Synovectomy

- RA, haemophilia

- usually results in marked blood loss

- leave portals open to allow for drainage to prevent haemarthrosis and stiffness


6.  Washout sepsis


7. Excision of Radial Head

- useful combined with synovectomy in RA

- can excise head and 2-3mm of neck

- to ensure stability should keep annular ligament




Abnormal elbow scarring

Extensive HO

Previous ulna nerve transposition






4mm scope 

2.7mm wrist scope




A.  Patient lateral

- hip supports

- arm over L shaped bolster


Elbow Lateral Decubitus


B.  Patient supine

- anterior portals and arthroscopy with arm on arm board

- posterior portals and arthroscopy with arm bent over patient




Outline surface markings with a pen

- epicondyles, radial head, olecranon

- medial and lateral supracondylar ridge

- draw ulna nerve


PIN landmarks

- anterior to radial head

- posterior to mobile wad


Anterior elbow arthroscopy


Lateral portals


A.  Proximal Anterolateral portal



- intial viewing portal



- 1-2 cm proximal to lateral epicondyle

- just anterior to lateral intermuscular septum

- onto anterior humerus

- walk down into joint

- insufflate with 20 mls

- incision in skin

- same technique to insert portal



- radial nerve

- moved further away by insufflation

- most dangerous portal

- do first before swelling obscures anatomy


Elbow Arthroscopy Anterior Compartment


B.  Anterolateral Portal



- working portal

- microfracture capitellar OCD



- just in front of lateral epicondyle / anterior to radial head

- in sulcus between radial head and capitellum

- PIN most in danger here

- avoid distal / anterior placement


Elbow Arthroscopy AnterolateralElbow Scope Anterolateral Portal


Medial Portals


Proximal Anteromedial Portal 



- 2cm proximal to the medial epicondyle

- just anterior to humerus / medial intermuscular septum

- ulna nerve behing medial epicondyle

- median nerve and brachial artery anterior



- insert needle under vision

- incision in skin

- pass haemostat under vision


Elbow Scope Anterolateral Portal



- removal of loose body

- visualise chondral surfaces ulnohumeral and radiocapitellar


Anteromedial portal



- 2cm anterior and 2cm distal to medial epicondyle


Posterior elbow arthroscopy




Posterior loose bodies

Olecranon tip / fossa impingement

Retrograde capitellum OCD drilling



- ulnar nerve when debriding medially




Posterocentral portal

- 3 cm proximal to tip olecranon

- in midline


Posterolateral portals



- 2 - 3 cm proximal to tip olecranon

- in line lateral edge of triceps


Soft spot portal


Anconeus triangle

- olecranon tip / radial head / lateral epicondyle

- through skin, anconeus, capsule



- posterior cutaneous nerve



- retrograde drilling of capitellum


Elbow Arthroscopy Posterior CompartmentElbow Arthroscopy Medial CompartmentElbow Arthroscopy PosterolateralElbow Arthroscopy Posterolateral 2




Nerve injuries


All nerves at risk especially PIN



- no LA

- minimise tourniquet time

- minimise pump pressure to 40


If PIN palsy post op

- need to explore

- usually cut

- very difficult to defend medicolegally

- only do elbow arthroscopy if trained in it and have done cadaver course


Vascular injury











Capitellar OCD



Adolescents & young adults


Usually between 12 - 21 years 


Throwing athletes / gymnasts


Little Leaguer's Elbow

- combination of capitellar OCD and MCL injury

- a repetitive throwing injury / seen in pitchers




1.  Trauma & Overuse


Common throwing sports / gymnastics

- dominant limb predominates

- repetitive overuse

- valgus overload on radiocapitellar joint 

- fatigue failure of the subchondral area 

- overlying cartilage fails under shear stress & separates


Capitellum loaded more heavily

- less able to take load than radial head articular surface

- especially if have some slight eccentric loading which can occur in throwing athlete or gymnast


2.  Ischaemia


Predominant blood supply to capitellum from posterior vessels

- histopathology shows osteonecrosis


Pappas Classification   


Category 1  - patients < 13 years of age 

Category 2  - 13 years to adulthood 

Category 3  - adults 


Found better prognosis with younger patients 

- especially with open capitellar growth plate

- respond better to non operative treatment




Dominant arm / history of over-use


Pain activity related


Limited range

- very common presentation


Clicking, grinding, catching, locking

- ? Loose bodies




Tender over lateral aspect elbow


Loss of extension


Radio-capitellar compression test

- active supination and pronation with arm fully extended


Examine MCL


Iwase's Classification Xray


Grade 1

- localised flattening and translucency


Capitellar OCDElbow OCD


Grade 2


A:  Small fragment without sclerosis

B:  Small fragment with sclerosis


Elbow OCD Type 2BElbow OCD Type 2B CT


Grade 3

- in situ loose body




Panner's disease / osteochondrosis

- child 4 - 8 years old

- entire capitellum involved

- not sure if is earlier spectrum of same disease




Fluid interface denotes detachment / instability


Capitellar OCD MRI




Non Operative




Stable lesion

- intact cartilage

- nil detachment / no synovial fluid behind OCD




Protected ROM

- hinged brace

- attempt to reduce axial load

- nil sports until full ROM

- 3-6 months




Mihara et al Am J Sports Med 2009

- 39 baseball players mean age 13 years

- cessation of throwing, weights, push ups

- healing of lesion in 16/17 patients with open growth plates

- healing of lesion in 11/22 with closed growth plates

- 25/30 early stage lesions healed

- only 1/9 advanced stage lesions healed (Grade 2A and Grade 3)

- suggest early surgical intervention in advanced OCD

- recommend surgical intervention if no sign of healingin 3-6 months






1.  Failure non operative treatment

2.  Loose bodies

3.  Instability / displacement


Large / salvageable fragments


A.  Stable / Drill in situ


Elbow OCD InsituElbow OCD Retrograde Drilling


Arthroscopic technique

- anterograge via anterolateral portal if possible

- retrograde via ACL jig / posterolateral portal with elbow flexed


B.  Unstable / Fixation


Arthroscopic technique

- via soft spot portal


Takahara et al JBJS Am 2007

- demonstrated fragment fixation or reconstruction better than removal

- fragment fixation with bone graft


Small / unsalvageable Fragments


A. Arthroscopic Debridement


Elbow Scope Capitellar OCDElbow Scope OCD Debridement


Schoch et al Arthroscopy 2010

- arthroscopic debridement in 13 patients

- follow up average 3 years

- symptomatic relief

- 6/13 had to cease some sport


B.  Microfracture


Elbow Scope OCDElbow scope OCD Microfracture


C.  Abrasion


Elbow OCDElbow OCD Abrasion


Large Chondral Defects


A.  Mosaicplasty


Ovesen et al J Should Elbow Surg 2011

- 10 patients treated with mosaicplasty

- average age 21

- incorporation in all patients

- significant improvement in Mayo elbow scores




Coronoid Process Fracture

BackgroundClassification Coronoid Fractures


The coronoid is the most important portion of ulno-humeral articulation



1.  Provides anterior buttress

2.  Anterior capsule and brachialis attach to coronoid

2.  Anterior band of the MCL attaches to it

- distally and medially on sublime tubercle


Instability rises and prognosis deteriorates according to the amount of coronoid process that is fractured


Fracture patterns



Anteromedial facet fragment




Most commonly associated with elbow dislocations

Anteromedial facet fractures may be caused by varus / rotational force


Regan and Morrey Classification


Coronoid Process Classification


Type I 

- usually stable

- shear fracture not avulsion fracture

- may rarely cause residual instability in elbow dislocation


Coronoid Fracture Type 1Coronoid Fracture Type 1 CT


Type II 

- 50% coronoid

- elbow usually unstable

- lose attachment of capsule

- ORIF screws or sutures

- any ? about stability use hinged fixator


Coronoid Fracture Type 2


Type III

- > 50% coronoid

- Uncommon

- unstable as lose capsule +/- MCL with anteromedial fragment

- ORIF with screw / sutures / anteromedial buttress plate

- again may need hinged fixator


Type 3 Coronoid FractureCoronoid Fracture Type 3


Operative Management


Surgical approach


1.  Universal posterior approach

- if performing surgery for complex dislocation

- allows medial and lateral access to joint


2.  Lateral approach through radial head

- if excising radial head, then replacing


3.  Medial approach

- isolate and protect ulna nerve  

- elevation of ulna origin of flexor pronator group anterior to FCU

- important if fracture is anteromedial


4.  Approach through fractured olecranon




Type 1

- capsular suture repair


Type 2 / 3

A.  Screws (AP or PA)

B.  Pass sutures through capsule and tie over drill holes in ulna


Anteromedial fragment

- medial approach / buttress plate


Coronoid Process Buttress Plate


Unrepairable / unstable

- reconstruct with radial head, iliac crest, or allograft


Cubitus Varus



Occurs 10% of supracondylar humeral fractures

- varus malunion


Lateral condyle fracture

- AVN trochlea


Elbow Cubitus Varus


Growth arrest of medial aspect physis

- rare

- post traumatic




Usually little functional defect


Cosmetic problem

- appearance can be unacceptable to parents and child




Does not correct with time


Operative Management


1.  Lateral closing wedge osteotomy of the supracondylar region 

- perform at skeletal maturity

- metaphyseal not diaphyseal

- preserve medial cortex

- beware abnormal position of radial nerve (passes through callous)

- 1mm of wedge for each degree

- fixation with plate


2.  Complex Osteotomies

- posterior approach

- bilateral plates

- for severe deformities


Elbow post distal Osteotomy


3.  Young patient / open physis

- guided growth

- application lateral 8 plate





Anatomy Pathology

EpidemiologyElbow Dislocation LateralComplex Elbow Dislocation AP


6 /100 000

- second most common dislocation after shoulder








1.  Obtain and maintain a concentric reduction 

2.  Achieve a painless and functional ROM


Associated Injuries


20% neuropraxia (ulna nerve / AIN)




Final position of Ulna Relative to Humerus







1.  Complete 


2.  Subluxed / Perched (Drop sign)

- < 10 % patients


Simple / Complex


25-50% associated with fracture




Acute / Chronic / Recurrent


Bony Anatomy


Ulnohumeral Joint


Trochlea and ulna highly conformed

- trochlea covered by cartilage in arc 300o

- trochlea separated from the capitellum by groove in which rim of radial head articulates

- trochlea 6o valgus which creates carrying angle


Radiocapitellar Joint


60% of load at elbow

- concave radial head with capitellum

- posteromedial 2/3 articulates with sigmoid notch ulna

- anterolateral 1/3 has no cartilage /  safe zone


Anterior part of radial head fractures normally

- part of spectrum in dislocation

- radial head important secondary stabiliser, especially when MCL deficient


Radial head and neck form an angle of 15o with the shaft


Distal Humerus


Tilted anteriorly 30o in lateral plane

- 5o internally in transverse plane

- 6o of valgus in front plane


Elbow Valgus Carrying angleElbow Trochela Anterior Angulation


Centre of rotation

- trochlea

- centre of rotation offset anteriorly from humeral shaft


Elbow Centre of Rotation




LCL anatomy elbow



- Varus Stability


LCL has 4 Components


1. Annular Ligament

- anterior edge supinator crest to posterior edge


2. Radial Collateral Ligament

- CEO to annular ligament

- fan-shaped


3. Lateral Ulna Collateral Ligament 


Most important restraint to PL instability

- CEO to supinator crest


Must protect in Kocher approach

- in line with edge of anconeus, deep to it

- must protect in surgical approach between anconeus and ECU


4.  Accessory Collateral Ligament

- from crest to diffusely over annular ligament




Elbow MCL



- primary restraint to valgus stability

- especially in flexion

- this is the position in the throwing athlete

- in extension radial-capitellar joint important


3 parts


1. Anterior band

- CFO to sublime tubercle

- most important


2. Transverse band

- olecranon - sublime

- groove for ulna nerve


3. Posterior band

- CFO to olecranon


Constraints to Elbow Instability 


Primary Static


1.  Ulnohumeral articulation

- olecranon and coronoid


2.  MCL 


3.  LCL


Secondary Static


1.  Radio-capitellar joint


2.  CFO / EFO


3.  Capsule


Dynamic Stabilisers


Anconeus - PLR stability


Triceps / Brachialis / Biceps


Pathoanatomy / Horii circle


Begins on the lateral side, progresses to the medial side in three stages

- anterior band of MCL is the last torn


Stage 1


Damage to LCL

- Posterolateral Rotatory Subluxation

- this can reduce spontaneously


Stage 2


Damage to anterior and posterior capsule

- posterior capsule quite insignificant

- anterior important


Coronoid appears perched on trochlea

- incomplete PL dislocation

- concave medial edge of ulna on trochlea

- can be easily reduced or even by patient


Stage 3


Medial disruption


Stage 3A


Anterior band of MCL intact

- postero-lateral dislocation

- pivots about this anterior band

- often seen with radial head and coronoid fracture


Reduce with traction, varus and pronation


Maintain stability with hand pronated

- stability provided by anterior MCL


Stage 3B


Entire MCL disrupted

- varus / valgus / rotatory instability present after reduction


Need to be flexed > 30 - 40o to be stable


Stage 3C


Unstable at 90o


Entire distal humerus stripped / CFO / CEO

- reduction maintained only with flexion > 90o


Hinged External Fixator

External fixator elbow 1External Fixator Elbow 2




1.  Persistent instability despite ORIF and LCL repair


2.  Gross acute instability, not suitable for surgery


3.  Delayed treatment > 4 weeks


Compass hinge  / S&N


Compass Hinge Lateral XrayCompass Hinge AP Xray


Compass HInge Medial ClinicalCompass Hinge Clinical


Set up

- two incomplete rings proximal and distal

- hinge in centre

- can be used actively or passively

- adjustment wheel is medial (to use with other hand)

- rings posterior, open anteriorly

- rings compatible with ilizarov equipment

- hinge can also be adjusted in the varus valgus plane

- do so that distal ring is perpendicular to plane of ulna


Compass Hinge Centre of Rotation


Key is distal humeral axis

- imagine axis is in spool at end of humerus

- open laterally to identify capitellum

- open medially to identify trochlea

- confirm centre of rotation on lateral


A. Insert medial and lateral 3.5 mm pins partially

- place external fixator over pins but this can be difficult

- adjust pins so hinge slides easily over them

- insert pins 2mm


B.  Insert a single pin through axis of rotation

- slightly easier to apply the external hinge over the pin

- may not have to open the medial side as much

- only slight to identify and protect the ulna nerve


Medial Humeral half pin

- posterior to ulna nerve

- ensure proximal ring is perpendicular to humerus

- use two hole rancho cube with centering sleeve

- drop off undersurface off ring

- insert 5mm pin (drill, measure, insert HA pin by hand)

- need bicortical fixation


Lateral humeral pin

- anterior to radial nerve

- 2 hole post with single hole rancho

- allows angulation of pin from proximal to distal

- also angle posterior to anterior


Ulna pins

- 4mm pins into subcutaneous border

- must reduce elbow first and hold reduced whilst inserting pins

- ring must be perpendicular to ulna

- usually put elbow in 90 degrees of flexion

- proximal pin off proximal side of ring wth rancho cube

- bicortical usually into coronoid

- check is stable reduction

- insert second +/- third pin distally


Acute Elbow Dislocation Management

Elbow Dislocation Lateral


1.  Reduction under IV / conscious sedation

- assistant applies traction in slight flexion

- second person corrects lateral displacement by manipulating olecranon medially

- flexion to 90o


2.  Post reduction assess stability

- stable if can extend to within 30 - 40o without instability

- if unstable, pronate forearm and see if can extend to within 30 - 40o (MCL intact)

- if unstable pronated with elbow < 45o extended, elbow will need surgery


3.  Confirm concentric reduction

- 2 view check x-rays mandatory


4.  Stable elbow

- manage in POP 90o 2 weeks

- weekly check xray

- then begin ROM exercises


Elbow ROM Brace


Management Problems


A. Simple Elbow Dislocation


B.  Complex Elbow Dislocation

- radial head fracture

- coronoid process fracture

- Terrible Triad (MCL / coronoid / radial head)

- olecranon fracture +/- radial head +/- coronoid

- capitellar fractures



- difficult problem

- need to prepared at all times to

- ORIF / replace radial head

- repair / reconstruct LCL

- ORIF / suture coronoid

- repair MCL

- apply external fixator


1.  Simple Elbow Dislocation


A.  Stable Simple Elbow Dislocation


 Simple Elbow DislocationElbow Simple Dislocation Reduced






Assess Stability 

- OT if unstable > 45o in pronation


X-ray weekly


Mobilise 2 - 3 weeks


If FFD at 6/52 > 40o

- night extension splint

- turnbuckle elbow extension splints


Josefsson et al 1987 JBJS AM

- randomised 30 patients with elbow dislocations

- non-operative group 2 weeks in plaster at 90°

- operative group had ruptures of both collaterals / most had avulsions from the humeral epicondyles

- no difference in outcome between the two groups regardless of initial stability

- loss of extension was commonest complication

- seen 50% more in operative group


B.  Unstable simple elbow dislocation


Uncommon but not rare

- may be intact medially

- avulsed LCL and CEO




1.  Kocher approach & Reconstruct / Repair LCL + CEO

- lateral ulna collateral ligament is usually avulsed from lateral condyle

- centre of rotation is centre of capitellum

- place suture anchor

- repair anconeus and ECU over top

- +/- reconstruct / augment with slip Palmaris if required

- ROM brace


2.  Elbow still unstable / address MCL

- usually avulsed from medial epicondyle 

- usually can do direct repair / suture anchors

- mid-substance probably have to reconstruct with Palmaris


Medial approach centred on medial epicondyle

- locate, mobilise and protect ulna nerve

- proximally between brachialis and triceps

- distally between pronator teres and brachialis

- can reflect PT

- protect median nerve distally


C.  Chronic Simple Elbow dislocation


Missed injury / delayed presentation

- open reduction

- removal scar tissue

- repair / reconstruction LCL

- +/- hinged external fixation


2.  Dislocation with Radial Head Fracture


Manage as per radial head classification


Hotchkiss Modified Mason class (R&G)


Type I


Non / minimally (<2mm) displaced fracture of head 

- forearm rotation (pronation/supination) is limited only by acute pain and swelling 

- diagnose by LA injection and full pronation and supination


Non operative treatment


Type II


Displaced fracture of the head or neck 

- > 2mm and amenable to fixation


Motion may be mechanically limited with or without significant joint incongruity 


CT Radial Head FractureRadial Head ORIF



- Kocher approach


- LCL repair / reconstruction


Type III


Severely comminuted fracture of the radial head and neck 

- not reconstructable 

- Titanium replacement


Radial Head Replacement


Ashwood et al JBJS Am 2004

- 16 patients titanium monoblock radial head

- 81% G/E at 2 years


Radial Neck Fracture


Morrey et al J Orthop Trauma

- concern regarding loss of rotation with plating

- prefer to ORIF with oblique screws or radial head replacement


3.  Dislocation with Coronoid Fracture


Elbow Dislocation Large Coronoid Fragment


The coronoid is the most important portion of ulno-humeral articulation



- provides anterior buttress

- attachment of capsule and brachialis

- anterior band of the MCL attaches to it


Manage as per Regan and Morrey Classification

- ORIF / repair type I / II


Regan and Morrey Classification


Type I 

- stable as nothing attaches to tip 

- shear fracture, not avulsion fracture


Type II 

- 50% coronoid

- elbow usually unstable / ORIF or suture


Type III

- > 50%

- uncommon

- can be comminuted

- ORIF or suture


Elbow Dislocation Large Coronoid Fragment 2




Universal posterior approach

- single posterior skin incision

- elevate flaps laterally and medially as required

- lateral approach to repair ulna LCL

- medial approach to repair coronoid


Medial approach

- isolate and protect ulna nerve  

- elevation of ulna origin of flexor pronator group anterior to FCU

- important if fracture is medial




1.  Screw / buttress plate


Coronoid Buttress Plate APCoronoid Buttress Plate Lateral


2.  Sutures through capsule / Lasso repair 

- tie over drill holes through olecranon / endobutton


3.  Reconstruct with radial head, iliac crest, or allograft


Note:  Acknowledged by world class names as being difficult


4.  Dislocation + Terrible Triad


Complex Elbow Dislocation APComplex Elbow Dislocation Lateral



- radial head fracture + coronoid fracture + MCL


Surgical Algorigthm


Universal Posterior Approach


1.  Type 2 radial head

- Kocher approach


- repair / reconstruct ulna LCL

- reassess stability

- if unstable, additional medial approach

- isolate and protect ulna nerve

- if type II / III coronoid elevate CFO and ORIF / suture

- repair / reconstruct MCL

- assess stability

- rarely may require external fixator


2.  Type 3 radial head

- Kocher approach

- excise radial head

- attempt ORIF / suture coronoid process through this gap

- unless large anteromedial fracture which is best treated with anteromedial buttress plate

- replace radial head

- repair / reconstruct LCL

- reassess stability

- may then need medial approach and MCL repair / reconstruction

- reassess stability

- may need hinged external fixator


5.  Dislocation with Olecranon Fracture +/- Coronoid Fracture +/- Radial Head Fracture


Elbow Dislocation Fracture Olecranon and Radial HeadElbow Dislocation ORIF Olecranon Replace Radial Heal LCL repairElbow Dislocation ORIF Olecranon Replace Radial Heal LCL repair


A.  Anterior / Trans Olecranon Fracture Dislocations


Less common, better outcomes because

- coronoid fragment usually larger / easier to ORIF

- collaterals often intact

- radial head often intact



- universal posterior approach

- ORIF / suture coronoid through olecranon fracture

- TBW or plate for olecranon fracture

- can repair coronoid with lag screw from olecranon plate

- Kocher approach

- ORIF / replace radial head

- repair / reconstruct LCL

- reassess stability

- +/- repair reconstruct MCL


B.  Posterior Monteggia Fracture


Elbow Dislocation Posterior Monteggia


More common, worse outcome because

- LCL more likely to be ruptured as well

- coronoid more likely to be comminuted

- radial head fracture



- ORIF coronoid through olecranon fracture

- ORIF olecranon (often plate as distal to centre of rotation of elbow)

- +/- ORIF /replace radial head

- +/- repair / reconstruct LCL

- +/- hinged fixator


6. Other


Dislocation with distal radius fracture


Dislocated Elbow Fracture wristDislocated Elbow Fractured Wrist



Distal Biceps Tendon Rupture



Dominant arm of middle aged men

- between 40 and 60




Sudden dramatic event

- sporting / weightlifting injury

- resisting heavy extension load




Degenerative changes seen on histology





- retracted / rupture of lacertus fibrosis

- minimally retracted



- small - partial tears of some fibres

- large - near complete avulsion of biceps tendon from radial tuberosity




Complete tears / non operative management

- 30% loss of flexion strength

- 50% loss of supination strength




Distal Biceps Rupture


Acute onset pain / distal swelling / bruising


Biceps muscle may bulge proximally

- not always seen as lacertus fibrosis may be intact


Hook test

- attempt to hook finger about biceps tendon

- unable to palpate biceps tendon


O'Driscoll et al Am J Sports Med 2007

- Hook test negative in partial tears

- but 9/12 painful with this test


Biceps Tendon Hook Test



- supination > flexion


Distal Biceps Rupture 1Distal Biceps Rupture 2Distal Biceps Rupture 3




May see bony avulsion from radial tuberosity




Confirm diagnosis


A.  Complete tear / retracted

- relatively easy to diagnose


Distal Biceps Rupture MRI


B.  Partial tear


Best evaluated on the axial view

- absence of low signal intensity biceps tendon insertion onto tuberosity

- present of soft tissue oedema


MRI Biceps Partial TearBiceps Partial tear


Festa et al J Hand Surg Am 2010

- MRI 100% sensitive for full thickness tears

- MRI only 59.1% sensitive for partial tears






Indication for complete tears


Elderly patients who do not require full strength and endurance


Usually lose one grade power with distal avulsion

- decreased strength and endurance 

- supination and flexion

- i.e. labourer might have difficult with inserting screws






Young active patients with recent rupture 

- may be more difficult with chronic tears




Two incision Boyd and Anderson

- anterior incision to retrieve tendon

- posterior incision to attach tendon to radial tuberosity

- associated with radioulnar synostosis

- less risk of inadvertant PIN injury


One incision

- single anterior incision

- use suture anchors / endobutton to fix to tuberosity through this incision

- theoretical higher risk PIN injury

- endobutton fixation 2 - 3 x higher strength than suture anchors


Operative Technique:  One incision technique with endobutton


Set up

- supine, arm board, tourniquet



- longitudinal medially / transverse across cubital fossa / longitudinal mobile wad

- S shaped


Find biceps tendon

- proximally above brachialis

- Allis clamp

- mobilise by blunt dissection

- deliver into wound


Distal Biceps Repair IncisionDistal Biceps Tendon with EndobuttonDistal Biceps Repair Final


Fixation with no 2 Ethibond / Fibre wire

- Krackow suture

- enter lateral aspect tendon proximally

- suture down to distal aspect

- pass around middle two holes of endobutton

- back up medial aspect and tie

- leave 2 mm space between endobutton and distal end of tendon

- allows space for dorsal cortex of radius


Insert passing sutures and flipping sutures in lateral holes

- no 2 ethibond to pull through

- 1 vicryl to flip

- different colours to help you tell which is which


Dissect down to radial tuberosity

- find and protect LCNFA

- under cephalic vein

- mobile wad laterally with radial nerve

- blunt dissect down to radial tuberosity


Prepare radial tuberosity

- forearm fully supinated

- make trough for tendon with burr

- avoid lateral retractors which can inadvertantly injure PIN


Pass guide wire through dorsal cortex 

- aim distal and medial

- pass cannulated 4.5 endobutton reamer

- pass beath needle with sutures

- pass and flip endobutton

- check II


Distal Biceps Endobutton RepairDistal Biceps Endobutton Repair


Post op

- splint for 2 weeks

- then active assist ROM

- no heavy lifting for 8/52




Greenberg et al J Should Elbow Surg 2003

- endobutton technique

- patients had 97% flexion strength

- 82% supination strength


Khan et al Arthroscopy 2008

- suture anchor repair in 17 patients

- 5 degee loss of extension and rotation

- strength 80% other side


John et al JSES 2007

- suture anchor repair in 53 patients

- 46 excellent results, 7 good

- HO in 2 patients


Chavan et al Am J Sports Med 2008

- systematic review

- endobutton strongest

- increased complications in two-incision techniques


Mazzocca et al Am J Sports Med 2007

- biomechanical study

- endobutton (440N) stronger than suture anchors (380N) or bone tunnel (300)


Lo et al Arthroscopy 2011

- 11 mm to PIN if aim directly across long axis of radius

- increases to 16 mm if aim 30 degrees to the ulna side

- aiming distally 45 degrees and radially decreased this to 2 mm


2 incision Boyd and Anderson Technique




Anterior Henry approach as before


Passed curved haemostat 

- maximally pronate forearm

- hug border of radius

- avoid periosteum of ulna to prevent synostosis

- palpate tip dorsally in extensor mass

- dissect down to radius


Thompson's approach

- line from lateral epicondyle to lister's tubercle

- between EDC and ECRB

- expose supinator

- find and protect PIN

- subperiosteally detach supinator



- performed through bone tunnels




Greewal et al JBJS Am 2012

- single incision (anchors) v double incision (drill holes)

- RCT 91 patients

- double incision 10% stronger flexion strength

- increased transient neuropraxis LCNF in single incision

- ASES / DASH scores same in each group

- 4 re-ruptures due to lack of complicance


Partial Tears


Management Options


Bain et al Sports Med Arthrosc 2008

- non operative treatment < 50%

- operative treatment for > 50%


Surgical Treatment of a Partial Tear


Biceps ApproachBiceps Partial TearBiceps Partial Tear 2Biceps Partial Tear 3


Repair with suture anchors


Biceps Suture Anchor Repair


Chronic Tears


> 3 weeks old

- harder to repair

- associated with higher complication rates

- have to repair in significant position of flexion


Typically run into problems > 6 - 8 weeks

- tendon involutes into biceps

- need either hamstring autograft or allograft reconstruction

- secure to radial tuberosity with endobutton first

- then weave through distal biceps stump

- pulve taft weave through tendon


Hamstring autograft biceps reconstruction


Biceps reconstruction with tendoachilles allograftDistal biceps reconstruction with allograft






Injury LCNFA

Injury PIN

Loss of extension

- more common with chronic injuries

Distal Humerus Fractures

EpidemiologyDistal Humeral Fracture


2 groups

- young patient with high velocity injury

- older patient with comminuted, osteoporotic fracture


In the second group fixation can be very difficult




Hinged Joint

- trochlea axis is centre of rotation

- 40o anterior angulation in sagittal plane

- trochlea 3-8o externally rotated

- 4 - 8o valgus

- medial and lateral columns


Elbow Lateral NormalElbow Lateral Normal 40 degree anterior angulation


Elbow AP NormalElbow Normal AP 4 degrees valgus


CT scan


Aids preoperative planning

- identify capitellar fracture

- identify if trochlea deficiencies which might need bone grafting

- aid diagnosis / reconstruction intr-articular extension


Muller's Classification


Type A: Extra-articular fracture


Distal Humerus Fracture


Type B: Uni-condylar fracture

- lateral /  medial


Elbow Medial Condyle FractureElbow Lateral Condyle Fracture


Type C: Bi-condylar fracture


Distal Humeral Fracture APDistal Humeral Fracture BicondylarDistal Humeral Fracture


Operative Management




Within 24 hours or at 5 - 7 days

- minimises inflammation

- minimises risk HO




1.  ORIF


2.  Distal humeral replacement / osteoporotic and highly comminuted fractures


Kalogrianitis et al J Should Elbow Surg 2008

- 9 patients mean age 37

- highly comminuted, osteoporotic, non reconstructable fractures

- no deep infections

- ROM 15 - 120o


McKee et al JSES 2009

- RCT 42 patients > 65 years of age


- 5 ORIF patients converted to TEA intraop

- better outcomes and decreased reoperation rate with TEA



- good treatment if unable to ORIF

- high level of skills required

- can replace distal humerus only if ligaments and proximal ulna preserved

- otherwise must replace ulna +/- linked prosthesis


3.  "Bag of bones" treatment

- patient elderly and not operative candidate

- intial rest in plaster

- then mobilisation

- surprisingly good ROM and function


Distal Humerus Non Operative




Extra-articular fracture


Distal Humerus Extraarticular ORIF


1.  Mobilise triceps either side of humerus 

- reduce distal fragment and hold with K wires

- application 2 x perpendicular plates


2.  Bryan - Morrey Triceps sparing posteromedial approach

- find and protect ulna nerve

- elevate triceps aponeurosis medial to lateral off ulna

- leave one side of periosteum intact


3.  Split triceps

- feather with osteotome off ulna medial and laterally


Intra-articular fracture


Need to visualise distal humerus to get anatomical reduction

- olecraonon blocks visualisation

- Chevron Osteotomy


Technique for Intra-articular fracture


Distal Humerus ORIF APDistal Humerus ORIF Lateral



- lateral decubitus with bolsters

- arm over bolster

- tourniquet

- may need to prep and drape iliac crest for bone graft


Elbow Lateral Decubitus


Posterior approach

- midline posterior incision is used

- deviate radial side of olecranon (prevents painful incision)

- ulnar nerve identified / mobilised / vessiloops / protected


Chevron Olecranon Osteotomy


Chevron Osteotomy



- predrill proximal ulna with 3.2 mm bit 

- partially tapped for 6.5 mm cancellous screw

- cut with oscillating saw, apex distal

- homan retractors each side to protect structures

- attempt to make in bare area of central olecranon

- 3 cm from tip olecranon

- complete with osteotome so can interdigitate fracture and not saw away segment of articular cartilage

- take fragment and retract proximally, taking triceps with it to expose distal humerus

- radial nerve 14 cm proximal to lateral epicondyle

- wrap in wet sponge, clip with artery to drapes


Restoration of Articular Anatomy

- Anatomic reduction of the condyles / distal articular surface

- ORIF with cannulated 4.0 mm partially threaded screws

- reduce fragment onto distal humerus

- fix with K wires in medial and lateral columns

- check with II


Pre-contoured locking plates

- posterolateral and medial

- ensure not of equal length to decrease stress risers proximally

- can get variants of posteriorlateral plate to fix coronal plane fracture of capitellum (AP screws in PL plate)

- fix with locking screws

- ensure not in olecranon or coronoid fossa  


Assess ROM

- no block to motion

- good stability


Check II


Assess ulna nerve 

- ensure not impinging on medial plate   

- may need to consider anterior transposition  


ORIF olecranon

- 6.5 mm screw + washer, then wire tension band

- may need plate if screw does not get good bite

- can use K wires and TBW


Post op 


POP backslab 2/52 for wound healing

Range if stable with physio / active assist

- avoid PROM (HO)




G/E 75%





- loss of 10 - 20o extension common


Humeral non union


Olecranon osteotomy non union

- 5%

- bone graft and plate


Ulna nerve palsy

- keep in mind the need to perform anterior transposition in original OT

- treat with neurolysis + transposition


Painful Hardware

- most common

- re-fracture risk if remove both plates


Adult Lateral Condyle Fracture


Elbow Lateral Condyle FractureElbow Lateral Condyle Fracture 2




Fracture of lateral condyle

- involve capitulum alone

- may extend medially to involve the lateral portion of trochlea


Management Options


These fractures are typically displaced and require surgical treatment

- Kocher approach and ORIF with compression screws

- Posterior approach and posterolateral plate


Adult Medial Condyle Fracture


Elbow Medial Condyle Fracture




Medial epicondyle is common origin of several flexor muscles of hand and wrist

When medial epicondyle is fractured, flexor muscles pull fragment distally




1.  Medial approach

- find and protect ulna nerve

- ORIF with screws


2.  Posterior approach

- find and protect ulna nerve

- application of medial plate / ORIF with screws

- ensure at end no encroachment of  plate on nerve or might need anterior transposition


Transcondylar Fracture




Type of supracondylar fractures that occurs within joint capsule

- very distal / often very comminuted

- most commonly occurs with osteoporotic bone




Non-displaced fractures are treated with splinting or percutaneous pinning


Displaced fracture

- consider ORIF

- may need to consider primary hemiarthroplasty / elbow replacement


Capitellar Fracture


Uncommon fracture which is difficult to diagnose if fracture fragment is small


Elbow Capitellar FractureCapitellar Fracture CT SagittalCapitellar Fracture CT Axial


Type I

- Hans Steinthal fracture

- fracture of the capitellum in the coronal plane

- involves large part of the osseous portion of capitulum

- fracture hinges anteriorly between radial head and radial fossa producing a block to flexion




If closed reduction is obtained, then reduction is usually stable with elbow flexion


Open reduction


A. Posterolateral / Kocher approach

- between aconeus and ECU


B. Lateral approach

- between EDC and ECRB

- may place PIN at increased risk


One or two headless compression screws

- front to back

- buried


Capitellar Fracture ORIF0001Capitellar Fracture ORIF0002


Type II

- Kocher Lorenz fracture               

- affects primarily articular cartilage and very little underlying bone

- these usually cause few subsequent joint problems



- healing potential is minimal & excision is recommended


Lateral Epicondylitis / Tennis Elbow



Lateral : Medial 9:1




4th & 5th decades

- M = F

- 75% dominant arm 


50% of regular tennis players

- especially > 2 hrs / week




Insertion pathology / Enthesopathy


Over-extension of the elbow with supination / pronation




Lateral epicondyle

- anconeus from posterior face

- ECRB and EDC from anterior face (CEO)

- ECRL and BR from lateral supracondylar ridge


Differentiate ECRB from ECRL

- ECRB tendinous insertion onto lateral epicondyle

- ECRL still muscular at this point (arises more proximally)



- apex of lateral epicondyle



- radial nerve between brachialis and BR

- divides at level of radial head

- enters supinator at this level (radial tunnel)




1.  OCD capitellum / radial head

2.  Radial tunnel / supinator / PIN syndrome

3.  PLRI

4.  OA, RA

5.  Referred Pain / C6-7 radiculopathy

6.  Enthesopathy

7.  Annular ligament tears


Risk factors



- poor technique

- poor grip

- hard court surfaces

- strings too taut



- plumbers

- painters




Starts as micro-tear in ECRB 

Get high grade partial tear




Angiofibrotic hyperplasia

- marked fibroblast proliferation

- extensive vascular hyperplasia

- disorganised collagen production

- may go on to dystrophic calcification


Disruption of parallel orientation of collagen fibres 

- invasion of fibroblasts and vascular granulation type tissue

- without an acute or chronic inflammatory component




History of overuse

Pain lateral elbow

Backhand in tennis main problem




Localised Swelling



- few degrees loss of extension = CEO

- >15-20° loss is intra-articular pathology


Tender ECRB

- 5 mm distal and anterior to CEO



- pain with resisted wrist dorsiflexion with elbow extended


Examine for Stability - PLRI

Examine Supination / Pronation - radiocapitellar OA

Examine C spine




Radial Tunnel Syndrome

- tenderness 3-4 cm distal to lateral epicondyle

- pain with resisted thumb / IF and supination




Usually normal

25% soft tissue calcification


Tennis Elbow CalcificationTennis Elbow Bone Spur








Will demonstrate tears and oedema on T2


Elbow MRI Lateral Epicondylitis


High grade partial tear


Tennis elbow High grade tear MRI




Non Operative




6-9 months

- successful ~ 75- 85%


Rest Phase


Complete rest lasting for 3-6/52

-  avoid precipitating factors



- oral or topical



- wrist in extension

- cock up wrist splint


Forearm tennis band

- limit muscle expansion

- may create new force direction


HCLA injection

- find patient's maximum tenderness deep to fascia 

- repeat 2-3 times over 6-12 months

- peri not intra-tendinous

- must then rest the tendon for it to work long term

- risks of local skin depigmentation and CEO rupture


Conditioning Phase


Once pain settled

- Extensor origin stretching 

- Wrist extension exercises (1lb increments)

- eccentric muscle training

- ART (active release technique)

- Activity modification / change racquet and stroke


Tyler et al J Should Elbow Surg 2010

- RCT using eccentric muscle training

- significant improvement in outcome


Adjuctive Therapy


1.  Shock wave lithotripsy


Meta-analysis of RCT

- minimal effect comparted with placebo


2.  Autologous Blood / PRP Injections


Peerbooms et al Am J Sports Med 2010

- RCT autologous blood v corticosteroid

- superior outomes with plasma cell injections at one year


3.  Botox Injections


Improvements compared with placebo

Inferior to corticosterioid


Operative Management




Failure of good non-operative management

- > 6 - 12/12



- open debridement

- percutaneous tenotomy

- arthroscopic

- radiofrequency microtenotomy


Open debridement


3 cm incision 

- centred on CEO

- ECRB is deep and posterior to ECRL

- ECRL muscular at this point


Surgical dissection

- Detach ECRB

- Debride degenerative tissue

- Decorticate underlying CEO

- +/- reattach ECRB


Tennis Elbow ReleaseTennis Elbow Release 2


Tennis Elbow Release 3Tennis Elbow 4



- Z lengthen

- denervate sensory nerves to epicondyle

- combine with decompression PIN

- cover with anconeus flap in chronic or recurrent cases



- splint 10 days

- gentle ROM to 6/52

- then strengthening exercises


Arthroscopic Release


Arthroscopic Tennis Elbow Release 1Arthroscopic Tennis Elbow Release 2Arthroscopic Tennis Elbow Release 3





- inadvertant release LCL



- posterior cutaneous nerve forearm

- runs 1.5 cm anterior to lateral epicondyle on BR fascia



- rare, but can be devastating




Dunn et al Am J Sports Med 2008

- retrospective study of 92 elbows over 12 years

- open release

- 84% good to excellent results


Baker et al Am J Sports Med 2008

- 42 patients with arthroscopic resection followed up for 10 years average

- 87% patient satisfaction


Dunkow et al JBJS Br 2004

- RCT open v percutaneous tenotomy

- earlier return to work and faster recovery


Meknas et al Am J Sports Med 2008

- RCT of open release v microfrequency tenotomy

- no difference in pain relief

- better grip strength at 12 weeks

Medial Epicondylitis / Golfers Elbow



10% of elbow tendonitis




Overuse injury

- poor swing in golf

- poor throwing technique

- overuse of topspin in tennis

- occupational (repetitive hammering / screwing)


Some patients also have lateral epicondylitis




Tenderness CFO


Stimulate pain

- flexion of WJ with fingers resisting

- resisted pronation 

- resisted ulna deviation


May have ulna nerve symptoms




Rule out OA / OCD elbow




MCL insufficiency

- must differentiate from MCL instability

- if release CFO in setting of MCL laxity will have frank instability post-op




Non-Operative Management


As per tennis elbow


Operative Management


Surgical Release


Medial incision

- identify and protect ulna nerve

- release of CFO

- protection of MCL

- debridement of scar and bony prominence

- drill holes into epicondyle

- reattachment of CFO

- + / - Ulnar nerve decompression


Post op

- splint

- no resisted wrist flexion / pronation 6 - 8 weeks

- no sport for 4 - 6 months




Segal 1992

- small series 

- 11 of 16 good results with operative release


Vangness JBJS Br 1991

- 35 operative cases

- felt the underlying pathology was a tear in the CFO

- incomplete healing

- treatment as described above

- 34/35 good or excellent results

- 1 patient could not return to sport




Forearm Fractures



Radial bow radius

- important for rotation


Interosseous membrane

- Z pattern

- proximal radius to distal ulna




Direct blow

- ulna / night stick


Ulna Fracture Night Stick





- Proximal 1/3 ulna fracture with radial head dislocation


Elbow Monteggia FractureElbow Monteggia Fracture ORIF


Monteggia Variant

- proximal 1/3 ulna fracture with radial head / neck fracture


Monteggia Variant APMonteggia Variant Lateral



- distal 1/3 radial fracture with DRUJ disruption


Galleazzi APGalleazzi LateralGalleazzi Xray APGalleazzi Xray Lateral


Associated Injuries


Ulna can be compound

Compartment Syndrome


Compound Ulna




Joint above and below



- always assess radial capitellar line on two views


DRUJ disruption

- widened space between R & U

- radial shortening > 5 mm

- ulna styloid fracture




Isolated single bone


Both bone


Fracture of one bone with ligament rupture

- Galleazzi, Monteggia


Fractures of bone bones with ligament rupture


Non operative Management





- < 10o angulation


Ulna Fracture Undisplaced



- completely undisplaced

- maintenance radial bow


Operative Management




Intramedullary fixation

- children (good remodelling potential)

- prophylaxis to prevent pathological fracture


Ulna Intramedullary Wire


External Fixation

- severe injury / compound


Plate fixation


Ulna Plating




Anatomical reduction with absolute stability

- length

- rotation

- radial bow (need to bend plate for long fractures)




Forearm Fractures Plate LateralForearm Fractures Plate AP



- approach between ECU / FCU





- between FCR and radial artery



- between BR and pronator teres

- supinate forearm

- elevate supinator from ulna to radial




Incident DRUJ instability

- up to 50% if fracture radius < 7.5 cm to distal articular surface

- < 5% if > 7.5 cm


Galleazzi ORIF 1Galleazzi ORIF 2


Plate distal radius

- assess DRUJ stability

- if stable, early ROM

- unstable, splint in supination

- if still unstable, ensure that radius is anatomical

- may have to repair TFCC / ORIF ulnar styloid

- if still unstable, may rarely have to K wire ulna to radius


Galleazzi ORIF APGalleazzi ORIF Lateral


Yohe et al Hand 2017

- irreducible dorsal dislocations usually due to extensor tendonds, or fracture fragments

- no soft tissue block to volar dislocations


Tsismenakis et al Injury 2017

- 7/66 (11%) incidence of DRUJ instability after fixation

- 4/7 had ulnar styloid fracture

- may need ORIF ulnar styloid / fixation of TFCC to obtain stability

- can pin DRUJ proximal to fossa





- 2%

- exclude infection


Radial Fracture Non Union CTUlna Non Union






- > 10o angulation leads to loss of ROM



- osteotomy


Radial Fracture Malunion Radial Fracture Malunion 2Radial Osteotomy Radial Osteotomy Lateral







- excise non union 

- debridement

- ABx cement spacer + external fixator

- eliminate infection


Obtain union

- BG and plate


Compartment syndrome

- don't close fascia

- good haemostasis




Risk factors

- fractures at same level / Monteggia

- proximal fractures

- open fractures

- head injuries

- bone grafting

- ORIF through single incision

- delayed surgery > 2 weeks





- usually posterior approach

- elevate ECU from ulna

- exposes synostosis and radius

- application of bone wax to bone after debridement

- +/- irradiation / indomethacin especially in head injured patients

- worst results with proximal synostosis

MCL Insufficiency

AetiologyTommy John Surgery


Throwing injury

- seen in the throwing athlete

- repetitive microtrauma / valgus stress

- develop laxity





- lose velocity / accuracy


Develop medial pain


40% ulna nerve symptoms




Pain on palpation of anterior bundle MCL


CFO muscle bulk covers insertion in full extension

- reveal UCL with flexion


Jobes test


Valgus stress with elbow flexed 25o to unlock olecranon

- forearm pronated to prevent false positives due to lateral side laxity

- problem is shoulder ER



- lie patient prone

- apply valgus stress


Elbow MCL Test ProneElbow MCL Test Prone 2


Milker test

- shoulder ER

- thumb pointing out

- extend arm whilst placing valgus strain


MIlkers Sign 1Milkers Sign 2




Elbow MCL Anatomy




40% calcification MCL


Stress view

- > 3mm difference from opposite side




Nearly all throwing athletes / pitchers will have abnormalities

- don't decide surgery on basis of MRI findings




Non Operative






- may be muscle imbalance in throwers 

- overactivity of EDC and ECRB aggravates valgus

- physio to balance flexors and extensors 

- radial deviators vs Ulna deviators

- if doesn't settle consider reconstruction


Really amounts to 6/12 rest

- problem for professional athletes




Tommy John Surgery


Named after famous American baseball pitcher

- first to have this surgery




1.  Repair

- not often able to be done

- perhaps in acute tear


2.  Reconstruction with free graft

+ / - transpose ulnar nerve anteriorly out of the way

- many techniques described


UCL reconstruction


Tommy John Surgery


Numerus techniques described


Palmaris longus / gracilis graft


Ulna tunnel

- proximal ulna at level coronoid tubercle

- AP


Humeral tunnel

- medial epicondyle

- Y shaped

- no posterior cortical penetration to avoid injury ulna nerve


Figure of 8

- tension at 30o

- suture both limbs together to improve tension




Immobilise for 10/7

ROM brace for 4/52


No throwing for 6/12

No sport for 12/12




Jimmy Andrews et al Am J Sports Med 2010

- modification Jobe technique + subcutaneous ulna nerve transfer

- 942 patients followed up for 2 years minimum

- 83% returned to previous level of sport

- returned to throwing at 4 - 5 months

- return to full sport at 12 months


Posterior Elbow Impingement




Cause posteromedial pain

- probably related to subtle UCL instability


May be protective




Pain posteromedially with full extension




Identify posterior olecranon osteophytes




Arthroscopic Resection


Maximum 2 - 3 mm

- if remove too much arthroscopically

- high incidence of UCL tear

- probably protective

Myositis Ossificans


Elbow Myositis OssificansElbow Myositis Ossificans




Parosteal OS

- bone is not continuous with cortex in MO




3% incidence in elbow joint trauma to some degree


Head + elbow joint trauma > 90%




Ectopic bone may ossify ligaments and capsule

- does not respect anatomical boundaries

- can completely envelope ulna nerve

- may form radio-ulnar synostosis


Usually in brachialis




Elbow HO




Show mature trabeculation

Define anatomical location


Elbow CT Posterior HOElbow CT HO Anterior







- negative Alk Phos and negative bone scan do not rule out recurrence after excision

- recommends do not resect till about 18/12

- well defined trabeculae on x-ray


Excision must be coupled with prophylaxis





- 25 mg tds for 2 - 6 weeks



- 700 Gray single dose post operatively




A poor neurological recovery and spasticity associated with recurrence




Depends on site of ectopic bone



- posterolateral

- anterolateral

- medial


Elbow HO Excision PreopElbow HO Excision Post op






Nerve injury


Beware post operative instability


Elbow Post HO Excision



Olecranon Fracture



Intra-articular proximal ulna fracture




Articulates with trochlea

- may have a central bare area


Triceps insertion

- via broad aponeurosis which blends with anconeus and CEO




Non operative Management


Undisplaced fracture

- need to ensure triceps mechanism is intact

- Long arm POP 3/52 in 90o flexion


Operative Management




1.  Disruption of extensor mechanism

- any displaced fracture

2.  Articular incongruity






Excision fragment / triceps advancement


TBW Technique


Elbow Olecranon FractureOlecranon Fracture AP TBWOlecranon TBW Lateral



- convert the tensile distraction force of triceps into a compressive force at the articular surface



- bi-cortical K wires

- intra-medullary k wires

- intramedullary screw



- fracture distal to centre of rotation / midpoint of trochlea notch

- highly comminuted fractures

- oblique fractures

- best to use plate in these situations



- lateral decubitus over bolster

- curvilinear incision to avoid prominence of olecranon

- clean and washout haematoma

- reduction (extend elbow to defunction triceps / place bone forcep)

- 2 x IM k wires (no need to bite anterior cortex / risk nerve injury)

- drill hole in ulna, pass 20 gauge wire

- form figure of 8 wire about wires, can pass under triceps

- twist via 2 knots

- bury end of K wires under triceps


Screw / TBW


Beware bow of proximal ulna

- may cause medial shift

- avoid long screw




Olecranon Fracture Lateral



- fracture distal to centre of rotation


Main problem is hardware prominence

- precontoured low profile

- proximal hooks to grip triceps

- beware over compression articular surface in comminuted fractures


Olecranon Plate


Excision fragment / triceps advancement



- elderly

- osteoporotic

- < 50% articular surface

- non reconstructable








Relatively rare


Average age 50


Men 4:1 Women


Usually dominant arm





- associated with strenuous manual labour



- trauma


- synovial chondromatosis

- valgus extension overload / MCL insufficiency




Begins radiocapitellar joint


Progresses to ulnohumeral joint


Forces across joint about 1/2 body weight

- increased in strenuous work

- small cross sectional area

- increases contact stresses




Often have end range pain

- minimal in mid range

- pain when olecranon and coronoid osteophytes impinge




May have well preserved radiocapitellar and ulnohumeral joints


Osteophytes olecranon and coronoid


Elbow OA LateralElbow OA AP




Useful in defining antomy pre operation / identification loose bodies


Elbow Arthritis CT


Elbow Loose Bodies CTElbow Loose Bodies CT 2




Useful in detecting early chondral damage


MRI Radiocapitellar OAMRI Ulna Trochlea OA




Capitellar Chondral InjuryRadial Head Chondral DamageUlna Chondral Damage




Inflammatory arthritis / RA

- minimal osteophytes

- severely arthritic joint spaces

- have pain throughout range of motion




Non operative







1.  Open procedures


A.  Open capsular releases

- for stiffness

- releases as required


See Elbow / Stiffness


B.  OK procedure

- removal of coronoid and olecranon osteophytes


See Elbow / Stiffness


2.  Arthroscopic Osteochondroplasty and Releases


Anterior joint

- remove loose bodies

- resect coronoid osteophytes

- anterior capsular release to improve extension

- +/- radial head resection


Posterior joint

- remove loose bodies

- resect olecranon osteophytes


See Elbow / Arthroscopy


3.  Total elbow arthroplasty



- > 65

- sedentary




? reduced long term survival compared to RA


Bjord-Tilde et al J Should Elbow Surg 2009

- Norwegian Joint Registry

- 469 RA revision rates 7% at 5 years and 15% at 10 years

- OA numbers small (24) with 5% revision rate at 5 years, 10 year not available


Posterolateral Rotatory Instability



Radius rotates externally in relation to the ulna

- posterior displacement of the radial head relative to the capitellum

- in flexion


Posterolateral rotatory Instability


Anatomy LCL


LCL Elbow




1.  Laxity or tear of ulna LCL

- posterior dislocation / subluxation / perching

- most common cause


2.  Torn CEO

- dynamic restraint


3.  Depressed fracture of radial head / malunion coronoid fractures

- leading to loss of secondary restraint




Dislocation occurs with a valgus ER force pivoting the elbow on the intact MCL





- acute LCL tear after dislocation



- tennis elbow release

- Kocher approach


Ligamentous laxity


Long standing cubitus varus




Posterolateral elbow pain


Describe clunk on full extension


Patient may be able to demonstrate instability




Test combines external rotation / supination with valgus and axial loading


1.  O'Driscoll Pivot Shift Test


Best with patient anaesthetised

- can sublux joint


If patient awake, only get pain and apprehension


Patient supine

- examiner at head of bed

- GHJ full flexed with hand over head

- elbow resembles knee in this position

- forearm supinated

- elbow fully extended


Valgus stress with axial load & slowly flex joint

- at 40o the radial head is subluxed maximally posterolaterally

- radial head becomes prominent as it dislocates

- patient feels apprehension as the radial head subluxes

- past 40o flexion the radial head reduces



- prominent radial head (dislocates)

- pivot

- pain  (apprehension)

- maximum subluxation is at 40o flexion but with increased flexion reduces with snap


2.  Table Top Test


Push up on table with forearms in supination

- radial head subluxes, patient has apprehension

- relieved by thumb pressing on radial head


Table Top Test 1Table Top Test BeforeTable Top Test After





Usually normal

- may be slight widening of radiohumeral joint

- radial head may appear slightly posterior




Difficult to distinguish lateral complex






Does not improve with time

- usually requires surgery if very symptomatic




1. Repair 

2. Imbricate

3. Reinforce/Reconstruct with PL graft




Kocher approach between Anconeus & ECU

- drill holes x 2 base sublime tubercle

- drill holes x 2 at lateral epicondyle (isometric point)

- palmaris graft in figure of 8

- tighten with elbow at 30 - 40o of flexion


Post op

- hold flexed 2/52

- then allow ROM in hinged brace


Lateral Ligament Elbow Reconstruction




O'Driscoll et al JBJS Br 2005

- retrospective review of 44 cases

- some direct repair, some autograft reconstruction

- 86% satisfaction

- better outcomes in reconstruction group

Radial Head & Neck Fractures

Radial Head Fracture





- axial load with a valgus force




1.  Provides Valgus stability

- especially if MCL deficient


2.  Longitudinal stability

- aided by interosseous membrane


3.  Load Transfer

- 60% of load at elbow

- with radial head excision, load is transferred to ulno-humeral joint

- increase risk of OA


Hotchkiss modification of Mason Classification


Type I


Undisplaced fracture

- intra-articular displacement < 2mm

- no mechanical limit forearm rotation

- if in doubt, inject LA into radiocapitellar joint / soft spot

- ensure no mechanical block to rotation


Radial Head Mason 1Radial Head Fracture Mason 1


Type II


Displacement > 2mm

- motion mechanically limited

- reconstructable


Radial Head Fracture Type 2Radial Head Fracture Type 2 CTRadial Head Fracture Mason 2


Type III


Severely comminuted fracture of the radial head and neck

- not reconstructable

- requires excision for movement


Type IV


Associated with elbow dislocation


Complicated Radial Head Fracture


1.  Elbow Dislocation


2.  Essex Lopresti


Fracture Radial Head + Disruption DRUJ / Interosseous membrane

- dorsal dislocation of DRUJ

- ORIF / replacement radial head

- supinate DRUJ to reduce +/- TFCC repair +/- K wire


Surgical Options


1.  ORIF


Radial Head ORIF


Kocher approach

- between anconeus and ECU

- dissect muscles off capsule

- protect ulna collateral ligament under anterior edge of anconeus

- pronate forearm to protect PIN

- divide capsule in line with incision, create anterior and posterior flaps


Safe Zone for implants

- posterolateral portion of cartilage

- yellow and thinner

- non articulating

- 90o arc between radial styloid and lister's



- headless compression screws





- soft tissue stripping


Non union 

- same reasons

- 10%




Ring et al JBJS Am 2002

- results of ORIF Type III radial head

- overall 54% poor results

- good results with 2 or 3 fragments

- poor results with 4 results


2.  Excision



- elderly patient



- MCL or interosseous membrane disrupted



- reduced strength

- proximal radial translation

- DRUJ instability and pain

- valgus instability elbow

- arthrosis (deceased SA, increased contact stresses)


3.  Replacement


Radial Head Replacement LateralRadial Head Replacement APRadial Head Replacement Monoblock




1.  Silastic 

- less resistant to compressive forces

- can get synovitis

- good as temporary spacer

- can cut out later


2.  Titanium

- monoblock / modular / bipolar


Technique Modular Titanium Radial Head


Radial Head Replacement


Excise radial head

- insert trial broaches into neck

- small or large diameter, standard or long

- insert trial head size and thickness

- check xray

- ensure not overstuffed

- put through range

- prepare real implant on operating table

- have to insert head and neck as one piece


Radial Head Replacement Lysis APRadial Head Replacement Lysis Lateral




Grewal JBJS Am 2006

- modular radial head

- 26 patients followed prosectively for 2 years

- no revisions

- mild OA in 19%


Burhart et al J Should Elbow Surg 2010

- bipolar radial head

- 17 patients followed up for between 6 and 10 years

- 2 dislocations, 8 had evidence capitellar OA

- no loosening

- 16/17 good or excellent results Mayo elbow scores




1.  Aseptic loosening

2.  Overstuffing

3.  Capitellar OA

4.  Malpositioning


Radial Head Poorly Positioned


Radial neck fracture


Radial Neck Fracture


Indications for surgery

- > 30o angulated



- Z incision annular ligament

- elevate supinator with arm pronated




1. T plate in safe zone

- distal limit is bicipital tuberosity

- pre-contoured low profile plates

- may need to lag articular surface first

- check ROM intra-operatively

- plates often bulky and may limit ROM


Radial Neck Plate


2.  Fix with headless compression screws

- proximal to distal

- cross fracture site


Radial Neck Fracture ORIF Screws APRadial Neck Fracture ORIF Screws Lateral


3.  Retrograde Intramedullary Wire


4.  Radial Head Replacement

Rheumatoid Elbow

Elbow Rheumatoid ArthritisElbow Rheumatoid Arthritis 2




50% rheumatoid patients have elbow pathology

- 80% also have shoulder pathology

- 90% hand and wrist


Always consider entire upper limb





- swelling and pain

- may develop FFD due to holding in flexed position


Annular ligament may rupture

- anterior displacement of radial head

- due to pull of biceps


Collateral ligaments may rupture

- ML instability


Ulna nerve neuropathy

- synovitis

- rheumatoid nodule


Cartilage and bone destruction

- severe cartilage damage

- instability

- bony destruction




Non Operative


SMART / DMART / Immunological medications






Turnbuckle braces

- night time

- for loss of extension




1.  Synovectomy +/- radial head excision



- minimal OA

- significant synovitis

- young patient


Radial head excision

- to improve rotation




Elbow instability

- can worsen

- may develop progressive valgus




1.  Open


A. Extended Kocher

- limited access to posterior olecranon

- limited access to medial side


B.  Universal Posterior approach


2.  Arthroscopic




Maenpaa et al J Shoulder Elbow Surg 2003

- 103 synovectomies open synovectomies via Kocker approach

- 5 year survival (reoperation / TER) 77%

- best with early OA
- no improvement in ROM but good pain relief


2.  Arthrodesis / Resection arthroplasty


Salvage only


3.  Interposition arthroplasty


Results inferior to arthroplasty


4.  Arthroplasty


A.  Non constrained


Need ST stability and balancing

- there is an incidence of postoperative instability (7 - 19%)

- good ROM

- need stems to prevent loosening (high failure rate of resurfacing)


Ewald et al JBJS Am 1993

- 202 follow up for 6 years

- 1.5% revision 


B.  Constrained


Higher early rates of failure

- 22% 4 year revision rate


C.  Semi constrained


Morrey JBJS Am 1998

- Coonrad - Morrey prosthesis

- 97% minimally painful at 10 years



- anterior flange on humeral prosthesis very important to survival


Latitude prosthesis

- unconstrained can be converted to constrained


Total Elbow Replacement RA LatitudeTotal Elbow Replacement RA Latitude







Functional range


30- 130o - Flexion / Extension

50o each - Pronation / Supination





- skin / subcutaneous tissue

- capsule (anterior / posterior)

- collateral ligament contracture

- muscle contracture

- HO



- articular deformity / malunion

- articular adhesions

- impinging osteophytes (olecranon / coranoid)

- impinging fibrosis (olecranon / coranoid)

- loose bodies






Decreased flexion / extension

- ulno-humeral joint


Decreased pronation / supination

- radio-capitellar joint



- post-traumatic elbow stiffness is usually not painful

- indicates chondral damage




Active v passive ROM









- graduated active assisted stretching 


Dynamic hinged elbow splint 

- often poorly tolerated


Static progressive 

- turnbuckle splint


Operative Treatment





- not recommended

- may worsen stiffness

- due to haematoma or articular damage


1.  Arthroscopic Release

2.  Open Release

3.  OK Procedure

4.  Interposition arthroplasty

5.  Total Elbow Arthroplasty


1.  Arthroscopy 


Used increasingly to treat stiffness


Relative Contra-indications

- previous ulna nerve transposition

- severe soft tissue contractures

- bridging HO



- remove scar tissue / loose bodies

- remove olecranon / coronoid osteophytes

- radial head resection

- resect bony malunions

- can perform modified O-K procedure




Post elbow fracture malunion / posterior impingement / FFD 40o


Elbow Malunion LateralElbow Malunion MRI


Elbow Malunion ImpingementElbow Malunion Impingement


Elbow Malunion Partial DebridementElbow Malunion Post Debridement


Elbow Malunion PreopElbow Malunion Post Op


2.  Open Soft tissue releases 




Universal posterior approach

- arm over patient held by assistant


Lateral interval

- to distal humeral elevating BR and ECRL

- distally between ECRB and EDC


Medial interval

- find and protect ulna nerve

- between triceps and brachialis proximally

- detach pronator teres distally


Technique Morrey


A.  Muscle releases

- brachialis released from humerus

- triceps released from humerus


B.  Capsulotomy / capsulectomy

- anteriorly elevate brachialis off capsule


C.  Excision of HO


D.  Removal of osteophytes

- coronoid / olecranon 


E.  Debridement of osteochondral flaps / loose bodies


F.  +/- Release of collateral ligaments

- preserve anterior band of MCL 

- ligament reconstruction & hinged elbow fixator if becomes unstable


G.  Radial head debridement / excision 

- especially if blocking supination / pronation




Increases of 30 - 40o


3.  OK procedure


Elbow OK Procedure APElbow OK Procedure Lateral




Outerbridge - Kashiwagi procedure

- debridement athroplasty




Posterior approach 

- triceps split


Excision of posterior capsule


Excision of tip of olecranon


Access to anterior compartment via olecranon fossa

- 1 cm diameter hole

- use burr

- need to minimise bone dust


Debridement of coranoid and radial head


Removal of loose bodies




4.  Interposition Arthroplasty



- stiff elbow joint

- damage to >50% of ulno-humeral articular surface

- failure to achieve good range of motion following soft tissue release




Kocher Approach


Detach lateral ligament from humerus


Refashion ulno-humeral surface

- may be necessary in fracture or extensive malunion 

- create congruent surfaces for flexion / extension


Strip of fascia lata 

- fashioned and attached to anterior humerus

- fascia passed around end of humerus to cloth front and back

- then doubled on itself and attached to anterior ulna

- articular surface is fascia on fascia


Lateral ligament is then reattached


+/- hinged external fixation with distraction


5.  Total elbow replacement (arthroplasty)



- 70% satisfaction

- less successful than RA

- some improvement in range (20o)