A number of questions must be asked before the management of the elbow elbows: when the initial trauma was assessed, were all the lesions diagnosed?Are bone masses consolidated? If so, is the anatomy reestablished or is there a vicious callus of incongruence? Is the elbow centered or dislocated in the frontal plane, sagittal or axial?
As we have seen, a thorough, comparative and complete clinical examination is necessary before any treatment.Similarly, after a standard radiological examination, computed tomography (CT) remains the best iconographic examination to analyze at best these great lesions that are pseudarthrosis, vicious calluses and instabilities. The fundamental notion of treatment that is surgical, is to restore the anatomy, possibly associated with a secondary gesture of mobilization.
Their functional tolerances are always mediocre.
The problem of treatment is above all technical, linked to the good stability of the synthesis and function of the seat in height of the stroke as well as the stiffness of the underlying elbow.
We can distinguish supra-articular pseudarthroses (metaphyseal high, metaphyseal low) and intraarticular.
The supra-articular pseudarthroses:
These are the most frequent. They pose problems close to the vicious calluses whatever their seat, we must resist the temptation to treat simultaneously pseudarthrosis and stiffening. These pseudarthroses are, in fact, all the more generating of stiffening because they are sequellar of fractures intra-articular or para-articular low. The para-articular seat of the pseudarthrosis trait limits the solidity of the synthesis in the lower fragment, irrespective of the reconstruction artifacts, the quality of the surgery and the progress of the equipment used. The precaution is to stick to the gestures of consolidation of the pseudarthrosis: decortication, excision, possible graft and synthesis. If there is any doubt as to the strength of the assembly, this synthesis must be protected by an external humerus ulnar fixation. This protection is temporary and will be maintained until consolidated. A rehabilitation program will follow. It is not unusual that the consolidation of the pseudarthrosis allows to recover a better mobility than before the treatment of the latter.Otherwise, a surgical program of arthrolysis will be considered at a distance, at least one year after obtaining the consolidation.
The intra-articular pseudarthroses:
They are often fragments of limited size behaving like intra-articular foreign bodies and which will be the object of a simple intraoperative excision. This is true for the frontal fractures of the humerus, some fragmental fractures of the radial head, but must be qualified on the pseudarthroses of sagittal fracture fractures of the palette which, as a rule, can be edited and osteosynthesized, allowing a fairly reeducation precocious; the same holds true for ulnar epiphyseal fractures.
The vicious calluses:
They can be supra-articular, usually humeral, but also intra-articular can then touch each of the three bones of the elbow.
The supra-articular vicious corals of the humerus:
In all cases, when a recovery of the axis seems necessary, it must be carried out in a time prior to the mobilizing surgery. Simultaneous arthrolysis may lead to devascularization of the osteotomized bone end.
On the other hand, the demands of rehabilitation may interfere pejoratively with the consolidation of the corrective osteotomy.
The intra-articular vicious calluses:
The balance is made, at best by CT, with reconstruction.
The essential question is whether the vicious callus is tolerable or not:
• the vicious callus is a factor of incongruence and is not yet complicated with osteoarthritis: it justifies a correction;
• the vicious callus is associated with advanced osteoarthritis: the indication of osteotomy is to be weighed and may involve associated or alternative gestures: bone rework and articular distraction, or even in some cases prosthesis or arthrodesis.
As a rule, osteotomy and correction of the vicious callus require a wide arthrotomy associated with a gesture of articular release. On these fractures, which are often fragmentary and intra-articular, the stresses are relatively small and can withstand effective rehabilitation.
Consequently, the attitude is to the correction of the vicious callus associated with arthrolysis by ensuring that osteosynthesis is strong enough to withstand rehabilitation, while not being aggressive for cartilage surfaces. the repositioning of a frontal or sagittal fracture of the palette or the restoration of the humeru-ulnar congruence in the case of fracture of the upper extremity of the ulna. At this level, the gesture is easy if the elbow is not in posterior subluxation. At the level of the radius, the problem is to define the limits of indication of the regularization of a vicious callus of the radial head by remodeling or the decision of the resection. When complete arthrolysis, potentially destabilizing, is associated with a resection gesture or when other destabilizing lesions (coronoid, internal plane) exist simultaneously, it is advisable to replace the resected radial head with a prosthesis.
A particular point must be noted in the vicious Monteggia fracture callus neglected: the vicious callus is ulnar, the radial head is dislocated and its reposition imposes a wide release of the external compartment. If the head is stable after osteotomy of the ulna and repositioning, a rehabilitation can be proposed from the outset. In contrast, if the head is unstable despite an anatomical repositioning by perfect restoration of the ulnar curvature and a release of the lateral compartment, it is necessary to broach it.
This broaching, temporary, in humeroradial rule, obviously prohibits any reeducation. A gesture mobilizing arthrolysis is then postponed.
The osteoligamentary sequelae of dislocations:
It is important to understand, once again, why the patient has reached this stage of evolution. We will therefore seek a lack of knowledge of initial lesion, insufficiency of initial therapy or secondary surveillance.
Examples in common trauma are frequent: repair of an internal plane associated with uncontrolled approximate stabilization, association of medial dislocation and fracture of the radial head, each of which is a factor of instability. It must never be forgotten that a bad initial reduction never corrects itself spontaneously.
Their tolerances are rarely satisfactory and their management difficult because they associate a technical gesture of refocusing the delicate articulation, early rehabilitation with random results.
In the frontal plane, they are in sequential order of a fracture of the radial head associated with a sprain of the medial collateral ligament in the context of a dislocation of the elbow. On the radiological level, the existence of calcifications under the medial epicondyle lower border is a sign practically pathognomonic. The radial head may have been previously resected, often with an unstable elbow and already osteoarthritic lesions. It is then essential to restore the lateral stability by reconstruction of the humeroradial column by implanting a radial head prosthesis.
In the sagittal plane, they are sequelae of “ terrible triads “ responsible for very early osteoarthritis of the elbow by incongruence, brought about by the posterior subluxation that allows the simultaneous loss of the coronoidal stop and the lateral radiohumoral console.
The evolving potential is catastrophic.
Surgery of these eccentric and enraidis elbows is a rescue surgery that combines restoration of the lateral console by a radial head prosthesis, a reconstruction of the coronoid (bone lock screwed according to Milch) and arthrolysis. This gesture may be sufficient.
A persistent decoaptation of the elbow due to ligament insufficiency, in particular postero-internal insufficiency, must cause the discussion of the implantation of a distractor-stabilizer.
The longitudinal instabilities of the radial diaphyses can be brought into this nosological framework. They are seen in the syndromes of Essex-Lopresti and must make the indication of resection of the radial head prudent.
In all cases, pseudarthroses are still poorly tolerated and need to be consolidated.
The functional tolerance of a vicious callus is variable; its correction is often the first step in a rehabilitation program where bone surgery must always precede re-mobilization surgery.
The correction and stabilization of any total or partial dislocation is imperative to refocus the elbow even at the cost of the temporary loss of mobility.
Whatever the quality of the management of the sequelae, the result will always be worse than that of an optimal initial treatment.