Complex Proximal Ulna Nonunion
Lee Hunter MD, MBA (Hunter Medical Founder and Chief Medical Officer)
April 2020
Some proximal ulna fractures are more challenging than others. This is a case of a complex proximal ulna nonunion which ultimately required a modified triceps advancement reconstructive procedure.
67 YOM with Complex Olecranon Nonunion and Bone Loss
The patient sustained a complex olecranon fracture of his dominant arm from a fall. Within six weeks of his initial surgery, the hardware had loosened and the distal humerus subluxed through the olecranon fracture. The ulna hardware was then revised and a dynamic external fixator applied and left in place 6 weeks. The patient developed a pin tract infection, which apparently resolved with oral antibiotics. He presented to my office 10 months after the original injury, 3 months post fixator removal complaining of persistent pain and loss of function of his arm/elbow. He denied any fever or chills. He had 30 - 130 degrees of painful elbow motion with healthy skin with 3/5 elbow extension strength. His medical history is negative for diabetes, and he has never smoked. Neurovascular exam was normal. Examination and labs were negative for infection. HIs presenting images are below.
SThe patient was positioned supine and through a posterior approach, the radial and ulnar nerves were identified and the ulnar nerve decompressed. Hardware was removed and cultures taken. No clinical evidence of infection was present. The trochlea had a longitudinal defect from articulating against a screw. The triceps/olecranon unit was mobilized and the olecranon fragment contoured with a saw to mate as well as possible with the intact native ulna distally providing a relatively congruent articulating surface. Fiberwire sutures were woven through the distal triceps and passed through the olecranon fragment.The elbow was held statically in moderate extension while these sutures were passed though three parallel bone tunnels in the metaphyseal ulna, tied over dorsal cortical bridges, then woven back through the triceps. Demineralized bone matrix allograft was injected prior to final seating and fixation. A hinged elbow brace with a 45 degree flexion block was applied over the dressing, and gradually loosened to allow flexion to 90 degrees by 6 weeks post op. Intraoperative photos and 6 month post op films are below. Active elbow ROM was 15 > 135 degrees with 4+/ 5 extension strength with only occasional mld discomfort.
The ElbowLOC® Supine Positioner is the only arm positioner that gives the surgeon the ability to “dial in” the desired amount of elbow extension while allowing unencumbered access to the forearm. This makes difficult cases such as this one technically easier to perform. This case is another great example of how the ElbowLOC® simplifies and accelerates procedural times for many elbow surgeries and makes surgery easier for the surgeon, patient, and staff!