The Journal of Bone & Joint Surgery

The Journal of Bone & Joint Surgery, Volume 86, Issue 6

Scientific Articles | June 01, 2004

Standard Surgical Protocol to Treat Elbow Dislocations with Radial Head and Coronoid Fractures

David M.W. Pugh, MD, FRCS(C)¹; Lisa M. Wild, BScN¹; Emil H. Schemitsch, MD, FRCS(C)¹; Graham J.W. King, MD, MSc, FRCS(C)²; Michael D. McKee, MD, FRCS(C)¹

¹ Upper Extremity Reconstructive Service, St. Michael's Hospital, 55 Queen Street East, Suite 800, Toronto, ON M5C 1R6, Canada. E-mail address for M.D. McKee: mckee@the-wire.com
² University of Western Ontario, Hand and Upper Limb Centre, 268 Grosvenor Street, London, ON N6A 4L6, Canada

View Disclosures and Other Information

The authors did not receive grants or outside funding in support of their research or preparation of this manuscript. They did not receive payments or other benefits or a commitment or agreement to provide such benefits from a commercial entity. No commercial entity paid or directed, or agreed to pay or direct, any benefits to any research fund, foundation, educational institution, or other charitable or nonprofit organization with which the authors are affiliated or associated.

Investigation performed at Upper Extremity Reconstructive Service, St. Michael's Hospital, and University of Western Ontario, Hand and Upper Limb Centre, London, Ontario, Canada

The Journal of Bone and Joint Surgery, Incorporated

J Bone Joint Surg Am, 2004 Jun 01;86(6):1122-1130

5 Recommendations (Recommend) | 3 Comments | Saved by 3 Users Save Case

Article

Comments (0)

text A A A

Abstract

Background: The results of elbow dislocations with associated radial head and coronoid fractures are often poor because of recurrent instability and stiffness from prolonged immobilization. We managed these injuries with a standard surgical protocol, postulating that early intervention, stable fixation, and repair would provide sufficient stability to allow motion at seven to ten days postoperatively and enhance functional outcome.

Methods: We retrospectively reviewed the results of this treatment performed, at two university-affiliated teaching hospitals, in thirty-six consecutive patients (thirty-six elbows) with an elbow dislocation and an associated fracture of both the radial head and the coronoid process. Our surgical protocol included fixation or replacement of the radial head, fixation of the coronoid fracture if possible, repair of associated capsular and lateral ligamentous injuries, and in selected cases repair of the medial collateral ligament and/or adjuvant hinged external fixation. Patients were evaluated both radiographically and with a clinical examination at the time of the latest follow-up.

Results: At a mean of thirty-four months postoperatively, the flexion-extension arc of the elbow averaged 112° ± 11° and forearm rotation averaged 136° ± 16°. The mean Mayo Elbow Performance Score was 88 points (range, 45 to 100 points), which corresponded to fifteen excellent results, thirteen good results, seven fair results, and one poor result. Concentric stability was restored to thirty-four elbows. Eight patients had complications requiring a reoperation: two had a synostosis; one, recurrent instability; four, hardware removal and elbow release; and one, a wound infection.

Conclusions: Use of our surgical protocol for elbow dislocations with associated radial head and coronoid fractures restored sufficient elbow stability to allow early motion postoperatively, enhancing the functional outcome. We recommend early operative repair with a standard protocol for these injuries.

Level of Evidence: Therapeutic study, Level IV (case series [no, or historical, control group]). See Instructions to Authors for a complete description of levels of evidence.

Figures in this Article

Elbow dislocations associated with both radial head and coronoid fractures have been termed the terrible triad of the elbow because of the difficulties inherent in treatment and the consistently poor reported outcomes, especially when compared with the results of treatment of simple elbow dislocations^1-5. There are few published reports dealing specifically with the management and outcome of elbow dislocation with associated radial head and coronoid fractures^6,7. Most available information is contained in studies of elbow injuries with a small subset of patients with the so-called terrible triad. The authors of those studies have noted poor results due to acute recurrent instability, chronic instability, stiffness, posttraumatic arthrosis, and pain. In 1989, Josefsson et al. reported the long-term outcomes in twenty-three patients who had sustained an elbow dislocation with a displaced radial head fracture⁵. They reported redislocation in four patients, all of whom also had an untreated fracture of the coronoid process. Two other reports described series of patients with an acute elbow injury who required revision surgery and application of a hinged fixator to restore concentric stability following failure of the initial treatment: in both series, patients with an elbow dislocation associated with radial head and coronoid fractures predominated^8,9. Ring et al. described unsatisfactory results in seven of eleven patients with this injury pattern¹⁰.

Improved understanding of the mechanism of elbow injuries, the primary and secondary constraints providing stability, the soft-tissue injury patterns, and better methods of surgical repair led us to develop a consistent surgical strategy for these injuries. We routinely perform open reduction and internal fixation of the coronoid fracture and/or repair of the anterior capsule, repair or replacement of the radial head, and repair of the lateral ligament complex. Repair of the medial collateral ligament and/or application of a hinged external fixator is reserved for patients who demonstrate residual instability after standard treatment.

The purpose of our review was to determine the clinical and radiographic outcomes following application of this management protocol to a consecutive series of patients who had sustained an elbow dislocation associated with radial head and coronoid fractures.

Materials and Methods

Materials and Methods | Results | Discussion | References

We identified forty consecutive skeletally mature patients (forty elbows) in whom an elbow dislocation associated with fractures of the radial head and coronoid process had been treated at two university-affiliated teaching hospitals between June 1995 and January 2001. At the time that this review commenced, our institution did not require approval of this type of study by the research ethics board. Four patients were lost to follow-up prior to definitive assessment of the outcome, leaving thirty-six patients (thirty-six elbows) for evaluation. There were twenty-two male patients and fourteen female patients with a mean age of 41.4 years (range, thirteen to seventy-six years). The mechanism of injury included fourteen falls from a standing height, eleven high-velocity falls from a height, five bicycle accidents, four sports injuries, one motorcycle accident, and one crush injury. The thirty-six elbows were treated surgically by us at a mean of 4.5 days (range, zero to seventeen days) after the injury. The specific indications for operative intervention included a displaced intra-articular fracture, an inability to obtain or maintain a concentric reduction in a closed fashion, and residual instability of the elbow in a functional (30° to 130°) arc of motion following closed reduction¹¹.

Radiographs made at the time of presentation showed all thirty-six elbow dislocations to be posterior. We categorized the coronoid fractures according to the radiographic classification system of Regan and Morrey¹². With this system, type I indicates a fracture involving the tip of the coronoid process; type II, =50% of the coronoid process; and type III, >50% of the coronoid process. There were ten type-I, eighteen type-II, and eight type-III coronoid fractures. Eighteen type-II and III fractures of the coronoid process were treated with open reduction and internal fixation with screws, and we performed an anterior capsular repair in the other eighteen elbows (as described under Operative Technique).

According to the Mason-Johnston classification¹³, all radial head fractures were type IV since they were associated with a dislocation. There were three marginal fractures involving <25% of the head, which could be considered a Mason type-I fracture. There were fourteen "partial" head fractures (Mason type II), in which part of the head was still in continuity with the radial shaft, and nineteen "total" head fractures (Mason type III), in which there was no such continuity. We performed open reduction and internal fixation of the radial head in thirteen elbows and prosthetic replacement in twenty. The other three radial head fractures were irreparable, marginal injuries involving <25% of the joint surface. These were débrided, and the native head was maintained as intraoperative examination revealed acceptable stability of the elbow and proximal radioulnar articulation.

The lateral soft-tissue structures had been disrupted, and were repaired, in every patient. Six patients also had a repair of the medial collateral ligament, and two had an articulated external fixator applied because of residual instability.

The patients were followed clinically and radiographically until fracture union had occurred and elbow motion had plateaued with appropriate supervised physiotherapy. Clinical evaluation included determination of pain, function, range of motion, and stability. Anteroposterior and lateral radiographs were assessed for fracture union, implant loosening, heterotopic ossification, degenerative changes, and joint congruity. The Mayo Elbow Performance Score (MEPS) was determined for each patient at the final clinic visit¹⁴.

Statistical analysis was performed with the SAS software package (SAS Institute, Cary, North Carolina). A Student t test was used to evaluate the differences between groups. A level of p = 0.05 was considered significant.

Operative Technique

All procedures were performed by or under the direct supervision of one of two fellowship-trained orthopaedic surgeons (M.D.McK. or G.J.W.K.). The technique for the repair and the rationale behind it have been described in detail previously¹⁵. The general approach was to repair the damaged structures sequentially from deep to superficial, as seen from the lateral approach (coronoid to anterior capsule to radial head to lateral ligament complex to common extensor origin). Elbow stability was then evaluated, with the goal being concentric stability with no observed posterior or posterolateral subluxation through a flexion-extension arc of 20° to 130° with the forearm in neutral rotation. Instability was typically most evident in extension and supination. If instability persisted, we repaired the medial collateral ligament and/or applied a hinged external fixator. Valgus instability alone was not an indication for repair of the medial collateral ligament or application of a hinged fixator.

The principles of the operative technique were to (1) restore coronoid stability through fixation when the fracture was type II or type III or through anterior capsular repair when the injury was type I, (2) restore radial head stability through fracture fixation or replacement with a metal prosthesis, (3) restore lateral stability through repair of the lateral collateral ligament complex and associated so-called secondary constraints such as the common extensor origin and/or the posterolateral capsule, (4) repair the medial collateral ligament in patients with residual posterior instability, and (5) apply a hinged external fixator when conventional repair did not establish sufficient joint stability to allow early motion.

The surgical approach was either a posterior (universal) incision with subcutaneous dissection laterally (and medially if required) (eight elbows) or an extended lateral approach only (twenty-six elbows) or in combination with a separate medial approach (two elbows). The lateral soft tissues deep to the myofascia are invariably disrupted with this injury. The typical patterns of lateral soft-tissue injury have been previously described¹⁶; the most common was avulsion of the lateral collateral ligament complex from the posterolateral aspect of the humerus. Care was taken to work through any soft-tissue disruption created by the trauma (with proximal and distal surgical extension as required), preserving intact soft-tissue structures as much as possible (Fig. 1).

View Large | Download Slide(.ppt)
Add to My JBJS

Fig. 1: Intraoperative photograph made through a lateral surgical approach of a patient with the so-called terrible triad injury of the elbow. There is characteristic stripping of the lateral collateral ligament complex from the distal part of the humerus. A portion of the common extensor origin/lateral ligament complex can be seen hanging down from the bare lateral condyle. The coronoid fragment is trapped in the joint (arrowhead). There is a defect in the radial head, which can be seen behind the coronoid fragment. There has been very little surgical dissection; the degree of damage done by the injury is evident.

The first structure to be addressed was the coronoid. Visualization was improved by resection of a radial head with an irreparable fracture, as described below. The injury to the coronoid was typically a transverse fracture. If a large fragment (a type-II or III coronoid fracture) was found, we performed an open reduction and placed one or two lag screws from the posterior surface of the ulna to capture the fracture fragment. In comminuted fractures, we attempted to fix the largest fragment that was possible to fix, which was typically the articular portion. Cannulated screws were very useful in this regard. We fixed the coronoid fracture in eighteen of the thirty-six elbows. Type-I coronoid fractures were too small to be fixed with screws, so they either were excised if the fragment was free (which was rare) (Figs. 2-A, 2-B, and 2-C) or were repaired by placing lasso-type sutures around the fragment and the attached anterior capsule and tying those sutures to the base of the coronoid through drill holes made with an eyed Kirschner wire (ten elbows). We performed a similar maneuver for type-II and III fractures, in which comminution precluded stable internal fixation with screws (eight elbows).

View Large | Download Slide(.ppt)
Add to My JBJS

Fig. 2-A: Initial lateral radiograph of a posterior elbow dislocation associated with radial head and coronoid fractures.

View Large | Download Slide(.ppt)
Add to My JBJS

Fig. 2-B: Following closed reduction, the position is much improved, but there is still a nonconcentric reduction of the ulnotrochlear joint (small arrowheads), the radial head is subluxated posteriorly (large arrowhead), and the coronoid fracture remains displaced.

View Large | Download Slide(.ppt)
Add to My JBJS

Fig. 2-C: After coronoid excision, anterior capsule repair, radial head fixation, and reconstruction of the lateral ligament complex, concentric stability was restored and early motion could be initiated.

The radial head fracture was evaluated. Generally, the primary goal was to fix the fracture when there was one or two fracture fragments of the head (thirteen patients). If fracture comminution (three or more fragments), impaction, cartilage damage, or an associated radial neck fracture indicated that a stable anatomic reduction was not feasible, the radial head was excised, enhancing visualization of the coronoid fracture¹⁷, pending later replacement (twenty elbows; Figs. 3-A, 3-B, and 3-C). Minor fragments (<25% of the head) that were too small or damaged to fix were débrided, and the residual intact radial head was left in situ (three elbows). If prosthetic replacement was necessary, we used a metal (rather than a silicone) implant because of its better mechanical properties¹⁷.

View Large | Download Slide(.ppt)
Add to My JBJS

Fig. 3-A: Lateral radiograph of a posterior fracture-dislocation of the elbow, demonstrating a large coronoid fragment (arrowhead) and radial head and neck fracture (arrow).

View Large | Download Slide(.ppt)
Add to My JBJS

Figs. 3-B and 3-C: Postoperative radiographs made following fixation of the coronoid fracture and replacement of the radial head. Excellent stability was achieved, and the initiation of early motion contributed to an excellent clinical result.

Detachment of the lateral ligament complex from the humerus was then repaired with nonabsorbable sutures placed through drill holes in the distal part of the humerus (thirteen elbows) or with suture anchors (fifteen elbows). Midsubstance tears were repaired with direct suture with use of number-1 or 2 nonabsorbable suture (eight elbows). We used local tissue only, and we did not perform any tendon grafts or ligament augmentations in this series. We also did not routinely repair the medial collateral ligament, but if unacceptable instability persisted (as defined above), then the medial collateral ligament was exposed and repaired (six elbows). In two cases in which repair of the injured structures did not restore adequate stability, we applied a hinged external fixator to help maintain a concentric reduction of the elbow while allowing elbow motion exercises⁹. Wounds were closed in layers, after which a sterile dressing was applied. Drains were not routinely used.

Postoperative Management

A well-padded posterior plaster splint was applied with the elbow in 90° of flexion and the forearm fully pronated to protect the lateral repair and maintain reduction. If both the medial and the lateral soft tissues had been repaired, the forearm was splinted in neutral rotation. Supervised motion was begun within seven to ten days after the surgery, when the sutures and splint were removed. As our experience increased, we began earlier mobilization, typically on the first or second postoperative day. Active and active-assisted range-of-motion exercises, including both flexion and extension, were initiated. We believe that, rather than being detrimental, active elbow motion following surgical repair enhances stability through the recruitment of muscle groups that act as dynamic stabilizers of the elbow. We allowed flexion and extension exercises to be done with the forearm in pronation and active forearm rotation exercises to be done with the elbow at 90°. We had our patients avoid the terminal 30° of extension until four weeks postoperatively, and most patients avoided this position anyway because of pain. We did not routinely use hinged splints or casts. Unrestricted shoulder and wrist motion was encouraged. One senior author (M.D.McK.) did not use indomethacin or irradiation as prophylaxis against heterotopic ossification, whereas the other (G.J.W.K.) prescribed 25 mg of indomethacin three times a day for three weeks postoperatively.

Results

Materials and Methods | Results | Discussion | References

The mean duration of follow-up was thirty-four months, with a range of twenty to sixty-five months. The mean arc of flexion-extension (and standard deviation) was 112° ± 11°, the mean flexion contracture was 19° ± 9°, the mean flexion was 131° ± 11°, and the mean arc of forearm rotation was 136° ± 16°. The functional arc of motion, as determined according to the criteria of Morrey et al. (a flexion-extension arc of 30° to 130° and 100° of forearm rotation)¹⁸, was achieved in twentynine of the thirty-six patients.

According to our intraoperative examination, two patients demonstrated unacceptable residual instability in extension following fixation of both the radial head and the coronoid fracture and the ligament repair. These two patients required placement of an articulated external fixator to maintain concentric joint reduction and allow early motion. Another patient demonstrated unacceptable postoperative instability following radial head fixation, débridement of a type-I coronoid fracture, and repair of the anterior capsule and the lateral ligament complex, necessitating placement of an articulated external fixator. Despite this treatment, joint incongruity persisted at the time of final follow-up, as described under Complications. The hinged fixator was in place for a mean of 6.2 weeks in these three patients. All three patients had severe soft-tissue disruption and inherently poor-quality tissue that made soft-tissue repair tenuous.

At the time of follow-up, thirty-four of the thirty-six patients had maintained a concentric reduction of both the ulnotrochlear and the radiocapitellar articulation. The mean Mayo Elbow Performance Score (MEPS) was 88 points (range, 45 to 100 points), which corresponded to an excellent result in fifteen elbows, a good result in thirteen, a fair result in seven, and a poor result in one¹⁴.

Radiographs

All coronoid and radial head fractures treated with internal fixation had solid osseous union on the final follow-up radiographs. There were two delayed unions of radial head fractures, which took twenty and twenty-four weeks to unite. One patient had evidence of partial osteonecrosis and irregularity of the radial head but was asymptomatic (MEPS score, 90 points).

We used the scale of Knirk and Jupiter for the radiographic assessment of posttraumatic arthritis¹⁹. Twenty-two patients had no evidence of degenerative change (Grade 0), eight had Grade-1 changes, five had Grade-2 changes, and one had Grade-3 changes. Two patients had evidence of residual joint incongruity: one had Grade-2 degenerative changes and one, Grade-3 changes.

There were radiolucent lines around eleven of the twenty radial head prostheses but no evidence of dislocation, subluxation, or progressive bone loss or shortening. This phenomenon has been described previously and does not appear to affect the clinical outcome¹⁷.

Calcification in the medial and lateral ligaments was common: it was seen to some degree in twenty-six of the thirty-six elbows. There were two cases of radiographically evident synostosis of the forearm that required a reoperation. Slight heterotopic ossification was evident in three other patients, none of whom required additional surgery; their mean range of flexion-extension was 112°. With the numbers available, there was no significant difference in the rate of synostosis or heterotopic ossification between the group that received indomethacin and the group that did not (p = 0.34).

Complications

Eight patients (22%) had a complication requiring a reoperation. One patient who had demonstrated posterolateral rotatory instability following the initial procedure had a revision to include an articulated external fixator. However, the instability and a nonconcentric reduction persisted after the fixator was removed. Although the patient had a poor result, she had not had any additional reconstructive surgery by the time of writing. A radioulnar synostosis occurred in two patients. One of them had had the primary treatment of the elbow injury at the same time as treatment of a segmental forearm injury with a disruption of the distal radioulnar joint. He subsequently had the synostosis resected, the contracture released, and the metal radial head removed²⁰. The other patient with synostosis had a similar reconstructive procedure. A wound infection developed in one patient, and it healed uneventfully after surgical débridement and antibiotic therapy. Four patients underwent hardware removal and elbow release. The release consisted of resection of any heterotopic bone or calcification, and, depending on which motion or motions were limited, anterior and/or posterior capsular resection. The mean gain in flexion-extension was 35° (range, 25° to 60°) and the mean gain in forearm rotation was 25° (range, 0° to 50°) after the releases. One sixty-eight-year-old patient had radiographic and clinical evidence of persistent posterolateral instability but had a fair result clinically and declined further intervention.

Discussion

Materials and Methods | Results | Discussion | References

There is a paucity of literature dealing specifically with elbow dislocations associated with radial head and coronoid fractures, the injury termed the terrible triad of the elbow. Heim reviewed the AO experience with combined radial and ulnar fractures at the elbow in 1998²¹. Of the 120 cases, twenty-five involved fractures of the coronoid process and the radial head. Of these, eleven were treated with primary radial head resection. Premature arthrosis developed in eight of the eleven cases, and another eight demonstrated valgus instability. Heim concluded that reduction of the coronoid fragment is critical to restore elbow stability and that radial head resection is contraindicated when the elbow is unstable. Josefsson et al. noted a high prevalence of osteoarthrosis in patients who had had radial head excision following elbow fracture-dislocation⁵. They also noted a coronoid fracture in all four patients who had a redislocation following treatment of an elbow dislocation with an associated radial head fracture. They concluded that preservation of the radial head and ligament repair are imperative to maintain stability in this setting. (Three of the patients had undergone primary excision of the radial head.) In 1987, Broberg and Morrey reported similar findings²². At an average of ten years postoperatively, they noted arthrosis in twenty-two of twenty-four patients in whom a fracture-dislocation of the elbow had been treated without repair or replacement of the radial head. In one of the few papers dealing solely with the so-called terrible triad injury pattern, Ring et al. reported a poor result due to instability, arthrosis, and stiffness in seven of eleven patients¹⁰. In a 1989 report on the Mayo Clinic experience with fractures of the coronoid process, Regan and Morrey indicated that the results of treatment of type-II fractures were worse in patients with an associated radial head fracture and elbow instability¹². Of the five patients with a type-III fracture in that study, four had a poor result secondary to stiffness, pain, and recurrent elbow instability. These data (which parallel our clinical experience) emphasize the importance of accurate primary treatment.

It is well recognized that prolonged immobilization following an acute episode of elbow instability is associated with poor results². The dilemma in management of the terrible triad is that, without proper surgical reconstruction, instability rapidly recurs with attempted motion, but extended cast immobilization leads to unacceptable stiffness. In fact, Ring et al. showed that immobilization in a cast does not ensure concentric reduction of the elbow¹⁰. In previous studies, standard reconstruction strategies based on restoring osseous and soft-tissue structures were not used to enhance stability, leading to a high prevalence of prolonged cast immobilization followed by stiffness and arthrosis^4,5,9,10.

Elbow stability depends on both osseous integrity and soft-tissue constraint in roughly equal proportions. The coronoid process is particularly important (Fig. 4) because of the osseous constraint that it offers against posterior translation of the ulna and because of the attachment of the medial collateral ligament to its base. Since the medial collateral ligament is the primary stabilizer against valgus loading, repairing a type-III coronoid fracture reduces the risk of both valgus and posterior instability^23,24. Failure to reconstitute the coronoid in this setting has been associated with instability and a poor functional outcome^9,12.

View Large | Download Slide(.ppt)
Add to My JBJS

Fig. 4: A three-dimensional computed tomography reconstruction of a terrible triad injury of the elbow. The view is from the anterolateral aspect of the joint. The elbow is subluxated posteriorly. The loss of the anterior bone buttress against posterior displacement due to the coronoid (arrowhead) and radial head fractures is demonstrated.

There remains some controversy over the mechanism of type-I coronoid fractures, which have been termed avulsion fractures and have been postulated to be a consequence of avulsion by the anterior elbow capsule and brachialis muscle. However, the tip of the coronoid is an intra-articular structure, can be clearly visualized during elbow arthroscopy, and is devoid of soft-tissue attachments. The anterior capsule typically inserts 5 to 6 mm from the tip of the coronoid²³. We believe that coronoid fractures typically occur from a shearing mechanism that produces a transverse fracture and results as the coronoid is driven against the unyielding distal part of the humerus (as the radius and ulna dislocate or subluxate posteriorly). The fracture fragment typically remains attached to the anterior capsule. Thus, in our opinion, a coronoid fracture is a pathognomonic sign of an episode of (posterior) elbow instability⁶. When patients who have what appears to be an isolated coronoid fracture on radiographs are questioned carefully, they may volunteer that they felt or saw the elbow fall back into the joint as part of an episode of subluxation or dislocation with spontaneous reduction.

The radial head is an important secondary stabilizer against valgus loading and posterior translation. As the medial collateral ligament is usually torn in patients with this injury, the radial head takes on a more important role as a stabilizing structure against valgus stresses²⁴. Zagorski reported the prevalence of redislocation to be as high as 62% following radial head excision in patients with an elbow fracture-dislocation⁷. In a long-term review, Josefsson et al. noted severe osteoarthritis in twelve of nineteen elbows that had undergone radial head resection following an elbow dislocation with an associated radial head fracture⁵. They concluded that the radial head should be preserved if possible. Given the young age of our patients (mean, forty-one years), we made every attempt to repair, rather than replace, the radial head. If a stable anatomic reduction is not possible, however, a replacement arthroplasty must be peformed¹⁷.

For better biomechanical and biological compatibility, we used a metal radial head in patients who required prosthetic replacement. King et al. noted, in a cadaver model, that a silicone radial head offered no improvement in stability in medial collateral ligament-deficient elbows, whereas a metal head provided stability similar to that of the native radial head²⁵. In a clinical study, the same group reported a mean MEPS score of 80 points and a low complication rate in a series of twenty-five elbows treated with a metal radial head replacement following trauma¹⁷. Carn et al. noted evidence of prosthetic deformation, ulnar positive variance, and degenerative change in patients with a silicone radial head implant²⁶. Others have also raised concerns regarding failure of silicone implants and silicone synovitis caused by silicone implants²⁷. While a variety of prosthetic designs are now available, we believe that a metal modular component is the best option. Modularity allows the surgeon to alter the length, stem width, and depth independently, optimizing stability without overstuffing the joint or restricting motion.

The characteristic lateral soft-tissue injury patterns seen in association with unstable elbow dislocations and fracture-dislocations have been described previously¹⁶. In the present series, lateral soft-tissue injury was a universal finding, and, consistent with observations in previous studies^10,16,17, the most common pathological finding was an avulsion of the lateral collateral ligamentous complex and capsule from the posterolateral aspect of the distal part of the humerus. Less common were midsubstance tears, and ulna-sided lesions were rare. Recognition of these patterns is important for two reasons: (1) defects in soft-tissue planes created by the trauma should be utilized in the surgical approach, and (2) these structures should be repaired as an integral part of the closure. Thus, repair of the lateral collateral ligament complex with suture anchors or drill holes in the distal, lateral part of the humerus was the most common form of lateral ligament repair.

In a prospective, randomized trial, Josefsson et al. noted that nonoperative treatment of simple elbow dislocations yielded results similar to those of collateral ligament repair²⁸. This suggests that a concentrically reduced, stable elbow promotes healing of the medial collateral ligament in a manner similar to surgical repair. Our approach is to stabilize the elbow from the lateral side, producing a stable, concentric joint and allowing a similar healing process to occur on the medial side. We only proceed to the medial side for ligament repair if instability persists; other authors have supported this approach²⁹.

There are weaknesses in our study. Although patients were identified from a prospectively gathered fracture database, the study was essentially retrospective, with all of the biases inherent in such a review, including the four patients lost to follow-up prior to a definitive outcome evaluation. Also, since many of our patients were referred for definitive care, it may be that they represent a spectrum of injury that was more severe than average. In addition, our mean duration of follow-up was approximately three years, and the prevalence of radiographic changes was relatively high (39%). It is conceivable that, with longer follow-up, the degenerative changes may become more important than what we have reported.

Given the severity of these injuries, conventional surgical treatment may sometimes be inadequate to restore elbow stability. When it is, we have found that articulated external fixation is an ideal option for restoring stability to the elbow, and we used it in two patients in this series. One of us (M.D.McK.) and coworkers⁹ and Cobb and Morrey⁸ both described series of unstable elbow fracture-dislocations (sixteen and seven cases, respectively), many with the "terrible triad" pattern of injury, for which initial management had failed. Application of a hinged fixator to the elbow restored concentric stability and allowed early motion while ligamentous healing occurred, with a satisfactory outcome (mean MEPS score of 80 to 85 points) in twenty of those twenty-three cases. However, both groups of authors pointed out that this is a specialized technique with a high complication rate and that successful primary management is greatly preferable.

These injuries are difficult to treat, and, even with optimal care, stiffness (mean arc in the present series, 112°), recurrent instability (two of thirty-six patients; 6%) and the need for secondary intervention (eight of thirty-six patients; 22%) are possible. However, it appears that elbow dislocations with associated radial head and coronoid fractures can be treated successfully by strict application of a standard surgical protocol including fixation of large fractures of the coronoid process and/or repair of the anterior capsule, radial head fixation or replacement, repair of the primary and secondary lateral soft-tissue constraints, and, in selected cases, repair of the medial collateral ligament. If instability persists after this conventional treatment, application of an articulated external fixator is a useful adjunctive treatment.

References

Materials and Methods | Results | Discussion | References

Morrey B.The elbow and its disorders. 2nd ed. Philadelphia: WB Saunders; 1993. 1993

Mehlhoff TL, Noble PC, Bennett JB, Tullos HS. Simple dislocation of the elbow in the adult. Results after closed treatment. J Bone Joint Surg Am.1988;70: 244-9.70244 1988 [PubMed]

Josefsson PO, Johnell O, Gentz CF. Long-term sequelae of simple dislocation of the elbow. J Bone Joint Surg Am.1984;66: 927-30.66927 1984

Hotchkiss RN. Fractures and dislocations of the elbow. In: Rockwood CA, Green DP, Bucholz RW, Heckman JD, editors. Rockwood and Green's fractures in adults. 4th ed, vol 1. Philadelphia: Lippincott-Raven; 1996. p 929-1024.1929 1996

Josefsson PO, Gentz CF, Johnell O, Wendeberg B. Dislocations of the elbow and intraarticular fractures. Clin Orthop.1989;246: 126-30.246126 1989 [PubMed]

O'Driscoll SW, Jupiter JB, King GJ, Hotchkiss RN, Morrey BF. The unstable elbow. Instr Course Lect.2001;50: 89-102.5089 2001

Zagorski JB. Complex fractures about the elbow. Instr Course Lect.1990; 39: 265-70.39265 1990 [PubMed]

Cobb TK, Morrey BF. Use of distraction arthroplasty in unstable fracture dislocations of the elbow. Clin Orthop.1995;312: 201-10.312201 1995 [PubMed]

McKee MD, Bowden SH, King GJ, Patterson SD, Jupiter JB, Bamberger HB, Paksima N. Management of recurrent, complex instability of the elbow with a hinged external fixator. J Bone Joint Surg Br.1998;80: 1031-6.801031 1998 [PubMed][CrossRef]

Ring D, Jupiter JB, Zilberfarb J. Posterior dislocation of the elbow with fractures of the radial head and coronoid. J Bone Joint Surg Am.2002;84: 547-51.84547 2002 [PubMed]

Morrey BF, Askew LJ, Chao EY. A biomechanical study of normal functional elbow motion. J Bone Joint Surg Am.1981;63: 872-7.63872 1981

Regan W, Morrey B. Fractures of the coronoid process of the ulna. J Bone Joint Surg Am.1989;71: 1348-54.711348 1989

Johnston GW. A follow-up of one hundred cases of fracture of the head of the radius with a review of the literature. Ulster Med J.1962;31: 51-6.3151 1962 [PubMed]

Gill DR, Morrey BF. The Coonrad-Morrey total elbow arthroplasty in patients who have rheumatoid arthritis. A ten to fifteen-year follow-up study. J Bone Joint Surg Am.1998;80: 1327-35.801327 1998

Pugh DM, McKee MD. The "terrible triad" of the elbow. Tech Hand Upper Extrem Surg. 2002;6: 21-9.621 2002 [CrossRef]

McKee MD, Schemitsch EH, Sala MJ, O'Driscoll SW. The pathoanatomy of lateral ligamentous disruption in complex elbow instability. J Shoulder Elbow Surg.2003;12: 391-6.12391 2003 [PubMed][CrossRef]

Moro JK, Werier J, MacDermid JC, Patterson SD, King GJ. Arthroplasty with a metal radial head for unreconstructable fractures of the radial head. J Bone Joint Surg Am.2001;83: 1201-11.831201 2001

Morrey BF, Askew LJ, An K-N, Chao EY. A biomechanical study of normal functional elbow motion. J Bone Joint Surg Am.1981;63: 872-7.63872 1981

Knirk J, Jupiter JB. Intra-articular fractures of the distal end of the radius in young adults. J Bone Joint Surg Am.1986;68: 647-59.68647 1986 [PubMed]

Boyd HB. Surgical exposure of the ulna and proximal third of the radius through one incision. Surg Gynecol Obstet.1940;71: 86-8.7186 1940

Heim U. [Combined fractures of the radius and the ulna at the elbow level in the adult. Analysis of 120 cases after more than 1 year]. Rev Chir Orthop Reparatrice Appar Mot.1998;84: 142-53. French.84142 1998

Broberg MA, Morrey BF. Results of treatment of fracture-dislocations of the elbow. Clin Orthop.1987;216: 109-19.216109 1987

Cage DJ, Abrams RA, Callahan JJ, Botte MJ. Soft tissue attachments of the ulnar coronoid process. An anatomic study with radiographic correlation. Clin Orthop.1995;320: 154-8.320154 1995

Morrey BF, Tanaka S, An KN. Valgus stability of the elbow. A definition of primary and secondary constraints. Clin Orthop.1991;265: 187-95.265187 1991 [PubMed]

King GJ, Zarzour ZD, Rath DA, Dunning CE, Patterson SD, Johnson JA. Metallic radial head arthroplasty improves valgus stability of the elbow. Clin Orthop.1999;368: 114-25.368114 1999 [PubMed]

Carn RM, Medige J, Curtain D, Koenig A. Silicone rubber replacement of the severely fractured radial head. Clin Orthop.1986;209: 259-69.209259 1986 [PubMed]

Vanderwilde RS, Morrey BF, Melberg MW, Vinh TN. Inflammatory arthritis after failure of silicone rubber replacement of the radial head. J Bone Joint Surg Br.1994;76: 78-81.7678 1994 [PubMed]

Josefsson PO, Gentz CF, Johnell O, Wendeberg B. Surgical versus nonsurgical treatment of ligamentous injuries following dislocation of the elbow joint. A prospective randomized study. J Bone Joint Surg Am.1987;69: 605-8.69605 1987 [PubMed]

Ring D, Jupiter JB, Zilberfarb J. Roles of the medial collateral ligament and the coronoid in elbow stability. J Bone Joint Surg Am.2003;85: 568-9.85568 2003 [PubMed]

Topics

fracture ; elbow region ; ligaments ; external fixation devices ; elbow dislocations ; coronoid fracture ; radial head

Username

Password

Access for Patients

Forgot Password?

Have a subscription to the print edition?

Not a Subscriber?

Buy this Article

Get online access for 30 days for $35

New to JBJS?

Subscribe to the online edition for 30 days for $75

Register for a FREE limited account to get full access to all CME activities, to comment on public articles, or to sign up for alerts.

Have a subscription to the print edition?

Current subscribers to The Journal of Bone & Joint Surgery in either the print or quarterly DVD formats receive free online access to JBJS.org.

Activate your online account now

Forgot your password?

Enter your username and email address. We'll send you a reminder to the email address on record.

Username:*

Email Address:*

Forgot your username or need assistance? Please contact customer service at subs@jbjs.org. If your access is provided
by your institution, please contact you librarian or administrator for username and password information. Institutional
administrators, to reset your institution's master username or password, please contact subs@jbjs.org

References

Accreditation Statement

These activities have been planned and implemented in accordance with the Essential Areas and policies of the Accreditation Council for Continuing Medical Education (ACCME) through the joint sponsorship of the American Academy of Orthopaedic Surgeons and The Journal of Bone and Joint Surgery, Inc. The American Academy of Orthopaedic Surgeons is accredited by the ACCME to provide continuing medical education for physicians.

CME Activities Associated with This Article

Submit a Comment

Please read the other comments before you post yours. Contributors must reveal any conflict of interest.
Comments are moderated and will appear on the site at the discretion of JBJS editorial staff.

* = Required Field

Comment Author(s) * (if multiple authors, separate names by comma)

Example: John Doe

Affiliation & Institution*

Comment Title*

Comment*

Cancel

Print
PDF
Email

Recipient(s) will receive an email with a link (good for 5 days) to 'Standard Surgical Protocol to Treat Elbow Dislocations with Radial Head and Coronoid Fractures'.
Your Name:*
Example: John Doe

Email Address:* CC Me:
Enter your valid email address. Example: jdoe@example.com

Recipient's Email Address:*

Separate multiple email address with semi-colons (up to 5).

Subject:* 's The Journal of Bone & Joint Surgery: 'Standard Surgical Protocol to Treat Elbow Dislocations with Radial Head and Coronoid Fractures'
Subject for your email.

Message:

(Optional, message will truncate at 1000 characters)

Processing your request... Please Wait...

Copyright © in the material you requested is held by The Journal of Bone & Joint Surgery, Inc. (unless otherwise noted). This email ability is provided as a courtesy, and by using it you agree that that you are requesting the material solely for personal, non-commercial use, and that it is subject to Journal of Bone & Joint Surgery, Inc.'s Terms of Use. The information provided in order to email this topic will not be used to send unsolicited email, nor will it be furnished to third parties. Please refer to The Journal of Bone & Joint Surgery Inc.'s Privacy Policy for further information.

Copyright © The Journal of Bone & Joint Surgery Inc. All rights reserved.
Share
Get Citation

David M.W. Pugh, Lisa M. Wild, Emil H. Schemitsch, Graham J.W. King, Michael D. McKee; Standard Surgical Protocol to Treat Elbow Dislocations with Radial Head and Coronoid Fractures. The Journal of Bone & Joint Surgery. 2004 Jun;86(6):1122-1130.

Download citation file:

RIS (Zotero)

EndNote

BibTex

Medlars

ProCite

RefWorks

Reference Manager

Copyright © The Journal of Bone and Joint Surgery, Inc.
Rights & Permissions
Article Alerts

Processing your request... Please Wait.
Submit a Comment