Complex elbow instability: surgical management of elbow fracture dislocations

Abstract

There are three main patterns of complex elbow instability: posterolateral (terrible triad), varus posteromedial (anteromedial coronoid fracture with lateral collateral ligament complex disruption), and trans-olecranon fracture dislocations.Radial head fractures, in the setting of complex elbow instability, often require internal fixation or arthroplasty; the outcome of radial head replacement is dictated by adequate selection of the head diameter, correct restoration of radial length, and proper alignment and tracking.Small coronoid fractures can be ignored. Larger coronoid fractures, especially those involving the anteromedial facet, require fixation or graft reconstruction, particularly in the presence of incongruity.The lateral collateral ligament complex should be repaired whenever disrupted. Medial collateral ligament disruptions seem to heal reliably without surgical repair provided all other involved structures are addressed.The most common mistakes in the management of trans-olecranon fracture dislocations are suboptimal fixation, lack of fixation of coronoid fragments, and lack of restoration of the natural dorsal angulation of the ulna. Cite this article: Sanchez-Sotelo J, Morrey M. Complex elbow instability. EFORT Open Rev 2016;1:183-190.

Keywords: coronoid; elbow; instability; radial head.

Fig. 1

Lateral radiograph obtained after a posterolateral fracture dislocation (a). Fracture comminution of the radial head and coronoid are best appreciated by computed tomography (b).

Fig. 2

a) Gravitational stresses tend to stretch the lateral collateral ligament complex (red arrow-heads) and shear or compress the anteromedial coronoid (blue arrow); b), the radial head transmits a fair amount of load when the upper extremity is used to push an object.

Fig. 3

A displaced anteromedial coronoid fracture with an intact radial head; an avulsion of the lateral collateral ligament complex occurs through a varus posteromedial mechanism.

Fig. 4

Lateral radiograph after a trans-olecranon fracture-dislocation.

Fig. 5

Internal fixation of radial head fractures is commonly performed using headless compression screws. a) Intra-operative photograph; b). intra-operative fluoroscopy.

Fig. 6

Radiograph obtained after radial head replacement with excessive lengthening of the radius will lead to a poor outcome.

Fig. 7

Anteroposterior a) and lateral b) radiographs after radial head replacement using an uncemented implant.

Fig. 8

Large coronoid fractures may require a medial exposure for reduction and plate fixation. Radiographs: a) pre-operative AP; b) pre-operative lateral; c) post-operative AP; d) post-operative lateral.

Fig. 9

Formal repair of the lateral collateral ligament complex using heavy non-absorbable suture through bone tunnels.