Chapter 34: Elbow Fractures and Dislocations

Daphne M. Beingessner, J. Whitcomb Pollock, Graham J.W. King

Chapter Outline

Introduction to Simple Elbow Dislocation

A simple elbow dislocation is one in which there are no associated fractures. The elbow joint is the second most commonly dislocated joint in the adult population with a reported rate of 5.21 per 100,000 person-years in the US population.105 Nearly half of simple dislocations are the result of sports with males at highest risk during football and females during gymnastics and skating. Adolescent males are the highest-risk group. The elbow is typically stable after a closed manipulative reduction in this injury; however, older patients or those with high-energy mechanisms may be at risk for residual instability that requires operative intervention.31 A good functional outcome is typically reported by these patients, but some patients report residual subjective stiffness and pain. Less than 10% of patients report residual instability.2 

Assessment of Simple Elbow Dislocation

Mechanisms of Injury for Simple Elbow Dislocations

Simple elbow dislocations are typically the result of a fall on an outstretched hand. O’Driscoll described a valgus, axial, and posterolateral force that results in the typical posterolateral dislocation of the elbow joint (Fig. 34-1).81 The soft tissue injury is thought to begin on the lateral side of the elbow with disruption of the lateral collateral ligament (LCL) and then proceeds through the capsule to the medial side with the medial collateral ligament (MCL) being injured last. The MCL may remain intact in some injuries. Less commonly, simple dislocation may be the result of a varus, axial, and posteromedial force where the injury proceeds from medial to lateral, but this mechanism typically results in a small anteromedial coronoid fracture, and this injury is discussed later in the chapter.31 
Figure 34-1
 
A, B: Elbow dislocations are thought to occur with a progression from lateral to medial. Complete dislocation is usually associated with disruption of the medial and lateral collateral ligaments and anterior capsule.
A, B: Elbow dislocations are thought to occur with a progression from lateral to medial. Complete dislocation is usually associated with disruption of the medial and lateral collateral ligaments and anterior capsule.
View Original | Slide (.ppt)
Figure 34-1
A, B: Elbow dislocations are thought to occur with a progression from lateral to medial. Complete dislocation is usually associated with disruption of the medial and lateral collateral ligaments and anterior capsule.
A, B: Elbow dislocations are thought to occur with a progression from lateral to medial. Complete dislocation is usually associated with disruption of the medial and lateral collateral ligaments and anterior capsule.
View Original | Slide (.ppt)
X

Associated Injuries with Simple Elbow Dislocation

By definition, simple elbow dislocations are not associated with fractures. However, they typically are accompanied by significant disruption of the collateral ligaments, elbow capsule, and forearm flexor and extensor muscle origins.53 Although rare, injury to the brachial artery has been described in closed simple dislocations and nerve palsies are possible. The ulnar nerve is the most commonly injured nerve following elbow dislocation, but entrapment of the median nerve in the joint after reduction has been described.66 

Signs and Symptoms of Simple Elbow Dislocation

Patients typically present with an obvious deformity and pain about the affected elbow. Some patients may self-reduce or spontaneously reduce and will present with pain, swelling, and ecchymosis but no deformity. With the elbow flexed to 90 degrees, the medial and lateral epicondyles and the olecranon process should form an isosceles triangle; and if they do not, the elbow is likely dislocated or subluxated, with the elbow “jumping a runner” in the medial or lateral direction. The elbow should be evaluated for open wounds. A complete peripheral neurologic examination should be performed for both motor and sensory functions. Radial and ulnar pulses should be compared to the opposite side. If they are decreased, arm–arm indices are useful to help determine if there is a vascular injury. 

Imaging and Other Diagnostic Studies for Simple Elbow Dislocations

Anteroposterior, lateral, and oblique radiographs are used to diagnose elbow dislocation and help to rule out associated fractures. Computed tomography (CT) scanning is rarely needed but can be useful if there is a questionable associated fracture. MRI is not needed unless there is concern for ulnar nerve entrapment in the joint since the pathology of the soft tissue injury associated with elbow dislocations has been well established. 

Classification of Simple Elbow Dislocations

Simple elbow dislocations are often described based on the direction of dislocation. The majority of dislocations are posterior or posterolateral. However, anterior, medial, lateral, and divergent dislocations are possible. They can also be classified as acute, subacute (less than 6 weeks), or chronic. 

Outcome Measures for Simple Elbow Dislocations

Several scoring systems have been used to evaluate the outcomes of simple elbow dislocation. Most recent publications have evaluated outcomes using the Disabilities of the Arm, Shoulder and Hand Questionnaire (DASH) and the Oxford Elbow Questionnaire. 

Pathoanatomy and Applied Anatomy Relating to Simple Elbow Dislocations

Elbow stability is provided by the soft tissue structures surrounding the joint as well as by bony articulations of the joint itself. The soft tissue restraints can be divided into both static and dynamic stabilizers. The static stabilizers include the joint capsule and the LCLs and MCLs. The normal joint capsule is thin but does contribute to stability with the elbow in full extension and flexion. The LCL has three components, the radial collateral ligament, annular ligament, and the lateral ulnar collateral ligament. It is the primary varus and posterolateral rotational stabilizer of the elbow. The radial head is surrounded by the annular ligament which attaches to the anterior and posterior margins of the radial notch of the proximal ulna. The radial collateral ligament arises from the lateral epicondyle and blends with the annular ligament. The lateral ulnar collateral ligament is posterior to the radial collateral ligament and attaches to the crista supinatoris of the proximal ulna, just distal to the annular ligament. The MCL consists of the anterior and posterior bundles. The anterior bundle is the key valgus stabilizer of the elbow, arising from the anterior-inferior aspect of the medial epicondyle to insert on the sublime tubercle of the proximal ulna. The posterior bundle provides a secondary restraint to valgus load and also resists ulnar rotation. 
The dynamic restraints include the biceps, brachialis, and triceps which provide compressive stability to the elbow due to their joint reactive forces and are particularly important when the static stabilizers have been injured. The common extensor muscles provide varus stability and the common flexor muscles provide valgus stability. Pronation will stabilize the LCL-deficient elbow while supination decreases stability in this setting.32 
Patients with simple elbow dislocations routinely have disruption of both the MCL and LCL and the elbow capsule.81 The muscular origins may be disrupted as well; typically the injury to the lateral common extensor origin is more extensive than the medial common flexor origin. Although the MCL was once thought to be the most important stabilizer of the elbow joint, this is only true in patients that routinely load their elbow in valgus such as throwing athletes. Since most activities of daily living exert a varus force on the elbow than a valgus force, residual instability is usually due to incompetence of the LCL in the majority of patients. Sometimes when the elbow dislocates, the radial head causes an impression fracture of the posterior capitellum which can contribute to recurrent instability. 

Simple Elbow Dislocation Treatment Options

Nonoperative Treatment of Simple Elbow Dislocations

The majority of simple elbow dislocations can be treated nonoperatively with closed manipulative reduction, evaluation of stability, and an early rehabilitation program (Fig. 34-2). 
Figure 34-2
 
A, B: A healthy 22-year-old male fell sustaining a simple elbow dislocation. C, D: A closed reduction was performed under conscious sedation in the emergency room and postreduction examination revealed a stable elbow through a full arc of motion. E, F: Follow-up at 3 months demonstrated some ossification of the lateral ligament complex with a concentric elbow joint and full range of motion.
A, B: A healthy 22-year-old male fell sustaining a simple elbow dislocation. C, D: A closed reduction was performed under conscious sedation in the emergency room and postreduction examination revealed a stable elbow through a full arc of motion. E, F: Follow-up at 3 months demonstrated some ossification of the lateral ligament complex with a concentric elbow joint and full range of motion.
View Original | Slide (.ppt)
Figure 34-2
A, B: A healthy 22-year-old male fell sustaining a simple elbow dislocation. C, D: A closed reduction was performed under conscious sedation in the emergency room and postreduction examination revealed a stable elbow through a full arc of motion. E, F: Follow-up at 3 months demonstrated some ossification of the lateral ligament complex with a concentric elbow joint and full range of motion.
A, B: A healthy 22-year-old male fell sustaining a simple elbow dislocation. C, D: A closed reduction was performed under conscious sedation in the emergency room and postreduction examination revealed a stable elbow through a full arc of motion. E, F: Follow-up at 3 months demonstrated some ossification of the lateral ligament complex with a concentric elbow joint and full range of motion.
View Original | Slide (.ppt)
X

Indications/Contraindications (Table 34-1)

 
Table 34-1
Simple Elbow Dislocation
View Large
Table 34-1
Simple Elbow Dislocation
Nonoperative Treatment
Indications Relative Contraindications
Closed elbow dislocation Open dislocation
Vascular injury
Instability after closed reduction
X

Techniques

A closed manipulative reduction of the elbow is usually performed in the emergency room or the operating room. Adequate conscious sedation with appropriate relaxation and monitoring of vital signs is important. The medial and lateral epicondyles are palpated and their relationship to the olecranon is determined in order to first correct and medial/lateral displacement in the coronal plane. The elbow is typically flexed to approximately 30 degrees, and traction is placed through the forearm while stabilizing the humerus. Direct pressure over the olecranon may help to guide it over the distal humerus and into joint. Supination of the forearm may be helpful to gain the reduction. The reduction maneuver should employ a steady slow force in order to avoid iatrogenic fracture of the distal humerus or proximal forearm. 
After reduction, the elbow is taken through an arc of flexion–extension in pronation, neutral, and supination in order to evaluate for residual instability. Since the lateral sided soft tissue injuries are typically more severe, pronation of the forearm often improves stability. If the elbow redislocates when flexed to less than 30 degrees, operative treatment should be considered. However, in the majority of cases, the elbow will be stable after closed reduction, particularly after muscle tone returns in the arm. Most patients will have varus–valgus instability given the pathoanatomy of elbow dislocation, but this plane of instability alone is not an indication for operative treatment. The elbow is then immobilized in a light plaster splint with the forearm in pronation, neutral, or supination (depending on the position of maximal stability) and the elbow at 90 degrees of flexion. Radiographs are performed to ensure a congruous reduction has been achieved and to evaluate for the presence of fractures not visualized on the prereduction radiographs. Isometric exercises should be encouraged while immobilized in the splint to promote muscle activation and improved dynamic stability. The patient is seen within a week to ensure maintenance of the reduction and to begin active range of motion of the elbow. 
After 1 week the splint is removed. The patient is examined for stability again and asked to actively extend and flex the elbow. Patients will typically move only within their stable arc and are unlikely to redislocate if they had a stable reduction and examination initially. A rehabilitation program is initiated encouraging active and active-assisted motion. A collar and cuff is used between exercises. Rarely, a hinged splint with an extension block can be used in those occasional patients with residual instability past 30 degrees of extension where compliance with avoiding this position is of concern. The patient is seen weekly for the first 3 weeks to decrease the extension block by 10 degrees per week. Radiographs are performed to confirm concentric reduction at each visit. The patient is then seen again at 6 weeks and may resume most normal activities and start a light strengthening program, avoiding varus or valgus loading until 12 weeks. Immobilization greater than 3 weeks should be avoided as this has been demonstrated to cause an increased incidence of stiffness and poorer functional outcomes. 
Some patients may have subtle residual mild posterolateral subluxation following a closed reduction. Coonrad et al.22 described the “drop sign,” an increase in the static ulnohumeral distance in unstressed postreduction lateral radiographs of dislocated elbows. In those patients, an active motion protocol should be employed. It consists of avoiding varus stress at all times by exercising with the elbow at the side while sitting or standing. Active motion is performed with the forearm pronated through the full range of motion. Supination is performed with the forearm flexed to 90 degrees or greater. This protocol takes advantage of the effects of the dynamic elbow stabilizers. Wolff and Hotchkiss116 also describe performing the exercises with an overhead protocol which allows the effects of gravity to improve stability. 

Outcomes

Several studies have reported good to excellent outcomes in the majority of patients after simple elbow dislocation. However, these injuries are not entirely benign. Josefsson et al.52 reported on a series of 52 patients followed for an average of 24 years. More than half of the patients had mild residual symptoms. Nineteen patients reported loss of motion but the majority of patients did not have late arthritis. Recently, Anakwe et al.2 reported outcomes of 110 patients with simple elbow dislocation at an average of 7.3 years after injury. The mean DASH Score was 6.7 points (the DASH is a disability score where a higher score is worse, 0 = a perfect arm, and 100 = completely disabled) and the mean Oxford Elbow Score was 90.3 points (0 = poor, 100 = good). Fifty-six percent of patients reported residual subjective stiffness, and 62% of patients reported residual pain. Eight percent of patients reported residual instability although no patient required operative intervention for their instability. Reduced elbow flexion and female sex were predictors of a lower outcome score. Eygendaal et al.34 evaluated 50 patients with closed simple dislocations with a mean follow-up of 9 years. Twenty-four patients had medial instability on stress radiographs, and 21 had degenerative changes. Medial instability was correlated with radiographic degeneration and a worse overall clinical result. Mehlhoff et al.72 evaluated 50 patients at an average of 34.4 months. Sixty percent of patients reported residual symptoms including flexion contracture in 15%, residual pain in 45%, and pain on valgus stress in 35%. Prolonged immobilization after injury was associated with a worse result with increasing duration of immobilization leading to increased flexion contracture and more severe residual pain: In general, prolonged immobilization is to be avoided in this setting. 

Operative Treatment of Simple Elbow Dislocations

Indications/Contraindications

The main indication for operative management of simple elbow dislocations is an inability to maintain a concentric elbow joint after closed reduction or a recurrent dislocation. Elbows which are so unstable that prolonged immobilization will be required should also be considered for early surgical management to avoid excessive stiffness. Open dislocations, vascular disruption (Fig. 34-3), and irreducible dislocations are also indications for operative treatment but these are rare injuries. Throwing athletes may benefit from direct repair of the MCL.88 
Figure 34-3
A 15-year-old male sustained a simple elbow dislocation while skiing.
 
He self-reduced on the hill but presented with elbow subluxation (A, B). (Note the increased ulnotrochlear space) and a decreased radial pulse. CT angiogram demonstrated transection of his brachial artery (C). After vascular bypass and forearm fasciotomy, the elbow was placed into an external fixator to protect the vascular repair. The fixator was removed after 3 weeks. No ligament repair was done as the elbow was relatively stable following reduction and the open wound was anterior (D, E). Follow-up at 3 months demonstrated some ossification of his collateral ligaments with a full range of motion, stable elbow, and intact vascular repair (F, G).
He self-reduced on the hill but presented with elbow subluxation (A, B). (Note the increased ulnotrochlear space) and a decreased radial pulse. CT angiogram demonstrated transection of his brachial artery (C). After vascular bypass and forearm fasciotomy, the elbow was placed into an external fixator to protect the vascular repair. The fixator was removed after 3 weeks. No ligament repair was done as the elbow was relatively stable following reduction and the open wound was anterior (D, E). Follow-up at 3 months demonstrated some ossification of his collateral ligaments with a full range of motion, stable elbow, and intact vascular repair (F, G).
View Original | Slide (.ppt)
Figure 34-3
A 15-year-old male sustained a simple elbow dislocation while skiing.
He self-reduced on the hill but presented with elbow subluxation (A, B). (Note the increased ulnotrochlear space) and a decreased radial pulse. CT angiogram demonstrated transection of his brachial artery (C). After vascular bypass and forearm fasciotomy, the elbow was placed into an external fixator to protect the vascular repair. The fixator was removed after 3 weeks. No ligament repair was done as the elbow was relatively stable following reduction and the open wound was anterior (D, E). Follow-up at 3 months demonstrated some ossification of his collateral ligaments with a full range of motion, stable elbow, and intact vascular repair (F, G).
He self-reduced on the hill but presented with elbow subluxation (A, B). (Note the increased ulnotrochlear space) and a decreased radial pulse. CT angiogram demonstrated transection of his brachial artery (C). After vascular bypass and forearm fasciotomy, the elbow was placed into an external fixator to protect the vascular repair. The fixator was removed after 3 weeks. No ligament repair was done as the elbow was relatively stable following reduction and the open wound was anterior (D, E). Follow-up at 3 months demonstrated some ossification of his collateral ligaments with a full range of motion, stable elbow, and intact vascular repair (F, G).
View Original | Slide (.ppt)
X

Surgical Procedure

Preoperative Planning.
Operative treatment may include open reduction with direct repair of ligaments, capsule, and muscle origins. Application of a static or hinged external fixation may occasionally be required to protect a tenuous soft tissue repair. Cross-pinning of the joint can be considered in patients that cannot tolerate an external fixator or when a fixator is unavailable. Temporary bridge plating of the elbow can also be considered to manage residual instability when application of an external fixator may be contraindicated such as in noncompliant or morbidly obese patients (Table 34-2). 
 
Table 34-2
ORIF of Simple Elbow Dislocation
View Large
Table 34-2
ORIF of Simple Elbow Dislocation
Preoperative Planning Checklist
  •  
    OR Table: Radiolucent
  •  
    Position/positioning aids: Supine with arm table or lateral decubitus
  •  
    Fluoroscopy location: From head
  •  
    Equipment: Suture anchors, large external fixator, hinged external fixator, large fragment locking set with screws
  •  
    Tourniquet (sterile/nonsterile): Sterile preferred
X
Positioning.
The patient is placed supine on the operating table with a radiolucent arm table on the affected side. Since both medial and lateral deep surgical approaches may be necessary, a preoperative examination of the shoulder should be performed to be sure that there is adequate external rotation of the shoulder in order to approach the medial side of the elbow. In the setting of significant shoulder stiffness, an alternative choice is to position the arm across the chest or use a lateral decubitus position. The C-arm is brought in from the head of the patient for both anteroposterior and lateral fluoroscopy. A sterile tourniquet should be available, but its use is optional. 
Surgical Approach.
A posterior midline incision is employed and a full thickness lateral flap is elevated on the deep fascia. In some dislocations, there is visible disruption of the lateral fascia and muscular origins from the injury itself. However, if there is not, then a fascial incision is made through the Kocher interval between the anconeus and extensor carpi ulnaris (ECU) for exposure of the LCL. If the medial structures require repair, full thickness elevation of the medial flap is performed and the ulnar nerve is identified and protected but not transposed. The MCL may be approached through the traumatic muscle disruption. The flexor pronator mass can be further elevated off the ulna to aid exposure as required. An alternative approach is to make paired medial and lateral skin incisions in the setting where the quality of the posterior skin is not suitable. 
Technique: Soft Tissue Repair.
Disruption of the LCL and extensor origins off of the posterolateral aspect of the distal humerus with capsular disruption is typically encountered.71 The joint is inspected for chondral debris and injury and thoroughly irrigated. 
The LCL can be repaired using transosseous bone tunnels or suture anchors (Fig. 34-4).39 A single drill hole is placed at the center of the flexion–extension axis located at the center of the arc of curvature of the capitellum. Two drill holes are then placed on the posterior column of the lateral supracondylar ridge in patients with good bone or one drill hole placed anteriorly and one posteriorly to the supracondylar ridge in patients with poorer quality bone. Shuttle sutures are placed through these drill holes. Locking Krackow stitches are placed in the LCL while a second suture is placed in the extensor fascia. The sutures are tensioned while maintaining the forearm in pronation and the elbow at 90 degrees of flexion. Avoid over tensioning of the lateral ligaments if the MCL is deficient as medial gaping of the elbow can occur.39 The elbow is then taken through a range of motion using gravity extension in pronation, supination, and neutral rotation and reduction is verified both clinically and fluoroscopically. Care should be taken not to “hold” the elbow in joint during this examination so that residual instability can be recognized. In the vast majority of cases, a medial ligament repair is not required and the surgery is complete. 
Figure 34-4
Repair of the LCL is performed using transosseous bone tunnels placed at the center of the capitellum and exiting anterior and posterior to the lateral epicondyle.
 
Locking Krackow sutures are placed in the LCL, and then the common extensor origin is also repaired. Suture retrievers are used to pass the sutures through the bone tunnels which are then tensioned and tied across the bone bridge (A–F). In young patients with good-quality bone, both tunnels can be placed posterior to the epicondyle to simplify the procedure. (Illustration by Elizabeth Martin, ©2011. Reprinted with permission from Green’s Operative Hand Surgery, 6th ed, Churchill Livingstone, Inc.)
Locking Krackow sutures are placed in the LCL, and then the common extensor origin is also repaired. Suture retrievers are used to pass the sutures through the bone tunnels which are then tensioned and tied across the bone bridge (A–F). In young patients with good-quality bone, both tunnels can be placed posterior to the epicondyle to simplify the procedure. (Illustration by Elizabeth Martin, ©2011. Reprinted with permission from Green’s Operative Hand Surgery, 6th ed, Churchill Livingstone, Inc.)
View Original | Slide (.ppt)
Figure 34-4
Repair of the LCL is performed using transosseous bone tunnels placed at the center of the capitellum and exiting anterior and posterior to the lateral epicondyle.
Locking Krackow sutures are placed in the LCL, and then the common extensor origin is also repaired. Suture retrievers are used to pass the sutures through the bone tunnels which are then tensioned and tied across the bone bridge (A–F). In young patients with good-quality bone, both tunnels can be placed posterior to the epicondyle to simplify the procedure. (Illustration by Elizabeth Martin, ©2011. Reprinted with permission from Green’s Operative Hand Surgery, 6th ed, Churchill Livingstone, Inc.)
Locking Krackow sutures are placed in the LCL, and then the common extensor origin is also repaired. Suture retrievers are used to pass the sutures through the bone tunnels which are then tensioned and tied across the bone bridge (A–F). In young patients with good-quality bone, both tunnels can be placed posterior to the epicondyle to simplify the procedure. (Illustration by Elizabeth Martin, ©2011. Reprinted with permission from Green’s Operative Hand Surgery, 6th ed, Churchill Livingstone, Inc.)
View Original | Slide (.ppt)
X
In the unusual setting that the elbow remains unstable in spite of repair of the lateral structures, the medial side of the elbow is approached with care taken to protect the ulnar nerve. Repair of the MCL is performed using drill holes located at the anterior-inferior aspect of the medial epicondyle and two holes more proximally.82 The flexor–pronator muscles are also repaired if they have been avulsed. Suture anchors can also be employed. 
If the elbow is still unstable, then a static or hinged external fixator should be placed or, as a last resort, the elbow should be transfixed with a screw or robust Steinman pin. In the setting of a noncompliant patient, head-injured patient, or morbid obesity, a locking large fragment bridge plate can be used to temporarily fix the elbow using a triceps-splitting approach.78 
The wound should be irrigated and closed in layers. Because an early motion protocol is desirable, suture rather than staple closure of skin is preferred for wound edge security. 
Technique: External Fixation.
There are many external fixation systems available and familiarity with the system on hand is important. A hinged fixator will allow for range of motion exercises to be performed while the external fixator is in place and should be considered if the surgeon has access to this and the experience to apply it. Static fixators are easier to apply and are more widely available. There are no studies comparing the outcome of static or dynamic fixators in the setting of simple elbow dislocations. 
The key to all hinged devices is an understanding of the axis of elbow rotation. If the axis pin is malaligned, maltracking or even dislocation of the elbow may occur during motion. Device-specific instructions should be followed when applying these fixators and care must be taken not to damage the ulnar nerve when inserting the axis pin or the radial nerve when inserting the humeral pins. Elbow motion is initiated postoperatively within the first week. The frame is left in place for approximately 4 to 6 weeks, depending on a number of factors including the stability of the elbow, associated pin tract problems, etc. 
If a hinged external fixator is not available or the surgeon is unfamiliar with its use, placement of a static external fixator is an alternative method that can be used. The elbow is placed at 90 degrees of flexion with the joint concentrically reduced. Two pins are placed in the humeral shaft laterally and two pins are placed in the ulnar shaft laterally in a position that allows for forearm rotation. Open pin placement is recommended to avoid injury to the radial nerve. Imaging is employed to ensure the pins are not placed too deep to avoid injury to the ulnar nerve. A static frame is assembled with the elbow joint reduced. The external fixator is left in place for approximately 4 weeks and then a range of motion protocol is initiated as outlined above for closed treatment. 
Technique: Cross-pins or Screws.
In patients with residual instability where an external fixator is not available or in patients that are not candidates for an external fixator, a cross-screw technique may be employed. It should be emphasized that this technique is rarely required and should be reserved for use only as a salvage procedure. The elbow is concentrically reduced and a screw or pin is placed from the posterior aspect of the ulna, across the joint, exiting on the posterior border of the humerus. The screw or pin size should be consistent with the patent’s size and compliance so that breakage does not occur (Fig. 34-5). Several screw threads should protrude from the posterior humeral border for the ease of extraction should the screw break. A 4.5-mm cortical screw or shaft screw is appropriate. The elbow is placed into a cast for 3 to 4 weeks, and the screw is then removed, and a motion protocol is started as above. Alternatively a robust Steinman pin can be utilized driven from the subcutaneous border of the ulna and out the posterior humerus. 
Figure 34-5
 
A 75-year-old male sustained an open elbow dislocation treated with irrigation and debridement of the medial wound and medial ligament repair (A, B). He was presented to clinic 4 weeks later with increased pain, and radiographs demonstrated a redislocation likely due to the lack of repair of the lateral ligament resulting in posterolateral rotatory subluxation (C, D). The patient was a poor candidate for extensive surgery due to multiple medical comorbidities. He was treated with a closed reduction and transarticular placement of a 4.5-mm screw (E, F). He was casted until screw removal 6 weeks later (G). Final follow-up revealed restricted range of motion with fixed varus alignment but a functional extremity (H, I).
A 75-year-old male sustained an open elbow dislocation treated with irrigation and debridement of the medial wound and medial ligament repair (A, B). He was presented to clinic 4 weeks later with increased pain, and radiographs demonstrated a redislocation likely due to the lack of repair of the lateral ligament resulting in posterolateral rotatory subluxation (C, D). The patient was a poor candidate for extensive surgery due to multiple medical comorbidities. He was treated with a closed reduction and transarticular placement of a 4.5-mm screw (E, F). He was casted until screw removal 6 weeks later (G). Final follow-up revealed restricted range of motion with fixed varus alignment but a functional extremity (H, I).
View Original | Slide (.ppt)
Figure 34-5
A 75-year-old male sustained an open elbow dislocation treated with irrigation and debridement of the medial wound and medial ligament repair (A, B). He was presented to clinic 4 weeks later with increased pain, and radiographs demonstrated a redislocation likely due to the lack of repair of the lateral ligament resulting in posterolateral rotatory subluxation (C, D). The patient was a poor candidate for extensive surgery due to multiple medical comorbidities. He was treated with a closed reduction and transarticular placement of a 4.5-mm screw (E, F). He was casted until screw removal 6 weeks later (G). Final follow-up revealed restricted range of motion with fixed varus alignment but a functional extremity (H, I).
A 75-year-old male sustained an open elbow dislocation treated with irrigation and debridement of the medial wound and medial ligament repair (A, B). He was presented to clinic 4 weeks later with increased pain, and radiographs demonstrated a redislocation likely due to the lack of repair of the lateral ligament resulting in posterolateral rotatory subluxation (C, D). The patient was a poor candidate for extensive surgery due to multiple medical comorbidities. He was treated with a closed reduction and transarticular placement of a 4.5-mm screw (E, F). He was casted until screw removal 6 weeks later (G). Final follow-up revealed restricted range of motion with fixed varus alignment but a functional extremity (H, I).
View Original | Slide (.ppt)
X
Technique: Bridge Plate.
In patients with residual instability that are not candidates for an external fixator, a temporary bridge plate may be employed. Indications are conditions where maintenance of reduction is challenging such as morbid obesity and patients with neurologic injuries such as spasticity or flaccid paralysis. After repair of the collateral ligaments as previously described a narrow 4.5-mm large fragment locking plate is bent to 90 degrees. A triceps-splitting approach is employed proximally to identify and protect the radial nerve. The triceps can be left attached to the olecranon. Three to four locking screws are placed in the ulna and the distal humerus avoiding the articulation and fossae. The plate is removed at 4 weeks, and a posterior capsulectomy and an elbow manipulation can be considered at the time of plate removal to increase the recovery of motion (Table 34-3). 
 
Table 34-3
ORIF of Simple Elbow Dislocation
View Large
Table 34-3
ORIF of Simple Elbow Dislocation
Surgical Steps
  •  
    Posterior midline incision
  •  
    Approach lateral side first
  •  
    Inspect and clean joint
  •  
    Repair LCL and extensor muscle origin to the lateral epicondyle of the humerus and repair fascia
  •  
    Test for stability using gravity extension
  •  
    If still unstable, repair MCL and flexor–pronator origin
  •  
    If still unstable, apply hinged or static external fixator
  •  
    Consider cross-pin or cross-screw as a salvage
  •  
    Temporary bridge plating can also be employed
X
Postoperative Care.
The patient is placed into a well-padded light splint with the elbow at 90 degrees of flexion and the forearm in pronation. Antibiotics are given for 24 hours. Ideally, the dressing will be removed and motion begun 48 hours after surgery unless static joint fixation has been required. The incision is covered and sutures are not removed before 14 days. The elbow should not be immobilized for longer than 1 week. 
The precise rehabilitation protocol will depend on the integrity of the ligaments or any ligament repairs and the intraoperative evaluation for residual elbow instability. A safe arc of motion should be defined fluoroscopically under anesthesia so this can be taken into account when performing early motion. Active motion is preferred over passive motion as this tends to stabilize the elbow. If the MCL is intact and the LCL requires protection, then the forearm should be rehabilitated with the forearm in pronation with prosupination only performed at 90 degrees or greater of flexion.107 Varus positioning of the arm should be avoided in patients with LCL injuries and repairs. Less commonly, if the MCL has been injured but not repaired and the LCL is competent, then flexion–extension of the elbow should be performed with the forearm maintained in supination. If both the MCL and LCL have been injured, active range of motion should be initiated with the forearm in neutral position. Extension is allowed only to the extent that allows congruent tracking intraoperatively. As muscle tone and stability improves, further extension is permitted. 
Passive stretching of the elbow is not performed until ligament healing is progressing, typically beginning 6 weeks postoperatively. Static progressive splints are not routinely applied but can be employed to improve the range of motion as can turnbuckle splinting if motion goals are not being achieved. Light strengthening may be started 6 weeks postop with a formal strengthening program initiated at 3 months. 
Potential Pitfalls and Preventative Measures.
Symptomatic instability is uncommon after simple elbow dislocations treated operatively. However, inadequate or failed repair of the lateral structures may lead to persistent subluxation. Mild subluxation may be treated with an active motion or overhead rehabilitation protocol as previously described but frank dislocation may require repeat operative fixation or salvage procedures. Early recognition of this problem is important as late treatment of a stiff subluxated elbow is very difficult and may require extensive reconstruction including elbow release and LCL and MCL reconstruction. 
Early postoperative motion is mandatory to prevent stiffness. Some patients may require elbow release or excision of heterotopic bone to restore motion. The use of indomethacin continues to be controversial and has not been proven to prevent heterotopic ossification around the elbow. Given the low incidence of heterotopic ossification with simple elbow dislocations and the lack of proven efficacy, indomethacin is not recommended by the authors. 
Nerve palsies are uncommon but the ulnar and radial nerves are at risk with placement of an external fixator, with medial ligament repair or with extensive retraction of soft tissue structures. Direct visualization of the bone to ensure the nerve is not damaged by placement of the pin is recommended (Table 34-4). 
 
Table 34-4
Simple Elbow Dislocation
View Large
Table 34-4
Simple Elbow Dislocation
Potential Pitfalls and Preventions
Pitfall Preventions
Residual instability Anatomic repair of ligaments with the elbow concentrically reduced while repairs are tightened
Active motion protocol avoiding varus stress at all times
Elbow stiffness Early range of motion
Secure repair
Nerve palsy Direct visualization of bone during pin placement
Gentle retraction
X
Treatment-specific Outcomes.
Open treatment of unstable elbow dislocations is not commonly required. However, when necessary, the outcomes are generally satisfactory. In one group of 17 patients with persistent dislocation, 15 underwent open reduction and ligament repair and 2 had a closed reduction with cross-pinning of the joint.31 Three patients had a hinged external fixator applied. There was one redislocation treated with the addition of a hinge, and four patients had residual subluxation treated with active motion and bracing. All patients eventually achieved a concentric stable reduction. These techniques may be successful as much as 30 weeks from injury without need for ligament reconstruction although early recognition is preferable.56 

Management of Expected Adverse Outcomes and Unexpected Complications in Simple Elbow Dislocations (Table 34-5)

 
Table 34-5
Simple Elbow Dislocation
View Large
Table 34-5
Simple Elbow Dislocation
Common Adverse Outcomes and Complications
Elbow stiffness and heterotopic ossification → Initiate early motion
Redislocation → Careful follow-up, recognize, and treat surgically
Residual subluxation → Active motion protocol, proceed with operative treatment if persists
X

Author’s Preferred Method of Treatment for Simple Elbow Dislocations (Fig. 34-6)

Rockwood-ch034-image006.png
View Original | Slide (.ppt)
Figure 34-6
Author’s preferred treatment.
Rockwood-ch034-image006.png
View Original | Slide (.ppt)
X

Summary, Controversies, and Future Directions in Simple Elbow Dislocations

Simple elbow dislocations are common injuries that generally do well with closed manipulative reduction and early motion. Although thought to be relatively benign injuries, a large percentage of patients may have persistent subjective stiffness and mild residual pain; early discussion with the patient about outcomes is important. Throwing athletes may benefit from direct repair of an acute MCL injury. Similarly, high-energy injuries or those in the elderly may be more unstable and careful follow-up is mandatory to recognize and promptly treat persistent instability. 

Introduction to Radial Head Fractures

Radial head fractures are the most common fractures of the elbow with an estimated incidence of 2.5 to 2.9 per 10,000 people per year.1 Radial head fractures are more common in women than men and most frequently occur between the ages of 20 and 60 years.30 Undisplaced and minimally displaced radial head fractures typically occur as isolated injuries while more displaced and comminuted fractures commonly have associated injuries to the collateral ligaments and may have associated fractures of the coronoid, capitellum, or proximal ulna. In high-energy trauma, dislocations of the elbow and/or forearm can also occur. Disruption of the interosseous membrane and distal radial ulnar joint ligaments may result in axial instability of the forearm, termed the Essex–Lopresti lesion. The majority of radial head and neck fractures are minimally displaced and are isolated injuries. These fractures typically have a good functional outcome with nonsurgical treatment. The optimal management of displaced radial head fractures has not been established. 

Assessment of Radial Head Fractures

Mechanisms of Injury for Radial Head Fractures

Most radial head fractures occur as the result of low-energy mechanisms such as a trip and fall on an outstretched hand. Sporting activities as well as motor vehicle collisions cause higher-energy fractures typically with greater displacement and a higher incidence of concomitant injuries. Mechanisms of fracture vary but include three common patterns: (1). A valgus load causes impaction of the radial head into the capitellum, commonly with rupture of the MCL. (2). Posterolateral rotatory subluxation of the radial head with respect to the capitellum causes a partial articular shear fracture of the anterior portion of the radial head often with rupture of the LCL. (3). An axial forearm load causes impaction of the radial head into the capitellum with more severe trauma producing a fracture of the coronoid or rupture of the interosseous membrane and distal radioulnar joint ligaments; the so-called Essex–Lopresti injury. 

Associated Injuries with Radial Head Fractures

Tears of the LCLs and/or MCLs are most commonly associated with radial head fractures. Dislocations of the elbow and fractures of the coronoid, capitellum, olecranon, and proximal ulna are also frequent. Rupture of the interosseous membrane while uncommon is best diagnosed and treated early as late reconstruction is challenging and often unsatisfactory.33 

Signs and Symptoms of Radial Head Fractures

Patients present with complaints of pain, swelling, and stiffness of the elbow and forearm. Ecchymosis may develop several days later. Tenderness laterally over the radial head is expected; however, tenderness over the lateral epicondyle may indicate the presence of an associated LCL injury while similar tenderness over the medial epicondyle or sublime tubercle may suggest MCL disruption. The alignment of the elbow is assessed to rule out an associated dislocation or Monteggia fracture-dislocation. A careful examination of range of motion is performed since loss of forearm rotation is one of the primary indications for surgical intervention in the setting of displaced fractures. If pain precludes a proper evaluation of forearm rotation, the surgeon can aspirate the hemarthrosis and inject local anesthetic or re-evaluate the patient several days later when they are more comfortable. A loss of terminal extension is expected as a consequence of the hemarthrosis which accompanies all radial head fractures. The presence of clicking or crepitus with forearm rotation should be noted. The shoulder and wrist are examined for associated injuries. In particular, the distal radial ulnar joint should be palpated and balloted for both tenderness and instability. 

Imaging and Other Diagnostic Studies for Radial Head Fractures

Anteroposterior and lateral radiographs are typically sufficient to diagnose most displaced radial head fractures. Undisplaced fractures may initially be difficult to diagnose, and they may only be suspected by the presence of an anterior and posterior fat pad sign from the concomitant hemarthrosis. A radiocapitellar view which places the radial head in profile can be a helpful adjunct to standard radiographs. Bilateral wrist radiographs should be performed in patients with wrist pain to evaluate for the presence of associated axial instability. CT can be helpful to better characterize the size, location, and displacement of radial head fractures. It is also useful to assess concomitant injuries of the coronoid, capitellum and to look for the presence of associated osteochondral fragments. While magnetic resonance imaging may be useful to define the presence of associated collateral ligament injuries, it is not commonly required for the management of acute radial head fractures.57 

Classification of Radial Head Fractures

Numerous classifications have been described for fractures of the radial head. Mason described a Type I fracture as a fissure or marginal sector fracture without displacement; Type II as a marginal sector fracture with displacement; and a Type III as a comminuted fracture involving the whole head.69 A Type IV injury was subsequently described which includes any radial head fracture associated with an elbow dislocation. The most popular classification is the Broberg and Morrey modification of the original Mason classification.16 A Type I fracture is undisplaced or displaced less than 2 mm and involves less than 30% of the articular surface. A Type II fracture is displaced greater than 2 mm and involves greater than 30% of the articular surface. A Type III fractures is comminuted. Van Reit further modified this classification describing the Mayo–Mason classification whereby a suffix is added to the original modified Mason classification for concomitant soft tissue injuries, fractures, or dislocations of the elbow and forearm.110 

Outcome Measures for Radial Head Fractures

Several scoring systems are commonly used to evaluate the outcomes of radial head fractures: The Broberg and Morrey Elbow Score, the American Shoulder and Elbow Surgeons elbow assessment system, the Mayo Elbow Performance Index, the Patient-rated Elbow Evaluation, the SF-36, and the DASH scoring system. 

Pathoanatomy and Applied Anatomy Relating to Radial Head Fractures

The radial head consists of a concave dish which articulates with the capitellum and a flattened articular margin which articulates with the lesser sigmoid (radial) notch of the ulna. The nonarticular margin comprises about one-third of the diameter and is more rounded and often devoid of cartilage. A “safe zone” for placement of a plate on the nonarticular margin of the proximal radius has been defined, best identified during surgery by positioning the forearm in neutral rotation and placing the plate 10-degree anterior to the mid-axial line (Fig. 34-7).19,104 The radial head is not circular but is somewhat elliptical in shape. Furthermore, the radiocapitellar dish is also elliptical and typically offset from the neck of the radius.60,112 An understanding of the complex geometric shape of the radial head is required when repairing more comminuted fractures and when performing radial head replacement. Vascular supply of the radial head is supplied by branches of the radial recurrent artery and a branch of the ulnar artery which form a pericervical arterial ring. A branch of the interosseous artery supports the neck and the nutrient artery provides intraosseous blood supply.63 
Figure 34-7
The nonarticular portion of the radial head is the area where plates can be applied without interfering with forearm rotation.
 
Smith and Hotchkiss defined it based on lines bisecting the radial head in full supination, full pronation, and neutral. Implants can be placed as far as halfway between the middle and posterior lines and the anterior and middle lines. Caputo et al. recommended using the radial styloid and Lister’s tubercle as guides. Alternatively the plate can be placed just anterior to the mid-axial line with the forearm in neutral rotation.
Smith and Hotchkiss defined it based on lines bisecting the radial head in full supination, full pronation, and neutral. Implants can be placed as far as halfway between the middle and posterior lines and the anterior and middle lines. Caputo et al. recommended using the radial styloid and Lister’s tubercle as guides. Alternatively the plate can be placed just anterior to the mid-axial line with the forearm in neutral rotation.
View Original | Slide (.ppt)
Figure 34-7
The nonarticular portion of the radial head is the area where plates can be applied without interfering with forearm rotation.
Smith and Hotchkiss defined it based on lines bisecting the radial head in full supination, full pronation, and neutral. Implants can be placed as far as halfway between the middle and posterior lines and the anterior and middle lines. Caputo et al. recommended using the radial styloid and Lister’s tubercle as guides. Alternatively the plate can be placed just anterior to the mid-axial line with the forearm in neutral rotation.
Smith and Hotchkiss defined it based on lines bisecting the radial head in full supination, full pronation, and neutral. Implants can be placed as far as halfway between the middle and posterior lines and the anterior and middle lines. Caputo et al. recommended using the radial styloid and Lister’s tubercle as guides. Alternatively the plate can be placed just anterior to the mid-axial line with the forearm in neutral rotation.
View Original | Slide (.ppt)
X

Radial Head Fracture Treatment Options

Nonoperative Treatment of Radial Head Fractures

Indications/Contraindications

Patients with undisplaced or minimally displaced radial head fractures without a block to forearm rotation should be treated nonsurgically. In the setting where there is a block to forearm rotation in a patient with radiographically undisplaced or minimally displaced fracture, the patient should be re-evaluated several days after injury when the elbow is less painful. Alternatively, aspiration of the hemarthrosis and injection of local anesthetic can be used to check for the presence of a mechanical block to rotation. A chondral flap of capitellar cartilage can be the cause of limited rotation and cannot be detected on imaging, typically noted at surgery.19 It is unclear as to how large and how displaced a radial head fracture can be and still have a good outcome with nonsurgical management. While it has been suggested that partial articular fractures of the radial head which are displaced more than 2 mm and involve more than 30% of the articulation should be considered for open reduction and internal fixation, there are no comparative randomized clinical trials demonstrating an improved outcome relative to nonsurgical management. Displaced radial head fractures which have crepitus with forearm rotation may also be considered a relative indication for surgery (Table 34-6). 
 
Table 34-6
Radial Head Fractures
View Large
Table 34-6
Radial Head Fractures
Nonoperative Treatment
Indications Relative Contraindications
Undisplaced fracture Block to forearm rotation
Displaced fracture without motion impairment Incarcerated intra-articular fragment
Concomitant injuries requiring surgical management
X

Techniques

Radial head fractures treated nonoperatively are immobilized for 2 or 3 days for comfort and then active motion is encouraged with the use of a sling or collar and cuff between exercises. Aspiration of the hemarthrosis can be considered for initial pain relief; however, it has not been shown to improve outcome so is not routinely indicated.47 Careful radiographic and clinical follow-up is required to monitor for fracture displacement and recovery of motion. 

Outcomes

Undisplaced or minimally displaced radial head fractures can be managed nonoperatively with good long-term results in the majority of patients.46 The outcome of nonoperative management for displaced fractures of the radial head is variable in the literature with some series reporting mainly good outcomes and others reporting mixed results (Fig. 34-8). Mason reported that 9 of 15 patients had some pain following nonoperative treatment for fractures involving greater than 25% of the joint surface at an average of 11-year follow-up.69 He advocated excision of the radial head for displaced radial head fractures. Radin and Riseborough reported better motion in patients with displaced radial head fractures managed with radial head excision than that achieved with nonoperative treatment.86 Burton reported that only two of nine patients with displaced radial head fractures managed nonoperatively had good results; he recommended radial head excision in such cases.18 Khalfayan et al.58 reported on 26 patients with Mason Type II radial head fractures at an average of 18 months following either open reduction and internal fixation or nonoperative treatment with early motion. The operatively treated group had 90% good or excellent results while the nonoperatively treated group had 44% good or excellent results. Pain, functional limitations, and osteoarthritis were more frequent in the nonoperatively treated group. Akesson et al.1 reported on the outcome of 49 patients with moderately displaced Mason II fractures. At 19-year follow-up, the incidence of osteoarthritis was high at 82%; however, only six patients had an unsatisfactory result requiring a subsequent radial head excision and only 9 of the 49 patients had subjective complaints. 
Figure 34-8
 
A–C: Anteroposterior, lateral, and oblique radiographs of a 53-year-old woman who sustained a slip and fall. D: CT scan shows an undisplaced coronoid fracture and a minimally displaced radial head fracture. E, F: One year postop, the patient had minimal pain and a near full range of motion in spite of radiographic malunion.
A–C: Anteroposterior, lateral, and oblique radiographs of a 53-year-old woman who sustained a slip and fall. D: CT scan shows an undisplaced coronoid fracture and a minimally displaced radial head fracture. E, F: One year postop, the patient had minimal pain and a near full range of motion in spite of radiographic malunion.
View Original | Slide (.ppt)
Figure 34-8
A–C: Anteroposterior, lateral, and oblique radiographs of a 53-year-old woman who sustained a slip and fall. D: CT scan shows an undisplaced coronoid fracture and a minimally displaced radial head fracture. E, F: One year postop, the patient had minimal pain and a near full range of motion in spite of radiographic malunion.
A–C: Anteroposterior, lateral, and oblique radiographs of a 53-year-old woman who sustained a slip and fall. D: CT scan shows an undisplaced coronoid fracture and a minimally displaced radial head fracture. E, F: One year postop, the patient had minimal pain and a near full range of motion in spite of radiographic malunion.
View Original | Slide (.ppt)
X

Operative Treatment of Radial Head Fractures

Indications/Contraindications

Patients with displaced radial head fractures with a block to motion, those who have concomitant injuries which require surgical intervention such as unstable fracture-dislocations, or those with retained intra-articular loose bodies are best treated surgically. Treatment options include radial head fragment excision, radial head excision, open reduction and internal fixation, and radial head arthroplasty. 
Fragment excision is indicated in patients with a block to forearm motion by a small (less than 25% of the articular diameter) nonreconstructable displaced articular fracture of the radial head. The excision of large fragments of the radial head can cause painful clicking and contribute to instability in the setting of concomitant bony and ligament injuries as a consequence of loss of concavity–compression stability of the radiocapitellar joint.8 
Radial head excision may be considered for isolated displaced fractures of the radial head that are not amenable to internal fixation. Given the documented high incidence of concomitant soft tissue injuries in patients with comminuted radial head fractures, primary excision of the radial head is infrequently performed. If excision is planned, a careful examination under anesthesia is mandatory to evaluate for the presence of elbow or forearm instability. Even in the presence of intact collateral ligaments, radial head excision has been documented to alter load transfer and kinematics across the elbow; however, the benefit of routine replacement of the radial head versus radial head excision has not been evaluated in randomized clinical trials. 
The indications for open reduction and internal fixation remain controversial. Clear indications include displaced, noncomminuted fractures of the radial head limit forearm rotation, or radial head fractures fixed as a component of the surgical repair of an elbow fracture-dislocation. It has been suggested that fractures displaced greater than 2 mm and involving greater than 30% of the articular surface (a Type II fracture in the modified Mason classification) might be best treated with surgery; however, this remains unproven. The best candidates for internal fixation are younger patients with good-quality bone with three or fewer fragments.91 The management of partial articular fractures tends to be more successful than complete fractures of the radial head and neck likely due to both improved stability with partial articular fractures and compromised vascularity with complete fractures of the radial neck. Low-profile tripod screw fixation has been shown to provide improved results relative to plate fixation; however, screw fixation alone is only indicated for radial neck fractures without comminution.102 
Radial head arthroplasty is preferred in the setting of unreconstructable comminuted radial head fractures due to the high incidence of associated ligamentous and bony injuries. Radial head arthroplasty should not be performed in the setting of gross wound contamination, if the radial neck cannot be reconstructed to accept an implant, or if the capitellum is deficient or missing from an associated injury. 

Fragment Excision

Preoperative Planning.
Displaced fragments can be removed either arthroscopically or using standard open surgical techniques. A decision between an arthroscopic or open surgical approach is based on surgeon experience and the presence of concomitant injuries requiring treatment. Fragment excision is most commonly performed when fixation is planned but cannot be executed due to comminution, small fragment size, or osteopenia. The open surgical approaches for fragment excision will usually be the same as those chosen for open reduction and internal fixation. 
Arthroscopic fragment removal requires surgeon experience with arthroscopy of the elbow. Supine, prone, or lateral decubitus arthroscopy can be performed depending on the surgeon’s preference. Standard 4.5-mm arthroscope, motorized shavers, electrocautery devices, and pituitary rongeurs are required. Arthroscopic portals vary depending on the location of the fragment(s) (Table 34-7). 
 
Table 34-7
Arthroscopic Excision of Radial Head Fragment(s)
View Large
Table 34-7
Arthroscopic Excision of Radial Head Fragment(s)
Preoperative Planning Checklist
  •  
    OR Table: Standard
  •  
    Position/positioning aids: Lateral decubitus, prone or supine
  •  
    Fluoroscopy: Operative side
  •  
    Equipment: 4.5-mm arthroscope, shavers, electrocautery, pituitary rongeurs
  •  
    Tourniquet (sterile/nonsterile): Sterile
  •  
    Instruments: Pituitary rongeurs/graspers
X
Positioning.
Lateral decubitus on beanbag with arm positioner preferred by senior author. 
Surgical Approach(es).
Begin with an evaluation of joint stability using fluoroscopy. Insufflate the articulation with 20 cm3 of normal saline to make instrument insertion safer. Use proximal anterolateral, mid-anterolateral, and proximal anteromedial portals for anterior arthroscopy, posterocentral and mid-posterolateral portals for posterior arthroscopy, and a distal posterolateral portal for lateral arthroscopy. After the skin incision, use blunt dissection to enter the joint and safely insert the arthroscope and instruments. 
Technique.
Improve visualization by using shaver and electrocautery devices as required. Localize loose radial head fragment(s) and remove using a pituitary rongeur or grasper (Table 34-8). 
 
Table 34-8
Arthroscopic Excision of Radial Head Fragment(s)
View Large
Table 34-8
Arthroscopic Excision of Radial Head Fragment(s)
Surgical Steps
  •  
    Evaluate elbow stability
  •  
    Insufflate joint
  •  
    Insert arthroscope
  •  
    Localize and remove radial head fragment(s)
X
Postoperative Care.
Immediate active motion in a soft dressing is permitted if there are no associated injuries. Concomitant ligament injuries will direct the rehabilitation plan as outlined in the section on the operative treatment of elbow dislocations. 
Potential Pitfalls and Preventative Measures.
Avoid excision of larger radial head fragments, particularly in the setting of concomitant instability. The procedure should be abandoned and an open surgical approach performed if articular visualization is not adequate. Wait 5 days post injury to reduce intraoperative bleeding and improve visualization. Carefully examine for the location of the ulnar nerve preoperatively to avoid injury to a congenitally subluxating ulnar nerve. If an arthroscopic pump is used, keep the pressure low and ensure good fluid outflow to avoid excessive joint swelling (Table 34-9). 
 
Table 34-9
Arthroscopic Excision of Radial Head Fragment(s)
View Large
Table 34-9
Arthroscopic Excision of Radial Head Fragment(s)
Potential Pitfalls and Preventions
Pitfall Preventions
Excision of large radial head fragment leading to instability or clicking Measure fragment size on CT preoperatively and at arthroscopy
Poor visualization at arthroscopy Wait 5 d before arthroscopy
Use tourniquet
Neurovascular injury Check location and stability of ulnar nerve
Careful portal placement
Joint distention
Elbow arthroscopic experience
Failure to remove loose fragments CT imaging preoperatively to localize fragment(s)
Full arthroscopic evaluation of the elbow
X
Treatment-specific Outcomes.
The outcome of patients undergoing open fragment excision of the radial head is variable in the limited available literature. There are no series reporting the outcome of arthroscopic fragment removal. Some authors have reported up to 80% good or excellent results in patients treated with open fragment excision.51,77,115 However, Carstam reported that only half of their patients managed with fragment excision had good or excellent results. Avoid fragment excision in the setting of associated ligament and osseous injuries as the radial head is an important secondary stabilizer in this situation. 

Radial Head Excision

Preoperative Planning.
Excision of unreconstructable radial head fractures is not commonly performed in the setting of acute trauma due to a high incidence of associated injuries. The radial head may be removed for the treatment of malunions and nonunions. If radial head excision is contemplated, a careful inspection of the preoperative imaging is required to rule out associated fractures. The stability of the elbow should be evaluated fluoroscopically with varus, valgus, rotational, and axial stress tests before and after radial head excision. A radial head arthroplasty should be available for use if the elbow is determined to be unstable in any of these planes. The radial head can be removed using standard open surgical approaches as well as arthroscopically using the techniques described in the previous section for radial head fragment excision (Table 34-10). 
 
Table 34-10
Open Radial Head Excision
View Large
Table 34-10
Open Radial Head Excision
Preoperative Planning Checklist
  •  
    OR Table: Standard
  •  
    Position/positioning aids: Arm across chest or on arm table
  •  
    Fluoroscopy location: Operative side
  •  
    Equipment: Microsagittal saw, radial head arthroplasty system
  •  
    Tourniquet (sterile/nonsterile): Sterile
X
Positioning.
The radial head can be excised with the arm placed across the chest with the surgeon standing or using an arm table with the surgeon sitting. 
Surgical Approach.
A direct lateral or a posterior skin incision is utilized. A posterior incision is longer but is more cosmetic, avoids cutaneous nerves and allows for an extensile approach to repair other structures if required. A Kocher approach between the ECU and anconeus is used when the LCL is ruptured and a common extensor tendon-splitting approach is preferred when the lateral ulnar collateral ligament is intact (Fig. 34-9). 
Figure 34-9
A Kocher approach between the anconeus and the extensor carpi ulnaris is preferred if the lateral collateral ligament is disrupted to facilitate ligament repair.
 
A more anterior approach splitting the common extensor tendon at the mid-portion of the radial head is preferred when the ligaments are intact.
A more anterior approach splitting the common extensor tendon at the mid-portion of the radial head is preferred when the ligaments are intact.
View Original | Slide (.ppt)
Figure 34-9
A Kocher approach between the anconeus and the extensor carpi ulnaris is preferred if the lateral collateral ligament is disrupted to facilitate ligament repair.
A more anterior approach splitting the common extensor tendon at the mid-portion of the radial head is preferred when the ligaments are intact.
A more anterior approach splitting the common extensor tendon at the mid-portion of the radial head is preferred when the ligaments are intact.
View Original | Slide (.ppt)
X
Technique.
Perform a fluoroscopic examination to rule out concomitant ligament injuries using varus, valgus, rotational, and axial stress tests. Use a common extensor-splitting approach when the LCL is intact, which is typical in the setting of a planned radial head excision. Divide the common extensor tendon and annular ligament at the mid-portion of the radial head. Iatrogenic lateral instability is avoided if dissection is maintained anterior to the mid-axis of the radial head. Maintain the forearm in pronation while approaching the radial head and neck to protect the posterior interosseous nerve.23 Further exposure can be achieved if needed by detaching the anterior portion of the radial collateral ligament off the lateral epicondyle and the extensor carpi radialis longus and brevis off the lateral supracondylar ridge. Do not dissect distal to the biceps tuberosity without visualizing the posterior interosseous nerve. Section the radial head perpendicular to the neck at the junction of the radial head and neck. Ensure that the stump of the proximal radius does not impinge with the lesser sigmoid notch of ulna during forearm rotation. Reconstruct the excised fragments of radial head to ensure all fragments are accounted for. Perform a fluoroscopic evaluation of the elbow to look for retained fragments and to reevaluate elbow and forearm stability. Repair the annular ligament and extensor split (Table 34-11). 
 
Table 34-11
Open Radial Head Excision
View Large
Table 34-11
Open Radial Head Excision
Surgical Steps
  •  
    Evaluate elbow and forearm stability using fluoroscopy
  •  
    Lateral or posterior skin incision
  •  
    Common extensor tendon-splitting approach
  •  
    Excise radial head at head–neck junction
  •  
    Remove all fragments of radial head
  •  
    Reevaluate elbow and forearm stability using fluoroscopy
  •  
    Repair annular ligament and extensor split
X
Postoperative Care.
Immediate active motion in a soft dressing is permitted if there are no associated injuries. Concomitant ligament injuries will direct the rehabilitation plan as outlined in the section on the operative treatment of elbow dislocations. 
Potential Pitfalls and Preventative Measures.
Do not excise the radial head without replacement in the setting of associated collateral ligament injuries, concomitant elbow dislocation, interosseous membrane disruption, or coronoid fractures due to the high incidence of persistent instability. Perform a careful fluoroscopic examination intraoperatively. Convert to a radial head arthroplasty if there is significant instability after radial head excision. Maintain the forearm in pronation and retract gently to protect the posterior interosseous nerve during the surgical approach. Avoid placing retractors around the anterior radial neck due to the risk of nerve compression (Table 34-12). 
 
Table 34-12
Open Radial Head Excision
View Large
Table 34-12
Open Radial Head Excision
Potential Pitfalls and Preventions
Pitfall Preventions
Elbow or forearm instability Fluoroscopic evaluation before and after radial head excision
Replace radial head where possible
Avoid radial head excision if concomitant ligamentous or osseous injuries
Posterior interosseous nerve injury Maintain forearm in pronation during surgical approach
Do not place retractors anterior to radial neck
Do not dissect distal to biceps tuberosity
Retained fragment(s) of radial head Reassemble radial head to check if all fragments removed
Fluoroscopic evaluation of elbow
X
Treatment-specific Outcomes.
Given the high incidence of associated ligamentous injuries with more complex radial head fractures, our understanding of the key role of the radial head as a stabilizer in ligament deficient elbows, and its importance in load transfer across the elbow, primary excision of unreconstructable radial head fractures is less commonly performed. Long-term outcome studies have shown a high incidence of radiographic arthritis, an increase in the carrying angle, and proximal radial migration; however, the functional outcome with radial head excision for isolated fractures has been good in the majority of patients.4,48,99 Since the outcome of late radial head excision is generally good, early radial head excision should probably be avoided.15 Radial head excision should be avoided in patients with fracture-dislocations of the elbow. 

Open Reduction and Internal Fixation

Preoperative Planning.
Early surgery is preferred when managing radial head fractures operatively; however, urgent fixation is not required unless there is persistent subluxation following a closed reduction, a progressive neurologic deficit, or an open injury. Small diameter (1.5- or 2-mm) screws should be available. Some surgeons prefer differential pitch bone screws. Cannulated (2.5- or 3-mm) screws are helpful when performing internal fixation of fractures of the radial neck. Small plates or radial head-specific periarticular locking plates should be available when treating complete articular fractures of the radial head and neck. Some radial head fractures that appear amenable to internal fixation will in fact have greater comminution than demonstrated by plain radiographs or CT. The surgeon should be prepared to proceed with arthroplasty if unexpected comminution or damage is found. In these situations, the availability of a radial head implant in the operating room and consent for placement is advisable when open reduction and internal fixation is planned (Table 34-13). 
 
Table 34-13
ORIF of Radial Head and Neck Fractures
View Large
Table 34-13
ORIF of Radial Head and Neck Fractures
Preoperative Planning Checklist
  •  
    OR Table: Standard
  •  
    Position/positioning aids: Supine, arm across chest or on arm table; lateral decubitus an alternative
  •  
    Fluoroscopy location: Operative side
  •  
    Equipment: 0.035, 0.045 K-wires, 1.5- and 2-mm screws, 2.5-mm cannulated screws, periarticular locking plates, radial head arthroplasty system
  •  
    Tourniquet (sterile/nonsterile): Sterile
X
Positioning.
The radial head can be fixed with the arm placed across the chest with the surgeon standing or using an arm table with the surgeon sitting. When treating concomitant proximal ulna and olecranon fractures, the lateral decubitus position may be preferred. 
Surgical Approach(es).
Same as for radial head excision. 
Technique.
Periosteal attachments of the fragments should be preserved to maintain any residual blood supply and stability. The fractures are manipulated and provisionally reduced using Kirschner wires (K-wires). For partial articular fractures 1.5- or 2-mm countersunk screws are placed from the displaced fragments into the intact column of the radius typically using the same tracts as the provisional K-wire fixation (Fig. 34-10). In the setting of noncomminuted fractures of the radial neck, cross-cannulated screw fixation is performed using 2.5-mm screws. Cannulated fixation techniques are preferred as standard screws tend to deflect off the cortex of the radial neck when placed at an oblique angle of approach (Fig. 34-11). Low-profile nonlocking plates or periarticular fixed angle locking plates may be used in younger patients with more comminuted radial head and neck fractures; however, secondary plate removal is often required to treat rotational stiffness (Fig. 34-12). Plates should be placed on the nonarticular portion of the radial head which presents itself laterally with the forearm in neutral rotation (Fig. 34-7). In some circumstances where there are no periosteal attachments to the fragments, the radial head can be assembled on the back table, fixed to the plate and then the plate is attached to the radial neck. A careful fluoroscopic evaluation is performed to check the congruity of the reduction and to ensure optimal placement of internal fixation. 
Figure 34-10
 
A, B: Anteroposterior and lateral radiographs of a 33-year-old woman who fell snowboarding and had a block to supination. C: CT scan shows a displaced radial head fracture. D, E: Six months after open reduction and internal fixation, the patient had no pain and a full range of motion.
A, B: Anteroposterior and lateral radiographs of a 33-year-old woman who fell snowboarding and had a block to supination. C: CT scan shows a displaced radial head fracture. D, E: Six months after open reduction and internal fixation, the patient had no pain and a full range of motion.
View Original | Slide (.ppt)
Figure 34-10
A, B: Anteroposterior and lateral radiographs of a 33-year-old woman who fell snowboarding and had a block to supination. C: CT scan shows a displaced radial head fracture. D, E: Six months after open reduction and internal fixation, the patient had no pain and a full range of motion.
A, B: Anteroposterior and lateral radiographs of a 33-year-old woman who fell snowboarding and had a block to supination. C: CT scan shows a displaced radial head fracture. D, E: Six months after open reduction and internal fixation, the patient had no pain and a full range of motion.
View Original | Slide (.ppt)
X
Figure 34-11
 
A: Anteroposterior radiograph of a 30-year-old man with a displaced radial head fracture and a block to rotation. B: CT scan shows pattern of fracture. C: Six months postop ORIF with cannulated “tripod” screws, the patient had minimal pain and a full forearm rotation.
A: Anteroposterior radiograph of a 30-year-old man with a displaced radial head fracture and a block to rotation. B: CT scan shows pattern of fracture. C: Six months postop ORIF with cannulated “tripod” screws, the patient had minimal pain and a full forearm rotation.
View Original | Slide (.ppt)
Figure 34-11
A: Anteroposterior radiograph of a 30-year-old man with a displaced radial head fracture and a block to rotation. B: CT scan shows pattern of fracture. C: Six months postop ORIF with cannulated “tripod” screws, the patient had minimal pain and a full forearm rotation.
A: Anteroposterior radiograph of a 30-year-old man with a displaced radial head fracture and a block to rotation. B: CT scan shows pattern of fracture. C: Six months postop ORIF with cannulated “tripod” screws, the patient had minimal pain and a full forearm rotation.
View Original | Slide (.ppt)
X
Figure 34-12
 
A, B: Anteroposterior and lateral radiographs of a 56-year-old man with a proximal radius and ulna fracture. C, D: Two years after locking plate fixation of the radius and ulna, the patient had an occasional ache and lacked 20 degrees of supination and extension.
A, B: Anteroposterior and lateral radiographs of a 56-year-old man with a proximal radius and ulna fracture. C, D: Two years after locking plate fixation of the radius and ulna, the patient had an occasional ache and lacked 20 degrees of supination and extension.
View Original | Slide (.ppt)
Figure 34-12
A, B: Anteroposterior and lateral radiographs of a 56-year-old man with a proximal radius and ulna fracture. C, D: Two years after locking plate fixation of the radius and ulna, the patient had an occasional ache and lacked 20 degrees of supination and extension.
A, B: Anteroposterior and lateral radiographs of a 56-year-old man with a proximal radius and ulna fracture. C, D: Two years after locking plate fixation of the radius and ulna, the patient had an occasional ache and lacked 20 degrees of supination and extension.
View Original | Slide (.ppt)
X
A side-to-side repair of the annular ligament and anterior portion of the radial collateral ligament with the overlying common extensor tendon is performed if an EDC-splitting approach is used. In the setting where the LCL is detached to facilitate exposure or is avulsed from the lateral epicondyle by the injury, transosseous sutures are preferred over suture anchors as this technique allows the tissues to be drawn toward the epicondyle for optimal tensioning (Fig. 34-4, Table 34-14). 
 
Table 34-14
ORIF of Radial Head and Neck Fractures
View Large
Table 34-14
ORIF of Radial Head and Neck Fractures
Surgical Steps
  •  
    Expose proximal radius
  •  
    Divide annular ligament
  •  
    Provisional reduction of fragments with K-wires
  •  
    Fixation with countersunk screws or plate as indicated
X
Postoperative Care.
Immediate active motion in a soft dressing is permitted if there are no associated injuries. Concomitant ligament injuries will direct the rehabilitation plan as outlined in the section on the operative treatment of elbow dislocations. Strengthening is performed after fracture healing is secure, typically at 6 to 8 weeks postoperatively. 
Some surgeons employ indomethacin 25 mg three times daily for a 3-week period in an effort to prevent heterotopic ossification. The effectiveness of this approach, however, has not been proven scientifically and complications such as delayed and/or nonunions, gastrointestinal side effects and allergies can occur with these medications. Radiation should be avoided as it has been demonstrated to increase the incidence of nonunions when employed for acute distal humeral fractures.44 
Potential Pitfalls and Preventative Measures.
The surgeon should not accept tenuous fixation of radial head fractures as clinical failure is common in such circumstances. If an anatomic reduction with stable internal fixation cannot be achieved, a radial head replacement should be considered. Maintain the forearm in pronation to protect the posterior interosseous nerve during the surgical approach. Avoid overzealous retraction anterior to the radial neck due to the risk of nerve compression (Table 34-15). 
 
Table 34-15
Radial Head and Neck Fractures
View Large
Table 34-15
Radial Head and Neck Fractures
Potential Pitfalls and Preventions
Pitfall Preventions
Fixation failure Avoid fixation of small osteoporotic fractures
Use locking plates
Place screws through tracts of K-wires to avoid fragmentation of small fractures
Ensure stable ligament repairs to avoid elbow subluxation which leads to fixation failure
Use radial head arthroplasty if fixation is tenuous
Stiffness Early motion
Avoid plate fixation
Posterior interosseous nerve injury Avoid dissection distal to biceps tuberosity
Do not place retractors anterior to radial neck
Maintain forearm in pronation during surgical approach
Avascular necrosis Preserve periosteal attachments of fragments
Rigid internal fixation to allow for fragment union and revascularization
X
Treatment-specific Outcomes.
Open reduction and stable internal fixation of displaced radial head fractures yields good results in the majority of patients.59,65,91 Partial articular fractures have better results than complete articular fractures. More comminuted fractures, especially those with more than three fragments or concomitant elbow instability have poorer outcomes; radial head arthroplasty should be strongly considered.21,91 Patients treated with radial head excision have been reported to have poorer outcomes and a higher rate of osteoarthritis than those treated with ORIF.14,49,65 At an average of 17 years postoperatively, Lindenhovius et al. reported a lower severity of arthritis and a reduced incidence of elbow dislocations in patients that had ORIF compared to those who had a radial head excision. Countersunk screws have a lower incidence or stiffness than ORIF with plates for patients with fractures of the radial neck.79,102 

Radial Head Arthroplasty

Preoperative Planning.
A modular metallic radial head arthroplasty system should always be available when operating on displaced radial head fractures because comminution is often more severe than predicted by plain radiographs or CT. In the setting of neck comminution, small plates or cerclage wires should be available to allow for neck reconstruction and the use of a standard prosthesis. Alternatively a long stem bipolar prosthesis should be available in the uncommon situation where reconstruction of the radial neck to accept a standard prosthesis is not possible (Table 34-16). 
 
Table 34-16
Radial Head Arthroplasty
View Large
Table 34-16
Radial Head Arthroplasty
Preoperative Planning Checklist
  •  
    OR Table: Standard
  •  
    Position/positioning aids: Supine with arm across chest or arm table; lateral decubitus an alternative
  •  
    Fluoroscopy location: Operative side
  •  
    Equipment: Modular metallic radial head implant system, cerclage wires, and small plating systems in setting of concomitant neck fractures
  •  
    Tourniquet: Sterile
X
Positioning.
The radial head can be replaced with the arm placed across the chest with the surgeon standing or using an arm table with the surgeon sitting. When treating concomitant proximal ulna and olecranon fractures, the lateral decubitus position may be preferred. 
Surgical Approach.
Same as for radial head excision as outlined previously. 
Technique.
The annular ligament must be sectioned to adequately expose the radial head and neck and to facilitate the prosthesis insertion. The exact replacement technique will depend on the prosthesis system to be employed. After removing any loose fragments, section the radial neck at the junction of the radial head and neck or at the level of the fracture using an oscillating saw. Most radial head systems are modular to improve size matching with the native radial head and neck. Reassemble the excised fragments of radial head on the back table to ensure all fragments are removed from the elbow and to determine the optimal diameter and thickness of the radial head prosthesis to be employed. The native radial head is somewhat elliptical and is offset relative to the radial neck. Most commercially available implants are axisymmetric and nonanatomic; some employ a bipolar articulation. The optimal diameter of a radial head implant is not known but the articular dish of the implant should likely approximate the articular dish of the native radial head. The optimal implant diameter is typically the minor diameter of the elliptical native radial head, most commonly 2 mm smaller than the maximum diameter. An implant whose diameter is too large may cause an erosion of the lateral trochlea, prevents optimal closure of the annular ligament and may contribute to residual instability. When in between sizes, a smaller prosthesis is chosen both in diameter as well as thickness. 
Measurement of radial head thickness should be performed using the excised fragments of the radial head where available. Over-lengthening (over-stuffing) with the placement of a radial head prosthesis that is too thick may be associated with the development of pain, stiffness, and capitellar wear.13 
Place a Homan retractor around the posterior aspect of the radial neck and lever it against the ulna to translate the proximal radius laterally to prepare the radial canal and to insert the assembled modular prosthesis. If a smooth stem prosthesis is to be used choose a stem 1 mm smaller than the maximum-sized diameter neck rasp to allow the stem to move slightly in the neck such that the articular surface of the implant tracks optimally with the capitellum. 
After placing the trial implants, the radial head should articulate at the level of the proximal radial ulnar joint which is typically 2 mm distal to the tip of the coronoid.25 A careful evaluation for congruent tracking of the radial head implant on the capitellum both visually and fluoroscopically is required. Radiographic parameters are not very useful to detect over-lengthening of the radial head.5,38,96 The medial ulnohumeral joint space should be parallel; over-lengthening causes the medial ulnohumeral joint to open laterally. However, this may not be evident until there is 6- to 8-mm over-lengthening of the radial head insert. Following insertion of the definitive radial head prosthesis, careful repair of the annular ligament and any concomitant osseous and ligament injuries are required to maintain elbow stability (Table 34-17). 
 
Table 34-17
Radial Head Arthroplasty
View Large
Table 34-17
Radial Head Arthroplasty
Surgical Steps
  •  
    Expose radial head and neck
  •  
    Use oscillating saw to section radial neck at the head–neck junction or at the level of the fracture
  •  
    Reassemble excised radial head fragments to measure diameter and thickness
  •  
    Use Homan retractor placed posterior to the radial neck to gently lever the proximal radius laterally to allow access to radial neck
  •  
    Rasp radial neck and select stem size 1 mm smaller than rasp
  •  
    Trial reduction
    •  
      Check sizing of implant
    •  
      Ensure congruent tracking of radial head on capitellum visually and with fluoroscopy
    •  
      Evaluate radial length
  •  
    Insert radial head prosthesis
  •  
    Repair annular ligament and any concomitant osseous and ligament injuries
X
Postoperative Care.
Immediate active motion in a soft dressing is permitted if there are no associated injuries. Concomitant ligament injuries will direct the rehabilitation plan as outlined in the section on the operative treatment of elbow dislocations. 
Potential Pitfalls and Preventative Measures.
Incorrect implant sizing is a common problem following radial head arthroplasty. Unfortunately radiographic parameters are unreliable intraoperatively making the use of the excised radial head and the relationship of the radial head to the proximal ulna the most useful sizing tools. Do not use the distance between the capitellum and radial neck cut to size the implant as partial and complete LCL tears are common and this may lead to over-lengthening of the radial head implant. 
Contralateral radiographs can be helpful to make the diagnosis of radial head over-lengthening postoperatively and to assist in planning preoperatively if the radial head has previously been removed. A measurement technique has been developed based on contralateral radiographs which can accurately quantify radial head implant length within 1 mm.5 
Radial neck fractures can occur with overzealous retraction, reaming, and prosthesis insertion. Meticulous surgical technique should prevent this complication in most circumstances. Repair of the radial neck with cerclage wires usually allows successful prosthesis insertion. 
Stiffness is prevented by encouraging early active motion. Indomethacin can be used in an effort to prevent heterotopic ossification in patients without contraindications; however, its effectiveness remains unproven. 
Posterior interosseous nerve injuries can be avoided by maintaining the forearm in pronation during the surgical approach and avoidance of Homan retractors placed anterior to the radial neck. 
Capitellar wear or erosions can occur, particularly with over-lengthening of a radial head prosthesis or maltracking of the implant.13 Management can include revision or removal of the implant if the elbow is stable. Mechanical failure of the prosthesis can arise from failure to link the modular implant correctly, or a failure of the coupling mechanism such as a screw or polyethylene in the setting of a bipolar device. Revision should be corrective. Polyethylene wear with secondary osteolysis and implant loosening can also develop with a bipolar implant and is more problematic; prosthesis removal or revision should be considered as appropriate.17,84 Nonprogressive radiolucent lines around smooth stemmed implants are common and are not usually associated with the presence of residual symptoms (Fig. 34-13).35 Progressive lucency around a smooth-stemmed implant should raise the possibility of infection or residual instability which should be confirmed and managed. Implants with ingrowth stems which are loose may be symptomatic and require revision or removal (Table 34-18).37 
Figure 34-13
 
Anteroposterior and lateral radiographs of a 50-year-old woman who fell from a height (A, B). CT scan shows a comminuted, displaced radial head fracture and undisplaced coronoid fracture (C, D). Two years postop ORIF coronoid, radial head replacement, and LCL repair. The patient had no pain and a near full range of motion. The lucent lines around the smooth uncemented stem did not progress after 1 year (E, F).
Anteroposterior and lateral radiographs of a 50-year-old woman who fell from a height (A, B). CT scan shows a comminuted, displaced radial head fracture and undisplaced coronoid fracture (C, D). Two years postop ORIF coronoid, radial head replacement, and LCL repair. The patient had no pain and a near full range of motion. The lucent lines around the smooth uncemented stem did not progress after 1 year (E, F).
View Original | Slide (.ppt)
Figure 34-13
Anteroposterior and lateral radiographs of a 50-year-old woman who fell from a height (A, B). CT scan shows a comminuted, displaced radial head fracture and undisplaced coronoid fracture (C, D). Two years postop ORIF coronoid, radial head replacement, and LCL repair. The patient had no pain and a near full range of motion. The lucent lines around the smooth uncemented stem did not progress after 1 year (E, F).
Anteroposterior and lateral radiographs of a 50-year-old woman who fell from a height (A, B). CT scan shows a comminuted, displaced radial head fracture and undisplaced coronoid fracture (C, D). Two years postop ORIF coronoid, radial head replacement, and LCL repair. The patient had no pain and a near full range of motion. The lucent lines around the smooth uncemented stem did not progress after 1 year (E, F).
View Original | Slide (.ppt)
X
 
Table 34-18
Radial Head Arthroplasty
View Large
Table 34-18
Radial Head Arthroplasty
Potential Pitfalls and Preventions
Pitfall Preventions
Incorrect implant size Measure size of excised RH diameter and thickness
Evaluate articulation of implant with respect to proximal radioulnar joint and coronoid
Fluoroscopic evaluation of the ulnohumeral joint and implant alignment
Radial neck fracture Gentle retraction of radial neck
Avoid use of press fit stem that is too large
Stiffness Early motion
Possible use of indomethacin
Posterior interosseous nerve palsy Maintain forearm in pronation during surgical approach
Avoid dissection distal to biceps tuberosity
Do not lever on retractors anterior to radial neck
Prosthesis failure Ensure modular implant is securely coupled
Avoid use of bipolar implants in younger more active patients were polyethylene wear may be more of a concern
Ensure secure press fit of uncemented ingrowth stems
X
Treatment-specific Outcomes.
The outcome of metallic radial head replacements in the medium term is good with a variety of implant designs.17,26,42,94,98 Radiolucent lines around the stems of uncemented smooth stem components are commonly seen but do not correlate with patient symptoms.35 However, radiolucent lines around rough ingrowth stems may indicate loosening and are often associated with pain, a common reason for reoperation.37,111 Proximal radius stress shielding has been noted when using fully grit blasted uncemented stems. An uncemented smooth stem bipolar radial head replacement has shown good early results with no evidence of polyethylene wear.118 Progressive osteolysis due to polyethylene wear debris has been reported at longer follow-up with cemented bipolar radial head replacements.84 Early results with pyrocarbon implants have reported some catastrophic failures at the head–neck junction.98 

Management of Expected Adverse Outcomes and Unexpected Complications in Radial Head Fractures

Osteoarthritis is common following fractures of the radial head. Even minimally displaced fractures have a high incidence of arthritis at long-term follow-up, likely as a consequence of traumatic articular damage at the time of injury as well as residual articular incongruity. Radial head replacement can be considered if the capitellar cartilage is relatively well preserved; however, radial head excision is preferred in the setting where the capitellar cartilage or bone has advanced disease. If there is post-traumatic arthritis of the radiocapitellar joint associated with residual elbow instability, radial head excision is contraindicated. A uni-compartmental radiocapitellar arthroplasty should be considered; however, these implants are relatively new, and their outcome remains unknown. Total elbow arthroplasty may be required to manage post-traumatic arthritis that involves the ulnohumeral joint. 
Stiffness is common following radial head fractures. It can be isolated to a loss of flexion–extension or forearm rotation. The most common cause is capsular contracture; however, mechanical causes such as prominent hardware or retained cartilaginous or osseous fragments can also be responsible. The development of post-traumatic heterotopic ossification should also be considered. In the setting of capsular contracture passive stretching under the supervision of a therapist as well as the use of static progressive splinting is often successful. Turnbuckle splinting can also be employed. Patients with persistent stiffness following radial head fractures can be treated with standard techniques of open or arthroscopic debridement and capsular release. 
Malunions are common with nonsurgical management of displaced radial head fractures; however, in most cases patients have minimal, if any, symptoms. In some cases patients present restricted rotation, pain, clicking, or crepitus. Secondary degenerative changes of the capitellum and radial head can occur. Management options can include an intra- or extra-articular osteotomy of the radial head in younger patients without secondary degenerative changes of the capitellum.93 Most patients presenting with symptomatic malunions have significant chondral damage to the radial head and/or capitellum and are therefore best treated by radial head excision or radial head arthroplasty.101 Nonunions of radial neck fractures can occur with nonsurgical management; however, these may be asymptomatic. Nonunions following internal fixation are typically due to compromised vascularity and often do not respond to revision open reduction and internal fixation and grafting. Radial head excision or replacement is recommended in most circumstances. 
Chronic valgus or axial instability is most commonly seen in patients who have had a radial head excision without replacement. This problem can typically be prevented by fixation or replacement of the radial head. Management of late valgus instability includes replacement of the radial head as well as an MCL reconstruction. Chronic varus and posterolateral rotatory instability (PLRI) can also occur in patients with radial head fractures due to deficient healing of the LCL. The absence of a radial head to provide concavity compression of the lateral column or properly tension the lateral ligaments exacerbates underlying instability. Reconstruction of the LCL using a tendon graft is preferred in the presence of a native radial head or prosthesis to help tension the graft and improve stability. 
Early recognition and prevention of axial forearm instability is preferred. Unfortunately, most patients present late following radial head excision. While 2 to 3 mm of proximal migration of the radial head is expected after radial head excision with intact ligaments of the distal radial ulnar joint and interosseous membrane, marked proximal migration can occur with disruption of these stabilizing structures. The optimal management for chronic Essex–Lopresti injuries is unknown. Treatment options include a one-bone forearm, replacement of the radial head with an immediate or staged ulnar shortening, or techniques of interosseous membrane reconstruction combined with a radial head prosthesis (Table 34-19).68 
 
Table 34-19
Radial Head Fractures
View Large
Table 34-19
Radial Head Fractures
Common Adverse Outcomes and Complications
Post-traumatic arthritis
Stiffness
Symptomatic nonunion, malunion, or avascular necrosis
Elbow and/or forearm instability
X

Author’s Preferred Method of Treatment for Radial Head Fractures (Fig. 34-14)

Rockwood-ch034-image014.png
View Original | Slide (.ppt)
Figure 34-14
Author’s preferred treatment.
Rockwood-ch034-image014.png
View Original | Slide (.ppt)
X

Summary, Controversies, and Future Directions in Radial Head Fractures

Radial head fractures are common; however, the majority are minimally displaced or undisplaced and can be treated successfully nonoperatively. Advances in imaging, fixation devices, and newer prosthetic designs have improved the outcome of displaced fractures; however, the indications for surgery remain unclear. Randomized clinical trials are needed to provide a scientific rationale for the management of displaced radial head fractures without a block to motion. Radial head excision is uncommonly performed for acute radial head fractures due to a significant incidence of concomitant ligament injuries and the advent of reliable prosthetic arthroplasty. 

Introduction to Coronoid Fractures

Isolated fractures of the coronoid are uncommon with the majority having associated fractures of the radial head or proximal ulna, collateral ligament injuries, or concomitant dislocations. Fractures of the coronoid occur in 2% to 15% of patients with ulnohumeral dislocations.114 The pattern and size of the coronoid fracture and the extent of concomitant osseous and ligament injuries dictate the optimal treatment strategy. 
Coronoid fractures have traditionally been classified using the Regan–Morrey classification system.87 This classification system focuses on the height of the fracture in the coronal plane. Type I fractures are small coronoid tip fractures. Type II fractures involve less than 50% of the total coronoid height and Type III fractures involve greater than 50%. The classification is modified based on the presence or absence of an associated fracture-dislocation, with Type A defining an isolated fracture and Type B defining an associated dislocation. 
O’Driscoll et al.80 introduced a more comprehensive classification system that included fracture size, anatomic location, and mechanism of injury. This system is divided into three types. Type I fractures involve the coronoid tip and are divided into two subtypes based on size. Subtype I are tip fractures less than 2 mm, while subtype II are larger than 2 mm, but less than 50% of the coronoid height. Type II fractures involve the anteromedial facet and are divided into three subtypes. Subtype I involves the rim only, subtype II involves the rim and tip, and subtype III involves the rim, and sublime tubercle, with or without involvement of the tip. Type III fractures include the coronoid base and consist of two subtypes. Subtype I comprises body and basal fractures while subtype II includes the former in addition to a transolecranon fracture (Fig. 34-15). 
Figure 34-15
The O’Driscoll classification of coronoid fractures includes Type I, fractures of the tip, Type II, fractures involving the anteromedial facet, and Type III, basal fractures.
 
Type I fractures are most commonly associated with terrible triad fracture-dislocations, Type II are associated with varus posteromedial rotatory instability, and Type III are associated with olecranon and proximal ulna fracture-dislocations.
Type I fractures are most commonly associated with terrible triad fracture-dislocations, Type II are associated with varus posteromedial rotatory instability, and Type III are associated with olecranon and proximal ulna fracture-dislocations.
View Original | Slide (.ppt)
Figure 34-15
The O’Driscoll classification of coronoid fractures includes Type I, fractures of the tip, Type II, fractures involving the anteromedial facet, and Type III, basal fractures.
Type I fractures are most commonly associated with terrible triad fracture-dislocations, Type II are associated with varus posteromedial rotatory instability, and Type III are associated with olecranon and proximal ulna fracture-dislocations.
Type I fractures are most commonly associated with terrible triad fracture-dislocations, Type II are associated with varus posteromedial rotatory instability, and Type III are associated with olecranon and proximal ulna fracture-dislocations.
View Original | Slide (.ppt)
X
O’Driscoll Type I coronoid tip fractures are typically associated with fractures of the radial head and a concomitant elbow dislocation, the “terrible triad” injury of the elbow. These injuries typically occur with a PLRI mechanism, shearing off the anterolateral radial head and coronoid tip while dislocating. Type II anteromedial coronoid fractures are seen with posteromedial rotatory instability (PMRI) and are almost always have a concomitant avulsion of the LCL. Type III basal coronoid fractures are most commonly associated with fractures of the olecranon and proximal ulna and have a more direct posterior injury mechanism. They typically have larger fractures of the radial head and less ligamentous injuries. The management of coronoid fractures is best understood by considering the patterns of injury rather than focusing on the isolated treatment of the coronoid. 

Introduction to Terrible Triad Injuries of the Elbow

Terrible triad injuries consist of a fracture of the radial head and coronoid and an elbow dislocation. These injuries may be challenging to treat and suboptimal clinical outcomes have been commonly described in the past. Advances in our knowledge of elbow biomechanics and improvements in implants have resulted in improved patient outcomes. 

Assessment of Terrible Triad Injuries

Mechanisms of Injury for Terrible Triad Injuries

Terrible triad injuries are thought to occur by posterolateral rotatory displacement of the ulna, resulting in elbow subluxation or dislocation (Fig. 34-1).81 The proposed mechanism is a fall onto an outstretched arm, with supination, valgus, and axial-directed force. The trochlea causes a shear fracture of the coronoid and is accompanied by an LCL injury and/or radial head fracture. 

Associated Injuries with Terrible Triad

Ipsilateral upper extremity injuries have been reported in 10% to 20% of patients with fracture-dislocations of the elbow with the majority involving fractures of the wrist.27,54 Associated injuries of the head, chest, abdomen, pelvis, or lower extremities are seen in patients with higher-energy trauma. Neurovascular injuries are uncommon. 

Signs and Symptoms of Terrible Triad Injuries

A detailed neurovascular examination must be performed before and after reduction of a dislocated elbow. Soft tissue status and the condition of the skin should be carefully assessed. The elbow should be palpated for signs of tenderness over the collateral ligament insertions. The shoulder, wrist, and distal radioulnar joint should be examined. Radiographic signs of these fractures are often subtle stressing the importance of detailed physical examination. 

Imaging of Terrible Triad Injuries

Once the initial evaluation is complete, standard radiographs (AP and lateral views) are required to determine the direction of the dislocation and to identify associated fractures. Radiographs of the shoulder, forearm, and wrist are ordered as clinically indicated. Radiographs are repeated following a gentle closed reduction of the elbow dislocation under conscious sedation. The radiocapitellar joint can be widened with LCL disruption and the radial head can be subluxated posteriorly. CT may help to better evaluate radial head fracture patterns and demonstrate osteochondral fragments within the joint. Three-dimensional CT reconstructions have been shown to improve interobserver agreement on the classification and treatment of coronoid fractures relative to two-dimensional CT.64 CT can also assist with selecting the surgical approach and type of internal fixation required. 

Classification of Terrible Triad Injuries

Terrible triad injuries are subclassified by the pattern of radial head and coronoid fractures. The most common coronoid fractures seen in terrible triad injuries are Types I and II.29 The radial head fracture classifications were outlined in the previous section. 

Outcome Measures for Terrible Triad Injuries

Several scoring systems have been used to evaluate the outcomes of terrible triad injuries including the DASH Questionnaire, the Mayo Elbow Performance Score, and the Patient-rated Elbow Evaluation. 

Pathoanatomy and Applied Anatomy Relating to Terrible Triad Injuries

The primary stabilizers of the elbow joint are the coronoid, MCL, and LCL. The secondary constraints are the capsule, the radiocapitellar articulation, and the common extensor and flexor origins.74 The radial head is a secondary valgus stabilizer while the coronoid is primary stabilizer to varus stress and an important stabilizer to axial, posteromedial and posterolateral rotatory forces.7,75,83,100 
Biomechanical studies of a terrible triad model demonstrate that ligament repair and radial head arthroplasty can restore near normal elbow kinematics and stability if the coronoid fracture is small (Type I). However, larger coronoid fractures, such as Regan and Morrey Types II and III resulted in vertical and coronal plane instability, even in the setting of ligament repair and radial head repair or replacement.9 

Terrible Triad Injuries Treatment Options

Nonoperative Treatment of Terrible Triad Injuries

Indications/Contraindications

Terrible triad injuries of the elbow are usually treated surgically due to residual instability precluding a congruous reduction and early motion. If the radial head and coronoid fractures are small and the elbow is congruously reduced following a closed reduction, nonoperative treatment should be considered. Fracture fragments which are interposed within the articulation and the presence of residual instability are contraindications to nonoperative treatment. Radial head fractures which are displaced and causing a block to forearm rotation are also contraindications for nonsurgical management (Table 34-20). 
 
Table 34-20
Terrible Triad Injuries
View Large
Table 34-20
Terrible Triad Injuries
Nonoperative Treatment
Indications Relative Contraindications
Concentric elbow following closed reduction of dislocation Nonconcentric elbow reduction
Undisplaced radial head fracture or displaced radial head fracture without a block to rotation Displaced radial head fracture interfering with forearm rotation
Regan and Morrey subtype Type I coronoid fracture, undisplaced subtype II and III coronoid fractures Displaced Regan and Morrey subtype Type II and III coronoid fractures. Fracture fragment interposed in articulation
X

Technique

A closed manipulative reduction of the elbow is usually performed in the emergency room or the operating room. After reduction, the elbow is taken through an arc of flexion–extension in pronation, neutral, and supination in order to evaluate for residual instability. Since the lateral sided soft tissue injuries are typically more severe in terrible triad injuries, pronation of the forearm often improves stability. If the elbow redislocates between 0 and 30 degrees of flexion, operative treatment should be considered. Terrible triad injuries treated nonoperatively are immobilized in a light splint at 90 degrees of flexion for 7 to 10 days for comfort and to allow muscle tone to return to the elbow. Prolonged treatment in excessive flexion to maintain joint reduction should be avoided. Isometric contraction of the elbow muscles is encouraged while in the postreduction splint. After splint removal the patient is re-examined for stability and asked to actively extend and flex the elbow. Patients will typically move only within their stable arc and are unlikely to redislocate if they had a stable reduction and examination initially. Abduction of the arm and elbow from the chest and passive range of motion exercises are avoided as this produces a varus stress on their elbow. A 90-degree resting splint is used between exercises, typically the forearm in pronated which is usually the most stable position in the setting of more extensive lateral than medial sided soft tissue injury. Full extension in supination is not typically permitted for 4 weeks to limit the potential for elbow subluxation. Weekly radiographic and clinical follow-up is required to monitor for fracture displacement and recovery of motion. Persistent joint subluxation or redislocation is an indication for surgical management. At 6 weeks the resting splint is discontinued and gentle stretching may be initiated to manage residual stiffness. Varus or valgus loading as well as strengthening are avoided until 12 weeks. Static progressive splinting can be used to improve elbow motion. 

Outcomes

There is little information regarding the nonoperative treatment of terrible triad injuries of the elbow. Nonoperative treatment has been associated with less desirable outcomes including stiffness, late instability, and arthrosis.45,90 More recently, Guitton and Ring reported that three of the four patients treated nonoperatively had good results. The authors concluded that nonsurgical treatment could be considered for small and minimally displaced fractures of the coronoid and radial head with good elbow alignment.43 

Operative Treatment of Terrible Triad Injuries

Indications/Contraindications

The majority of patients with terrible triad injuries require surgical management to achieve a stable congruous reduction of the elbow allowing early motion. Residual subluxation of the elbow following a closed reduction or residual instability precluding early motion is an indication for surgery. Displaced radial head fractures blocking motion or incarcerated fracture fragments in the articulation are also indications for surgery. Surgery may occasionally be contraindicated in patients whose medical comorbidities place them at an unacceptable risk as well as patients with nonfunctional upper extremities due to neurologic or other impairments. 

Open Reduction and Internal Fixation

A systematic approach is important to address the critical components of this injury. This includes fixation or replacement of the radial head, fixation of the coronoid fragment, and repair of the LCL. The elbow is then evaluated intraoperatively for residual instability to determine if MCL repair is required or rarely if an external fixator is needed. 
Preoperative Planning (Table 34-21)
 
Table 34-21
ORIF of Terrible Triad Injuries
View Large
Table 34-21
ORIF of Terrible Triad Injuries
Preoperative Planning Checklist
  •  
    OR Table: Radiolucent arm table
  •  
    Position/positioning aids: Supine with arm table or arm across chest
  •  
    Fluoroscopy location: Operative side
  •  
    Equipment: Suture anchors, 0.035, 0.045 K-wires, 1.5- and 2-mm screws, 2.5-mm cannulated screws, periarticular locking plates, radial head arthroplasty system, large external fixator, hinged external fixator, large fragment locking set with screws
X
Positioning.
Terrible triad injuries can be repaired with the arm placed across the chest with the surgeon standing or using an arm table with the surgeon sitting. The use of a rolled-up sheet placed underneath the elbow can be helpful to approach the medial elbow when the arm is placed across the chest. 
Surgical Approach.
A posterior midline elbow skin incision is typically employed when managing terrible triad injuries of the elbow as it allows lateral, medial, and posterior access to the elbow. Alternatively separate lateral, medial, and posterior skin incisions can be employed as needed. A Kocher approach is preferred to allow repair of the LCL which typically is avulsed off the lateral epicondyle in terrible triad injuries.71 
The optimal surgical approach to repair the coronoid has not been determined with various lateral, anterior, and medial options reported. In many cases the coronoid can be accessed and repaired from a lateral surgical exposure, particularly if a radial head replacement is required. A flexor pronator split can be used for Regan and Morrey Type I and II coronoid fractures (Fig. 34-16).103 A Taylor and Scham approach may be preferred for the Type III basal fractures and when a medial plate is required.108 This approach involves detaching the entire flexor pronator mass from the medial epicondyle and supracondylar ridge and provides excellent exposure to the entire coronoid and MCL. Our preferred surgical approach is to use the interval between the two heads of the flexor carpi ulnaris (FCU).97 This also provides adequate access to the sublime tubercle and MCL. Meticulous release and mobilization of motor branches of the ulnar nerve can help improve distal exposure. Proximal articular branches may need to be sacrificed in order to obtain adequate exposure. Elevating the flexor–pronator muscles from distal to proximal helps isolate the sublime tubercle and identify and protect the anterior bundle of the MCL when it is intact. The authors routinely perform an in situ release of the ulnar nerve; transposition of the ulnar nerve should be considered if there are preoperative ulnar nerve symptoms or if further mobilization is needed to allow coronoid fixation. 
Figure 34-16
There are three medial approaches to fix the coronoid.
 
A flexor pronator split, using the floor of the ulnar nerve which splits the two heads of the flexor carpi ulnaris, and elevation of the entire flexor carpi ulnaris of the ulna.
A flexor pronator split, using the floor of the ulnar nerve which splits the two heads of the flexor carpi ulnaris, and elevation of the entire flexor carpi ulnaris of the ulna.
View Original | Slide (.ppt)
Figure 34-16
There are three medial approaches to fix the coronoid.
A flexor pronator split, using the floor of the ulnar nerve which splits the two heads of the flexor carpi ulnaris, and elevation of the entire flexor carpi ulnaris of the ulna.
A flexor pronator split, using the floor of the ulnar nerve which splits the two heads of the flexor carpi ulnaris, and elevation of the entire flexor carpi ulnaris of the ulna.
View Original | Slide (.ppt)
X
Technique.
A fluoroscopic assessment of the elbow under anesthesia is important to determine the extent of collateral ligament injury and the magnitude of elbow instability. After performing a lateral or posterior elbow skin incision, an extended Kocher approach is used to provide a more complete exposure of the elbow and facilitate repair of the LCL. When extending the exposure a cuff of fascia should be left attached to the supracondylar ridge to assist with closure. In order to protect the posterior interosseous nerve, the forearm should be pronated and the distal extent of the exposure should not exceed 2 cm from the radiocapitellar joint.23 The coronoid can be accessed through the radial head fracture or by hinging the elbow open through the lateral ligament injury. Coronoid fractures too small or comminuted to be amenable to screw fixation can be repaired using sutures passed around the coronoid process and anterior capsule through transosseous tunnels on the dorsal ulna.40,70 Small tip fractures of the coronoid, less than 10% may be left unrepaired if a secure repair of the concomitant injuries is achieved.11 If the radial head is nonreconstructable, resection will improve exposure of the coronoid. An anatomic reduction of the coronoid fracture fragments is performed and tentatively held with K-wires from a cannulated screw system. Once the coronoid is reduced the K-wires are systematically replaced with cannulated screws.70 Use of an anterior cruciate ligament or similar targeting device can assist with accurate screw placement. 
Coronoid fixation is followed by ORIF or replacement of the radial head. Partial or complete excision of the radial head is not recommended in the setting of terrible triad injuries as it has been shown to result in instability and arthrosis.45 The decision between repair and replacement of the radial head has been described previously, understanding that secure fixation is needed in the setting of these more complex injuries especially with concomitant elbow instability. The LCL is usually ruptured at the origin on the lateral epicondyle. An isometric, anatomic repair of the LCL is essential to restore stability (Fig. 34-4). The isometric point corresponds to the center of the capitellum when viewing from the lateral side. 
If the coronoid cannot be accessed from the lateral surgical approach, a medial surgical approach is performed as described above to repair the coronoid and MCL (Fig. 34-16). Reduction and fixation is performed with transosseous sutures, posterior to anterior cannulated screws or a buttress plate (Fig. 34-17). Rarely reconstruction of the coronoid is not possible due to bone lost or severe comminution and a structural bone graft is indicated.92 Various options have been described, including iliac crest,61 resected radial head,109 allografts, and a fragment of the ipsilateral proximal olecranon.73 
Figure 34-17
A 59-year-old female sustained a fall from two stairs onto her right outstretched arm.
 
Radiographs following a closed reduction of an elbow dislocation demonstrate a displaced coronoid and radial head fracture with residual elbow subluxation. A, B: The 3D CT demonstrates significant comminution of both the coronoid and radial head fracture. C, D: Six months following radial head arthroplasty, transosseous LCL repair, and ORIF of the coronoid with cancellous bone graft taken from the radial head. Radiographs demonstrate a congruous elbow with mild heterotopic ossification. E, F: The patient achieved a functional range of motion.
Radiographs following a closed reduction of an elbow dislocation demonstrate a displaced coronoid and radial head fracture with residual elbow subluxation. A, B: The 3D CT demonstrates significant comminution of both the coronoid and radial head fracture. C, D: Six months following radial head arthroplasty, transosseous LCL repair, and ORIF of the coronoid with cancellous bone graft taken from the radial head. Radiographs demonstrate a congruous elbow with mild heterotopic ossification. E, F: The patient achieved a functional range of motion.
View Original | Slide (.ppt)
Figure 34-17
A 59-year-old female sustained a fall from two stairs onto her right outstretched arm.
Radiographs following a closed reduction of an elbow dislocation demonstrate a displaced coronoid and radial head fracture with residual elbow subluxation. A, B: The 3D CT demonstrates significant comminution of both the coronoid and radial head fracture. C, D: Six months following radial head arthroplasty, transosseous LCL repair, and ORIF of the coronoid with cancellous bone graft taken from the radial head. Radiographs demonstrate a congruous elbow with mild heterotopic ossification. E, F: The patient achieved a functional range of motion.
Radiographs following a closed reduction of an elbow dislocation demonstrate a displaced coronoid and radial head fracture with residual elbow subluxation. A, B: The 3D CT demonstrates significant comminution of both the coronoid and radial head fracture. C, D: Six months following radial head arthroplasty, transosseous LCL repair, and ORIF of the coronoid with cancellous bone graft taken from the radial head. Radiographs demonstrate a congruous elbow with mild heterotopic ossification. E, F: The patient achieved a functional range of motion.
View Original | Slide (.ppt)
X
The elbow should be examined under fluoroscopy for evidence of residual instability with the forearm in pronation, neutral, and supination after repair of the coronoid, radial head, and LCL. If the elbow is still unstable, the MCL should be repaired. Static or dynamic external fixation can be used to protect complex osteoporotic fractures of the coronoid when stable fixation is not achieved and in the uncommon circumstance in patients who demonstrate residual instability in spite of repair of the radial head, coronoid, and both collateral ligaments.70 Hinged external fixation is often useful in revision situations. Temporary cross-screw or bridge plate fixation of the elbow can also be considered as described previously (Table 34-22). 
 
Table 34-22
Operative Repair of Terrible Triad Injuries
View Large
Table 34-22
Operative Repair of Terrible Triad Injuries
Surgical Steps
  •  
    Fluoroscopic examination of elbow under anesthesia
  •  
    Lateral surgical approach to elbow through posterior midline or lateral skin incision
  •  
    Deep Kocher approach
  •  
    Fix coronoid from lateral surgical approach if possible using posterior to anterior screws if larger fragment or suture fixation of anterior capsule if smaller fragment(s)
  •  
    Fix or replace radial head
  •  
    Repair LCL and common extensor muscles using transosseous sutures or suture anchors
  •  
    Re-evaluate elbow stability using fluoroscopy
  •  
    Perform medial surgical approach if unable to fix coronoid fracture from lateral surgical approach if residual instability is present following repair of coronoid, radial head, and LCL
  •  
    Use floor of ulnar nerve approach to access coronoid and MCL
  •  
    Perform in situ release or transpose ulnar nerve
  •  
    Fix coronoid with posterior to anterior screws or buttress plate
  •  
    Repair MCL and common flexor muscles using transosseous sutures or suture anchors
  •  
    Re-evaluate elbow stability using fluoroscopy
  •  
    If the elbow is still unstable apply external fixator or temporary bridge plate
X
Postoperative Care.
The integrity of the osseous and ligament repairs and the examination under anesthesia for stability at the conclusion of the operation will direct the rehabilitation plan as outlined in the section on the operative treatment of elbow dislocations. In general, a stiff stable elbow is preferred over a loose incongruous one. 
Potential Pitfalls and Preventative Measures.
Symptomatic instability is uncommon after operative repair of terrible triad injuries. However, inadequate or failed repair of the lateral structures can lead to persistent subluxation. Mild subluxation may be treated with an active motion or overhead rehabilitation protocol, as previously described, but frank dislocation may require repeat operative fixation or salvage procedures. Early recognition of this problem is critical as late treatment of a stiff subluxated elbow may require extensive surgical management including elbow release and LCL and MCL reconstruction. Failure of radial head or coronoid fixation may also cause residual instability. The judicious use of static or dynamic external fixation or temporary bridge plate fixation should be considered in the setting of tenuous bony or soft tissue repairs, in patients with morbid obesity and those who are unable to be compliant with postoperative care such as patients in an intensive care unit. 
Early postoperative motion is preferable to prevent stiffness; however, occasionally delayed mobilization is required due to poor soft tissues or tenuous fixation. Some patients may require elbow release or excision of heterotopic bone to restore motion. The use of indomethacin, while preferred by the authors in patients without contraindications to this medication, continues to be controversial and has not been proven to prevent heterotopic ossification around the elbow. 
Ulnar nerve symptoms are common with medial surgical approaches to the coronoid and the radial nerve is at risk with plate fixation of the radial neck and with placement of an external fixator (Table 34-23). 
 
Table 34-23
Terrible Triad Injuries
View Large
Table 34-23
Terrible Triad Injuries
Potential Pitfalls and Preventions
Pitfall Preventions
Residual instability Repair or replacement of the radial head, fixation of larger coronoid fractures, and secure anatomic repair of collateral ligaments
Active motion protocol avoiding varus stress at all times
Employ external fixation or temporary bridge plate fixation if concerns about residual instability
Elbow stiffness Early range of motion
Nerve palsy Protect ulnar nerve during medial surgical approaches
Direct visualization of bone during external fixator pin placement
Gentle nerve and soft tissue handling
X
Treatment-specific Outcomes.
Doornberg et al.24 retrospectively studied 26 terrible triad injuries of the elbow. They reported good to excellent outcomes when stable fixation of the coronoid was achieved and unsatisfactory outcomes when stable fixation was not achieved. Pugh et al.85 reviewed 36 terrible triad injuries that were treated with ORIF of the coronoid fracture and/or repair of the anterior capsule, repair or replacement of the radial head, and repair of the lateral ligament. In addition, repair of the MCL and/or application of a hinged external fixator were used for patients who demonstrated residual instability. They achieved 78% good to excellent results with a mean flexion–extension arc of 112 degrees and forearm rotation of 136 degrees. Ring et al.90 reported poor results due to instability, arthrosis, and stiffness in 7 of 11 patients with terrible triad injuries who did not have the internal fixation of the coronoid. 

Management of Expected Adverse Outcomes and Unexpected Complications in Terrible Triad Injuries (Table 34-24)

 
Table 34-24
Terrible Triad Injuries
View Large
Table 34-24
Terrible Triad Injuries
Common Adverse Outcomes and Complications
Elbow stiffness and heterotopic ossification → Initiate early motion
Redislocation → Careful follow-up and recognize and treat surgically
Residual subluxation → Active motion protocol, proceed with operative treatment if persists
X

Author’s Preferred Method of Treatment for Terrible Triad Injuries (Fig. 34-18)

Rockwood-ch034-image018.png
View Original | Slide (.ppt)
Figure 34-18
Authors preferred treatment.
Rockwood-ch034-image018.png
View Original | Slide (.ppt)
X

Summary, Controversies, and Future Directions in Terrible Triad Injuries

While the outcome of terrible triad injuries has improved, a reliably good outcome continues to be difficult to achieve. Current challenges with the management of terrible triad injuries are the ability to achieve stable internal fixation of both coronoid and radial head fractures. While there are good radial head implants available for the management of unreconstructable radial head fractures, there is currently no available coronoid implant which makes the management of the comminuted coronoid difficult. The optimal surgical approach to the coronoid remains unknown as does the management of the ulnar nerve. The role of suture fixation of small coronoid fragments and repair of the MCL remains controversial. While some authors prefer articulated external fixation in the setting of residual instability, these devices are difficult to apply to precisely replicate the axis of motion and our experience has been mixed. We now prefer static external fixation or an internal bridge plate. Future studies are needed to determine the role of indomethacin in preventing heterotopic ossification in patients with terrible triad injuries. 

Introduction to Posteromedial Rotatory Instability (PMRI) of the Elbow

Anteromedial fractures of the coronoid (AMC) and varus PMRI were first described by O’Driscoll et al.80 in 2003. While these fractures are uncommon relative to coronoid fractures associated with terrible triad injuries, they are often subtle and may be missed, often leading to suboptimal outcomes due to a poor “natural history.” Advances in our understanding of the mechanism of this injury and the biomechanics of treatment should lead to improved outcomes. 

Assessment of Posteromedial Rotatory Instability of the Elbow

Mechanisms of Injury for Posteromedial Rotatory Instability of the Elbow

The anteromedial coronoid fracture (O’Driscoll Type II) has been postulated to occur by pronation, varus, and axially directed forces. It is commonly accompanied by avulsion injuries to the LCL and posterior bundle of the MCL, resulting in PMRI. Injury to the anterior bundle of the MCL can also occur with AMC fractures.80 

Associated Injuries with Posteromedial Rotatory Instability of the Elbow

Given the limited reports available on AMC fractures the incidence of associated injuries is not known. While partial or complete injuries of the LCL are common the incidence of injury to the posterior bundle of the MCL is unclear. Unlike terrible triad injuries, the radial head is usually not fractured in patients with anteromedial coronoid fractures and this is a key to its recognition (Fig. 34-19). An anteromedial coronoid fracture should be suspected in any patient who appears to have a coronoid fracture when a radial head fracture is not present. While some patients present with a frank dislocation, the majority of patients do not: In such individuals a history of dislocation, “clunking” or instability with spontaneous reduction can often be elicited. 
Figure 34-19
A 39-year-old woman following a fall on ice.
 
The AP and lateral views demonstrate a subtle coronoid fracture without a radial head fracture. The patient had crepitus and pain with attempted motion with the arm abducted from the side. A, B: The 3D CT provides further detail of the subtype II anteromedial coronoid fracture. C: AP and lateral radiographs 1 year following transosseous LCL repair and buttress plate fixation of the anteromedial facet (D, E).
The AP and lateral views demonstrate a subtle coronoid fracture without a radial head fracture. The patient had crepitus and pain with attempted motion with the arm abducted from the side. A, B: The 3D CT provides further detail of the subtype II anteromedial coronoid fracture. C: AP and lateral radiographs 1 year following transosseous LCL repair and buttress plate fixation of the anteromedial facet (D, E).
View Original | Slide (.ppt)
Figure 34-19
A 39-year-old woman following a fall on ice.
The AP and lateral views demonstrate a subtle coronoid fracture without a radial head fracture. The patient had crepitus and pain with attempted motion with the arm abducted from the side. A, B: The 3D CT provides further detail of the subtype II anteromedial coronoid fracture. C: AP and lateral radiographs 1 year following transosseous LCL repair and buttress plate fixation of the anteromedial facet (D, E).
The AP and lateral views demonstrate a subtle coronoid fracture without a radial head fracture. The patient had crepitus and pain with attempted motion with the arm abducted from the side. A, B: The 3D CT provides further detail of the subtype II anteromedial coronoid fracture. C: AP and lateral radiographs 1 year following transosseous LCL repair and buttress plate fixation of the anteromedial facet (D, E).
View Original | Slide (.ppt)
X

Signs and Symptoms of Posteromedial Rotatory Instability of the Elbow

A detailed neurovascular examination must be performed before and after reduction of a dislocated elbow if present. Soft tissue status and the condition of the skin should be carefully assessed. The elbow should be carefully palpated for signs of tenderness, particularly over the LCL. A patient may complain of crepitus with elbow motion with the arm abducted from the side (which produces a varus stress). This symptom is secondary to maltracking due to varus PMRI. 

Imaging of Posteromedial Rotatory Instability of the Elbow

Standard radiographs (AP and lateral views) of the elbow are performed. Radiographs of the shoulder, forearm, and wrist are ordered as clinically indicated. Radiographs are repeated following the reduction of an associated elbow dislocation. Findings can be subtle, such as loss of a parallel medial ulnohumeral joint line, or varus malalignment of the elbow.97 The radiocapitellar joint may be widened with LCL disruption and a “flake” fragment from the lateral condyle may be visible. CT scans with three-dimensional reconstruction improve the recognition and understanding of the pattern of anteromedial coronoid fractures and are recommended routinely in the evaluation of these injuries.64 

Classification of Anteromedial Coronoid Fractures

O’Driscoll et al.80 described three anteromedial coronoid fracture subtypes. Subtype I involves the anteromedial rim only, subtype II involves the rim and tip, and subtype III involves the rim, and sublime tubercle, with or without involvement of the tip. 

Outcome Measures for Posteromedial Rotatory Instability of the Elbow

Several scoring systems have been used to evaluate the outcomes of anteromedial coronoid fractures including the DASH Questionnaire and the Mayo Elbow Performance Index. 

Pathoanatomy and Applied Anatomy Relating to Posteromedial Rotatory Instability of the Elbow

A biomechanical study focusing on anteromedial coronoid fractures demonstrated that the size of the anteromedial facet fracture and the presence of a concomitant LCL injury appear to be important determinants of the need for open reduction and internal fixation. The LCL and the anteromedial coronoid are key varus stabilizers of the elbow. The authors reported that even small anteromedial coronoid fractures affect elbow kinematics, particularly with varus stress. LCL repair alone was not able to restore stability with anteromedial coronoid facet fractures larger than 2.5 mm.83 Involvement of the sublime tubercle, (Subtype III) results in concomitant valgus instability due to disruption of the ulnar insertion of the MCL. 

Posteromedial Rotatory Instability Treatment Options

Nonoperative Treatment of Posteromedial Rotatory Instability of the Elbow

Indications/Contraindications

The role of nonoperative treatment of PMRI of the elbow is unclear. If the anteromedial coronoid fracture is small and undisplaced, and the elbow is congruously reduced, nonoperative treatment should be considered. A fluoroscopic examination with stress views can be helpful to guide treatment; gross instability should be managed with surgery. CT should be performed to confirm the fracture pattern and joint congruity. Fracture fragments which are interposed within the articulation and the presence of articular subluxation are contraindications to nonoperative treatment (Table 34-25). 
 
Table 34-25
Posteromedial Rotatory Instability Treatment
View Large
Table 34-25
Posteromedial Rotatory Instability Treatment
Nonoperative Treatment
Indications Relative Contraindications
Concentric elbow Nonconcentric elbow
Small undisplaced anteromedial coronoid fracture Displaced anteromedial coronoid fracture
Fracture fragment interposed in articulation
X

Technique

Anteromedial coronoid fractures, treated nonoperatively, are immobilized at 90 degrees of flexion for 7 to 10 days for comfort and to allow muscle tone to return to the elbow. Isometric contraction of the elbow muscles is encouraged while in the splint. After splint removal, the patient is asked to actively extend and flex the elbow. Patients will typically move only within their stable arc. Crepitus during motion suggests incongruity of the ulnohumeral joint and the need for examination under anesthesia and probable surgical repair. Abduction of the elbow away from the chest causes a varus moment on the elbow and should be avoided. A 90-degree resting splint with the forearm in neutral rotation is used between exercises. While pronation stabilizes the LCL deficient elbow, supination stabilizes the coronoid deficient elbow; hence neutral rotation is selected for flexion and extension exercises and for immobilization. Weekly radiographic and clinical follow-up is required to monitor for fracture displacement and recovery of motion. Joint subluxation or dislocation is an indication for surgical management. At 6 weeks the resting splint is discontinued and gentle stretching may be initiated to manage residual stiffness. Varus or valgus loading as well as strengthening are avoided until 12 weeks. Static progressive splinting can be used to improve elbow motion. 

Outcomes

There is little information regarding outcome of nonoperative PMRI of the elbow. Doornberg and Ring reported on 18 patients with anteromedial facet fractures with an average follow-up of 26 months. Of these, three patients had nonoperative treatment, and two had an excellent outcome and one fair.28 Fragment malunion may lead to persistent subluxation and secondary osteoarthritis for which there is currently no good reconstructive option. 

Operative Treatment of Posteromedial Rotatory Instability of the Elbow

Indications/Contraindications

The majority of patients with PMRI require surgical management to achieve a stable elbow allowing early motion. Residual subluxation or crepitus with motion suggests dynamic incongruity and are indications for surgery. 

Open Reduction and Internal Fixation

Restoration of varus posteromedial rotatory stability is achieved by internal fixation of the coronoid and repair of the LCL. The sublime tubercle is fixed or the MCL is repaired if injured. An external fixator is used to manage residual instability or to protect tenuous internal fixation. 
Preoperative Planning (Table 34-26)
 
Table 34-26
ORIF of Posteromedial Rotatory Instability of the Elbow
View Large
Table 34-26
ORIF of Posteromedial Rotatory Instability of the Elbow
Preoperative Planning Checklist
  •  
    OR Table: Radiolucent arm board
  •  
    Position/positioning aids: Supine with arm table or arm across chest
  •  
    Fluoroscopy location: Operative side
  •  
    Equipment: Suture anchors, 0.035, 0.045 K-wires, 1.5- and 2.0-mm screws, 2.5-mm cannulated screws, periarticular radial head and coronoid plates, radial head arthroplasty system, large external fixator, hinged external fixator, large fragment locking set with screws
X
Positioning.
Posteromedial rotatory instability injuries of the elbow are best approached using an arm table with the surgeon sitting. A prerequisite for this positioning is sufficient external rotation of the shoulder to allow a medial surgical approach. Alternatively the injury can be repaired with the arm placed across the chest with the surgeon standing. A rolled-up sheet placed underneath the elbow can be helpful for medial exposure. 
Surgical Approach.
A posterior midline elbow skin incision is typically employed when managing PMRI as it allows lateral and medial access to the elbow as required. Alternatively separate lateral and medial skin incisions can be employed. The optimal surgical approach to repair the anteromedial coronoid has not been determined as outlined in the previous section on terrible triad injuries. Our preferred surgical approach for anteromedial coronoid fractures is to use the interval between the two heads of the FCU.97 This approach also provides adequate access to the sublime tubercle and MCL. Meticulous release and mobilization of motor branches of the ulnar nerve help improve distal exposure. The flexor–pronator muscles are elevated from distal to proximal to isolate the sublime tubercle and identify and protect the anterior bundle of the MCL. The authors routinely perform an in situ release of the ulnar nerve; transposing the nerve if there are preoperative ulnar nerve symptoms or if further mobilization is needed to allow coronoid fixation. 
Deep lateral surgical approaches to the radial head and LCL have been described previously. In the setting of PMRI a Kocher approach is preferred to allow repair of the LCL which typically is avulsed off the lateral epicondyle. 
Technique.
An initial fluoroscopic assessment of the elbow under anesthesia is important to determine the extent of collateral ligament injury and magnitude of elbow instability. The anteromedial coronoid fracture is fixed first. After performing a medial or posterior elbow skin incision the ulnar nerve is released and protected for the remainder of the case. A transposition is performed if the nerve is tethered or interferes with coronoid exposure. After splitting the FCU the anterior portion is elevated off the ulna from distal to proximal protecting the insertion of the MCL on the sublime tubercle when it remains intact. To visualize the tip of the coronoid (a subtype II fracture), the flexor pronator muscles are detached from the medial epicondyle and medial supracondylar ridge leaving a small cuff of fascia for later repair. After reduction and preliminary fixation with K-wires, posterior to anterior cannulated screws, anterior to posterior screws, or buttress plate fixation is used for definitive repair. Suture fixation of coronoid tip fragments is not recommended because the anteromedial rim requires stable internal fixation to prevent varus collapse. A buttress plate is preferred if the fragments are large enough. 
If secure, coronoid fixation is achieved; a repeat fluoroscopic examination is performed and the elbow gently stressed in varus to determine if the LCL needs to be addressed. If only mild varus laxity is present, the LCL may be left untreated and a ligament-specific rehabilitation protocol is employed as described earlier. If the coronoid fixation is tenuous or the patient has residual varus instability, a lateral surgical approach to the elbow is performed using a posterior incision or a separate lateral incision and the LCL is repaired. 
Static or dynamic external fixation can be used to protect complex osteoporotic fractures of the coronoid when stable fixation is not achieved and in patients who demonstrate residual instability in spite of repair of the coronoid and collateral ligaments.85 Temporary cross-screw or bridge plate fixation of the elbow can also be considered as described previously (Table 34-27). 
Table 34-27
Operative Repair of Posteromedial Rotatory Instability of the Elbow
Surgical Steps
  •  
    Fluoroscopic examination of elbow under anesthesia
  •  
    Medial surgical approach to elbow through posterior midline or medial skin incision
  •  
    Split flexor carpi ulnaris and perform an in situ release of ulnar nerve; transpose if needed
  •  
    Use floor of ulnar nerve approach to coronoid
  •  
    Elevate flexor pronator muscles off ulna from distal to proximal, preserving the MCL insertion on the sublime tubercle
  •  
    Fix coronoid with posterior to anterior screws or buttress plate
  •  
    Use suture fixation of anterior capsule and small tip fragment(s)
  •  
    Repair MCL if injured and reattach flexor–pronator mass
  •  
    Re-evaluate elbow stability using fluoroscopy
  •  
    Perform lateral Kocher approach and repair LCL if required using transosseous sutures or suture anchors
  •  
    Re-evaluate elbow stability using fluoroscopy
  •  
    If elbow still unstable or coronoid fixation is tenuous, apply external fixator or temporary bridge plate
X
Postoperative Care.
The elbow is placed into a well-padded light posterior splint with the elbow at 90 degrees of flexion and the forearm in neutral rotation. Ideally, the dressing is removed and motion begun 48 hours after surgery unless static joint fixation has been required. The elbow can be immobilized for up to 14 days if there is concern about the quality of the soft tissues or the stability of the fractures, quality of the ligament repairs, or stability of the elbow achieved at the end of the surgical procedure. An active motion protocol is then begun as outlined above for nonoperative treatment of anteromedial coronoid fractures including active and active-assisted exercises with the arm at the side avoiding varus stress at all times. The patient may actively flex and extend the elbow in the position of forearm rotation where they were most stable during the examination under anesthesia at the conclusion of the operative repair, most commonly neutral rotation. They may perform forearm rotation exercises at 90 degrees of flexion or greater. Passive stretching may be started 6 weeks postop with a formal strengthening program initiated at 3 months. 
Potential Pitfalls and Preventative Measures.
Symptomatic instability is uncommon after operative repair of PMRI of the elbow. However, inadequate or failed repair of the lateral structures or collapse of the coronoid fixation may lead to persistent subluxation. Early recognition and treatment of this problem is crucial to salvage a good outcome. The judicious use of static external fixation or temporary bridge plate fixation should be considered. 
Early postoperative motion is preferable to prevent stiffness; however, sometimes delayed mobilization is required due to tenuous fixation with a plan for a subsequent contracture release to restore functional motion. Ulnar nerve symptoms are common with medial surgical approaches to the coronoid and prophylactic in situ release or transposition should be considered (Table 34-28). 
 
Table 34-28
Posteromedial Rotatory Instability of the Elbow
View Large
Table 34-28
Posteromedial Rotatory Instability of the Elbow
Potential Pitfalls and Preventions
Pitfall Preventions
Residual instability Secure repair of larger anteromedial coronoid fractures and collateral ligament(s)
Active motion protocol avoiding varus stress at all times
Employ external fixation or temporary bridge plate fixation if concerns about residual instability
Elbow stiffness Early range of motion
Nerve palsy Protect ulnar nerve during medial surgical approaches
Direct visualization of bone during external fixator pin placement
Gentle nerve and soft tissue retraction
X
Treatment-specific Outcomes.
Reports on the outcome of operative treatment of anteromedial coronoid fractures are limited. Doornberg and Ring completed a retrospective review of 67 fracture-dislocations of the elbow.27 Eleven of those patients demonstrated varus posteromedial instability, all of which had anteromedial facet fractures of the coronoid. In a separate study, Doornberg and Ring reported on 18 patients with anteromedial facet fractures with an average follow-up of 26 months.28 Of these, six patients had malalignment of the anteromedial facet, and all developed varus subluxation, arthrosis of the elbow, and a fair or poor functional result. The remaining 12 patients, with secure anatomical fixation of the anteromedial coronoid fracture, had good or excellent elbow function. Based on this limited information, repair of the LCL and ORIF of most anteromedial coronoid fractures is recommended.27,28,83 

Management of Expected Adverse Outcomes and Unexpected Complications in Posteromedial Rotatory Instability (Table 34-29)

 
Table 34-29
Posteromedial Rotatory Instability of the Elbow
View Large
Table 34-29
Posteromedial Rotatory Instability of the Elbow
Common Adverse Outcomes and Complications
Elbow stiffness and heterotopic ossification → Initiate early motion.
Elbow subluxation or dislocation → Achieve stable fixation of the anteromedial coronoid and LCL. Use external fixator to protect repairs if tenuous. Careful follow-up to recognize instability and treat surgically.
Elbow arthritis → Achieve and anatomic reduction of the coronoid fracture and avoid residual instability.
X

Author’s Preferred Method of Treatment for Posteromedial Rotatory Instability (Fig. 34-20)

Rockwood-ch034-image020.png
View Original | Slide (.ppt)
Figure 34-20
Author’s preferred treatment.
Rockwood-ch034-image020.png
View Original | Slide (.ppt)
X

Summary, Controversies, and Future Directions in Posteromedial Rotatory Instability

The optimal management of PMRI remains unclear. This entity can easily be missed because, relative to many elbow injuries, the history, physical examination, and radiographic findings can be subtle. Unfortunately if this instability pattern is not identified and the elbow remains subluxated, the outcome is often poor. Current challenges with the management of anteromedial coronoid fractures are the ability to achieve stable internal fixation and the lack of available coronoid prostheses to reconstruct the coronoid when it is deficient. The optimal surgical approach and technique of internal fixation of the coronoid remains unknown as does the management of the ulnar nerve. Furthermore the role of nonoperative treatment of these injuries needs to be better defined. 

Introduction to Proximal Ulna Fractures

Proximal ulna fractures are common adult injuries that account for approximately 10% of fractures around the elbow. Proximal ulna fractures comprise a broad spectrum of injuries that include not only olecranon fractures but also transolecranon fracture-dislocations and the posterior Monteggia lesion.55,89 As such, there is no single treatment or technique that is best suited for all injuries. However, these injury patterns are all intra-articular fractures of the proximal ulna that, in most cases, require anatomic alignment and secure fixation to allow for early elbow motion and to optimize functional outcome. 

Assessment of Proximal Ulna Fractures

Mechanisms of Injury for Posterior Ulna Fractures

Proximal ulna fractures may result from either direct or indirect elbow trauma. Olecranon fractures typically result from a direct blow to the olecranon. More complex fracture-dislocation patterns may be the result of a more indirect injury such as a fall onto the outstretched hand. Transolecranon fracture-dislocations are typically the result of higher-energy trauma such as a fall from a height, assaults, or motor vehicle collisions. Although posterior Monteggia lesions may also result from high-energy trauma, they are typically lower-energy injuries that occur in more osteopenic bone and result from a ground-level fall. 

Associated Injuries with Proximal Ulna Fractures

Given the subcutaneous location of the olecranon, open fractures are not uncommon and have a reported rate of 2% to 30% of fractures. Transolecranon fracture-dislocations may be associated with injuries to the coronoid process or segmental fractures of the ulna. Posterior Monteggia lesions may be associated with coronoid process fractures (26%), radial head fractures (68%), ipsilateral upper extremity injuries (24%), and injuries to the collateral ligaments. 

Signs and Symptoms of Proximal Ulna Fractures

Although typically isolated upper extremity injuries, 20% of proximal ulna fractures are associated with polytrauma, and a complete examination of the patient for systemic injuries is important.117 The affected extremity should be evaluated for shoulder, forearm, wrist, or hand injuries. The arm should be examined for open wounds and abrasions that typically occur over the dorsal surface of the proximal ulna. There is typically swelling about the elbow with fluid accumulation in the olecranon bursa. The elbow may have obvious deformity in the case of a fracture-dislocation. Examination of distal neurologic status with close attention to ulnar, median, and posterior interosseous nerve function is performed. Evaluation of vascular status and forearm compartments is necessary. 

Imaging and Other Diagnostic Studies for Proximal Ulna Fractures

Anteroposterior, lateral, and radiocapitellar radiographs of the elbow are performed. In the case of a fracture-dislocation, radiographs should be performed after a closed reduction in order to better delineate the fracture components. A traction view is useful in these cases, especially if the elbow is unstable after closed reduction. The fracture components can be further evaluated in the operating room under general anesthesia using traction prior to fixation. CT may be useful to evaluate the pattern of associated coronoid or radial head fracture to aid with preoperative planning; however, it is not commonly required. 

Classification of Proximal Ulna Fractures

Olecranon Fractures

The Mayo classification divides olecranon fractures into three groups based on fracture displacement and elbow stability (Fig. 34-21).76 These groups include Type I (undisplaced), Type II (displaced but stable), and Type III (unstable). Each group is then subdivided into comminuted (A) or noncomminuted (B) fractures. This classification helps direct treatment with Type I generally being amenable to nonoperative management while Type II and III fractures generally require operative treatment. Type B fractures are more suitably treated with plate fixation while Type A fractures may be treated with tension-band constructs if preferred. 
Figure 34-21
The Mayo classification of olecranon fractures is based on the displacement of the fracture, subluxation of the articulation, and the presence of comminution.
Rockwood-ch034-image021.png
View Original | Slide (.ppt)
X

Olecranon Fracture-Dislocations

Anterior fracture-dislocations of the olecranon have been termed “transolecranon fracture-dislocations”.89 These fractures are also represented by the Mayo Type III classification. An important feature of these injuries is that the proximal radioulnar joint is relatively preserved. Also, while fractures of the coronoid are not uncommon, the radial head and collateral ligaments are usually intact with this pattern. Although they may be multifragmentary, the coronoid fractures are typically single large anterior fragments or a fragment with a single longitudinal split. 
Posterior fracture-dislocations are typically posterior Monteggia lesions (Bado Type II). Jupiter et al.55 have classified these injuries into Type IIA (fracture at the level of the coronoid process with the coronoid as a separate fragment), IIB (fracture distal to the coronoid), IIC (fracture through the diaphysis), and IID (complex fracture extending from the olecranon to the diaphysis). Type IIA and Type IID fractures involve the proximal ulna and joint surface of the greater sigmoid notch. These fractures encompass a unique set of injuries including posterior angulation of the proximal ulna, a radial head fracture, a coronoid fracture, and collateral ligament injuries.10,55 When this pattern is recognized, careful evaluation of radiographs should be carried out to define associated injuries. Traction films, fluoroscopy, and/or CT scanning are often useful. The coronoid fracture pattern is variable and may include a large anterior fragment, a small tip fragment, or both. 

Outcome Measures for Proximal Ulna Fractures

Several studies evaluated the clinical and radiographic outcomes of proximal ulna fractures. The Broberg and Morrey Elbow Score in addition to the American Shoulder and Elbow Surgeons elbow assessment system, the Mayo Elbow Performance Index, the SF-36, and the DASH scoring system have been used. 

Pathoanatomy and Applied Anatomy Relating to Proximal Ulna Fractures

The proximal ulna contributes to two articulations: The ulnohumeral joint and the proximal radioulnar joint. Both of these articulations may be involved with fractures and fracture-dislocations in this area. The greater sigmoid notch is covered with articular cartilage and comprises the ulnar articulation of the ulnohumeral joint. Radially, there is a small area of cartilage that articulates with the radial head at the proximal radioulnar joint. The greater sigmoid notch has a bare area that corresponds with the base of the coronoid. It is important during fixation of proximal ulna fractures to restore appropriate alignment to these articulations. In particular, avoidance of overcompression of the greater sigmoid notch in comminuted fractures is essential to prevent joint incongruity and the rapid progression of post-traumatic osteoarthritis. 
The olecranon process prevents anterior subluxation of the ulna. Bell et al. demonstrated that valgus–varus angulation and ulnohumeral rotation progressively increase with sequential excision of up to 75% of the olecranon with gross instability occurring at greater than 87.5% of the olecranon.12 The coronoid contributes to elbow stability, and injury to it has complex effects on elbow stability depending on the direction of loading and the location and size of fracture. In general, increasing coronoid fracture size leads to decreased stability of the elbow.9 
The triceps tendon has a broad insertion onto the proximal ulna near the subcutaneous border. The medial head of the triceps has a tendon that is deep to the common tendon of the long and lateral heads but the insertion of the tendons is confluent. In addition to the ulnar attachment of the tendon proper, there is a triceps expansion that inserts onto the ECU fascia, the anconeus insertion, and the antebrachial fascia.67 

Proximal Ulna Fracture Treatment Options

Nonoperative Treatment of Proximal Ulna Fractures

Indications/Contraindications

Since these injuries involve an articular surface, the majority of proximal ulna fractures are treated operatively. However, a nondisplaced fracture or a minimally displaced fracture that remains reduced with the elbow flexed may be treated nonoperatively. Patients with significant medical comorbidities that are poor surgical candidates may be treated nonoperatively even with displaced fractures as long as there is no skin compromise or elbow instability. Displaced olecranon fractures involving 75% or less of the greater sigmoid notch in the elderly are the most common fractures which fulfill these criteria. This treatment may result in a fibrous union or a nonunion with some discomfort and limitation in both terminal extension and extensor strength. These limitations can be problematic for patients arising from a chair and ambulating with a walker (Table 34-30). 
 
Table 34-30
Proximal Ulna Fractures
View Large
Table 34-30
Proximal Ulna Fractures
Nonoperative Treatment
Indications Relative Contraindications
Nondisplaced fracture Displaced fracture in young active patient
Poor surgical candidate Elbow instability
Displaced fracture in elderly patient with medical comorbidities Associated fractures (radial head, coronoid)
X

Techniques

Typically, the elbow is splinted for 2 to 3 weeks and then gentle active-assisted flexion is started avoiding active extension against gravity or resistance for the first 6 weeks after injury. At 6 weeks, the patient can begin active motion against gravity with resistive exercises started at 3 months. 

Outcomes

There is currently no literature on the outcomes of nonoperatively managed olecranon fractures. However, in our experience, in appropriately selected patients, this treatment method leads to acceptable results and a functional range of motion. 

Operative Treatment of Proximal Ulna Fractures

Indications/Contraindications

The majority of proximal ulna fractures are treated surgically. Most fractures with displacement and those associated with dislocations or elbow instability as well as open fractures should be managed operatively. 
Simple olecranon fractures without comminution or instability may be managed with tension-band wiring, plating, or an intramedullary rod. Comminuted fractures or those associated with elbow instability should be managed with plate fixation. In osteoporotic bone with significant comminution that precludes stable internal fixation, excision with triceps advancement may be used if the excised fragment comprises less than 75% of the olecranon, but this technique should be reserved for elderly, low-demand patients if possible. 

Surgical Procedure—Olecranon Excision and Triceps Advancement

Preoperative Planning (Table 34-31)
 
Table 34-31
ORIF of Proximal Ulna Fractures—Olecranon Excision
View Large
Table 34-31
ORIF of Proximal Ulna Fractures—Olecranon Excision
Preoperative Planning Checklist
  •  
    OR Table: Radiolucent
  •  
    Position/positioning aids: Lateral, prone, or supine with arm over chest
  •  
    Fluoroscopy location: From head
  •  
    Equipment: No. 2 FiberWire or No. 2 Ticron suture, 2-mm drill
  •  
    Tourniquet (sterile/nonsterile): Sterile preferred
X
Positioning.
The patient is placed supine on a radiolucent table. The arm is placed over the chest on a chest roll or on a radiolucent arm table. A sterile tourniquet should be available and used at the discretion of the surgeon. 
Surgical Approach.
A posterior midline incision is made and full thickness medial and lateral fasciocutaneous flaps are raised. The skin incision is placed just radial to the tip of the olecranon. The ulnar nerve should be identified so that it can be protected during the case but it is not necessary to dissect it free of the cubital tunnel. The interval between the ECU and FCU is developed and the subcutaneous border of the ulna is exposed. On the ulnar side, the FCU is elevated from the olecranon to visualize the joint. On the radial side, the anconeus fascia is incised and the muscle can be elevated from the olecranon fragment for further visualization if needed. 
Technique.
The fracture is exposed and the fragments of the olecranon are identified and excised. Drill holes are then made in the ulna using a 2-mm drill bit starting adjacent to the dorsal surface and exiting on the shaft, just off the dorsal surface. Dorsal placement provides for improved extension strength relative to placement adjacent to the articular surface without sacrificing stability.36 Care should be taken to protect the ulnar nerve. A running-locking nonabsorbable suture is then placed in the triceps over a broad area and passed through the drill holes and tied, avoiding dorsal placement of a prominent knot (Table 34-32). 
 
Table 34-32
Olecranon Excision and Triceps Advancement
View Large
Table 34-32
Olecranon Excision and Triceps Advancement
Surgical Steps
  •  
    Olecranon fragments excised
  •  
    Nonabsorbable No. 2 suture (FiberWire, Ticron) placed in triceps tendon
  •  
    2-mm drill holes placed in proximal ulna adjacent to the dorsal surface
  •  
    Suture placed through drill holes and tied avoiding dorsal prominence
X
Postoperative Care.
The patient is placed into a long-arm splint in a semi-extended position to protect the skin incision. Sutures are removed in 2 weeks and active and active-assisted flexion and gravity-assisted extension are initiated. Active extension begins at 6 weeks and strengthening at 3 months postoperatively. 
Potential Pitfalls and Preventative Measures.
Careful attention to soft tissue dissection and incision placement is important. Elbow stability can be affected if more than 75% of the olecranon is excised and therefore this technique should only be used in carefully selected patients (Table 34-33). 
 
Table 34-33
Proximal Ulna Fractures—Olecranon Excision
View Large
Table 34-33
Proximal Ulna Fractures—Olecranon Excision
Potential Pitfalls and Preventions
Pitfall Preventions
Elbow instability Be sure fracture involves less than 75% of the articular surface
Be sure there is no associated instability or other injuries preoperatively
X
Treatment-specific Outcomes.
Excision should be reserved for low-demand patients with poor bone quality. Attaching the triceps tendon directly adjacent to the joint will allow for a more congruent surface for motion. However, it may result in triceps weakness. Ferreira et al.36 demonstrated a 30% decrease in triceps strength with a more anterior repair compared to a 24% decrease in triceps strength with a more anterior repair. However, clinically it is unclear if this affects functional outcomes. Gartsman et al.41 found no differences in strength between patients treated with internal fixation and those treated with excision. However, this trial was not randomized and selection bias may have contributed to this result. Excision should be reserved for those cases in which open reduction and internal fixation is likely to fail, or for intraoperative failure of osseous repair. 

Surgical Procedure—Olecranon Tension-Band Wiring

Preoperative Planning.
Radiographs are carefully examined to determine the fracture morphology. Tension-band technique is appropriate for stable elbows with noncomminuted fractures that are proximal to the coronoid (Table 34-34). 
 
Table 34-34
ORIF of Olecranon Fractures—Tension Banding
View Large
Table 34-34
ORIF of Olecranon Fractures—Tension Banding
Preoperative Planning Checklist
  •  
    OR Table: Radiolucent
  •  
    Position/positioning aids: Lateral position, supine or prone, chest rolls, radiolucent arm board
  •  
    Fluoroscopy location: From the head of the table
  •  
    Equipment: 0.062 K-wires, 20-gauge stainless steel wire, pointed reduction clamps
  •  
    Tourniquet (sterile/nonsterile): Sterile tourniquet available
X
Positioning.
The patient is placed lateral or prone on a radiolucent table. A radiolucent arm positioner is placed under the arm so that the elbow joint can be flexed and extended. The C-arm is brought in from the head of the table. The lateral and prone positions allow for easier access to fluoroscopy while hardware is being applied. The lateral position decreases risks, such as eye injury, associated with prone positioning, particularly in cases where operative time is prolonged. However, prone positioning gives the best exposure for fluoroscopy and may be useful in patients that have spine injuries. If the patient cannot tolerate lateral or prone positioning or a regional anesthetic is to be employed, a supine position with a bump may be used and the arm is placed over the chest. It may be more difficult to visualize and reduce more comminuted articular fractures in this position and imaging may be more difficult. Also, an assistant is usually required to hold the arm across the chest. In this case, the C-arm is brought in from the side of the table. Before draping, test images should be obtained to be sure high-quality images can be obtained during the procedure. A sterile tourniquet should be available and used at the discretion of the surgeon. 
Surgical Approach.
A posterior midline incision is made and full thickness medial and lateral fasciocutaneous flaps are raised. The skin incision is placed just radial to the tip of the olecranon for better coverage of hardware. The ulnar nerve should be identified so that it can be protected during the case, but it is not necessary to dissect it free of the cubital tunnel. The interval between the ECU and FCU is developed and the subcutaneous border of the ulna is exposed. On the ulnar side, the FCU is elevated from the olecranon to visualize the joint. On the radial side, the anconeus fascia is incised and the muscle can be elevated from the olecranon fragment for further visualization if needed. 
Technique.
The fracture edges are exposed, cleaned, and the joint is inspected for damage to the trochlea or loose bodies. The fracture is reduced by extending the elbow. A drill hole is placed on the ulnar shaft both radially and ulnarly so that a pointed reduction clamp can be used to hold the reduction and apply compression on both sides with one tine in the drill hole and the other tine at the tip of the olecranon. A shoulder hook or dental pick can be used to hold the reduction of smaller fragments. Two 0.062-in K-wires are placed from the superior aspect of the olecranon exiting the anteromedial cortex and then are backed out a small amount to accommodate future impaction of the wires (Fig. 34-22). Avoid lateral placement as the K-wires can irritate the radial tuberosity and predispose to rotational stiffness and synostosis. Excessive length of the medial K-wire can injure the ulnar or median nerve. A drill hole is placed in the dorsal side of the ulna distal to the coronoid. Using an angiocath catheter, 20-gauge wire is used to create one or two figure-of-eight tension band(s) around the proximal end of the K-wires deep to the triceps and exiting through the distal drill hole. The wire is tensioned on both the ulnar and radial side simultaneously to create equal compression across the joint. The tips of the K-wires wires are bent and the wires are impacted into the olecranon tip through small incisions in the triceps. Alternatively, an intramedullary 4.5- or 6.5-mm screw may be used instead of the K-wires but care must be taken to not induce a deformity in the proximal segment secondary to a mismatch between the sigmoid shape of the ulna and the straight screw. The elbow is then taken through a full range of motion to be sure the fixation is secure, particularly in full flexion. The wound should be closed in a layered fashion, so early range of motion can begin while the sutures are still in place (Table 34-35). 
Figure 34-22
 
A: The fracture is reduced and secured with two 0.62-in K-wires drilled so as to engage the anteromedial cortex of the ulna. B: One or two 20-gauge stainless steel wires are placed underneath the triceps and through transverse drill holes placed distal to the fracture. The figure-of-eight wires are then tensioned evenly. C: The K- wires are bent 180 degrees and impacted underneath the triceps into the olecranon.
A: The fracture is reduced and secured with two 0.62-in K-wires drilled so as to engage the anteromedial cortex of the ulna. B: One or two 20-gauge stainless steel wires are placed underneath the triceps and through transverse drill holes placed distal to the fracture. The figure-of-eight wires are then tensioned evenly. C: The K- wires are bent 180 degrees and impacted underneath the triceps into the olecranon.
View Original | Slide (.ppt)
Figure 34-22
A: The fracture is reduced and secured with two 0.62-in K-wires drilled so as to engage the anteromedial cortex of the ulna. B: One or two 20-gauge stainless steel wires are placed underneath the triceps and through transverse drill holes placed distal to the fracture. The figure-of-eight wires are then tensioned evenly. C: The K- wires are bent 180 degrees and impacted underneath the triceps into the olecranon.
A: The fracture is reduced and secured with two 0.62-in K-wires drilled so as to engage the anteromedial cortex of the ulna. B: One or two 20-gauge stainless steel wires are placed underneath the triceps and through transverse drill holes placed distal to the fracture. The figure-of-eight wires are then tensioned evenly. C: The K- wires are bent 180 degrees and impacted underneath the triceps into the olecranon.
View Original | Slide (.ppt)
X
 
Table 34-35
ORIF of Olecranon Fractures—Tension Band
View Large
Table 34-35
ORIF of Olecranon Fractures—Tension Band
Surgical Steps
  •  
    Fracture edges cleaned and joint inspected
  •  
    Fracture reduced and held with pointed reduction clamps
  •  
    Two 0.062-in K-wires placed from tip of olecranon exiting the anteromedial ulnar cortex
  •  
    Drill hole placed in dorsal cortex distal to coronoid
  •  
    20-gauge wire placed in a figure-of-eight fashion through drill hole and around wires
  •  
    Figure-of-eight wire tightened simultaneously radially and ulnarly
  •  
    K-wires impacted into tip of olecranon underneath triceps tendon
X
Postoperative Care.
The patient is placed into a semi-extended position in a long-arm splint. The splint and postoperative dressings are taken down 48 hours after surgery and the patient begins range of motion exercises including active and active-assisted flexion and gravity-assisted extension. Active exercises against gravity are started at 6 weeks with very gentle resistance progressing to full resistive exercises at 3 months or when the fracture has united. 
Potential Pitfalls and Preventative Measures.
Tension-band wiring can be successful in properly selected patients. To avoid loss of fixation, an anatomic reduction is necessary and this technique should be used only in simple fracture patterns. Hardware prominence requiring removal is common. To decrease the incidence of symptomatic hardware, the K-wires should be buried under the triceps and the cerclage wire knots should be buried as well. If the wires are left too prominent on the anteromedial aspect of the ulna, median and ulnar nerve injury is possible. Avoid wires that exit laterally in the region of the biceps tuberosity to prevent impingement or heterotopic ossification and subsequent synostosis (Table 34-36). 
 
Table 34-36
Olecranon Fractures—Tension-band Wiring
View Large
Table 34-36
Olecranon Fractures—Tension-band Wiring
Potential Pitfalls and Prevention
Pitfall Preventions
Loss of fixation Anatomic reduction
Use only for simple fractures
Prominent hardware Bury K-wire tips
Bury cerclage wire knots
Biceps tuberosity impingement and synostosis Avoid lateral placement of wires
Ulnar/median nerve injury Avoid excessive length of the K-wires through the anteromedial cortex
X
Treatment-specific Outcomes.
Outcomes of tension-band wiring for simple fractures are generally favorable. The most frequently reported problem with tension-band technique is hardware prominence that requires removal. Villanueva et al.113 reported on 37 consecutive olecranon fractures treated with tension-band wiring. Mean elbow extension was 7 degrees and flexion was 131 degrees with the majority reporting no or mild pain at 4-year follow-up. Mayo Elbow Performance Sores were rated as good or excellent in 86% of patients and patients had an average DASH score of 18. Almost one-third of patients developed arthritic changes and these were more commonly seen with associated fractures and/or elbow instability and at longer follow-up. More than half of the patients required hardware removal due to prominent or migrating K-wires which has been the most significant problem with this procedure. 

Surgical Procedure—Olecranon Plating

Preoperative Planning.
Plating of the olecranon is appropriate for fractures that are comminuted, associated with elbow instability such as transolecranon fracture-dislocations, or fractures that have extension down the shaft of the ulna such as posterior Monteggia injuries (addressed in a later section). Some surgeons routinely fix all olecranon fractures with a plate to avoid the high incidence of hardware complications from tension-band wiring (Fig. 34-23). Fractures proximal to the coronoid may be secured with periarticular nonlocking or locking precontoured plates or 2.7- or 3.5-mm reconstruction plates contoured around the tip of the olecranon. If the fracture extends distal to the coronoid, a reconstruction plate may not be strong enough, and a 3.5-mm LCDCP or equivalent strength precontoured plate should be used (Fig. 34-24, Table 34-37). 
Figure 34-23
 
A, B: A 25-year-old female fell and sustained a simple olecranon fracture without dislocation. C, D: The fracture was treated with open reduction and plate fixation. At final follow-up, she had a healed fracture with asymptomatic hardware and a full range of motion.
A, B: A 25-year-old female fell and sustained a simple olecranon fracture without dislocation. C, D: The fracture was treated with open reduction and plate fixation. At final follow-up, she had a healed fracture with asymptomatic hardware and a full range of motion.
View Original | Slide (.ppt)
Figure 34-23
A, B: A 25-year-old female fell and sustained a simple olecranon fracture without dislocation. C, D: The fracture was treated with open reduction and plate fixation. At final follow-up, she had a healed fracture with asymptomatic hardware and a full range of motion.
A, B: A 25-year-old female fell and sustained a simple olecranon fracture without dislocation. C, D: The fracture was treated with open reduction and plate fixation. At final follow-up, she had a healed fracture with asymptomatic hardware and a full range of motion.
View Original | Slide (.ppt)
X
Figure 34-24
An 18-year-old female sustained a transolecranon fracture-dislocation in a motor vehicle accident.
 
A, B: Plain radiographs demonstrate an anterior fracture-dislocation with an intact proximal radioulnar joint. C, D: She underwent operative fixation which included anatomic restoration of the comminuted joint, bone grafting the impacted central area, and plate fixation with a subchondral screw to support the elevated joint. Restoration of the sigmoid notch restored elbow stability. Final follow-up at 3 months demonstrated a stable elbow with a healed fracture and a well-aligned joint.
A, B: Plain radiographs demonstrate an anterior fracture-dislocation with an intact proximal radioulnar joint. C, D: She underwent operative fixation which included anatomic restoration of the comminuted joint, bone grafting the impacted central area, and plate fixation with a subchondral screw to support the elevated joint. Restoration of the sigmoid notch restored elbow stability. Final follow-up at 3 months demonstrated a stable elbow with a healed fracture and a well-aligned joint.
View Original | Slide (.ppt)
Figure 34-24
An 18-year-old female sustained a transolecranon fracture-dislocation in a motor vehicle accident.
A, B: Plain radiographs demonstrate an anterior fracture-dislocation with an intact proximal radioulnar joint. C, D: She underwent operative fixation which included anatomic restoration of the comminuted joint, bone grafting the impacted central area, and plate fixation with a subchondral screw to support the elevated joint. Restoration of the sigmoid notch restored elbow stability. Final follow-up at 3 months demonstrated a stable elbow with a healed fracture and a well-aligned joint.
A, B: Plain radiographs demonstrate an anterior fracture-dislocation with an intact proximal radioulnar joint. C, D: She underwent operative fixation which included anatomic restoration of the comminuted joint, bone grafting the impacted central area, and plate fixation with a subchondral screw to support the elevated joint. Restoration of the sigmoid notch restored elbow stability. Final follow-up at 3 months demonstrated a stable elbow with a healed fracture and a well-aligned joint.
View Original | Slide (.ppt)
X
 
Table 34-37
ORIF of Proximal Ulna Fractures
View Large
Table 34-37
ORIF of Proximal Ulna Fractures
Preoperative Planning Checklist
  •  
    OR Table: Radiolucent
  •  
    Position/positioning aids: Lateral, prone, or supine position, chest rolls, radiolucent arm board
  •  
    Fluoroscopy location: From the head of the table
  •  
    Equipment: Small fragment set, precontoured proximal ulna plates, 3.5-mm reconstruction plates, 2.7-mm reconstruction plates
  •  
    Tourniquet (sterile/nonsterile): Sterile available
X
Positioning.
See previous section. 
Surgical Approach.
See previous section. 
Technique.
The fracture is reduced and clamped as above and held with provisional K-wires. A split is created in the triceps attachment to accommodate the proximal end of the plate. The plate should be held over the reduced fracture before making the split so it is made centrally over the olecranon tip. A precontoured plate or a plate contoured by the surgeon is placed around the tip of the olecranon extending distally along the ulnar border between the ECU and FCU. Due to the variable shape of the olecranon, some contouring of the proximal aspect of the plate is often required to ensure it is positioned against the bone. Fluoroscopy is recommended to check the position and contouring of the plate prior to placement of the screws. A short screw may be placed at the tip of the plate away from the lag hole to bring the plate to bone before applying the long subcortical screw. For noncomminuted fractures, a lag screw is placed from the tip of the plate exiting the anteromedial aspect of the ulna. For comminuted fractures, this screw should be placed in a nonlag fashion so the greater sigmoid notch is not overcompressed. Keeping the screw adjacent to the subchondral bone and placing it in a bicortical fashion will provide support to any comminution. The screw is directed medially so that there will be no impingement with the proximal radius. The shaft is secured with three screws. A final screw is placed into the tip of the olecranon for rotational control or to neutralize small proximal fragments. For fractures that are very proximal, care must be taken to capture the fragment in its entirety. If there is concern that the proximal fragment is comminuted or small, a “back-up” triceps suture can be placed to help secure the fragment and it can be tied to the proximal end of the plate or placed through a drill hole.50 The elbow is examined clinically and fluoroscopically to be sure that there is no hardware in the proximal radioulnar joint or impinging on the biceps tuberosity. The wound is closed in layers to obtain as much deep coverage over the plate as possible (Table 34-38). 
 
Table 34-38
ORIF of Proximal Ulna Fracture—Plating
View Large
Table 34-38
ORIF of Proximal Ulna Fracture—Plating
Surgical Steps
  •  
    Fracture reduced and held with pointed reduction clamp and K-wires
  •  
    Triceps split and plate placed onto bone
  •  
    Screw at tip of plate to bring plate to bone
  •  
    Apply fixation including a lag screw for noncomminuted fractures
  •  
    Protect tenuous fixation with suture through triceps for short proximal segments
X
Postoperative Care.
The rehabilitation protocol is the same as for tension-band wiring. 
Potential Pitfalls and Preventative Measures.
Although plating of olecranon fractures has generally good outcomes, attention to detail is important to avoid complications. Placement of the incision just radial to the tip of the olecranon, and not directly over it, will help to decrease wound complications. Skin flaps should be developed only as much as needed for adequate fracture reduction and hardware placement. The plate should be buried under the triceps proximally and if possible fascia should be closed over the plate distally to decrease hardware prominence. 
Fixation of a small proximal fragment can fail if the implants do not adequately capture the fragment. The plate should be placed as proximal as possible and retrograde screws into the tip of the fragment can be placed for extra purchase. If needed, a “back-up” suture into the triceps can be placed and sewn to the proximal ulna through drill holes or attached to the plate. 
The joint range of motion should be carefully examined at the conclusion of the case. Any crepitus in flexion and extension could indicate hardware in the ulnohumeral joint. Similarly, restrictions in rotation indicate potential hardware placement in the proximal radioulnar joint. By directing the long screw from the tip of the plate in an ulnar direction, this joint can be avoided while leaving room for further screws into the coronoid region to be placed safely (Table 34-39). 
 
Table 34-39
Proximal Ulna Fractures—Plating
View Large
Table 34-39
Proximal Ulna Fractures—Plating
Potential Pitfalls and Preventions
Pitfall Preventions
Failure of fixation with small proximal fragments Be sure plate is as proximal as possible
“Back up” triceps suture to plate
Capture with screws into the tip of the fragment
Hardware in Proximal Radioulnar Joint Direct long tip screw ulnarly
Careful examination radiographically and clinically prior to wound closure
X
Treatment-Specific Outcomes.
Plate fixation of olecranon fractures generally has good outcomes. Bailey et al.6 demonstrated good outcomes with few complications and a relatively low incidence of hardware removal. Anderson et al.3 demonstrated a high rate of union, low incidence of complications and 92% of patients in their series had good or excellent outcomes as measured by MEPI and DASH scores. Three of 32 patients had symptomatic hardware requiring removal. 

Surgical Procedure—Posterior Monteggia Fractures

Posterior Monteggia lesions in adults are a spectrum of injuries involving the olecranon, coronoid, collateral ligaments, and radial head (Fig. 34-25). This section pertains to Jupiter Type IIA and IID Monteggia injuries that involve the elbow joint. 
Figure 34-25
A 55-year-old male fell and sustained a posterior Monteggia fracture-dislocation.
 
A, B: Radiographs demonstrated a proximal ulna fracture including a coronoid fracture, a radial head fracture, and disruption of the proximal radioulnar joint. C: Intraoperatively, the proximal ulna was provisionally reduced so that the radial head component could be properly sized. D: The definitive radial head prosthesis was then implanted, and the coronoid fracture was then reduced and held with small screws. The olecranon and shaft were then neutralized with a long proximal ulna plate. Suture anchors were used to repair the collateral ligaments, and the elbow was stable after repair. E, F: The final construct demonstrated excellent alignment with a concentrically reduced elbow joint.
A, B: Radiographs demonstrated a proximal ulna fracture including a coronoid fracture, a radial head fracture, and disruption of the proximal radioulnar joint. C: Intraoperatively, the proximal ulna was provisionally reduced so that the radial head component could be properly sized. D: The definitive radial head prosthesis was then implanted, and the coronoid fracture was then reduced and held with small screws. The olecranon and shaft were then neutralized with a long proximal ulna plate. Suture anchors were used to repair the collateral ligaments, and the elbow was stable after repair. E, F: The final construct demonstrated excellent alignment with a concentrically reduced elbow joint.
View Original | Slide (.ppt)
A, B: Radiographs demonstrated a proximal ulna fracture including a coronoid fracture, a radial head fracture, and disruption of the proximal radioulnar joint. C: Intraoperatively, the proximal ulna was provisionally reduced so that the radial head component could be properly sized. D: The definitive radial head prosthesis was then implanted, and the coronoid fracture was then reduced and held with small screws. The olecranon and shaft were then neutralized with a long proximal ulna plate. Suture anchors were used to repair the collateral ligaments, and the elbow was stable after repair. E, F: The final construct demonstrated excellent alignment with a concentrically reduced elbow joint.
View Original | Slide (.ppt)
Figure 34-25
A 55-year-old male fell and sustained a posterior Monteggia fracture-dislocation.
A, B: Radiographs demonstrated a proximal ulna fracture including a coronoid fracture, a radial head fracture, and disruption of the proximal radioulnar joint. C: Intraoperatively, the proximal ulna was provisionally reduced so that the radial head component could be properly sized. D: The definitive radial head prosthesis was then implanted, and the coronoid fracture was then reduced and held with small screws. The olecranon and shaft were then neutralized with a long proximal ulna plate. Suture anchors were used to repair the collateral ligaments, and the elbow was stable after repair. E, F: The final construct demonstrated excellent alignment with a concentrically reduced elbow joint.
A, B: Radiographs demonstrated a proximal ulna fracture including a coronoid fracture, a radial head fracture, and disruption of the proximal radioulnar joint. C: Intraoperatively, the proximal ulna was provisionally reduced so that the radial head component could be properly sized. D: The definitive radial head prosthesis was then implanted, and the coronoid fracture was then reduced and held with small screws. The olecranon and shaft were then neutralized with a long proximal ulna plate. Suture anchors were used to repair the collateral ligaments, and the elbow was stable after repair. E, F: The final construct demonstrated excellent alignment with a concentrically reduced elbow joint.
View Original | Slide (.ppt)
A, B: Radiographs demonstrated a proximal ulna fracture including a coronoid fracture, a radial head fracture, and disruption of the proximal radioulnar joint. C: Intraoperatively, the proximal ulna was provisionally reduced so that the radial head component could be properly sized. D: The definitive radial head prosthesis was then implanted, and the coronoid fracture was then reduced and held with small screws. The olecranon and shaft were then neutralized with a long proximal ulna plate. Suture anchors were used to repair the collateral ligaments, and the elbow was stable after repair. E, F: The final construct demonstrated excellent alignment with a concentrically reduced elbow joint.
View Original | Slide (.ppt)
X
Preoperative Planning (Table 34-40)
Table 34-40
ORIF of Proximal Ulna Fractures—Posterior Monteggia Fractures
Preoperative Planning Checklist
  •  
    OR Table: Radiolucent
  •  
    Position/positioning aids: Lateral or prone position
  •  
    Fluoroscopy location: From head of table
  •  
    Equipment: Precontoured proximal ulna plates, LCDC plates, 2 minifragment straight plates and T-plates, 2- and 2.4-mm screws, radial head arthroplasty system, No. 2 nonabsorbable suture, suture anchors
  •  
    Tourniquet (sterile/nonsterile): Sterile preferred
X
Positioning.
See previous section. The lateral decubitus position is preferred. 
Surgical Approach.
A posterior midline incision is made and full thickness medial and lateral fasciocutaneous flaps are raised. The skin incision is curved radially around the tip of the olecranon for better coverage of hardware. The ulnar nerve should be identified so that it can be protected but it is not necessary to mobilize it. The interval between the ECU and FCU is developed for exposure of the ulnar shaft. The trochlea, capitellum, and radial head are exposed by retracting the olecranon fragment proximally. The region of the lateral ligament complex origin on the lateral epicondyle of the humerus is palpated with a blunt instrument under the fascia, which is typically intact. If the epicondyle is devoid of soft tissue attachments, the fascia is incised so that a repair can be performed. The ECU and anconeus are elevated radially as required to expose the joint and shaft on the radial side and the FCU may be elevated laterally to expose the joint and shaft on the ulnar side. 
Technique.
The radial head is inspected to determine whether or not it can be repaired. If it is repairable, the fracture is fixed with small screws with or without plate supplementation depending on the fracture pattern. If the radial head is not repairable, the remaining head is resected and sized for a radial head arthroplasty. In order to determine appropriate height of the radial head implant, the coronoid, ulnar shaft, and olecranon components are temporarily reduced and held with clamps, hooks, and K-wires to be sure the correct height of implant is used. The height is checked with the trial implant using direct visualization as well as fluoroscopy to ascertain the relationship to the base of the coronoid. The olecranon and coronoid temporary fixation is then removed and the definitive radial implant is placed. 
The fractured ulnar shaft is then reduced. Lag screws or small plates are used to provisionally hold the reduction. An anterior or anteromedial oblique fragment is often present which aligns with the coronoid more proximally and accurate reduction of this fragment is important. Restoring accurate length and alignment of the ulnar shaft is mandatory for maintenance of elbow stability. Due to the variable apex dorsal angulation of the proximal ulna, application of straight uncontoured plates may contribute to malreduction of the radiocapitellar joint. 
The coronoid is then repaired with small plates, screws, or sutures depending on the fragment size. Small fragments are repaired using number 2 nonabsorbable sutures placed in the anterior capsule and through drill holes in the coronoid. These sutures are passed through drill holes and tied on the dorsal surface of the ulna. This suture may be placed before reduction of other ulnar components for ease of access and it also may be necessary in conjunction with plate fixation for comminuted coronoids that include large and small fragments. This suture is not tied until the remaining hardware has been placed to minimize the chance of suture laceration by screws or wires. 
The olecranon fragment is then reduced. A stout plate of 3.5 LCDC thickness is applied to the dorsal aspect of the ulna to hold the reduction of the olecranon and shaft components. Reconstruction or tubular plates are not sufficient for fixation. Periarticular precontoured plates are useful to reduce surgical time and assist in ulnar alignment. A screw from the tip of the olecranon is placed exiting the anteromedial ulnar cortex if possible. Screws from this plate into the coronoid fragment, if it is large enough, also augment stability and should be placed if possible. If there is significant comminution of the coronoid that has been held with suture fixation and there is no adequate docking site for a screw, a locked plate may be helpful to gain proximal fixation with shorter screws avoiding screws in the region of the sutures coronoid. If coronoid sutures have been placed, they are then tied over the dorsal aspect of the plate. 
There is often a small fragment of bone ulnarly that includes the sublime tubercle with the insertion of the MCL. If it is large enough, it may be repaired with a small plate. If not, suture anchors are used. The LCL may be avulsed off the lateral epicondyle; however, the overlying fascia may be intact. The lateral ligament and extensor muscle origins are repaired with suture anchors or transosseous bone tunnels into the lateral epicondyle. 
The elbow is then taken through a full range of motion to evaluate for stability (Table 34-41). 
Table 34-41
ORIF of Proximal Ulna Fracture—Posterior Monteggia Fractures
Surgical Steps
  •  
    Repair or replacement of the radial head
  •  
    Repair of the ulnar shaft with minifragment plates or lag screws
  •  
    Repair of the coronoid fracture with minifragment plates, screws, or suture
  •  
    Olecranon fragment reduced and plate spanning olecranon and shaft components are placed
  •  
    MCL evaluated and repaired as needed
  •  
    LCL evaluated and repaired as needed
X
Postoperative Care.
The elbow is splinted at 90 degrees of flexion with the forearm in neutral rotation for 48 hours. The splint is then removed and the patient is started on range of motion exercises. These exercises include active and active-assisted flexion and extension. Concomitant ligament injuries will direct the rehabilitation plan as outlined in the section on the operative treatment of elbow dislocations. Active extension and extension against gravity begins at 6 weeks. Static progressive splinting may be used if the patient has stiffness and the fracture has healed. At 3 months, a strengthening regimen is instituted. 
Potential Pitfalls and Preventative Measures.
Recognition of the fracture pattern and associated injuries is the first step in restoring stability. Nonunion is not common; however, it is important that surgeon technique does not contribute to this problem. Appropriate choice of fixation is essential and adherence to basic fracture principles is essential. Plates for Monteggia injuries should be of sufficient strength to support the proximal shaft of the ulna and tubular and reconstruction plates are to be avoided when the fracture extends distal to the coronoid. Tension-band wiring is not appropriate in these cases. 
Recurrent instability may occur if restoration of the ulnar anatomy is not achieved. The ulna has a serpentine shape with a variable apex dorsal angulation and application of straight uncontoured plates may contribute to malreduction.95 Precontoured plates may help with restoration of alignment, particularly in comminuted fractures. Alternatively, radiographs of the opposite extremity can help to determine the correct shape and length of the ulna to allow for more accurate contouring of implants if precontoured plates are not available. Also, since the fascia overlying the lateral ligament is often intact, an extensive LCL injury can be missed. Therefore it is imperative that the surgeon assesses for ligament injuries and repairs them when found. 
Elbow stiffness and heterotopic ossification are possible. Sufficient fixation stability is mandatory to allow for early range of motion. The use of prophylaxis for heterotopic ossification remains controversial. Radiation has been shown to lead to an increased nonunion rate in the setting of distal humeral fractures and is not recommended (Table 34-42). 
 
Table 34-42
Proximal Ulna Fractures—Posterior Monteggia Fractures
View Large
Table 34-42
Proximal Ulna Fractures—Posterior Monteggia Fractures
Potential Pitfalls and Preventions
Pitfall Preventions
Instability Accurate restoration of ulnar length, dorsal angulation, and serpentine shape
Repair of lateral ligament complex
Loss of fixation and nonunion Appropriate choice of implant for fracture pattern with avoidance of tension-band constructs
Elbow stiffness Secure fixation to allow for early range of motion
X
Treatment-specific Outcomes.
Posterior Monteggia fractures are complex injuries to manage. Complications may include nonunion, heterotopic ossification, recurrent subluxation, elbow stiffness, and post-traumatic arthritis. Konrad et al.62 followed patients for an average of 9 years and satisfactory results were found in 34 of 47 patients. Factors predicting a poor outcome included fractures involving the radial head, coronoid, and complications requiring further surgery with 26% of patients requiring a secondary surgery within 12 months of the initial procedure. Strauss et al.106 reported that patients with posterior Monteggia fractures that had a concomitant ulnohumeral dislocation had worse outcome. Beingessner et al.10 evaluated a series of 16 patients with Type IID Monteggia fractures. All fractures united and there were no patients with recurrent instability. Three patients developed elbow stiffness with associated heterotopic ossification, one patient had prominent hardware, one had loss of radial head fixation but no subluxation, and one developed pronator syndrome. However, the majority of patients had good results with anatomic repair of all injured structures. 

Management of Expected Adverse Outcomes and Unexpected Complications in Proximal Ulna Fractures (Table 34-43)

 
Table 34-43
Proximal Ulna Fracture
View Large
Table 34-43
Proximal Ulna Fracture
Common Adverse Outcomes and Complications
Prominent and symptomatic hardware → Careful technique of implant placement, hardware removal as needed
Heterotopic ossification and elbow stiffness → Secure fixation to allow for early range of motion
Nonunion and malunion → Adherence to proper fracture principles and techniques
Failure of fixation and elbow instability → Understand the fracture pattern and address each component
X

Author’s Preferred Method of Treatment for Proximal Ulna Fractures

 
 

We prefer to treat both simple and complex olecranon fractures with plate fixation since it is reliable and with improved implant designs hardware is typically not sufficiently symptomatic to require removal (Fig. 34-26A). In patients with significant osteopenia and poor bone quality, triceps advancement is used; however, this technique is rarely needed and significantly debilitated patients or those with very low functional demands can do well with nonoperative treatment as long as there is no associated elbow instability. We prefer a fragment-specific approach to Monteggia fractures including repair of all injured structures as outlined above (Fig. 34-26B).

 
Figure 34-26
 
A, B: Author’s preferred treatment.
A, B: Author’s preferred treatment.
View Original | Slide (.ppt)
A, B: Author’s preferred treatment.
View Original | Slide (.ppt)
Figure 34-26
A, B: Author’s preferred treatment.
A, B: Author’s preferred treatment.
View Original | Slide (.ppt)
A, B: Author’s preferred treatment.
View Original | Slide (.ppt)
X

Summary, Controversies, and Future Directions in Proximal Ulna Fractures

Proximal ulna fractures include a spectrum of fractures from simple olecranon fractures to complex fracture-dislocations. An accurate understanding of the injury pattern will lead to appropriate fixation choices for these injuries. The development of periarticular implants and the judicious use of fragment fixation with small plates have led to an improved outcome for these often difficult fractures. 

References

Akesson T, Herbertsson P, Josefsson PO, et al. Primary nonoperative treatment of moderately displaced two-part fractures of the radial head. J Bone Joint Surg Am. 2006;88(9):1909–1914.
Anakwe RE, Middleton SD, Jenkins PJ, et al. Patient-reported outcomes after simple dislocation of the elbow. J Bone Joint Surg Am. 2011;93(13):1220–1226.
Anderson ML, Larson AN, Merten SM, et al. Congruent elbow plate fixation of olecranon fractures. J Orthop Trauma. 2007;21(6):386–393.
Antuna SA, Sanchez-Marquez JM, Barco R. Long-term results of radial head resection following isolated radial head fractures in patients younger than forty years old. J Bone Joint Surg Am. 2010;92(3):558–566.
Athwal GS, Rouleau DM, MacDermid JC, et al. Contralateral elbow radiographs can reliably diagnose radial head implant overlengthening. J Bone Joint Surg Am. 2011;93(14):1339–1346.
Bailey CS, MacDermid J, Patterson SD, et al. Outcome of plate fixation of olecranon fractures. J Orthop Trauma. 2001;15(8):542–548.
Beingessner DM, Dunning CE, Gordon KD, et al. The effect of radial head excision and arthroplasty on elbow kinematics and stability. J Bone Joint Surg Am. 2004;86A(8):1730–1739.
Beingessner DM, Dunning CE, Gordon KD, et al. The effect of radial head fracture size on elbow kinematics and stability. J Orthop Res. 2005;23(1):210–217.
Beingessner DM, Dunning CE, Stacpoole RA, et al. The effect of coronoid fractures on elbow kinematics and stability. Clin Biomech (Bristol, Avon). 2007;22(2):183–190.
Beingessner DM, Nork SE, Agel J, et al. A fragment-specific approach to Type IID Monteggia elbow fracture-dislocations. J Orthop Trauma. 2011;25(7):414–419.
Beingessner DM, Stacpoole RA, Dunning CE, et al. The effect of suture fixation of type I coronoid fractures on the kinematics and stability of the elbow with and without medial collateral ligament repair. J Shoulder Elbow Surg. 2007;16(2):213–217.
Bell TH, Ferreira LM, McDonald CP, et al. Contribution of the olecranon to elbow stability: an in vitro biomechanical study. J Bone Joint Surg Am. 2010;92(4):949–957.
Birkedal JP, Deal DN, Ruch DS. Loss of flexion after radial head replacement. J Shoulder Elbow Surg. 2004;13(2):208–213.
Boulas HJ, Morrey BF. Biomechanical evaluation of the elbow following radial head fracture. Comparison of open reduction and internal fixation vs. excision, silastic replacement, and non-operative management. Chir Main. 1998;17(4):314–320.
Broberg MA, Morrey BF. Results of delayed excision of the radial head after fracture. J Bone Joint Surg Am. 1986;68(5):669–674.
Broberg MA, Morrey BF. Results of treatment of fracture-dislocations of the elbow. Clin Orthop. 1987;(216):109–119.
Burkhart KJ, Mattyasovszky SG, Runkel M, et al. Mid- to long-term results after bipolar radial head arthroplasty. J Shoulder Elbow Surg. 2010;19(7):965–972.
Burton AE. Fractures of the head of the radius. Proc R Soc Med. 1942;35:764–765.
Caputo AE, Mazzocca AD, Santoro VM. The nonarticulating portion of the radial head: anatomic and clinical correlations for internal fixation. J Hand Surg Am. 1998;23(6):1082–1090.
Carstam N. Operative treatment of fractures of the upper end of the radius. Acta Orthop Scand. 1950;59:502–523.
Chen X, Wang SC, Cao LH, et al. Comparison between radial head replacement and open reduction and internal fixation in clinical treatment of unstable, multi-fragmented radial head fractures. Int Orthop. 2011;35(7):1071–1076.
Coonrad RW, Roush TF, Major NM, et al. The drop sign, a radiographic warning sign of elbow instability. J Shoulder Elbow Surg. 2005;14(3):312–317.
Diliberti T, Botte MJ, Abrams RA. Anatomical considerations regarding the posterior interosseous nerve during posterolateral approaches to the proximal part of the radius. J Bone Joint Surg Am. 2000;82(6):809–813.
Doornberg J, Ring D, Jupiter JB. Effective treatment of fracture-dislocations of the olecranon requires a stable trochlear notch. Clin Orthop Relat Res. 2004;(429):292–300.
Doornberg JN, Linzel DS, Zurakowski D, et al. Reference points for radial head prosthesis size. J Hand Surg Am. 2006;31(1):53–57.
Doornberg JN, Parisien R, van Duijn PJ, et al. Radial head arthroplasty with a modular metal spacer to treat acute traumatic elbow instability. J Bone Joint Surg Am. 2007;89(5):1075–1080.
Doornberg JN, Ring D. Coronoid fracture patterns. J Hand Surg Am. 2006;31(1):45–52.
Doornberg JN, Ring DC. Fracture of the anteromedial facet of the coronoid process. J Bone Joint Surg Am. 2006;88(10):2216–2224.
Doornberg JN, van Duijn J, Ring D. Coronoid fracture height in terrible-triad injuries. J Hand Surg Am. 2006;31(5):794–797.
Duckworth AD, Clement ND, Jenkins PJ, et al. The epidemiology of radial head and neck fractures. J Hand Surg Am. 2012;37(1):112–119.
Duckworth AD, Ring D, Kulijdian A, et al. Unstable elbow dislocations. J Shoulder Elbow Surg. 2008;17(2):281–286.
Dunning CE, Zarzour ZD, Patterson SD, et al. Muscle forces and pronation stabilize the lateral ligament deficient elbow. Clin Orthop. 2001;(388):118–124.
Essex-Lopresti P. Fractures of the radial head with distal radio-ulnar dislocation. J Bone Joint Surg Br. 1951;33B:244–247.
Eygendaal D, Verdegaal SH, Obermann WR, et al. Posterolateral dislocation of the elbow joint. Relationship to medial instability. J Bone Joint Surg Am. 2000;82(4):555–560.
Fehringer EV, Burns EM, Knierim A, et al. Radiolucencies surrounding a smooth-stemmed radial head component may not correlate with forearm pain or poor elbow function. J Shoulder Elbow Surg. 2009;18(2):275–278.
Ferreira LM, Bell TH, Johnson JA, et al. The effect of triceps repair techniques following olecranon excision on elbow stability and extension strength: an in vitro biomechanical study. J Orthop Trauma. 2011;25(7):420–424.
Flinkkila T, Kaisto T, Sirnio K, et al. Short- to mid-term results of metallic press-fit radial head arthroplasty in unstable injuries of the elbow. J Bone Joint Surg Br. 2012;94(6):805–810.
Frank SG, Grewal R, Johnson J, et al. Determination of correct implant size in radial head arthroplasty to avoid overlengthening. J Bone Joint Surg Am. 2009;91(7):1738–1746.
Fraser GS, Pichora JE, Ferreira LM, et al. Lateral collateral ligament repair restores the initial varus stability of the elbow: an in vitro biomechanical study. J Orthop Trauma. 2008;22(9):615–623.
Garrigues GE, Wray WH III, Lindenhovius AL, et al. Fixation of the coronoid process in elbow fracture-dislocations. J Bone Joint Surg Am. 2011;93(20):1873–1881.
Gartsman GM, Sculco TP, Otis JC. Operative treatment of olecranon fractures. Excision or open reduction with internal fixation. J Bone Joint Surg Am. 1981;63(5):718–721.
Grewal R, MacDermid JC, Faber KJ, et al. Comminuted radial head fractures treated with a modular metallic radial head arthroplasty. Study of outcomes. J Bone Joint Surg Am. 2006;88(10):2192–2200.
Guitton TG, Ring D. Nonsurgically treated terrible triad injuries of the elbow: report of four cases. J Hand Surg Am. 2010;35(3):464–467.
Hamid N, Ashraf N, Bosse MJ, et al. Radiation therapy for heterotopic ossification prophylaxis acutely after elbow trauma: a prospective randomized study. J Bone Joint Surg Am. 2010;92(11):2032–2038.
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(2):142–153.
Herbertsson P, Josefsson PO, Hasserius R, et al. Uncomplicated Mason type-II and III fractures of the radial head and neck in adults. A long-term follow-up study. J Bone Joint Surg Am. 2004;86-A(3):569–574.
Holdsworth BJ, Clement DA, Rothwell PN. Fractures of the radial head–the benefit of aspiration: a prospective controlled trial. Injury. 1987;18(1):44–47.
Iftimie PP, Calmet GJ, de Loyola GF, et al. Resection arthroplasty for radial head fractures: long-term follow-up. J Shoulder Elbow Surg. 2011;20(1):45–50.
Ikeda M, Sugiyama K, Kang C, et al. Comminuted fractures of the radial head. Comparison of resection and internal fixation. J Bone Joint Surg Am. 2005;87A:76–84.
Izzi J, Athwal GS. An off-loading triceps suture for augmentation of plate fixation in comminuted osteoporotic fractures of the olecranon. J Orthop Trauma. 2012;26(1):59–61.
Jones SG. Fractures of the head and neck of the radius – separation of upper radial epiphysis. New England J Med. 1935;212:914–917.
Josefsson PO, Johnell O, Gentz CF. Long-term sequelae of simple dislocation of the elbow. J Bone Joint Surg Am. 1984;66(6):927–930.
Josefsson PO, Johnell O, Wendeberg B. Ligamentous injuries in dislocations of the elbow joint. Clin Orthop. 1987;(221):221–225.
Josefsson PO, Nilsson BE. Incidence of elbow dislocation. Acta Orthop Scand. 1986;57(6):537–538.
Jupiter JB, Leibovic SJ, Ribbans W, et al. The posterior Monteggia lesion. J Orthop Trauma. 1991;5(4):395–402.
Jupiter JB, Ring D. Treatment of unreduced elbow dislocations with hinged external fixation. J Bone Joint Surg Am. 2002;84-A(9):1630–1635.
Kaas L, Turkenburg JL, van Riet RP, et al. Magnetic resonance imaging findings in 46 elbows with a radial head fracture. Acta Orthop. 2010;81(3):373–376.
Khalfayan EE, Culp RW, Alexander AH. Mason type II radial head fractures: operative versus nonoperative treatment. J Orthop Trauma. 1992;6(3):283–289.
King GJ, Evans DC, Kellam JF. Open reduction and internal fixation of radial head fractures. J Orthop Trauma. 1991;5(1):21–28.
King GJ, Zarzour ZD, Patterson SD, et al. An anthropometric study of the radial head: implications in the design of a prosthesis. J Arthroplasty. 2001;16(1):112–116.
Kohls-Gatzoulis J, Tsiridis E, Schizas C. Reconstruction of the coronoid process with iliac crest bone graft. J Shoulder Elbow Surg. 2004;13(2):217–220.
Konrad GG, Kundel K, Kreuz PC, et al. Monteggia fractures in adults: long-term results and prognostic factors. J Bone Joint Surg Br. 2007;89(3):354–360.
Koslowsky TC, Schliwa S, Koebke J. Presentation of the microscopic vascular architecture of the radial head using a sequential plastination technique. Clin Anat. 2011;24(6):721–732.
Lindenhovius A, Karanicolas PJ, Bhandari M, et al. Interobserver reliability of coronoid fracture classification: two-dimensional versus three-dimensional computed tomography. J Hand Surg Am. 2009;34(9):1640–1646.
Lindenhovius AL, Felsch Q, Ring D, et al. The long-term outcome of open reduction and internal fixation of stable displaced isolated partial articular fractures of the radial head. J Trauma. 2009;67(1):143–146.
Linscheid RL, Wheeler DK. Elbow dislocations. JAMA. 1965;194(11):1171–1176.
Madsen M, Marx RG, Millett PJ, et al. Surgical anatomy of the triceps brachii tendon: anatomical study and clinical correlation. Am J Sports Med. 2006;34(11):1839–1843.
Marcotte AL, Osterman AL. Longitudinal radioulnar dissociation: identification and treatment of acute and chronic injuries. Hand Clin. 2007;23(2):195–208.
Mason ML. Some observations on fracture of the head of the radius with a review of one hundred cases. Br J Surg. 1954;42:123–132.
McKee MD, Pugh DM, Wild LM, et al. Standard surgical protocol to treat elbow dislocations with radial head and coronoid fractures. Surgical technique. J Bone Joint Surg Am. 2005;87A(suppl 1):22–32.
McKee MD, Schemitsch EH, Sala MJ, et al. The pathoanatomy of lateral ligamentous disruption in complex elbow instability. J Shoulder Elbow Surg. 2003;12(4):391–396.
Mehlhoff TL, Noble PC, Bennett JB, et al. Simple dislocation of the elbow in the adult. Results after closed treatment. J Bone Joint Surg Am. 1988;70(2):244–249.
Moritomo H, Tada K, Yoshida T, et al. Reconstruction of the coronoid for chronic dislocation of the elbow. Use of a graft from the olecranon in two cases. J Bone Joint Surg Br. 1998;80(3):490–492.
Morrey BF, An KN. Articular and ligamentous contributions to the stability of the elbow joint. Am J Sports Med. 1983;11(5):315–319.
Morrey BF, Tanaka S, An KN. Valgus stability of the elbow. A definition of primary and secondary constraints. Clin Orthop. 1991;175(265):187–195.
Morrey BF. Current concepts in the treatment of fractures of the radial head, the olecranon, and the coronoid. Instr Course Lect. 1995;44:175–185.
Murray RC. Fractures of the head and neck of the radius. Br J Surg. 1940;27:106–118.
Neuhaus V, Alqueza A, Mudgal CS. Open reduction and temporary internal fixation of a subacute elbow dislocation. J Hand Surg Am. 2012;37(5):1011–1014.
Neumann M, Nyffeler R, Beck M. Comminuted fractures of the radial head and neck: is fixation to the shaft necessary? J Bone Joint Surg Br. 2011;93(2):223–228.
O’Driscoll SW, Jupiter JB, Cohen MS, et al. Difficult elbow fractures: pearls and pitfalls. Instr Course Lect. 2003;52:113–134.
O’Driscoll SW, Morrey BF, Korinek S, et al. Elbow subluxation and dislocation. A spectrum of instability. Clin Orthop. 1992;(280):186–197.
Pichora JE, Fraser GS, Ferreira LF, et al. The effect of medial collateral ligament repair tension on elbow joint kinematics and stability. J Hand Surg Am. 2007;32(8):1210–1217.
Pollock JW, Brownhill J, Ferreira L, et al. The effect of anteromedial facet fractures of the coronoid and lateral collateral ligament injury on elbow stability and kinematics. J Bone Joint Surg Am. 2009;91(6):1448–1458.
Popovic N, Lemaire R, Georis P, et al. Midterm results with a bipolar radial head prosthesis: radiographic evidence of loosening at the bone-cement interface. J Bone Joint Surg Am. 2007;89(11):2469–2476.
Pugh DM, Wild LM, Schemitsch EH, et al. Standard surgical protocol to treat elbow dislocation with radial head and coronoid fractures. J Bone Joint Surg Am. 2004;86A(6):1122–1130.
Radin EL, Riseborough EJ. Fractures of the radial head. A review of eighty-eight cases and analysis of the indications for excision of the radial head and non-operative treatment. J Bone Joint Surg Am. 1966;48(6):1055–1064.
Regan W, Morrey B. Fractures of the coronoid process of the ulna. J Bone Joint Surg Am. 1989;71(9):1348–1354.
Richard MJ, Aldridge JM III, Wiesler ER, et al. Traumatic valgus instability of the elbow: pathoanatomy and results of direct repair. J Bone Joint Surg Am. 2008;90(11):2416–2422.
Ring D, Jupiter JB, Sanders RW, et al. Transolecranon fracture-dislocation of the elbow. J Orthop Trauma. 1997;11(8):545–550.
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;84A(4):547–551.
Ring D, Quintero J, Jupiter JB. Open reduction and internal fixation of fractures of the radial head. J Bone Joint Surg Am. 2002;84-A(10):1811–1815.
Ring D. Fractures of the coronoid process of the ulna. J Hand Surg Am. 2006;31(10):1679–1689.
Rosenblatt Y, Young C, MacDermid JC, et al. Osteotomy of the head of the radius for partial articular malunion. J Bone Joint Surg Br. 2009;91(10):1341–1346.
Rotini R, Marinelli A, Guerra E, et al. Radial head replacement with unipolar and bipolar SBi system: a clinical and radiographic analysis after a 2-year mean follow-up. Musculoskelet Surg. 2012;96(suppl 1):S69–S79.
Rouleau DM, Faber KJ, Athwal GS. The proximal ulna dorsal angulation: a radiographic study. J Shoulder Elbow Surg. 2010;19(1):26–30.
Rowland AS, Athwal GS, MacDermid JC, et al. Lateral ulnohumeral joint space widening is not diagnostic of radial head arthroplasty overstuffing. J Hand Surg Am. 2007;32(5):637–641.
Sanchez-Sotelo J, O’Driscoll SW, Morrey BF. Medial oblique compression fracture of the coronoid process of the ulna. J Shoulder Elbow Surg. 2005;14(1):60–64.
Sarris IK, Kyrkos MJ, Galanis NN, et al. Radial head replacement with the MoPyC pyrocarbon prosthesis. J Shoulder Elbow Surg. 2012;21(9):1222–1228.
Schiffern A, Bettwieser SP, Porucznik CA, et al. Proximal radial drift following radial head resection. J Shoulder Elbow Surg. 2011;20(3):426–433.
Schneeberger A, Sadowski MM, Jacob HAC. Coronoid process and radial head as posterolateral rotatory stabilizers of the elbow. J Bone Joint Surg Am. 2004;86A(5):975–982.
Shore BJ, Mozzon JB, MacDermid JC, et al. Chronic posttraumatic elbow disorders treated with metallic radial head arthroplasty. J Bone Joint Surg Am. 2008;90(2):271–280.
Smith AM, Morrey BF, Steinmann SP. Low profile fixation of radial head and neck fractures: surgical technique and clinical experience. J Orthop Trauma. 2007;21(10):718–724.
Smith GR, Altchek DW, Pagnani MJ, et al. A muscle-splitting approach to the ulnar collateral ligament of the elbow. Neuroanatomy and operative technique. Am J Sports Med. 1996;24(5):575–580.
Smith GR, Hotchkiss RN. Radial head and neck fractures: anatomic guidelines for proper placement of internal fixation. J Shoulder Elbow Surg. 1996;5(2 Pt 1):113–117.
Stoneback JW, Owens BD, Sykes J, et al. Incidence of elbow dislocations in the United States population. J Bone Joint Surg Am. 2012;94(3):240–245.
Strauss EJ, Tejwani NC, Preston CF, et al. The posterior Monteggia lesion with associated ulnohumeral instability. J Bone Joint Surg Br. 2006;88(1):84–89.
Szekeres M, Chinchalkar SJ, King GJ. Optimizing elbow rehabilitation after instability. Hand Clin. 2008;24(1):27–38.
Taylor TK, Scham SM. A posteromedial approach to the proximal end of the ulna for the internal fixation of olecranon fractures. J Trauma. 1969;9(7):594–602.
van Riet RP, Morrey BF, O’Driscoll SW. Use of osteochondral bone graft in coronoid fractures. J Shoulder Elbow Surg. 2005;14(5):519–523.
van Riet RP, Morrey BF. Documentation of associated injuries occurring with radial head fracture. Clin Orthop Relat Res. 2008;466(1):130–134.
van Riet RP, Sanchez-Sotelo J, Morrey BF. Failure of metal radial head replacement. J Bone Joint Surg Br. 2010;92(5):661–667.
van Riet RP, Van Glabbeek F, Neale PG, et al. The noncircular shape of the radial head. J Hand Surg Am. 2003;28(6):972–978.
Villanueva P, Osorio F, Commessatti M, et al. Tension-band wiring for olecranon fractures: analysis of risk factors for failure. J Shoulder Elbow Surg. 2006;15(3):351–356.
Wells J, Ablove RH. Coronoid fractures of the elbow. Clin Med Res. 2008;6(1):40–44.
Wexner SD, Goodwin C, Parkes JC, et al. Treatment of fractures of the radial head by partial excision. Orthop Rev. 1985;14:83–86.
Wolff AL, Hotchkiss RN. Lateral elbow instability: nonoperative, operative, and postoperative management. J Hand Ther. 2006;19(2):238–243.
Wolfgang G, Burke F, Bush D, et al. Surgical treatment of displaced olecranon fractures by tension band wiring technique. Clin Orthop Relat Res. 1987;(224):192–204.
Zunkiewicz MR, Clemente JS, Miller MC, et al. Radial head replacement with a bipolar system: a minimum 2-year follow-up. J Shoulder Elbow Surg. 2012;21(1):98–104.