Management of complex elbow instability

Abstract

Complex elbow instability is a challenging injury even for expert elbow surgeons. The preoperative radiographs should be carefully evaluated to recognize all lesions that may occur in complex elbow instabilities. Recognizing all the possible lesions is critical to achieve an optimal outcome. The most common types of injuries are as follows: (1) radial head fractures associated with lateral and medial collateral ligaments lesions (with or without elbow dislocation); (2) Coronoid fractures and lateral collateral ligament lesion (with or without elbow dislocation); (3) Terrible Triad; (4) Transolecranon fracture-dislocation; (5) Monteggia-like-lesions; and (6) Humeral Shear fractures associated with lateral and medial collateral ligaments lesions (with or without elbow dislocation). A correct evaluation includes X-rays, CT scan with 2D and 3D reconstruction and stability test under fluoroscopy. The treatment is always surgical and is challenging, and outcomes are not predictable. The goals of treatment are (1) to perform a stable osteosynthesis of all fractures, (2) to obtain concentric and stable reduction of the elbow and (3) to allow early motion. The proximal ulna must be anatomically reduced and fixed; the radial head must be repaired or replaced, and the coronoid fractures must be repaired or reconstructed. With respect of soft tissue lesions, the LUCL must be reattached with suture anchors or trans-osseous suture. The next critical step is the intra-operative assessment of elbow stability. If the elbow remains unstable, MCL repair and/or application of hinged external fixator must be considered. The most recent clinical and experimental studies have significantly expanded our knowledge of elbow instability and its management. Definite treatment protocols may improve the clinical results of such complex injuries.

A study to assess epidemiological, clinical profile and outcome of Monteggia fracture dislocation in adults: a retrospective study

“…5 Other high-energy elbow fracturedislocations, including transolecranon fracturedislocations, may sometimes resemble Monteggia fractures on radiography and consequently result in misdiagnosis. 1,6 Depending on the direction of the dislocation of the radial head and the angulation of the ulnar fracture, Bado classified monteggia fracture as type I the dislocation is anterior, type II posterior, and type III lateral. Type IV is defined as a fracture of both bones of the forearm with dislocation of the radial head.…”

Effect of elbow flexion angles on stress distribution of the proximal ulnar and radius bones under a vertical load: measurement using resistance strain gauges

“…The proximal ends of the ulna (coronoid process and ulnar notch) and radius (radial head) are important proximal constituents of the elbow joint. Complex elbow fracture dislocations, such as fracture dislocation of the olecranon, posterior monteggia fracture dislocation, and terrible triad injury of the elbow, are caused by various injuries, most of which involve the proximal bone architectures of the ulna and radius as well as the soft tissue [4]-[7]. The different injury types are generally correlated with the flexion and extension positions of the elbow as well as the rotational position of the forearm when the injury was incurred [8]-[10].…”

Complex fracture-dislocations of the proximal ulna and radius in adults: a comprehensive classification

“…Terrible-triad injuries and elbow dislocations associated with coronoid or radial head fractures have their own therapeutic algorithm that is different from that of fracture-dislocations of the proximal ulna and radius. 15,28,31,44 The classification is based on specific anatomic injuries, defined as the ''main lesions,'' including (1) level of ulnar fracture (with respect to collateral ligament insertion and coronoid process), (2) radiohumeral dislocation, (3) proximal radioulnar dislocation, (4) radial fracture, (5) distal radioulnar and interosseous membrane lesion, and (6) ulnohumeral dislocation. In our experience, any pattern of fracturedislocation results from the association of 2 or more main lesions, including an ulnar fracture along with isolated or multiple dislocation of elbow joints (radiohumeral, ulnohumeral, and proximal radioulnar joint).…”