Management of Unstable Elbows Following Complex Fracture-Dislocations—the “Terrible Triad” Injury

Abstract

Complex fracture-dislocations of the elbow can often be either irreducible or unstable, with an inability to hold the reduction or with the delayed development of subluxation or dislocation. The aim of the present study was to evaluate the etiology of the instability, both osseous and ligamentous, and the results of stabilization with a combination of internal fixation, ligament repair, radial head arthroplasty and, when necessary, hinged external fixation. Figures 1 and 2 represent our formulated protocol and treatment algorithm for elbow fracture-dislocation in this series of thirty-two patients. Fig. 1 Constellation of the “terrible triad” injury and the anatomic structures encountered. LUCL = lateral ulnar collateral ligament, and MUCL = medial ulnar collateral ligament. The so-called terrible triad injury has a history of complicated outcomes as the surgeon attempts to maximize functional range-of-motion goals while maintaining stability1-3. On the basis of previous evaluations of these specific injuries and the recent evolution of surgical protocols, the restoration of congruency and stability coupled with progressive rehabilitation can reliably enhance the functional outcome4-6. Thirty-two consecutive patients with unstable elbow injuries who had been referred to three tertiary centers were prospectively recruited for the present study between 2001 and 2005. Six of these patients had been unsuccessfully managed at outside facilities and had been transferred to our care. The unsuccessful treatments had included attempted closed reduction (four patients), radial head excision (one patient), and open reduction and internal fixation of the proximal part of the ulna (one patient). Fig. 2 Treatment algorithm proposed for the achievement of anatomic fixation and mechanical stability in patients with complex fracture-dislocations of the elbow. EUA = examination under anesthesia, MUCL = medial ulnar collateral ligament, LUCL = lateral ulnar collateral ligament, P/L = posterolateral stability, and ORIF = open reduction and internal fixation. All …