Ulnohumeral Dislocation Research Articles

The use of hinged elbow orthosis following surgical management of terrible triad injuries of the elbow.

To determine outcomes following surgical management of terrible triad injuries in patients treated with and without a hinged elbow orthosis (HEO) in the post-operative setting. This study was a retrospective review of 41 patients who underwent surgical treatment of terrible triad injuries including radial head fracture, coronoid fracture, and ulnohumeral dislocation between 2008 and 2023 with at least 10-week follow-up. Nineteen patients were treated post-operatively without HEO, and 22 patients were treated with HEO. There were no differences in range of motion (ROM) between patients treated with and without HEO in final flexion-extension arc (118.4° no HEO, 114.6° HEO, p = 0.59) or pronation-supination arc (147.8° no HEO, 141.4° HEO, p = 0.27). Five patients treated without HEO and one patient treated with HEO returned to the operating roomfor stiffness (26%, 5%, p = 0.08). QuickDASH scores were similar between groups (p = 0.69). This study found no difference in post-operative ROM, complications, or QuickDASH scores in patients treated post-operatively with or without HEO. Based on these results, we cannot determine whether the use of HEO adds additional stability to the elbow while initiating ROM exercises post-operatively.

The Management of Elbow Dislocations and Associated Lesions: A Review Article

Dislocations around the elbow joint can be isolated (termed a simple elbow dislocation), or occur with concurrent ligamentous and/or bony injuries. In cases of a simple elbow dislocation, surgery is rarely required. Patients should be evaluated radiographically for a concentric reduction, immobilized for 7-10 days, and begin early range of motion activities. In patients who return for follow-up with no bony injuries but a loss of concentric reduction, surgical treatment is recommended. This may consist of static or dynamic external/internal fixation or direct repair of the damaged ligamentous structures. Fractures associated with elbow dislocations may be difficult to identify and require computed tomography (CT) scans to characterize. A terrible triad injury consists of a radial head fracture, coronoid fracture, and ulnohumeral dislocation. This may be associated with lateral collateral ligament (LCL) and/or medial collateral ligament (MCL) injuries. These injuries require operative treatment with open reduction and internal fixation of the coronoid, fixation or replacement of the radial head, and repair of damaged ligamentous structures, depending on the specific injuries.

Arthroscopic lateral collateral ligament imbrication of the elbow: short-term clinical results.

Chronic posterolateral rotatory instability (PLRI) of the elbow results from an insufficient lateral collateral ligament (LCL) complex. Arthroscopic LCL imbrication may prove a minimally invasive alternative to open lateral ulnar collateral ligament (LUCL) reconstruction with a quicker rehabilitation. The purpose of this study is to analyze the validity of a modified arthroscopic imbrication technique. We hypothesized that arthroscopic LUCL imbrication would yield stable elbows in patients with grade 1 or 2 chronic PLRI at a minimum of 2 year of follow-up. We retrospectively assessed data of all PLRI patients who underwent arthroscopic LUCL imbrication from 2010 to 2013 (n=20). Stage 3 PLRIs (frank ulnohumeral dislocations) were excluded from this treatment. After confirmation of PLRI during standard elbow arthroscopy, a doubled absorbable suture is shuttled through as much LCL tissue as possible (from the lateral ulnar border to the area proximal to the lateral epicondyle) and the sutures are tied. This results in a plication of the entire LCL complex. Objective elbow stability was assessed using a combination of the pivot shift, table top, and posterior drawer tests. Of 20 included patients, 18 were stable subjectively and objectively at a minimum of 2 year of follow-up. Mean Mayo Elbow Performance Score improved from 48 preoperatively to 88.9 at final follow-up (P<.001). Mean Quick-Disabilities of the Arm, Shoulder, and Hand score improved from 53 preoperatively to 10.3 at final follow-up (P<.001). One patient developed elbow stiffness. Two patients reported tenderness of the subcutaneous PDS knots. As a less invasive alternative to open LCL reconstruction using a graft, arthroscopic LCL imbrication has demonstrated acceptable rates of perceived elbow stability among patients with stage 1 or 2 PLRI.

Risk Factors for Elbow Joint Contracture After Surgical Repair of Traumatic Elbow Fracture.

The ability to predict contracture development after elbow fracture would benefit patients and physicians. This study aimed to identify factors associated with the development of posttraumatic elbow joint contracture. A retrospective review of elbow fractures (AO/Orthopaedic Trauma Association [OTA] type 13 and 21) treated at one institution between 2011 and 2015 was performed. Data collected included demographics, injury information, treatment, and postoperative elbow range of motion (ROM). Multivariate logistic regression analyses were performed to identify factors associated with contracture development. Notable contracture was defined as an arc of motion less than 100° flexion/extension, which has been associated with reduced ability to perform activities of daily living. A total of 278 patients at least 1 8 years of age underwent surgical repair of an elbow fracture or fracture-dislocation during the study period and had at least 6 months of postoperative follow-up. Forty-two (15.1%) developed a clinically notable elbow contracture, of whom 29 (69.0%) developed heterotopic ossification (HO). Multivariate analysis of preoperative variables demonstrated that AO/OTA 13-C fracture classification (odds ratio [OR], 13.7, P = 0.025), multiple noncontiguous fractures (OR, 3.7, P = 0.010), and ulnohumeral dislocation at the time of injury (OR, 4.9, P = 0.005) were independently associated with contracture development. At 6 weeks postoperatively, an arc of elbow ROM less than 50° flexion/extension (OR, 23.0, P < 0.0005) and the presence of HO on radiographs (OR, 6.7, P < 0.0005) were found to be independent risk factors for significant elbow stiffness. Ulnohumeral dislocation, multiple noncontiguous fractures, AO/OTA 13-C fracture classification, limited elbow ROM at 6 weeks postoperatively, and the presence of radiographic HO at 6 weeks postoperatively are associated with contracture development after surgical elbow fracture repair. Patients with these risk factors should receive aggressive physical therapy and be counseled as to the possible development of a contracture requiring surgical intervention.

Isolated displaced type II partial articular radial head fracture: correlation of preoperative imaging with intraoperative findings of lateral ulnar collateral ligament tear

The aim of this study was to determine the lateral ulnar collateral ligament (LUCL) injury associated with isolated radial head fracture (RHF) and the relationship of the ligament injury with the displacement of the fragment-loss of contact-in unstable displaced partial articular RHFin individuals without any history of ulnohumeral dislocation. We retrospectively identified 131 consecutive patients who underwent open reduction and internal fixation of isolated closed Mason type II RHF performed at our institution. We identified 3 subsets by the pattern of RHF and the position of the unstable fragment (anterior or posterior) relative to the capitulum humeri: displaced stable (group I), displaced anterior unstable (group II), and displaced posterior unstable (group III). Standard radiographs were obtained preoperatively and postoperatively. The pattern of lateral collateral ligament avulsion and its distribution were inferred from intraoperative records. Preoperative radiographs of the 131 patientsshowed 101 nonseparated fractures (77%, group I)and 30 unstable fractures (23%). Anterior displacement of the fragment was found in 18 elbows (14%, group II) and posterior displacement in 12 (9%, group III). LUCL avulsion was found in 18 of 30 unstable RHFs (60%) and in 1 of 60 stable RHFs (1.6%). RHF is a complex fracture often associated with soft tissue lesions. It is important to determine which structures need to be repairedto avoid complications that could lead to elbow instability. The RHF pattern and classification as stable or unstable can helpthe surgeon in the identification and treatment of LUCL lesions.

Outcome of Long Standing Ulno-Humeral Dislocation Managed by Open Reduction and Stabilization with V-Y Plasty; A Single Center Experience

To assess the outcome of long standing ulno-humeral dislocation managed by open reduction and stabilization with V-Y plasty.This cross sectional study included 14 patients with elbow dislocation that was more than 3 months without joint ankylosis, myositis ossificans or nerve injury. The surgical management not only included open reduction of the elbow joint, but also elongation of the triceps aponeurosis, collateral ligament repair along with the stabilization of the elbow joint. The results were analyzed using the Mayo Elbow score and the range of motion at 3 months and results were compared with the function of the patients elbows before surgery.Among the 14 included patients, there were 9 men and 5 women. The mean age of the patients was 27.8±8.3 years. The average ROM Increased from 37.0◦±25.8◦ to 99.7◦±23.3◦ of flexion in the postop followup. Whereas the extension lag changed from 15.5◦±14.6◦ to 19.6◦±18.3◦ . The mean Mayo score increased from 47 in the preop period to 87 in the postop period.This results demonstrates that relative good function with a pretty low risk can be obtained when comparing the functional results after 3 months with preoperative status. Based on these results we recommend that neglected elbow dislocation should be managed by surgical intervention even if the dislocations are old.

Outcome of Long Standing Ulno-Humeral Dislocation Managed by Open Reduction and Stabilization with V-Y Plasty; Our Experience.

To assess the outcome of long standing ulno-humeral dislocation managed by open reduction and stabilization with V-Y plasty. This cross sectional study included 14 patients with elbow dislocation that was more than 3 months without joint ankylosis, myositis ossificans or nerve injury. The surgical management not only included open reduction of the elbow joint, but also elongation of the triceps aponeurosis, collateral ligament repair along with the stabilization of the elbow joint. The results were analyzed using the Mayo Elbow score and the range of motion at 3 months and results were compared with the function of the patients elbows before surgery. Among the 14 included patients, there were 9 men and 5 women. The mean age of the patients was 27.8±8.3 years. The average ROM Increased from 37.0◦±25.8◦ to 99.7◦±23.3◦ of flexion in the postop followup. Whereas the extension lag changed from 15.5◦±14.6◦ to 19.6◦±18.3◦ . The mean Mayo score increased from 47 in the preop period to 87 in the postop period. This results demonstrates that relative good function with a pretty low risk can be obtained when comparing the functional results after 3 months with preoperative status. Based on these results we recommend that neglected elbow dislocation should be managed by surgical intervention even if the dislocations are old.

Capitellar Fractures in Children and Adolescents: Classification and Early Results of Treatment.

There has been limited published information regarding capitellar fractures in the pediatric population. The purpose of this investigation was to characterize capitellar fracture patterns in children and adolescents and to assess early clinical and radiographic treatment outcomes. A retrospective analysis of 37 children and adolescents with capitellar fractures presenting to a tertiary pediatric hospital from 2004 to 2014 was performed. The mean patient age at the time of injury was 11.8 years. Medical records and radiographs were evaluated for fracture pattern, treatment, healing, and complications. Fractures were categorized on the basis of prevailing patterns of injury, and a classification system is proposed that aids in treatment decision-making. Thirty-two patients had follow-up of at least 6 weeks and were included for assessment of treatment outcomes. The mean follow-up was 12.3 months. Three predominant capitellar fracture patterns were identified. Type-I fractures (n = 25) were anterior shear injuries. Nondisplaced anterior shear fractures were successfully treated with cast immobilization. Displaced anterior shear fractures were treated with open reduction and internal fixation, with good results in a majority of patients. Of the 21 patients with Type-Ib fractures eligible for analysis, 6 (29%) required a secondary surgical procedure for loss of motion related to soft-tissue contracture, osteonecrosis, implant prominence, and/or intra-articular loose bodies. Type-II fractures (n = 9) were posterolateral shear injuries, typically associated with ulnohumeral dislocations. Among 5 patients with displaced fractures and adequate follow-up, 3 patients were treated nonoperatively and had poor results, with loss of elbow motion or mechanical symptoms, and 2 patients were treated surgically and achieved good functional restoration. Type-III fractures (n = 3) were acute chondral shear injuries, which achieved full restoration of motion after surgical treatment. A classification of pediatric capitellar fractures is proposed, guiding treatment and prognosis. Nondisplaced fractures heal successfully with cast immobilization. Good results may be expected with surgical fixation of displaced Type-I fractures (anterior shear). Type-II fractures (posterolateral shear) and Type-III fractures (chondral shear) are more subtle; advanced imaging and timely surgical management for displaced injuries are recommended to optimize clinical results. Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Complications Associated With Hinged External Fixation for Chronic Elbow Dislocations

To evaluate the outcomes of patients who underwent application of hinged external fixators for chronic elbow fracture-dislocations. We hypothesized that patients treated for this injury pattern can achieve satisfactory outcomes but encounter many complications and require numerous additional procedures. We performed a retrospective review of 7 patients who were surgically treated with application of a hinged external fixator for chronic ulnohumeral elbow fracture-dislocation. Patients were included only if they had complete ulnohumeral dislocation of greater than 1month's duration. Demographics, injury pattern, and range of motion were documented. Preoperative and postoperative range of motion was recorded and any treatment complications or additional surgeries were noted. The interval between the initial injury and index procedure averaged 8 months. All patients underwent initial treatment with open reduction internal fixation. Average arc of ulnohumeral motion improved from 26° (range, 0° to 60°) to 120° (range, 100° to 145°). Overall, 4 of 7 patients developed at least one complication during treatment. Three patients required additional procedures aside from removal of the hinged external fixator. These 3patients underwent a total of 13 additional procedures. Although patients can achieve good outcomes, realistic expectations should be set. Patients should be aware that surgery can be associated with a high risk of complications, potential treatment failure, and a need for additional surgical procedures. Therapeutic IV.

Terrible Triad Elbow Fracture-Dislocation With Triceps and Flexor-Pronator Mass Avulsion

Terrible triad elbow injuries, consisting of fractures of the radial head and coronoid with ulnohumeral dislocation, are challenging to treat. They require a comprehensive understanding of the complex anatomy of the elbow to effectively treat all of the pathology and create a stable, congruent joint. The authors present a case of a terrible triad injury with avulsion of the triceps and flexor-pronator mass after a low-energy fall in a young patient. Although most terrible triad fracture-dislocations can be successfully treated with coronoid fixation, radial head fixation or replacement, and repair of the lateral collateral ligament complex, this case involved a completely circumferential injury to the elbow. The coronoid and anterior capsule were disrupted anteriorly, the radial head and lateral collateral ligament complex were disrupted laterally, the triceps was disrupted posteriorly, and the flexor-pronator mass was disrupted medially. Although the authors prefer to address most terrible triad injuries through a lateral approach, they suspected a circumferential injury preoperatively and elected to use a single posterior incision to address all of the pathology conveniently. This injury required treatment of all disrupted structures, because the elbow remained unstable until the triceps and flexor-pronator mass avulsions were ultimately repaired. With any elbow fracture-dislocation, surgeons should look for evidence of additional injuries that do not fit the commonly described patterns, because they may necessitate modifications to the treatment plan. Given the relatively common complications of stiffness and instability despite modern surgical techniques, additional injuries may further compromise functional outcomes unless they are addressed properly.

Terrible Triad Injuries of the Elbow: Does the Coronoid Always Need to Be Fixed?

The "terrible triad" of the elbow is a complex injury that can lead to pain, stiffness, and posttraumatic arthritis if not appropriately treated. The primary goal of surgery for these injuries is to restore stability of the joint sufficient to permit early motion. Although most reports recommend repair and/or replacement of all coronoid and radial head fractures when possible, a recent cadaveric study demonstrated that type II coronoid fractures are stable unless the radial head is removed and not replaced. The purposes of this study were to determine the (1) range of motion; (2) clinical scores using the Disabilities of the Arm, Shoulder and Hand (DASH) and the Broberg-Morrey questionnaires; and (3) rate of arthritic changes, heterotopic ossification (HO), or elbow instability postoperatively in patients whose terrible triad injuries of the elbow included Reagan-Morrey type I or II coronoid fractures that were treated without fixation. Between April 2008 and December 2010, 14 consecutive patients were treated for acute terrible triad injuries that included two Regan-Morrey type I and 12 Regan-Morrey type II coronoid fractures. Based on the senior author's (DGS) clinical experience that coronoid fractures classified as such do not require fixation to restore intraoperative stability to the posterolaterally dislocated elbow, all injuries were treated by the senior author with a surgical protocol that included radial head repair or prosthetic replacement and repair of the lateral ulnar collateral ligament (LUCL) followed by intraoperative fluoroscopic examination through a range of 20° to 130° of elbow flexion to confirm concentric reduction of the ulnohumeral joint. Using this protocol, intraoperative stability was confirmed in all cases without any attempt at coronoid or anterior capsular repair. Repair of the medial collateral ligament or application of external fixation was not performed in any case. All patients were available for followup at a minimum of 24months (mean, 41months; range, 24-56months). The mean patient age was 52years (range, 32-58years). At the followup all patients were evaluated clinically and radiographically by the senior author. Outcome measures included elbow range of motion, forearm rotation, elbow stability, and radiographic evidence of HO or arthritic changes using the Broberg and Morrey scale. Elbow instability was defined as clinical or radiographic evidence of recurrent ulnohumeral dislocation or subluxation at final followup. Clinical outcomes were assessed with the patient-reported DASH questionnaire and the physician-administered Broberg-Morrey elbow rating system. The mean arc of ulnohumeral motion at final followup was 123° (range, 75°-140°) and mean forearm rotation was 145° (range, 70°-170°). The mean Broberg and Morrey score was 90 of 100 (range, 70-100, higher scores reflecting better results) and the average DASH score was 14 of 100 (range, 0-38, higher scores reflecting poorer results). Radiographs revealed mild arthritic changes in one patient. One patient developed radiographically apparent but asymptomatic HO. None of the patients demonstrated instability postoperatively. These findings demonstrate that terrible triad injuries with type I and II coronoid process fractures can be effectively treated without fixation of coronoid fractures when repair or replacement of the radial head fracture and reconstruction of the LUCL complex sufficiently restores intraoperative stability of the elbow through a functional range of motion. Level IV, therapeutic study. See Guidelines to Authors for a complete description of levels of evidence.

Treatment of Monteggia and Transolecranon Fracture-Dislocations of the Elbow: A Critical Analysis Review.

The uninjured elbow is an inherently stable joint. The skeletal articulations, surrounding capsuloligamentous structures, and muscular attachments maintain stability. The primary stabilizers of the elbow are the coronoid process, olecranon, trochlea, and collateral ligaments1. Traumatic dislocations without substantial skeletal injury are considered simple and usually do not require operative repair. In contrast, complex dislocations, which are associated with fracture and may involve one or more of the primary stabilizing structures of the elbow, are unstable and typically require operative reduction and internal fixation to achieve stability. Complex elbow fracture-dislocations follow a subluxation or dislocation event. These injuries range from ulnohumeral dislocations with radial head and coronoid process fracture (“terrible triad” injuries) to ulnar fractures with an associated injury of the proximal part of the radius, proximal radioulnar joint, radiocapitellar joint, or ulnohumeral joint. Monteggia injuries involve a proximal ulnar fracture with disruption of the proximal radioulnar joint. Transolecranon fracture-dislocations involve a proximal ulnar fracture at the greater sigmoid notch and anterior dislocation of the elbow, without disruption of the proximal radioulnar joint. Some fracture-dislocations do not follow either pattern but have features consistent with one or the other that help to guide treatment. The focus of this article …

Injury Complexity Factors Predict Heterotopic Ossification Restricting Motion After Elbow Trauma

Heterotopic ossification (HO) is a common extrinsic cause of elbow stiffness after trauma. However, factors associated with the development of HO are incompletely understood. We retrospectively identified (1) patient-related demographic factors, (2) injury-related factors, and (3) treatment-related factors associated with the development of HO severe enough to restrict motion after surgery for elbow trauma. We also determined what percentage of the variation in HO restricting motion was explained by the variables studied. Between 2001 and 2007, we performed surgery on 417 adult patients for elbow fractures; of these, 284 (68%) were available for radiographs at a minimum of 4 months and clinical review at a minimum of 6 months after surgery (mean, 7.9 months; range, 6–31 months). HO was classified according to the Hastings and Graham system. Patients with HO restricting motion (defined as a Hastings and Graham Class II or III) were compared with patients without HO restricting motion in terms of demographics, fracture location, elbow dislocation, open wound, mechanism of injury, ipsilateral fracture, head trauma, time from injury to surgery, number of surgeries within 4 weeks, total number of surgeries, bone graft, and infection, using bivariate and multivariable analyses. A total of 96 patients had radiographic HO, and in 27 (10% of those available for followup), it restricted motion. There were no patient-related demographic factors that predicted the formation of symptomatic HO. Ulnohumeral dislocation in addition to fracture (odds ratio, 2.38; 95% CI, 1.01–5.64; p = 0.048) but not fracture location was associated with HO. Longer time from injury to definitive surgery and number of surgical procedures in the first 4 weeks were also independent predictors of HO (p = 0.01 and 0.004, respectively). These factors explained 20% of the variance in risk for HO restricting motion. HO restricting motion after operative elbow fracture treatment associates with factors that seem related to injury complexity, in particular, ulnohumeral dislocation, delay, and number of early surgeries; however, a substantial portion of the variation among patients with elbow fracture who develop restrictive HO remains unexplained. Level III, therapeutic study. See Instructions for Authors for a complete description of levels of evidence.

Posterior Monteggia Fractures in Adults with and Without Concomitant Dislocation of the Elbow

Background The present study comprised a retrospective review aiming to identify the differences between patients with a posterior Monteggia injury with and without concomitant dislocation of the elbow. Methods Forty-nine consecutive adult patients with 50 posterior Monteggia fractures were identified that had operative treatment. Demographics and injury characteristics were recorded for the entire cohort (13 with and 36 without ulnohumeral dislocation) and final motion was recorded in 29 patients (10 with and 19 without dislocation) that had more than 10 months of follow-up. Results Fractures with concomitant elbow dislocation occur in younger patients (45 years versus 56 years; p = 0.046); are associated with higher-energy injuries (54% versus 21%, p = 0.037); are more likely to have a Regan-Morrey type 2 (85% versus 26%, p = 0.003)/Mayo type 1 coronoid fractures (85% versus 21%; p &lt; 0.001); and are more likely to have a Mason type 2 radial head fracture (61% versus 30%; p = 0.046). Conclusions Patients with a posterior Monteggia fracture and concomitant elbow dislocation have smaller coronoid fractures and worse ultimate ulnohumeral motion than patients without anelbow dislocation.

Complex elbow dislocation associated with radial and ulnar diaphyseal fractures: a rare combination

We illustrate a rare complex dislocation of the elbow involving a posterior ulno-humeral dislocation associated with open diaphyseal fracture of the ulna, radial shaft fracture, Type 1 coronoid fracture and neuropraxia of the deep branch of the radial nerve. The isolated ulno-humeral dislocation without radio-capitellar involvement, and ulnar diaphyseal fracture, makes this “reverse Monteggia” type of injury pattern very unique. This patient was managed with an initial reduction of his ulno-humeral joint and stabilization of his radius and ulna fractures. He underwent a delayed medial collateral ligament reconstruction a few days later. His fractures went on to unite fully, his elbow joint remained stable, and he achieved good range of motion of his elbow.

Elbow Instability Associated With Bicolumnar Fracture of the Distal Humerus: Report of Three Cases

Ulnohumeral subluxation or dislocation is rare after open reduction and internal fixation of a bicolumnar fracture of the distal humerus. We report 3 patients in whom detachment of the origins of the lateral collateral ligament and common extensor muscle origins from the lateral epicondyle contributed to postoperative instability after open reduction and internal fixation of a fracture of the distal humerus. This may be due to either unrecognized ligament injury or iatrogenic injury during surgical dissection.

The posterior Monteggia lesion with associated ulnohumeral instability

The type II Monteggia (posterior) lesion is a rare injury which is sometimes associated with ulnohumeral instability. We have reviewed 23 of 28 patients with this injury. A clinical and radiographic assessment was undertaken at follow-up. Functional outcome scores, including the Broberg and Morrey Index and the Disabilities of the Arm, Shoulder or Hand (DASH), were used. The results from the six patients with associated posterior ulnohumeral dislocation were compared with 17 without ulnohumeral injury. Those with dislocation had reduced movement of the elbow and had outcome scores indicative of greater disability compared to those without associated dislocation.

Combined Posterior and Convergent Elbow Dislocations in an Adult: A Case Report and Review of the Literature

T ranslocation of the proximal radioulnar joint, so-called convergent dislocation, is an extremely rare injury that may occur in isolation or in association with a posterior ulnohumeral dislocation. In this injury, the ulnohumeral joint is disrupted, resulting in medial translation of the radius and lateral translation of the ulna. The cases of ten patients who had convergent dislocation have been reported previously1-7. All of those patients were children. To our knowledge, there has never been a report of convergent elbow dislocation in an adult patient. Our patient was informed that data concerning the case would be submitted for publication. Figs. 1-A and 1-B The initial radiographs demonstrating posterior dislocation of the left elbow. Fig. 1-A Lateral radiograph. Fig. 1-B Anteroposterior radiograph. A moderately obese thirty-five-year-old woman sustained multiple upper extremity fractures after falling off a porch from a height of approximately four feet. She was initially evaluated at a local emergency room where physical examination and radiographs revealed a posterior elbow dislocation of the left, nondominant arm (Figs. 1-A and 1-B), an ipsilateral displaced and comminuted intra-articular distal radial fracture, and a displaced fracture of the base of the contralateral thumb metacarpal. She was subsequently transferred to our facility for definitive treatment. The patient had pain in the left wrist and elbow, with a limited range of motion, and pain in the right thumb. She had an obvious dorsal deformity of the distal part of the radius in the left arm with minimal swelling. The left elbow was held at approximately 80° of flexion, and she had a painful and limited range of motion. The right thumb was tender to palpation at the base of the metacarpal with no obvious deformity. The neurovascular examination revealed normal findings. An initial review of the radiographs revealed an obvious posterior dislocation of the …

Coronoid process and radial head as posterolateral rotatory stabilizers of the elbow.

The purpose of this study was to evaluate the role of the radial head and the coronoid process as posterolateral rotatory stabilizers of the elbow and to determine the stabilizing effect of radial head replacement and coronoid reconstruction. The posterolateral rotatory displacement of the ulna was measured after application of a valgus and supinating torque (1). in seven intact elbows, (2). after radial head excision, (3). after sequential resection of the coronoid process, (4). after subsequent insertion of each of two different types of metal radial head prostheses (a rigid implant and a bipolar implant with a floating cup), and (5). after subsequent reconstruction of the coronoid with each of two different techniques in the same cadaveric elbow. The posterolateral rotatory laxity averaged 5.4 degrees in the intact elbows. The surgical approach used in this study insignificantly increased the mean laxity to 9 degrees. Excision of the radial head in an elbow with intact collateral ligaments caused a mean posterolateral rotatory laxity of 18.6 degrees (p < 0.0001). Additional removal of 30% of the height of the coronoid fully destabilized the elbows, always resulting in ulnohumeral dislocation despite intact ligaments. Implantation of a rigid radial head prosthesis stabilized the elbows. However, a mean laxity of 16.9 degrees persisted after insertion of a floating prosthesis (p < 0.0001). The elbows with a defect of 50% or 70% of the coronoid, loss of the radial head, and intact ligaments could not be stabilized by radial head replacement alone, but additional coronoid reconstruction restored stability. The results of this study suggest that the coronoid and the radial head contribute significantly to posterolateral rotatory stability.

Results of Treatment of Fracture-Dislocations of the Elbow

Twenty-four patients with ulnohumeral dislocation associated with radial head fracture were studied two to 35 years after injury. On the basis of an objective functional grading score that included elements of pain, motion, strength, and stability, results were excellent in three (12%), good in 15 (62%), and fair in six (25%). The best results were obtained in patients with Mason Type 2 injuries treated by closed reduction without fracture excision and with early complete radial head excision for a Type 3 fracture. Late instability was not observed in any of the 24 patients. Prolonged immobilization (greater than four weeks) was associated with poor results. Ectopic ossification occurred in only one patient who had surgical treatment at eight days after injury; the grading score was only fair. These observations demonstrate that the injury should be treated with early reduction of the ulnohumeral joint and treatment of the radial head fracture according to its type. Immobilization for more than four weeks should be avoided. The prognosis is better than what has been thought previously.