Elbow Dislocation With Intra-Articular Fracture: The Results of Operative Treatment Without Repair of the Medial Collateral Ligament

doi:10.1016/j.jhsa.2007.06.019

The Journal of Hand Surgery

Volume 32, Issue 8, October 2007, Pages 1200-1209

https://doi.org/10.1016/j.jhsa.2007.06.019 Get rights and content

Purpose

To determine the effectiveness of a protocol for the treatment of fracture-dislocations of the elbow based on the concept that, if dislocation of the elbow with associated fractures can be made to resemble a simple elbow dislocation by repairing or reconstructing the fractured structures, repair of the medial collateral ligament (MCL) will not be necessary.

Methods

Over a 5-year period, a single surgeon operated on 34 patients with a posterior dislocation of the elbow associated with one or more intra-articular fractures. The mean age of these 19 men and 15 women was 48 years. Associated fractures included the capitellum, trochlea, and lateral epicondyle in 3 patients; the olecranon in 1 patient; and the radial head in 30 patients (with concomitant fracture of the coronoid process—the so-called “terrible triad” of the elbow—in 22 patients, and concomitant fracture of the coronoid and olecranon in 1 patient). Operative treatment consisted of open reduction internal fixation (ORIF) or prosthetic replacement of all fractures and reattachment of the origin of the lateral collateral ligament (LCL) complex to the lateral epicondyle. The MCL was not repaired.

Results

Two patients (1 with a terrible triad injury and 1 with fracture of the capitellum and trochlea) had postoperative instability related to noncompliance, had reconstructive procedures, and were considered failures. An average of 32 months after injury, the remaining 32 patients regained an average of 120° ulnohumeral motion and 142° forearm rotation. Twenty-five of 34 patients (74%) had good or excellent results according to the system of Broberg and Morrey. Patients with terrible triad injuries had an average of 117° ulnohumeral motion and 137° forearm rotation, and 17 of 22 patients (77%) had good or excellent results.

Conclusions

MCL repair is unnecessary in the treatment of dislocation of the elbow with associated intra-articular fractures, provided that the articular fractures and the LCL are repaired or reconstructed.

Type of study/level of evidence

Therapeutic IV.

Section snippets

Materials and Methods

Over a 5-year period (from 1999 to 2004) 1 surgeon operated on 49 patients with a posterior dislocation of the elbow associated with one or more intra-articular fractures. Inclusion criteria were based on adherence to the following treatment protocol: 1) All fractures were either repaired (ie, open reduction and internal fixation) or reconstructed with a prosthesis; 2) The lateral collateral ligament was reattached to its origin from the lateral epicondyle; 3) The MCL was not repaired; 4)

Instability

Two patients experienced complications related to postoperative instability, both associated with noncompliance and inappropriate use of the arm. One patient with a complex articular fracture of the distal humerus did not return to the office for a month after surgery, at which time she was noted to have discarded her splint, used her arm inappropriately, and subluxated the elbow. The other patient with a terrible triad injury of the elbow had a dislocation when she was riding her bicycle

Discussion

Some surgeons treating acute traumatic elbow instability have been slow to adjust from the traditional focus on the MCL to the increasing importance placed on the LCL.¹⁶ The role of the MCL in traumatic elbow instability may have been overinterpreted in the light of biomechanical studies demonstrating its important role in valgus stability of the elbow. The contributions of the MCL are easier to isolate in the lab,19, 20, 31 and complete dislocation of the elbow occurs in the presence of both

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We conducted a systematic review to identify studies with trans-ulnar fracture dislocations that had documentation of associated coronoid injuries. A literature search identified 16 qualifying studies with 296 fractures. Elbows presenting with basal subtype 2 or Regan/Morrey III coronoid fractures and Jupiter IIA and IID injuries were classified as trans-ulnar basal coronoid fractures. Patients with trans-olecranon or Monteggia fractures were classified as such if the coronoid was not fractured or an associated coronoid fracture had been classified as O'Driscoll tip, anteromedial facet, basal subtype I, or Regan Morrey I/II.
The 296 fractures reviewed were classified as trans-olecranon in 44 elbows, Monteggia variant in 82 elbows, and trans-ulnar basal coronoid fracture dislocations in 170 elbows. Higher rates of complications and reoperations were reported for trans-ulnar basal coronoid injuries (40%, 25%) compared to trans-olecranon (11%, 18%) and Monteggia variant injuries (25%, 13%). The mean flexion-extension arc for basal coronoid fractures was 106° compared to 117° for Monteggia (P < .01) and 121° for trans-olecranon injuries (P = .02). The mean Mayo Elbow Performance Score was 84 points for trans-ulnar basal coronoid, 91 for Monteggia (P < .01), and 93 for trans-olecranon fracture dislocations (P < .05). Disabilities of the Arm, Shoulder and Hand and American Shoulder and Elbow Surgeons scores were 22 and 80 for trans-ulnar basal coronoid, respectively, compared to 23 and 89 for trans-olecranon fractures. American Shoulder and Elbow Surgeons was not available for any Monteggia injuries, but the mean Disabilities of the Arm, Shoulder and Hand was 13.
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Terrible triad injury of the elbow joint treated with total elbow arthroplasty: a case report
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Total elbow arthroplasty (TEA¹) improves pain outcomes in patients with a terrible triad injury of the elbow (TTIE) by restoring functional joint range of motion (ROM); however, there are limited reports regarding the treatment of TTIE with TEA. We report a case of TTIE treated with primary TEA.
A 74-year-old female was diagnosed with a TTIE and TEA was performed. At the 12-month follow-up, the patient was free of pain, and the elbow ROM was 125° of flexion, −20° of extension, 70° of pronation, and 80° of supination. The Japanese Orthopaedic Association and Mayo Elbow Performance scores were 86 and 80 points, respectively. The patient was satisfied with the surgical outcomes.
TEA resulted in satisfactory functional recovery of the elbow in an elderly patient with a TTIE, and may therefore be an effective surgical procedure to treat TTIE in the elderly. To the best of our knowledge, this is the first report of a TTIE being treated with primary TEA.
No difference in torque load to failure between split anconeus fascia transfer and autograft palmaris longus tendon for reconstruction of the lateral ulnar collateral ligament
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The split anconeus fascia transfer (SAFT) is an option for reconstruction of the lateral ulnar collateral ligament (LUCL) in chronic posterolateral rotatory instability (PLRI) of the elbow with potential advantages of using only local tissue within the surgical exposure and not requiring ulnar fixation. This study aimed to assess SAFT strength compared to a traditional free graft reconstruction in a PLRI biomechanical model.
To measure biomechanical strength, eight cadaveric upper extremity pairs were utilized. Within each pair, one specimen was randomly assigned to LUCL reconstruction with autograft palmaris longus and the other to SAFT reconstruction. Torque load to failure was assessed on a load frame with the elbow in 30 degrees of flexion, 5 degrees of valgus, and 25 N axial load as the elbow was brought into external rotation. Torque load to failure was compared between the two reconstruction techniques.
No difference was found in the torque load to failure between SAFT specimens compared to palmaris longus autograft specimens (mean 14.6 ± 4.4 Nm vs. mean 11.3 ± 3.9 Nm; P = .16).
In this biomechanical study, the SAFT LUCL reconstruction provided torque load to failure similar to that of the traditional technique. These findings suggest that the SAFT technique warrants continued study as a biomechanically sound option for LUCL reconstruction in the setting of elbow PLRI.
The effect of lateral collateral ligament repair tension on elbow stability: An in vitro biomechanical study
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The aim of this study was to determine the optimal repair tension of the lateral collateral ligament of the elbow by performing simulated active flexion with the arm in the varus gravity loaded position using an in vitro elbow simulator.
Eight cadaveric specimens were mounted in the varus gravity loaded orientation onto an elbow motion simulator. Four states were studied (intact, lateral collateral ligament injured, and 15 N and 20 N lateral collateral ligament repairs) with the forearm in supination and pronation. An electromagnetic tracking system was used to measure joint kinematics during active elbow flexion.
There was no difference in ulnohumeral rotation between the intact state and the 15 N repair (P = .150 for pronation; P = 1.0 for supination) or the 20 N repair (P = 1.0 for pronation; P = .568 for supination). For varus-valgus angulation, the 20 N repair was not statistically different from the intact state (P = .059 in pronation; P = 1.0 in supination).
Repair of the lateral collateral ligament following injury can restore joint kinematics with the arm in the varus position. A repair tension of 20 N was successful in restoring joint stability for simulated active motion with the forearm in pronation and supination. This study shows that when the lateral collateral ligament is repaired with adequate tension, avoidance of the varus position may not be as crucial during early motion.
Current concepts in the management of “Terrible Triad” injuries of the elbow
2023, Injury
Terrible triad injuries of the elbow are complex injuries which can result in long term complications and significant disability. They must be identified correctly, and managed appropriately in order to maximise functional outcomes. A clear understanding of the bony and ligamentous anatomy is essential to plan appropriate surgical reconstruction to provide elbow stability. Urgent reduction of the elbow, followed by 3-dimensional imaging and surgical repair or replacement of the injured structures is the mainstay of treatment in the majority of cases. This review presents a summary of the relevant anatomy and the evidence for the management of these complex injuries.
Indomethacin for heterotopic ossification prophylaxis following surgical treatment of elbow trauma: a randomized controlled trial
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Heterotopic ossification is a frequent complication following surgical treatment of elbow trauma. The use of indomethacin to prevent heterotopic ossification is reported in the literature; however, its effectiveness is controversial. The purpose of this randomized, double-blind, placebo-controlled study was to determine whether indomethacin is effective in reducing the incidence and severity of heterotopic ossification after surgical management of elbow trauma.
Between February 2013 and April 2018, 164 eligible patients were randomized to receive postoperative indomethacin or placebo medication. The primary outcome was the incidence of heterotopic ossification on elbow radiographs at 1-year follow-up. Secondary outcomes included the Patient Rated Elbow Evaluation score, Mayo Elbow Performance Index score, and Disabilities of the Arm, Shoulder and Hand score. Range of motion, complications, and nonunion rates were also obtained.
At 1-year follow-up, there was no significant difference in the incidence of heterotopic ossification between the indomethacin group (49%) and the control group (55%) (relative risk, 0.89; P = .52). There were no significant differences in postoperative Patient Rated Elbow Evaluation, Mayo Elbow Performance Index, and Disabilities of the Arm, Shoulder and Hand scores or range of motion (P = .16). The complication rate was 17% in both the treatment and control groups (P > .99). There were no nonunions in either group.
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: Supported by Wright Medical, AO Foundation, Smith & Nephew, Small Bone Innovations, Joint Active Systems, and Biomet.

^⁎: Equal contribution.

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ElbowElbow Dislocation With Intra-Articular Fracture: The Results of Operative Treatment Without Repair of the Medial Collateral Ligament

Purpose

Methods

Results

Conclusions

Type of study/level of evidence

Section snippets

Materials and Methods

Instability

Discussion

J Hand Surg

J Shoulder Elbow Surg

J Hand Surg

Injury

J Shoulder Elbow Surg

The operative treatment of elbow dislocation in the adult

J Bone Joint Surg

Surgical versus non-surgical treatment of ligamentous injuries following dislocation of the elbow jointA prospective randomized study

J Bone Joint Surg

Ligamentous injuries in dislocations of the elbow joint

Clin Orthop Relat Res

Simple dislocation of the elbow in the adultResults after closed treatment

J Bone Joint Surg

Dislocation of the elbow joint

J Bone Joint Surg

Treatment of unreduced elbow dislocations with hinged external fixation

J Bone Joint Surg

Medial instability of the elbow in throwing athletesTreatment by repair or reconstruction of the ulnar collateral ligament

J Bone Joint Surg

Reconstruction of the ulnar collateral ligament in athletes

J Bone Joint Surg

Difficult elbow fractures: Pearls and pitfallsInstructional Course Lectures

Fracture-dislocation of the elbow

J Bone Joint Surg

Posterolateral rotatory instability of the elbow

J Bone Joint Surg

Recurrent dislocation of the elbow

J Bone Joint Surg

Standard surgical protocol to treat elbow dislocations with radial head and coronoid fractures

J Bone Joint Surg

Standard surgical protocol to treat elbow dislocations with radial head and coronoid fracturesSurgical technique

J Bone Joint Surg

Roles of the medial collateral ligament and the coronoid in elbow stability

J Bone Joint Surg

Adult elbow dislocations: mechanism of instability

Instr Course Lect

Elbow
Elbow Dislocation With Intra-Articular Fracture: The Results of Operative Treatment Without Repair of the Medial Collateral Ligament