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World J Orthop. Jan 18, 2016; 7(1): 50-54
Published online Jan 18, 2016. doi: 10.5312/wjo.v7.i1.50
Review of management of unstable elbow fractures
Omer Ozel, Emre Demircay
Omer Ozel, Emre Demircay, Department of Orthopedic Surgery, Baskent University, 34662 Istanbul, Turkey
Author contributions: All the authors contributed to this paper.
Conflict-of-interest statement: All authors declare that they have no conflict of interest.
Open-Access: This article is an open-access article which was selected by an in-house editor and fully peer-reviewed by external reviewers. It is distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/
Correspondence to: Emre Demircay, Associate Professor, Department of Orthopedic Surgery, Baskent University, Oymaci Sokak No: 7 Altunizade, 34662 Istanbul, Turkey. emredemircay@hotmail.com
Telephone: +90-216-5541500 Fax: +90-216-6519746
Received: June 4, 2015
Peer-review started: June 5, 2015
First decision: July 6, 2015
Revised: October 7, 2015
Accepted: November 3, 2015
Article in press: November 4, 2015
Published online: January 18, 2016

Abstract

Stable and painless elbow motion is essential for activities of daily living. The elbow joint is the second most commonly dislocated joint in adults. The goals of treatment are to perform a stable fixation of all fractures, to achieve concentric and stable reduction of the elbow and to provide early motion. The treatment modality for complex elbow instability is almost always surgical. The treatment objectives are anatomic reduction, stable fixation, and early rehabilitation of the elbow. The common complications of these unstable fractures include recurrent instability, stiffness, myositis ossifications, heterotopic calcification, and neurovascular dysfunction. We analyzed the management of complex elbow fractures and instabilities on the basis of recent literature and suggested possible guidelines for the treatment in this paper. In conclusion, recognition of the injury pattern and restoration of the joint stability are the prerequisites for any successful treatment of an unstable elbow injury.

Key Words: Transolecranon fracture, Coronoid fracture, Monteggia injury, Radial head fracture, Terrible triad

Core tip: As the elbow joint is the second most commonly dislocated joint in adults, we aimed to analyze the management of complex elbow fractures and instabilities, on the basis of recent literature and suggested possible guidelines for the treatment in this paper.



INTRODUCTION

Basic elbow function requires stable and painless elbow motion. The three articulations, namely the ulnotrochlear, radiocapitellar, and proximal radioulnar joints, provide elbow flexion/extension and supination/pronation. Static and dynamic constraints create stability of the elbow joint. The ulnohumeral articulation, anterior bundle of the medial collateral ligament, and lateral collateral ligament complex form the primary static constraints. The joint capsule and radial head are among the secondary static constraints. The dynamic constraints, such as the common flexor and extensor muscle groups, are any muscles crossing the elbow joint that exert a compressive force on the joint[1].

The elbow is the second most commonly dislocated joint in adults[2]. The dislocations may be complex or simple. When dislocations are associated with fractures, they are designated as complex. The reported annual incidence of simple and complex elbow dislocations is 6.1 per 100000 patients[3]. Radial head fractures/dislocations, coronoid fractures, terrible triad injuries, transolecranon fracture-dislocations, and Monteggia-like lesions can be listed as common causes of complex elbow injuries.

Complex elbow fractures and instability typically present with edema, tenderness, pain in active/passive movement, and restriction of motion. A fall onto the extended outstretched hand or a direct trauma to the elbow is usually described as the mechanism of the injury. Anteroposterior and lateral standard radiographs and computerized tomography scans (either standard or 3D) are needed to properly evaluate the bone injuries and to accurately plan their surgical treatment. Neurovascular examination and documentation of the injuries before and after any manipulation are of critical importance. A temporary fracture alignment with cast immobilization may be done until definitive surgery in patients with severe injuries.

The treatment modality for complex elbow instability is almost always surgical. The treatment objectives are anatomic reduction, stable fixation, and early rehabilitation of the elbow.

The common complications of these unstable fractures include recurrent instability, stiffness, myositis ossifications, heterotopic calcification, and neurovascular dysfunction.

In this review, we analyze the management of complex elbow fractures and instability on the basis of recent literature, and suggest possible guidelines for the treatment of these injuries.

RADIAL HEAD FRACTURES

Radial head fractures are among the most common elbow fractures, occurring in up to 20% of all elbow injuries[4]. Radial head fractures are mostly associated with complex injuries like elbow dislocation, and lateral collateral ligament (LCL) and medial collateral ligament (MCL) tears. Impaction fractures of the capitellum may also be associated with radial head fractures, and can easily be overlooked[5]. Only about 5% of cases have a radial head fracture as an isolated injury[6,7]. In a large incidence study[8], the mean age was found to be 36 years and the female-to-male ratio was 47.7/53.3. A thorough physical examination is essential to diagnose associated ligament injuries. Fluoroscopy may be used to confirm an MCL injury if medial pain and ecchymosis are present. If the MCL is injured, the role of the radial head in valgus resistance increases up to 30%[9,10]. Stable anatomic reconstruction of the radial head is the primary objective of the treatment.

The Mason classification system[11] divided radial head fractures into three categories: type I, non-displaced fractures; type II, displaced partial head fractures; and type III, comminuted displaced fractures involving the whole head.

Modifications to the Mason classification were introduced to guide treatment. The Hotchkiss modification[12] defines type I fractures as non-displaced fractures (< 2 mm displacement) without mechanical blockage that do not require surgery, type II fractures as displaced fractures (> 2 mm displacement) of the radial head or neck that lack severe comminution, may have mechanical blockage to movement, and usually require open reduction and internal fixation, and type III fractures as severely comminuted fractures of the radial head and neck. Satisfactory reconstructions of these fractures are not possible, and therefore the radial head is either excised or replaced with a prosthesis[13]. Fragment excision is avoided in complex elbow instability to prevent valgus instability[14]. If there is an associated LCL rupture, it should be repaired after appropriate management of the radial head fracture, either by fixation or by prosthetic replacement. Suture anchors or transosseous sutures can be used for the reconstruction. The joint stability should be confirmed by dynamic fluoroscopic examination. If residual instability persists, MCL reconstruction and/or dynamic elbow fixation should be done[15,16].

CORONOID FRACTURES

The coronoid process plays a pivotal role as an anterior buttress in providing elbow stability. Although coronoid fractures may occur in isolation, they are more commonly seen as a component of unstable elbow fractures[17].

The classification proposed by Moon et al[18], which defines anteromedial facet lesions, may be better for guiding the surgical management of coronoid fractures. Type I injuries involve fractures of the coronoid tip, and are divided into two subtypes based on the fracture size. Subtype 1 fractures are smaller than 2 mm, and subtype 2 fractures are larger than 2 mm. In type IIinjuries, the anteromedial aspect of the coronoid is fractured. These injuries are divided into three subtypes based on the anatomic location. Subtype 1 fractures involve the rim, subtype 2 fractures involve the rim and the tip, and subtype 3 fractures involve the rim and the sublime tubercle with or without the tip. Type III fractures are basal coronoid fractures involving at least 50% of the height of the coronoid. They are divided into two subtypes depending on whether the fracture involves the base of the olecranon. Stable fixation and ligament repair are essential for the treatment of coronoid fractures[19,20].

TERRIBLE TRIAD INJURIES

Terrible triad injuries have the most common complex pattern. They comprise a radial head fracture and elbow dislocation along with a coronoid fracture. Both medial and lateral compartments can be exposed through a posterior incision. The Kocher approach can be used for the radial head fracture. Hotchkiss type I and type II radial head fractures can be fixed with headless screws or a plate[12]. Prosthetic replacement is mandatory for comminuted radial head fractures (type III) to avoid chronic instability. There is often a comminuted type 1 fracture in the coronoid, and it can usually only be fixed with a transosseous suture. If there is an isolated fragment that is sufficiently large, fixation with K wires or screws can be done[19]. The LCL is repaired last, and elbow stability is assessed by fluoroscopy. In the presence of a residual instability, the MCL should also be repaired or a hinged external fixator should be applied[7,21,22] (Table 1).

Table 1 Reviewed studies investigating unstable elbow fracture diagnosis and treatment.
AuthorRing et al[16]Chemama et al[22]Konrad et al[26]Mouhsine et al[29]Zeiders et al[21]Winter et al[13]Mortazavi et al[30]Strauss et al[27]
Year20022010200720072008200920062006
Mean age (range)36 (17-62)46 (26-75)42.1 (21-72)54 (22-82)NA40 (18-77)35 (22-58)UHD+: 46.8 UHD-: 55
n (female/male)56 (21/35)23 (7-16)63 (22/41)14 (8/6)32 (NA)13 (4/9)8 (1/7)UHD+: 6 (2/4) UHD-: 17 (12/5)
Radial fracture Mason classificationType 2: 30 Type 3: 26Type 1: 2 Type 2: 9 Type 3: 10 Radial neck: 2Type 2: 7 Type 3: 9NANA13 non-reperable RH fractureType 1: 1 Type 3: 1UHD+: Type 1: 1 Type 2: 2 Type 3 : 3
Coronoid fracture classification R-MNAType 1: 16 Type 2: 7NANANAType 1: 5 Type 2-3: 8Type 3: 4UHD+: Type 1: 4 Type 3: 2
Monteggia fracture classification (BADO)NANAType 1: 19 Type 2: 37 Type 3: 5 Type 4: 2NANANANAType 2: 6 (UHD+) Type 2: 17 (UHD-)
Time to surgeryNANAFirst 24 hNANA1.9 d (1-4)3.8 dNA
Monteggia fracture Ulna treatmentNANABado 1, 3, 4 (26 3.5 mm DCP) Bado 2 (26 plate, 11 tension band)NANANANAUHD+: Small fragment plates UHD-: Small fragment plates
Transolecranon fracture treatmentNANANAK-wire and tension band: 7 3.5 mm 1/3 plate: 2 3.5 mm DCP: 1 3.5 mm recon. plate: 4NANA3.5 mm AO recons. Plate: 7 K-wire and tension band: 1NA
Coronid treatmentNANone: 10 TOS: 3 Anchor: 2 Screw: 4 Plate: 1 Resection: 3Lag screws through the ulnar plate or indirect repositioningNA32 patients repair of coronoid brachialis Complex pull-through suture tecNA4 patients interfragmentary Screws through the plateUHD+: Type 3 (lag screws)
Radial head treatmentMason 2: 26 (screw), 4 (plate, screw) Mason 3: 22 (plate, screw), 4 (screw)13 mini screws Radial neck: 2 plate RHP: 4 PRHR: 2 TRHR: 246 luxation CR 12 RH ORIF 4 RH resectionNA6-intact RH 7-reconst 19-prothesis13 RHP1 type 1: Mini screws 1 type 3: Total exicision RHType 1, 2: mini fragment plates Type 3: 3 replacement
LCL repairNANANANone18 (anchor) 12 (mcl + lcl rep)No: 4 abs suture Used for repairNAUHD+: 6
MCL repairNANANANone2 (ancor) 12 (mcl + lcl rep)NANAUHD+: 0
External fixatorNANoneNANone21 hinged ex-fixNANAUHD+: 1 hinged ex-fix
Follow-up48 mo63 mo8.4 yr (5-14) (47 patients)42 mo (7-84)3 yr (1-5)25 mo (15-48)37.4 mo (10-50)UHD+: 28 mo (14-48) UHD-: 29 (12-60)
Range of motionMFA Mason 2: 119 Mason 3: 111MFA: 109 MSA: 64 MPA: 70MFA: 97.5 MFR: 125MFA: 103 MSA: 76 MPA: 68MFA: 100MFA: 120MFA: 93 MFR: 157.5UHD+: MFA 95, MSA 55, MPA 50 UND-: MFA 122, MSA 67, MPA 60
Mean scoreMason 2: BM: 92 Mason 3: BM: 86MEPS: 87 (75-100) 14 patients resultBM: 87.2 (45-100) DASH: 17.4 (0-70)BM: 82 (78-100)DASH: 23 (19/28)BM: 86.5 (55-100)BM: 88 (71-100) ASES: 89 (69-100)UHD+: DASH 34 (0-80), BM: 73.8 UHD-: DASH 23 (0-70), BM: 83
UnsatisfactoryMason 2: 4 Mason 3: 14BM: 0BM: (9 fair) (4 poor) resultBM: 2 fair 2 poor2 (stiffness, infection)BM: 1 fairUHD+: 2 UHD-: 7
MONTEGGIA-LIKE LESIONS

Monteggia injuries comprise a fracture of the ulnar shaft with an associated radial head dislocation. Monteggia originally described the lesions as a fracture of the proximal third of the ulna and an anterior dislocation of the proximal epiphysis of the radius[23]. Bado[23] classified these injuries by primarily focusing on the radial component. Jupiter et al[24] modified this classification by defining subtypes for the posterior Monteggia lesions (Bado type 2). Ulnohumeral dislocation, radial fracture, proximal and/or distal radioulnar dislocation, and interosseous membrane lesions may also accompany the ulnar fracture and radiohumeral dislocation. Each of these must be recognized and treated. The varying combinations of these injured structures explains the complexity and diversity of the management procedures.

Anatomic reduction and stabilization of the ulna and the ulnohumeral joint is the primary objective of surgical treatment for posterior elbow fracture-dislocations[25]. The radial head fracture is addressed initially. If the radial head cannot be salvaged satisfactorily, radial head arthroplasty is preferred. To size the radial head properly, the ulnar length should be restored by a provisional fixation[17]. The coronoid process is stabilized after the ulnar shaft fracture has been addressed, and the olecranon is fixed with a dorsal plate. Finally, ligamentous components of the injury are addressed[26,27] (Table 1).

TRANSOLECRANON FRACTURE-DISLOCATIONS (ANTERIOR OLECRANON FRACTURE-DISLOCATIONS)

The radial head is dislocated anteriorly with an associated olecranon fracture in this injury pattern[28]. Two subtypes have been described: One with a simple olecranon fracture, and one with a comminuted olecranon fracture[28]. The second subtype is more common and may be associated with trochlear and coronoid fractures. This injury pattern is distinct from the anterior Monteggia (Bado type 1) lesion, because in transolecranon fracture-dislocation, the ulnohumeral stability is lost but the radioulnar relationship remains intact. Bony disruption is the main reason for the failure of the ulnohumeral joint rather than the ligamentous structures.

Anatomic reduction with particular attention to restoring the ulnar length and greater sigmoid notch is essential in the treatment[29] (Table 1). Restoration of the ulnohumeral anatomy is crucial to prevent radiocapitellar instability or subluxation[25,30] (Table 1).

CONCLUSION

Surgical treatments of complex elbow fracture dislocations are among the most challenging procedures for orthopedic surgeons. Interpretation of the underlying mechanisms for elbow instability and accurate identification of the injured structures are crucial for surgical planning. Stable elbow fracture fixation is important for early elbow motion and avoiding joint stiffness. Recognition of the injury pattern and restoration of the joint stability are the prerequisites for any successful treatment of an unstable elbow injury.

In this review, we have examined the diagnosis, classification, and treatment of unstable elbow fractures. Future studies should be conducted to determine the optimal management strategies, the role of ligament reconstruction, and reductions in the complication rate.

Footnotes

P- Reviewer: Garg B, Malik H

S- Editor: Gong XM L- Editor: A E- Editor: Li D

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