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Management of complex elbow instability

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Musculoskelet Surg (2010) 94 (Suppl 1):S25–S36
DOI 10.1007/s12306-010-0065-8
Management of complex elbow instability
Giuseppe Giannicola • Federico Maria Sacchetti •
Alessandro Greco • Gianluca Cinotti •
Franco Postacchini
Ó Springer-Verlag 2010
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 col-
lateral ligament lesion (with or without elbow dislocation);
(3) Terrible Triad; (4) Transolecranon fracture-dislocation;
(5) Monteggia-like-lesions; and (6) Humeral Shear frac-
tures 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 out-
comes 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 ana-
tomically 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
G. Giannicola
F. M. Sacchetti
A. Greco
G. Cinotti

F. Postacchini
Department of Orthopaedic Surgery, ‘‘Sapienza’’ University
of Rome, Piazzale Aldo Moro 5, C.A.P., 00186 Rome, Italy
F. M. Sacchetti (&)
Via Duccio di Buoninsegna 72, C.A.P., 00142 Rome, Italy
e-mail: federicomariasacchetti@hotmail.it
remains unstable, MCL repair and/or application of hinged
external fixator must be considered. The most recent clin-
ical 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.
Keywords Complex elbow instability

Elbow dislocation
Radial head fracture

Coronoid fracture
Terrible triad

Transolecranon dislocation
Monteggia lesion

Distal humerus fracture
Introduction
Complex instabilities consist of one or more osteo-articular
fractures associated with capsule-ligaments tears and
muscle-tendinous lesions that determinate a loss of elbow
stability. The primary stabilizers are the coronoid pro-
cesses, the olecranon, the humeral trochlea and the col-
lateral ligaments (LCL and MCL) [1]. An elbow instability
occurs when two or more of such anatomical structures are
injured. The degree of instability, and the difficulty in the
surgical treatment, may further increase when associated
injuries of secondary elbow stabilizer, including the radial
head, capitulum humeri, anterior capsule, muscle-tendi-
nous units around the elbow and interosseus membrane, are
present [1–4].
The injury patterns of complex instability include (1)
radial head fractures associated with lateral and medial
collateral ligaments lesions (with or without elbow dislo-
cation); (2) Coronoid fractures and lateral collateral liga-
ment lesion (with or without elbow dislocation); (3)
Terrible Triad; (4) Transolecranon fracture-dislocations;
123
S26
(5) Monteggia-like-lesions; and (6) Humeral Shear frac-
tures associated with lateral and medial collateral ligament
lesions (with or without elbow dislocation).
The clinical presentation is usually a common fracture-
dislocation of the elbow; while in other cases, a complex
fracture without instability is initially diagnosed. However,
in the latter, an accurate observation of X-rays and CT
images may reveal any change in the normal alignment of
the elbow joint. Therefore, it is mandatory to perform an
accurate evaluation of complex articular fractures of the
elbow because an unrecognized instability is the most
important cause of unsatisfactory results.
In complex elbow instability, there is no place for
conservative treatments. The goal of surgery is to obtain a
concentric and stable reduction of the elbow which should
allow a functional and painless range of motion. The sur-
gical treatment of these complex injuries is one of the most
challenging in traumatic conditions, and despite significant
progress has occurred during the past decade (in functional
anatomy, comprehension of injury mechanisms, in diag-
nostic investigation and surgical techniques), definite
guidelines on the most appropriate treatments are not
reported. Moreover, recent investigations have shown that
unsatisfactory results are reported in 33–44% of cases and
that 26–55% of patients require revision surgery [5–12]. In
this paper, we analyse the management of each pattern of
complex elbow instability, on the basis of our surgical
experience and literature review, and indicate possible
guidelines for the surgical treatment.
Diagnosis
Patients with a complex elbow instability usually present
severe elbow pain, swelling and deformity. The clinical
history is characterized by a fall onto the outstretched hand
or a direct trauma at the elbow. During physical exami-
nation, it is mandatory to evaluate the ipsilateral wrist and
shoulder because concomitant injuries are present in almost
20% of patients [13]. A careful neuro-vascular examination
has to be performed before and after reduction. In the
presence of elbow dislocation associated with isolated
fracture (i.e. terrible triad, radial head fractures or coronoid
fractures associated with dislocation), a closed reduction
under general anaesthesia has to be performed to assess the
severity of ligament damage and residual stability after
reduction. To assess elbow stability, we evaluate under
fluoroscopy the maintenance of concentric reduction dur-
ing flexion–extension in varying degrees of forearm rota-
tion. We believe that the assessment of elbow stability
under fluoroscopy is essential to accurately diagnose the
severity of ligamentous damage, particularly of the MCL.
In many patients, the elbow is irreducible, and in those in
123
Musculoskelet Surg (2010) 94 (Suppl 1):S25–S36
whom reduction is achieved, the joint usually exhibits a
marked instability. In patients with severe bone injuries,
such as transolecranon and Monteggia fractures, a provi-
sional fracture alignment followed by cast immobilization
is accomplished until surgery. Finally, 2D and 3D CT scans
are mandatory to assess the extension and severity of bone
injuries and to plan the appropriate surgical treatment. The
radiologist should be familiar with the indications for CT
study, the current multidetector CT acquisition protocols
and the need to perform 2D and 3D CT angiography in the
presence of vascular injury. An accurate diagnosis of
associated injuries is necessary for a correct approach of
these difficult conditions.
Radial head fractures with associated lateral
and medial collateral ligaments lesion
(with or without elbow dislocation)
Radial head fracture (RHF) is the most frequent bone
elbow injury in adult; it occurs isolated in only less than
5% of patients, while in most of the cases concomitant
injuries, including elbow dislocation and/or LCL and MCL
tear are present [14, 15]. The latter should be carefully
investigated since they are frequently unrecognized [16].
A further lesion that is often underestimated is the
impaction fracture of capitellum [17].
This injury usually occurs as a combination of valgus
and axial loads onto a supine and extended elbow joint
(Posterolateral rotatory instability) [18]. To diagnose liga-
ment injuries associated with RHF, a careful clinical
examination is essential: for instance, the presence of
medial pain and ecchymosis may suggest a MCL
involvement which has to be confirmed by fluoroscopy.
The surgeon should suspect associated lesions particularly
in high energy trauma with radial neck comminution. The
radial head provides approximatively 30% of resistance to
valgus stress when all ligaments are intact, but this con-
tribution increases dramatically when the MCL is injured
[2, 19, 20]. The radial head also provides an anterior but-
tress to posterior elbow dislocation [21]. Therefore, the
goals of RHF treatment are the reconstitution of radial head
anatomy and recovery of elbow stability. The recovery of
radio-humeral joint function allows ligaments healing in
their physiological tension.
The Hotchkiss classification [22] is an useful tool for
surgical planning, even in complex elbow instability:
Type I fractures include non-displaced or minimally
displaced (\2 mm) fractures of the head or neck that do not
cause any mechanical block during forearm rotation. These
lesions often do not require surgery. When the lateral
compartment is exposed for concomitant conditions, the
Type I fractures can be synthesized.
Musculoskelet Surg (2010) 94 (Suppl 1):S25–S36
Type II fractures include displaced ([2 mm) fractures of
the head or neck (angulated), without severe comminution,
which may be treated by ORIF. The elbow motion may be
mechanically blocked or incongruous. These fractures
require surgery. The osteosynthesis of articular fragments
can be performed with mini-fragments screws or headless
screws; precontured plates can be used when the fracture
line involves completely the radius neck (Fig. 1). The plate
and screws should be positioned in correspondence of the
‘‘safe zone’’ (the non-articular portion of the radial head) to
avoid hardware impingement during forearm rotation [23].
Type III fractures include severely comminuted frac-
tures, and those which are not amenable to be fixed, of the
radial head and neck. Currently, radial head replacement is
performed in the presence of three or more fragments,
since osteosynthesis in these cases usually lead to poor
Fig. 1 a, b Preoperative radiographs of a 25-year-old man with radial head fracture and posterior elbow dislocation. c, d Postoperative
radiographs showing radial head osteosynthesis with plate
S27
results [24]. However, controversy still exists regarding the
types of fractures that are optimally treated with reduction
and internal fixation and whether a fracture may be too
comminuted to be fixed [25]. In complex elbow instability,
fragments excision is rarely indicated because it increases
valgus instability [2, 26]. Several studies, in fact, demon-
strated the association between radial head excision and
chronic valgus/longitudinal instability, osteoarthritis, car-
rying angle increase and ulnar neuropathy [26–30].
The Kocher’s interval is the most frequent surgical
approach utilized for RHF [31]. It allows an excellent
exposure of fractures and associated lesions, as LCL
complex tear. When radial head fractures are associated
with dislocation, the LCL must be repaired after radial
head osteosynthesis or replacement. The reconstruction can
be performed with suture anchors or trans-osseous suture.
123
S28
Rarely, it is necessary the augmentation with tendinous
auto graft (i.e. Palmaris gracilis). In cases showing an
associated tear of the anterior bundle of MCL, we occa-
sionally treat the medial side injury because instability
rarely persists after RH treatment and LCL complex repair.
After LCL reconstruction, the elbow should be tested under
fluoroscopy to assess the recovery of joint stability. In
the presence of significant persistent instability, MCL
reconstruction or/and dynamic elbow fixator (DEF) are
mandatory [32, 33]. In cases of mild persistent instability
(at 0°–40° of flexion), a possible option is the application
of a hinged brace with limited range of motion in extension
for the first 3 weeks. During flexion–extension exercises,
the forearm is positioned in pronation or supination in case
of inadequate LCL or MCL reconstruction, respectively.
When both ligaments reconstruction is inadequate, the
forearm is positioned in neutral rotation. However, the
complete forearm rotation is allowed immediately at 90° of
flexion. Four weeks after surgery, the recovery of full
extension is allowed.
Coronoid fractures and lateral collateral ligament
lesion (with or without elbow dislocation)
Fractures of the coronoid process are often combined with
other elbow injuries. An associated dislocation or LCL tear
without other fractures is uncommon [34]. This injury
occurs as a combination of varus and axial load onto an
elbow joint in pronated position (Varus postero-medial
instability) [35]. This mechanism of injury causes a frac-
ture of the anteromedial facet or the base of the coronoid
and elbow subluxation. If the injury force continues, the
lateral collateral ligament fails, and elbow dislocation may
occur. A fracture of the radial head may also occur
[35, 36]. In cases with dislocation associated with coronoid
tip fracture, a posterolateral mechanism of injury should be
suspected: such a lesion should be considered a simple
elbow instability, and a surgical treatment is not always
necessary [37, 38].
The O’Driscoll et al. classification of coronoid fractures
may better guide the surgical management of this injury
because it includes the anteromedial facet lesion [39].
The Type I includes fractures involving the coronoid tip.
Subtype 1 fractures involve less than 2 mm of the coronoid
and may be isolated or associated with dislocation. Subtype
2 fractures involve greater than 2 mm of the coronoid and
are often associated with terrible triad injuries.
The Type II coronoid fractures involve the anteromedial
aspect of the coronoid. Subtype 1 fractures extend from just
medial to the tip of the coronoid to the anterior half of the
sublime tubercle (insertion of the anterior band of the
MCL). In subtype 2, the fracture line extends into the tip of
123
Musculoskelet Surg (2010) 94 (Suppl 1):S25–S36
the coronoid. Subtype 3 fractures involve the anteromedial
rim and the entire sublime tubercle with or without
involvement of the tip of the coronoid.
Type III is a basal coronoid fracture, and it involves at
least 50% of the height of the coronoid. Subtype 1 fractures
involve the coronoid alone, whereas subtype 2 fractures are
associated with fractures of the olecranon.
The guidelines and results of surgical treatment of cor-
onoid fractures associated with dislocation or LCL tear are
uncertain, because few authors have reported the results of
a series of patients affected by this pattern of complex
instability [35, 40]. Recently, some authors pointed out the
biomechanical function of the anteromedial aspect of cor-
onoid, and they demonstrated that if these fractures are left
untreated they can cause subluxation of the ulnohumeral
joint, eventually leading to an early onset of posttraumatic
arthritis [40, 41]. This pattern of instability can be diag-
nosed radiographically by the wedge sign and the double
crescent sign [35]. It is essential to apply the principles of
treatment of complex elbow instability to these injuries,
including a stable osteosynthesis of coronoid fracture and
ligament repair.
In this injury, a posterior skin incision allowing a good
exposure of the medial and lateral compartment is indi-
cated. To perform a coronoid osteosynthesis, a medial
surgical approach is necessary, such as the ‘‘over the top’’
approach [42] or the elevation of flexor-pronator muscles
from the subcutaneous and medial border of the ulna. ORIF
can be performed with screws or a precontured plate. We
often utilize the fixation fragment system (FFS, Orthofix)
in type I-II and in some of Type III fractures (Fig. 2). The
FFS allows to perform the ostheosyntesis in one step and
achieve a stable fixation. Two or more wires must be also
used to guarantee rotation stability. We use a precontured
plate only in the presence of a large fragment extending to
the ulnar shaft, or in cases of unstable fixation with FFS.
Frequently, ORIF restores MCL function because the lig-
ament is still attached to the fracture fragment. Instead,
when the ligament is detached from the proximal or distal
insertion, and in cases with mid-substance lesions, we
proceed to the reconstruction of the ligamentous injury.
After coronoid fixation, the LCL lesions are repaired
through the Kocher approach. In the majority of cases, a
complex ligament lesion is present, and frequently, the
LCL is detached from the epycondile [43]. We repair LCL
with one or more anchors and with side to side sutures.
Commonly, we utilize Krachow or Mason sutures to rein-
force the ligaments reinsertion. After LCL reconstruction,
the elbow should be tested under fluoroscopy to verify the
recovery of joint stability. In the presence of significant
persistent instability and/or unstable ORIF of the coronoid
process, a dynamic elbow fixator (DEF) should be con-
sidered [32, 33]. After surgery, the elbow should be
Musculoskelet Surg (2010) 94 (Suppl 1):S25–S36
Fig. 2 a Preoperative 3D CT scan of a 40-year-old patient, demonstrating an anteromedial coronoid fracture. b, c Postoperative radiographs
after osteosynthesis with two Fixation Fragment System and LCL repair with suture anchor
protected from varus and gravitational stresses avoiding
shoulder elevation in internal rotation. This can also be
obtained with an hinged brace for 6 weeks. A limited
extension (-30°) may be indicated for the first 3–4 weeks
to avoid mechanical loads on the anterior part of coronoid.
During flexion–extension exercises, the forearm is posi-
tioned in pronation or supination in case of inadequate LCL
or MCL reconstruction, respectively. When both ligaments
reconstruction is inadequate, the forearm is positioned in
neutral rotation. However, the complete forearm rotation is
allowed immediately at 90° of flexion. At the fourth week,
the recovery of full extension is allowed.
Terrible triad
Elbow dislocation associated with both radial head and
coronoid fractures have been termed ‘‘terrible triad’’
because of the difficulties inherent in treatment and the
consistently poor reported results [44, 45]. Recently, some
authors proposed a standard surgical protocol to treat this
type of injury. However, the results are not predictable, and
despite an improvement in the clinical outcomes, stiffness,
chronic instability and post-traumatic osteoarthritis are still
frequently observed [45–48].
The correct management of terrible triad consists in the
diagnosis and treatment of the injured anatomical struc-
tures. A posterior skin incision (which allows a good
exposure of both medial and lateral compartment) is per-
formed, and RHF is exposed through Kocher interval.
Osteosynthesis with headless screws or plate is performed
in Type I and Type II fractures (Hotchkiss classification).
In comminuted radial head fractures (Type III) is manda-
tory a prosthetic replacement to avoid chronic instability
[49–52]. Before radial head reconstruction or artroplasthy,
S29
coronoid ostheosynthesis can be performed through a lat-
eral approach after the removal of radial fragments. The
coronoid fracture is often a comminuted type I, and it is
possible to perform only a trans-osseous suture (Fig. 3). If
an isolated fragment is present and this is large enough to
be fixed, it is possible to accomplish an osteosynthesis with
two FFS wires or screws. Instead, in cases of partial radial
head fracture (i.e. Type I-II Hotchkiss), a coronoid ORIF
must be performed through the medial approach as
described above. The LCL repair is then performed, and
elbow stability assessed with fluoroscopy. In presence of
residual instability, MCL should be repaired or an hinged
external fixator should be applied. This device allows early
mobilization of the elbow, ensures ligaments healing in
physiological tension and protects the osteosynthesis
[32, 33]. MCL is also repaired when a medial approach is
performed to treat a coronoid fracture. In cases of associ-
ated flexor-pronator and/or extensor-supinator muscles
lesions, the elbow may be still unstable after LCL recon-
struction. In these cases, we recommend the application of
an elbow fixator, especially when the medial side of the
elbow has not been exposed.
Transolecranon fracture-dislocation
Biga e Thomine first introduced the term of trans-olecranon
anterior fracture-dislocation to describe a definite lesion
[53]. This injury includes an olecranon fracture associated
with an anterior dislocation of the forearm with respect to
the distal humerus. In this fracture, the capsule-ligamen-
tous restraints of the proximal radio-ulnar joint, in partic-
ular the annular and quadrate ligaments, remain intact.
Commonly, this lesion results from a high energy blow to
the dorsal aspect of the forearm, with the elbow in middle
123
S30
Fig. 3 a, b Preoperative radiographs of a 45-year-old man with terrible triad injury, after reduction of elbow dislocation. c, d Postoperative
radiographs showing radial head arthroplasty, LCL repair with suture anchors and trans-osseous suture of type I coronoid fracture
flexion. The authors described also two subtypes of this
lesion based on absence (Type I) or presence (Type II) of
olecranon comminution [53]. The osseous injury can be a
stable, non-comminuted, transverse fracture of the olecra-
non but is more frequently a complex and comminuted
fracture involving the trochlear notch and, in some cases,
the coronoid process. This injury is extremely rare, and its
true incidence in literature is not well known, also because
it is often misidentified as an anterior or atypical
Monteggia lesion.
Some authors reported good results after the surgical
treatment of transolecranon fracture-dislocation, and this
seems to be particularly true when the radial head and
collateral ligaments are not injured [54, 55]. In these cases,
reduction and olecranon osteosynthesis restore elbow sta-
bility. In some cases, a large Type III coronoid fracture is
associated with transolecranon fracture-dislocation; if this
associated fracture fragment is not recognized and treated,
a poor outcome inevitably occurs [54]. Although the
essential step of the treatment is stable osteosynthesis of
the ulnar fracture, in transolecranon fracture-dislocation,
the key of the treatment is the restoration of the contour
123
Musculoskelet Surg (2010) 94 (Suppl 1):S25–S36
and width of the trochlear notch [56]. The synthesis is
performed with a posterior precontured plate (Fig. 4).
When the ulnar fracture is comminuted and a rigid internal
fixation cannot be achieved due to the severe bone loss, the
use of bone graft (chips) may be considered to sustain the
articular surface and obtain a stable ORIF. Although we
recommend fixation with plate, tension band wiring may be
sufficient in some simple transverse fracture (Type I). The
coronoid fracture osteosynthesis can be performed with
fixation fragment system, screws or precontured plate
based on the fragment size. After that, elbow stability is
assessed with fluoroscopy. In presence of residual insta-
bility, LCL should be repaired. A hinged external fixator
should be implanted in cases of unstable osteosynthesis of
small fracture fragments.
Monteggia-like-lesions
In 1814, Giovanni Battista Monteggia first described this
lesion like a fracture of the proximal ulna associated with
anterior dislocation of the radial head. However, recently,
Musculoskelet Surg (2010) 94 (Suppl 1):S25–S36
Fig. 4 a, b A 38-year-old man sustained an anterior transolecranon fracture-dislocation. c, d The ulnar fracture underwent ORIF with a
precontoured posterior plate
the eponym of Monteggia fracture includes various patterns
of complex fracture-dislocation of the proximal ulna and
radius which are not well defined yet. In these types of
lesions, it is common the association of coronoid, olecranon
and radial head injury, that is, most of the bone structures
implicated in the elbow stability are disrupted [57].
Several classifications have been proposed for this
condition. Bado proposed a first classification based on the
direction of the radial head displacement and the angular
deformity of ulnar fracture. The author classified this lesion
into four Types: Type 1 lesion is characterized by a fracture
S31
of the ulnar diaphysis at any level, with anterior angular
deformity, associated with anterior dislocation of the radial
head; Type 2 lesion is a fracture of the ulnar diaphysis at
any level, with posterior angular deformity, associated with
posterior dislocation of the radial head; Type 3 lesion is a
fracture of the ulnar metaphysis associated with lateral or
anterolateral dislocations of the radial head; and Type 4
lesion is defined as a fracture of both forearm bones with
anterior dislocation of the radial head. He described also
several Type 1 equivalent lesions, having in common the
same mechanism of injury [58].
123
S32
Jupiter further classified the posterior Monteggia lesion
(Bado Type II) depending on the location and type of the
ulnar fracture and the pattern of radial head injury. In Type
IIA, the fracture of the ulna involves the distal part of the
olecranon and the coronoid process; in type IIB, the frac-
ture involves the metaphyseal-diaphyseal junction, distally
to the coronoid process; in Type IIC, a diaphyseal fracture
is present and in Type IID, the fracture extends from the
olecranon to the proximal half of the ulna. Radial head
fractures were classified in 4 types: Type 0, no fracture;
Type 2, two part fracture; Type 3, three part fracture; Type
C, comminuted fractures [59].
In Monteggia-like-pattern, six essential lesions can be
identified and each of them must be recognized and treated:
(1) Ulnar fracture, (2) Radio-humeral dislocation, (3) Ulno-
humeral dislocation, (4) Proximal radio-ulnar dislocation,
(5) Radial fracture and (6) Distal radio-ulnar joint\inter-
osseus membrane lesion. The various combination of these
critical lesions can explain the complexity and variety of
their treatment.
In all ulnar fractures, osteosynthesis with a posterior
precontured plate is indicated. In the presence of sigmoid
notch comminution, the use of allograft might be consid-
ered to sustain the articular surface and to obtain a stable
ORIF. Although we advocate fixation with plate, tension
band wire may be sufficient in some cases of simple
transverse olecranon fracture. In ulnar shaft fracture, it is
essential to restore the rotational and longitudinal align-
ment as well ulnar length. In some metaphyseal ulnar
fracture with an isolated large coronoid fragment (Type III
subtype 2 O’Driscoll), osteosynthesis can be performed
with a second antero-medial plate (Fig. 5). The
Fig. 5 a, b Postoperative radiographs showing ulnar osteosynthesis with posterior and medial plates, in a 32-year-old man with Monteggia-like-
lesion
123
Musculoskelet Surg (2010) 94 (Suppl 1):S25–S36
osteosynthesis of coronoid fracture is mandatory also to
restore the biomechanical function of MCL. Likewise,
when the crista supinator is involved as an isolated frag-
ment, its reduction is essential to recover LCL function.
The radial head fracture is treated as previously described.
In this setting, radial head resection is not advisable since
this may cause a proximal migration of the radius as a
result of the lesion of the interosseous membrane which is
frequently associated. In these cases, capitellectomy may
worsen the elbow and forearm instability [26–30]. In cases
of radial shaft fractures (Bado Type IV), osteosynthesis
with plate is indicated to restore rotational and longitudinal
alignment and radial length.
When radial head instability persists after osteosynthesis
of the ulnar fracture, it is necessary to expose the radio-
humeral joint to evaluate possible tissues interposition (i.e.
interposition of annular ligament) and to repair LCL
complex. Persistent instability or irreducibility of the radial
head may also be related to an ulnar shortening, whereby in
these cases, it is essential to assess ulnar alignment.
The Essex-Lopresti lesion is frequently associated with
Monteggia-like lesions; in this condition, radio-ulnar pin-
ning and/or TFCC repair may be indicated when DRUJ
instability persists after treatment of the radial head
[60–62]. After ORIF and ligaments reconstruction, the
elbow should be evaluated under fluoroscopy to verify the
recovery of ulno-humeral, radio-humeral and proximal
radio-ulnar joint stability. In cases of Essex-Lopresti
lesion, the DRUJ stability must be also evaluated. The
dynamic elbow fixator (DEF) should be considered in cases
of persistent instability of the ulno-humeral joint or
unstable ORIF of small articular fragments (Fig. 6).
Musculoskelet Surg (2010) 94 (Suppl 1):S25–S36
Fig. 6 a, b Antero-posterior and lateral elbow radiographs demon-
strating Monteggia Bado II Jupiter A R2 lesion in a 53-year-old man.
c, d Postoperative radiographs showing ulnar osteosynthesis with
Humeral shear fractures associated with lateral
and medial collateral ligaments lesions
(with or without elbow dislocation)
Recently, we described a new pattern of complex elbow
instability: a distal humerus shear fracture associated with
elbow dislocation or MCL tear [63] (Fig. 7). This rare
injury may be successfully treated once the ligamentous
injury has been diagnosed and an appropriate surgical
treatment performed. In our case series, we described nine
patients with isolated capitellar or capitellar and trochelar
fractures associated with elbow dislocation (four patients)
or MCL tear (five patients). An osteosynthesis with Herbert
S33
posterior precontoured plate, radial head osteosynthesis with headless
screws, LCL repair with suture anchors, trans-osseous suture of type I
coronoid fracture and hinged external fixator
screws was performed along with the suture of LCL with
trans-osseous suture and the positioning of an hinged elbow
fixator. MCL was treated conservatively and left to heal
during the period in which the external fixator was in place
(Fig. 8). All our patients recovered or exceeded the func-
tional range of motion in 6 weeks; In all cases, the elbow
was stable, with the exception of 1 patient who had mod-
erate varus instability at the time of removal of the fixator,
and such an instability was found to persist at final eval-
uation (mean 29 months). Fracture union occurred in eight
cases, with no evidence of avascular necrosis. In one
patient, radiographs obtained at the 9-month follow-up
showed an asymptomatic pseudarthrosis and partial
123
S34
Fig. 7 Radiograph shows a capitulum humeri fracture associated
with elbow dislocation
Fig. 8 Capitulum humeri osteosynthesis with Herbert screws asso-
ciated with hinged elbow fixator, in a 43-year-old man who sustained
a capitulum humeri fracture-dislocation
123
Musculoskelet Surg (2010) 94 (Suppl 1):S25–S36
extrusion of an Herbert screw, which was removed. At final
follow-up, two patients had minimal bone resorption of the
capitellum with moderate lateral compartment osteoar-
thritis which did not affect the clinical result. All patients
were satisfied with their outcome and had returned to their
previous activity levels. The average score on the MEPS
was 98 (75–100), which reflects an excellent outcome. To
our knowledge, this is the first study which describes this
particular injury pattern and treatment. We believe that this
lesion is often underestimated. A correct surgical protocol
includes stable osteosynthesis and ligament repair. In
addition, a hinged external fixator should be implanted in
the presence of persistent instability after bone and liga-
ments reconstruction, and when a stable fixation of bone
fragments cannot be obtained with ORIF.
Postoperative management
The same postoperative management is carried out in all
patients. At the end of surgery, two drains are placed (one
endoarticular and one subcutaneous) followed by the
positioning of an elbow cast for 48 h. We decide the elbow
position at the end of the surgical procedure, having
evaluated the joint stability under fluoroscopy. We usually
position the elbow in maximum extension to avoid both
anterior bleeding and flexion contracture. At the third
postoperative days, all patients start active and passive self-
assisted range of motion exercises. Cryotherapy, antidec-
live position and kinesio-tape are applied in the first week.
We believe that in the peri-operative period it is essential a
correct analgesia to allow an early motion of the joint. The
range of motion is permitted within the range of stability
that was noted intraoperatively. In presence of LCL or
MCL deficiency, the patient may perform flexion–exten-
sion exercises in pronation or supination, respectively.
However, the complete forearm rotation is allowed
immediately at 90° of flexion. If the fractures and liga-
ments are securely repaired, unlimited exercises are
allowed.
Active shoulder, wrist and hand motion are encouraged
from the first postoperative day. All patients wear a hinged
brace during time intervals between exercises and are
encouraged to maintain the elbow in extension position. At
night, they wear a splint alternately locked in maximum
extension and flexion. The brace is removed 6 weeks after
surgery. Indomethacin (100 mg-daily) is administered for
4–5 weeks to prevent heterotopic ossifications and to
control swelling and pain. Strengthening exercises are
started when radiographs show evidence of fracture healing
and, in any case, 6 months after surgery. In patients
showing a delay in the recovery of the range of motion,
continuous passive motion is used.
Musculoskelet Surg (2010) 94 (Suppl 1):S25–S36
Finally, when, for any reason, the surgeon is forced to
choose between a stable or a mobile elbow; he should
consider that a stiff, but congruent, elbow is probably
easier to treat than a chronically unstable elbow [39].
Conflict of interest None.
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