3.4 Elbow
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1 Introduction
Older adults with elbow fracture dislocations (EFDs) present with a wide range of functional, physical, and cognitive impairments. Therefore, the surgical solution must be customized and adapted to the functional needs and ability to comply with postoperative care and rehabilitation. The most important goal is a stable joint to allow early postoperative motion [1]. Geriatric patients with a stiff elbow joint may lose independence in activities of daily living.
Geriatric EFD usually occur after low-energy falls from standing height with the elbow joint in extension and abduction, while the forearm is in supination. They are typically associated with poor bone quality [2, 3].
Patients generally present suffering from pain, swelling, and limited range of motion (ROM) of the elbow [4]. In older patients, simple elbow dislocations with ligamentous injuries only are rare because of the reduced bone quality. Elbow dislocations are mostly associated with fractures of the distal humerus or the olecranon [5].
In EFD, the extent of concomitant bony and ligamentous injuries is proportional to the functional outcome and complications [6]. Retrospective studies show primary total elbow replacement in elbow dislocation fractures produces good to excellent results [5, 7]. With the goal of single-shot surgery, the ideal treatment modality is often the one least prone to complications.
2 Epidemiology
Elbow dislocations are the most common dislocations after those involving the shoulder, with an incidence of 6–13 cases per 100,000 person-years [8]. A systematic review of elbow dislocations between 2002 and 2006 in 102 hospitals in the US reveal an incidence of 5.21 dislocations per 100,000 person-years, a slight male predominance (53%), with the majority caused by falls and in the home setting (51.5%) [9]. Elbow dislocations account for 11–28% of all elbow injuries and involve the nondominant extremity in approximately 60% of the cases [10–12].
While some authors report concomitant coronoid fractures in about 10% of the elbow dislocations [13], others claim that almost every elbow dislocation is associated with a coronoid fracture as a result of shear forces caused by posterior translation against the humeral trochlea [2] after falls on the outstretched hand [4]. An additional rupture of the anterior bundle causes compression fractures of the radial head [14].
McKee et al [15] demonstrated a lesion of the lateral collateral ligament (LCL) complex in 100% of elbow dislocations and involvement of medial collateral ligament (MCL) complex in 80% of cases.
3 Classification
There are three major patterns of traumatic EFD: posterolateral, anterior, and posterior transolecranon fracture dislocations.
3.1 Posterolateral instability (terrible triad)
Posterolateral EFD include fractures of the radial head and the coronoid with a rupture of the LCL complex ( Fig 3.4-1 ). In most cases, at the time of trauma the elbow pivots around the MCL leaving this ligament complex intact. Posterolateral impaction fractures of the capitellum are frequent [16].
3.2 Varus posteromedial instability
This injury is characterized by an anteromedial coronoid fracture with LCL complex rupture. In most cases, the coronoid is fractured at the level of the anteromedial facet, which is also known as the sublime tubercle, where the MCL inserts. The lateral ulnar collateral ligament is mostly avulsed from the dorsal radial epicondyle. The radial head stays intact in most of the cases ( Case 1: Fig 3.4-2 ).
CASE 1
Patient
A 75-year-old woman fell at home from standing height and sustained an elbow fracture dislocation with intraarticular fragments ( Fig 3.4-2a–b ).
Comorbidities
Hypertension
Hypothyroidism
Treatment and outcome
The coronoid is fractured with its anteromedial facet (sublime tubercle) as the insertion point of the anterior part of the medial collateral ligament complex. Additionally, the lateral ulnar collateral ligament is avulsed with a bone fragment from the posterolateral aspect of the distal humerus ( Fig 3.4-2c–f ). After closed reduction, the joint was unstable in < 40° of flexion.
Intraoperatively, the lateral ulnar collateral ligament was avulsed with a bony fragment from the posterolateral humeral surface ( Fig 3.4-2g ).
Open reduction and plate fixation of the radial distal humeral column was performed. The ulnar ligament complex was fixed to the plate using fiber wire. This resulted in a stable elbow joint in full extension ( Fig 3.4-2h–j ).
The 12 month follow-up demonstrates concentric reduction of the ulnohumeral joint and a good functional result ( Fig 3.4-2k–p ).
3.3 Anterior transolecranon fracture dislocation
In this pattern, the distal humerus displaces across the facets lunaris of the proximal ulna, fracturing the olecranon with variable involvement of the coronoid or the proximal ulnar shaft, leaving the radial head intact ( Fig 3.4-3 ).
3.4 Posterior transolecranon fracture dislocation
In this type, the proximal ulnar fractures and the radius dislocate posteriorly leading to shear fractures of the radial head and neck. Coronoid fractures also belong to this type of injury ( Fig 3.4-4 ).
In those cases in which the proximal radioulnar joint is disrupted, the subtype is called Monteggia equivalent. The proximal radioulnar dislocation may best be detected on axial computed tomographic (CT) scan views.
Ligaments are avulsed with bone fragments so that bone fixation restores the ligamentous instability ( Case 2: Fig 3.4-5 ).
CASE 2
Patient
An 83-year-old man fell on the extended right arm while skiing and sustained a Monteggia equivalent fracture dislocation with associated radial head and neck fractures. He presented with moderate swelling and pain ( Fig 3.4-5a–h ).
Comorbidities
No comorbidities were documented
Treatment and outcome
Surgery was performed in prone position. Findings showed a complete rupture of the medial collateral ligament complex. The radial head was dislocated posteriorly out of the proximal radioulnar joint. The attempt to reconstruct the radial head and neck failed so the remaining radial head was resected, making the exposure to the fractured coronoid easier. Cannulated screw fixation of the coronoid process and plate fixation of the olecranon was performed. The radial head was replaced by a prosthesis and repair of the lateral collateral ligament complex resulted in a stable condition on the ulnar site. Intraoperative x-rays showed no subluxation or dislocation.
Follow-up x-rays at 16 months showed a concentric radio- and ulnohumeral joint with bone union ( Fig 3.4-5i–j ).
4 Therapeutic options
4.1 Nonoperative treatment
The majority of EFD are treated operatively to avoid osseous nonunion or recurrent dislocation [17]. Operative intervention restores stability and permits early motion of the elbow. Chan et al [17] demonstrated that a small subset of patients can be treated nonoperatively. Criteria for the nonoperative management include:
Concentric elbow reduction, documented by CT scan
Stable arc of active motion to a minimum of 30° extension
Small and minimally displaced radial head fracture
Smaller coronoid tip fracture (Regan-Morrey classification types 1 or 2)
In these cases, the elbow fracture dislocation should be reduced and immobilized in an elbow cast with the forearm in neutral rotation for a maximum of 3 weeks. Frequent clinical and x-ray examinations can reveal potential complications like recurrent subluxation or dislocation which must initiate operative fixation. Physiotherapy can be initiated as soon as pain subsides and starts with passive and active exercises around the neutral position.
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