Management of Adult Elbow Fracture Dislocations

Elbow fracture dislocations are complicated injuries that are difficult to manage and fraught with complications. A complete series of radiographs is typically complemented with CT scan to evaluate the elbow and assist preoperative planning. Typically, operative intervention is necessary and a systematic approach to the elbow injuries should be chosen. This article addresses the coronoid and proceeds to the radial head, lateral soft tissues, and finally the medial ligaments if elbow instability persists. With a focused, systematic surgical approach, improved outcomes have been demonstrated and patients may recover full function and range of motion in the affected elbow.

Key points

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Complex elbow dislocations are typically high-energy injuries that present a challenge to the treating physician, almost always require surgery, and are commonly burdened with complications.
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Advanced imaging is often helpful to assess the extent of injury and to determine the approach and type of fixation necessary.
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A methodological surgical approach results in improved outcomes. The authors use an inside-out technique beginning with addressing any coronoid injuries if present, then proceed to the radial head, lateral ligament structures, and finally medial ligaments, if necessary.
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If elbow stability is in question after all bony and lateral ligamentous structures have been addressed, an external fixator may be applied with or without the repair of the medial ligaments.
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Early motion is crucial in avoiding postoperative stiffness and contractures; however, maintenance of a stable reduction is paramount.

Introduction

Adult elbow fracture dislocations present a significant challenge to the treating surgeon and are associated with a high complication rate. The elbow is a highly congruent trochoginglymoid joint with a significant amount of stability conferred from its bony structures. The elbow joint is comprised of articulations between the radial head and humeral capitellum, the olecranon and humeral trochlea, and the proximal radius and ulna. This construct is enhanced by the medial and lateral soft tissue constrains, which must also be addressed at the time of surgery.

Functional range of motion at the elbow is classically described as 50° of pronation and supination with a 100° arc of flexion, ranging from 30° to 130°. Contemporary studies using 3-D tracking techniques have found that required functional motion may be greater than previously reported. An important goal of treatment is to preserve or restore functional use of the elbow.

Dislocations of the elbow may be simple or complex, with simple dislocations representing a purely soft tissue injury of the elbow resulting in the dislocation. Complex dislocations are associated with a combination of fractures and soft tissue injuries, and for this reason may also be termed fracture dislocations .

In general, complex dislocations are described as anterior or posterior based on the translation of the ulna with respect to the distal humerus. Posterior dislocations are typically the result of an axial load applied through a supinated elbow with valgus stress. Conversely, anterior dislocations occur in the setting of a posterior force applied to the elbow in a flexed position or hyperextension trauma. The Horii circle, described by O’Driscoll and colleagues, outlines the typical pattern of soft tissue injury for elbow dislocations proceeding from lateral to medial ( Fig. 1 ).