This is a retrospective review of 21 patients who had chronic instability following a coronoid fracture-dislocation of the elbow (terrible triad). The authors retrospectively evaluated 21 patients treated at the Mayo Clinic from 1985-1996 with elbow fracture dislocations involving the coronoid, who had had prior surgery and presented with persistent subluxation. The patients were treated with a variety of procedures, with the goals being: 1) restoration of integrity of ulnohumeral joint; 2) reduction and stabilization of the ulnohumeral joint; and 3) early active motion.
The authors performed reconstruction of osseous deformity, reconstruction of the lateral collateral ligament and, if necessary, application of an external fixator. They report their outcomes of reconstruction at an average follow-up of 5 years. The results indicate that 13 of 21 patients were considered to have a satisfactory outcome. When the authors examine specific factors relating to the success, they found that the extent of the coronoid fracture did not predict the likelihood of a subjective satisfactory result. They felt that the delay to definitive treatment had a direct correlation with satisfactory outcome. Interestingly, the authors found that the coronoid reconstruction using an augmentation procedure was successful in only 56% of the cases, and this was not associated with change in either objective or subjective outcome.
The authors do note that repair or reconstruction of the lateral collateral ligament was an integral part of the solitary reconstructive effort. The authors evaluated the radial head fracture type and management and were able to conclude that radial head excision led to significantly worse outcomes than when an attempt was made for repair or reconstruction. The authors felt that the use of an articulated external fixator may have benefited patients. However, there was no direct correlation between the use of the external fixator and subjective and objective outcomes.
Interestingly, when the authors evaluated their radiographic outcomes, they found that only 13 of 21 elbows were perfectly reduced. They did find that this had a significant bearing on final functional rating.
This article points out the many complications associated with treating these difficult fracture dislocations on a late basis after failure of initial management. The authors had difficulty demonstrating the statistical significance of their procedure, largely due to small sample size and the integral relation between more advanced techniques being required for more difficult problems. The low percent of satisfactory outcomes highlights the importance of proper initial care of these injuries. The goals of initial treatment include repair or replacement of the bony injury and most importantly, repair of the soft-tissue envelope necessary to maintain elbow joint congruity and stability.
Elbow, Trauma, Fracture, Coronoid, Dislocation, Reconstruction, Instability