This study was a retrospective review by two surgeons of 36 patients with an elbow dislocation and associated fracture of the radial head and coronoid process, termed “terrible triad.” The operative approach included first addressing fixation of the coronoid fracture Type II and III injuries or anterior capsule in a Type I coronoid fracture. The radial head was either internally fixed or replaced with a metal prosthesis. The lateral collateral ligament complex and common extensor origin and/or posterior lateral capsule were repaired. The medial collateral ligament was repaired if there was residual posterior instability which was present in 6 patients. A hinged external fixator was then applied for instability, necessary in 2 patients. Postoperatively the elbow was placed at 90 degrees of flexion and forearm fully pronated to protect the lateral repair. If the medial and lateral soft tissues were repaired, the forearm was splinted in neutral rotation. Supervised range of motion was begun within 7 to 10 days after surgery, although this time to mobilization was shortened later in the study to within the first or second postoperative day. Flexion and extension exercises were performed with the forearm in pronation and active forearm rotation exercises were performed with the elbow in 90 degrees of flexion. The patients were instructed to avoid the terminal 30 degrees of extension until 4 weeks postoperatively. One surgeon used Indomethacin for 3 weeks postoperatively whereas the other author did not use any form of prophylaxis against heterotopic ossification.
At a mean of 34 months postoperatively, the flexion-extension arc of the elbow averaged 112 degrees + 11 degrees and forearm rotation averaged 130 degrees + 16 degrees. The mean Mayo Elbow Performance Score was 88 points (range, 45 to 100 points), which corresponded to 15 excellent results, 13 good results, 7 fair results and 1 poor result. Concentric reduction was maintained for 34 of the 36 elbows. Eight patients required a reoperation: 2 developed a synostosis, 1 had recurrent instability, 4 required hardware removal and elbow contracture release and 1 patient developed a wound infection. The mean time to surgical intervention was 4.5 days (range, 0 to 17 days). A total of 3 patients were placed in a hinged external fixator with 2 being placed at the index operation and 1 being placed after recurrent instability for a mean of 6.2 weeks. Calcification in the medial and lateral ligaments were common and was noted to some degree in 26 of the 36 elbows. There was no significant difference in the rate of synostosis or heterotopic ossification between the group that received Indomethacin and the group that did not.
This article essentially outlines the standard of care for the treatment of elbow fracture dislocations including a fracture of the coronoid and radial head. Although the results are much better than previous reviews, even for experienced elbow surgeons, there is still a 22% reoperation rate, 5% persistent instability rate despite reoperation and a 5% radioulnar synostosis rate. Therefore, these potential serious sequelae need to be discussed with patients who suffer this injury pattern, despite following standard protocol.
J Bone Joint Surg 86A: 1122-1130, 2004.