Complex Elbow Instability

Robert Z. Tashjian, MD Abstract

Julia A. Katarincic, MD Complex elbow instability consists of dislocation of the
ulnohumeral joint with a concomitant fracture of one or several of
the bony stabilizers of the elbow, including the radial head,
proximal ulna, coronoid process, or distal humerus. Recurrent
instability is not often associated with simple dislocation, but an
improperly managed complex dislocation may be a prelude to
chronic, recurrent elbow instability. Complex instability is
significantly more demanding to manage than simple instability.
Radial head, coronoid, and olecranon fracture associated with
dislocation each must be assessed and often require surgery. Long-
term outcome with surgical management of complex elbow
injuries is unknown. A few published series examine combinations
of different injury patterns managed with various methods.
Recently, however, several well-designed prospective outcome
studies have evaluated management of several different individual
fracture-dislocation patterns with a unified treatment algorithm.
Fixation or replacement of injured bony elements, ligamentous
repair, and hinged fixation may be used to successfully manage
complex elbow instability.
Dr. Tashjian is Shoulder and Elbow
Surgery Fellow, Department of
Orthopaedic Surgery, Washington
University School of Medicine, St. Louis,
MO. Dr. Katarincic is Assistant
Professor, Department of Orthopedic
E lbow instability may occur after
any one of a large group of di-
verse injuries, such as a fall on an
dislocation.2 Complex dislocations
may include fracture of the radial
head, coronoid process, olecranon, or
Surgery, Brown Medical School, outstretched hand, motor vehicle ac- distal humerus. The risk of recurrent
Providence, RI. cident, or direct trauma, resulting in or chronic instability and posttrau-
None of the following authors or the fractures or dislocations. Instability matic arthrosis is increased signifi-
departments with which they are may be categorized anatomically as cantly with complex dislocation.3,4
affiliated has received anything of value simple (with no associated fracture) Chronic unreduced dislocations and
from or owns stock in a commercial or complex (with associated fracture) recurrent instability in complex in-
company or institution related directly or or chronologically as acute, chronic, juries are very difficult to manage. In
indirectly to the subject of this article: or recurrent. These categories are not addition to surgical intervention,
Dr. Tashjian and Dr. Katarincic. mutually exclusive. The elbow is one they often require the use of a hinged
of the most commonly dislocated external fixator to hold the elbow in
Reprint requests: Dr. Katarincic,
joints in the body, with an average a reduced position.5,6
University Orthopedics, Suite 200, 2
Dudley Street, Providence, RI 02905.
annual incidence of acute dislocation Early clinical series laid the
of 6 per 100,000 persons.1 Simple dis- groundwork for understanding the
J Am Acad Orthop Surg 2006;14:278- locations, which are much more natural history of fractures of the
286 common than complex dislocations, coronoid process and radial head
Copyright 2006 by the American are described by the direction of the with and without associated
Academy of Orthopaedic Surgeons. dislocated ulna. Posterolateral dislo- dislocation.1,3,4,7-9 Recent clinical re-
cation is the most common simple search has focused on outcomes of

278 Journal of the American Academy of Orthopaedic Surgeons

 Robert Z. Tashjian, MD, and Julia A. Katarincic, MD

Figure 1

Structure of the medial collateral ligament complex (A) and the lateral collateral ligament complex (B).

currently recommended methods of ies have significantly expanded our fixation. Similarly, the anterolateral
treatment. For radial head fracture, knowledge of elbow instability and one third of the radial head is void of
monoblock titanium replacement is its management. cartilage, providing an optimal posi-
recommended, or internal fixation tion for hardware. The sigmoid
with low-profile plates and mini- Functional Elbow notch of the proximal ulna forms an
screws. Dislocation with associated Anatomy ellipsoid arc of 190°, with a void of
radial head and coronoid process articular cartilage in the midportion
fracture (ie, terrible triad injury) is Flexion and extension of the elbow allowing for osteotomy through a
managed by fixation, arthroplasty, or are provided by the ulnohumeral nonarticulating segment.18
ligament reconstruction. Recurrent joint. Pivoting (axial rotation) is pro- Besides the osseous structures, the
instability is treated with hinged el- vided by the radiohumeral and prox- medial collateral ligament (MCL) and
bow fixators.10-13 Long-term out- imal radioulnar joints. The trochlea, lateral collateral ligament (LCL) com-
comes have been reported on non- which is covered by articular carti- plexes are the other primary compo-
surgical management of radial head lage over an arc of 300°, is highly nents of elbow anatomy. They have
fractures.14 The classification of conformed to the proximal ulna. a significant role in elbow stability.
coronoid process fractures recently This articulation is predominantly The MCL complex includes an ante-
described by O’Driscoll et al,15 responsible for the bony stability of rior, posterior, and transverse seg-
which is based on the fracture pat- the elbow.16 The capitellum is spher- ment, of which the anterior bundle is
tern, may better guide the surgical ical in shape and is separated from the most important for stability (Fig-
management of these injuries. the trochlea by a groove in which the ure 1, A).16 The anterior bundle of the
The goal of managing complex el- radial head rim articulates. MCL originates from the anteroinfe-
bow instability is to regain a concen- With respect to the humeral rior surface of the medial epicondyle
tric and stable reduction of the el- shaft, the distal humerus is tilted an- and inserts on the sublime tubercle
bow that permits a functional range teriorly 30° in the lateral plane and of the coronoid process an average of
of painless motion. This outcome is internally 5° in the transverse plane, 18 mm distal to the tip of the coro-
often difficult to achieve. The sur- and is in 6° of valgus in the frontal noid.19,20 The LCL complex is com-
geon must have a thorough under- plane.16 The center of rotation of the posed of the radial collateral liga-
standing of the anatomy of the ulnohumeral joint is defined by its ment, annular ligament, lateral ulnar
elbow, including the bony and liga- axis, which projects laterally from collateral ligament, and an accessory
mentous components necessary for the center of the capitellum and me- lateral collateral ligament. The lat-
stability. Additionally, the surgeon dially from the anteroinferior aspect eral ulnar collateral ligament origi-
must understand the surgical op- of the medial epicondyle.17 The radi- nates from the lateral epicondyle,
tions and treatment outcomes for al head and neck form an angle of blends with the annular ligament,
complex instability. The most re- 15° with the radial shaft; this angle and inserts into the supinator crest of
cent clinical and basic research stud- must be considered during internal the proximal ulna (Figure 1, B). The

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Complex Elbow Instability

lateral ulnar collateral ligament is the sistent pain, results of delayed exci- dislocation, internal fixation of ra-
primary provider of posterolateral sion are favorable.14 Surgical fixation dial head fractures may restore
stability.21 of type II and III fractures with mini- valgus stability better than replace-
plates and screws also has been rec- ment. However, caution is war-
ommended, with favorable overall ranted when making this assump-
Complex Instability
results.7 Fixation of comminuted tion because it is true only when the
Complex elbow dislocation consists fractures (type III and IV) using low- fixation construct is as strong as the
of both ligamentous and bony in- profile miniplates has 90% good or native radial head.
juries. These injuries are less fre- excellent results.11 In contrast, the For a time, silicone was the most
quent, more difficult to treat, and results of another recent study sug- widely available prosthesis, and clin-
often have poorer results than simple gest that internal fixation should be ical experience suggested that re-
dislocation. Injury to at least one os- reserved for minimally comminuted placement with silicone yielded bet-
seous structure in conjunction with fractures with three or fewer articu- ter results than did simple resection.
elbow dislocation increases the risk lar fragments.12 Controversy still ex- A high failure rate (17% to 29%) has
of recurrent instability and arthro- ists regarding which fractures are op- been reported, with breakage or sil-
sis.3,4 The radial head and coronoid timally treated with reduction and icone synovitis requiring revision af-
process are the most commonly frac- internal fixation as well as whether ter silicone head replacement.31,32
tured structures in these injuries.22 a fracture may be too comminuted Clinical series reporting the results
Both the fractures and the soft- to fix. of monoblock titanium33 and Vitalli-
tissue injuries must be addressed Radial head reconstruction or re- um34 replacements for comminuted
during treatment, which includes re- placement is required in the setting radial head fracture indicate 68%
ducing the dislocation, managing the of complex elbow instability be- good or excellent results at 3 years33
fracture (eg, fixation, replacement), cause of its role as a secondary val- and 71% pain relief with no residu-
and repairing the collateral ligament gus stabilizer.24,25 The radial head al instability at 4.5 years.34 Isolated
(lateral and possibly medial). Hinged provides 30% of valgus stability. In fractures, fracture-dislocations, and
external fixation is applied when in- the setting of an intact MCL com- combined radial head and coronoid/
stability persists. Injury categories plex, however, its removal results in olecranon fractures were reported in
include ligament injuries combined no subluxation with valgus stress; these series. Harrington et al35 re-
with radial head fractures, isolated subluxation occurs only with forced viewed monoblock titanium radial
coronoid process fractures, terrible external rotation.24,26-28 With intact head replacement in 20 patients who
triad injury, posterior Monteggia le- ligaments and an absent radial head, had fracture-dislocations with coro-
sions, or anterior transolecranon removal of 30% of the coronoid ful- noid or olecranon fracture. At 12-
fracture-dislocation. ly destabilizes the elbow; stability is year follow-up, 80% had good or ex-
restored with metallic radial head re- cellent results; however, only 30%
Radial Head Fracture placement.28 were completely pain free, and 45%
Associated With Maintaining an intact or replaced had evidence of arthritis. Most re-
Dislocation radial head is much more important cently, Ashwood et al10 reported the
Radial head fracture is the most with deficiency of the MCL. With an results of 16 patients who under-
common bony injury to the adult el- intact radial head, release of the an- went titanium monoblock radial
bow.15 Hotchkiss23 modified the Ma- terior portion of the MCL produces head replacement and LCL repair for
son classification system to include mild increased laxity; subluxation Mason type III fractures (Figure 2).
treatment options for each type of occurs only after subsequent exci- At a mean of 2.8 years after injury,
isolated radial head fracture. In gen- sion of the radial head, emphasizing 81% had a good or excellent result.
eral, isolated type I fractures may be its role as a secondary stabilizer to The authors emphasized the benefits
treated nonsurgically, type II and III valgus stress.27 Silastic radial head re- of early (<2 weeks) surgical treat-
fractures should be fixed or excised. placement does not restore the val- ment followed by early motion with
Favorable long-term (>20 years) out- gus stability of the native radial head no period of splinting.10 Because all
comes of nonsurgically managed iso- after MCL release.26,29 Metallic radial series include heterogenous groups
lated Mason type II and III fractures head replacements, with either of injuries, it is difficult to make as-
have recently been reported, indicat- monoblock or bipolar radial heads, sumptions regarding the outcome of
ing that there is still reason for con- improve valgus stability that ap- treatment of radial head fractures
troversy.14 More than 75% of frac- proaches but does not completely with associated dislocation.
tured elbows develop some degree of achieve that of the native radial head With radial head fracture in the
arthritis, yet this seems to be of mi- when associated with MCL insuffi- setting of complex elbow instability,
nor relevance. In the presence of per- ciency.30 Thus, after a fracture- the head should be either fixed or re-

280 Journal of the American Academy of Orthopaedic Surgeons

 Robert Z. Tashjian, MD, and Julia A. Katarincic, MD

Figure 2

A, Preoperative lateral radiograph demonstrating posterolateral fracture-dislocation of the radial head. The anterior half of the
radial head at the time of surgery was extremely comminuted into multiple fragments. B, Metallic radial head replacement and
lateral collateral ligament reconstruction with suture anchors were performed. Emphasis was placed on appropriately sizing the
radial head to ensure that the proximal aspect of the implant was at the level of the coronoid and the anchor for the ligament
repair was in the center of the capitellum circumference.

Figure 3

Regan-Morrey classification of fractures of the coronoid process. A, Type I is a simple avulsion. B, Type II demonstrates a single
or comminuted portion involving approximately 50% of the coronoid process. C, Type III is a fracture involving >50% of the
articulation. (Reproduced with permission from Cohen MS: Fractures of the coronoid process. Hand Clin 2004;20:443-453.)

placed with a metallic radial head For the surgeon, internal fixation re- rey9 described a classification system
implant. Analyzing the literature on quires confidence in performing this of coronoid fractures based on the
fixation versus replacement in the demanding procedure. size of the fractured portion of the
setting of instability is difficult be- coronoid and noted that the rate of
cause most series include a mixture Coronoid Fracture dislocation, failed results, and resid-
of radial head fractures with and Very little has been written about ual stiffness increased with the size
without associated instability. For managing fractures of the coronoid of the coronoid fracture. They recom-
arthroplasty, modular metallic radi- process. The results of management mended fixation of fragments involv-
al head implants have made implan- are difficult to infer because they are ing >50% of the process (Figure 3).
tation much easier because they pro- combined with other fractures in Since then, several authors have rec-
vide the option of assembly in situ. most reported series. Regan and Mor- ommended that, in the setting of in-

Volume 14, Number 5, May 2006 281

Complex Elbow Instability

Figure 4

Coronoid fracture fixation techniques. A, Lasso repair, in which the suture is placed around a small coronoid piece and then
passed through drill holes posteriorly in the ulna. B, Medial approach to the coronoid. C, The flexor/pronator is partially reflected
just anterior to the flexor carpi ulnaris. D, Posterior reduction of the coronoid process through a proximal ulna fracture (arrow).

stability, most coronoid fractures be reflecting a portion of the flexor- lime tubercle and laterally extends
fixed independent of size.15,36,37 pronator mass distally after ulnar just medial to the tip of the coro-
A large coronoid process fragment nerve isolation; laterally through a noid), and base (involving the coro-
should be fixed with an an- fractured radial head; or posteriorly noid body with >50% of the height).
teromedial plate or with screws orig- through a fractured olecranon before Identifying the anteromedial frac-
inating from the posterior border of olecranon or radial head repair. tures is a key element of this classi-
the ulna. The anterior capsule with Most recently, O’Driscoll et al15 fication system. Despite the small
a small fragment should be repaired introduced a classification system of size of these fractures and their often
so as to reproduce an anterior but- coronoid fractures based on anatom- subtle radiographic presentation,
tress. Referred to as a Lasso repair, ic location of the fracture fragments they may predispose to rapid arthri-
this technique requires whipping a (Figure 5). Fractures are classified tis if left unreduced.15
stitch around the small fragment and into those involving the tip (fracture
the anterior capsule, passing the su- line does not extend medially past Terrible Triad Injury
ture ends through drill holes in the the sublime tubercle or into the Dislocations with associated radi-
ulna, and tying the sutures over the coronoid body), anteromedial frag- al head and coronoid process frac-
posterior ulna cortex (Figure 4). The ment (fracture line exits the medial tures have been termed terrible triad
fracture can be approached medially, cortex in the anterior half of the sub- injuries because they are difficult to

282 Journal of the American Academy of Orthopaedic Surgeons

 Robert Z. Tashjian, MD, and Julia A. Katarincic, MD

manage and result in poor outcomes Figure 5

secondary to recurrent acute insta-
bility, chronic instability, and arthri-
tis.38 Until very recently, limited
data existed regarding management
of these injuries. Most cases have
been reported as part of large series
of patients with a mixture of com-
plex elbow injuries. Broberg and
Morrey3 reported on 5 of 24 adult pa-
tients with dislocations associated
with fractures of the coronoid and
radial head that were managed surgi-
cally with partial resection, com-
plete resection, or Silastic implant
arthroplasty of the radial head. No
reference is made, however, as to
how the coronoid fractures were re-
paired, if at all. All patients had good
results based on the Mayo Perfor-
mance Index, with mild pain at an
average of 5 years.3
Josefsson et al4 reported on radial
head resection without ligament re-
pair in eight patients with combined
coronoid process and radial head
fractures; 50% redislocated within
2 months. More recently, Ring et
al36 noted that satisfactory results
were obtained only with retention of
the radial head and repair of the lat-
eral ulnar collateral ligament. Pugh
et al37 reported the most homoge- The O’Driscoll coronoid fracture classification system, including tip, anteromedial,
neous series of patients treated with and basal fractures. (Reproduced from O’Driscoll SW, Jupiter JB, Cohen MS, Ring
D, McKee MD: Difficult elbow fractures: Pearls and pitfalls. Instr Course Lect
a standardized protocol, including
2003;52:112-134.)
radial head fixation or metallic head
replacement, coronoid fracture fixa-
tion, and LCL complex repair. plex is performed by first finding the of the posterior Monteggia fracture
Thirty-four of 36 patients evaluated center of rotation, which is located pattern, which included posterior
at an average of 3 years after injury at the center of the capitellar circum- dislocation of the radial head and a
had concentric stability, with 82% ference on the lateral condyle, and proximal ulna fracture with an ante-
satisfactory results and an average then placing a bone tunnel or suture rior triangular fracture fragment at
flexion arc of 112°.37 anchor at this position. A nonabsorb- the level of the coronoid process.
Management of terrible triad in- able suture is then used in a running These injuries usually occurred sec-
jury requires fixation of the radial locking stitch through the ligament ondary to low-energy falls in women
head fracture or metallic arthro- to reattach it to the tunnel or anchor. in middle age and older. Radial head
plasty, fixation of the coronoid frac- The anconeus and extensor carpi ul- fracture and LCL complex disrup-
ture (with Lasso repair of the anterior naris fascia are then repaired over the tion were common. Overall, the re-
capsule, screw fixation, or an antero- ligament as secondary stabilizers. sults were only good, and it was rec-
medial plate fixation), and recon- Hinged external fixation may be re- ognized that failure to adequately
struction of the LCL complex (Figure quired when instability persists. stabilize the coronoid fragment led
4). The LCL is typically avulsed from to poor results.39
the lateral condyle; the injury gener- Posterior Monteggia In a follow-up study, Ring et al40
ally is not a mid-substance tear. Re- Lesion retrospectively reviewed the records
pair of the collateral ligament com- Jupiter et al39 described a variant of patients treated for Monteggia

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Complex Elbow Instability

Figure 6

Lateral (A) and anteroposterior (B) views of transolecranon fracture-dislocation of the elbow managed with open reduction and
fixation of the olecranon. C, Long direct posterior plating of the ulna was performed. Because the lateral collateral ligament
complex was intact, no ligament repair was required.

fractures during a 10-year period at commonly results from a high- olecranon fracture may facilitate fix-
Massachusetts General Hospital. energy blow to the dorsal aspect of ation. Temporary external fixation
Eighty-five percent of patients with the forearm with the elbow in mid- that provides distraction across the
posterior Monteggia fracture pat- flexion. Ring et al41 reported on a se- fracture zone may be useful in pa-
terns had satisfactory results, even ries of 13 patients treated with open tients with severe comminution.
though all patients with unsatisfac- reduction and plate fixation of the Common errors include failure to
tory results had radial head fractures ulna; 85% had good or excellent re- recognize and adequately fix the
and 67% had coronoid process frac- sults at 2-year follow-up. This injury coronoid fragment, which may re-
tures.40 Recognizing that the anteri- pattern is typically associated with quire medial exposure and plate fix-
or coronoid fragment requires stable large type III coronoid fractures, in- ation with a second small plate.
fixation is critical in achieving an tact collateral ligaments, and a pau-
optimal outcome. city of radial head fractures. Patients
Dynamic External
with these fractures have a better
Fixation
Transolecranon outcome than do those sustaining a
Fracture-Dislocation traditional terrible triad injury.41 Ap- Complex elbow instability that per-
Transolecranon fracture-disloca- plication of low-profile wrist fusion sists despite surgical repair may be
tion involves a comminuted proxi- plates to the proximal ulna has led to managed with external fixation. Ex-
mal ulna/olecranon fracture with excellent results42 (Figure 6). Proxi- ternal fixators also can be used in the
anterior subluxation or dislocation of mal ulna-specific internal fixation acute setting in which stability has
the radiocapitellar joint, disruption plates have recently been developed. been difficult to achieve. Both static
of the ulnohumeral joint, and ante- Fixation is obtained by posterior and dynamic external fixators have a
rior displacement of the entire fore- plating of the entire proximal ulna role in managing these difficult inju-
arm with maintenance of the radio- fracture. Medial or lateral plate ries. Static fixators are easy to apply,
ulnar relationship. Transolecranon placement does not allow adequate are more readily available, and may
fracture-dislocation differs from pos- resistance to tension forces.15 Indi- be used temporarily in the setting of
terior Monteggia fracture in that the rect plating of comminuted proximal persistent instability. Static fixators,
radius and ulna are both dislocated olecranon fractures with limited however, do not allow elbow motion
anteriorly and remain associated.41 soft-tissue stripping and reduction of and have a limited life span because
Transolecranon fracture-dislocation large coronoid fragments through the of pin site loosening.

284 Journal of the American Academy of Orthopaedic Surgeons

 Robert Z. Tashjian, MD, and Julia A. Katarincic, MD

Dynamic or hinged fixators are construction, internal fracture

Summary
more complicated to apply, but they fixation (radial head, coronoid pro-
allow early elbow motion and con- cess,olecranon,capitellum,andtroch- The severity of elbow instability
trolled passive motion. Indications lea), and radial head replacement. ranges from very simple to extreme-
for external fixation include tempo- The average duration of hinged exter- ly complex. Disruption of several of
rary stabilization of bony and liga- nal fixation was 8 weeks. Only one the bony and soft-tissue elements
mentous elbow injuries, persistent patient had recurrent instability, re- that confer stability to the elbow
elbow instability despite ligamen- quiring a transarticular pin to stabi- may lead to recurrent instability.
tous repair and bony fixation, fixa- lize the elbow. The mean Mayo El- Management of complex instability
tion of the coronoid process with an bow Performance Score (MEPS) was is much more demanding than it is
unstable elbow, protection of com- 84 points (range, 0 to 100), with 12
for simple dislocation, with a signif-
minuted radial head or capitellum good or excellent results.6
icantly increased chance of recurrent
fractures after fixation, and mainte- Ruch and Triepel13 retrospectively
instability and arthritis. Radial head
nance of elbow stability in the set- reviewed the results of eight patients
fractures should be repaired or re-
ting of comminuted coronoid frac- treated with a monolateral hinged
placed. Coronoid process fractures
tures not amenable to internal fixator for recurrent elbow instabil-
fixation.43 Hinged fixators also have ity. The patients had injuries to the should be assessed based not only on
a role in providing stability in chron- MCL, LCL, radial head, olecranon, their size but also in relation to dis-
ic unreduced dislocation.5 medial condyle, or coronoid process. placement and the stability of the el-
Examples of hinged fixators in- Patients were treated with a fixator bow joint. More complex injuries,
clude ring (Compass Universal when complete bony or ligamentous such as terrible triad injuries, poste-
Hinge, Smith & Nephew, Memphis, repair could not be completed be- rior Monteggia lesions, and trans-
TN) and monolateral (Dynamic Joint cause of bone or soft-tissue loss or olecranon fracture-dislocations, are
Distractor, Howmedica Osteonics, when treatment was delayed such much less common. Fixation or re-
Rutherford, NJ; Opti-ROM, EBI, Par- that joint congruity could not be placement of all of the injured bony
sipanny, NJ) systems. The key point maintained after open reduction. At elements, repair of the LCL com-
in applying a hinged fixator is plac- a mean follow-up of 1.5 years, the av- plex, and, potentially, hinged exter-
ing the distal humeral axis pin. Ap- erage elbow flexion-extension arc of nal fixation are standard treatment
plication is often technically de- motion was 97°, and the average Dis- methods that may improve an other-
manding. It can be performed with abilities of the Arm, Shoulder, and wise poor prognosis and produce sat-
either a single- or double-pin tech- Hand (DASH) questionnaire score isfactory results in most patients.
nique, depending on the extent of was 21 points (range, 0 to 100, with
surgical exposure and availability of <10 indicating greater success).13 References
surgical assistants. The axis pin is Ring et al44 reviewed a series of Evidence-based Medicine: Level III
placed such that the pin exits later- 13 patients treated for subluxation and IV case-controlled series, along
ally in the center of the capitellar or dislocation of the elbow at least with Level V expert opinion, are re-
circumference on the lateral condyle 1 month after elbow fracture-dis- peated. There are no Level I or II pro-
and medially just distal and anterior location. Seven patients had a terri- spective cohort studies.
to the medial epicondyle. Once the ble triad injury, and six had a poste-
axis pin is placed, the fixator is at- rior Monteggia pattern injury. The Citation numbers printed in bold
tached to the humerus and ulna, average duration of hinged external type indicate references published
which, in the case of the Compass fixation was 6 weeks. At an average within the past 5 years.
Universal Hinge, is done with one 57-month follow-up, stability was 1. Linscheid RL, Wheeler DK: Elbow dis-
medial and one lateral humeral half- restored in every patient, with an av- locations. JAMA 1965;194:1171-
pin and two posterior half-pins along erage MEPS of 84, DASH score of 15, 1176.
the posterior border of the ulna. and flexion arc of motion of 99°.44 2. Mezera K, Hotchkiss RN: Fractures
Hinged external fixation is a good and dislocations of the elbow, in Rock-
Several authors have reported sat-
wood CA, Bucholz RW, Heckman JD,
isfactory results using hinged fixators treatment option for patients with Green DP (eds): Rockwood and
in the setting of persistent instability severely comminuted fractures that Green’s Fractures in Adults, ed 5. Phil-
despite reconstruction of the bony limit coronoid fixation, or for pa- adelphia, PA: Lippincott-Raven, 2001.
and ligamentous structures.6,13,44 Mc- tients in whom soft-tissue deficits 3. Broberg MA, Morrey BF: Results of
Kee et al6 reported the use of the treatment of fracture-dislocations of
preclude MCL repair. Hinged exter-
the elbow. Clin Orthop Relat Res
Compass Universal Hinge in 16 pa- nal fixation is also indicated for 1987;216:109-119.
tients who failed treatment that in- chronic instability after failure of 4. Josefsson PO, Gentz CF, Johnell O,
cluded open reduction, ligament re- bony and/or ligamentous repair. Wendeberg B: Dislocations of the el-

Volume 14, Number 5, May 2006 285

Complex Elbow Instability

bow and intraarticular fractures. Orthop Relat Res 1986;208:100-103. 1979;61:494-497.

Clin Orthop Relat Res 1989;246:126- 19. O’Driscoll SW, Jaloszynski R, Morrey 32. Morrey BF, Askew L, Chao EY: Silas-
130. BF, An KN: Origin of the medial ulnar tic prosthetic replacement for the ra-
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duced elbow dislocations with hinged [Am] 1992;17:164-168. 63:454-458.
external fixation. J Bone Joint Surg 20. Cage DJ, Abrams RA, Callahan JJ, 33. Moro JK, Werier J, MacDermid JC,
Am 2002;84:1630-1635. Botte MJ: Soft tissue attachments of Patterson SD, King GJ: Arthroplasty
6. McKee MD, Bowden SH, King GJ, et the ulnar coronoid process: An ana- with a metal radial head for unrecon-
al: Management of recurrent, com- tomic study with radiographic corre- structible fractures of the radial head.
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Surg Br 1998;80:1031-1036. 21. O’Driscoll SW, Bell DF, Morrey BF: 34. Knight DJ, Rymaszewski LA, Amis
7. Geel CW, Palmer AK, Ruedi T, Leu- Posterolateral rotatory instability of AA, Miller JH: Primary replacement
tenegger AF: Internal fixation of prox- the elbow. J Bone Joint Surg Am of the fractured radial head with a
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Trauma 1990;4:270-274. 22. Hildebrand KA, Patterson SD, King 1993;75:572-576.
8. King GJ, Evans DC, Kellam JF: Open GJ: Acute elbow dislocations: Simple 35. Harrington IJ, Sekyi-Otu A, Bar-
reduction and internal fixation of ra- and complex. Orthop Clin North Am rington TW, Evans DC, Tuli V: The
dial head fractures. J Orthop Trauma 1999;30:63-79. functional outcome with metallic ra-
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286 Journal of the American Academy of Orthopaedic Surgeons