Review Question - QID 1013

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Terrible Triad Injury of Elbow Treatment Operative QID: 1013 (OBQ05.127)

QID 1013 (Type "1013" in App Search)

A 62-year-old man slips on ice and sustains an elbow dislocation. Post-reduction imaging reveals a highly comminuted radial head fracture and coronoid fracture through its base. What is the most appropriate treatment?

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Early passive range-of-motion in a hinged elbow brace

9/1312

Application of a static spanning external fixator for 6 weeks

8/1312

Radial head excision, coronoid excision, and repair of the lateral ulnar collateral ligament and medial collateral as needed

14/1312

Radial head excision, open reduction internal fixation of the coronoid, and repair of the lateral ulnar collateral ligament and medial collateral as needed

10%

134/1312

Radial head replacement, open reduction internal fixation of the coronoid, and repair of the lateral ulnar collateral ligament and medial collateral as needed

86%

1132/1312

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The results of elbow dislocations with associated radial head and coronoid fractures are often poor because of recurrent instability and/or stiffness from prolonged immobilization. Therefore radial head replacement and open reduction internal fixation of the coronoid is the most appropriate treatment.

Pugh et al reported their experiences with this difficult population. Their protocol consisted of ORIF or replacement of the radial head, ORIF of the coronoid fracture, repair of the LCL and capsule, and repair of the MCL and/or hinged external fixation. Of the 36 cases, the outcome was graded as 28 excellent to good, 7 fair, and 1 poor. 8 cases required re-operation. The authors concluded that their surgical protocol restored sufficient elbow stability to allow early motion post-op, thereby enhancing the functional outcome. In fracture dislocation of the elbow with radial head and coronoid fracture, the radial head must be fixed or replaced to restore stability. The ORIF of coronoid fracture and radial head restores some valgus stability therefore MCL repair may not be needed. However, the varus stability must be restored by LCL repair.