The Journal of Bone and Joint Surgery (American) 84:547-551 (2002)
© 2002 The Journal of Bone and Joint Surgery, Inc.
Posterior Dislocation of the Elbow with Fractures of the Radial Head and Coronoid
David Ring, MD,
Jesse B. Jupiter, MD and
Jeffrey Zilberfarb, MD
Investigation performed at the Hand and Upper Extremity Service,
Department of Orthopaedic Surgery, Massachusetts General Hospital,
and the Department of Orthopaedic Surgery, Beth Israel Deaconess
Medical Center, Boston, Massachusetts
David Ring, MD
Hand and Upper Extremity Service, Department of Orthopaedic Surgery,
Massachusetts General Hospital ACC 525, 15 Parkman Street, Boston,
MA 02114. E-mail address: dring{at}partners.org
Jesse B. Jupiter, MD
Hand and Upper Extremity Service, Department of Orthopaedic Surgery,
Massachusetts General Hospital, ACC 527, 15 Parkman Street, Boston,
MA 02114. E-mail address: jjupiter1@partners.org
Jeffrey Zilberfarb, MD
1101 Beacon Street, Brookline, MA 02146
In support of their research or preparation of this manuscript, one
or more of the authors received grants or outside funding from the
AO Foundation. None of the authors received payments or other benefits
or a commitment or agreement to provide such benefits from a commercial
entity. No commercial entity paid or directed, or agreed to pay
or direct, any benefits to any research fund, foundation, educational
institution, or other charitable or nonprofit organization with
which the authors are affiliated or associated.
Background:
Posterior dislocation of the elbow with associated fractures of the
radial head and the coronoid process of the ulna has been referred
to as the "terrible triad of the elbow" because of the difficulties
encountered in its management. However, there are few published
reports on this injury.
Methods:
Eleven patients with this pattern of injury were evaluated after
a minimum of two years. The radial head fracture had been repaired
in five patients, and the radial head had been resected in four.
None of the coronoid fractures had been repaired, and the lateral
collateral ligament had been repaired in only three patients. All
eleven patients returned for clinical examination, functional evaluation,
and radiographs.
Results:
Seven elbows redislocated in a splint after manipulative reduction.
Five, including all four treated with resection of the radial head,
redislocated after operative treatment. At the time of final follow-up,
three patients were considered to have a failure of the initial
treatment. One of them had recurrent instability, which was treated
with a total elbow arthroplasty after multiple unsuccessful operations;
one had severe arthrosis and instability resembling neuropathic
arthropathy; and one had an elbow flexion contracture and proximal
radioulnar synostosis requiring reconstructive surgery. The remaining eight
patients, who were evaluated at an average of seven years after
injury, had an average of 92° (range, 40° to 130°)
of ulnohumeral motion and 126° (range, 40° to 170°)
of forearm rotation. The average Broberg and Morrey functional score
was 76 points (range, 34 to 98 points), with two results rated as
excellent, two rated as good, three rated as fair, and one rated
as poor. Overall, the result of treatment was rated as unsatisfactory
for seven of the eleven patients. All four patients with a satisfactory
result had retained the radial head, and two had undergone repair
of the lateral collateral ligament. Seven of the ten patients who
had retained the native elbow had radiographic signs of advanced ulnohumeral
arthrosis.
Conclusions:
Elbow fracture-dislocations that involve a fracture of the coronoid
process in addition to a fracture of the radial head are very unstable
and prone to numerous complications. Identification of the coronoid
fracture is therefore important, and computed tomography should
be used if there is uncertainty. With operative treatment, the surgeon
should attempt to restore stability by providing radiocapitellar
contact (preserving the radial head when possible and replacing
it with a prosthesis otherwise), repairing the lateral collateral
ligament, and perhaps performing internal fixation of the coronoid
fracture.
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