A prospective study of early operative treatment of unstable elbow dislocations using a surgical algorithm, we present the early results of nine such injuries including five terrible triads of the elbow and four elbows which redislocated in plaster. All except two were high energy injuries. The lateral collateral ligament complex was found to be avulsed proximally in all cases and was reattached using a bone anchor. The common extensor origin was also torn to a variable extent in all cases and was repaired end to end. In the terrible triads, the coronoid fracture as fixed with a transosseous suture and the radial head reconstructed or, in one case with gross comminution, replaced. In the four redislocations, full stability was only restored when the medial collateral ligament was also reattached. Mobilization without a hinged external fixator was allowed from day one, but the elbows were protected in a hinged splint in between exercise sessions. Patients were assessed for stability, ROM, and functional disability using the DASH score at an average of 12 months. No elbows redislocated post-operatively and no patients complained of instability. Mean extension was 18° (95% CI 7° – 28°), flexion 131° (124° – 137°), pronation 76° (56° – 96°), and supination 82° (75° – 90°). Mean DASH score was 14.6 (95% CI 0.7 – 28.5) though this result was skewed by one patient who developed RSD and had a DASH score of 67.2. This was however the only complication. Early operative intervention with reconstruction of unstable elbow dislocations, including the terrible triad, prevents the poor results which are commonly found following non-operative treatment of such injuries. An external fixator is not usually required in the acute setting.
Fracture dislocations of the elbow are complex injuries that have a significant risk of long term instability and loss of function. The more severe injuries are fortunately rare and the published series are relatively small. This in turn means that there is less precise evidence and guidance as to the optimal treatment. With the improvements in the understanding of this injury we consider that the prognosis is not necessarily as poor as has been previously reported and we have attempted to quantify this in a prospective, single surgeon series with standard surgical and rehabilitation protocols using dedicated upper limb physiotherapists.
Information was collected prospectively recording function and stability. All patients were assessed with the Mayo clinic elbow score and the AAOS Disability of the Arm Shoulder and Hand score (DASH).
All fractures had united and there were no cases of migration or failure of metal fixation devices. There were no cases of symptomatic instability and no patient had signs of instability when assessed at clinically. A mean flexion arc of 106 degrees was recorded (range 60–145) with a mean extension limit of 23 degrees (range 0–40). Pronation and supination arcs were recorded with a mean of 127 degrees of rotation (range 0–160) There were no reoperations for infection or instability amongst this group of patients Mayo clinic performance index for the elbow produced a mean score of 91.5 with a range of 85–100 which equates to a good or excellent outcome for all patients.
