Session III - Upper Extremity
Fri., 10/8/04 Upper Extremity, Paper #17, 3:06 pm
Functional Outcome following Fracture-Dislocation of the Elbow
Purpose: Posterior dislocation of the elbow in combination with fracture of the radial head and the coronoid is known as the "terrible triad." This injury is notoriously difficult to treat, and the outcome is frequently unsatisfactory. To date, there are few reports regarding the management of this injury and no published data on the functional outcome of treatment. The purpose of this Institutional Review Board-approved study was to examine long-term functional outcome of elbow fracture-dislocations treated by an algorithmic protocol.
Methods: A retrospective review of the trauma database at our institution over a 7-year period was performed. Thirty-five patients who sustained an elbow fracture-dislocation with injuries that fit the "terrible triad" pattern were identified (OTA codes 21-C1.2 and 21-C2.3). All patients were treated with a similar protocol through a lateral approach to the elbow including: 1) treatment of the radial head; 2) repair of the lateral ligamentous complex; 3) if instability still persisted, application of a multi-planar, hinged external fixator. Several patients also underwent direct repair of the medial collateral ligament or fixation of the coronoid fracture or both. Patients were asked to return to the clinic for follow-up. Standard radiographs of the injured elbow were examined for the presence of heterotopic ossification, malalignment, and osteoarthritis (graded according the system of Broberg and Morrey). Range of motion and grip strength were evaluated. Post-injury function was evaluated via the Mayo Clinic Elbow Performance Score, the Morrey-Broberg Functional Score, the Disabilities of the Arm, Shoulder, and Hand (DASH) form, and the Short Form-36 (SF-36). The DASH and SF-36 scores were normalized to the population-based normative data.
Results: Twenty-five patients with twenty-five elbow fracture-dislocations returned for follow-up. There were 14 men and 11 women. The mean age at the time of injury was 49 years (range, 27 to 75), and the mean length of follow-up was 21 months (range, 7 to 79). There were 25 fractures of the radial head, of which 4 were Mason type 1, 8 were Mason type 2, and 13 were Mason type 3. There were 25 fractures of the coronoid process: 15 Morrey type 1, 8 Morrey type 2, and 2 Morrey type 3. Eighteen of 25 injuries were to the dominant arm. One patient sustained an open elbow fracture-dislocation. There were three fractures of the radial neck, one ipsilateral fracture of the radial shaft, one capitellum fracture, and two instances of medial collateral ligament avulsion fracture. Five patients sustained additional injuries. Only one patient underwent examination under anesthesia and was treated in a hinged brace. Two patients underwent examination under anesthesia, were deemed unstable, and had hinged external fixation placed. The average time to surgery was 10 days (range, 1 to 36). The radial head was fixed in 6 patients, replaced in 11, and either partially or completely excised in 4 patients. The coronoid process was fixed in three patients. The lateral collateral ligament was repaired in all 22 patients, and the medial collateral ligament was directly repaired in three. Nine of 25 patients required application of the hinged external fixator. Complications included postoperative stiffness in three, necessitating additional surgery at an average of 5 months. At follow-up, 11 patients had radiographic evidence of heterotopic ossification, and two had residual subluxation of the elbow. Fifteen patients had grade 1 elbow arthritis, four had grade 2, and six had no radiographic evidence of elbow arthritis. The average Mayo outcome score was 79, with 1 poor, 10 fair, 10 good, and 4 excellent outcomes. The average Broberg outcome score was 77, with 3 poor, 10 fair, 9 good, and 3 excellent results. The average DASH outcome score was 1.57 standard deviations worse than the age-based population norm. Twelve patients reported upper extremity function that was better or within one standard deviation of the population-based norm controlled for age. Five patients were between one and two standard deviations worse than the norm. Six patients were between two and three standard deviations worse than the norm. Two patients had significantly worse outcomes, at 4.2 and 5.6 standard deviations worse than normal. Interestingly, the patient with the worst score had a fair outcome according to both Mayo and Broberg functional scores. The average physical function summary component of the SF-36 was 0.8 standard deviations worse than the population norm, but 22 of 25 patients were within two standard deviations of the general population average. Of the eight patients whose DASH scores were more than two standard deviations worse than the population norm, one was treated with closed reduction, and seven required an external fixator.
Conclusion: In this series, application of a standard treatment protocol led to satisfactory outcomes for more than half of the patients. It is recommended that high-energy "terrible triad" injuries of the elbow be treated with timely open reduction, fixation of the fractures, and repair of the lateral and possibly medial ligaments. In addition, hinged external fixation is beneficial if stability is not achieved after repair.
Significance: Patients who sustain a fracture dislocation of the elbow have poorer outcomes with highly unstable injuries.