1. science
2. medicine
3. surgery

This is an enhanced PDF from The Journal of Bone and Joint Surgery
The PDF of the article you requested follows this cover page.
Standard Surgical Protocol to Treat Elbow Dislocations with Radial
Head and Coronoid Fractures
David M.W. Pugh, Lisa M. Wild, Emil H. Schemitsch, Graham J.W. King and Michael D. McKee
J Bone Joint Surg Am. 2004;86:1122-1130.
This information is current as of November 10, 2010
Reprints and Permissions
Click here to order reprints or request permission to use material from this
article, or locate the article citation on jbjs.org and click on the [Reprints and
Permissions] link.
Publisher Information
The Journal of Bone and Joint Surgery
20 Pickering Street, Needham, MA 02492-3157
www.jbjs.org

COPYRIGHT © 2004
BY
THE JOURNAL
OF
BONE
AND JOINT
SURGERY, INCORPORATED
Standard Surgical Protocol
to Treat Elbow Dislocations
with Radial Head
and Coronoid Fractures
BY DAVID M.W. PUGH, MD, FRCS(C), LISA M. WILD, BSCN, EMIL H. SCHEMITSCH, MD, FRCS(C),
GRAHAM J.W. KING, MD, MSC, FRCS(C), AND MICHAEL D. MCKEE, MD, FRCS(C)
Investigation performed at Upper Extremity Reconstructive Service, St. Michael’s Hospital,
and University of Western Ontario, Hand and Upper Limb Centre, London, Ontario, Canada
Background: The results of elbow dislocations with associated radial head and coronoid fractures are often poor because of recurrent instability and stiffness from prolonged immobilization. We managed these injuries with a standard
surgical protocol, postulating that early intervention, stable fixation, and repair would provide sufficient stability to allow motion at seven to ten days postoperatively and enhance functional outcome.
Methods: We retrospectively reviewed the results of this treatment performed, at two university-affiliated teaching
hospitals, in thirty-six consecutive patients (thirty-six elbows) with an elbow dislocation and an associated fracture of
both the radial head and the coronoid process. Our surgical protocol included fixation or replacement of the radial
head, fixation of the coronoid fracture if possible, repair of associated capsular and lateral ligamentous injuries, and
in selected cases repair of the medial collateral ligament and/or adjuvant hinged external fixation. Patients were evaluated both radiographically and with a clinical examination at the time of the latest follow-up.
Results: At a mean of thirty-four months postoperatively, the flexion-extension arc of the elbow averaged 112° ±
11° and forearm rotation averaged 136° ± 16°. The mean Mayo Elbow Performance Score was 88 points (range,
45 to 100 points), which corresponded to fifteen excellent results, thirteen good results, seven fair results, and
one poor result. Concentric stability was restored to thirty-four elbows. Eight patients had complications requiring a
reoperation: two had a synostosis; one, recurrent instability; four, hardware removal and elbow release; and one, a
wound infection.
Conclusions: Use of our surgical protocol for elbow dislocations with associated radial head and coronoid fractures
restored sufficient elbow stability to allow early motion postoperatively, enhancing the functional outcome. We recommend early operative repair with a standard protocol for these injuries.
Level of Evidence: Therapeutic study, Level IV (case series [no, or historical, control group]). See Instructions to Authors for a complete description of levels of evidence.
E
lbow dislocations associated with both radial head and
coronoid fractures have been termed the terrible triad
of the elbow because of the difficulties inherent in treatment and the consistently poor reported outcomes, especially
when compared with the results of treatment of simple elbow
dislocations1-5. There are few published reports dealing specifically with the management and outcome of elbow dislocation
with associated radial head and coronoid fractures6,7. Most
available information is contained in studies of elbow injuries
with a small subset of patients with the so-called terrible triad.
The authors of those studies have noted poor results due to
acute recurrent instability, chronic instability, stiffness, post-
traumatic arthrosis, and pain. In 1989, Josefsson et al. reported the long-term outcomes in twenty-three patients who
had sustained an elbow dislocation with a displaced radial
head fracture5. They reported redislocation in four patients, all
of whom also had an untreated fracture of the coronoid process. Two other reports described series of patients with an
acute elbow injury who required revision surgery and application of a hinged fixator to restore concentric stability following failure of the initial treatment: in both series, patients with
an elbow dislocation associated with radial head and coronoid
fractures predominated8,9. Ring et al. described unsatisfactory
results in seven of eleven patients with this injury pattern10.

THE JOUR NAL OF BONE & JOINT SURGER Y · JBJS.ORG
VO L U M E 86-A · N U M B E R 6 · J U N E 2004
Improved understanding of the mechanism of elbow injuries, the primary and secondary constraints providing stability, the soft-tissue injury patterns, and better methods of
surgical repair led us to develop a consistent surgical strategy
for these injuries. We routinely perform open reduction and
internal fixation of the coronoid fracture and/or repair of the
anterior capsule, repair or replacement of the radial head, and
repair of the lateral ligament complex. Repair of the medial
collateral ligament and/or application of a hinged external fixator is reserved for patients who demonstrate residual instability after standard treatment.
The purpose of our review was to determine the clinical
and radiographic outcomes following application of this management protocol to a consecutive series of patients who had
sustained an elbow dislocation associated with radial head and
coronoid fractures.
Materials and Methods
e identified forty consecutive skeletally mature patients
(forty elbows) in whom an elbow dislocation associated
with fractures of the radial head and coronoid process had been
treated at two university-affiliated teaching hospitals between
June 1995 and January 2001. At the time that this review commenced, our institution did not require approval of this type of
study by the research ethics board. Four patients were lost to
W
S T A N D A RD S U R G I C A L P RO T O CO L T O TRE A T E L B OW D I S L O C A T I O N S
W I T H R A D I A L H E A D A N D C O RO N O I D F R A C T U RE S
follow-up prior to definitive assessment of the outcome, leaving
thirty-six patients (thirty-six elbows) for evaluation. There were
twenty-two male patients and fourteen female patients with a
mean age of 41.4 years (range, thirteen to seventy-six years).
The mechanism of injury included fourteen falls from a standing height, eleven high-velocity falls from a height, five bicycle
accidents, four sports injuries, one motorcycle accident, and
one crush injury. The thirty-six elbows were treated surgically
by us at a mean of 4.5 days (range, zero to seventeen days) after
the injury. The specific indications for operative intervention
included a displaced intra-articular fracture, an inability to obtain or maintain a concentric reduction in a closed fashion, and
residual instability of the elbow in a functional (30° to 130°) arc
of motion following closed reduction11.
Radiographs made at the time of presentation showed
all thirty-six elbow dislocations to be posterior. We categorized the coronoid fractures according to the radiographic
classification system of Regan and Morrey12. With this system,
type I indicates a fracture involving the tip of the coronoid
process; type II, ≤50% of the coronoid process; and type III,
>50% of the coronoid process. There were ten type-I, eighteen
type-II, and eight type-III coronoid fractures. Eighteen type-II
and III fractures of the coronoid process were treated with
open reduction and internal fixation with screws, and we performed an anterior capsular repair in the other eighteen el-
Fig. 1
Intraoperative photograph made through a lateral surgical approach of a patient with the socalled terrible triad injury of the elbow. There is characteristic stripping of the lateral collateral
ligament complex from the distal part of the humerus. A portion of the common extensor origin/
lateral ligament complex can be seen hanging down from the bare lateral condyle. The coronoid
fragment is trapped in the joint (arrowhead). There is a defect in the radial head, which can be
seen behind the coronoid fragment. There has been very little surgical dissection; the degree of
damage done by the injury is evident.

THE JOUR NAL OF BONE & JOINT SURGER Y · JBJS.ORG
VO L U M E 86-A · N U M B E R 6 · J U N E 2004
Fig. 2-A
Initial lateral radiograph of a posterior elbow dislocation associated
with radial head and coronoid fractures.
bows (as described under Operative Technique).
According to the Mason-Johnston classification13, all radial head fractures were type IV since they were associated
with a dislocation. There were three marginal fractures involving <25% of the head, which could be considered a Mason
type-I fracture. There were fourteen “partial” head fractures
(Mason type II), in which part of the head was still in continuity with the radial shaft, and nineteen “total” head fractures
(Mason type III), in which there was no such continuity. We
performed open reduction and internal fixation of the radial
head in thirteen elbows and prosthetic replacement in twenty.
The other three radial head fractures were irreparable, mar-
S T A N D A RD S U R G I C A L P RO T O CO L T O TRE A T E L B OW D I S L O C A T I O N S
W I T H R A D I A L H E A D A N D C O RO N O I D F R A C T U RE S
ginal injuries involving <25% of the joint surface. These were
débrided, and the native head was maintained as intraoperative examination revealed acceptable stability of the elbow and
proximal radioulnar articulation.
The lateral soft-tissue structures had been disrupted,
and were repaired, in every patient. Six patients also had a repair of the medial collateral ligament, and two had an articulated external fixator applied because of residual instability.
The patients were followed clinically and radiographically
until fracture union had occurred and elbow motion had plateaued with appropriate supervised physiotherapy. Clinical
evaluation included determination of pain, function, range of
motion, and stability. Anteroposterior and lateral radiographs
were assessed for fracture union, implant loosening, heterotopic
ossification, degenerative changes, and joint congruity. The
Mayo Elbow Performance Score (MEPS) was determined for
each patient at the final clinic visit14.
Statistical analysis was performed with the SAS software
package (SAS Institute, Cary, North Carolina). A Student t test
was used to evaluate the differences between groups. A level of
p ≤ 0.05 was considered significant.
Operative Technique
All procedures were performed by or under the direct supervision of one of two fellowship-trained orthopaedic surgeons
(M.D.McK. or G.J.W.K.). The technique for the repair and the
rationale behind it have been described in detail previously15.
The general approach was to repair the damaged structures sequentially from deep to superficial, as seen from the lateral approach (coronoid to anterior capsule to radial head to lateral
ligament complex to common extensor origin). Elbow stability
was then evaluated, with the goal being concentric stability with
no observed posterior or posterolateral subluxation through a
Fig. 2-B
Following closed reduction, the position is
much improved, but there is still a nonconcentric reduction of the ulnotrochlear joint (small
arrowheads), the radial head is subluxated
posteriorly (large arrowhead), and the coronoid
fracture remains displaced.

THE JOUR NAL OF BONE & JOINT SURGER Y · JBJS.ORG
VO L U M E 86-A · N U M B E R 6 · J U N E 2004
flexion-extension arc of 20° to 130° with the forearm in neutral
rotation. Instability was typically most evident in extension and
supination. If instability persisted, we repaired the medial collateral ligament and/or applied a hinged external fixator. Valgus
instability alone was not an indication for repair of the medial
collateral ligament or application of a hinged fixator.
The principles of the operative technique were to (1) restore coronoid stability through fixation when the fracture
was type II or type III or through anterior capsular repair
when the injury was type I, (2) restore radial head stability
through fracture fixation or replacement with a metal prosthesis, (3) restore lateral stability through repair of the lateral
collateral ligament complex and associated so-called secondary constraints such as the common extensor origin and/or
the posterolateral capsule, (4) repair the medial collateral ligament in patients with residual posterior instability, and (5) apply a hinged external fixator when conventional repair did not
establish sufficient joint stability to allow early motion.
The surgical approach was either a posterior (universal)
incision with subcutaneous dissection laterally (and medially
if required) (eight elbows) or an extended lateral approach
only (twenty-six elbows) or in combination with a separate
medial approach (two elbows). The lateral soft tissues deep to
the myofascia are invariably disrupted with this injury. The
typical patterns of lateral soft-tissue injury have been previously described16; the most common was avulsion of the lateral collateral ligament complex from the posterolateral aspect
of the humerus. Care was taken to work through any softtissue disruption created by the trauma (with proximal and
distal surgical extension as required), preserving intact softtissue structures as much as possible (Fig. 1).
The first structure to be addressed was the coronoid.
Fig. 2-C
After coronoid excision, anterior capsule repair, radial head fixation, and reconstruction
of the lateral ligament complex, concentric
stability was restored and early motion could
be initiated.
S T A N D A RD S U R G I C A L P RO T O CO L T O TRE A T E L B OW D I S L O C A T I O N S
W I T H R A D I A L H E A D A N D C O RO N O I D F R A C T U RE S
Visualization was improved by resection of a radial head with
an irreparable fracture, as described below. The injury to the
coronoid was typically a transverse fracture. If a large fragment
(a type-II or III coronoid fracture) was found, we performed an
open reduction and placed one or two lag screws from the posterior surface of the ulna to capture the fracture fragment. In
comminuted fractures, we attempted to fix the largest fragment
that was possible to fix, which was typically the articular portion. Cannulated screws were very useful in this regard. We
fixed the coronoid fracture in eighteen of the thirty-six elbows.
Type-I coronoid fractures were too small to be fixed with
screws, so they either were excised if the fragment was free
(which was rare) (Figs. 2-A, 2-B, and 2-C) or were repaired by
placing lasso-type sutures around the fragment and the attached anterior capsule and tying those sutures to the base of
the coronoid through drill holes made with an eyed Kirschner
wire (ten elbows). We performed a similar maneuver for type-II
and III fractures, in which comminution precluded stable internal fixation with screws (eight elbows).
The radial head fracture was evaluated. Generally, the primary goal was to fix the fracture when there was one or two
fracture fragments of the head (thirteen patients). If fracture
comminution (three or more fragments), impaction, cartilage
damage, or an associated radial neck fracture indicated that a
stable anatomic reduction was not feasible, the radial head was
excised, enhancing visualization of the coronoid fracture17,
pending later replacement (twenty elbows; Figs. 3-A, 3-B, and
3-C). Minor fragments (<25% of the head) that were too small
or damaged to fix were débrided, and the residual intact radial
head was left in situ (three elbows). If prosthetic replacement
was necessary, we used a metal (rather than a silicone) implant
because of its better mechanical properties17.

THE JOUR NAL OF BONE & JOINT SURGER Y · JBJS.ORG
VO L U M E 86-A · N U M B E R 6 · J U N E 2004
S T A N D A RD S U R G I C A L P RO T O CO L T O TRE A T E L B OW D I S L O C A T I O N S
W I T H R A D I A L H E A D A N D C O RO N O I D F R A C T U RE S
Fig. 3-A
Lateral radiograph of a posterior fracture-dislocation of the elbow, demonstrating a large coronoid fragment (arrowhead) and radial head and neck fracture (arrow).
Detachment of the lateral ligament complex from the humerus was then repaired with nonabsorbable sutures placed
through drill holes in the distal part of the humerus (thirteen elbows) or with suture anchors (fifteen elbows). Midsubstance
tears were repaired with direct suture with use of number-1 or 2
nonabsorbable suture (eight elbows). We used local tissue only,
and we did not perform any tendon grafts or ligament augmentations in this series. We also did not routinely repair the medial
collateral ligament, but if unacceptable instability persisted (as
defined above), then the medial collateral ligament was exposed
and repaired (six elbows). In two cases in which repair of the in-
Fig. 3-B
jured structures did not restore adequate stability, we applied a
hinged external fixator to help maintain a concentric reduction
of the elbow while allowing elbow motion exercises9. Wounds
were closed in layers, after which a sterile dressing was applied.
Drains were not routinely used.
Postoperative Management
A well-padded posterior plaster splint was applied with the elbow in 90° of flexion and the forearm fully pronated to protect
the lateral repair and maintain reduction. If both the medial
and the lateral soft tissues had been repaired, the forearm was
Fig. 3-C
Figs. 3-B and 3-C Postoperative radiographs made following fixation of the coronoid fracture and replacement of the radial head. Excellent stability
was achieved, and the initiation of early motion contributed to an excellent clinical result.

THE JOUR NAL OF BONE & JOINT SURGER Y · JBJS.ORG
VO L U M E 86-A · N U M B E R 6 · J U N E 2004
S T A N D A RD S U R G I C A L P RO T O CO L T O TRE A T E L B OW D I S L O C A T I O N S
W I T H R A D I A L H E A D A N D C O RO N O I D F R A C T U RE S
splinted in neutral rotation. Supervised motion was begun
within seven to ten days after the surgery, when the sutures and
splint were removed. As our experience increased, we began
earlier mobilization, typically on the first or second postoperative day. Active and active-assisted range-of-motion exercises,
including both flexion and extension, were initiated. We believe
that, rather than being detrimental, active elbow motion following surgical repair enhances stability through the recruitment of
muscle groups that act as dynamic stabilizers of the elbow. We
allowed flexion and extension exercises to be done with the
forearm in pronation and active forearm rotation exercises
to be done with the elbow at 90°. We had our patients avoid
the terminal 30° of extension until four weeks postoperatively,
and most patients avoided this position anyway because of pain.
We did not routinely use hinged splints or casts. Unrestricted
shoulder and wrist motion was encouraged. One senior author
(M.D.McK.) did not use indomethacin or irradiation as prophylaxis against heterotopic ossification, whereas the other
(G.J.W.K.) prescribed 25 mg of indomethacin three times a day
for three weeks postoperatively.
Results
he mean duration of follow-up was thirty-four months,
with a range of twenty to sixty-five months. The mean arc
of flexion-extension (and standard deviation) was 112° ± 11°,
the mean flexion contracture was 19° ± 9°, the mean flexion was
131° ± 11°, and the mean arc of forearm rotation was 136° ±
16°. The functional arc of motion, as determined according to
the criteria of Morrey et al. (a flexion-extension arc of 30° to
130° and 100° of forearm rotation)18, was achieved in twentynine of the thirty-six patients.
According to our intraoperative examination, two patients
demonstrated unacceptable residual instability in extension following fixation of both the radial head and the coronoid fracture
and the ligament repair. These two patients required placement
of an articulated external fixator to maintain concentric joint reduction and allow early motion. Another patient demonstrated
unacceptable postoperative instability following radial head fixation, débridement of a type-I coronoid fracture, and repair of
the anterior capsule and the lateral ligament complex, necessitating placement of an articulated external fixator. Despite this
treatment, joint incongruity persisted at the time of final followup, as described under Complications. The hinged fixator was in
place for a mean of 6.2 weeks in these three patients. All three patients had severe soft-tissue disruption and inherently poorquality tissue that made soft-tissue repair tenuous.
At the time of follow-up, thirty-four of the thirty-six patients had maintained a concentric reduction of both the ulnotrochlear and the radiocapitellar articulation. The mean
Mayo Elbow Performance Score (MEPS) was 88 points (range,
45 to 100 points), which corresponded to an excellent result in
fifteen elbows, a good result in thirteen, a fair result in seven,
and a poor result in one14.
T
Radiographs
All coronoid and radial head fractures treated with internal fix-
Fig. 4
A three-dimensional computed tomography reconstruction of a terrible triad injury of the elbow. The view is from the anterolateral aspect of the joint. The elbow is subluxated posteriorly. The loss of the
anterior bone buttress against posterior displacement due to the
coronoid (arrowhead) and radial head fractures is demonstrated.
ation had solid osseous union on the final follow-up radiographs. There were two delayed unions of radial head fractures,
which took twenty and twenty-four weeks to unite. One patient
had evidence of partial osteonecrosis and irregularity of the radial head but was asymptomatic (MEPS score, 90 points).
We used the scale of Knirk and Jupiter for the radiographic assessment of posttraumatic arthritis19. Twenty-two
patients had no evidence of degenerative change (Grade 0),
eight had Grade-1 changes, five had Grade-2 changes, and one
had Grade-3 changes. Two patients had evidence of residual
joint incongruity: one had Grade-2 degenerative changes and
one, Grade-3 changes.
There were radiolucent lines around eleven of the
twenty radial head prostheses but no evidence of dislocation,
subluxation, or progressive bone loss or shortening. This phenomenon has been described previously and does not appear
to affect the clinical outcome17.
Calcification in the medial and lateral ligaments was
common: it was seen to some degree in twenty-six of the
thirty-six elbows. There were two cases of radiographically evident synostosis of the forearm that required a reoperation.
Slight heterotopic ossification was evident in three other patients, none of whom required additional surgery; their mean
range of flexion-extension was 112°. With the numbers available, there was no significant difference in the rate of synostosis or heterotopic ossification between the group that received
indomethacin and the group that did not (p = 0.34).

THE JOUR NAL OF BONE & JOINT SURGER Y · JBJS.ORG
VO L U M E 86-A · N U M B E R 6 · J U N E 2004
Complications
Eight patients (22%) had a complication requiring a reoperation. One patient who had demonstrated posterolateral rotatory
instability following the initial procedure had a revision to include an articulated external fixator. However, the instability
and a nonconcentric reduction persisted after the fixator was removed. Although the patient had a poor result, she had not had
any additional reconstructive surgery by the time of writing. A
radioulnar synostosis occurred in two patients. One of them
had had the primary treatment of the elbow injury at the same
time as treatment of a segmental forearm injury with a disruption of the distal radioulnar joint. He subsequently had the
synostosis resected, the contracture released, and the metal radial head removed20. The other patient with synostosis had a
similar reconstructive procedure. A wound infection developed
in one patient, and it healed uneventfully after surgical débridement and antibiotic therapy. Four patients underwent hardware
removal and elbow release. The release consisted of resection of
any heterotopic bone or calcification, and, depending on which
motion or motions were limited, anterior and/or posterior capsular resection. The mean gain in flexion-extension was 35°
(range, 25° to 60°) and the mean gain in forearm rotation was
25° (range, 0° to 50°) after the releases. One sixty-eight-year-old
patient had radiographic and clinical evidence of persistent posterolateral instability but had a fair result clinically and declined
further intervention.
Discussion
here is a paucity of literature dealing specifically with elbow
dislocations associated with radial head and coronoid fractures, the injury termed the terrible triad of the elbow. Heim reviewed the AO experience with combined radial and ulnar
fractures at the elbow in 199821. Of the 120 cases, twenty-five involved fractures of the coronoid process and the radial head. Of
these, eleven were treated with primary radial head resection.
Premature arthrosis developed in eight of the eleven cases, and
another eight demonstrated valgus instability. Heim concluded
that reduction of the coronoid fragment is critical to restore elbow stability and that radial head resection is contraindicated
when the elbow is unstable. Josefsson et al. noted a high prevalence of osteoarthrosis in patients who had had radial head excision following elbow fracture-dislocation5. They also noted a
coronoid fracture in all four patients who had a redislocation
following treatment of an elbow dislocation with an associated
radial head fracture. They concluded that preservation of the
radial head and ligament repair are imperative to maintain stability in this setting. (Three of the patients had undergone primary excision of the radial head.) In 1987, Broberg and Morrey
reported similar findings22. At an average of ten years postoperatively, they noted arthrosis in twenty-two of twenty-four patients in whom a fracture-dislocation of the elbow had been
treated without repair or replacement of the radial head. In one
of the few papers dealing solely with the so-called terrible triad
injury pattern, Ring et al. reported a poor result due to instability, arthrosis, and stiffness in seven of eleven patients10. In a 1989
report on the Mayo Clinic experience with fractures of the coro-
T
S T A N D A RD S U R G I C A L P RO T O CO L T O TRE A T E L B OW D I S L O C A T I O N S
W I T H R A D I A L H E A D A N D C O RO N O I D F R A C T U RE S
noid process, Regan and Morrey indicated that the results of
treatment of type-II fractures were worse in patients with an associated radial head fracture and elbow instability12. Of the five
patients with a type-III fracture in that study, four had a poor
result secondary to stiffness, pain, and recurrent elbow instability. These data (which parallel our clinical experience) emphasize the importance of accurate primary treatment.
It is well recognized that prolonged immobilization following an acute episode of elbow instability is associated with
poor results2. The dilemma in management of the terrible
triad is that, without proper surgical reconstruction, instability rapidly recurs with attempted motion, but extended cast
immobilization leads to unacceptable stiffness. In fact, Ring et
al. showed that immobilization in a cast does not ensure concentric reduction of the elbow10. In previous studies, standard
reconstruction strategies based on restoring osseous and softtissue structures were not used to enhance stability, leading to
a high prevalence of prolonged cast immobilization followed
by stiffness and arthrosis4,5,9,10.
Elbow stability depends on both osseous integrity and softtissue constraint in roughly equal proportions. The coronoid
process is particularly important (Fig. 4) because of the osseous
constraint that it offers against posterior translation of the ulna
and because of the attachment of the medial collateral ligament to
its base. Since the medial collateral ligament is the primary stabilizer against valgus loading, repairing a type-III coronoid fracture reduces the risk of both valgus and posterior instability23,24.
Failure to reconstitute the coronoid in this setting has been associated with instability and a poor functional outcome9,12.
There remains some controversy over the mechanism of
type-I coronoid fractures, which have been termed avulsion fractures and have been postulated to be a consequence of avulsion
by the anterior elbow capsule and brachialis muscle. However,
the tip of the coronoid is an intra-articular structure, can be
clearly visualized during elbow arthroscopy, and is devoid of
soft-tissue attachments. The anterior capsule typically inserts 5
to 6 mm from the tip of the coronoid23. We believe that coronoid
fractures typically occur from a shearing mechanism that produces a transverse fracture and results as the coronoid is driven
against the unyielding distal part of the humerus (as the radius
and ulna dislocate or subluxate posteriorly). The fracture fragment typically remains attached to the anterior capsule. Thus, in
our opinion, a coronoid fracture is a pathognomonic sign of an
episode of (posterior) elbow instability6. When patients who
have what appears to be an isolated coronoid fracture on radiographs are questioned carefully, they may volunteer that they felt
or saw the elbow fall back into the joint as part of an episode of
subluxation or dislocation with spontaneous reduction.
The radial head is an important secondary stabilizer
against valgus loading and posterior translation. As the medial
collateral ligament is usually torn in patients with this injury,
the radial head takes on a more important role as a stabilizing
structure against valgus stresses24. Zagorski reported the prevalence of redislocation to be as high as 62% following radial
head excision in patients with an elbow fracture-dislocation7.
In a long-term review, Josefsson et al. noted severe osteoar-

THE JOUR NAL OF BONE & JOINT SURGER Y · JBJS.ORG
VO L U M E 86-A · N U M B E R 6 · J U N E 2004
thritis in twelve of nineteen elbows that had undergone radial
head resection following an elbow dislocation with an associated radial head fracture5. They concluded that the radial head
should be preserved if possible. Given the young age of our
patients (mean, forty-one years), we made every attempt to
repair, rather than replace, the radial head. If a stable anatomic
reduction is not possible, however, a replacement arthroplasty
must be peformed17.
For better biomechanical and biological compatibility, we
used a metal radial head in patients who required prosthetic replacement. King et al. noted, in a cadaver model, that a silicone
radial head offered no improvement in stability in medial collateral ligament-deficient elbows, whereas a metal head provided
stability similar to that of the native radial head25. In a clinical
study, the same group reported a mean MEPS score of 80 points
and a low complication rate in a series of twenty-five elbows
treated with a metal radial head replacement following trauma17.
Carn et al. noted evidence of prosthetic deformation, ulnar positive variance, and degenerative change in patients with a silicone
radial head implant26. Others have also raised concerns regarding
failure of silicone implants and silicone synovitis caused by silicone implants27. While a variety of prosthetic designs are now
available, we believe that a metal modular component is the best
option. Modularity allows the surgeon to alter the length, stem
width, and depth independently, optimizing stability without
overstuffing the joint or restricting motion.
The characteristic lateral soft-tissue injury patterns seen
in association with unstable elbow dislocations and fracturedislocations have been described previously16. In the present
series, lateral soft-tissue injury was a universal finding, and,
consistent with observations in previous studies10,16,17, the most
common pathological finding was an avulsion of the lateral
collateral ligamentous complex and capsule from the posterolateral aspect of the distal part of the humerus. Less common
were midsubstance tears, and ulna-sided lesions were rare.
Recognition of these patterns is important for two reasons: (1)
defects in soft-tissue planes created by the trauma should be
utilized in the surgical approach, and (2) these structures
should be repaired as an integral part of the closure. Thus, repair of the lateral collateral ligament complex with suture anchors or drill holes in the distal, lateral part of the humerus
was the most common form of lateral ligament repair.
In a prospective, randomized trial, Josefsson et al. noted
that nonoperative treatment of simple elbow dislocations
yielded results similar to those of collateral ligament repair28.
This suggests that a concentrically reduced, stable elbow promotes healing of the medial collateral ligament in a manner
similar to surgical repair. Our approach is to stabilize the elbow
from the lateral side, producing a stable, concentric joint and allowing a similar healing process to occur on the medial side. We
only proceed to the medial side for ligament repair if instability
persists; other authors have supported this approach29.
There are weaknesses in our study. Although patients
were identified from a prospectively gathered fracture database, the study was essentially retrospective, with all of the biases inherent in such a review, including the four patients lost
S T A N D A RD S U R G I C A L P RO T O CO L T O TRE A T E L B OW D I S L O C A T I O N S
W I T H R A D I A L H E A D A N D C O RO N O I D F R A C T U RE S
to follow-up prior to a definitive outcome evaluation. Also,
since many of our patients were referred for definitive care, it
may be that they represent a spectrum of injury that was more
severe than average. In addition, our mean duration of followup was approximately three years, and the prevalence of radiographic changes was relatively high (39%). It is conceivable
that, with longer follow-up, the degenerative changes may become more important than what we have reported.
Given the severity of these injuries, conventional surgical treatment may sometimes be inadequate to restore elbow
stability. When it is, we have found that articulated external
fixation is an ideal option for restoring stability to the elbow,
and we used it in two patients in this series. One of us
(M.D.McK.) and coworkers9 and Cobb and Morrey8 both described series of unstable elbow fracture-dislocations (sixteen
and seven cases, respectively), many with the “terrible triad”
pattern of injury, for which initial management had failed.
Application of a hinged fixator to the elbow restored concentric stability and allowed early motion while ligamentous healing occurred, with a satisfactory outcome (mean MEPS score
of 80 to 85 points) in twenty of those twenty-three cases.
However, both groups of authors pointed out that this is a
specialized technique with a high complication rate and that
successful primary management is greatly preferable.
These injuries are difficult to treat, and, even with optimal care, stiffness (mean arc in the present series, 112°), recurrent instability (two of thirty-six patients; 6%) and the need
for secondary intervention (eight of thirty-six patients; 22%)
are possible. However, it appears that elbow dislocations with
associated radial head and coronoid fractures can be treated
successfully by strict application of a standard surgical protocol including fixation of large fractures of the coronoid process and/or repair of the anterior capsule, radial head fixation
or replacement, repair of the primary and secondary lateral
soft-tissue constraints, and, in selected cases, repair of the medial collateral ligament. If instability persists after this conventional treatment, application of an articulated external fixator
is a useful adjunctive treatment. David M.W. Pugh, MD, FRCS(C)
Lisa M. Wild, BScN
Emil H. Schemitsch, MD, FRCS(C)
Michael D. McKee, MD, FRCS(C)
Upper Extremity Reconstructive Service, St. Michael’s Hospital, 55
Queen Street East, Suite 800, Toronto, ON M5C 1R6, Canada. E-mail
address for M.D. McKee: [email protected]
Graham J.W. King, MD, MSc, FRCS(C)
University of Western Ontario, Hand and Upper Limb Centre, 268 Grosvenor Street, London, ON N6A 4L6, Canada
The authors did not receive grants or outside funding in support of their
research or preparation of this manuscript. They did not receive 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.

THE JOUR NAL OF BONE & JOINT SURGER Y · JBJS.ORG
VO L U M E 86-A · N U M B E R 6 · J U N E 2004
S T A N D A RD S U R G I C A L P RO T O CO L T O TRE A T E L B OW D I S L O C A T I O N S
W I T H R A D I A L H E A D A N D C O RO N O I D F R A C T U RE S
References
1. Morrey B. The elbow and its disorders. 2nd ed. Philadelphia: WB Saunders;
1993.
2. Mehlhoff TL, Noble PC, Bennett JB, Tullos HS. Simple dislocation of the
elbow in the adult. Results after closed treatment. J Bone Joint Surg Am.
1988;70:244-9.
3. Josefsson PO, Johnell O, Gentz CF. Long-term sequelae of simple dislocation
of the elbow. J Bone Joint Surg Am. 1984;66:927-30.
4. Hotchkiss RN. Fractures and dislocations of the elbow. In: Rockwood CA,
Green DP, Bucholz RW, Heckman JD, editors. Rockwood and Green’s fractures
in adults. 4th ed, vol 1. Philadelphia: Lippincott-Raven; 1996. p 929-1024.
16. McKee MD, Schemitsch EH, Sala MJ, O’Driscoll SW. The pathoanatomy of
lateral ligamentous disruption in complex elbow instability. J Shoulder Elbow
Surg. 2003;12:391-6.
17. Moro JK, Werier J, MacDermid JC, Patterson SD, King GJ. Arthroplasty with
a metal radial head for unreconstructable fractures of the radial head. J Bone
Joint Surg Am. 2001;83:1201-11.
18. Morrey BF, Askew LJ, An K-N, Chao EY. A biomechanical study of normal
functional elbow motion. J Bone Joint Surg Am. 1981;63:872-7.
19. Knirk J, Jupiter JB. Intra-articular fractures of the distal end of the radius in
young adults. J Bone Joint Surg Am. 1986;68:647-59.
5. Josefsson PO, Gentz CF, Johnell O, Wendeberg B. Dislocations of the elbow
and intraarticular fractures. Clin Orthop. 1989;246:126-30.
20. Boyd HB. Surgical exposure of the ulna and proximal third of the radius
through one incision. Surg Gynecol Obstet. 1940;71:86-8.
6. O’Driscoll SW, Jupiter JB, King GJ, Hotchkiss RN, Morrey BF. The unstable
elbow. Instr Course Lect. 2001;50:89-102.
21. Heim U. [Combined fractures of the radius and the ulna at the elbow level
in the adult. Analysis of 120 cases after more than 1 year]. Rev Chir Orthop
Reparatrice Appar Mot. 1998;84:142-53. French.
7. Zagorski JB. Complex fractures about the elbow. Instr Course Lect. 1990;
39:265-70.
8. Cobb TK, Morrey BF. Use of distraction arthroplasty in unstable fracture
dislocations of the elbow. Clin Orthop. 1995;312:201-10.
9. McKee MD, Bowden SH, King GJ, Patterson SD, Jupiter JB, Bamberger HB,
Paksima N. Management of recurrent, complex instability of the elbow with a
hinged external fixator. J Bone Joint Surg Br. 1998;80:1031-6.
10. Ring D, Jupiter JB, Zilberfarb J. Posterior dislocation of the elbow with fractures of the radial head and coronoid. J Bone Joint Surg Am. 2002;84:547-51.
11. Morrey BF, Askew LJ, Chao EY. A biomechanical study of normal functional
elbow motion. J Bone Joint Surg Am. 1981;63:872-7.
12. Regan W, Morrey B. Fractures of the coronoid process of the ulna. J Bone
Joint Surg Am. 1989;71:1348-54.
13. Johnston GW. A follow-up of one hundred cases of fracture of the head of the
radius with a review of the literature. Ulster Med J. 1962;31:51-6.
14. Gill DR, Morrey BF. The Coonrad-Morrey total elbow arthroplasty in patients
who have rheumatoid arthritis. A ten to fifteen-year follow-up study. J Bone
Joint Surg Am. 1998;80:1327-35.
15. Pugh DM, McKee MD. The “terrible triad” of the elbow. Tech Hand Upper Extrem Surg. 2002;6:21-9.
22. Broberg MA, Morrey BF. Results of treatment of fracture-dislocations of the
elbow. Clin Orthop. 1987;216:109-19.
23. Cage DJ, Abrams RA, Callahan JJ, Botte MJ. Soft tissue attachments of the
ulnar coronoid process. An anatomic study with radiographic correlation. Clin
Orthop. 1995;320:154-8.
24. Morrey BF, Tanaka S, An KN. Valgus stability of the elbow. A definition of
primary and secondary constraints. Clin Orthop. 1991;265:187-95.
25. King GJ, Zarzour ZD, Rath DA, Dunning CE, Patterson SD, Johnson JA.
Metallic radial head arthroplasty improves valgus stability of the elbow. Clin
Orthop. 1999;368:114-25.
26. Carn RM, Medige J, Curtain D, Koenig A. Silicone rubber replacement of the
severely fractured radial head. Clin Orthop. 1986;209:259-69.
27. Vanderwilde RS, Morrey BF, Melberg MW, Vinh TN. Inflammatory arthritis after failure of silicone rubber replacement of the radial head. J Bone Joint Surg
Br. 1994;76:78-81.
28. Josefsson PO, Gentz CF, Johnell O, Wendeberg B. Surgical versus nonsurgical treatment of ligamentous injuries following dislocation of the elbow
joint. A prospective randomized study. J Bone Joint Surg Am. 1987;69:605-8.
29. Ring D, Jupiter JB, Zilberfarb J. Roles of the medial collateral ligament and
the coronoid in elbow stability. J Bone Joint Surg Am. 2003;85:568-9.