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Elbow-spanning external fixation
6%
256/4244
Medial collateral ligament (MCL) repair
243/4244
Lateral collateral ligament (LCL) repair
2%
91/4244
Radial head excision
81%
3456/4244
Radial head replacement
4%
169/4244
Select Answer to see Preferred Response
This patient has an elbow fracture dislocation with a comminuted radial head fracture as well as a coronoid fracture (terrible triad). Operative treatment is indicated for this unstable injury and must include radial head fixation or replacement. Radial head excision alone is rarely appropriate. Restoration of elbow stability begins by restoring the congruity of bony articulation. In terrible triad injuries, coronoid and radial head fractures must be addressed. Radial head excision will not adequately restore articular congruity. Internal fixation and radial head replacement will both restore the articulation but radial head fixation should be reserved for simple, non-comminuted fracture patterns. Associated elbow dislocation makes fixation of radial head fractures less likely to be successful. Moro et al. found that in 24 patients (25 elbows) with unreconstructable radial head fractures, patients had mild-moderate impairment when fixed with a radial head replacement. Subjective patient satisfaction was high with radial head replacement. Ring et al. followed 11 patients with terrible triad injuries. The combination of radial head and coronoid injuries was very unstable. Seven patients redislocated in a splint after reduction and five redislocated after operative treatment, including all four patients treated with radial head resection. The authors concluded that restoration of radiocapitellar contact was essential for elbow stability. Figures A and B show an elbow fracture dislocation. Computed tomography confirmed coronoid fracture as well as multifragmentary articular comminution of the radial head. Incorrect answers: Answer 1: External fixation may be appropriate if the elbow remains unstable after bony and soft tissue repairs. Answer 2: Medial collateral ligament repair may be appropriate if fracture fixation or radial head replacement plus LCL repair does not restore stability. Answer 3: LCL repair is required to restore stability and would be appropriate Answer 5: Radial head replacement is appropriate for this comminuted fracture.
2.3
(11)
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