Unstable fracture-dislocations of the elbow

Fracture-dislocations of the elbow are devastating injuries. The surgeon must maintain a high index of suspicion when evaluating an elbow dislocation to avoid missing critical associated injuries. Patterns of unstable fracture-dislocations include the "terrible triad" injury of the elbow (elbow dislocation, radial head fracture, and coronoid fracture), transolecranon fracture-dislocations, and the posterior Monteggia lesion. Complex fracture-dislocations of the elbow are treated surgically and are challenging injuries to manage. Elbow stability must be restored by addressing the specific components of the injury. The proximal ulna must be anatomically reduced and internally fixed, the radial head must be repaired or replaced, and substantial coronoid fractures must be repaired or reconstructed. Soft-tissue injuries must also be treated. The lateral ulnar collateral ligament and extensor origin reattachment can be easily performed. The next critical step is to intraoperatively assess the stability of the elbow with a range-of-motion assessment with the forearm in pronation. If the elbow remains unstable, application of a hinged elbow external fixator or repair of the medial collateral ligament must be considered. The goal of reconstruction is early mobilization within a stable arc of motion. This treatment protocol has the potential to improve the suboptimal outcomes reported in the literature for such injuries.