The elbow remains one of the more unforgiving joints in its response to both trauma and surgical intervention. The complex articular relationships of humerus, ulna and radius coupled with a tight soft tissue envelope, make the elbow one of the more challenging joints in which to restore function.
As Orthopedic hand surgeons, we are best suited to treat these complex injuries due to our understanding of the anatomy and our less aggressive approach to soft tissue handling that is a necessity in the hand.
Radial head fractures remain the most common elbow injury with many allowing conservative treatment, but the displaced fractures are often the most challenging of all articular fractures. Adherence to AO principles of internal fixation is important. The medial collateral ligament should often be explored and repaired in many of these injuries. This attention to concomitant soft tissue injury is the key to a good functional result in the elbow.
Monteggia lesions are often extremely comminuted and may require a variety of fixation techniques to achieve stability. This is important if we are to begin early motion which is particularly important in this joint that is prone to contracture. Similar principles are involved in the treatment of intercondylar humerus fractures, where strict surgical techniques coupled with rehabilitation are a must.
In some cases, techniques of arthroplasty and even arthroscopy are indicated in addition to open reduction and internal fixation. The complex distal articular humerus fracture in the elderly may be best suited for immediate cemented total joint arthroplasty. These salvage procedures may also be indicated in late complications or even nonunion scenarios about the elbow.
Arthroscopy is often ideal in managing the young and active patient. Improved visualization of the fracture as well as rapidity of recovery are reasons that will soon expand the use of this technique in also managing elbow trauma. Post-traumatic contracture will also benefit from the surgeon’s adeptness with the scope.
Complex elbow articular trauma is now being given the attention it deserves as they are some of the most difficult posttraumatic sequelae problems to resolve in orthopedics. More diverse surgical techniques along with closer attention by the hand surgeon will hopefully minimize the common late complications seen in this most challenging of joints.
Alejandro Badia, MD, FACS