Distal humeral fractures
In adults, displaced intra-articular distal humeral fractures usually require anatomical reconstruction of the joint and stable fixation that permits early motion.
Key issues:
- articular comminution
- column integrity
- ulnar nerve
- bone quality
- feasibility of fixation in elderly patients
Total elbow arthroplasty is an option for selected older low-demand patients with fractures that are not reliably reconstructable.
Radial head fractures
Management depends on:
- displacement
- mechanical block
- associated elbow instability
- interosseous membrane/DRUJ injury
Options include:
- early motion for stable minimally displaced injuries
- fixation for reconstructable unstable fractures
- radial head replacement when the radial head is required for stability but is not reconstructable
Avoid excision alone in an unstable elbow or when longitudinal forearm stability is compromised.
Olecranon fractures
Assess displacement, extensor mechanism and elbow stability.
Options:
- non-operative management in selected stable fractures and selected frail elderly patients
- tension-band-type fixation for appropriate simple patterns
- plate fixation for comminuted or unstable patterns
Assess:
- extensor mechanism
- articular displacement
- comminution
- bone quality
- skin
Fixation choice depends on fracture pattern. Highly comminuted osteoporotic fractures behave differently from simple transverse injuries.
Terrible triad
Classically combines:
- elbow dislocation
- radial head fracture
- coronoid fracture
Treatment aims to restore stable concentric motion by addressing:
- radial head
- lateral ligament complex
- coronoid/anterior stability when required
The goal is sufficient stability for early movement because prolonged immobilisation produces severe stiffness.
The classic combination includes:
- elbow dislocation
- radial-head fracture
- coronoid fracture
The injury represents failure of multiple stabilisers. Surgical treatment aims to restore a stable elbow that can move early, commonly by addressing:
- coronoid/anterior buttress where required
- radial head reconstruction or replacement
- lateral collateral ligament complex
- additional medial stabilisation if instability persists
Why elbow trauma is challenging
The elbow is inherently stable because of the congruent ulnohumeral joint, radial head and ligament complexes. Trauma that disrupts multiple stabilisers can produce profound instability, while prolonged immobilisation rapidly causes stiffness.
Management therefore balances stability against early motion.
Dislocation
After reduction:
- document neurovascular status
- obtain radiographs
- assess stability through a controlled arc
- identify associated fracture
- consider CT when bony injury is complex
A simple stable dislocation is usually treated with brief protection followed by early motion.
Radial-head fractures
Treatment depends on:
- displacement
- mechanical block
- comminution
- associated instability
- interosseous membrane or wrist injury
Do not excise the radial head in an unstable forearm-elbow construct without appreciating its role in valgus and longitudinal stability.
Coronoid fractures
The significance of a coronoid fracture depends on fragment location and associated instability, not size alone. Anteromedial facet injuries can be associated with varus posteromedial instability and require specific attention.
Stiffness
Prevention of avoidable stiffness is a major goal. Once stability is restored, early controlled motion is usually preferable to unnecessary prolonged immobilisation.
FRCS synthesis
For complex elbow trauma, identify which stabilisers are disrupted and reconstruct enough of them to permit early motion. The endpoint is not simply an anatomic radiograph but a stable moving elbow.