COPYRIGHT 2002

BY

THE JOURNAL

OF

BONE

AND JOINT

SURGERY, INCORPORATED

Posterior Dislocation
of the Elbow with Fractures
of the Radial Head and Coronoid
BY DAVID RING, MD, JESSE B. JUPITER, MD, AND JEFFREY ZILBERFARB, MD
Investigation performed at the Hand and Upper Extremity Service, Department of Orthopaedic Surgery,
Massachusetts General Hospital, and the Department of Orthopaedic Surgery, Beth Israel Deaconess Medical Center, Boston, Massachusetts

Background: Posterior dislocation of the elbow with associated fractures of the radial head and the coronoid
process of the ulna has been referred to as the terrible triad of the elbow because of the difficulties encountered in its management. However, there are few published reports on this injury.
Methods: Eleven patients with this pattern of injury were evaluated after a minimum of two years. The radial
head fracture had been repaired in five patients, and the radial head had been resected in four. None of the
coronoid fractures had been repaired, and the lateral collateral ligament had been repaired in only three patients. All eleven patients returned for clinical examination, functional evaluation, and radiographs.
Results: Seven elbows redislocated in a splint after manipulative reduction. Five, including all four treated with
resection of the radial head, redislocated after operative treatment. At the time of final follow-up, three patients
were considered to have a failure of the initial treatment. One of them had recurrent instability, which was
treated with a total elbow arthroplasty after multiple unsuccessful operations; one had severe arthrosis and instability resembling neuropathic arthropathy; and one had an elbow flexion contracture and proximal radioulnar
synostosis requiring reconstructive surgery. The remaining eight patients, who were evaluated at an average of
seven years after injury, had an average of 92 (range, 40 to 130) of ulnohumeral motion and 126 (range,
40 to 170) of forearm rotation. The average Broberg and Morrey functional score was 76 points (range, 34 to
98 points), with two results rated as excellent, two rated as good, three rated as fair, and one rated as poor.
Overall, the result of treatment was rated as unsatisfactory for seven of the eleven patients. All four patients
with a satisfactory result had retained the radial head, and two had undergone repair of the lateral collateral ligament. Seven of the ten patients who had retained the native elbow had radiographic signs of advanced ulnohumeral arthrosis.
Conclusions: Elbow fracture-dislocations that involve a fracture of the coronoid process in addition to a fracture
of the radial head are very unstable and prone to numerous complications. Identification of the coronoid fracture is therefore important, and computed tomography should be used if there is uncertainty. With operative
treatment, the surgeon should attempt to restore stability by providing radiocapitellar contact (preserving the
radial head when possible and replacing it with a prosthesis otherwise), repairing the lateral collateral ligament,
and perhaps performing internal fixation of the coronoid fracture.

osterior dislocation of the ulnohumeral joint with a

fracture of the radial head has been treated adequately
by radial head resection and cast immobilization1,2. In
one series, the only treatment failures were due to repeat dislocation of the ulnohumeral joint in patients who also had a fracture of the coronoid process2. The fact that experienced elbow
surgeons often refer to this combination of injuriesposterior
dislocation of the ulnohumeral joint, fracture of the radial
head, and fracture of the coronoidas the terrible triad of the
elbow3 reflects the difficulties encountered in its management.
However, this injury pattern is relatively uncommon, and little
information has been published regarding its treatment.

Materials and Methods

leven skeletally mature patients with posterior dislocation
of the ulnohumeral joint and fracture of both the head of
the radius and the coronoid process of the ulna were treated at
one of two level-I trauma centers over a seven-year period,
and they were followed for at least two years. These patients
were drawn from a larger series of sixty patients with an elbow
fracture-dislocation treated during this period. All eleven patients returned for an examination and radiographs under a
protocol approved by the Human Research Committee.
There were six male patients and five female patients
with an average age of forty-nine years (range, seventeen to


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sixty-seven years). Six patients sustained the injury as the result of a fall from a standing height and five, as the result of a
fall from a greater height. One patient had an open wound
that was Grade 2 according to the system of Gustilo and Anderson4. Two patients had an ipsilateral fracture of the distal
part of the radius. One patient had multiple injuries.
The fracture of the radial head was classified, according
to the system of Mason5, as Type 2 (involving part of the head)
in two patients and Type 3 (a comminuted fracture involving
the entire head) in nine patients. The fracture of the coronoid
process was classified, according to the system of Regan and
Morrey6, as Type 2 (more than a small fleck but <50% of the
height of the coronoid) in all eleven patients.
Each patient initially underwent manipulative reduction
and immobilization in a posterior plaster splint with the elbow
in 90 of flexion. Seven elbows redislocated in the splint. One
patientwho had long-standing diabetes mellitus and advanced peripheral neuropathywas treated with four weeks of

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Five elbows, including all four in which the radial head

had been resected, redislocated in the postoperative splint
(Figs. 1-A, 1-B, and 1-C). Following repeat reduction by
closed means, four of these five patients were treated with
transfixation of the ulnohumeral joint with smooth Steinmann pins for three to six weeks (average, four weeks). The
remaining patient had numerous subsequent unsuccessful
operations and was ultimately treated with total elbow arthroplasty. A proximal radioulnar synostosis developed in
one patient, and it was treated with resection of the synosto-

Fig. 1-B

Initial operative treatment consisting of open reduction, partial resection of the radial head, and reattachment of the lateral collateral ligaFig. 1-A

ment complex to the lateral epicondyle failed to restore stability, and

the elbow redislocated in the postoperative splint. The patient was

Figs. 1-A, 1-B, and 1-C A sixty-seven-year-old woman tripped and fell
onto the left, nondominant elbow; the elbow dislocated, with fractures

then treated with closed reduction and percutaneous transfixation of

the ulnohumeral joint with smooth Kirschner wires. The wires were

of the radial head and the coronoid process. Fig. 1-A After manipulative reduction, a lateral radiograph showed persistent subluxation of

removed four weeks later.

the ulnohumeral joint. The triangular fragment of bone in the coronoid

fossa above the trochlea of the distal part of the humerus is the fractured coronoid process. The subluxation progressed to a complete dislocation in spite of splint immobilization with the elbow in 90 of flexion
and neutral rotation.

cast immobilization only. The seven patients who had redislocation of the elbow in the splint and three others had subsequent operative treatment. In one patient, the operative
treatment was limited to dbridement of a traumatic wound.
Of the remaining nine patients, five had open reduction and internal fixation of the radial head fracture and four were treated
with radial head resection. In three patients, the origin of the
lateral collateral ligament complex was reattached to the lateral
epicondyle. None of the coronoid fractures were repaired. All
patients were treated with a postoperative dressing that incorporated a posterior plaster splint with the ulnohumeral joint
held in 90 of flexion and the forearm in neutral rotation.

Fig. 1-C

Nine months later, a third operation consisting of resection of a proximal

radioulnar synostosis and release of an elbow contracture was required
to restore motion. The remaining radial head was resected at that time.
Seven years after the injury, this lateral radiograph demonstrated
advanced arthrosis and destruction of the ulnohumeral articulation.


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sis and elbow capsular release eight months after the injury.
Evaluation
The patient who required a total elbow arthroplasty was
considered to have had a failure of the index treatment. The
final overall result for the remaining ten patients was rated
according to the system of Broberg and Morrey7 and with the
American Shoulder and Elbow Surgeons elbow evaluation
instrument8. When the score was calculated according to the
system of Broberg and Morrey, 95 to 100 points was considered an excellent result; 80 to 94 points, good; 60 to 79 points,
fair; and 0 to 59 points, poor. Radiographic signs of arthrosis
were also rated according to the system of Broberg and
Morrey7. According to this system, a normal elbow is Grade 0,
an elbow with slight joint-space narrowing with minimum
osteophyte formation is Grade 1, an elbow with moderate
joint-space narrowing and moderate osteophyte formation is
Grade 2, and an elbow with severe degenerative change and
gross destruction of the joint is Grade 3.
Results
n addition to the patient treated with total elbow arthroplasty, two patients who retained the native elbow were
considered to have had a failure of the index treatment. One, a
diabetic patient with a peripheral neuropathy, had advanced
radiographic signs of destruction suggestive of a neuropathic
arthropathy and severe instability but had only mild pain. The
other patient had a proximal radioulnar synostosis and elbow
contracture. This patient had a good result after a second operative procedure was performed to release these constraints.
The remaining eight patients were evaluated at an average of seven years (range, three to ten years) after the injury.
The flexion-extension arc averaged 92 (range, 40 to 130),
with an average arc of flexion of 123 (range, 110 to 140) and
an average flexion contracture of 31 (range, 5 to 70). The
arc of forearm rotation averaged 126 (range, 40 to 170),
with supination averaging 60 (range, 20 to 90) and pronation averaging 66 (range, 20 to 90).
The average score on the American Shoulder and Elbow
Surgeons elbow evaluation instrument8 was 80 points (range,
52 to 100 points), with 100 points representing the best possible score. The average score according to the system of Broberg and Morrey7 was 76 points (range, 34 to 98 points), with
100 points representing the best possible score. There were
two excellent results, two good results, three fair results, and
one poor result. Of the eleven patients in the series, seven had
an unsatisfactory result of early treatment. The four patients
with a satisfactory result had had successful internal fixation
of the radial head. Two of these patients also had had reattachment of the lateral collateral ligament complex to the lateral epicondyle.
Of the ten patients who retained the native elbow, nine
had ulnohumeral arthrosis; it was rated as Grade 1 in two patients, Grade 2 in two, and Grade 3 in five (including the patient with neuropathic arthropathy). Elbow arthrosis was less
severe among the four patients with successful internal fixa-

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tion of the radial head and a stable, concentric reduction: it

was Grade 0 in one, Grade 1 in two, and Grade 2 in one.
Discussion
he patients in this series were each treated by a different
surgeon, and the surgeons had varied training, experience, and familiarity with elbow trauma. It is therefore likely
that this series reflects the common pattern of treatment of
this injury in the United States during the study period. However, a major weakness of the series is that standard treatment
protocols were not used. Specifically, it would be useful to
know how these patients would have fared if radiocapitellar
contact had been preserved (either with internal fixation of
the radial head or with replacement with a metal prosthesis)
and the lateral collateral ligament complex had been reattached to the lateral epicondyle9,10. Nonetheless, some important information about this troublesome pattern of injury can
be gleaned from this series.
It is clear that this specific combination of injuries can
rarely be treated with immobilization alone, as seven of eleven
elbows redislocated in spite of splint immobilization. Physicians involved in the emergency care of these patients should
advise them that the elbow may redislocate in a cast or splint
and that prompt, definitive treatment should be arranged.
When operative treatment is undertaken, a cast or splint cannot be relied on to maintain the reduction if adequate stability cannot be restored; thus, external fixation or transfixation
of the elbow should be considered. Some authors9 have suggested that stability is adequate when the elbow can be extended to 45. We think that, to be confident that the elbow is
stable, it should be possible to extend the elbow nearly completely (to perhaps 30 of flexion) without redislocation10.
Prolonged dislocation or subluxation of the elbow should be
avoided, as it can damage the articular surfaces or lead to attenuation of the collateral ligaments requiring a more complex reconstructive procedure11.
Resection of the radial head also is not advisable, as all
four patients treated with resection in this series had severe
postoperative instability requiring additional operative procedures. On the other hand, restoration of radiocapitellar contact is not always sufficient to restore stability, as evidenced by
the patient with recurrent instability after internal fixation of
the radial head.
Even when a concentric reduction of the elbow is
achieved, advanced ulnohumeral arthrosis develops relatively
quickly in most patients. While arthrosis may be due to damage that occurred at the original injury, it probably also reflects the long-term effects of diminished elbow stability.
Achieving sufficient stability to maintain concentric reduction
is a necessary minimum goal of treatment, but it is probably
worthwhile to try to restore as many of the contributors to ulnohumeral stability as feasible.
All eleven fractures of the coronoid were small (<50% of
the total height of the coronoid), and the fractures often appeared as a very small triangular fragment in the coronoid
fossa on the lateral radiograph. These small coronoid frag-


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ments are often difficult to distinguish from fragments of the

radial head (Figs. 2-A, 2-B, and 2-C). This fracture pattern
contrasts with the very large fragment (between 50% and 100%
of the total coronoid height) that was seen in twenty-five of

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lar disruption occurs with most posterior dislocations of the

elbow15,16; it is not unique to fracture-dislocations. The fracture of the coronoid usually involves its tip but may preferentially involve its medial facet, leading to a greater decrease in
stability. At a minimum, it is clear that the associated fracture
of the coronoidno matter how smallcan be a marker for
greatly diminished elbow stability. When there is doubt
about the source of anterior fracture fragments, the question
of whether the coronoid is fractured may be of sufficient importance to merit computed tomography imaging. In our experience, three-dimensional reconstructions of the injured
elbow are particularly useful and easy to interpret.
Open reduction and internal fixation of fractures of the

Fig. 2-A

Figs. 2-A, 2-B, and 2-C A sixty-seven-year-old man fell from a standing
height, injuring the left, nondominant elbow. Fig. 2-A A manipulative
reduction proved unstable in spite of splint immobilization. The small
fragment of bone adjacent to the trochlea of the distal part of the
humerus is the coronoid fracture fragment.

Fig. 2-C

A lateral radiograph made one year after open reduction and internal
fixation of the fracture of the coronoid with use of a suture placed
through drill-holes in the ulna and two screws. There is heterotopic
bone anterior to the radial head, but a stable concentric reduction and
a functional range of motion were achieved.

Fig. 2-B

A sagittal computed tomography image shows the coronoid fracture

and gives some idea of its size.

twenty-six fractures of the coronoid in patients with an anterior or posterior olecranon fracture-dislocation of the elbow
treated during the same period. Larger coronoid fractures have
been reported to be more difficult to manage6, but we have
found that these larger fractures are more straightforward to
repair and that the repair usually restores elbow stability12,13. As
the treatment of olecranon fracture-dislocationsincluding
large coronoid fracturesbecomes more predictable, it seems
that the smaller fractures of the coronoid associated with elbow
instability should now be regarded as the most troublesome.
Given that these fractures of the coronoid are so small,
it is not clear whether the substantial decrease in elbow stability can be ascribed entirely to them. The anterior aspect of
the capsule is attached to this fragment14, but anterior capsu-

coronoid has been considered more frequently in the setting

of the terrible-triad injury pattern17. The operation often can
be accomplished with a suture passed through drill-holes in
the ulna that captures either the coronoid fragment itself or
its anterior capsular attachment. While this step does not always provide an anatomical reduction, it does enhance elbow
stability. Larger fragments can be more securely reduced and
fixed with ancillary screw fixation. Fractures that involve the
medial facet of the coronoid process may be best addressed
with a direct medial exposure and fixation with a small plate
and screws.
This pattern of injury is so troublesome and unpredictable that the surgeon should be prepared intraoperatively for
persistent elbow instability in spite of repair of the coronoid,
radial head, and lateral collateral ligament. Our limited experience with this situation suggests that repair of the medial
collateral ligament may not add much stability and that a brief
period of hinged external fixation, static external fixation, or
transfixation of the ulnohumeral joint should be considered.
Our current preference is hinged external fixation, but this re-


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quires equipment and technical skills that may not be readily

available. Static external fixation or transfixation of the ulnohumeral joint are also reasonable alternatives. While excessive
immobilization can lead to a stiff elbow, this problem can be
treated, with a high degree of success, with operative capsular
release18,19, but chronic subluxation or dislocation of the elbow
may lead to irreparable articular injury. In the treatment of
this troublesome pattern of injuries, the primary goal should
always be restoration of elbow stability. !
David Ring, MD
Hand and Upper Extremity Service, Department of Orthopaedic Surgery,
Massachusetts General Hospital ACC 525, 15 Parkman Street, Boston,
MA 02114. E-mail address: dring@partners.org

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Jesse B. Jupiter, MD
Hand and Upper Extremity Service, Department of Orthopaedic Surgery,
Massachusetts General Hospital, ACC 527, 15 Parkman Street, Boston,
MA 02114. E-mail address: jjupiter1@partners.org
Jeffrey Zilberfarb, MD
1101 Beacon Street, Brookline, MA 02146
In support of their research or preparation of this manuscript, one or
more of the authors received grants or outside funding from the AO
Foundation. None of the authors received 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.

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and intraarticular fractures. Clin Orthop. 1989;246:126-30.

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3. Hotchkiss RN. Fractures and dislocations of the elbow. In: Rockwood CA Jr,
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