Gabriel Clembosky, MD, and Jorge G. Boretto, MD.
Journal of Hand Surgery. July/August 2009. Vol. 34. No. 6. Pp. 1120-1123.
What’s the best way to treat a badly broken elbow? Some say you must save the elbow at all costs. Others debate the point that complex elbow fractures respond better with a prosthetic. Usually just the radial head needs replacing, but sometimes the entire elbow is replaced.
Studies show that Open reduction and internal fixation (ORIF) is an acceptable choice IF it is possible to realign the bones closely enough to get good enough fixation and union. If not, then it’s best to go right to the replacement option.
The more the bone is fragmented into pieces, the greater the chances that the patient will lose motion and function with any attempts at fixation. If the radial head is involved, forearm rotation is often compromised. Over the years, bone grafting and improved fixation devices like miniplates has made it possible to preserve more elbows than ever before.
Studies presenting outcomes of radial prostheses report a mix of results from poor to excellent, with equally varying levels of patient satisfaction. The implants are expensive and don’t always fit the patient well. Overstuffing the joint is a real concern. Over time, the joint cartilage gets worn down and the elbow can start to dislocate.
There is still room for research in this area. What kind of materials and types of devices would work best for fixation and/or implants? Studies are needed to compare the results of open reduction and internal fixation against the different types of implants. Studies that follow patients for 10, 15, and 20 years to give long-term results are needed. Surgeons who are familiar with the different types of prostheses need to know how the results of each of these compare.
The authors conclude by sharing their own preferences. First, they say that they make every effort to repair complex, fragmented fractures of the radial head. This decision is based on personal experience as well as published results of a limited number of studies. The bottom-line is that it’s impossible to mimic the natural anatomy, movement, and function with an implant because there’s of the slight valgus angle of the normal forearm/elbow complex.
Disruption of the medial ligament along the inside of the elbow makes it difficult to reproduce this angle. Surgery to repair or replace any part of the elbow just doesn’t restore the normal dynamics of mechanical motion provided by the angle.
