The Elbow pp 143-163 | Cite as

Complex Elbow Instability: Treatment and Rehabilitation

  • Giuseppe GiannicolaEmail author
  • David Polimanti
  • Marco Scacchi


Complex elbow instability represent a challenging injury even for expert elbow surgeons. Chronic instability, posttraumatic osteo-arthritis, stiffness and poor functional outcomes are frequent if these injuries are not adequately treated. A correct preoperative evaluation includes X-rays, CT scan with 2D and 3D reconstruction and stability tests under fluoroscopy in order to recognize all osseous and ligamentous lesions. The most common patterns of complex elbow instability includes: (1) radial head fractures associated with lateral and medial collateral ligaments lesions; (2) coronoid fractures and lateral collateral ligament lesion; (3) Terrible Triad; (4) fracture-dislocations of the proximal ulna and radius, also referred to as transolecranon fracture-dislocations and Monteggia-like lesions; and (5) humeral shear fractures associated with lateral and medial collateral ligament lesions.

The main goals of the treatment are (1) to perform a stable osteosynthesis of all fractures, (2) to obtain concentric and stable reduction of the elbow throught the repair of soft tissue constraint lesions and (3) to allow early motion. All the patterns of complex elbow instability share the same therapeutic algorithm based on seven main principles: 1) the proximal ulna must be anatomically reduced and fixed; 2) the radial head or humeral shear fracture must be repaired or replaced, 3) bone length, alignment and rotation of ulnar and radial shaft fractures must be recovered; 4) the lateral collateral ligament complex must be repaired to obtain elbow stability; 5) the medial collateral ligament must be repaired if persistent instability is observed after lateral collateral ligament repair; 6) an hinged external fixator must be considered if the elbow remains unstable or the protection of the joint reconstruction is required; 7) re-evaluation of the surgical steps if congruent ulno-humeral and radio-humeral joints have not been achieved.

Following the surgical treatment an adequate rehabilitation programme should be started promptly and continued for at least 6 months since a significant improvement of the range of motion occurs prevalently in this period, which should be considered the critical time period to obtain a functional elbow.


  1. Ahmad MA, White A, Reza SA et al (2007) When is a Monteggia fracture not a Monteggia fracture? Inj Extra 38:51–53CrossRefGoogle Scholar
  2. Al-Burdeni S, Abuodeh Y, Ibrahim T et al (2015) Open reduction and internal fixation versus radial head arthroplasty in the treatment of adult closed comminuted radial head fractures (modified Mason type III and IV). Int Orthop 39(8):1659–1664PubMedCrossRefGoogle Scholar
  3. Alolabi B, Gray A, Ferreira LM et al (2012) Rehabilitation of the medial- and lateral collateral ligament-deficient elbow: an in vitro biomechanical study. J Hand Ther 25(4):363–372PubMedCrossRefGoogle Scholar
  4. Ashwood N, Verma M, Hamlet M (2010) Transarticular shear fractures of the distal humerus. J Shoulder Elb Surg 19:46–52CrossRefGoogle Scholar
  5. Beingessner DM, Dunning CE, Stacpoole RA (2007) The effect of coronoid fractures on elbow kinematics and stability. Clin Biomech (Bristol, Avon) 22(2):183–190CrossRefGoogle Scholar
  6. Biga N, Thomine JM (1974) Trans-olecranal dislocations of the elbow. Rev Chir Orthop Reparatrice Appar Mot 60(7):557–567PubMedGoogle Scholar
  7. Biyani A, Olscamp AJ, Ebraheim NA (2000) Complications in the management of complex monteggia-equivalent fractures in adults. Am J Orthop 29(2):115–118PubMedGoogle Scholar
  8. Boyd HB (1947) Surgical approaches to the elbow joint. Instruct Course Lect 4:147Google Scholar
  9. Boyd HB, Boals JC (1969) The Monteggia lesion: a review of 159 cases. Clin Orthop Relat Res 66:94–100PubMedCrossRefGoogle Scholar
  10. Broberg MA, Morrey BF (1987) Results of treatment of fracture-dislocations of the elbow. Clin Orthop Relat Res 216:109–119Google Scholar
  11. Bruce HE, Harvey JP, Wilson JC (1974) Monteggia fractures. J Bone Joint Surg Am 56:1563–1576PubMedCrossRefGoogle Scholar
  12. Budoff JE (2012) Coronoid fractures. J Hand Surg Am 37:2418–2423PubMedCrossRefGoogle Scholar
  13. Chan K, MacDermid JC, Faber KJ et al (2014) Can we treat select terrible triad injuries nonoperatively? Clin Orthop Relat Res 472(7):2092–2099PubMedPubMedCentralCrossRefGoogle Scholar
  14. Chemama B, Bonnevialle N, Peter O et al (2010) Terrible triad injury of the elbow: how to improve outcomes? Orthop Traumatol Surg Res 96(2):147–154PubMedCrossRefGoogle Scholar
  15. Chen HW, Liu GD, Wu LJ (2014) Complications of treating terrible triad injury of the elbow: a systematic review. PLoS One 9(5):e97476PubMedPubMedCentralCrossRefGoogle Scholar
  16. Cheung EV, Steinmann SP (2009) Surgical approaches to the elbow. J Am Acad Orthop Surg 17(5):325–333PubMedCrossRefGoogle Scholar
  17. Closkey RF, Goode JR, Kirschenbaum D et al (2000) The role of the coronoid process in elbow stability. A biomechanical analysis of axial loading. Bone Joint Surg Am 82-A(12):1749–1753CrossRefGoogle Scholar
  18. Deutch SR, Jensen SL, Tyrdal S et al (2003) Elbow joint stability following experimental osteoligamentous injury and reconstruction. J Shoulder Elb Surg 12(5):466–471CrossRefGoogle Scholar
  19. Doornberg JN, Ring D (2004) Effective treatment of fracture dislocation of the olecranon requires a stable trochlear notch. Clin Orthop Relat Res 429:292–300CrossRefGoogle Scholar
  20. Doornberg JN, Ring D (2006) Coronoid fracture patterns. J Hand Surg Am 31(1):45–52PubMedCrossRefGoogle Scholar
  21. Doornberg JN, de Jong IM, Lindenhovius AL et al (2007) The anteromedial facet of the coronoid process of the ulna. J Shoulder Elb Surg 16(5):667–670CrossRefGoogle Scholar
  22. Dowdy PA, Bain GI, King GJ et al (1995) The midline posterior elbow incision. An anatomical appraisal. J Bone Joint Surg Br 77(5):696–699PubMedCrossRefGoogle Scholar
  23. Dubberley JH, Faber KJ, Macdermid JC (2006) Outcome after open reduction and internal fixation of capitellar and trochlear fractures. J Bone Joint Surg Am 88:46–54PubMedGoogle Scholar
  24. Eathiraju S, Mudgal C, Jupiter JB (2007) Monteggia fracture-dislocations. Hand Clin 23:165–177PubMedCrossRefGoogle Scholar
  25. Egol KA, Tejwani N, Bazzi J et al (2005) Does a Monteggia variant lesion result in a poor functional outcome? A retrospective study. Clin Orthop Relat Res 438:233–238PubMedCrossRefGoogle Scholar
  26. Egol KA, Immerman I, Paksima N et al (2007) Fracture-dislocation of the elbow functional outcome following treatment with a standardized protocol. Bull NYU Hosp Jt Dis 65(4):263–270PubMedGoogle Scholar
  27. Elkowitz SJ, Polatsch DB, Egol KA (2002) Capitellum fractures: a biomechanical evaluation of three fixation methods. J Orthop Trauma 16:503–506PubMedCrossRefGoogle Scholar
  28. Fitzgibbons PG, Louie D, Dyer GS et al (2014) Functional outcomes after fixation of "terrible triad" elbow fracture dislocations. Orthopedics 37(4):e373–e376PubMedCrossRefGoogle Scholar
  29. Forthman C, Henket M, Ring DC (2007) Elbow dislocation with intra-articular fracture: the results of operative treatment without repair of the medial collateral ligament. J Hand Surg Am 32(8):1200–1209PubMedCrossRefGoogle Scholar
  30. Fowler JR, Goitz RJ (2013) Radial head fractures: indications and outcomes for radial head arthroplasty. Orthop Clin North Am 44(3):425–431PubMedCrossRefGoogle Scholar
  31. Garrigues GE, Wray WH 3rd, Lindenhovius AL et al (2011) Fixation of the coronoid process in elbow fracture-dislocations. J Bone Joint Surg Am 93(20):1873–1881PubMedCrossRefGoogle Scholar
  32. Giannicola G, Zangrando F (2012) Patologie e riabilitazione del gomito. Verduci, RomaGoogle Scholar
  33. Giannicola G, Sacchetti FM, Greco A et al (2010a) Management of complex elbow instability. Musculoskelet Surg 94(Suppl 1):S25–S36PubMedCrossRefGoogle Scholar
  34. Giannicola G, Sacchetti FM, Greco A et al (2010b) Open reduction and internal fixation combined with hinged elbow fixator in capitellum and trochlea fractures. Acta Orthop 81(2):228–233PubMedPubMedCentralCrossRefGoogle Scholar
  35. Giannicola G, Greco A, Sacchetti FM et al (2011) Complex fracture-dislocations of the proximal ulna and radius in adults: a comprehensive classification. J Shoulder Elb Surg 20(8):1289–1299CrossRefGoogle Scholar
  36. Giannicola G, Polimanti D, Sacchetti FM et al (2012a) Soft tissue constraint injuries in complex elbow instability: prevalence, pathoanatomy, and classification. Orthopedics 35(12):e1738–e1745PubMedCrossRefGoogle Scholar
  37. Giannicola G, Polimanti D, Sacchetti FM et al (2012b) Soft tissue constraint injuries in complex elbow instability: surgical techniques and clinical outcomes. Orthopedics 35(12):e1746–e1753PubMedCrossRefGoogle Scholar
  38. Giannicola G, Polimanti D, Gumina S et al (2013a) Use of fine-threaded K-wires in the treatment of coronoid fractures in complex elbow instability. Orthopedics 36(10):e1233–e1238PubMedCrossRefGoogle Scholar
  39. Giannicola G, Scacchi M, Sacchetti FM et al (2013b) Clinical usefulness of proximal ulnar and radial fracture-dislocation comprehensive classification system (PURCCS): prospective study of 39 cases. J Shoulder Elb Surg 22(12):1729–1736CrossRefGoogle Scholar
  40. Giannicola G, Polimanti D, Bullitta G et al (2014) Critical time period for recovery of functional range of motion after surgical treatment of complex elbow instability: prospective study on 76 patients. Injury 45(3):540–545PubMedPubMedCentralCrossRefGoogle Scholar
  41. Giannicola G, Sedati P, Cinotti G et al (2015) The ulnar greater sigmoid notch “coverage angle”: bone and cartilage contribution. Magnetic resonance imaging anatomic study on 78 elbows. J Shoulder Elbow Surg 24(12):1934–1938PubMedCrossRefGoogle Scholar
  42. Givon U, Pritsch M, Levy O (1997) Monteggia and equivalent lesions: a study of 41 cases. Clin Orthop Relat Res 337:208–215CrossRefGoogle Scholar
  43. Goodman HJ, Choueka J (2005) Complex coronal shear fractures of the distal humerus. Bull Hosp Jt Dis 62:85–89PubMedGoogle Scholar
  44. Gordon ML (1967) Monteggia fracture. A combined surgical approach employing a single lateral incision. Clin. Orthop. 50:87.PubMedCrossRefGoogle Scholar
  45. Guitton TG, Ring D (2010) Nonsurgically treated terrible triad injuries of the elbow: report of four cases. J Hand Surg Am 35(3):464–467PubMedCrossRefGoogle Scholar
  46. Gul A, Sambandam S, Rangaswamy S (2007) Ipsilateral Monteggia fracture dislocation with volar lunate dislocation of wrist: a case report. Eur J Orthop Surg Traumatol 17:331–333CrossRefGoogle Scholar
  47. Harding P, Rasekaba T, Smirneos L et al (2011) Early mobilisation for elbow fractures in adults. Cochrane Database Syst Rev 15:CD008130Google Scholar
  48. Herbertsson P, Josefsson PO, Hasserius R et al (2004) Fractures of the radial head and neck treated with radial head excision. J Bone Joint Surg Am 86-A(9):1925–1930PubMedCrossRefGoogle Scholar
  49. Hotchkiss RN (1996) Fractures and dislocations of the elbow. In: Rockwood CA, Green DP, Bucholz RW, Heckman JD (eds) Rockwood and Green’s fractures in adults, vol vol. 1, 4th edn. Lippincott-Raven, Philadelphia, pp 929–1024Google Scholar
  50. Hotchkiss RN (1997) Displaced fractures of the radial head: internal fixation or excision? J Am Acad Orthop Surg 5(1):1–10PubMedCrossRefGoogle Scholar
  51. Hotchkiss RN, An KN, Sowa DT (1989) An anatomic and mechanical study of the interosseous membrane of the forearm: pathomechanics of proximal migration of the radius. J Hand Surg Am 14(Pt 1):256–261PubMedCrossRefGoogle Scholar
  52. Hull JR, Owen JR, Fern SE et al (2005) Role of the coronoid process in varus osteoarticular stability of the elbow. J Shoulder Elb Surg 14(4):441–446CrossRefGoogle Scholar
  53. Ikeda M, Sugiyama K, Kang C (2005) Comminuted fractures of the radial head. Comparison of resection and internal fixation. J Bone Joint Surg Am 87(1):76–84PubMedCrossRefGoogle Scholar
  54. Issack PS, Egol KA (2006) Posttraumatic contracture of the elbow: current management issues. Bull Hosp Jt Dis 63:129–136PubMedPubMedCentralGoogle Scholar
  55. Jeong WK, Oh JK, Hwang JH et al (2010) Results of terrible triads in the elbow: the advantage of primary restoration of medial structure. J Orthop Sci 15(5):612–619PubMedCrossRefGoogle Scholar
  56. Josefsson PO, Gentz CF, Johnell O et al (1989) Dislocations of the elbow and intraarticular fractures. Clin Orthop Relat Res 246:126–130Google Scholar
  57. Josten C, Freitag S (2009) Monteggia and Monteggia-like-lesion: classification, indication and techniques in operative treatment. Eur J Trauma Emerg Surg 35:296–304PubMedCrossRefGoogle Scholar
  58. Jupiter JB, Leibovic SJ, Ribbans W (1991) The posterior Monteggia lesion. J Orthop Trauma 5:395–402PubMedCrossRefGoogle Scholar
  59. Kälicke T, Muhr G, Frangen TM (2007) Dislocation of the elbow with fractures of the coronoid process and radial head. Arch Orthop Trauma Surg 127(10):925–931PubMedCrossRefGoogle Scholar
  60. Kaplan EB (1941) Surgical approaches to the proximal end of the radius and its use in fractures of the head and neck of the radius. J Bone Joint Surg 23(86):1941Google Scholar
  61. Karlstad R, Morrey BF, Cooney WP (2005) Failure of fresh-frozen radial head allografts in the treatment of Essex-Lopresti injury: a report of four cases. J Bone Joint Surg Am 87:1828–1833PubMedCrossRefGoogle Scholar
  62. Kasparyan NG, Hotchkiss RN (1997) Dynamic skeletal fixation in the upper extremity. Hand Clin 13:643PubMedGoogle Scholar
  63. Keschner MT (2007) Paksima N (2007) The stiff elbow. Bull NYU Hosp Jt Dis 65:24–28PubMedGoogle Scholar
  64. Kocher T (1911) Textbook of Operative Surgery, 3rd edn. A. and C, Black, LondonGoogle Scholar
  65. Kodde IF, van Rijn J, van den Bekerom MP et al (2013) Surgical treatment of post-traumatic elbow stiffness: a systematic review. J Shoulder Elb Surg 22:574–580CrossRefGoogle Scholar
  66. Konrad G, Kundel K (2007) Monteggia fractures in adults. Long term results and prognostic factors J Bone Joint Surg Br 69:354–360CrossRefGoogle Scholar
  67. Lee JJ, Lawton JN (2012) Coronal shear fractures of the distal humerus. J Hand Surg Am 37:2412–2417PubMedCrossRefGoogle Scholar
  68. Leigh WB, Ball CM (2012) Radial head reconstruction versus replacement in the treatment of terrible triad injuries of the elbow. J Shoulder Elb Surg 21(10):1336–1341CrossRefGoogle Scholar
  69. Li N, Chen S (2014) Open reduction and internal-fixation versus radial head replacement in treatment of Mason type IIIradial head fractures. Eur J Orthop Surg Traumatol 24(6):851–855PubMedCrossRefGoogle Scholar
  70. Lindenhovius AL, Felsch Q, Doornberg JN (2007) Open reduction and internal fixation compared with excision for unstable displaced fractures of the radial head. J Hand Surg Am 32(5):630–636PubMedCrossRefGoogle Scholar
  71. Lindenhovius AL, Jupiter JB, Ring D (2008) Comparison of acute versus subacute treatment of terrible triad injuries of the elbow. J Hand Surg Am 33(6):920–926PubMedCrossRefGoogle Scholar
  72. Liu R, Liu P, Shu H et al (2015) Comparison of primary radial head replacement and ORIF (open reduction and internal fixation) in Mason type III fractures: a retrospective evaluation in 72 elderly patients. Med Sci Monit 21:90–93PubMedPubMedCentralCrossRefGoogle Scholar
  73. Llusa Perez M, Lamas C, Martinez I (2002) Monteggia fractures in adults: review of 54 cases. Chir Main 21:293–297PubMedCrossRefGoogle Scholar
  74. Manidakis N, Sperelakis I, Hackney R et al (2012) Fractures of the ulnar coronoid process. Injury 43(7):989–998PubMedCrossRefGoogle Scholar
  75. Marotte JH, Samuel P, Lord G (1982) La fracture-luxation conjointe de l’extremit_e superieure des deux os de l’avant-bras. Rev Chir Orthop 68:104–114Google Scholar
  76. Mathew PK, Athwal GS, King GJ (2009) Terrible triad injury of the elbow: current concepts. J Am Acad Orthop Surg 17(3):137–151PubMedCrossRefGoogle Scholar
  77. McKee MD, Jupiter JB, Bamberger HB (1996) Coronal shear fractures of the distal end of the humerus. J Bone Joint Surg Am 78(1):49–54PubMedCrossRefGoogle Scholar
  78. McKee MD, Schemitsch EH, Sala MJ et al (2003) The pathoanatomy of lateral ligamentous disruption in complex elbow instability. J Shoulder Elb Surg 12(4):391–396CrossRefGoogle Scholar
  79. Mellema JJ, Janssen SJ, Guitton TG (2015) Quantitative 3-dimensional computed tomography measurements of coronoidfractures. J Hand Surg Am 40(3):526–533PubMedCrossRefGoogle Scholar
  80. Mighell M, Virani NA, Shannon R et al (2010) Large coronal shear fractures of the capitellum and trochlea treated with headless compression screws. J Shoulder Elb Surg 19(1):38–45CrossRefGoogle Scholar
  81. Monteggia GB (1814) Istruzioni chirurgiche, Vol 5. Pirotta & Maspero, Milano, pp 52–138Google Scholar
  82. Morrey BF (1993) Radial head fracture. In: Morrey BF (ed) The elbow, 2nd edn. WB Saunders, Philadelphia, pp 383–404Google Scholar
  83. Morrey BF (1998) Complex instability of the elbow. Instr Course Lect 47:157–164PubMedGoogle Scholar
  84. Morrey BF (2005) The posttraumatic stiff elbow. Orthop Relat Res 431:26–35Google Scholar
  85. Morrey BF (2009) Current concepts in the management of complex elbow trauma. Surgeon 7(3):151–161PubMedCrossRefGoogle Scholar
  86. Morrey BF, An KN (1983) Articular and ligamentous contributions to the stability of the elbow joint. Am J Sports Med 11(5):315–319PubMedPubMedCentralCrossRefGoogle Scholar
  87. Morrey BF, An KN (2005) Stability of the elbow: osseous constraints. J Shoulder Elbow Surg 14(1 suppl):S174–S178CrossRefGoogle Scholar
  88. Morrey BF, Chao EY, Hui FC (1979) Biomechanical study of the elbow following excision of the radial head. J Bone Joint Surg Am 61(1):63–68PubMedCrossRefGoogle Scholar
  89. Morrey BF, Askew LJ, Chao EY (1981) A biomechanical study of normal functional elbow motion. J Bone Joint Surg Am 63:872–877PubMedCrossRefGoogle Scholar
  90. Morrey BF, Tanaka S, An KN (1991) Valgus stability of the elbow. A definition of the primary and secondary constraints Clin Orthop Relat Res 265:187–195Google Scholar
  91. Mouhsine E, Akiki A, Castagna A et al (2007) Transolecranon anterior fracture dislocation. J Shoulder Elb Surg 16:352–357CrossRefGoogle Scholar
  92. Nielsen D, Nowinski RJ, Bamberger HB (2002) Indications, alternatives, and complications of external fixation about the elbow. Hand Clin 18(1):87–97PubMedCrossRefGoogle Scholar
  93. O’Driscoll SW, Jupiter JB, King GJ (2001) The unstable elbow. Instr Course Lect 50:89–102PubMedGoogle Scholar
  94. O'Driscoll SW, Jupiter JB, Cohen MS et al (2003) Difficult elbow fractures: pearls and pitfalls. Instr Course Lect 52:113–134PubMedGoogle Scholar
  95. Papatheodorou LK, Rubright JH, Heim KA et al (2014) Terrible triad injuries of the elbow: does the coronoid always need to be fixed? Clin Orthop Relat Res 472(7):2084–2091PubMedPubMedCentralCrossRefGoogle Scholar
  96. Park MC, Ahmad CS (2004) Dynamic contributions of the flexor–pronator mass to elbow valgus stability. J Bone Joint Surg Am 86(10):2268–2274PubMedCrossRefGoogle Scholar
  97. Park SM, Lee JS, Jung JY et al (2015) How should anteromedial coronoid facet fracture be managed? A surgical strategy based on O'Driscoll classification and ligament injury. J Shoulder Elb Surg 24(1):74–82CrossRefGoogle Scholar
  98. Penrose JH (1951) The Monteggia fracture with posterior dislocation of the radial head. J Bone Joint Surg Br 33:65–73PubMedCrossRefGoogle Scholar
  99. Pilato G, De Pietri M, Vernieri W et al (2004) The surgical treatment of fractures of the radial head: a comparison between osteosynthesis and capitellectomy. Chir Organi Mov 89(3):213–222PubMedGoogle Scholar
  100. Pollock JW, Brownhill J, Ferreira L et al (2009) The effect of anteromedial facet fractures of the coronoid and lateral collateral ligament injury on elbow stability and kinematics. J Bone Joint Surg Am 91(6):1448–1458PubMedCrossRefGoogle Scholar
  101. Pomianowski S, O’Driscoll SW, Neale PG et al (2001) The effect of forearm rotation on laxity and stability of the elbow. Clin Biomech (Bristol, Avon) 16:401–407CrossRefGoogle Scholar
  102. Reckling FW (1982) Unstable fracture-dislocations of the forearm (Monteggia and Galeazzi lesions). J Bone Joint Surg Am 64:857–863PubMedCrossRefGoogle Scholar
  103. Regan W, Morrey B (1989) Fractures of the coronoid process of the ulna. J Bone Joint Surg Am 71(9):1348–1354PubMedCrossRefGoogle Scholar
  104. Ring D (2006) Fractures of the coronoid process of the ulna. J Hand Surg Am 31(10):1679–1689PubMedCrossRefGoogle Scholar
  105. Ring D, Jupiter JB (2002) Fracture–dislocation of the elbow. Hand Clin 18(1):55–63PubMedCrossRefGoogle Scholar
  106. Ring D, Jupiter JB, Simpson S (1998) Monteggia fractures in adults. J. Bone Joint Surg Am 80:1733–1744CrossRefGoogle Scholar
  107. Ring D, Jupiter JB, Zilberfarb J (2002) Posterior dislocation of the elbow with fractures of the radial head and coronoid. J Bone Joint Surg Am 84-A(4):547–551PubMedCrossRefGoogle Scholar
  108. Rodriguez-Martin J, Pretell-Mazzini J, Andres-Esteban EM et al (2011) Outcomes after terrible triads of the elbow treated with the current surgical protocols A review. Int Orthop 35(6):851–860PubMedCrossRefGoogle Scholar
  109. Ruan HJ, Fan CY, Liu JJ et al (2009) A comparative study of internal fixation and prosthesis replacement for radial head fractures of Mason type III. Int Orthop 33(1):249–253PubMedCrossRefGoogle Scholar
  110. Ruchelsman DE, Tejwani NC, Kwon YW et al (2008) Coronal plane partial articular fractures of the distal humerus: current concepts in management. J Am Acad Orthop Surg 16:716–728PubMedCrossRefGoogle Scholar
  111. Sabo MT, Fay K, McDonald CP (2010) Effect of coronal shear fractures of the distal humerus on elbow kinematics and stability. J Shoulder Elb Surg 19(5):670–680CrossRefGoogle Scholar
  112. Sanchez-Sotelo J, O’Driscoll SW, Morrey BF (2006) Anteromedial fracture of the coronoid process of the ulna. J Shoulder Elb Surg 15(5):e5–e8CrossRefGoogle Scholar
  113. Schneeberger AG, Sadowski MM, Jacob HA (2004) Coronoid process and radial head as posterolateral rotatory stabilizers of the elbow. J Bone Joint Surg Am 86-A(5):975–982PubMedCrossRefGoogle Scholar
  114. Seiber K, Gupta R, McGarry MH (2009) The role of the elbow musculature, forearm rotation, and elbow flexion in elbow stability: an in vitro study. J Shoulder Elb Surg 18(2):260–268CrossRefGoogle Scholar
  115. Seijas R, Ares-Rodriguez O, Orellana A et al (2009) Terrible triad of the elbow. J Orthop Surg (Hong Kong) 17(3):335–339CrossRefGoogle Scholar
  116. Shukla DR, Fitzsimmons JS, An KN (2012) Effect of radial head malunion on radiocapitellar stability. J Shoulder Elb Surg 21(6):789–794CrossRefGoogle Scholar
  117. Shukla DR, Thoreson AR, Fitzsimmons JS et al (2015) The effect of capitellar impaction fractures on radiocapitellar stability. J Hand Surg Am 40(3):520–525PubMedCrossRefGoogle Scholar
  118. Singh AP, Singh AP, Vaishya R et al (2010) Fractures of capitellum: a review of 14 cases treated by open reduction and internal fixation with Herbert screws. Int Orthop 34:897–901PubMedCrossRefGoogle Scholar
  119. Søjbjerg JO, Ovesen J, Nielsen S (1987) Experimental elbow instability after transection of the medial collateral ligament. Clin Orthop Relat Res 218:186–190Google Scholar
  120. Sotereanos DG, Darlis NA, Wright TW (2007) Unstable fracture-dislocations of the elbow. Instr Course Lect 56:369–376PubMedGoogle Scholar
  121. Steinmann SP (2008) Coronoid process fracture. J Am Acad Orthop Surg 16:519–529PubMedCrossRefGoogle Scholar
  122. Strauss EJ, Tejwani NC, Preston CF (2006) The posterior Monteggia lesion with associated ulnohumeral instability. J Bone Joint Surg Br 88:84–89PubMedCrossRefGoogle Scholar
  123. Tan V, Daluiski A, Capo J (2005) Hinged elbow external fixators: indications and uses. J Am Acad Orthop Surg 13(8):503–514PubMedCrossRefGoogle Scholar
  124. Tarassoli P, McCann P, Amirfeyz R (2013) Complex instability of the elbow. Injury 48(3):568–577PubMedCrossRefGoogle Scholar
  125. Terada N, Yamada H, Seki T et al (2000) The importance of reducing small fractures of the coronoid process in the treatment of unstable elbow dislocation. J Shoulder Elb Surg 9(4):344–346CrossRefGoogle Scholar
  126. Van Riet RP, Morrey BF, O'Driscoll SW (2005a) Use of osteochondral bone graft in coronoid fractures. J Shoulder Elb Surg 14(5):519–523CrossRefGoogle Scholar
  127. Van Riet RP, Morrey BF, O’Driscoll SW (2005b) Associated injuries complicating radial head fractures: a demographic study. Clin Orthop Relat Res 441:351–355PubMedCrossRefGoogle Scholar
  128. Wadia F, Kamineni S, Dhotare S (2007) Radiographic measurements of normal elbows: clinical relevance to olecranon fractures. Clin Anat 20:407–410PubMedCrossRefGoogle Scholar
  129. Wadström J, Kinast C, Pfeiffer K (1986) Anatomical variations of the semilunar notch in elbow dislocations. Arch Orthop Trauma Surg 105(5):313–315PubMedCrossRefGoogle Scholar
  130. Wang ML, Beredjiklian PK (2015) Management of radial head fracture with elbow dislocation. J Hand Surg Am 40(4):813–816PubMedCrossRefGoogle Scholar
  131. Wang YX, Huang LX, Ma SH (2010) Surgical treatment of “terrible triad of the elbow”: technique and outcome. Orthop Surg 2(2):141–148PubMedCrossRefGoogle Scholar
  132. Watters TS, Garrigues GE, Ring D et al (2014) Fixation versus replacement of radial head in terrible triad: is there a difference in elbow stability and prognosis? Clin Orthop Relat Res 472(7):2128–2135PubMedCrossRefGoogle Scholar
  133. Watts AC, Morris A, Robinson CM (2007) Fractures of the distal humeral articular surface. J Bone Joint Surg Br 89:510–515PubMedCrossRefGoogle Scholar
  134. Wells J, Ablove RH (2008) Coronoid fractures of the elbow. Clin Med Res 6:40–44PubMedPubMedCentralCrossRefGoogle Scholar
  135. Winter M, Chuinard C, Cikes A et al (2009) Surgical management of elbow dislocation associated with non-reparable fractures of the radial head. Chir Main 28(3):158–167PubMedCrossRefGoogle Scholar
  136. Wolff AL, Hotchkiss RN (2006) Lateral elbow instability: nonoperative, operative, and postoperative management. J Hand Ther 19(2):238–243PubMedCrossRefGoogle Scholar
  137. Wyrick JD, Dailey SK, Gunzenhaeuser JM et al (2015) Management of Complex Elbow Dislocations: A Mechanistic Approach. J Am Acad Orthop Surg 23(5):297–306PubMedCrossRefGoogle Scholar
  138. Yari SS, Bowers NL, Craig MA et al (2015) Management of distal humeral coronal shear fractures. World J Clin Cases 3(5):405–417PubMedPubMedCentralCrossRefGoogle Scholar
  139. Zeiders GJ, Patel MK (2008) Management of unstable elbows following complex fracture-dislocations–the “terrible triad” injury. J Bone Joint Surg Am 90(Suppl 4):75–84PubMedCrossRefGoogle Scholar
  140. Zhang C, Zhong B, Luo CF (2014) Treatment strategy of terrible triad of the elbow: experience in Shanghai 6th People’s Hospital. Injury 45(6):942–948PubMedCrossRefGoogle Scholar

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© Springer International Publishing AG, part of Springer Nature 2018

Authors and Affiliations

  • Giuseppe Giannicola
    • 1
    Email author
  • David Polimanti
    • 1
  • Marco Scacchi
    • 1
  1. 1.Department of AnatomicalHistological, Forensic Medicine and Orthopedic Sciences, Sapienza University of Rome - Policlinico Umberto IRomeItaly

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