Fracture-dislocations of the elbow are complex injuries

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1 Bulletin of the NYU Hospital for Joint Diseases 2007;65(4): Fracture-Dislocation of the Elbow Functional Outcome Following Treatment with a Standardized Protocol Kenneth A. Egol, M.D., Igor Immerman, M.D., Nader Paksima, D.O., M.P.H., Nirmal Tejwani, M.D., and Kenneth J. Koval, M.D. Abstract Fracture-dislocation of the elbow is a significant injury with mixed outcomes. The purpose of the study was to evaluate patient perceived outcome following surgical stabilization of these complex injuries. Twenty-nine available patients (76%) from 37 identified with terrible triad injury patterns, including ulnohumeral dislocation, radial head fracture, and coronoid fracture, were available for a minimum 1-year follow-up (mean, 27 months). All patients were evaluated by their treating physician. Radiographic outcome was evaluated at latest follow-up. Functional outcome was based upon DASH, Mayo elbow performance, and Broberg-Morrey scores. Complications were recorded. Results included that the average flexion-extension arc of elbow motion was 109 ± 27, and the average pronation-supination arc was 128 ± 44. Grip strength averaged 72% of the contralateral extremity. The Mayo score was a mean of 81 (range, 45 to Kenneth A. Egol, M.D., is Associate Professor of Orthopaedic Surgery, New York University School of Medicine and Chief of the Division of Orthopaedic Trauma, NYU Hospital for Joint Diseases Department of Orthopaedic Surgery, NYU Hospital for Joint Diseases, New York, New York. Igor Immerman, M.D., is a Resident in the NYU Hospital for Joint Diseases Department of Orthopaedic Surgery, NYU Hospital for Joint Diseases, New York, New York. Nader Paksima, D.O., M.P.H., is Clinical Assistant Professor of Orthopaedic Surgery, New York University School of Medicine, and Attending in the Division of Hand and Wrist Surgery, NYU Hospital for Joint Diseases, New York, New York. Nirmal Tejwani, M.D., is Associate Professor, New York University School of Medicine, and an Attending in the Division of Trauma Surgery, NYU Hospital for Joint Diseases, NYU Medical Center, New York, New York. Kenneth J. Koval, M.D., is Professor of Orthopaedic Surgery at the Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire. Correspondence: Kenneth A. Egol, M.D., Suite 1402, NYU Hospital for Joint Diseases, 301 East 17th Street, New York, New York 10003; egolk01@nyumc.org. 100), the Broberg-Morrey mean was 77 (range, 33 to 100). The mean DASH was 28 (range, 0 to 72). When compared to the age-based normal values, the mean patient s DASH score was 1.4 SD worse than an average person of the same age. None of the injury characteristics, patient demographics, or treatment modalities was significantly associated with a poor outcome at the 95% confidence interval. Conclusions are that the results with terrible triad injuries are often unsatisfactory, but surgical management with the use of a systematic approach may be beneficial. Our approach led to the restoration of elbow joint stability in all patients. Fracture-dislocations of the elbow are complex injuries that require intensive treatment and frequently result in unsatisfactory outcomes. The syndrome of terrible triad of the elbow is a severe pattern of injury that consists of an ulnohumeral dislocation associated with the fractures of the radial head and the coronoid process of the ulna 1 (Fig. 1). This injury pattern is frequently associated with the disruption of the lateral band of the ulnar collateral ligament, as it is the first structure to be disrupted in the so-called Horii circle of soft tissue disruption of the elbow, the latter of which refers to the three consecutive stages of the lateral to medial progression of elbow dislocation. 1,2 These stages are first, the disruption of the lateral ulnar collateral ligament, followed in the second stage by the rest of the lateral as well as the anterior and posterior aspects of the capsule, and in the third stage, the disruption of the medial ulnar collateral ligament. The structure disrupted in the first stage, the lateral band of the ulnar collateral ligament, is critical to the stability of the elbow, and its reconstruction may be crucial in the restoration of the joint. 3 The fracture of the coronoid associated with this injury is usually small and frequently involves the tip of the coronoid process. 4 Biomechanically, a type I fracture of the coronoid involving just the tip is not Egol KA, Immerman I, Paksima N, Tejwani N, Koval KJ. Fracture-dislocation of the elbow: functional outcome following treatment with a standardized protocol. Bull NYU Hosp Jt Dis. 2007;65(4):

2 264 Bulletin of the NYU Hospital for Joint Diseases 2007;65(4): A B C D Figure 1 A 23-year-old male sustained an elbow fracture-dislocation following a fall off a ladder at work. Attempted AP (A) and lateral (B) radiographs reveal a radial head fracture and coronoid and ulnohumeral dislocation. Postoperative AP (C) and lateral (D) radiographs reveal a reduced joint with radial head replacement and repair of the lateral ligament. a substantial insult to the stability of the elbow, but a type II injury or worse significantly increases elbow instability. 3 Fixation of the more significant coronoid fractures may, therefore, be beneficial for the patient. Similarly, the radial head fracture requires close attention. The radial head is a significant constraint to gross joint motion, and its restoration even in the presence of the coronoid fracture protects against subluxation. 3 There are few reports in the current literature on the terrible triad pattern of injury, and to date no report of the detailed functional results of such injuries Ring and colleagues reported on a series of 11 patients with the terrible triad injury pattern and found the long-term results to be unsatisfactory for the majority of patients. 5 A more recent paper reported on the outcome of a step-wise approach to such injuries, including the repair of the soft tissue capsule;

3 Bulletin of the NYU Hospital for Joint Diseases 2007;65(4): Table 1 Treatment and Injury Details Patient Side Radial Head Treatment Coronoid Coronoid Ex Fix Additional Mason Fracture Fracture Placed? Procedures Classification Type Treatment 1 Dominant III Fixed I No Yes 2 Non II Fixed II Fixed No 3 Dominant II Replaced I No No 4 Dominant II Non-op I No Yes 5 Non I Partial Excision I No Yes 6* Dominant II Partial Excision I No Yes Elbow release at 4.5 months 7 Dominant I Non-op I No Yes 8 Dominant II Replaced II Fixed Yes 9 Non III Replaced I No No 10 Non I Fixed I No No Elbow release and radial head replacement at 6 months 11 Non III Replaced I No Yes 12 Dominant III Replaced I No No 13 Dominant III Replaced I No No 14 Dominant I Partial Excision II No Yes 15 Dominant III Fixed II No No 16 Dominant I Non-op III Fixed No 17 Dominant III Replaced I No Yes 18 Non III Replaced II No Yes 19 Non II Fixed III Fixed No 20 Non III Replaced II No Yes 21 Dominant II Fixed II No No 22 Non II Fixed I No Yes Recurrent dislocation; radial head replaced at 8 weeks with elbow release 23 Non II Fixed I No No 24 Non III Replaced I No No 25 Dominant III Replaced III Fixed Yes 26 Non III Replaced I No No 27 Dominant III Replaced I No No 28 Dominant III Replaced I No No Radial head prosthesis removed at 36 months 29 Dominant III Replaced I No No Elbow release at 3 months *Open injury. nearly half the patients achieved excellent results. 6 Our purpose is to report on the long-term functional outcome following repair of the terrible triad elbow injury treated with a step-wise surgical protocol. Materials and Methods A total of 44 patients who were diagnosed with an elbow fracture-dislocation from 1995 to present were identified in our institution s database. After obtaining permission from the Institutional Review Board (IRB), these patients charts and radiographs were reviewed. Following evaluation of the radiographs, it was determined that 37 patients had met the criteria for inclusion regarding the injury pattern (radial head fracture, coronoid fracture, and ulnohumeral dislocation). These patients were contacted and asked to return for a follow-up visit consisting of radiographic and functional evaluation of the elbow. All patients presented to the emergency departments of one of two level-one trauma centers or were referred to our tertiary care orthopaedic center. Patients were treated by one of three fellowship-trained traumatologists. Eight patients were either lost to follow-up or did not wish to return for functional evaluation and were excluded from the analysis. Surgical treatment of the patients constellation of injuries was based on an algorithmic approach. All patients underwent a lateral Kocher approach to the elbow joint. In the two patients with nondisplaced radial head fractures, the Kocher approach was used to visualize the coronoid or help place the external fixator. Comminuted radial head fractures were addressed with repair, if possible, or replacement at

4 266 Bulletin of the NYU Hospital for Joint Diseases 2007;65(4): the surgeon s discretion. If the fracture was nondisplaced, it was treated without fixation, and if only a small fragment of the radial head was involved (less than 20%) and it was not fixable, the fragment was excised. The ulnar band of the lateral collateral ligament of the elbow was repaired with a bone-suture anchor or sutures through a bone tunnel using a nonabsorbable braided stitch. Repair of the coronoid was reserved for only some type II and all type III fractures. Stability was then tested. If there was adequate ulnohumeral stability at 30 less than full extension, the wounds were closed and the patient was placed in a hinged brace that allowed range of elbow motion through the stable range. If instability persisted beyond 30, a hinged external fixator was placed across the elbow joint and stability was retested. The medial collateral ligament was not addressed in this protocol. Once stability was restored, the wounds were closed. All patients received a single dose of 700 cg radiation therapy to help prevent heterotopic ossification. All patients were followed by the treating surgeon, with biweekly radiographs to confirm maintenance of the elbow reduction. In general, the external fixator was maintained for 6 weeks and was removed in the office or clinic. Patients were encouraged to move actively and were started on outpatient physical therapy after the first office visit. Physical therapy consisted of active assisted range of elbow motion, active shoulder, and wrist and hand therapy. Standard AP and lateral radiographs of the elbow were taken. At the time of the latest follow-up, elbow flexion, extension, pronation, and supination were measured using a goniometer. Grip strength was evaluated using a dynamometer. Radiographs were reviewed by the senior investigators (KA Egol, KJ Koval) to evaluate maintenance of reduction, development of posttraumatic arthritic changes, and development of heterotopic ossification. Posttraumatic arthritic changes were classified according to the system of Broberg and Morrey. 11 Functional outcome was assessed using the Mayo, 12 Broberg-Morrey, 11 Disability of the Arm, Shoulder, and Hand (DASH), 13 and SF-36v2 14 functional scales. These results were further normalized to the published age-based population norms, which are available from the American Academy of Orthopaedic Surgeons. The SF-36v2 scores are scaled such that the score of 50 and standard deviation (SD) of 10 are the normal values for the general population; higher scores are better and lower are worse than the general population. 14 Statistical Analysis Ranges of motion and grip strength comparisons were done using the nonparametric Mann-Whitney test, and the frequencies of the remaining variables were compared using Fisher s exact test (GraphPad Prism, GraphPad Software, Inc.; San Diego, California. Patients who performed at a level of 1.9 SDs or worse, below their age-matched population norm on the DASH, were selected for further analysis. These patients performed worse than 97% of their peers. A number of variables thought to have the potential to affect the results were evaluated for association with these low scores. These variables included the use of the hinged external fixator, the presence of concomitant orthopaedic injuries, the presence of heterotopic ossification on follow-up radiographs, range of motion, grip strength, and the persistence of nerve symptoms on follow-up. Patients with the low (1.9 SDs or more) DASH scores were compared to the remaining patients with regard to these variables. Results Twenty nine patients (78%) with 29 elbow fracture-dislocations returned for the complete follow-up, including physical, radiographic, and functional examination. There were 15 males, with a mean age of 49 years (range, 28 to 68 years), and 14 females, with a mean age of 57 (range, 32 to 79 years). There were 17 dominant and 12 nondominant arm injuries. Twenty-six patients sustained their fracture-dislocations as a result of a fall; two were secondary to a motor vehicle accident, and one a motorcycle accident (MCA). All elbows except one were closed injuries (MCA). Four patients sustained concomitant injuries to the same elbow in addition to the terrible triad pattern, including three patients with fracture of the radial neck and one patient with a capitellum fracture. In addition, there were four patients with associated orthopaedic injuries: an ipsilateral distal radius fracture in one patient, a contralateral distal radius and ipsilateral acetabular fracture in another, a contralateral radial head fracture in the third, and an ipsilateral scaphoid fracture in the fourth. One patient sustained an open injury Figure 2 A 47-year-old male who sustained an open fracture-dislocation of the elbow. The wound was a traumatic Kocher approach with the radial head extruded.

5 Bulletin of the NYU Hospital for Joint Diseases 2007;65(4): A B Figure 3 Same patient as in Figure 1, demonstrating range of elbow motion with a hinged external fixator. Flexion (A) and extension (B). (Fig. 2). All 29 terrible triad elbow injuries were posterior or posterolateral dislocations associated with fractures of the coronoid and the radial head. Injury details are listed in Table 1. Eight radial head fractures were fixed with mini-fragment plates and screws; 15 were replaced with a nonmodular uncemented prosthesis (Wright Medical, Arlington, Tennessee; Stryker Corp., Allendale, New Jersey); three underwent partial excision (debrided); and three were treated nonoperatively. One of the radial head fractures that had originally undergone fixation was later converted to a replacement at a secondary surgery. In addition, one of the patients, originally treated with a radial head replacement, went on to have a radial head removal at 3 years, secondary to symptomatic prosthesis loosening. Of the coronoid fractures, only five underwent operative fixation. All patients underwent repair of the ulnar collateral ligament, and 13 patients were treated with a hinged external-fixator (EBI, Parsippany, New Jersey, and Smith and Nephew Richards, Memphis, Tennessee) (Fig. 3). Time from injury to surgery averaged 10 days (range, 1 to 36 days) and follow-up averaged 27 months (range, 12 to 105 months). For the 13 patients with poorer outcomes, the mean time to surgery was 8.6 days (range, 1 to 36 days) compared to a mean of 11 days (range, 1 to 35 days) for the rest of the cohort. This difference was not significant (p = 0.24). At follow-up, radiographic evaluation showed 10 patients (36%) to have minor incidental heterotopic ossification. There were 18 patients with grade 1, three patients with grade 2, and one patient with grade 3 osteoarthritic changes in the elbow according to the system of Broberg and Morrey. In addition, two patients were noted to have residual subluxation on follow-up and underwent subsequent surgery. The average flexion-extension arc of elbow motion at follow-up was 109 ± 27 (range, 45 to 140 ), and the average pronation-supination arc was 128 ± 44 (range, 15 to 165 ). Grip strength averaged 72% of the contralateral extremity (range, 0% to 125%). Both the Mayo (average of 81, range of 45 to 100) and the Broberg-Morrey (average of 77, range of 33 to 100) functional scores for the elbow were calculated, and the results are detailed in Table 2. Thirteen patients were back to work at the time of follow-up. The average time to return to work was 11 months (range, 0 to 60 months). Further functional results were assessed with the DASH and SF-36. The average DASH score was 28 (range, 0 to 72, where lower scores indicate better function). When compared to the age-based normal values, the average patient s DASH score was 1.4 SDs worse (range, 1 SD better to 5.6 SDs worse) than would be expected in an average person of the same age. The average Physical Component Summary score on the SF-36 was 44 (range, 18 to 61, with a higher number denoting better function). This average score was 0.6 SDs worse than the population norm (range, 1.1 SDs better to 3.2 SDs worse). The 13 patients that scored 1.9 or more SDs worse on the DASH were compared to the remaining 16. These 13 patients were more likely to have required a hinged external fixator (54% vs. 38%, p = 0.38), have radiographic evidence of heterotopic ossification (46% vs. 25%, p = 0.27), and have concomitant orthopaedic injuries (23% vs. 6%, p = 0.3). None of these factors, however, were significant at the 95% confidence level. The flexion-extension arc of motion was 99 ± 29 for these patients, as compared to 118 ± 22 for the patients that scored better in the DASH (p = 0.509). The number of patients with an elbow flexion-extension arc below 100 was significantly higher in the lower functioning patients (54% vs. 13%, p = 0.04). The forearm rotation arc was 100 ± 51 for the 13 patients with poor functional outcomes, as compared to 151 ± 16 for the remaining 16 patients. This difference was statistically significant (p = ). Furthermore, the number of patients with the rotation arc below 100 was significantly higher in the lower functioning

6 268 Bulletin of the NYU Hospital for Joint Diseases 2007;65(4): Table 2 Functional Outcomes Patient Mayo Broberg-Morrey DASH - SDs SF-36 PCS - SDs Functional Functional Worse than Normal Worse than Normal Outcome Outcome 1 Fair Fair Fair Fair Fair Fair Fair Poor * Fair Fair Good Fair Good Fair Good Good Good Good * Poor Poor Excellent Good Good Fair Good Good Excellent Good Fair Poor Excellent Excellent Good Good Fair Fair Good Good Excellent Excellent Good Fair * Good Poor Excellent Excellent Good Good Fair Fair Good Fair Excellent Good Fair Fair Excellent Good *Ulnar nerve symptoms at follow-up. Complex regional pain syndrome. group of patients (46% vs. 0%, p = ). There was also a statistically significant difference in grip strength between these two groups, as 13 patients with poor DASH results averaged 50 ± 34 of the contralateral side, versus 90 ± 19 in the other group (p = ). Complications A total of five patients required further operative procedures. One patient s external fixator was removed at 6 weeks, and the ulnohumeral articulation resubluxed within 2 weeks. The hinged fixator was replaced and left on for the next 10 weeks. At the time of external-fixator replacement, the same patient had a radial head excision and replacement, as well as an elbow release. This patient did not experience further instability of the elbow by the time of latest follow-up. The second patient underwent elbow release and radial head replacement at 6 months. The third and fourth patients underwent elbow release procedures at 4.5 months and 3 months postinjury, respectively. Finally, the fifth patient was found to have painful loosening of the radial head prosthesis at 36 months postinjury and underwent removal of the prosthesis (see Table 1). There were no wound infections in this series. Six of the 13 patients (46%) who had an external fixator placed, developed minor pin drainage at the proximal pin cluster. All were treated with oral antibiotics, and there were no long-term sequelae. Three patients had evidence of ulnar nerve neuritis at latest follow-up. All of these three patients were among the 13 poor performers on the DASH. No ulnar nerve symptoms were noted among the remaining 16 patients (23% vs. 0%, p = 0.078). One patient developed a complex regional pain syndrome in the affected extremity at 2 months postsurgery and was successfully treated with stellate ganglion blocks. Discussion The long-term functional results of this series are somewhat disappointing. While as many as 19 patients achieved a good or excellent result on the Mayo elbow score, only 13 did so by the Broberg-Morrey criteria. Eighteen out of the 29 patients (62%) performed at least 1 SD worse than the average population of their age, and nearly half of the patients reported function that was two SDs or worse below their peers on the DASH score. The poor correlation of these vari-

7 Bulletin of the NYU Hospital for Joint Diseases 2007;65(4): ous scoring systems has been documented previously, with questionnaire based scales, such as the DASH being more consistent. 15 The DASH may be a more accurate representation of the results, as it accounts for many of the everyday tasks that require use of the elbow. This discordance becomes evident on observing that of the 13 patients with particularly poor results on the DASH, six were classified as good on the Mayo scale, one as good on the Broberg-Morrey score, and only one and four were classified as poor on the Mayo and Broberg-Morrey scales, respectively. The particularly poor results seen in 13 patients (46%) may have been associated with higher energy injuries. The higher incidence of associated injuries is indicative of more serious trauma. More of these patients (the majority) required the placement of the hinged external fixator than did patients with better results, suggesting a serious injury with extensive soft tissue disruption. The hinged external fixator has been shown to be an effective tool in the management of complex instability 8 and has likely improved the outcomes in these patients. Although treated with radiation after surgery, heterotopic ossification developed in 34% of cases and was most likely a result of a more extensive soft tissue injury. The reduced range of motion, particularly forearm rotation, further contributed to poor functional outcome. The majority of the activities of daily living require an arc of forearm rotation from 50 supination to 50 pronation, and personal hygiene activities require supination of the forearm. 16 The rotation arc in the 13 patients with poor DASH results averaged 100, with 6 patients having a rotation arc below 100. The lowest rotation arc in the better functioning group of patients was 100, and most had full rotation. The statistically significant difference in the forearm rotation detected in the poorly functioning patients was likely a large contributor to the decreased function and quality of life, as activities such as tying the shoes, cooking, personal grooming and hygiene, and eating may have been impaired. Similarly, functional flexion-extension arc requires 100 of motion. 16 Our series showed a significant difference between the two groups for this parameter, and limited flexion and extension were likely a serious detriment to function for these patients. While only performed in four patients in our series, elbow contracture release has proven to be an effective treatment for limited range of motion and has the potential to improve patient function. 17 It is possible that some of the patients in our series will undergo the procedure in the future. The statistically significant association of the poorly functioning patients with a reduction in grip strength could be the result of a number of factors. The reduced grip strength could be a direct contributor to the lower DASH score, whereby patients may be unable to use their arm for the same activities as before, particularly in the case of injury to the dominant side. Conversely, the reduced strength may be the result of disuse secondary to the reduced function. Finally, persistent ulnar neuropathy may have been a significant contributor to poor results in three patients. The results of this series are similar to previously reported case series. 5, 6 In the largest series by Pugh and colleagues, 15 out of 36 patients achieved an excellent result on the Mayo score, and only one patient scored poorly. 6 This is encouraging, but it may not be representative of all the morbidity associated with the injury. Future investigations should focus on question-based functional outcome measures, such as the DASH. Ring and associates reported on a case series of 11 patients with terrible triad injuries. 5 These investigators did not repair the small coronoid fractures in their series, and only three out of 11 patients underwent repair of the lateral ligamentous structures. The average Broberg-Morrey functional score in this series was 76. This number is remarkably similar to our results, but excludes three patients that were deemed to have failed the original treatment. Ring and associates felt that only four patients achieved satisfactory results at follow-up, and two out of the three patients with repaired lateral ligaments had satisfactory outcomes. Hinged external fixation was not used in their series, but it was suggested by the investigators that its use may be beneficial in these injuries. 5 Other investigators have reported on a limited number of terrible triad injuries. Popovic and coworkers reported two good and two fair Broberg-Morrey scores in four patients treated with a floating radial head prosthesis. 10 Cobb and Morrey reported satisfactory results on two patients with a terrible triad injury as part of their series evaluating the use of distraction arthroplasty in unstable elbow fracturedislocations. 9 Broberg and Morrey reported good results in four patients with terrible triad injuries treated with radial head excision. Finally, McKee and colleagues reported good results with the use of hinged external fixation in elbow dislocations, but their series included only one true terrible triad injury pattern. 8 Our study is limited by the retrospective nature of followup and the lack of baseline functional data on the patients. Availability of such information (i.e., baseline DASH scores) would have permitted the calculation of the percentage of return to baseline function. The number of patients lost to follow-up is another drawback of this study. Because of our limited data, all categorical comparisons between those who did better (two or more SDs) on the DASH and those who did worse did not have sufficient power to detect significant differences. The minimum detectable difference in proportions was 59% for all such categorical comparisons. The minimum detectable difference in mean flexion-extension arc of motion was 32. As such, larger samples will be required in future investigations to detect actual differences if they exist. Finally, our protocol did not address the medial collateral ligament of the elbow in a systematic fashion. This ligament is most certainly damaged in a severe injury, and

8 270 Bulletin of the NYU Hospital for Joint Diseases 2007;65(4): future work may show its repair to be beneficial in restoring stability and function. Type III coronoid fractures are not as associated with the terrible triad injury as are types I and II. However, in our series, we classified three patients with type III fractures. Surgical fixation of the coronoid process was initially reserved for the larger type III fractures, and later in our learning curve, type II fractures, as biomechanical studies demonstrated type II fractures to be detrimental to elbow stability. 3 Future studies should further examine the value of coronoid repair in the context of the terrible triad of the elbow. Conclusion This study further illuminates the difficulty of management of the terrible triad of the elbow. Results in this study ranged from excellent to unsatisfactory, but aggressive management with the use of a standard protocol appears to be beneficial in restoring ultimate elbow stability. Future studies of this complex injury should be prospective and perhaps compare the effectiveness of different treatment approaches. Acknowledgment The authors would like to thank Richard Rhim, M.D., of Rush University Medical Center, Chicago, Illinois, for his help in the preparation of this manuscript. Disclosure Statement None of the authors have a financial or proprietary interest in the subject matter or materials discussed, including, but not limited to, employment, consultancies, stock ownership, honoraria, and paid expert testimony. References 1. O Driscoll SW, Jupiter JB, King GJ, et al. The unstable elbow. Instr Course Lect. 2001;50: McKee MD, Schemitsch EH, Sala MJ, O Driscoll SW. The pathoanatomy of lateral ligamentous disruption in complex elbow instability. J Shoulder Elbow Surg Jul- Aug;12(4): Deutch SR, Jensen SL, Tyrdal S, et al. Elbow joint stability following experimental osteoligamentous injury and reconstruction. J Shoulder Elbow Surg Sep-Oct;12(5): Ring DC. Coronoid fracture patterns. Presented at the 2003 Annual Orthopaedic Trauma Association Meeting, Salt Lake City, Utah, October Ring D, Jupiter JB, Zilberfarb J. Posterior dislocation of the elbow with fractures of the radial head and coronoid. J Bone Joint Surg Am Apr;84(4): Pugh DM, Wild LM, Schemitsch EH, et al. Standard surgical protocol to treat elbow dislocations with radial head and coronoid fractures. J Bone Joint Surg Am Jun;86(6): Broberg MA, Morrey BF. Results of treatment of fracturedislocations of the elbow. Clin Orthop Relat Res Mar;(216): McKee MD, Bowden SH, King GJ, et al. Management of recurrent, complex instability of the elbow with a hinged external fixator. J Bone Joint Surg Br. 1998;80(6): Cobb TK, Morrey BF. Use of distraction arthroplasty in unstable fracture-dislocations of the elbow. Clin Orthop Relat Res Mar;(312): Popovic N, Gillet P, Rodriguez A, Lemaire R. Fracture of the radial head with associated elbow dislocation: Results of treatment using a floating radial head prosthesis. J Orthop Trauma. 2000;14(3): Broberg MA, Morrey BF. Results of delayed excision of the radial head after fracture. J Bone Joint Surg Am Jun;68(5) Morrey BF, An KN, Chao EY. Functional evaluation of the elbow. In: Morrey BF (ed): Elbow and Its Disorders. W.B. Saunders: Philadelphia, 1993, pp Hudak PL, Amadio PC, Bombardier C. Development of an upper extremity outcome measure: The DASH (disabilities of the arm, shoulder and hand) [corrected]. The Upper Extremity Collaborative Group (UECG). Am J Ind Med Jun;29(6): Ware JE, Kosinski M, Dewey JE. How to Score Version Two of the SF-36 Health Survey. (3rd ed). Lincoln, Rhode Island: QualityMetric, Inc., Turchin DC, Beaton DE, Richards RR. Validity of observerbased aggregate scoring systems as descriptors of elbow pain, function, and disability. J Bone Joint Surg Am Feb;80(2): Morrey BF, Askew LJ, Chao EY. A biomechanical study of normal functional elbow motion. J Bone Joint Surg Am Jul;63(6): Ring D, Kipps A, Jupiter JB. Functional outcome of elbow contracture release. Presented at the 2000 Combined OTA- AAST Meeting, San Antonio, Texas, October 12-14, 2000.