What Do the Experts Say About a Broken Elbow? Repair or Replace?

In this case report, orthopedic surgeons who specialize in the treatment of traumatic upper extremity injuries ask the question, What's the best way to treat a badly broken elbow? It's dislocated and fractured into bits. Should it be wired together? Would it just be better to replace the elbow with an artificial replacement? What to do -- what to do!

These are some of the questions surgeons face, especially when dealing with a broken and often dislocated radial head. The radius is one of two forearm bones that meet the humerus (upper arm bone) to form the elbow. The radial head is the top of the radial bone. It sits up under one side of the humerus and articulates (moves) against the other bone of the forearm (the ulna).

Today's current approach with a radial head fracture is to take all the individual patient-factors into consideration. Then look at current opinion of the experts and combine that information with any evidence available from published studies. The result is a set of guidelines to help with the decision. There isn't always a clear treatment path. In other words, one approach doesn't work for everyone.

Let's see what is the reported current opinion of-the-day. Well, it looks like there is a 50-50 split over what to do. Some surgeons say they 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.

No matter what decision is made, the goal is to restore forearm and elbow stability and motion. In order to accomplish this, it is important that both bones of the forearm (radius and ulna) must be kept equal in length. The surgeon must assess the entire arm for injuries in case there are other bones broken or torn soft tissues.

The next consideration is for current evidence available through published studies. Since complex fractures of this type are uncommon, the number of patients in each study are fairly limited (sometimes only one as in this case study). But each study brings to light different things to consider. For example, the surgeon must evaluate the blood vessels and nerves to the area and see if there has been any damage there. Does the patient have strong enough bones to hold pins, miniplates, screws, or wires necessary to hold the bone fragments together while it is healing?

There are many ways to evaluate the treatment choices available. Some surgeons try to repair the damage with a procedure called open reduction and internal fixation (ORIF). Open reduction involves an open incision to get to the elbow. Fixation refers to the different ways of holding the bones together. If that procedure fails, then the elbow can be converted to a prosthetic (replacement) joint. Studies show that 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. And without the ability to rotate the forearm, the patient cannot turn the palm up, a movement called supination and palm down (pronation). The loss of forearm supination and pronation can be very limiting. Imagine trying to turn a key in the door, wipe yourself after going to the bathroom, or even carry a bowl of cereal without these motions.

Over the years, bone grafting and improved fixation devices like the miniplates has made it possible to preserve more elbows than ever before. And that's good because implants cannot successfully replace a natural radial head. It's just such a unique and unusual bone in shape, form, and function. One advantage the prosthetic head does offer is stability when torn elbow ligaments cannot be repaired.

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. This means the implant is too large for the joint space available and too long. 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 (e.g., metal, pyrocarbon, plastic) 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 (e.g., loose monoblock, fixed monoblock, fixed bipolar) need to know how the results of each of these compare. Studies comparing the various prosthetic implants would help surgeons choose the best one for each patient.

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 a slight valgus angle of the normal forearm/elbow complex. As you hold your arm out straight, you'll see how the inside of the elbow angles inward slightly. 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.

References: Gabriel Clembosky, MD, and Jorge G. Boretto, MD. Open Reduction and Internal Fixation Versus Prosthetic Replacement for Complex Fractures of the Radial Head. In Journal of Hand Surgery. July/August 2009. Vol. 34. No. 6. Pp. 1120-1123.