Management of complex elbow instability.

Complex elbow instability is a challenging injury even for expert elbow surgeons. The preoperative radiographs should be carefully evaluated to recognize all lesions that may occur in complex elbow instabilities. Recognizing all the possible lesions is critical to achieve an optimal outcome. The most common types of injuries are as follows: (1) radial head fractures associated with lateral and medial collateral ligaments lesions (with or without elbow dislocation); (2) Coronoid fractures and lateral collateral ligament lesion (with or without elbow dislocation); (3) Terrible Triad; (4) Transolecranon fracture-dislocation; (5) Monteggia-like-lesions; and (6) Humeral Shear fractures associated with lateral and medial collateral ligaments lesions (with or without elbow dislocation). A correct evaluation includes X-rays, CT scan with 2D and 3D reconstruction and stability test under fluoroscopy. The treatment is always surgical and is challenging, and outcomes are not predictable. The goals of treatment are (1) to perform a stable osteosynthesis of all fractures, (2) to obtain concentric and stable reduction of the elbow and (3) to allow early motion. The proximal ulna must be anatomically reduced and fixed; the radial head must be repaired or replaced, and the coronoid fractures must be repaired or reconstructed. With respect of soft tissue lesions, the LUCL must be reattached with suture anchors or trans-osseous suture. The next critical step is the intra-operative assessment of elbow stability. If the elbow remains unstable, MCL repair and/or application of hinged external fixator must be considered. The most recent clinical and experimental studies have significantly expanded our knowledge of elbow instability and its management. Definite treatment protocols may improve the clinical results of such complex injuries.