Patients
Cases treated from January 2015 to December 2019 were reviewed. A total of 42 patients with complex elbow fractures still had elbow instability after open reduction and internal fixation and were treated with hinged external fixators or adjustable braces. The inclusion criteria were as follows: (1) patients initially diagnosed with a complex elbow fracture, (including the terrible triad of the elbow, a posterior Monteggia fracture and transolecranon fracture-dislocation); (2) patients who did not exhibit strong osseous or soft tissue stability after open reduction and internal fixation and need to undergo external fixation; (3) patients with a follow-up period of more than one year. The exclusion criteria were as follows: (1) open fractures; (2) multiple fractures of the same upper limb; (3) fractures in both upper limbs or those accompanied by nerve injury; and (4) severe medical diseases before surgery precluding surgical treatment. A total of 81 cases treated within the past 5 years were included, and 39 cases were excluded after screening. There were 14 cases of open fracture, 7 cases of multiple fractures in the same upper limb, 4 cases of fractures in both upper limbs, 4 cases of nerve injury, and 10 cases that were followed up for less than 12 months. Finally, 42 patients were included in this study (Fig 1). Twenty-four patients were treated with a hinged external fixator (external fixation group). These patients’ ages ranged from 20-60 years (average 41.5±10.6 years), and there were 18 males and 6 females. There were 14 cases of the terrible triad of the elbow, 5 cases of posterior Monteggia fracture, and 5 cases of transolecranon fracture-dislocation; 15 cases involved the dominant side, including 8 cases of fall-related injuries, 14 cases of traffic-related injuries and 2 cases of sports-related injuries. The time from injury to the operation was 3-12 days (average 5.4±2.4 days). There were 18 patients treated with adjustable brace fixation (brace group). These patients’ ages ranged from 20-60 years (average 41.2 ±9.8 years), and there were 13 males and 5 females. There were 11 cases of the terrible triad of the elbow, 3 cases of posterior Monteggia fracture, and 4 cases of transolecranon fracture-dislocation; 12 cases involved the dominant side, including 5 cases of fall-related injuries, 12 cases of traffic-related injuries and 1 case of a sports-related injury. The time from injury to the operation was 3-12 days (average 5.6±2.3 days) (Table 1). This study all methods were carried out in accordance with guidelines and regulations. This study was approved by the ethics committee of HongHui Hospital, Xi’an Jiaotong University, and all patients provided informed consent prior to participating. Typical case images have been allowed by participant to be displayed in the manuscript.
Surgical methods
All patients were treated with general anesthesia and placed in a supine position or lateral supine position, depending on the fracture type; an air bag tourniquet was placed at the root of the upper arm, The surgical site is routinely disinfected and covered with aseptic towels. The surgical methods presented by Pugh [13] and McKee [14] for the treatment of complex elbow fractures were used. The surgical approach used was the combined medial and lateral elbow approach or posterior median approach [15-17]. For the treatment of the fractures, the radial head fractures were fixed with countersunk nails or miniature plates. If severe comminution could not be repaired, artificial radial head replacement was performed. The olecranon fractures were fixed with a plate and screw or both a Kirschner wire and tension band. Coronal process fractures were fixed with lag screws, miniature plates or loop plates. Moreover, the articular capsule and medial and ligament were explored, in accordance with the injury mechanism and joint dislocation, and the structures of the articular capsule and ligament were sutured and repaired with thread anchors. After the completion of the above operation, omnidirectional passive movement of the elbow joint (flexion and extension, pronation, supination) was carried out to confirm the stability of the elbow joint, and the elbow joint was fixed with an external fixator or adjustable brace if there was still instability.
Installation of external fixture
The shoulder was abducted, and the forearm was placed on the operating table in a pronated position to determine the center of rotation. Standard positive and lateral films of the distal humerus were taken by a C-arm X-ray machine to determine the needle entry point. The lateral film focused on the center of the head of the humerus and the concentric circle of the pulley. A Kirschner needle with a diameter of 2.0 mm was slowly inserted from the outside to the inside from this point. The standard X-ray film of the front and side of the elbow joint was taken again to ensure it was located in the rotation center of the elbow joint. The two movable arms of the external fixator were fixed on the lateral humerus and the ulnar crest with semithreaded nails. A small incision was made in the corresponding part of the skin, blunt separation was performed directly to the bone surface, and the nerves and other important tissues were protected. After drilling, two half-threaded needles were manually implanted at the distal and proximal ends. It was confirmed by X-ray that the tip of the needle passed through the medial cortex. The force line of the elbow joint was adjusted, the range of motion of the elbow joint was measured, the elbow was flexed to 90 °, the distance between the joints was maintained at 2 mm, and finally, the humerus end and the ulnar end of the external fixator were connected. Then, the bleeding was thoroughly stopped, the incision was rinsed with normal saline, a drainage tube was placed, the incision was sutured layer by layer, and the wound was wrapped with aseptic dressing.
Postoperative treatment
Antibiotics were routinely used to prevent infection within 24 hours after the operation. Metacarpophalangeal joint and interphalangeal joint movement was performed as soon as possible after the operation, as this movement can promote distal blood circulation and actively eliminate swelling. If the drainage volume was less than 30 ml within 24 hours after the operation, the drainage tube was removed. It was recommended that all patients take indomethacin enteric-coated tablets (25 mg, 3 times a day) for 4 weeks to prevent heterotopic ossification. Under the guidance of a professional rehabilitation physician, the brace group began functional exercises 3 days after the operation under the protection of the brace; the elbow joint was fixed at different flexion angles (30°, 90°, 130°) for 30 minutes each time, three times a day, and fixed in a straight position at night. The external fixator group began functional exercises 3 days after the operation. The elbow was fixed in a straight position at night, and the lock was released during the day so that passive flexion and extension exercises could be performed for a continuous 30 min period 3 times a day. When the edema of the elbow joint was alleviated, the frequency of exercise was increased appropriately, and the adjustable brace and external fixator were removed 6 ~ 8 weeks after the operation.
Evaluation project
Three days after the operation, the anterior and lateral X-ray films of the elbow joint and plain CT scan and three-dimensional reconstruction were reexamined to evaluate the repair of the fracture. The positive and lateral X-ray films of the affected limbs were reexamined at 1, 2, 3, 6 and 12 months after the operation to evaluate the extent of fracture healing. The operation time, the number of intraoperative fluoroscopies, the cost of hospitalization, the time needed for fracture healing, the incidence of postoperative complications and the range of motion of the elbow joint (range of extension and flexion, range of rotation) at the last follow-up were compared between the two groups. The function of the elbow joint was evaluated by the Mayo elbow performance score, (MEPS) [18] during the last follow-up. The scores for pain (45 points), range of motion (20 points), joint stability (10 points) and daily function (25 points) were categorized as follows: > 90 points was considered excellent, 75-89 points was considered good, 60-74 points was considered fair, < 60 points was considered poor.
Statistical analysis
Statistical analyses were performed using IBM SPSS, statistics version 22.0 (SPSS, Chicago, IL, USA). The count data are expressed as numbers (n), and the comparisons between the two groups were performed by the χ2-test; the measurement data are presented as M ±SD, and the comparisons between the two groups were performed by the t-test. P values < 0.05 were considered statistically significant.