Difficult elbow fractures: pearls and pitfalls.

Complex elbow fractures are exceedingly challenging to treat. Treatment of severe distal humeral fractures fails because of either displacement or nonunion at the supracondylar level or stiffness resulting from prolonged immobilization. Coronal shear fractures of the capitellum and trochlea are difficult to repair and may require extensile exposure. Olecranon fracture-dislocations are complex fractures of the olecranon associated with subluxation or dislocation of the radial head and/or the coronoid process. The radioulnar relationship usually is preserved in anterior but disrupted in posterior fracture-dislocations. A skeletal distractor can be useful in facilitating reduction. Coronoid fractures can be classified according to whether the fracture involves the tip, the anteromedial facet, or the base (body) of the coronoid. Anteromedial coronoid fractures are actually varus posteromedial rotatory fracture subluxations and are often serious injuries. These patterns of injury predict associated injuries and instability as well as surgical approach and treatment. The radial head is the bone most commonly fractured in the adult elbow. If the coronoid is fractured, the radial head becomes a critical factor in elbow stability. Its role becomes increasingly important as other soft-tissue and bony constraints are compromised. Articular injury to the radial head is commonly more severe than noted on plain radiographs. Fracture fragments are often anterior. Implants applied to the surface of the radial head must be placed in a safe zone.