Prevention and management of early treatment failures in elbow injuries.

The appropriate management of early treatment failures in patients with elbow injuries requires the identification of the cause of failure. In this work, six types of elbow injury are considered: (i) identification of early failed reduction of a dislocation or fracture-dislocation of the elbow should lead to a repeat reduction procedure, testing for elbow instability, and ligament repair, followed by the use of a hinged external fixator to allow early mobilisation. Differentiating an isolated dislocation from a dislocation combined with a fracture of the coracoid process is crucial. Re-implantation of the coronoid process allows repair of the ligaments and restoration of stability in the sagittal plane; (ii) early secondary displacement of a distal humeral fracture after internal fixation is usually due to insufficient fixation confined to a single humeral pillar. If both humeral pillars are fractured, then both must be repaired; (iii) early treatment failure of an intra-articular distal humeral fracture in an elderly patient with bone loss warrants distal humeral hemiarthroplasty or total elbow arthroplasty; (iv) in fractures of the olecranon, treatment failures are due to insufficient fixation or to a mistaken diagnosis of trans-olecranon fracture-dislocation; (v) in fractures of the radial head, causes of early revision include excessive tilting of the head in radial neck fractures, with secondary displacement due to insufficient internal fixation, and adverse effects on the wrist of radial head resection performed without assessing the ulnar variance. In patients with radial head fractures, no treatment decisions can be made before performing an anteroposterior radiograph of the wrist; (vii) in fracture-dislocations of both the radius and ulna, accurate reduction of the ulnar fracture is a pre-requisite to proper reduction of the radio-humeral and proximal radio-ulnar joints. An early postoperative assessment, within 10 days after surgery, is of paramount importance to re-evaluate the initial treatment and, if needed, to introduce modifications. Early failure of the initial treatment of an elbow injury should lead to the prompt implementation of corrective measures: follow-up anteroposterior and lateral radiographs must be obtained on day 8 to ensure the diagnosis of initial treatment failure and to allow the institution of an appropriate management strategy; the dogma stating that the elbow should never be immobilised remains valid, and every effort should be made to ensure that mobilisation starts as early as possible.