Treatment of Floating Elbow Injury

Background: A floating elbow injury (FEI, concomitant ipsilateral fractures of the humerus, ulna, and radius shafts) is rare and difficult to treat. The optimal methods for treating this complex injury have not been well defined. Materials and methods: Twenty-six adult patients with a FEI were treated between 2004 and 2010. Twenty patients were followed for at least one year and were included in this study. Each forearm fracture was treated with open reduction and plate fixation. Humeral fractures were treated with internal fixation using a plate or intramedullary nail. 6 patients received one stage operation and 14 patients were staged operation. The Mayo Elbow Performance Score was used to evaluate elbow function. Prognostic factors were studied according to injury severity and treatment methods. Results: Twenty patients (77%, 20/26) were followed for at least one year (average, 25.8 ± 10.2 month) and were included in this study. The rate of open forearm fractures (45%, 9/20) was higher than that of humeral fractures (30%, 6/20); moreover, 66.7% (10/15) of these open fractures were Gustilo type III open fractures. The union rates of the humerus, radius, and ulna were 95%, 90% and 85%, respectively. The average union times of the humerus, radius, and ulna were 17.7 ± 8.6, 25.9 ± 10, and 25.1 ± 10.8 weeks, respectively. The union time of the humerus was significantly shorter than that of the radius (p=0.008) and ulna (p=0.01). Satisfactory elbow function was observed in 13 patients (65%, 13/20). Eleven patients (55%, 11/20) had isolated or multiple nerve injuries. Radial nerve injury was most common (40%, 8/20). Recovery may be spontaneous in 62.5% of all radial nerve injury cases and 100% in patient with isolated radial nerve injury. In univariate analysis (Mann-Whitney U test), open fractures, vascular injury, nonunion, and deep infection were found to significantly associated with unsatisfactory elbow functions. Based on a Kruskal Wallis test, BPI or multiple nerve injuries was associated with significantly poorer surgical outcomes than no nerve injury and transient nerve palsy (p=0.01). Conclusions: A FEI is difficult to treat and only 65% of patients may achieve satisfactory elbow function. An unsatisfactory prognosis may be related to open fractures, BPI or multiple nerve injuries, vascular injury, nonunion, and deep infection. Radial nerve injury was most common (40%, 8/20). Recovery may be spontaneous in 62.5% of all radial nerve injury cases and 100% in patient with isolated radial nerve injury. Humeral fractures may heal faster than radial or ulnar fractures.