High-velocity trauma now often results in complex injuries to the uppe
r extremity, and especially the elbow joint. These can lead to both an
enormous reduction in the range of motion of the shoulder, elbow and
wrist joints, in severe cases with complete loss of upper extremity fu
nction. A complex injury is defined as a fracture and/or dislocation o
f the elbow in association with(1) a serial injury of the upper extrem
ity, (2) a severe soft tissue trauma, or (3) concomitant injury to ves
sels or nerves. Serial fractures, in particular, can lead to enormous
problems with treatment and are often associated with special complica
tions. A standardized operative approach therefore seems essential. An
analysis of our patient population was made to compare the frequency
of different injury types, develop specific treatment regimens, and do
cument the clinical course. We made a retrospective analysis of patien
ts admitted to our facility between 1981 and 1992, with particular ref
erence to cause of accident, severity of injury (ISS), type of fractur
e of the upper extremity (according to the AO classification), extent
of soft tissue trauma and whether closed or open, and the concomitant
injuries (vascular, compartment and nerve lesions). Type and sequence
of therapy and any complications were noted, and the clinical course u
p to consolidation was recorded. The functional result (i.e., ROM, neu
rology) was observed at primary discharge and 12 weeks, 6 months and 2
years later. In the time period mentioned 224 complex injuries of the
elbow region were noted. Often MVAs were the cause of the complex tra
uma (39% car/30% motorcycle). The average injury severity was scored a
s 32(ISS) in these, mostly polytraumatized, patients (68%). The most f
requent fracture combination at the elbow region was combined with C2/
C3 fractures of the distal humerus (57%) and proximal ulna (43%). A ve
ry commonly seen complex injury was the Monteggia equivalent, with fra
cture dislocation of the proximal ulna. Most (82%) of the injuries at
the elbow region were open, and open lesions were similarly frequently
seen at the forearm shaft. The most frequent concomitant injuries was
were to the nerves (63.5%) and the plexus. A compartment syndrome dev
eloped in 23.8%. This complication was frequently seen in multiple tra
uma patients after primary resuscitation (extensive volume therapy) an
d in serial fractures with more than three associated lesions. In 67%
of these complex injuries a definitive operation was performed as prim
ary treatment (in the first 24 h after injury). Debridement of open fr
actures and fasciotomy in compartment syndrome of the forearm are stan
dard techniques in the initial care. In serial fractures all concomita
nt (humerus, forearm, wrist, etc.) fractures were operated on primaril
y. This primary treatment included ORIF of humeral and forearm fractur
es in 76%. In patients with multiple injuries (ISS > 30) primary treat
ment was not possible in 37%, and in these cases transfixation of the
elbow joint was performed. Other indications for transfixation were se
vere comminution of the elbow joint, impossibility of achieving comple
te stability after ORIF, extensive soft tissue injuries with healing d
ependent on short-term immobilization, and finally status following ex
tensive ligamentous reconstruction. The most frequent permanent distur
bance was a persisting nerve lesion in our patients. A significantly r
educed range of motion (30% deficit flexion/extension) was mostly seen
at the elbow (17%); most frequently associated with serial fractures
(> 3 associated injuries) and with severe semicircular soft tissue tra
uma. The most severe injury in combined trauma of the upper extremity
is a serial fracture in the elbow region. Such fractures are often ass
ociated with vascular and nerve lesions. Even with primary fracture st
abilization and early soft tissue management these often end with sign
ificant functional deficits. Planned arthrolysis (6 months posttrauma)
and enforced rehabilitation can significantly improve the outcome of
these complex injuries.