A sequential management was performed in all cases, following the recommendation from McKee et al13 and Mathew et al.11, 12 A universal posterior elbow approach was performed in all cases with lateral fasciocutaneous flap. The Kocher interval was performed, between the anconeus and extensor carpi ulnaris, and lateral ulnar colateral ligament involvement was observed. The decision of a radial head arthroplasty (Evolve; Wright Medical Technology, Inc., Memphis, TN, USA) was taken if the radial head fracture had more than three fragments as recommended by King,7 otherwise, screw fixation was used. Subsequently, osteosynthesis of the coronoid is performed using a cannulated retrograde screw or anterior capsular reinsertion using a pullout technique depending on the fragment size.4 If the bony fragment was less than 5 mm, pull out was performed, otherwise screw was used unless comminution of the coronoid was present.

A 5.5 double-loaded suture anchor (Corkscrew, Arthrex, Naples, FL, USA) was used in the capitellar isometric point under fluoroscopy. The lateral capsule ligamental repair was performed using a Krackow knot and above it, the muscular plane was sutured in the same fashion. Both knots were tied with the elbow at 90 degree, with the forearm in pronation and with no valgus or varus stress23 (Fig. 3).

Posterolateral rotary pattern surgery. (A) Kocher approach, lesion of humeral insertion of U-LCL. (B) Radial head replacement and suture anchor for LCL repair. (C) Close lateral approach. (D) Postoperative x-ray.

Before definitive closure, stability was evaluated by fluoroscopy using varus-valgus stress maneuvers at 30° of flexion looking for a medial or lateral ulno humeral articular widening. Hypersupination-pronation test in 90° of elbow flexion by fluoroscopy were also performed looking for an anterior-posterior radial head subluxation. If instability persisted, a medial fasciocutaneous flap was performed, to repair anterior band of the medial collateral ligament through a split in the flexor carpi ulnaris muscle (FCU-split) with a corkscrew 3.5 (Arthrex, Naples, FL, USA) or though transosseous tunnel depending on the surgeon preference. If instability continued, a fixed-angle monoplanar external elbow fixator at 90° of flexion or an ulnar-humeral bridge plate was applied.

A deep drain was used for 24 hours, and an anterior cast was installed at a 90° flexion and neutral position until discharge from the hospital, where an articulated elbow splint with controlled range was installed with free flexion and extension locked at 90°.