Elbow dislocation

Abstract: After sequential releases of the ligaments and capsules of 13 fresh autopsy specimen elbows, external rotation and valgus moments with axial forces resulted in posterior dislocations in 12 of the 13 with the anterior medical collateral ligament (AMCL) intact. Kinematic displacements measured with a three-dimensional electromagnetic tracking device showed that dislocation involved posterolateral rotation of 34 degrees-50 degrees and 5 degrees-23 degrees valgus at about 80 degrees flexion. Dislocation is the final of three sequential stages of elbow instability resulting from posterolateral rotation, with soft-tissue disruption progressing from lateral to medial. In each stage, the pathoanatomy correlated with the pattern and degree of instability. Testing for valgus stability of the elbow during simulated active flexion revealed no significant increase (-0.3 degrees-2.4 degrees) in valgus laxity after reduction compared with the intact specimens (p greater than 0.05, beta = 0.1, delta = 2.5 degrees). In no case did the digitized AMCL origin-to-insertion distance increase beyond normal during the dislocation (p less than 0.01). The mechanism of dislocation during a fall on the outstretched hand would involve the body "rotating internally" on the elbow, which experiences an external rotation/valgus moment as it flexes. Posterior dislocations should therefore be reduced in supination. If valgus stability in pronation is demonstrated, the AMCL can be assumed to be intact, and rehabilitation in a hinged cast-brace with the elbow in full pronation can be commenced immediately.

Abstract: BACKGROUND: The results of elbow dislocations with associated radial head and coronoid fractures are often poor because of recurrent instability and stiffness from prolonged immobilization. We managed these injuries with a standard surgical protocol, postulating that early intervention, stable fixation, and repair would provide sufficient stability to allow motion at seven to ten days postoperatively and enhance functional outcome. METHODS: We retrospectively reviewed the results of this treatment performed, at two university-affiliated teaching hospitals, in thirty-six consecutive patients (thirty-six elbows) with an elbow dislocation and an associated fracture of both the radial head and the coronoid process. Our surgical protocol included fixation or replacement of the radial head, fixation of the coronoid fracture if possible, repair of associated capsular and lateral ligamentous injuries, and in selected cases repair of the medial collateral ligament and/or adjuvanthinged external fixation. Patients were evaluated both radiographically and with a clinical examination at the time of the latest follow-up. RESULTS: At a mean of thirty-four months postoperatively, the flexion-extension arc of the elbow averaged 112° ± 11° and forearm rotation averaged 136° ± 16°. The mean Mayo Elbow Performance Score was 88 points (range, 45 to 100 points), which corresponded to fifteen excellent results, thirteen good results, seven fair results, and one poor result. Concentric stability was restored to thirty-four elbows. Eight patients had complications requiring a reoperation: two had a synostosis; one, recurrent instability; four, hardware removal and elbow release; and one, a wound infection. CONCLUSIONS: Use of our surgical protocol for elbow dislocations with associated radial head and coronoid fractures restored sufficient elbow stability to allow early motion postoperatively, enhancing the functional outcome. We recommend early operative repair with a standard protocol for these injuries.

Abstract: Background: Posterior dislocation of the elbow with associated fractures of the radial head and the coronoid process of the ulna has been referred to as the "terrible triad of the elbow" because of the difficulties encountered in its management. However, there are few published reports on this injury. Methods: Eleven patients with this pattern of injury were evaluated after a minimum of two years. The radial head fracture had been repaired in five patients, and the radial head had been resected in four. None of the coronoid fractures had been repaired, and the lateral collateral ligament had been repaired in only three patients. All eleven patients returned for clinical examination, functional evaluation, and radiographs. Results: Seven elbows redislocated in a splint after manipulative reduction. Five, including all four treated with resection of the radial head, redislocated after operative treatment. At the time of final follow-up, three patients were considered to have a failure of the initial treatment. One of them had recurrent instability, which was treated with a total elbow arthroplasty after multiple unsuccessful operations; one had severe arthrosis and instability resembling neuropathic arthropathy; and one had an elbow flexion contracture and proximal radioulnar synostosis requiring reconstructive surgery. The remaining eight patients, who were evaluated at an average of seven years after injury, had an average of 92° (range, 40° to 130°) of ulnohumeral motion and 126° (range, 40° to 170°) of forearm rotation. The average Broberg and Morrey functional score was 76 points (range, 34 to 98 points), with two results rated as excellent, two rated as good, three rated as fair, and one rated as poor. Overall, the result of treatment was rated as unsatisfactory for seven of the eleven patients. All four patients with a satisfactory result had retained the radial head, and two had undergone repair of the lateral collateral ligament. Seven of the ten patients who had retained the native elbow had radiographic signs of advanced ulnohumeral arthrosis. Conclusions: Elbow fracture-dislocations that involve a fracture of the coronoid process in addition to a fracture of the radial head are very unstable and prone to numerous complications. Identification of the coronoid fracture is therefore important, and computed tomography should be used if there is uncertainty. With operative treatment, the surgeon should attempt to restore stability by providing radiocapitellar contact (preserving the radial head when possible and replacing it with a prosthesis otherwise), repairing the lateral collateral ligament, and perhaps performing internal fixation of the coronoid fracture.

Abstract: The long-term results after treatment of simple dislocation of the elbow in fifty-two adults were evaluated with regard to limitation of motion, pain, instability, and residual neurovascular deficit. All patients were treated with traditional closed reduction, but the duration of immobilization before commencement of active motion varied. Goniometric, photographic, and radiographic data were compiled for these patients, who had an average follow-up of 34.4 months. Despite the generally favorable prognosis for this injury, 60 per cent of the patients reported some symptoms on follow-up. A flexion contracture of more than 30 degrees was documented in 15 per cent of the patients; residual pain, in 45 per cent; and pain on valgus stress, in 35 per cent. Prolonged immobilization after injury was strongly associated with an unsatisfactory result. The longer the immobilization had been, the larger the flexion contracture (p less than 0.001) and the more severe the symptoms of pain were. The results indicate that early active motion is the key factor in rehabilitation of the elbow after a dislocation.