Sideswipe injuries around the elbow: Management and functional evaluation

Abstract

Introduction:

Sideswipe injuries constitute a subgroup of complex elbow trauma. Almost all of these are high energy open injuries. There is no fixed protocol that is followed in the earlier studies. The injury pattern is grotesque and ill managed with poor functional outcome. We report the functional outcome in our series of patients who sustained sideswipe injuries.

Materials and Methods:

Thirty four patients presenting with sideswipe injuries around the elbow were managed and functional results evaluated. The patients were followed for 15-94 months (mean 74 months). 32 of these were males and two were females. The injuries were sustained between 8 years and 48 years age group (mean 30 years). The right side was affected in 20 and left side was injured in 14 patients. Road traffic accident was the cause in all patients. Principles of management followed were (1) debridement and stabilization of fractures, (2) vascular repair, (3) redebridement, (4) nerve repair and (5) soft tissue cover. An external fixator was used for fracture stabilization in 20 patients with open fractures. Internal fixation was used as a stabilization modality in 12 patients. Primary nerve repair was carried out in 4 cases. In case of segmental loss, tendon transfers or nerve grafting was carried out at a later date once softtissue healing was complete. Soft tissue coverage was provided within 24-48 h of injury. Results were evaluated using the Mayo elbow performance score.

Results:

The average Mayo elbow performance score was 70. Excellent results (score > 90) in accordance with Mayo elbow score were seen in 30% of the patients. Good results (score 75-89) were seen in 33% of the patients.

Conclusion:

Sideswipe injuries should be managed timely, aggressively and an algorithmic protocol should be followed to achieve best results. The injury pattern is distinct for which a multispecialty approach is needed and an orthopedic, vascular and plastic surgeon must be involved. Limb salvage is possible in most cases.

INTRODUCTION

Sideswipe injuries (syn. baby car injuries, traffic elbow injury) are sustained when a patient while travelling in a vehicle with elbow resting on the window is hit by a coming object or a vehicle on the road.¹ These injuries constitute a subgroup of complex elbow trauma.¹,²,³ Almost all of these are high energy trauma.⁴ Majority of these are open injuries and can be prevented by keeping the limbs inside the vehicles. Patients usually have polytrauma, commonly head and chest injuries.²,⁴,⁵,⁶ Commonly sustained in countries where open window buses or cars are still used for travelling.¹ Management of these injuries is difficult and involves a multidisciplinary approach using orthopedic, plastic and vascular surgeons. These injuries have a high complication rate and poor outcome. Complications such as stiffness, contractures, nonunion, deformity and loss of function are common.²,³,⁵ Management of sideswipe injuries requires a specific treatment algorithm which should be followed to maximize functional outcome. A meticulous assessment in the triage followed by careful planning and a staged surgical protocol with initial soft tissue debridement, fracture stabilization followed by the vascular repair should be followed. Wound coverage is given primarily in cases where soft tissue is not much contaminated and approximation is achieved primarily. Secondary coverage such as split skin graft and flaps are used in case of soft tissue loss. The authors have analyzed the results of sideswipe injury cases in this study.

MATERIALS AND METHODS

Thirty four patients presenting with sideswipe injuries around the elbow between July 2004 and June 2008 were managed and functional results evaluated. This is a prospective case study approved by the Ethics Committee and informed consent was taken from all the patients. We grossly followed an algorithmic protocol to manage sideswipe injuries [Figure 1].

Figure 1.

The protocol followed in treating sideswipe injuries

Twenty two of these were open injuries according to Gustilo and Anderson classification [Figure 2a].⁶ Classification was carried out postdebridement. Twelve of these were closed injuries. All the patients sustained injuries while their elbow were protruding outside their vehicles and were hit by another vehicle on the road. All of them presented within 12 h of the injury. None of the patients died of polytrauma. Associated injuries were Chest-pneumothorax, (n=1), flail chest, (n=2), head injury-skull fracture, (n=4), extradural hematoma, (n=1). Isolated management cannot be described Comorbid conditions such as diabetes and hypertension were seen in two patients. 32 of these were males and two were females. The mean age was 30 years (range 8-48 years). The right side was affected in 20 patients. Right side was the dominant hand in 30 patients. All patients were managed in accordance with the advanced trauma management guidelines. Bony injury pattern commonly encountered in sideswipe injuries include comminuted fractures of the lower end of humerus, fracture of olecranon at coronoid level, anterior dislocation of the radial head, fracture of radius and ulna and fracture shaft of humerus. All these were accompanied by variable degree of bone loss [Figure 2b]. Three patients had a concomitant elbow dislocation. Table 1 enlists the type of neurovascular insult sustained and the procedure adopted. Radial nerve palsy was the most commonly encountered nerve injury (n = 10) presenting as neuropraxia, division or segmental loss. Four patients had a loss of bony segment in the humerus. The average injury severity score was 24. Principles of management followed were (1) debridement and stabilization of fractures, (2) vascular repair, (3) redebridement, (4) nerve repair and (5) soft tissue cover. Protocol followed in acute management was initial joint assessment by orthopedic, vascular and plastic surgeon in triage and decide salvageability and plan accordingly. All patients were triaged and subjected to limb salvage. All patients were given intravenous antibiotics at their arrival to the emergency. A thorough wound lavage was done using 4-5 L of normal saline in all open fractures, followed by aseptic dressing and splintage. Thorough, primary debridement was followed by redraping and rescrubbing of the same operating team and then followed by stabilization of fractures with the external or internal fixation and reassessment of vascular status after bony fixation. Redebridement was carried out after vascular repair so that bleeding margins are achieved. Postoperative radiographs were carried out to assess the fixation and reduction [Figure 2c]. A relook debridement was carried out after 24-48 h before proceeding for any kind of soft tissue cover. An external fixator was used for fracture stabilization in 20/34 patients [Figure 2] (18/22 patients with open fractures and two closed fractures). In 16 patients (12/34 patients with closed fractures and in 4/22 open cases) internal fixation was used as a stabilization modality. External fixation was used as a temporary stabilization measure and converted to internal fixation after wound coverage. We did not use trans-fixation for stabilization in our patients. Infection was seen in two open fractures and was managed by wound lavage, intravenous antibiotic and vacuum assisted closure [Table 2]. Primary nerve repair was carried out in 4 cases (two radial and two median nerve) [Table 1]. In case of segmental loss, tendon transfers or nerve grafting was left for a later date once softtissue healing was complete. Soft tissue coverage was provided within 24-48 h of injury to prevent tissue necrosis and bone death [Table 3 and Figure 2]. Secondary procedures carried out were bone grafting (n = 8), tendon transfers (n = 6) and free fibular transfers (n = 4) [Figure 2d, e] extensor mechanism repair (n = 1). Rehabilitation in the acute stage was aimed at prevention of deformity and to keep joints supple for secondary procedures. Physiotherapy in the later stages was focused at improving range of motion and to maximize power after tendon transfers.

Figure 2.

(a) Clinical photograph showing a typical sideswipe injury around the elbow (b) Anteroposterior view of the arm showing the bone loss in the humerus (c) Postoperative picture showing the external fixator stabilization and latissimus dorsi myocutaneous flap (d) Postoperative radiographs showing the free fibula used as a bone graft to fill the humeral defect (e) clinical photograph showing functional result

Table 1.

Neuro-vascular injury and treatment given

Table 2.

Secondary procedures and soft tissue cover

Table 3.

Complications

RESULTS

Results were evaluated using the Mayo elbow performance score.⁷ The average Mayo elbow performance score

was 70. The average followup was for 74 months (range 15-94 months). Excellent results (score > 90) in accordance with Mayo elbow score were seen in nine patients. Good results (score 75-89) were seen in 10 patients [Figures 3, 4]. Four patients lost to followup after a period of one year. Limb salvage was possible in 32/34 patients. In two patients attempts at limb salvage had to be abandoned, one in the early stages due to a mangled extremity and one later in the course of treatment due to a resultant non-functional limb. Above elbow amputation was done in these two patients. Six patients had fused elbow, ankylosis of elbow (2 cases) and arthrodesis (4 cases that had a free fibular transfer) and had poor results (score < 60). Bone loss of less than 5 cm in the humerus was managed by docking and defects more than 5 cm were managed by free fibula transfer [Figure 2b]. Fusion (arthrodesis) was carried out in 4 cases with >5 cm bone loss and severe softtissue loss. A free fibular graft was used to fill the gap and fixation was carried out with a plate [Figure 2d].

Figure 3.

(a) Clinical photograph showing typical sideswipe injury in a child. (b) Intraoperative photgraph after debridement showing fixator in situ. (c) Postoperative lateral radiograph showing fixation of humerus, elbow and forearm fractures. (d-f) Clinical photographs showing functional result and a good hand grip

Figure 4.

(a) Clinical photograph showing sideswipe injury with open fractures (b and c) Radiographs showing fractured humerus and forearm bones (d) Intraoperative photograph after debridement showing fixator in situ (e and f) Clinical photographs showing final functional outcome

Complications of the procedures and their management are listed in Table 3. Pin tract infection was the most common early complication and nonunion was the most common late complication encountered. Nonunion was seen in eight patients for whom autogenous corticocancellous bone grafting had to be carried out at a later stage. All nonunions healed. Nonunion was commonly seen in the humerus (n=4), ulna (n=3) and radius shaft (n=1) in our series [Table 3]. It is a common complication and is also reported by other authors.²,⁸ Tendon transfer procedures were done in cases segmental loss of radial nerve (modified Jones transfer in six patients) and Volkman's ischemic contracture (brachioradialis to flexor pollicis longus and extensor carpi radialis to flexor digitorum profundus in two patients) after an average of 6 months. All regained good function of the hand such as the ability to write, hold the glass of water, able to tie shirt buttons [Figure 2e]. Refractures were not seen in our series. Range of motion at the elbow in the functional range (30-130°) average 110° and a good hand function was the end result in 10 patients. Twelve patients had a reasonable range of motion at the elbow (60-110°) average 70°.

DISCUSSION

The term “Sideswipe injuries” is grossly insufficient as it describes only mode of trauma and gives little information about the nature of the injury.

This particular injury around the elbow often involves multiple bone fractures and variable injury patterns. They are defined as complex elbow injuries as standardized concepts usually do not apply.²,⁴,⁵,⁶ Fracture pattern may be at single or multiple levels in the same bone or may involve multiple bones. There may be variable degree of bone comminution and softtissue and/or bone loss. Stable fixation and pain free motion is the goal of treatment.³,⁹,¹⁰,¹¹ The most frequent combination fracture pattern was a supracondylar fracture of the humerus associated with intraarticular extension and fracture of radius and ulna. Internal fixation should be the preferred stabilization modality of choice in closed fractures and in clean open grade one and grade two injuries.³,⁵ External fixation should be limited to open fractures, marked comminution, bone loss, extensive softtissue damage and multiple injured patient (in accordance with the principles of damage control orthopaedics).¹,¹²,¹³,¹⁴,¹⁵ We used internal fixation in 47% patients (n = 16) and external fixation combined with limited internal fixation in 58% patients (n = 20). We have used a tubular external fixator in all our cases,⁹ as opposed to the dynamic fixator preferred by some authors.²,¹⁶,¹⁷ Transfixation of the elbow joint has been used by Morrey et al. in cases of severe comminution, instability and extensive softtissue injuries.⁹ Articulated external fixator has been used as an alternative to transfixation in cases of complex elbow trauma.¹⁷

Wound coverage was needed in 22 cases of open injuries [Table 2]. We resorted to early wound coverage with skin grafts and flaps so as to decrease infection, tissue edema and tissue death and allow early mobilization.¹¹,¹⁸ Some authors believe that tissue hypoxia in the early postoperative period delays wound healing and increases chances of infection.¹⁹ We have successfully skin grafted open wounds, within 24-48 h after a redebridement and with split skin grafts and flaps within 2-3 weeks of the injury [Table 2]. The authors believe that early split skin graft acts as a biological dressing and prevents tissue death and helps control infection. Muscle transposition was carried out in two patients and six patients needed latissimus dorsi myocutaneous flap. Stevanovic et al.¹⁸ recommend pedicled latissimus dorsi flaps for defects not extending more than 8 cm below the elbow. Free tissue transfer was carried out in four patients.

Radial nerve palsy was the most common nerve deficit found in 29% of our injured patients, as opposed to the ulnar nerve lesions found commonly in some series.⁵ Six of these radial nerve injuries had segmental loss and tendon transfers (modified Jones transfer) had to be carried out later. Ulnar nerve lesions were found in 5.8% of patients and median nerve injuries were found in 11.6% of patients. All ulnar nerve lesions recovered after a period of observation of 3-6 months. Median nerve injuries recovered after end to end anastomosis or nerve grafting [Table 1]. Some authors have reported a 50%¹⁹ and 63.5%⁵ neural complications. We did not encounter any brachial plexus injuries in our series. Vascular injury was found in 17.6% patients. End to end anastomosis and vein grafts were performed [Table 1] in 5 cases only after primary debridement and stabilization with an external fixation. Compartment syndrome was not seen as a complication in our series, contrary to that reported by other authors.⁵ Bone graft was used in case of nonunions. Wild et al. in 1982¹⁵ achieved primary union with the external fixator in 5/16 patients. The functional results did not correlate with the Injury Severity score of the individual patients. Open fractures, associated nerve injuries, softtissue loss, bone loss, primary method of fracture stabilization (external fixation) and poor rehabilitation, all had poor results and did correlate with poor functional results. All the above factors had a bearing on the end results of the study, individually as well as cumulatively. Seekamp et al.²⁰ have evaluated prognostic criteria for poor functional results in elbow injuries and found nerve lesions as the most significant factor for poor outcome. They also found the method of primary treatment to be of prognostic implication with external fixator application correlating with a poor functional outcome. Solomon et al. in their study published in 2003²¹ also found nerve injuries to be associated with lower functional outcomes at a minimum of one year followup. Contrary to the observations, Yokoyama et al. in their publication in 1998²² found that there was no correlation between injury severity score, open injuries, neurovascular injuries or the timing of surgery and the functional outcome in floating elbow injury in adults.

To conclude limb salvage is possible in most cases if an algorithmic approach is followed and multiple procedures may be needed to achieve functional results with a multidisciplinary approach consisting of an orthopaedic, vascular and plastic surgeons. The authors stress the need for an aggressive, timely and step wise approach for treatment of such injuries.