Management of Neglected Elbow Dislocations in a Setting with Low Clinical Resources

Abstract

Objective

To investigate the effect of open reduction operative treatment in neglected elbow dislocation.

Methods

Between January 2009 and October 2010, 13 patients (mean, 27 years, nine men and four women) with old unreduced posterior dislocation of the elbow were treated by open reduction and removal of fibrous tissue between distal humerus and ulna with Kirschner wire fixation with or without triceps lengthening in our hospital.

Results

The patients were followed up for a mean of 18 (range, 14–22) months. The mean operating time was 69.53 (range, 56–90) min. Mean operative blood loss 361.53 mL (range, 300–450 mL), mean tourniquet time 51.92 min (range, 46–70 min). According to the Mayo Elbow Performance Index at the final follow‐up, 11 patients had satisfactory outcomes (six excellent, five good) and two patients had unsatisfactory outcomes (one fair and one poor). The mean score was 87. Nine patients had no pain, two had mild pain during repetitive elbow movements or weight lifting, and two had moderate pain. The mean pain score was 38 (range, 15–45). At the final follow‐up, two patients had signs of instability; the mean score was 15. Seven achieved a flexion range of 105° to 130°, two achieved 100°, two achieved 95°, one achieved 80°, and one 60°.

Conclusion

Operative treatment of late‐presenting, unreduced elbow dislocation is effective in restoring the joint to a painless, stable and functional limb.

Introduction

Elbow dislocation is a common orthopaedic injury with an incidence of approximately 20% of all articular dislocations1. After the shoulder, the elbow is the second most frequently dislocated major joint in adults2. Neglected elbow dislocation is defined as dislocation which is left unreduced for more than 3 weeks3, 4, 5, 6. In developing countries, neglected dislocations of the elbow are a quite common4 and most patients initially go to local bonesetters for massage and manipulation, which only aggravates the problem. At least 80% of elbow dislocations are posterior or posterolateral7, 8, resulting in most cases from a fall on the outstretched hand with the forearm pronated. Dislocations without concomitant fractures are termed as “simple dislocations”8. Dislocations associated with fractures of the coronoid process, radial head or neck, distal humerus, or olecranon are termed as “complex dislocations”. In neglected elbow dislocation, elbows are fixed in either extension or flexion with only a few degrees of flexion, supination, and pronation, and have a non‐functional range of movement for activities of daily living9. Various treatment methods have been described such as closed reduction, open reduction and internal fixation with k‐wire, open reduction with triceps lengthening and medial and lateral collateral ligament release, creation of an intra‐articular “cruciate” ligament to stabilize the joint, hinged external fixator, excisional arthroplasty, arthrodesis, total elbow arthroplasty. We treated 13 patients with neglected unreduced elbow dislocation (three had complex dislocation) by open reduction and removal of fibrous tissue between distal humerus and ulna with Kirschner wire fixation with or without triceps lengthening.

Materials and Methods

Patient Data

Between January 2009 and October 2010, 13 patients with old elbow dislocation (nine men and four women), aged 15 to 52 years (mean, 27 years), were treated in Chittagong Medical College Hospital, Chittagong, Bangladesh. The time since injury ranged from 6 weeks to 14 weeks (mean, 8.7 weeks). Seven were on right side and six were on the left. Nine patients were initially treated with massage by local bonesetters; one patient was initially treated by closed reduction and plasters immobilization at a government hospital but the patient was lost to follow up and attended after 6 weeks with deformed dislocated elbow; three patients did not receive any treatment.

Indication for surgery was elbow stiffness, pain, reduced functional range of movement. Four patients had no pain in the elbow, six had mild pain and occasionally used analgesics, and three had moderate pain and regularly used analgesics. All patients had an anteriorly prominent distal humerus. The olecranon was prominent and the shortened triceps was seen tenting on the posterior aspect of the elbow (Fig. 1). The 3‐point relationship of the tips of the olecranon, medial and lateral epicondyles was disturbed and the joint was tender. The elbow was stable in eight patients and moderately stable in four but one patient had unstable elbow joint. Out of 13 patients, 10 had simple dislocation with no associated fracture, whereas three patients had complex dislocation with associated fracture of medial epicondyle (two patients) and radial head (one patient). The active range of flexion, extension, pronation, and supination were measured using a handheld goniometer. The joints were fixed in either extension or flexion with only a few degrees of flexion. All patients had non‐functional elbow movement. Hypoaesthesia of the hand over the ulnar nerve was present in two patients. Dislocation was posterolateral in nine patients and posteromedial in four. More details about patients are shown in Table 1.

Figure 1.

The preoperative X‐ray, showing the dislocation of left elbow, distal humerus was prominent anteriorly, and the olecranon was prominent posteriorly.

Table 1.

Patients' data

Patient	Age (years)	Sex	Duration of injury (weeks)	Mode of injury	Side involved	Associated fracture	Neurovascular problem
1	15	M	9	Fall	Right	—	—
2	23	M	12	Fall	Right	—	—
3	44	M	7	Fall	Left	—	—
4	16	M	6	Fall	Right	—	—
5	26	F	10	Fall	Left	Medial epicondyle	Ulnar nerve paresthesia
6	19	M	6	RTA	Left	Radial head	—
7	27	M	7	Fall	Right	—	—
8	23	F	14	RTA	Left	—	—
9	32	F	12	Fall	Left	—	—
10	30	M	8	Fall	Left	—	—
11	15	M	6	RTA	Right	Medial epicondyle	Ulnar nerve paresthesia
12	52	M	9	RTA	Right	—	—
13	29	F	8	Fall	Right	—	—

RTA, road traffic accident.

Surgical Technique

Under supraclavicular block or general anaesthesia, patients were positioned in a lateral position with elbow flexed over a pillow. Elbow was exposed through long posterior incision. Ulnar nerve was identified and secured. Dense fibrous tissue was cleared off carefully from olecranon, coronoid fossa, radial head and between distal humerus and proximal radius and ulna. The contracted capsule and collateral ligaments were cut to expose the joint surfaces. Articular surfaces were found relatively well preserved in all patients. The ulnar nerve was under tension in three cases including two with hypoaesthesia of the hand. Radiocapitellar and ulnotrochlear reduction was achieved by manipulation. Three patients had associated fractures around the elbow. Two had a medial condyle fracture, one with radial head fracture. One medial condyle fracture was 10 weeks old with malunion, which was left undisturbed. Another medial condyle fracture was 6 weeks old with fragments that were excised carefully without injuring the ulnar nerve. For patients with radial head fracture, the radial head was excised. After reduction, in 10 patients the olecranon was transfixed to the distal humerus in 90° flexion of the elbow using two 1.8 mm Kirschner wires (Fig. 2), and in three others radius were also transfixed using 1.6 mm Kirschner wires. Only one patient had difficulty in achieving reduction, in which V‐Y triceps myoplasty was done. The wound was closed in layers over a drain. A posterior above‐elbow plaster of paris slab was applied with elbow at 90°. Our procedures were in accordance with other reports3, 4, 10.

Figure 2.

The postoperative X‐ray showing the fractured radial head was excised, the olecranon was transfixed to the distal humerus in 90° flexion of the elbow using Kirschner wire. Concentric reduction and anatomic alignment of the ulno‐humeral was achieved in the patients.

Postoperative Management

Drains were removed after 48 h and suture was removed 10–14 days after operation. Kirschner wires were removed 2–3 weeks postoperatively, at which time active movements of the elbow were initiated. The elbow was supported on an elbow bag in between exercises. Depending on individual progress, use of the sling was discontinued after 6 weeks to 3 months. Postoperative radiographs were evaluated. Follow‐ups were conducted at 3 weeks, 6 weeks, 12 weeks, 6 months, 12 months, and 18 months. The Mayo Elbow Performance Index (MEPI)11 was used to assess subjective, objective, and functional characteristics before and after operation. This scoring system has four parameters: 45 points are given for a pain‐free elbow, 20 points for normal elbow movement, 10 for a stable elbow, and 25 for performance of five activities of daily living. Stability of the elbow is rated as stable (no apparent varus/valgus), moderate instability (<10° varus/valgus), and gross instability (≥10° varus/valgus). Depending on the score, results were rated as excellent (90–100), good (75–89), fair (60–74), or poor (<60).

Results

The mean operating time was 69.53 min (range, 56–90 min). The mean operative blood loss was 361.53 mL (range, 300–450 mL), and mean tourniquet time was 51.92 min (range, 46–70 min). The patients were followed up for a mean of 18 months (range, 14–22 months).

According to the Mayo Elbow Performance Index11 at the final follow‐up, 11 patients had satisfactory outcomes (six excellent, five good) and two patients had unsatisfactory outcomes (one fair, one poor). The mean score was 87. Nine patients had no pain, two had mild pain during repetitive elbow movements or weight lifting, and two had moderate pain. The mean pain score was 38 (range, 15–45). Seven patients achieved a flexion range of 105° to 130°, two achieved 100°, two achieved 95°, one achieved 80° and one 60°. Concentric reduction and anatomic alignment of the ulno‐humeral and the radiocapitellar joints were achieved in all patients (Figs 3,4). But two patients had signs of instability in which the mean score was 15.

Figure 3.

Postoperative range of motion, the affected elbow achieved a flexion range of 130° 2 years after the operation.

Figure 4.

Postoperative range of motion, the affected elbow achieved a nearly normal extension 2 years after the operation.

Three of seven patients who underwent wire removal at 3 weeks postoperatively developed pin track infection, which was successfully treated with oral antibiotics. Two of three patients with ulnar nerve compression recovered within 2 weeks after operation, one patient having persisting sensory abnormalities for 12 weeks.

Discussion

Most cases of old unreduced elbow dislocations are found in developing countries, where qualified doctors are lacking and traditional bonesetters are easily available. Such patients are often neglected and maltreated before being seen by a specialist in a city hospital. Most of these dislocations are caused by a fall on the outstretched hand with the elbow incompletely extended and the forearm pronated‐the best posture to absorb the shock12, 13, 14. This may explain why all patients had a better pronation than supination. Most surgeons recommend closed reduction for elbow dislocation before 3 weeks post injury. After 3 weeks, soft tissue contractures and localized osteoporosis makes closed reduction hazardous in that manipulation may result in fracture of the bone or damage to the articular surface3, 4, 15. Various treatment methods have been described, closed reduction, open reduction and internal fixation with K‐wire, open reduction with triceps lengthening and medial and lateral collateral ligament release, creation of an intra‐articular “cruciate” ligament to stabilize the joint, hinged external fixator, excisional arthroplasty, arthrodesis, and total elbow arthroplasty. Most authorities advise open reduction for elbow dislocation up to 3 months; total elbow arthroplasty; excisional arthroplasty, or arthrodesis is advised thereafter4, 10, 16. Arthrodesis is not well accepted by patients and is appropriate only for those engaged in heavy labor. Though total elbow arthroplasty may provide a better range of movement, it has a limited life span and is cost‐prohibitive and not applicable in children with open epiphyses, or in countries where facilities and cost are the main constraints. Hinged external fixator is an excellent tool for managing neglected elbow dislocation with very favourable outcomes. But in our context it also has limited value due to unavailability and lack of technical expertise. When unreduced dislocation lasts for 6 months to a year, changes occur in articular surfaces. In our study, open reduction achieved a fair outcome and a useful range of movement even up to 4 months post‐injury. Our findings are consistent with those of another two studies that achieved favourable results by open reduction even up to 2 years after neglected dislocations15.

Relatively healthy articular cartilage was found in all patients with neglected elbow dislocation with scattered area of unhealthy cartilage. None of our patients had such a good range of elbow movement preoperatively. Incarceration of the medial epicondyle in the joint occurred more often in children as a traction injury and less commonly in adults17. External or internal fixation is needed to stabilize the joints18. One of our patients underwent open reduction and radial head excision for the associated radial head fracture without coronoid fracture and their elbows remained stable. The presence of concomitant fractures is associated with poor functional results10. In our study, patients with associated fractures achieved less range of movement than those without. Most activities of daily living can be performed with a 100° flexion arc and a 100° supination‐pronation arc; such an elbow was termed as “useful”9. All our patients were within this range and could perform activities of daily living. Some of these activities can be accomplished even with less range of elbow movement, due to compensatory movements of adjacent joints. One of our patients with a range of flexion of 80° could perform most activities of daily living except those requiring extreme flexion such as reaching the occiput.

Mahaisavariya and Laupattarakasem19 recommended open reduction without triceps lengthening to achieve better results in elbow flexion in patients who had a dislocation for 1 to 3 months. However, in another larger study with patients having elbow dislocation for 1 to 60 months, the same authors performed triceps lengthening in 22 out of 24 patients20. In our study, one patient needed triceps lengthening to help reduction. The older the dislocation, the greater the need for triceps lengthening. This allowed reduction without putting undue pressure on the already compromised articular cartilage. Other open reduction methods include splitting of the triceps, but this causes a greater degree of postoperative muscular contracture and elbow flexion restriction. Unlike Mahaisavariya et al.'s study20, we did not repair the collateral ligament after reduction to avoid any unduly tight joint reduction. In their study, patients were sent to the physiotherapist for assisted flexion exercises for 2–3 weeks. We advised only active elbow exercises for an initial period of 2 weeks. None of our patients felt pain on lifting heavy weights, while some experienced elbow pain attributed to flexion contracture. Our rehabilitation program included 2 weeks of active physiotherapy after removal of the Kirschner wires to prevent myositis ossificans. Passive and assisted elbow movements were allowed once the inflammation had settled. Regular follow‐up and a strict physiotherapy regimen are of utmost importance. Arafiles21 performed open reduction with tendon graft stabilization to create a medial collateral and intra‐articular cruciate ligament, with exercises starting 6 days after operation. We had no experience with this method. Their patients achieved a mean arc of flexion of 105°. Valgus‐varus instability of 33° was reported in patients who underwent tricepsplasty, but it was only 4° in those whose aponeurosis was kept intact. Tricepsplasty was performed in all our patients who had a mean flexion contracture of 10° and none of our patients had instability. Some authors recommend open reduction and hinged external fixation without V‐Y plasty of the triceps bow to facilitate early rehabilitation and better stability22, 23. We had no experience with this method.

In treating chronic unreduced elbow dislocation the apparently conflicting goals of restoring elbow stability and regaining a satisfactory arc of motion, is a challenge even for the experienced trauma surgeon. Several newer methods report good result as hinged external fixator. But in developing countries like ours, open reduction as described by Speed remains the basis of handsome tool to gain a functional limb.