Abstract
Background
Floating elbow injuries are complex injuries. Due to frequent association with severe soft tissue injuries and polytrauma, they have unpredictable functional outcome. This prospective study is aimed to evaluate the factors affecting functional outcome.
Methods
Thirty patients with floating elbow injuries were treated at a level 1 trauma center from July 2018 to June 2019 with minimum follow-up of 9 months. The outcome was assessed by disability for arm shoulder and hand score (DASH) and mayo elbow performance score (MEPS).
Results
The overall incidence was 16.09 per 1000, mostly caused by road traffic accidents and all cases were managed surgically. Age, gender, education, occupation, arm dominance, and mechanism of injury did not significantly affect the outcomes. Open fractures and patients requiring staged procedure were associated with poorer outcomes (p < 0.05); however, delay in surgery for more than 24 h significantly increased the rate of complications. There was no statistical difference in the proportion of patients who had nerve injury pre operatively and post operatively on the final outcome.
Conclusion
Floating elbow injuries are relatively rare but nowadays the numbers are on the rise. Timely intervention with a multimodal approach and well-supervised rehabilitation can assure better final outcome.
Keywords: Floating elbow, Prognostic factor, Functional outcome, Polytrauma
Introduction
Classical floating elbow injury is a constellation of injuries involving the supracondylar or humeral diaphyseal area and proximal part of radius and ulna, initially described by Stanitski and Micheli [1]. Floating elbow variants include concomitant articular fracture or the fracture dislocation of elbow or both, fracture distal humerus with shaft radius or ulna or both that can act as functionally floating elbow [2, 3]. It has been reported to occur in combination—severe soft tissue damage and neurovascular injury [4]. As per the available literature on floating elbow, it has an unpredictable clinical outcome after treatment [5]; however, surgical treatment has been widely accepted as the best possible treatment for these injuries [2].
The outcomes of floating elbow injuries can be affected by severity, pattern of injury, type of fixation done for humerus and forearm, open fracture, multiple injuries and risk factors like age, arm dominance, level of activity [6]. Therefore, there is increased demand for such data on floating elbow injuries that can help to plan and monitor the effectiveness of measures to manage floating elbow injuries. Taking into consideration all these facts, this study was designed to evaluate the incidence, risk factors, fracture patterns, associated injuries, average delay in the treatment and the functional outcomes of floating elbow injuries and its variants in a tertiary care center in an Indian setup, to make suggestions regarding adequate management and rehabilitation.
Materials and Methods
This was a prospective cohort study, which included patients presenting with a floating elbow injury and its variants to Level 1 Trauma Centre [AS1] from 1 July 2018 to 30 June 2019. The patients aged more than 18 years with classical floating elbow injuries and variants such as fracture distal humerus with shaft ulna or shaft radius or both, shaft humerus fracture with proximal ulna or a radial head fracture or both, intra-articular fracture of elbow and fracture associated dislocation of the elbow were included in the study group, including both closed fractures and open grade 1, 2, 3a and 3b injuries. The patients having vascular injury (Gustilo Anderson grade 3c), preoperative brachial plexus injury, history of neuromuscular disorder, and patients not consenting to be the part of the study were excluded from this study group.
Patients who presented with floating elbow injuries were divided into three groups with subgroups in the same manner that Fraser and Hunter classified ipsilateral fractures of the femur and tibia in 1978 [7] (Fig. 1). For open fractures, Gustilo–Anderson classification [8] was used. CT scan was done in cases of intra-articular fracture patterns for better delineation of fracture pattern. Patients were shifted to the operative room as soon as possible after adequate resuscitation and stabilization.
Fig. 1.
Groups on basis of anatomic site of fracture in floating elbow
The data were collected with special emphasis on patient demographics, functional outcomes, and complications. The management of floating elbow injuries was performed in a single stage or multiple stages, which were determined by the type of fracture, associated soft tissue injuries, and general condition of the patient. Patients requiring soft tissue coverage were managed meticulously by the plastic surgery team. Intravenous antibiotics were given as per institutional antibiotic protocol. The pain was managed with oral and intravenous analgesics. The range of motion exercises were started from day one of the postoperative period wherever feasible. Oral Indomethacin 25 mg thrice a day for 4–6 weeks was given to the patients with a high risk of heterotopic ossification like patients with fractures involving elbow joint, intra-articular fracture and patients with severe soft tissue injuries [9].
On each visit, clinical evaluation and radiology of the involved part were checked to see the progress of bony union, implant status, and any complication. The functional outcome was assessed by Mayo Elbow Performance Score (MEPS) [10] and Disability of the Arm Shoulder and Hand (DASH) score system [11]. The DASH scores were categorized into four categories of excellent (0–5), good (6–15), satisfactory (15–35), and poor (more than 35). The MEPS was used to categorize in four categories of excellent (90–100), good (75–89), fair (60–74), and poor, less than 60 [12].
Statistical Analysis
Data acquired were entered into Microsoft excel sheet and analyzed with Statistical Package for Social sciences (SPSS Inc., Chicago, IL, Version 7.0 for windows 10).
We used descriptive analysis for describing the numerical data in terms of mean and standard deviation or median and interquartile range. We also transformed the numerical data of DASH scores and MEPS. Two categorical variables for comparing the functional outcome of DASH scores and MEPs were used at 6 weeks, 3 months, 6 months, and at final follow-up and used the Chi-square test of association. In the cells where the value was less than 5, we used Fisher’s exact test. For comparing the numerical outcome such as pronation, supination, and range of motion, a paired t test was used. Similarly, we used the Chi-square test of analysis for finding prognostic factors for various outcomes such as DASH scores, MEPS, union, and nerve injury. For all the tests of association, a p value less than 0.05 was considered to be statistically significant.
Results
The incidence was found to be 16.09 cases per 1000 orthopedic injuries over 1 year. Most injuries were caused by road accidents (76.7%) followed by machine-related injuries (13.3%) and rest were caused by fall from a significant height (10%). The majority of injuries belonged to Group 1 (53.3%) followed by Group 2 (33.4%) while there were four cases for Group 3. We observed that most patients were right dominant (53.3%) (Table 1). The majority of cases (86.7%) were managed as single-stage procedures while four cases (13.33%) were managed with two-stage procedures. Age, gender, education, and occupation of patients with floating elbow injuries and its variants were not statistically significant to influence the functional outcome of patients (p value > 0.05). We observed that the groups of injuries, side, dominancy, and mechanism of injury were not statistically significant in predicting the functional outcome of floating elbow injuries; however, intra-articular fracture tends to influence the outcome but was not statistically significant. We found that the open and closed nature of injury and type of surgery (ORIF, External fixator, Intramedullary nail) done to manage the injuries were statistically significant in predicting the final outcome, favoring the ORIF group (p = 0.013, p = 0.005). Delay in surgery for more than 24 h was statistically significant to predict complications like stiff elbow, decreased ROM of the elbow, wrist, and shoulder, and nerve injury (p = 0.024). The results were analyzed with the minimum follow-up of 9 months (range 9–24 months and mean 16 months) (Tables 2, 3).
Table 1.
Socio-demographic and injury characteristics of 30 patients
| Parameter | Attributes | N = 30 |
|---|---|---|
| Gender | Male | 23 |
| Female | 7 | |
| Education | Graduate and post-graduate | 13 |
| Twelfth | 8 | |
| Till tenth | 8 | |
| Illiterate | 1 | |
| Occupation | Driver, daily wager, factory worker | 11 |
| Students and housewife | 10 | |
| Government and private job | 7 | |
| Shop keeper | 2 | |
| Mechanism of injury | Fall from height | 3 |
| Machine injury | 4 | |
| Road side accident | 23 | |
| Group of injury | 1a | 13 |
| 1b | 3 | |
| 2a | 2 | |
| 2b | 8 | |
| 3 | 2 | |
| Side | Right | 16 |
| Left | 14 | |
| Dominant hand | Yes | 16 |
| No | 14 | |
| Type of surgery | Single stage | 26 |
| Multiple stage | 4 | |
| Open or closed | Open | 13 |
| Closed | 17 | |
| Duration of surgery | Less than 24 h | 17 |
| More than 24 h | 13 | |
| Nerve injury preoperative | Yes | 9 |
| No | 21 |
Table 2.
Prognostic factors for DASH and MEPS at 6 months
| Parameters | Attributes | DASH at 6 months | p value | MEPS at 6 months | MEPS | ||||||
|---|---|---|---|---|---|---|---|---|---|---|---|
| Excellent | Good | Poor | Satisfactory | DASH | Excellent | Fair | Good | Poor | p value | ||
| Category of age | 18–25 (Gp1-7, Gp2-3, Gp3-1, op-4, closed-7) | 1 | 5 | 4 | 2 | 0.569 | 6 | 2 | 3 | 1 | 0.696 |
| 25–35 (Gp1-7, Gp2-5, Gp3-1, op-9, closed-4) | 2 | 3 | 2 | 5 | 7 | 1 | 4 | 0 | |||
| More than 35 (Gp1-4, Gp2-2, op-1, closed-5) | 1 | 3 | 0 | 2 | 5 | 0 | 1 | 0 | |||
| Sex | Male (Gp1-16, Gp2-5, Gp3-2, op-13, closed-10) | 4 | 7 | 5 | 7 | 0.491 | 14 | 3 | 6 | 0 | 0.238 |
| Female (Gp1-2, Gp2-5, op-1, closed-6) | 0 | 4 | 1 | 2 | 4 | 0 | 2 | 1 | |||
| Category education | 12th or above (Gp1-10, Gp2-9, Gp3-2, op-9, closed-12) | 4 | 7 | 3 | 7 | 0.3436 | 14 | 1 | 5 | 1 | 0.379 |
| Less than 12th | 0 | 4 | 3 | 2 | 4 | 2 | 3 | 0 | |||
| Occupation | Government and private job | 2 | 0 | 1 | 4 | 0.198 | 4 | 0 | 3 | 0 | 0.407 |
| Driver, daily wager, factory worker | 1 | 4 | 4 | 2 | 6 | 3 | 2 | 0 | |||
| Shop keeper | 0 | 2 | 0 | 0 | 2 | 0 | 0 | 0 | |||
| Students and housewife | 1 | 5 | 1 | 3 | 6 | 0 | 3 | 1 | |||
| Categories of injury group | 1 (op-6, closed-12) | 2 | 7 | 4 | 5 | 0.782 | 11 | 2 | 5 | 0 | 0.445 |
| 2 (op-5, closed-5) | 2 | 4 | 1 | 3 | 7 | 0 | 2 | 1 | |||
| 3 (open-2) | 0 | 0 | 1 | 1 | 0 | 1 | 1 | 0 | |||
| Articular involvement | Extraarticular (Group 1) | 2 | 7 | 4 | 5 | 0.9376 | 11 | 2 | 5 | 0 | 0.662 |
| Intraarticular(Group 2 and 3) | 2 | 4 | 2 | 4 | 7 | 1 | 3 | 1 | |||
| Open or closed | Open (Gp1-6, Gp2-5, Gp3-2) | 2 | 1 | 5 | 5 | 0.021 | 4 | 3 | 6 | 0 | 0.011 |
| Closed (Gp1-12, Gp2-5) | 2 | 10 | 1 | 4 | 14 | 0 | 2 | 1 | |||
| Side | Right (Gp1-12, Gp2-2, Gp3-2, op-7, closed-9) | 1 | 7 | 5 | 3 | 0.146 | 9 | 3 | 3 | 1 | 0.223 |
| Left (Gp1-6, Gp2-8, op-7, closed-7) | 3 | 4 | 1 | 6 | 9 | 0 | 5 | 0 | |||
| Dominant hand | Yes | 1 | 7 | 5 | 3 | 0.146 | 9 | 3 | 3 | 1 | 0.223 |
| No | 3 | 4 | 1 | 6 | 9 | 0 | 5 | 0 | |||
| Duration between surgery and hospital arrival | Less than 24 h (Gp1-8, Gp2-7, Gp3-2, op-12, closed-4) | 3 | 4 | 5 | 5 | 0.247 | 8 | 3 | 5 | 1 | 0.234 |
| More than 24 h (Gp1-10, Gp2-3, op-1, closed-13) | 1 | 7 | 1 | 4 | 10 | 0 | 3 | 0 | |||
| Type of surgery | Single stage (Gp1-16, Gp2-9, Gp3-1, op-9, closed-17) | 4 | 11 | 3 | 8 | 0.025 | 18 | 2 | 5 | 1 | 0.046 |
| Multiple stage (Gp1-2, Gp2-1, Gp3-1, op-4) | 0 | 0 | 3 | 1 | 0 | 1 | 3 | 0 | |||
Table 3.
Associated injury in patients with floating elbow
| Associated injury | Yes—14 patients (46.7%) | Number of patients |
|---|---|---|
| No—16 patients (53.3%) | ||
| Associated injury details | Blunt trauma abdomen | 1 |
| Blunt trauma chest | 1 | |
| Facio-maxillary injury | 1 | |
| Left acetabulum n hip dislocation | 1 | |
| Left segmental femur, right proximal tibia fracture closed without neurovascular defect | 1 | |
| Left shaft of femur fracture, open knee joint, left Lisfranc injury | 1 | |
| Left patella open Grade 2 without neurovascular defect | 1 | |
| Open knee joint, left both bone leg fracture open grade 1, right medial malleolus fracture closed without neurovascular defect | 1 | |
| Right acetabulum fracture closed without neurovascular defect and blunt trauma abdomen, managed conservative | 1 | |
| Right both bone leg fracture | 1 | |
| Right mangled lower extremity | 1 | |
| Right scapula with acromioclavicular joint disruption | 1 | |
| Right sacroiliac joint disruption, bilateral superior pubic rami, inferior pubic rami, left iliac blade fracture, with sacrum fracture closed without neurovascular defect | 1 | |
| Right shaft of femur fracture closed without neurovascular defect | 1 |
DASH and MEPS Score
The mean DASH score in group 1, 2, and 3 were 19.9, 18, and 40.15, respectively (Fig. 2). There was statistically significant improvement (p = 0.000) in DASH scores at three follow-up periods of 6 weeks, 3 months, and 6 months. The mean MEPS score in groups 1, 2, and 3 were 89.4, 87.5, and 77.5, respectively (Fig. 2). There was a statistically significant improvement in MEPS at 6 months when compared to 3 months (p = 0.003).
Fig. 2.
Mean outcome scores and mean range of motion in different groups
Pronation, Supination, and Range of Motion
The mean pronation and supination in groups 1, 2, and 3 were 67, 64, 72.5 and 60, 66.5, 87.5, respectively (Fig. 2), while the mean range of motion was 107, 100.5 and 82.5, respectively. It was observed that the mean degree of pronation, supination, and range of motion improved from 6 weeks to 3 months and from 3 to 6 months. The improvement was found significant statistically using a paired t test (p = 0.000) (Fig. 3).
Fig. 3.
Preoperative and postoperative radiographs of a patient with group 3 type of floating elbow injury
The overall mean values of DASH score, MEPS, Range of motion, pronation and supination were 20.6, 88, 103°, 66° and 64°, respectively.
Nerve Injury
Nine patients (30%) with preoperative nerve injury cases were surgically explored and found to have neuropraxia, hence were managed conservatively. There was no statistical difference in the proportion of patients who had nerve injury before or after surgery on the final outcome of these injuries (p > 0.05).
Union
Union was achieved in 86.7% of cases and four cases had nonunion; two cases (6.7%) had nonunion of radius and ulna, two cases (6.6%) had nonunion of humerus and radius. It was found that nonunion was observed in cases with open grade 3b and those treated with external fixator with delay in surgery for more than 24 h. All patients underwent re-surgery and union was achieved.
Complications
Nine patients (30%) presented with different complications such as stiff wrist, decreased elbow range of motion, stiff shoulder, postoperative nerve injury, and decreased ROM in the wrist. Associated multisystem injuries and delay in surgery were the factors which were statistically significant for causing these complications (p = 0.024).
Discussion
Floating elbow is a rare injury caused by high-energy trauma, it occurs in combination with severe soft tissue damage leading to open fracture and neurovascular injury [4]. Floating elbow injury significantly affects the normal routine activities of the person suffering from it. We searched for the possible prognostic factors that can influence the outcome of floating elbow injuries; we included age, sex, education, occupation, side, dominance, type of surgery, open and closed fracture, type of injury pattern, duration between surgery and hospital arrival, nerve injury, mechanism of injury, as our expected prognostic factors (Table 2).
In previously published data on incidence [13–17], the floating elbow injuries are very rare injuries and thus had a very low incidence. Stoik et al. [18] found an incidence of 1 patient per year in their study; however, in our study, incidence was 16.09 cases per 1000 orthopedic injuries over 1 year. Higher incidence can be attributed to the fact that our institute is a tertiary care center that provides services to a large population and receives a large number of referrals of patients with polytrauma. Jockel et al. [6] observed that the patient’s age, arm, dominance, type of surgery, multiple surgeries, and fracture patterns were not statistically significant to influence the functional outcome, and our study also shows similar findings.
Pierce and Hodorski [13], Solomon et al. [4] and Yokoyama et al. [3] reported poorer outcomes in patients with associated radial nerve palsy and Ditsios et al. [19] found that nerve injury leads to poor clinical outcome. However, Jimenez-Diaz et al. [20] concluded that nerve injury is not statistically significant in predicting the functional outcome of these injuries. We observed that nerve injury was not statistically significant to influence the long-term functional outcome, which could be attributed to the fact that all the nerve injuries were neuropraxia in our study, and recovered subsequently without any intervention.
Bisinella and Bellon [21] in their case series found that associated injuries with floating elbow injuries need planning regarding timing of surgical intervention and this can reduce the risk of complication and result in good functional outcome, which was also applicable in our study. We found that patients with multisystem injuries (46.7%) such as polytrauma, blunt trauma abdomen, blunt trauma chest, and head injury (Table 3) suffered complications such as stiffness of elbow, shoulder, and wrist, death due to head injury and amputation due to severe soft tissue injury.
Jimenez-Diaz et al. [20] and Yokoyama et al. [3] found correlation between associated multisystem injuries, open nature and anatomic site and the complications such as infection or nonunion with functional outcome; however, they did not evaluate the relationship of factors such as timing of surgery, open/closed fracture and associated nerve injury on functional outcome. We found that open nature and type of technique used for fixation had a significant influence on final functional outcomes (p = 0.013, 0.005, respectively), whereas the timing of surgery affected the outcomes in terms of complications (p = 0.024). Stoik et al. [18] found that the conservative method of management of these injuries definitely leads to complete loss of function and thus emphasized on surgical stabilization of these fractures both above and below elbow to improve functional outcome; this finding can also be reiterated with our study.
In our study that there was a significant improvement in DASH scores, MEPS scores, range of motion, and pronation/supination during follow-up from 3 to 6 months (p < 0.05). The open fractures with grade 3b and intra-articular fractures which were managed with an external fixator or square nail showed poor DASH score, MEPS score, decreased elbow ROM and nonunion (p > 0.05). We observed that educated patients had a tendency towards better functional outcomes as compared to uneducated patients. Five patients who were lost to follow-up, all were from low socioeconomic status and the majority of them were not educated. Although it was not statistically significant (p > 0.05), but it is an important factor in developing countries like ours.
Ditsios et al. [19] found intra-articular fractures to have a poorer outcome; we also observed that intra-articular fracture tends to influence the outcome but was not statistically significant in our study. We also observed that Group 1 and 2 types of injuries (Fig. 2) had better functional outcomes as compared to Group 3, although it was not statistically significant.
Strength and Limitations
It is the first prospective study that describes factors influencing the functional outcome of floating elbow injuries and their variations. All cases were operated at the same institute and by the same surgeon and data were collected by a single investigator throughout the period of study to avoid false data and to maintain uniformity. The limitation was the small sample size and relatively shorter duration of follow-up.
Conclusion
The incidence of floating elbow injuries is increasing day by day and frequently associated with polytrauma. The functional outcome of these injuries is not affected by differences in age, gender, education, occupation, side/dominance, and anatomic site of fractures. However, open fracture, type of surgery performed, and delay in surgery have a significant influence on the final outcome. Neuropraxic nerve injuries recover over a period of time and did not influence the final outcome significantly. Timely intervention and a multimodal approach can lead to good results.
Declarations
Conflict of Interest
The authors declare that they have no conflict of interest.
Ethical Approval
Obtained.
Informed Consent
Obtained.
Footnotes
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