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JINJ-6216; No. of Pages 5 Injury, Int. J. Care Injured xxx (2015) xxx–xxx

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Clinical and functional outcomes and treatment options for paediatric elbow dislocations: Experiences of three trauma centres M. Subasi a,*, M. Isik a, M. Bulut b, O. Cebesoy a, A. Uludag c, L. Karakurt d a

University of Gaziantep, Faculty of Medicine, Department of Orthopaedics and Traumatology, Turkey University of Dicle, Faculty of Medicine, Department of Orthopaedics and Traumatology, Turkey c University of Adiyaman, Faculty of Medicine, Department of Orthopaedics and Traumatology, Turkey d University of Firat, Faculty of Medicine, Department of Orthopaedics and Traumatology, Turkey b

A R T I C L E I N F O

A B S T R A C T

Keywords: Posterior elbow dislocation Pure dislocation Paediatric elbow dislocation

Although elbow dislocations are seen rarely in children, their management remains controversial. In this study, over a 7 years period, we evaluated retrospectively the clinical and functional results of paediatric elbow dislocations managed in three different trauma centres. Pure dislocations and dislocations with associated injuries were evaluated separately. In total 56 patients met the inclusion criteria. The number of patients without additional injury was 22 out of which according to the Robert’s criteria, 15 children (68%) had an excellent, four (18%) a good, one (5%) a fair, and two (9%) a poor outcome. From the thirtyfour patients that had associated injuries, two (6%) had an excellent, 6 (18%) a good, 10 (29%) a fair and 16 (47%) a poor result. Overall, patients with pure dislocation were found to have a better range of motion compared to patients with dislocation and associated injuries. Prolonged follow ups, and effective rehabilitation programs are required in order to expect good outcomes. ß 2015 Published by Elsevier Ltd.

Introduction The elbow joint is composed of the articulation of the radius with the capitellum and the articulation of semilunar notch of the olecranon with the trochlea. The most common type of elbow dislocation involves displacement of both proximal radial and ulnar articular surfaces from their respective articulating surfaces of distal humerus [1]. Traumatic dislocation of the elbow is a rare injury in children, with an incidence of 3–6% of all elbow injuries [1–4]. Paediatric elbow dislocations typically occurred in the second decade, usually between 13 and 14 years of age, when the physes begin to close [1]. Associated fractures are likely to occur when the physes are still open; when they are closed, collateral ligaments might be ruptured [1,3,4]. Dislocations of the elbow are classified according to the direction of displacement of the radioulnar unit from the distal humerus. Ninety-five percent of dislocations are posterior and of

* Corresponding author at: Department of Orthopaedics and Traumatology University of Gaziantep, Universite Bulvari Sahinbey Hastanesi, Ortopedi Klinigi, 27310, Sahinbey – Gaziantep, Turkey. Tel.: +90 533 746 0013. E-mail address: [email protected] (M. Subasi).

these 70% are posterolateral [5]. Avulsion of the medial epicondyle is the most common associated injury and infrequently fractures of lateral humeral condyle might be present [1,3,5,6]. In this study, the clinical results of pure elbow dislocations in children collected from three different trauma centres were compared with results of elbow dislocations with associated injuries. Patients and methods Between January 2006 and January 2012 young patients below the age of 16 that sustained an elbow dislocation were eligible to participate in this study. Exclusion criteria were adult patients and patients lost to follow up. Treatment protocol In all cases, standard general clinical assessment was carried out at presentation. Neurovascular pathology was evaluated and documented. Anterior–posterior and lateral elbow radiographs were obtained immediately. Closed reduction was carried out to all dislocations under sedation and analgesia in the emergency room. Following reduction, stability of each elbow joint was examined and elbows which redislocated spontaneously during gentle

http://dx.doi.org/10.1016/j.injury.2015.05.026 0020–1383/ß 2015 Published by Elsevier Ltd.

Please cite this article in press as: Subasi M, et al. Clinical and functional outcomes and treatment options for paediatric elbow dislocations: Experiences of three trauma centres. Injury (2015), http://dx.doi.org/10.1016/j.injury.2015.05.026

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movement were diagnosed as unstable and those patients underwent surgery. Elbow casts were applied to cases, that were thought to be stable and not requiring additional fixation. In patients who presented with associated injuries, stabilisation was performed under general anaesthesia in the operating room. All pure dislocations (22 patients), which had been reduced by closed manipulation were immobilised with an above cast for two weeks. All dislocations with displaced fractures (29 patients) were reduced (open reduction) and stabilised with K-wires and were immobilised for 4 weeks. Demographics, mechanisms of injury, other associated injuries, neurological and vascular injuries, and complications noted during treatment and follow up periods were recorded and entered in a computerised database. Functional results were evaluated according to the criteria of Roberts [6] (excellent no symptoms, no limitation of extension/flexion in the elbow movement; good mild symptoms, not >108 of loss of movement; fair, moderate symptoms and 10–308 loss of movement; and poor, severe symptoms, >308 loss of movement). We compared the results of pure dislocations and dislocations with associated fractures and/or ruptures of collateral ligaments or vascular injuries. Statistical analysis was carried out using the Chi Square Test. Significance was assumed for p value less than 0.05. The minimum follow up was 2 years (range 2–4.5).

Fig. 2. Follow up radiograph of pure dislocation at 6th month after closed reduction.

In total 56 patients met the inclusion criteria. There were 39 boys and 17 girls with a mean age of 11 years (5–15). 31 of patients had right elbow dislocation, whereas 25 a left one. All dislocations were unilateral and the mechanism of injury was a direct fall on an outstretched hand. All dislocations were in the form of posterior dislocation (17 had a posterior direction, 33 a posterolateral and 6 a posteromedial direction). The number of patients without additional injury was 22. Mean age of those patients was 11.6 years (range 5.0–15.0). All pure dislocations, which had been reduced by closed manipulation as previously stated were immobilised for a period of 2 weeks (Fig. 1). All patients had normal radiograph at the final follow up showing

axial alignment of the elbow joint, no disturbances of growth plates and no joint capsule calcifications (Fig. 2). No persistent or recurrent joint instabilities or permanent pain were documented. The results documented (according to Roberts [7]) were 15 cases (68%) excellent, four (18%) good, one (5%) fair, and two (9%) poor. Follow up complications were noted in patients who had fair and poor results. Failure to comply with recommended follow-up and rehabilitation programs in those patients were detected and many of those patients came from families with low socioeconomic status. Thirty-four patients had associated injuries. The mean age of those patients was 8.6 (range 6–14). The most frequently seen additional injury was fracture of the medial epicondyle (20 patients), (Fig. 3) followed by lateral condyle fracture (four patients). The associated injury types are presented in Table 1. Two non-displaced fractures of medial epicondyle and three avulsion fractures of coronoid were treated conservatively. One child had a compound injury with soft-tissue disruption and damage to the median nerve and brachial artery. The brachial artery was

Fig. 1. Radiograph of a pure dislocation of elbow.

Fig. 3. Radiograph of the elbow dislocation with fracture of medial epicondyle.

Results

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Table 1 Mostly seen associated injuries with elbow dislocations in children, literature review. Author

Number of cases

Associated fractures

Carlioz

58

Medial epicondyle Olecranon Radial head, neck Lateral flakes of bone Coronoid Combined

24 1 3 5 2 2

Pulse deficit Ulnar nerve Osteochondral flap (ulna) Radioulnar synostosis

4 2 2 2

90%

Rasool

33

Lateral condyle Olecranon Radial neck Coronoid Combined 7 (Divergent 2)

11 5 1 1

Median nerve Radial nerve Ulnar nerve Brachial artery injury

1 1 2 1

67%

Lieber

33

Medial epicondyle Lateral condyle Lateral epicondyle Transcondylar fracture Radial neck Processus coronoideus Collateral ligament (isolated) Collateral ligament (and fracture)

10 5 1 1 4 2 3 7

Pseudartrosis of the radial neck Hypervalgus

1 4

97%

Present study

56

Medial epicondyle Lateral condyle Lateral epicondyle Radial neck Processus coronoideus Olecranon

20 4 2 4 3 2

Ulnar nerve Median Brachial artery injury cubitus recurvatum

3 1 1 2

48%

reconstructed using a reverse saphenous graft by vascular surgeons. The injury type of median nerve was evaluated as neuropraxia and recovery was delayed by 3 months. Leading to severe loss of elbow movement. Atrophy and contractures were developed on the patient’s hand. This patient was evaluated as having poor results. A patient with ulna nerve injury had sustained olecranon fracture, lateral condyle fracture and posteromedial dislocation of the elbow (Fig. 4). Ulnar nerve recovery was seen by 8 weeks but hypotenar atrophy, interosseous muscles atrophy and

Fig. 4. Radiograph of posteromedial dislocation of elbow with olecranon fracture, and fracture of lateral condyle.

Complications

Results % (excellent and good)

mild contractures of fingers developed during that period. This patient scored a fair result. Two other patients with ulnar nerve injury recovered within 4 weeks. Although non-union of the medial epicondylar fragment with the distal metaphysis was seen in one patient, the patient had no associated symptoms. Cubitus recurvatum was seen in two patients, but the patients had no symptoms. Two (6%) excellent result, 6 (18%) good result, 10 (29%) fair result and 16(47%) poor result were found according to Roberts criteria [7]. There were eight children (24%) with excellent or good results (Figs. 5 and 6).

Fig. 5. Lateral clinical view of an excellent result.

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Fig. 6. Anterior clinical view of excellent result.

Grouping all the patients together, 27 (48%) of them had excellent or good, and 29 (52%) fair or poor result. Patients with closed reduction had a better outcome than those requiring open reduction. The functional results of both groups were compared statically by Chi Square Test. There was a significant difference between two groups (p < 0.05). Discussion Elbow dislocations in children are less frequent than fractures or epiphyseal separation of the distal humerus, proximal radius, and ulna. Posterior dislocation of the elbow is by far the most common type of dislocation; usually it results from indirect forces transmitted to the elbow from a fall on the outstretched hand [7]. All of our cases had posterior dislocation. Most of these dislocations were posterolateral (59%). Anterior and divergent dislocations are usually rare [3,5,7–9]. Anterior dislocation may occur from a direct blow to the posterior aspect of the elbow, with avulsion of the insertion of the triceps from the olecranon [10] whereas divergent dislocation is a rare subgroup of the posterior dislocation group [8]. The ulna is reported to dislocate posteromedially and the radial head laterally to lie over the lateral condyle. The suspected mechanism of injury is thought to be a combination of axial loading on the ulna and a strong pronation force causing disruption to the proximal radio-ulnar joint, the interosseous membrane and the annular ligament [5]. The peak age for posterior dislocation of the elbow in the skeletally immature patient is 13–14 years [10]. Mean age of our patients was 11. As with most elbow injuries in children, boys outnumber girls (70% of our patients were male). Concomitant fractures occur in over half of posterior elbow dislocations [10]. Fractures involving the medial epicondyle, radial head and neck, and coronoid process are the most common type of injuries. Fractures involving the lateral epicondyle, lateral condyle, olecranon, capitellum, and trochlea occur less frequently [10]. Associated injury to the elbow has been reported to range between 64% and 75% [3,5,9]. In this study, 61% of the dislocations had an associated injury to the elbow. In all published studies, the most common injury appears to be fracture of the medial epicondyle. The reported incidence of medial epicondylar fractures in association with dislocation of the elbow has varied from 30% to 55% in many of the reported series and is also comparable with our

study (36%) [3,5,9,10]. The epicondyle is small and when displaced, it may be confused with the ossification centre of the trochlea or olecranon [4]. There is no consensus in the literature regarding surgical or conservative treatment. Some authors recommend surgery in all cases to prevent non-union and instability whilst others recommend surgery in the case of entrapment and in fractures with a displacement over 2 mm. Lieber et al. recommends surgical treatment for elbow dislocation even with minimally displaced epicondyle fractures to achieve solid bone union and to prevent valgus instability [3]. They also recommend fixation with screw aiming to start early joint motion. We have fixed 18 of 20 medial epicondylar fractures with K-wiring. 2 of 20 nondisplaced fractures of medial epicondyle were treated. Fibrous union of the medial epicondylar fracture was seen in one patient, but the patient had no symptoms. The radial neck may be fractured during the process of dislocation. Such injury was seen in four patients in our series. It is recommended that less common seen non-displaced fractures of lateral condyle, lateral epicondyle, coronoid, and olecranon to be treated non-operatively. Surgical treatment is recommended if these fractures are displaced [3,5,6]. Three avulsion fractures of the coronoid and two nondisplaced fractures of medial epicondyle were treated conservatively in our cases. K-wire fixation was carried out for the other fractures. Early complications associated with posterior elbow dislocations include neurological and vascular injuries. Vascular injury after dislocation of the elbow is unusual. It is usually associated with open dislocation [5,11], but rarely is the vessel injured by closed dislocation [12]. It is reported that reconstruction mostly would not be necessary because of adequate collateral circulation. If there is any concern of ischemia, excessive swelling at the elbow or a totally absent distal pulse, then surgical exploration is essential [11]. One of our cases had an open injury concerning adequate circulation, reconstruction was performed by vascular surgeons. No sequalae were noted during the follow up period. The ulnar nerve is more frequently affected in elbow dislocations [10]. These injuries are usually transient and resolve completely [5,10]. Three of our patients (5%) had ulnar nerve injury. Two patients’ symptoms resolved within 4 weeks whilst it took 8 weeks for the third patient for recovery to take place. Interosseous muscle atrophy, hypothenar atrophy, and mild contractures of the fingers occurred in the meantime. The median nerve has been found to be trapped behind the medial epicondyle or within the joint after reduction [10,13–15]. Delay in diagnosis has been common [13]. One of our cases which had injury of both brachial artery and median nerve improved in 10 weeks. Radial nerve injury wasn’t observed in any of our patients. Late complications include loss of movement, myositis ossificans, recurrent dislocations, radio-ulnar synostosis, and cubitus recurvatum. Some type of immobilisation, usually a posterior splint, is advocated by most investigators after successful closed or open reduction. Most authors agree that one reason of persistent limitation of movement is related to prolonged immobilisation [3,10,16]. According to Lieber et al., immobilisation should be limited to 1 week for children with pure dislocation. In patients with associated displaced fractures, stable osteosynthesis should be performed and mobilisation should start early [3]. In our cases, mobilisation began within 2 weeks for pure dislocation, and 6 weeks for dislocation with associated injuries after immobilisation. Myositis ossificans is rare in children and disruption of the brachialis muscle is believed to be a contributing factor [10]. The delay in treatment, long-term immobilisation, and vigorous early active physiotherapy have been reported to cause myositis ossificans and heterotopic ossification [3,5,10]. Josefsson et al. reported that calcifications do not lead to functional impairment

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[10,17]. None of our patients was diagnosed to have developed myositis ossificans. A severe posterior elbow dislocation results in significant tearing of the anterior capsule. As a result, the patient may have some hyperextension (cubitus recurvatum) of the elbow. This usually is minimally symptomatic [10]. Although two children were diagnosed with cubitus recurvatum, they did not have any symptoms. Recurrent dislocation is rare in children. Only two (0.1%) recurrent dislocations have been reported [10,18]. These recurrent dislocations in children were due to a failure of the capsule and ligamentous structures to become reattached after traumatic dislocation [5,19]. Reocurrence of dislocation was not seen in our series. Hinged elbow external fixators can be used for old dislocations after extensive soft tissue release [20]. However, the results of using hinged elbow external fixators for children with acute posterior elbow dislocations are unknown. Different rates have been reported for results of acute posterior elbow dislocation in children after treatment. The results reported in literature that were good or excellent ranged from 67% to 97% (Table 1). Lieber et al. reported 100% excellent or good results for cases with pure dislocations, and 96% excellent or good results for cases with associated injuries. According to Lieber, this could be due to the low complication rates and the accurately treated diagnoses without delay in all cases. In addition, no comorbid conditions such as neurovascular injuries occurred [3]. Rasool has reported 67% excellent or good, 30% fair, and 3% poor results [5]. Altuntas et al. have reported 7% fair, and only 3% poor results in their series [8]. In our cases, the number of patients with pure dislocation had better results than patients with associated fractures. Combined and compound injuries resulted in greater loss of movement than isolated fractures. Patients with closed reduction had better outcome than those requiring open reduction. Living in rural areas, with low socioeconomic levels, and avoiding routine visits were most commonly seen as problems in the follow up period. In conclusion, we found that our success rate is lower than the rates reported in the literature. Prolonged follow up, good dialog with families, and effective rehabilitation programs are required for good results in patients with posterior elbow dislocations. Otherwise, serious limitation in the range of elbow movement should be expected.

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Conflict of interest No conflict of interest.

References [1] Wilkins KE. Fractures and dislocations of the elbow region., In: Rockwood CA, Wilkins KE, King RE, editors. 4th, Fractures in children, Vol. 3, 4th Philadelphia: Lippincott Raven; 1996. p. 653–887. [2] Canale ST, Beaty JH. Elbow dislocations. In: Daugherty K, Jones L, editors. Campbell’s operative orthopaedics. 11th ed., Philadelphia: Elsevier; 2008. p. 1564–5. [3] Lieber J, Zundel SM, Luithle T, Fuchs J, Kirschner HJ. Acute traumatic posterior elbow dislocation in children. J Pediatr Orthop B 2012;21:474–81. [4] Sinikumpu JJ, Lautamo A, Pokka T, Serlo W. Complications and radiographic outcome of children’s both-bone diaphyseal forearm fractures after invasive and non-invasive treatment. Injury 2013;44(Apr (4)):431–6. [5] Rasool MN. Dislocations of the elbow in children. J Bone Joint Surg Br 2004;86:1050–8. [6] Kirkos JM, Beslikas TA, Papavasiliou VA. Posteromedial dislocation of the elbow with lateral condyle fracture in children. Clin Orthop Relat Res 2003;408:232–6. [7] Roberts PH. Dislocation of the elbow. Br J Surg 1969;56:806–15. [8] Altuntas AO, Balakumar J, Howells RJ, Graham HK. Posterior divergent dislocation of the elbow in children and adolescents: a report of three cases and review of the literature. J Pediatr Orthop 2005;25:317–21. [9] Carlioz H, Abols Y. Posterior dislocation of the elbow in children. J Pediatr Orthop 1984;4:8–12. [10] Beaty JH, Kasser JR. Elbow dislocations fractures in children. 6th ed. Philedelphia: Lippincott Williams & Wilkins; 2006. p. 663–79. [11] Grimer RJ, Brooks S. Brachial artery damage accompanying closed posterior dislocation of the elbow. J Bone Joint Surg Br 1985;67:378–81. [12] Wilmshurst AD, Millner PA, Batchelor AG. Brachial artery entrapment in closed elbow dislocation. Injury 1989;20:240–1. [13] Green NE. Entrapment of the median nerve following elbow dislocation. J Pediatr Orthop 1983;3:384–6. [14] Hallett J. Entrapment of the median nerve after dislocation of the elbow. A case report. J Bone Joint Surg Br 1981;63:408–12. [15] Pritchett JW. Entrapment of the median nerve after dislocation of the elbow. J Pediatr Orthop 1984;4:752–3. [16] Mader K, Koslowsky TC, Gausepohl T, Pennig D. Mechanical distraction for the treatment of posttraumatic stiffness of the elbow in children and adolescents, surgical technique. J Bone Joint Surg Am 2007;89:26–35. [17] Josefsson PO, Nilsson BE. Incidence of elbow dislocation. Acta Orthop Scand 1986;57:537–8. [18] Royle SG. Posterior dislocation of the elbow. Clin Orthop Relat Res 1991;269:201–4. [19] Schwab GH, Bennett JB, Woods GW, Tullos HS. Biomechanics of elbow instability: the role of the medial collateral ligament. Clin Orthop Relat Res 1980;146:42–52. [20] Subasi M. Neglected dislocation of the elbow. Clin Orthop Relat Res 2005;439:292.

Please cite this article in press as: Subasi M, et al. Clinical and functional outcomes and treatment options for paediatric elbow dislocations: Experiences of three trauma centres. Injury (2015), http://dx.doi.org/10.1016/j.injury.2015.05.026

Clinical and functional outcomes and treatment options for paediatric elbow dislocations: Experiences of three trauma centres.

Although elbow dislocations are seen rarely in children, their management remains controversial. In this study, over a 7 years period, we evaluated re...
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