European Journal of Trauma and Emergency Surgery
Focus on Elbow Fractures
Current Concepts: Simple and Complex Elbow Dislocations – Acute and Definitive Treatment Pascal Jungbluth, Mohssen Hakimi, Wolfgang Linhart, Joachim Windolf 1
Abstract Dislocations of the elbow account for 20% of all dislocations. Thus, after the shoulder, the elbow joint is the joint most frequently afflicted by dislocations. A distinction is made between simple elbow dislocations without associated fractures and fracture-dislocations of the elbow, which are frequently referred to as complex elbow dislocations. Treatment principles are reduction of the joint, stabilization of associated fractures, and early motion. Ligament repairs or reconstruction and hinged external fixators are necessary in some cases to restore stability for early motion. In general, simple dislocations have a better prognosis than complex dislocations. Eur J Trauma Emerg Surg 2008;34:120–30 DOI 10.1007/s00068-008-8033-9
Background Dislocations of the elbow account for 20% of all dislocations. After the shoulder, this makes the elbow joint the second-most frequently dislocated joint [1]. A distinction is made between simple dislocations without associated fractures and fracture-dislocations of the elbow, which are frequently also referred to as complex elbow dislocations [2]. The high number of dislocations accounted for by elbow dislocations indicates the great importance of this injury. This article provides a review of the pertinent literature on both forms of dislocations. In this connection, the anatomy of the elbow joint and its stability are described, followed by a discussion of the epidemiology and classification of elbow dislocations. Finally, we provide a discussion on clinical management, including diagnostics, non-operative or operative interventions, prognoses, and rehabilitation. 1
Anatomy The elbow joint is composed of three joints, the humeroulnar, the humeroradial, and the proximal radioulnar joint. As a hinge joint, the humeroulnar joint makes possible one major motion and a high level of congruence, ensuring bony guidance. The trochlear notch of the ulna extends around the trochlea of humerus like a forceps. The humeroradial joint is a ball joint with two principle arcs of motion. Moreover the annular radial ligament provides a narrow ligamentous channel for the radial head to the ulna. Rotating movements of the radius with pronation and supination are possible in the proximal radioulnar joint. This three-part joint complex is surrounded by a common capsule, which is strengthened on the side by the collateral ligaments [the medial collateral ligament (MCL) and the lateral collateral ligament (LCL)]. These are composed of three fan-shaped sub-parts each, which means that in every joint position parts of the collateral ligaments are tensed, contributing to and ensuring stability of the joint.
Epidemiology and Classification Elbow dislocations represent 11–28% of all elbow injuries, with an annual incidence of 6–8 cases per 100,000 people [2]. This classification is based on the direction of the dislocation of the forearm with respect to the humerus [3]. A distinction is made between posterior, posterolateral, posteromedial, anterior, and divergent forms (Table 1), whereby the posterior and posterolateral dislocations, the most frequently encountered types, account for 80–90% [4, 5]. The other forms occur much less frequently, whereby the divergent dislocations, in which the humerus is jammed between the radius and ulna and the interosseous membrane is destroyed, constitutes an absolute rarity
Department of Trauma and Hand Surgery, Heinrich Heine University Hospital Duesseldorf, Moorenstr. 5, 40225 Duesseldorf, Germany.
Received: February 25, 2008; revision accepted: March 17, 2008; Published Online: April 3, 2008
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Table 1. Classification of elbow dislocations. Simple dislocations: soft tissue injuries Anterior Posterior Direct posterior Posterolateral Posteromedial Divergent Complex simple dislocations: bone and soft tissue injuries Anterior Posterior
[6, 7]. Another distinction is made between simple and complex dislocations. In the latter case fractures occur to the distal humerus, the proximal ulna or the proximal radius [8]. By the same token, simple dislocations without any secondary injuries to the bone occur more often than complex dislocations [2]. The latter account for 15–20% of all elbow dislocations [8, 9].
Mechanisms of Injury The type of accident causing a posterior dislocation is a fall on the wrist while the elbow joint is extended and the wrist is pronated. The impact of the tip of the olecranon on the olecranon fossa has a leverage effect as a result of the combination of valgus-, supinationand outward rotating position of the forearm, while the coronoid process slips in a dorsal direction over the trochlea of humerus [10–12]. When a person falls on his/her hand with a flexed elbow joint, the force acting in a direct axial direction causes the olecranon to slip out [13, 14]. An anterior dislocation, which occurs much less frequently, only comes about through a combination between a flexed elbow and a force acting dorsally. On the one hand, the osseous structures are responsible for guiding the elbow joint, while on the other hand the collateral ligaments, the joint capsule and the muscular soft tissue sheath are important stabilizers for the elbow. Especially, injuries to the anterior medial collateral ligament (AMCL) are a subject of controversy. This is characterized by many authors as one of the most important joint stabilizers of the elbow joint [15, 16]. In this regard O’Driscoll et al. [10] have been able to use biomechanical studies to devise a circle strategy for the sequence of injuries to soft tissue with respect to a simple posterior dislocation. As a result of the combined force emanating from axial compression, varus stress and the impact of various rotation
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components, a force is generated which flows from lateral to medial. In almost every case this leads to a rupture of the LCL. In declining order, the anterior and posterior capsule, and last of all the MCL are involved [17]. It is necessary for oligamentous capsule structures to be torn in the dislocation for the circle strategy developed by O’Driscoll [10] to be applied. Complex dislocations, on the other hand, have not been examined biomechanically thus far. Simple or complex injuries to elbows can, however, also occur in connection with trauma caused by accidents involving high energies such as motor vehicle collisions or in other situations where high levels of trauma-inducing forces occur. Complex types of dislocations are usually the result in these cases.
Clinical Evaluation The clinical analysis of the elbow affected is first performed to determine deformities and open injuries. Although neurovascular injuries are rare [8], it is first of all important to examine the blood circulation, motor function, and sensitivity prior to any manipulation. In particular, the status of the median nerve, the ulnar nerve and the brachial artery is to be determined, as these are most frequently affected, and moreover can be injured in the first place through the manipulation in the examination [8]. The ipsilateral shoulder and the ipsilateral wrist of the injured person should also be examined to determine if there are any secondary injuries. An evaluation of the ipsilateral distal radioulnar joint and the interosseous membrane for the presence of an Essex– Lopresti injury would also appear to be of importance [18, 19]. Clinically, a marked swelling often stands out as an indication of massive injury to soft tissue in a dislocation injury. Of special relevance in this connection is ruling out a compartment syndrome, which is already present from the start in rare cases. It usually occurs later, however, which means that a close monitoring of the neurovascular status should routinely be carried out during the first hours [10]. In addition to the evaluation of associated fractures, an examination of stability and tendency toward re-dislocation are crucial aspects of further treatment. To this end, the stability of the collateral ligaments should be checked in full extension and 20° of flexion, while the pivot-shift test should be performed to determine whether there is a tendency toward subluxation [10]. Some patients arrive in emergency rooms with joints, which have already been spontaneously reduced.
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In such cases, the diagnosis is derived from the case history and any possible instability, which may be present. Diagnostic Imaging In addition to conventional radiographs, additional diagnostic possibilities are available in the form of computed tomography (CT) and magnetic resonance imaging (MRI). Conventional plain anteroposterior and lateral radiographs should be made relatively quickly before much time passes prior to reduction. Should the findings be indeterminate, oblique views may facilitate a better assessment of the coronoid process and the radial head [2, 18]. Depending on the symptoms and pain experienced, radiographs should also be made of the adjacent joints. In assessing complex dislocations, the execution of a CT is the gold standard [8]. This is primarily aimed at supporting the planning of an operation [2, 18]. Because the MRI only plays a limited role in the evaluation of acute elbow dislocations, it is therefore warranted more in the case of chronic instability [2, 20]. If there is a suspicion that the interosseous membrane has been injured, especially if the radial head has been injured at the same time, it may, however, play a crucial diagnostic role [21].
Management: General Principles The objective in treatment should always be an anatomical and stable reduction of the elbow to ensure movement without any functional restrictions or pain over the long term. Open wounds must be treated immediately. The treatment of simple and complex elbow dislocations is discussed separately in the following.
Simple Dislocations Conservative Therapy A crucial factor in the case of simple dislocations is a reduction of the elbow joint early on [2, 22]. It is necessary to examine carefully the neurovascular status prior to any reduction. The reduction maneuver generally does not require general anesthesia and can instead be performed with mild intravenous sedation. Ideally, the reduction maneuver should take place in the operating room, as it is easier to monitor things here if general anesthesia is used and muscle relaxation is necessary [2, 18]. In everyday clinical work, however, the reduction is performed in the emergency room for logistical reasons [2, 8].
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Various reduction maneuvers are described in the literature [21]. The technique we use in the reduction of the posterior dislocation is carried on with one assistant with the patient lying down. The first important step is to carefully pull the longitudinal humerus axis in order to free the coronoid process from the olecranon fossa. While an assistant is holding the patient, the physician then pulls in the anterior direction of the forearm while the elbow is slightly flexed. After the reduction has been successfully performed, the arm should be fixated with the elbow flexed in a 90° position and the forearm in a neutral position with respect to pronation/ supination. Then an examination of elbow stability is obligatory. If possible, this should be carried out using an image intensifier. The examination concentrates on translation stress with the elbow in 30° of flexion and valgus and varus stress with the elbow in 20° of flexion. Other authors describe the stability examination in an even more differentiated manner [2]. The elbow joint is extended and flexed completely. A so-called stable arc of motion is only attained when the elbow joint remains reduced in a range from at least 60° of flexion to full flexion. After determining the neurological status once again, the arm is immobilized in a dorsal forearm plaster splint with the elbow in 90° of flexion and the forearm placed in a neutral position with respect to pronation/supination. It is also important to produce plain anteroposterior and lateral radiographs following reduction in order to discover any incorrect subluxation positions owing to possible interpositioning of soft tissue [22]. If the ligaments do not exhibit any instability and there are no other indications warranting operation, the elbow is immobilized by us for a maximum of 2 weeks in the dorsal splint or orthesis at 90° and in a neutral position. The physiotherapy should be performed with active and passive movement exercises after the end of the first week out of the splint without limiting the degree of movement. The splint is removed by us at the end of the second week (see case 1, Figures 1a–e). As a result of this treatment, the elbow can also be used for sporting activities after only 3 months [6, 23]. Repeat radiographs should then be performed after 3–5 days. Then, a follow-up check-up is to be performed in addition 2 weeks later and radiological controls are recommended [2, 18, 24]. The treatment of the rare anterior and divergent dislocations is performed in a similar manner. Here it is
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Figures 1a to 1e. a, b) A 37-year-old patient with a spontaneously reduced, simple elbow dislocation suffered in a bicycle accident on his way to work. At first, radiographs showed a limitation of movement due to pain without any other serious injuries. c) A torn LCL was diagnosed in the MRI. d, e) The elbow was immobilized for 2 weeks in a dorsal splint at 90° of flexion and in a neutral position with respect to pronation/ supination. Early physiotherapy was performed with active and passive movement exercises after the end of the first week out of the splint. Four weeks after the accident patient exhibits extension/flexion of 0°–0°–110° with free pronation/supination and a stable elbow joint.
a good idea, however, to carry out the reduction maneuver using a general anesthesia and muscle relaxation in the operating room, as these forms of dislocations are usually associated with trauma from accidents involving high energies, where experience has shown difficulties to occur more frequently in the reduction, often making an open reduction necessary [2, 8]. If the elbow joint is stable after the reduction, then further therapy is conducted along the same lines as for a posterior dislocation. Surgical Treatment There are only very few indications for surgical treatment for acute, simple elbow dislocations. Irreducible dislocations are very rare and are usually caused secondarily by entrapped osteochondral fragments or soft tissue. These are an indication for an operation [8]. This especially applies to medial instabilities resulting from injuries to the MCL. In this case it is necessary to reattach or reconstruct the MCL. Subacute or chronic dislocations also require an open reduction. In the case of elbow dislocations which require open surgery, a repair or reconstruction of the ligaments should generally be performed to allow functional use as early as possible. The authors reattach the ligaments using titanium anchors.
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In the case of a dislocation tendency when flexing 60° and more, surgical reconstruction or reattachment of the ligaments is generally recommended, as in this constellation it is not possible to use the joint early on without dislocating it and immobilization for a lengthy period means considerable restrictions in mobility [2, 18, 22]. Nevertheless, instabilities resulting from ruptures of the collateral ligaments do not rule out a conservative therapy, as one can expect a high rate of spontaneous healing to occur when using functional therapies. In such cases, it is advisable to immobilize the joint in a dorsal plaster splint or orthesis with the elbow in 90° of flexion and neutral position of the forearm for a maximum of 1 week. Further treatment applying physiotherapy exercises should then be performed on a movement scale for extension/flexion of 0°/20°/130° for a total of 3 weeks followed by an increase in extension. In this case, the patient cannot engage in athletic activities for a period of 6 months [9]. In the case of neurovascular injuries or a compartment syndrome, on the other hand, immediate surgery is necessary [10, 25]. Further treatment following surgical reconstruction or reattachment of the ligaments is performed as follows:
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If the reduction proves to be stable after the surgical operation, a hinged brace should be used, possibly with an extension block. If on the other hand the situation following surgery is unstable, a hinged external fixator is advisable, as this allows movement early on while helping to prevent a re-dislocation [2, 18]. In general, physiotherapy should be commenced with as soon as possible after the operation [3, 24, 26, 27]. Both hinged brace and hinged external fixator should be used for a maximum of 6 weeks in the case of reattachment or 8 weeks if the ligaments are reconstructed [8]. An extension block should be removed after 4–6 weeks [10, 18, 24]. Figure 2 shows the treatment algorithm in the case of a simple dislocation. The prognosis following a simple elbow dislocation is generally good [3, 6, 24, 26–32]. Re-dislocations or instabilities are rare. More than 95% of patients return to their previous occupation [6, 33, 34]. More than 50% of patients nevertheless report that their elbow is no longer like it was before the accident or like the elbow on the opposite site [8]. A loss of extension of 10°–20° is described relatively frequently [3, 10, 28, 32]. These vary considerably, however, depending upon the period of immobilization. When immobilizations Simple Dislocation
Reducible Stable
Reducible Unstable
Rehabilitation No Motion Restrictons
Irreducible
Stable Arc of Motion 60° to Full Flexion
Yes
Supervised Rehabilitation in Stable Arc in Hinged Brace ± Extension Block (Forearm Positioned for Stability)
Yes
Supervised Rehabilitation in Stable Arc in Hinged Brace ± Extension Block (Forearm Positioned for Stability)
Open Reduction
Conclusion Surgery is only clearly indicated when the elbow only becomes stable with less than 60° of flexion or if it is not possible to reduce it anatomically or if there are neurovascular injuries. (see case 2, Figures 3a–g).
No
Ligament Repair or Reconstruction
Stable Arc of Motion 60° to Full Flexion
No
Hinged External Fixator Supervised Rehabilitation
Figure 2. Algorithm for treatment of simple elbow dislocations.
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are less than 1 week, these are generally below 10° [6, 24, 29, 33, 35]. Loss of flexion is virtually nil here [24, 29, 35]. The mobility of the forearm is rarely affected as well [6, 24, 29, 33, 35]. Persistent pain rarely occurs later on, and when it occurs, it is usually mild [29]. The same applies to persistent neurological deficits [3, 10, 28, 32, 36]. In most cases radiographic abnormalities crop up in the long-term follow-up. These are usually low-level, however [6, 27, 33–35, 37]. These generally involve, as it were, heterotopic ossifications of the collateral ligaments and the anterior capsule among up to 95% of the patients [33]. These result in restrictions of movement in less than 5% of cases. Most follow-up studies do not show any correlation between the presence of heterotopic ossifications and restrictions of movement [3, 6, 18, 24, 27, 29, 33, 34]. Arthrotic changes are reported in up to 40% of the follow-up studies, although these are usually only mild [6, 27, 33–35, 37]. The consensus in the literature regarding the treatment of simple elbow relocations tends more in the direction of a non-operative approach and an early functional treatment. Examinations and results produced by Joseffsson et al. [6] within the framework of a retrospective cohort study and a randomized clinical study have even been able to demonstrate that in functional terms no better results could be reached for patients with a simple posterior or posterolateral dislocation who underwent surgical treatment than patients who underwent a conservative therapy.
Complex Dislocations Complex dislocations of the elbow usually exhibit injuries to both ligaments and bones, and usually involve articular surfaces. These constellations of injury lead to instability of the elbow [38]. The most frequent fractures in the case of complex dislocations are to be found in the area of the coronoid process and the radial head [2, 39]. Fractures of the proximal ulna and Monteggia-like lesions are furthermore observed [1, 7, 38–42]. The treatment principles of complex dislocations involve reduction of the dislocation and treatment of the fracture, on the basis of its own merits. If a stable
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Figures 3a to 3g. a–c) 22-year-old patient who fell from a scaffold at a building site with subtotal amputation of the elbow, complete disruption of the brachial artery and compartment syndrome on the forearm. In addition the patient had a fracture of the distal radius. d, e) Primary reduction of the elbow and the distal radius, reconstruction of the brachial artery with interposition vein graft and external fixator on the elbow joint and the wrist joint. A fasciotomy on the forearm was carried out in addition. f, g) After consolidation of the soft tissue, the external fixator was removed 3 weeks after the trauma and movement commenced on a CPM (continuous passive motion) machine. In addition, a palmar plate osteosynthesis was carried out on the distal radius fracture. The MCL was stable, and complete mobility was possible without any tendency toward dislocation. A hinged brace was worn for 6 weeks. The periarticular ossification prophylaxis was commenced with on the day of the accident.
arc of motion (60° of flexion to full flexion) cannot be achieved after treating the fractures, the ligaments need to be reattached or reconstructed. The use of a hinged brace or hinged external fixator may also be indicated in order to allow function of the elbow to be regained in subsequent treatment, which is the basis for a satisfactory result. Coronoid Fractures Coronoid fractures are the most common bone injuries in a complex dislocation. The coronoid process of the ulna is an important joint stabilizer. Many clinical and experimental studies have underscored the importance of fixing large coronoid fractures in the case of elbow dislocations [41, 43, 44]. By the same token, the contour and size of the coronoid contributes to the stability of the ulnohumeral joint [2]. In addition, the anterior part of the MCL inserts onto the medial aspect of the coronoid process. As a result, fractures or avulsion injuries to the
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coronoid may potentially lead to a dissociation of the MCL and the anterior capsule of the ulna and thus destabilize the joint. In the case of smaller fractures, there is generally sufficient stability if the MCL is not affected, making surgery unnecessary. In the case of larger fragments of the coronoid, sufficient stability depends on the involvement of ligamentous structures, which are attached to the coronoid, and possibly affect the radial head. In both cases there may be a tendency toward instability with dislocation, indicating surgical therapy. Non-dislocated fractures, on the other hand, are treated conservatively if the joint is stable. All dislocated fractures are treated surgically to stabilize the joint and make movement possible in a functional manner as soon as possible. Radial Head Fractures The therapy for radial head fractures is based on the usual criteria of Mason et al. [1, 39, 45–47]. In the case
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of complex fractures of the radial head, it should be attempted to retain the radial head, as it is an important stabilizer of the elbow. In the further therapy, the maintenance of the radial head should be assigned top priority in order to ensure the stability of the elbow joint. Experimental studies have demonstrated that the radial head, in particular in the case of injuries to the MCL, is an important stabilizer when valgus stress is present [48]. Hence, when there is at the same time an MCL rupture, excising the radial head without any replacement is contraindicated. With this type of injury constellation, we recommend that the radial head be replaced by prosthesis. If need be, the MCL can be reattached or reconstructed at the same time. The reconstruction or replacement of the radial head moreover prevents later longitudinal radioulnar dissociation [21, 49, 50]. In any case the distal radioulnar joint should be examined to determine whether there is any pain or swelling to rule out the presence of an Essex–Lopresti injury, which leads to a proximal migration of the radius [19, 51].
The Terrible Triad of the Elbow One extreme form is the ‘‘terrible triad of the elbow’’ described by Hotchkiss. Here a dislocation of the elbow is accompanied both by a fracture of the radial head, a fracture of the coronoid process and a rupture of the lateral ulnar collateral ligament (LUCL). The term ‘‘terrible’’ is used owing to the fact that this injury constellation usually occurs among active, young persons and is accompanied by a high risk of persistent instability, stiffness, arthrosis, non-union, and malunion [39]. In the few publications to date, end results have tended to be poor, especially in comparison to simple dislocations [41, 52]. Ultimately, the only alternative is to attempt to restore all fractures and ligamentous injuries as effectively as possible, possibly using a radial head prosthesis [38]. The treatment of this complex injury constellation remains difficult, and even with optimal treatment, persistent instabilities and the additional corrective surgery accompanying these can be expected [8, 38]. In this case as well, early functional treatment using a hinged external fixator is warranted [38].
Figures 4a to 4i. a–c) Complex elbow dislocation suffered by a 62-year-old patient when she fell in her home. She suffered a dislocated radial neck fracture, a torn coronoid process and the MCL was completely torn off of the bone. d, e) The first step after closed reduction was fixation of the elbow by use of an external fixator in the face of massive soft tissue swelling and considerable instability of the humeroulnar joint with a tendency toward dorsal dislocation. f, g) Definitive treatment was performed after 10 days through a resection of the radial head and refixation of the front capsule and the coronoid process by means of a transossary suture. Additional implantation of a radial head prosthesis and refixation of the MCL with a titanium anchor. h, i) Early functional treatment using a hinged brace for 6 weeks. One year after the operation patient exhibits extension/flexion of 0°–20°–140° with free pronation/supination and a stable elbow joint. The periarticular ossification prophylaxis was commenced with on the day of the accident.
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Summary on the Treatment of Complex Dislocations The basic objective is to convert a complex dislocation into a simple dislocation and then to follow the guidelines described in the foregoing to treat the simple dislocation. If the joint remains stable following a closed reduction of the elbow and the secondary injuries to the bone do not require any surgical treatment, an early functional therapy should be initiated as soon as possible. In those cases in which a closed reduction is possible, but the fractures have not been reduced or are unstable, an open reduction and internal fixation of the fractures all the way to a radial head prosthesis are generally recommended (see case 3 Figures 4a–i). In some cases closed reduction is not possible and the direct open reduction including the fixation of the fractures or a radial head prosthesis is necessary. After the reconstruction of the fractures, one should definitely check the stability of the elbow. If there is a stable arc of motion, an early functional therapy in the arc is recommended whenever a hinged external fixator has been used. In the case of unstable joints, it is necessary to repair or reconstruct the injured ligaments. If this does not bring about stability so as to allow a stable arc of motion, a hinged external fixator should be used. The same measures as taken in the case of simple dislocations apply to post-operative rehabilitation and movement (see the algorithm in Figure 5). On the whole, the functional results in the case of complex elbow dislocations are not assessed as being as good as results in the case of simple dislocations [7, 37, 41, 53–56]. There is a greater frequency of flexion contractures, while there is frequently more pain as well. An ulnohumeral arthrosis is not unusual, either, and recurrent dislocations occur among up to 17% of patients [7].
Complications in the Case of Simple and Complex Dislocations Chronic Instabilities These occur much more frequently in the case of complex dislocations than with simple dislocations [8]. If there are symptoms of medial instability, one should consider a reconstruction of the anterior ligament of the MCL. The posterolateral instability represents the most frequent form of chronic instability and is based on an insufficiency of the LCL [38]. In this case, we recommend reconstruction of the LCL complex [52].
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Complex Dislocation
Joint Reducible Stable Fracture
Joint Reducible Unstable or Irreducible Fracture
Joint Irreducible
Open Reduction Joint
ORIF Fractures and / or Radial Head Arthroplasty
ORIF Fractures and / or Radial Head Arthroplasty
Stable Arc 60° Full Flexion No
Yes
Rehab in Stable Arc + / - Extension Block Hinged Brace
Ligament Repair or
Reconstruction
Yes Stable Arc 60° Full Flexion
No
Hinged External Fixator
Rehabilitation
Figure 5. Algorithm for treatment of complex elbow dislocations.
With both forms of instability, follow-up treatment in a hinged external fixator is recommended [1, 41]. Contractures Contractures of the elbow joint can develop both in the case of simple as well as complex dislocations, whereby these are observed more frequently in connection with the latter [38]. As mentioned earlier, early physiotherapeutic movement of the elbow is important in prevention [34, 35, 37, 54]. If contractures nevertheless occur, it is first recommended to adopt a conservative procedure with forced movement. Only if there is no significant improvement in mobility 3 months after the trauma should mobilization in general anesthesia be carried out [38]. If mobility cannot be subsequently ensured for an extension/flexion of 0°–30°–130°, surgical treatment with capsule release or the removal of heterotopic ossifications must be performed. The authors insert a plexus catheter within the framework of an arthrolysis to attain analgesia, which is especially helpful in post-operative in-patient physiotherapeutical exercise treatments.
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Figures 6a to 6o. a–c) A 42-year-old patient suffered a complex elbow dislocation with a torn coronoid process and a radial head fracture after an inline skates accident. After closed reduction the elbow joint was stable. The patient was treated conservatively by immobilizing the elbow for 3 weeks in a dorsal splint. d–k) Although the periarticular ossification prophylaxis was commenced with on the day of the accident, the patient exhibited extensive periarticular ossifications with serious and painful restrictions on movement of his elbow (extension/flexion 0°–40°–80°) 3 months after the accident due to a chronic subluxation of the elbow with remaining instability. l–n) An early open arthrolysis was performed with removal of ossifications. In addition a plexus catheter was inserted to attain analgesia for early physiotherapeutical exercise treatment. o) Because of postoperative elbow instability a hinged external fixator was used for 4 weeks. With continuous physiotherapy the patient exhibited extension/flexion of 0°–10°–110° with free pronation/supination and a stable elbow joint
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Heterotopic Ossification Heterotopic ossifications or periarticular calcifications are present in up to 55% of all elbow dislocations [2]. Although most patients are asymptomatic, especially when there is radiological evidence of calcification of the MCL or LCL, individual cases exhibit serious and painful restrictions on movement. Serious ossifications have particular been described in connection with serious head injuries, third-degree burns and genetic dispositions [1]. Anti-inflammatories are routinely taken for 2 to 3 weeks both in the case of simple and complex dislocations such as, e.g., Indomethacin (25 mg orally 3 times daily) have proven to be effective in preventing this [1, 2]. Renal, gastrointestinal, and hematological complications may occur, however. One alternative is irradiation. When there are significant restrictions on movement and pain and all conservative methods have failed, the only alternative which ultimately remains is a surgical resection of the ossifications around 12 to 18 months after the accident [57] (see case 4 Figures 6a–o). If soft tissue begins to heal naturally, some studies even recommend that this be done earlier, around 6 to 9 months after the trauma [2].
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18. 19.
General Conclusion The basis for successful therapy of elbow dislocations and secondary injuries is the restoration of a stabile joint. This allows early functional follow-up treatment to be initiated. Immobilization, both in the case of conservative and surgical therapy, should not exceed 1 to 2 weeks. Surgical treatment should be performed as quickly as possible. A careful pre-operative analysis of the injury morphology is imperative.
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21. 22.
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Sheps DM, Hildebrand KA, Boorman RS. Simple dislocations of the elbow: evaluation and treatment. Hand Clin 2004;20:389–404. Lill H, Korner J, Rose T, et al. Fracture-dislocations of the elbow joint: strategy for treatment and results. Arch Orthop Trauma Surg 2001;121:31–7. O’Driscoll SW, Morrey BF, Korinek S, et al. Elbow subluxation and dislocation. A spectrum of instability. Clin Orthop Relat Res 1992;280:186–97. Osborne G, Cotterill P. Recurrent dislocation of the elbow. J Bone Joint Surg Br 1966;48:340–6. Sojbjerg JO, Helmig P, Kjaersgaard-Andersen P. Dislocation of the elbow: an experimental study of the ligamentous injuries. Orthopedics 1989;12:461–3. Deutch SR, Olsen BS, Jensen SL, et al. Ligamentous and capsular restraints to experimental posterior elbow joint dislocation. Scand J Med Sci Sports 2003;13:311–6. Deutch SR, Jensen SL, Olsen BS, et al. Elbow joint stability in relation to forced external rotation: an experimental study of the osseous constraint. J Shoulder Elbow Surg 2003;12:287–92. Morrey BF, An KN. Articular and ligamentous contributions to the stability of the elbow joint. Am J Sports Med 1983;11:315–9. Schwab GH, Bennett JB, Woods GW, et al. Biomechanics of elbow instability: the role of the medial collateral ligament. Clin Orthop Relat Res 1980;146:42–52. McKee MD, Schemitsch EH, Sala MJ, et al. The pathoanatomy of lateral ligamentous disruption in complex elbow instability. J Shoulder Elbow Surg 2003;12:391–6. Cohen MS, Hastings H II. Acute elbow dislocation: evaluation and management. J Am Acad Orthop Surg 1998;6:15–23. Jungbluth P, Frangen TM, Arens S, et al. The undiagnosed Essex–Lopresti injury. J Bone Joint Surg Br 2006;88:1629–33. Potter HG, Weiland AJ, Schatz JA, et al. Posterolateral rotatory instability of the elbow: usefulness of MR imaging in diagnosis. Radiology 1997;204:185–9. Hotchkiss RN. Displaced fractures of the radial head: internal fixation or excision?. J Am Acad Orthop Surg 1997;5:1–10. Deml C, Arora R, Oberladstatter J, et al. Functional therapy and the limitations for acute elbow dislocation. Unfallchirurg 2007;110:845–51. Riel KA, Bernett P. Simple elbow dislocation: comparison of long-term results after immobilization and functional treatment. Unfallchirurg 1993;96:529–33. Ross G, McDevitt ER, Chronister R, et al. Treatment of simple elbow dislocation using an immediate motion protocol. Am J Sports Med 1999;27:308–11. Noonan KJ, Blair WF. Chronic median-nerve entrapment after posterior fracture-dislocation of the elbow: a case report. J Bone Joint Surg Am 1995;77:1572–5. Linscheid RL, Wheeler DK. Elbow dislocations. JAMA 1965;194:1171–6. Neviaser JS, Wickstrom JK. Dislocation of the elbow: a retrospective study of 115 patients. South Med J 1977;70:172–3. Durig M, Muller W, Ruedi TP, et al. The operative treatment of elbow dislocation in the adult. J Bone Joint Surg Am 1979;61:239–44. Schippinger G, Seibert FJ, Steinbock J, et al. Management of simple elbow dislocations: does the period of immobilization affect the eventual results?. Langenbecks Arch Surg 1999;384:294–7. Akansel G, Dalbayrak S, Yilmaz M, et al. MRI demonstration of intra-articular median nerve entrapment after elbow dislocation. Skeletal Radiol 2003;32:537–41.
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Borris LC, Lassen MR, Christensen CS. Elbow dislocation in children and adults: a long-term follow-up of conservatively treated patients. Acta Orthop Scand 1987;58:649–51. Maggi G, Del Prete G, Cantagalli S, et al. Pure traumatic dislocation of the elbow. Chir Organi Mov 1992;77:195–8. Josefsson PO, Johnell O, Gentz CF. Long-term sequelae of simple dislocation of the elbow. J Bone Joint Surg Am 1984;66:927–30. Mehlhoff TL, Noble PC, Bennett JB, et al. Simple dislocation of the elbow in the adult. Results after closed treatment. J Bone Joint Surg Am 1988;70:244–9. Protzman RR. Dislocation of the elbow joint. J Bone Joint Surg Am 1978;60:539–41. Conway JE, Jobe FW, Glousman RE, et al. Medial instability of the elbow in throwing athletes: treatment by repair or reconstruction of the ulnar collateral ligament. J Bone Joint Surg Am 1992;74:67–83. Royle SG. Posterior dislocation of the elbow. Clin Orthop Relat Res 1991;269:201–4. Saati AZ, McKee MD. Fracture-dislocation of the elbow: diagnosis, treatment, and prognosis. Hand Clin 2004;20:405–14. Phillips CS, Segalman KA. Diagnosis and treatment of posttraumatic medial and lateral elbow ligament incompetence. Hand Clin 2002;18:149–59. Ring D, Jupiter JB, Simpson NS. Monteggia fractures in adults. J Bone Joint Surg Am 1998;80:1733–44. Cobb TK, Morrey BF. Use of distraction arthroplasty in unstable fracture dislocations of the elbow. Clin Orthop Relat Res 1995;312:201–10. Korner J, Hoffmann A, Rudig L, et al. Monteggia injuries in adults: critical analysis of injury pattern, management, and results. Unfallchirurg 2004;107:1026–40. Regan W, Morrey B. Fractures of the coronoid process of the ulna. J Bone Joint Surg Am 1989;71:1348–54. Selesnick FH, Dolitsky B, Haskell SS. Fracture of the coronoid process requiring open reduction with internal fixation: a case report. J Bone Joint Surg Am 1984;66:1304–6. Frankle MA, Koval KJ, Sanders RW, et al. Radial head fractures associated with elbow dislocations treated by immediate stabilization and early motion. J Shoulder Elbow Surg 1999;8:355–60. Popovic N, Gillet P, Rodriguez A, et al. Fracture of the radial head with associated elbow dislocation: results of treatment
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using a floating radial head prosthesis. J Orthop Trauma 2000;14:171–7. Lill H, Voigt C. Injuries of the elbow joint (quiz 51). Chirurg 2004;75:1037–50. Hotchkiss RN, Weiland AJ. Valgus stability of the elbow. J Orthop Res 1987;5:372–7. Essex-Lopresti P. Fractures of the radial head with distal radioulnar dislocation: report of two cases. J Bone Joint Surg Br 1951;33B:244–7. Sowa DT, Hotchkiss RN, Weiland AJ. Symptomatic proximal translation of the radius following radial head resection. Clin Orthop Relat Res 1995;317:106–13. Jungbluth P, Frangen TM, Muhr G, et al. A primarily overlooked and incorrectly treated Essex-Lopresti injury: what can this lead to?. Arch Orthop Trauma Surg 2008;128:89–95. McKee MD, Bowden SH, King GJ, et al. Management of recurrent: complex instability of the elbow with a hinged external fixator. J Bone Joint Surg Br 1998;80:1031–6. Morrey BF. Acute and chronic instability of the elbow. J Am Acad Orthop Surg 1996;4:117–28. Broberg MA, Morrey BF. Results of treatment of fracture-dislocations of the elbow. Clin Orthop Relat Res 1987;216:109–19. Scharplatz D, Allgower M. Fracture-dislocations of the elbow. Injury 1975;7:143–59. Vichard P, Tropet Y, Dreyfus-Schmidt G, et al. Fractures of the proximal end of the radius associated with other traumatic lesions of the upper limb: a report of seventy-three cases. Ann Chir Main 1988;7:45–53. Summerfield SL, DiGiovanni C, Weiss AP. Heterotopic ossification of the elbow. J Shoulder Elbow Surg 1997;6:321–32.
Address for Correspondence PD Dr. Wolfgang Linhart Department of Trauma and Hand Surgery Heinrich Heine University Hospital Duesseldorf Moorenstr. 5 40225 Duesseldorf Germany Phone (+49/211)8104-410, Fax -902 e-mail: [email protected]
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Focus on Elbow Fractures
Current Concepts: Simple and Complex Elbow Dislocations – Acute and Definitive Treatment Pascal Jungbluth, Mohssen Hakimi, Wolfgang Linhart, Joachim Windolf 1
Abstract Dislocations of the elbow account for 20% of all dislocations. Thus, after the shoulder, the elbow joint is the joint most frequently afflicted by dislocations. A distinction is made between simple elbow dislocations without associated fractures and fracture-dislocations of the elbow, which are frequently referred to as complex elbow dislocations. Treatment principles are reduction of the joint, stabilization of associated fractures, and early motion. Ligament repairs or reconstruction and hinged external fixators are necessary in some cases to restore stability for early motion. In general, simple dislocations have a better prognosis than complex dislocations. Eur J Trauma Emerg Surg 2008;34:120–30 DOI 10.1007/s00068-008-8033-9
Background Dislocations of the elbow account for 20% of all dislocations. After the shoulder, this makes the elbow joint the second-most frequently dislocated joint [1]. A distinction is made between simple dislocations without associated fractures and fracture-dislocations of the elbow, which are frequently also referred to as complex elbow dislocations [2]. The high number of dislocations accounted for by elbow dislocations indicates the great importance of this injury. This article provides a review of the pertinent literature on both forms of dislocations. In this connection, the anatomy of the elbow joint and its stability are described, followed by a discussion of the epidemiology and classification of elbow dislocations. Finally, we provide a discussion on clinical management, including diagnostics, non-operative or operative interventions, prognoses, and rehabilitation. 1
Anatomy The elbow joint is composed of three joints, the humeroulnar, the humeroradial, and the proximal radioulnar joint. As a hinge joint, the humeroulnar joint makes possible one major motion and a high level of congruence, ensuring bony guidance. The trochlear notch of the ulna extends around the trochlea of humerus like a forceps. The humeroradial joint is a ball joint with two principle arcs of motion. Moreover the annular radial ligament provides a narrow ligamentous channel for the radial head to the ulna. Rotating movements of the radius with pronation and supination are possible in the proximal radioulnar joint. This three-part joint complex is surrounded by a common capsule, which is strengthened on the side by the collateral ligaments [the medial collateral ligament (MCL) and the lateral collateral ligament (LCL)]. These are composed of three fan-shaped sub-parts each, which means that in every joint position parts of the collateral ligaments are tensed, contributing to and ensuring stability of the joint.
Epidemiology and Classification Elbow dislocations represent 11–28% of all elbow injuries, with an annual incidence of 6–8 cases per 100,000 people [2]. This classification is based on the direction of the dislocation of the forearm with respect to the humerus [3]. A distinction is made between posterior, posterolateral, posteromedial, anterior, and divergent forms (Table 1), whereby the posterior and posterolateral dislocations, the most frequently encountered types, account for 80–90% [4, 5]. The other forms occur much less frequently, whereby the divergent dislocations, in which the humerus is jammed between the radius and ulna and the interosseous membrane is destroyed, constitutes an absolute rarity
Department of Trauma and Hand Surgery, Heinrich Heine University Hospital Duesseldorf, Moorenstr. 5, 40225 Duesseldorf, Germany.
Received: February 25, 2008; revision accepted: March 17, 2008; Published Online: April 3, 2008
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Table 1. Classification of elbow dislocations. Simple dislocations: soft tissue injuries Anterior Posterior Direct posterior Posterolateral Posteromedial Divergent Complex simple dislocations: bone and soft tissue injuries Anterior Posterior
[6, 7]. Another distinction is made between simple and complex dislocations. In the latter case fractures occur to the distal humerus, the proximal ulna or the proximal radius [8]. By the same token, simple dislocations without any secondary injuries to the bone occur more often than complex dislocations [2]. The latter account for 15–20% of all elbow dislocations [8, 9].
Mechanisms of Injury The type of accident causing a posterior dislocation is a fall on the wrist while the elbow joint is extended and the wrist is pronated. The impact of the tip of the olecranon on the olecranon fossa has a leverage effect as a result of the combination of valgus-, supinationand outward rotating position of the forearm, while the coronoid process slips in a dorsal direction over the trochlea of humerus [10–12]. When a person falls on his/her hand with a flexed elbow joint, the force acting in a direct axial direction causes the olecranon to slip out [13, 14]. An anterior dislocation, which occurs much less frequently, only comes about through a combination between a flexed elbow and a force acting dorsally. On the one hand, the osseous structures are responsible for guiding the elbow joint, while on the other hand the collateral ligaments, the joint capsule and the muscular soft tissue sheath are important stabilizers for the elbow. Especially, injuries to the anterior medial collateral ligament (AMCL) are a subject of controversy. This is characterized by many authors as one of the most important joint stabilizers of the elbow joint [15, 16]. In this regard O’Driscoll et al. [10] have been able to use biomechanical studies to devise a circle strategy for the sequence of injuries to soft tissue with respect to a simple posterior dislocation. As a result of the combined force emanating from axial compression, varus stress and the impact of various rotation
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components, a force is generated which flows from lateral to medial. In almost every case this leads to a rupture of the LCL. In declining order, the anterior and posterior capsule, and last of all the MCL are involved [17]. It is necessary for oligamentous capsule structures to be torn in the dislocation for the circle strategy developed by O’Driscoll [10] to be applied. Complex dislocations, on the other hand, have not been examined biomechanically thus far. Simple or complex injuries to elbows can, however, also occur in connection with trauma caused by accidents involving high energies such as motor vehicle collisions or in other situations where high levels of trauma-inducing forces occur. Complex types of dislocations are usually the result in these cases.
Clinical Evaluation The clinical analysis of the elbow affected is first performed to determine deformities and open injuries. Although neurovascular injuries are rare [8], it is first of all important to examine the blood circulation, motor function, and sensitivity prior to any manipulation. In particular, the status of the median nerve, the ulnar nerve and the brachial artery is to be determined, as these are most frequently affected, and moreover can be injured in the first place through the manipulation in the examination [8]. The ipsilateral shoulder and the ipsilateral wrist of the injured person should also be examined to determine if there are any secondary injuries. An evaluation of the ipsilateral distal radioulnar joint and the interosseous membrane for the presence of an Essex– Lopresti injury would also appear to be of importance [18, 19]. Clinically, a marked swelling often stands out as an indication of massive injury to soft tissue in a dislocation injury. Of special relevance in this connection is ruling out a compartment syndrome, which is already present from the start in rare cases. It usually occurs later, however, which means that a close monitoring of the neurovascular status should routinely be carried out during the first hours [10]. In addition to the evaluation of associated fractures, an examination of stability and tendency toward re-dislocation are crucial aspects of further treatment. To this end, the stability of the collateral ligaments should be checked in full extension and 20° of flexion, while the pivot-shift test should be performed to determine whether there is a tendency toward subluxation [10]. Some patients arrive in emergency rooms with joints, which have already been spontaneously reduced.
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In such cases, the diagnosis is derived from the case history and any possible instability, which may be present. Diagnostic Imaging In addition to conventional radiographs, additional diagnostic possibilities are available in the form of computed tomography (CT) and magnetic resonance imaging (MRI). Conventional plain anteroposterior and lateral radiographs should be made relatively quickly before much time passes prior to reduction. Should the findings be indeterminate, oblique views may facilitate a better assessment of the coronoid process and the radial head [2, 18]. Depending on the symptoms and pain experienced, radiographs should also be made of the adjacent joints. In assessing complex dislocations, the execution of a CT is the gold standard [8]. This is primarily aimed at supporting the planning of an operation [2, 18]. Because the MRI only plays a limited role in the evaluation of acute elbow dislocations, it is therefore warranted more in the case of chronic instability [2, 20]. If there is a suspicion that the interosseous membrane has been injured, especially if the radial head has been injured at the same time, it may, however, play a crucial diagnostic role [21].
Management: General Principles The objective in treatment should always be an anatomical and stable reduction of the elbow to ensure movement without any functional restrictions or pain over the long term. Open wounds must be treated immediately. The treatment of simple and complex elbow dislocations is discussed separately in the following.
Simple Dislocations Conservative Therapy A crucial factor in the case of simple dislocations is a reduction of the elbow joint early on [2, 22]. It is necessary to examine carefully the neurovascular status prior to any reduction. The reduction maneuver generally does not require general anesthesia and can instead be performed with mild intravenous sedation. Ideally, the reduction maneuver should take place in the operating room, as it is easier to monitor things here if general anesthesia is used and muscle relaxation is necessary [2, 18]. In everyday clinical work, however, the reduction is performed in the emergency room for logistical reasons [2, 8].
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Various reduction maneuvers are described in the literature [21]. The technique we use in the reduction of the posterior dislocation is carried on with one assistant with the patient lying down. The first important step is to carefully pull the longitudinal humerus axis in order to free the coronoid process from the olecranon fossa. While an assistant is holding the patient, the physician then pulls in the anterior direction of the forearm while the elbow is slightly flexed. After the reduction has been successfully performed, the arm should be fixated with the elbow flexed in a 90° position and the forearm in a neutral position with respect to pronation/ supination. Then an examination of elbow stability is obligatory. If possible, this should be carried out using an image intensifier. The examination concentrates on translation stress with the elbow in 30° of flexion and valgus and varus stress with the elbow in 20° of flexion. Other authors describe the stability examination in an even more differentiated manner [2]. The elbow joint is extended and flexed completely. A so-called stable arc of motion is only attained when the elbow joint remains reduced in a range from at least 60° of flexion to full flexion. After determining the neurological status once again, the arm is immobilized in a dorsal forearm plaster splint with the elbow in 90° of flexion and the forearm placed in a neutral position with respect to pronation/supination. It is also important to produce plain anteroposterior and lateral radiographs following reduction in order to discover any incorrect subluxation positions owing to possible interpositioning of soft tissue [22]. If the ligaments do not exhibit any instability and there are no other indications warranting operation, the elbow is immobilized by us for a maximum of 2 weeks in the dorsal splint or orthesis at 90° and in a neutral position. The physiotherapy should be performed with active and passive movement exercises after the end of the first week out of the splint without limiting the degree of movement. The splint is removed by us at the end of the second week (see case 1, Figures 1a–e). As a result of this treatment, the elbow can also be used for sporting activities after only 3 months [6, 23]. Repeat radiographs should then be performed after 3–5 days. Then, a follow-up check-up is to be performed in addition 2 weeks later and radiological controls are recommended [2, 18, 24]. The treatment of the rare anterior and divergent dislocations is performed in a similar manner. Here it is
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Figures 1a to 1e. a, b) A 37-year-old patient with a spontaneously reduced, simple elbow dislocation suffered in a bicycle accident on his way to work. At first, radiographs showed a limitation of movement due to pain without any other serious injuries. c) A torn LCL was diagnosed in the MRI. d, e) The elbow was immobilized for 2 weeks in a dorsal splint at 90° of flexion and in a neutral position with respect to pronation/ supination. Early physiotherapy was performed with active and passive movement exercises after the end of the first week out of the splint. Four weeks after the accident patient exhibits extension/flexion of 0°–0°–110° with free pronation/supination and a stable elbow joint.
a good idea, however, to carry out the reduction maneuver using a general anesthesia and muscle relaxation in the operating room, as these forms of dislocations are usually associated with trauma from accidents involving high energies, where experience has shown difficulties to occur more frequently in the reduction, often making an open reduction necessary [2, 8]. If the elbow joint is stable after the reduction, then further therapy is conducted along the same lines as for a posterior dislocation. Surgical Treatment There are only very few indications for surgical treatment for acute, simple elbow dislocations. Irreducible dislocations are very rare and are usually caused secondarily by entrapped osteochondral fragments or soft tissue. These are an indication for an operation [8]. This especially applies to medial instabilities resulting from injuries to the MCL. In this case it is necessary to reattach or reconstruct the MCL. Subacute or chronic dislocations also require an open reduction. In the case of elbow dislocations which require open surgery, a repair or reconstruction of the ligaments should generally be performed to allow functional use as early as possible. The authors reattach the ligaments using titanium anchors.
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In the case of a dislocation tendency when flexing 60° and more, surgical reconstruction or reattachment of the ligaments is generally recommended, as in this constellation it is not possible to use the joint early on without dislocating it and immobilization for a lengthy period means considerable restrictions in mobility [2, 18, 22]. Nevertheless, instabilities resulting from ruptures of the collateral ligaments do not rule out a conservative therapy, as one can expect a high rate of spontaneous healing to occur when using functional therapies. In such cases, it is advisable to immobilize the joint in a dorsal plaster splint or orthesis with the elbow in 90° of flexion and neutral position of the forearm for a maximum of 1 week. Further treatment applying physiotherapy exercises should then be performed on a movement scale for extension/flexion of 0°/20°/130° for a total of 3 weeks followed by an increase in extension. In this case, the patient cannot engage in athletic activities for a period of 6 months [9]. In the case of neurovascular injuries or a compartment syndrome, on the other hand, immediate surgery is necessary [10, 25]. Further treatment following surgical reconstruction or reattachment of the ligaments is performed as follows:
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If the reduction proves to be stable after the surgical operation, a hinged brace should be used, possibly with an extension block. If on the other hand the situation following surgery is unstable, a hinged external fixator is advisable, as this allows movement early on while helping to prevent a re-dislocation [2, 18]. In general, physiotherapy should be commenced with as soon as possible after the operation [3, 24, 26, 27]. Both hinged brace and hinged external fixator should be used for a maximum of 6 weeks in the case of reattachment or 8 weeks if the ligaments are reconstructed [8]. An extension block should be removed after 4–6 weeks [10, 18, 24]. Figure 2 shows the treatment algorithm in the case of a simple dislocation. The prognosis following a simple elbow dislocation is generally good [3, 6, 24, 26–32]. Re-dislocations or instabilities are rare. More than 95% of patients return to their previous occupation [6, 33, 34]. More than 50% of patients nevertheless report that their elbow is no longer like it was before the accident or like the elbow on the opposite site [8]. A loss of extension of 10°–20° is described relatively frequently [3, 10, 28, 32]. These vary considerably, however, depending upon the period of immobilization. When immobilizations Simple Dislocation
Reducible Stable
Reducible Unstable
Rehabilitation No Motion Restrictons
Irreducible
Stable Arc of Motion 60° to Full Flexion
Yes
Supervised Rehabilitation in Stable Arc in Hinged Brace ± Extension Block (Forearm Positioned for Stability)
Yes
Supervised Rehabilitation in Stable Arc in Hinged Brace ± Extension Block (Forearm Positioned for Stability)
Open Reduction
Conclusion Surgery is only clearly indicated when the elbow only becomes stable with less than 60° of flexion or if it is not possible to reduce it anatomically or if there are neurovascular injuries. (see case 2, Figures 3a–g).
No
Ligament Repair or Reconstruction
Stable Arc of Motion 60° to Full Flexion
No
Hinged External Fixator Supervised Rehabilitation
Figure 2. Algorithm for treatment of simple elbow dislocations.
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are less than 1 week, these are generally below 10° [6, 24, 29, 33, 35]. Loss of flexion is virtually nil here [24, 29, 35]. The mobility of the forearm is rarely affected as well [6, 24, 29, 33, 35]. Persistent pain rarely occurs later on, and when it occurs, it is usually mild [29]. The same applies to persistent neurological deficits [3, 10, 28, 32, 36]. In most cases radiographic abnormalities crop up in the long-term follow-up. These are usually low-level, however [6, 27, 33–35, 37]. These generally involve, as it were, heterotopic ossifications of the collateral ligaments and the anterior capsule among up to 95% of the patients [33]. These result in restrictions of movement in less than 5% of cases. Most follow-up studies do not show any correlation between the presence of heterotopic ossifications and restrictions of movement [3, 6, 18, 24, 27, 29, 33, 34]. Arthrotic changes are reported in up to 40% of the follow-up studies, although these are usually only mild [6, 27, 33–35, 37]. The consensus in the literature regarding the treatment of simple elbow relocations tends more in the direction of a non-operative approach and an early functional treatment. Examinations and results produced by Joseffsson et al. [6] within the framework of a retrospective cohort study and a randomized clinical study have even been able to demonstrate that in functional terms no better results could be reached for patients with a simple posterior or posterolateral dislocation who underwent surgical treatment than patients who underwent a conservative therapy.
Complex Dislocations Complex dislocations of the elbow usually exhibit injuries to both ligaments and bones, and usually involve articular surfaces. These constellations of injury lead to instability of the elbow [38]. The most frequent fractures in the case of complex dislocations are to be found in the area of the coronoid process and the radial head [2, 39]. Fractures of the proximal ulna and Monteggia-like lesions are furthermore observed [1, 7, 38–42]. The treatment principles of complex dislocations involve reduction of the dislocation and treatment of the fracture, on the basis of its own merits. If a stable
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Figures 3a to 3g. a–c) 22-year-old patient who fell from a scaffold at a building site with subtotal amputation of the elbow, complete disruption of the brachial artery and compartment syndrome on the forearm. In addition the patient had a fracture of the distal radius. d, e) Primary reduction of the elbow and the distal radius, reconstruction of the brachial artery with interposition vein graft and external fixator on the elbow joint and the wrist joint. A fasciotomy on the forearm was carried out in addition. f, g) After consolidation of the soft tissue, the external fixator was removed 3 weeks after the trauma and movement commenced on a CPM (continuous passive motion) machine. In addition, a palmar plate osteosynthesis was carried out on the distal radius fracture. The MCL was stable, and complete mobility was possible without any tendency toward dislocation. A hinged brace was worn for 6 weeks. The periarticular ossification prophylaxis was commenced with on the day of the accident.
arc of motion (60° of flexion to full flexion) cannot be achieved after treating the fractures, the ligaments need to be reattached or reconstructed. The use of a hinged brace or hinged external fixator may also be indicated in order to allow function of the elbow to be regained in subsequent treatment, which is the basis for a satisfactory result. Coronoid Fractures Coronoid fractures are the most common bone injuries in a complex dislocation. The coronoid process of the ulna is an important joint stabilizer. Many clinical and experimental studies have underscored the importance of fixing large coronoid fractures in the case of elbow dislocations [41, 43, 44]. By the same token, the contour and size of the coronoid contributes to the stability of the ulnohumeral joint [2]. In addition, the anterior part of the MCL inserts onto the medial aspect of the coronoid process. As a result, fractures or avulsion injuries to the
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coronoid may potentially lead to a dissociation of the MCL and the anterior capsule of the ulna and thus destabilize the joint. In the case of smaller fractures, there is generally sufficient stability if the MCL is not affected, making surgery unnecessary. In the case of larger fragments of the coronoid, sufficient stability depends on the involvement of ligamentous structures, which are attached to the coronoid, and possibly affect the radial head. In both cases there may be a tendency toward instability with dislocation, indicating surgical therapy. Non-dislocated fractures, on the other hand, are treated conservatively if the joint is stable. All dislocated fractures are treated surgically to stabilize the joint and make movement possible in a functional manner as soon as possible. Radial Head Fractures The therapy for radial head fractures is based on the usual criteria of Mason et al. [1, 39, 45–47]. In the case
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of complex fractures of the radial head, it should be attempted to retain the radial head, as it is an important stabilizer of the elbow. In the further therapy, the maintenance of the radial head should be assigned top priority in order to ensure the stability of the elbow joint. Experimental studies have demonstrated that the radial head, in particular in the case of injuries to the MCL, is an important stabilizer when valgus stress is present [48]. Hence, when there is at the same time an MCL rupture, excising the radial head without any replacement is contraindicated. With this type of injury constellation, we recommend that the radial head be replaced by prosthesis. If need be, the MCL can be reattached or reconstructed at the same time. The reconstruction or replacement of the radial head moreover prevents later longitudinal radioulnar dissociation [21, 49, 50]. In any case the distal radioulnar joint should be examined to determine whether there is any pain or swelling to rule out the presence of an Essex–Lopresti injury, which leads to a proximal migration of the radius [19, 51].
The Terrible Triad of the Elbow One extreme form is the ‘‘terrible triad of the elbow’’ described by Hotchkiss. Here a dislocation of the elbow is accompanied both by a fracture of the radial head, a fracture of the coronoid process and a rupture of the lateral ulnar collateral ligament (LUCL). The term ‘‘terrible’’ is used owing to the fact that this injury constellation usually occurs among active, young persons and is accompanied by a high risk of persistent instability, stiffness, arthrosis, non-union, and malunion [39]. In the few publications to date, end results have tended to be poor, especially in comparison to simple dislocations [41, 52]. Ultimately, the only alternative is to attempt to restore all fractures and ligamentous injuries as effectively as possible, possibly using a radial head prosthesis [38]. The treatment of this complex injury constellation remains difficult, and even with optimal treatment, persistent instabilities and the additional corrective surgery accompanying these can be expected [8, 38]. In this case as well, early functional treatment using a hinged external fixator is warranted [38].
Figures 4a to 4i. a–c) Complex elbow dislocation suffered by a 62-year-old patient when she fell in her home. She suffered a dislocated radial neck fracture, a torn coronoid process and the MCL was completely torn off of the bone. d, e) The first step after closed reduction was fixation of the elbow by use of an external fixator in the face of massive soft tissue swelling and considerable instability of the humeroulnar joint with a tendency toward dorsal dislocation. f, g) Definitive treatment was performed after 10 days through a resection of the radial head and refixation of the front capsule and the coronoid process by means of a transossary suture. Additional implantation of a radial head prosthesis and refixation of the MCL with a titanium anchor. h, i) Early functional treatment using a hinged brace for 6 weeks. One year after the operation patient exhibits extension/flexion of 0°–20°–140° with free pronation/supination and a stable elbow joint. The periarticular ossification prophylaxis was commenced with on the day of the accident.
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Summary on the Treatment of Complex Dislocations The basic objective is to convert a complex dislocation into a simple dislocation and then to follow the guidelines described in the foregoing to treat the simple dislocation. If the joint remains stable following a closed reduction of the elbow and the secondary injuries to the bone do not require any surgical treatment, an early functional therapy should be initiated as soon as possible. In those cases in which a closed reduction is possible, but the fractures have not been reduced or are unstable, an open reduction and internal fixation of the fractures all the way to a radial head prosthesis are generally recommended (see case 3 Figures 4a–i). In some cases closed reduction is not possible and the direct open reduction including the fixation of the fractures or a radial head prosthesis is necessary. After the reconstruction of the fractures, one should definitely check the stability of the elbow. If there is a stable arc of motion, an early functional therapy in the arc is recommended whenever a hinged external fixator has been used. In the case of unstable joints, it is necessary to repair or reconstruct the injured ligaments. If this does not bring about stability so as to allow a stable arc of motion, a hinged external fixator should be used. The same measures as taken in the case of simple dislocations apply to post-operative rehabilitation and movement (see the algorithm in Figure 5). On the whole, the functional results in the case of complex elbow dislocations are not assessed as being as good as results in the case of simple dislocations [7, 37, 41, 53–56]. There is a greater frequency of flexion contractures, while there is frequently more pain as well. An ulnohumeral arthrosis is not unusual, either, and recurrent dislocations occur among up to 17% of patients [7].
Complications in the Case of Simple and Complex Dislocations Chronic Instabilities These occur much more frequently in the case of complex dislocations than with simple dislocations [8]. If there are symptoms of medial instability, one should consider a reconstruction of the anterior ligament of the MCL. The posterolateral instability represents the most frequent form of chronic instability and is based on an insufficiency of the LCL [38]. In this case, we recommend reconstruction of the LCL complex [52].
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Complex Dislocation
Joint Reducible Stable Fracture
Joint Reducible Unstable or Irreducible Fracture
Joint Irreducible
Open Reduction Joint
ORIF Fractures and / or Radial Head Arthroplasty
ORIF Fractures and / or Radial Head Arthroplasty
Stable Arc 60° Full Flexion No
Yes
Rehab in Stable Arc + / - Extension Block Hinged Brace
Ligament Repair or
Reconstruction
Yes Stable Arc 60° Full Flexion
No
Hinged External Fixator
Rehabilitation
Figure 5. Algorithm for treatment of complex elbow dislocations.
With both forms of instability, follow-up treatment in a hinged external fixator is recommended [1, 41]. Contractures Contractures of the elbow joint can develop both in the case of simple as well as complex dislocations, whereby these are observed more frequently in connection with the latter [38]. As mentioned earlier, early physiotherapeutic movement of the elbow is important in prevention [34, 35, 37, 54]. If contractures nevertheless occur, it is first recommended to adopt a conservative procedure with forced movement. Only if there is no significant improvement in mobility 3 months after the trauma should mobilization in general anesthesia be carried out [38]. If mobility cannot be subsequently ensured for an extension/flexion of 0°–30°–130°, surgical treatment with capsule release or the removal of heterotopic ossifications must be performed. The authors insert a plexus catheter within the framework of an arthrolysis to attain analgesia, which is especially helpful in post-operative in-patient physiotherapeutical exercise treatments.
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Figures 6a to 6o. a–c) A 42-year-old patient suffered a complex elbow dislocation with a torn coronoid process and a radial head fracture after an inline skates accident. After closed reduction the elbow joint was stable. The patient was treated conservatively by immobilizing the elbow for 3 weeks in a dorsal splint. d–k) Although the periarticular ossification prophylaxis was commenced with on the day of the accident, the patient exhibited extensive periarticular ossifications with serious and painful restrictions on movement of his elbow (extension/flexion 0°–40°–80°) 3 months after the accident due to a chronic subluxation of the elbow with remaining instability. l–n) An early open arthrolysis was performed with removal of ossifications. In addition a plexus catheter was inserted to attain analgesia for early physiotherapeutical exercise treatment. o) Because of postoperative elbow instability a hinged external fixator was used for 4 weeks. With continuous physiotherapy the patient exhibited extension/flexion of 0°–10°–110° with free pronation/supination and a stable elbow joint
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Heterotopic Ossification Heterotopic ossifications or periarticular calcifications are present in up to 55% of all elbow dislocations [2]. Although most patients are asymptomatic, especially when there is radiological evidence of calcification of the MCL or LCL, individual cases exhibit serious and painful restrictions on movement. Serious ossifications have particular been described in connection with serious head injuries, third-degree burns and genetic dispositions [1]. Anti-inflammatories are routinely taken for 2 to 3 weeks both in the case of simple and complex dislocations such as, e.g., Indomethacin (25 mg orally 3 times daily) have proven to be effective in preventing this [1, 2]. Renal, gastrointestinal, and hematological complications may occur, however. One alternative is irradiation. When there are significant restrictions on movement and pain and all conservative methods have failed, the only alternative which ultimately remains is a surgical resection of the ossifications around 12 to 18 months after the accident [57] (see case 4 Figures 6a–o). If soft tissue begins to heal naturally, some studies even recommend that this be done earlier, around 6 to 9 months after the trauma [2].
8. 9.
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11. 12.
13.
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15. 16.
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18. 19.
General Conclusion The basis for successful therapy of elbow dislocations and secondary injuries is the restoration of a stabile joint. This allows early functional follow-up treatment to be initiated. Immobilization, both in the case of conservative and surgical therapy, should not exceed 1 to 2 weeks. Surgical treatment should be performed as quickly as possible. A careful pre-operative analysis of the injury morphology is imperative.
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Address for Correspondence PD Dr. Wolfgang Linhart Department of Trauma and Hand Surgery Heinrich Heine University Hospital Duesseldorf Moorenstr. 5 40225 Duesseldorf Germany Phone (+49/211)8104-410, Fax -902 e-mail: [email protected]
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