Open reduction for late-presenting posterior dislocation of the elbow

Journal of Orthopaedic Surgery, Apr 2007 by Mehta, S, Sud, A, Tiwari, A, Kapoor, S K

ABSTRACT

Purpose. To evaluate results of open reduction for late-presenting (more than 3 weeks) posterior dislocation of the elbow in 10 patients.

Method. Elbow stiffness was the main indication for surgery. The mean age of the patients was 34 (range, 13-65) years; the mean time since injury was 4 (range, 2-6) months. All patients had non-functional elbow movement for any activity of daily living. Three patients had associated fractures around the elbow joint.

Results. At a mean follow-up of 19 (range, 11-28) months, 8 patients regained a functional range of movement for activities of daily living and maintained a median arc of flexion of 100 degrees and a supination-pronation arc of 140 degrees. According to the Mayo Elbow Performance Index, the results of 5 patients were excellent, 3 were good, and 2 were poor. Complications included pin site infection (n=2), ulnar neuritis (n=1), and delayed wound healing (n=1).

Conclusion. In patients with late-presenting, unreduced elbow dislocation occurring up to 6 months earlier, open reduction is effective in restoring the joint to a painless, stable and functional state.

Key words: dislocations; elbow

INTRODUCTION

Late-presenting, unreduced posterior dislocation of the elbow is a challenge for surgeons. Due to misconceptions and ignorance, many patients go to local bonesetters for traditional treatment such as massage and manipulation, which only aggravates the problem. 'Unreduced' is defined as those posterior elbow dislocations not treated within 3 weeks of injury.1-3 These elbows are fixed in either extension or flexion with only a few degrees of flexion, supination, and pronation, and have a non-functional range of movement for activities of daily living.2,4

The time since injury and patient age determine the mode of treatment.3,5 Most authorities recommend open reduction for late-presenting cases (up to 3 months after injury).1,6,7 The likelihood of restoring useful function of the elbow by open reduction alone is inversely proportional to the time since injury.7 Total elbow arthroplasty, excisional arthroplasty or arthrodesis is advised for cases presenting after 3 months,1,8,9 though there are no clear-cut treatment guidelines for such cases. We treated 10 patients with unreduced posterior dislocation of the elbow using open reduction, regardless of the time since injury or the age of the patient.

MATERIALS AND METHODS

Between the period October 1999 and October 2002 inclusive, 7 men and 3 women aged 13 to 65 (mean, 34) years were treated at our institute for unreduced posterior dislocation of the elbow. The time since injury ranged from 2 to 6 (mean, 4) months. The numbers of dominant or non-dominant elbows involved were equal. Six patients were initially treated with massage by local bonesetters. Elbow stiffness was the main indication for surgery. Four patients had no pain in the elbow, 3 had mild pain and occasionally used analgesics, and 3 had moderate pain and regularly used analgesics. All patients had an anteriorly prominent distal humerus. The olecranon was prominent and the shortened triceps was seen tenting on the posterior aspect of the elbow. The 3-point relationship of the tip of the olecranon, medial and lateral epicondyles was disturbed and the joint was tender. The elbow was stable in 4 patients and moderately stable in 6. The active range of flexion, extension, pronation, and supination were measured using a handheld goniometer. The joints were fixed in either extension or flexion with only a few degrees of flexion (Table). All patients had non-functional elbow movement preoperatively.2,4 Hypoaesthesia of the hand over the ulnar nerve was present in 2 patients. Dislocation was posterolateral in 7 patients and posteromedial in 3.

The patient was positioned laterally with the elbow flexed at 90° on a sandbag. A pneumatic tourniquet was applied high up. Speed's procedure for open reduction was used.1 Dense fibrous tissue filled up the olecranon, coronoid fossae, and the radial head, whilst the collateral ligaments were contracted (Fig. 1). The cartilage came off the bone easily so the fibrous tissue was carefully excised to avoid peeling off of the underlying cartilage. The ulnar nerve was under tension in 4 cases including the 2 with hypoaesthesia of the hand. The contracted capsule and collateral ligaments were cut. The shortened triceps bound down by fibrous tissue to the humerus was incised to expose the joint surfaces. Well-preserved articular surfaces were seen in all. Subperiosteal new bone formation was seen on the anterior aspect of the elbow in one patient and in another it was on the posterior aspect (and was therefore removed to facilitate reduction). Radiocapitellar and ulnotrochlear reduction was achieved by manipulation.

Three patients had associated fractures around the elbow. One had a 4-month-old malunited medial condyle fracture, which was left untreated. Another with a 3-month-old dislocation had a fracture of the radial head, which was excised and the olecranon reduced. The third was treated in another hospital for radial head and ulnar shaft fractures; the radial head was excised and the ulna plated. The patient subsequently dislocated his elbow inside the splint. The latter injury was undetected due to lack of followup in that hospital. This patient was treated with open reduction and Kirschner wire fixation 4 months post dislocation.