Management of Complex elbow dislocations
Management of Complex elbow dislocations
Elbow dislocation can be partial or complete. It generally occurs after trauma.: A motor vehicle accident, or a fall or even occasionally in violent sports like wrestling. The joint surfaces lose their contact with each other and the dislocation is seen partially when part of the joint is dislocated or totally when all the joints are dislocated. A partial dislocation is called a subluxation.
Three bones form the elbow joint: the end portion of the humerus (arm) and both bones of the forearm, radius and the ulna.
The elbow is a hinge joint as well as a ball and socket joint on which the muscles impose a range of motion when they contract or relax allowing flexion, extension and rotation. A hinge joint allows bending and extension while a ball and socket joint allow the forearm to pronate and supinate to facilitate the hand to palm up or down. Dislocations can affect either motion of the elbow included the ability to bring the hand to the mouth, essential function of the daily living activity. Let us review a little this complexed anatomy:
The ligaments around the elbow are important for its good functioning: the inner side with the Medial Collateral Ligament (MCL) and the lateral side with the Lateral collateral Ligament (LCL) assuring a medial or a lateral stability.
An elbow dislocation is not a common event. I have seen them with a fall especially when an individual fall down onto an outstretched hand. The impact with the ground carries the force to the elbow and result into a dislocation or a fracture with a turning motion forcing the elbow out of socket. Many victims of car accidents may present with such an injury especially when passengers brace for the impact.
Once a dislocation occurs, any of the structures can be injured. A simple dislocation does not have any major bone injury but a complex dislocation has severe bone and ligamentous injuries. In more severe dislocations, arteries, veins and nerves can be injured, carrying the risk of losing the extremity. Some individuals are born with ligamentous laxity while others may be born with a shallow groove at the elbow hinge joint exhibiting a higher risk for dislocation.
Let us show 3 images for the understanding of the definition of a Dislocation and a subluxation of an elbow joint:
Posterior elbow dislocation
Post reduction elbow dislocation
Partial elbow dislocation (subluxation).
A partial elbow dislocation or subluxation is more subtle and can be difficult to detect. The joint may appear normal in appearance or spontaneously relocate while the joint appears fairly normal and the elbow can still move fairly well with pain. There may be bruising around the elbow as the ligament medially or laterally may be stretched or torn. A partial dislocation will continue to recur if left untreated.
At physical examination, the clinician should look for an obvious deformity, swelling, ecchymosis and pain or even bony crepitation. Pulse should be checked at the wrist as an evaluation for vascular injury in which case the hand can be cool to touch or discolored purple or white.
Nerve injury may be possible as well and the sensation should be recorded while X-rays are ordered for bony evaluation. Regular X-Rays or even CT scan or MRI may be necessary to evaluate bony or ligamentous injuries. Often the orthopedist may choose to perform the reduction prior to take any radiographic studies to check on the alignment.
A simple dislocation may be splinted after the reduction and an early mobilization is generally desired to avoid any stiffness. Active range of motion is preferable as soon as the patient become comfortable or a short period of immobilization in a splint can facilitate the scarring of the joint capsule and the return to a normal activity. Physical therapy may be needed in extreme cases. Often some patients may lose 5 to 10 degrees of extension after recovery from a dislocated elbow.
When we deal with a complex dislocation there is always a loss of joint alignment with ligamentous instability and bony fractures which need to be given attention in order to restore the joint line. A surgical treatment is generally the only solution. We will review closer some of the useful techniques of repair and reconstruction. We may opt after surgical treatment to look for additional support with the wear of a brace preventing further dislocations while the fractures and ligaments are healing. An example in this case can be of an elbow dislocated with communitive fractures of the olecranon process and proximal ulna as well as fractures of the radial head and the distal end of the humerus as shown on our next radiographic image.
Complex fracture elbow dislocation
Complex elbow fracture dislocations are definitively injuries which present a challenge for the orthopedist. They may result in significant disability as well as in chronic instability, post traumatic arthritis but most commonly a poor functional outcome. It is important for us, orthopedists to restore the integrity of the joint and provide stability through an early rehabilitation.
In most of complex elbow fracture dislocation, different surgical management can be available for the best outcome through a good understanding of the biomechanical aspects of this particular joint. Identifying the mechanism of injury and understanding the fracture pattern remain the leitmotiv of a skilled orthopedist. What are the forces responsible for the injury? An axial loading with varus or valgus rotatory forces? So many questions to try to answer prior to resolve the puzzle. Once understood, the bony fragments and ligamentous structures can be anatomically repaired.
The elbow joint represents the second most common joint of the upper extremity to be dislocated after the shoulder with an incidence of a little more than 5 elbows on 100,000. A quarter of those injuries are associated with a fracture of one of the bones at least. One can already understand why there is an increase in instability among such patients compared to one victim of a simple dislocation.
A good orthopedic evaluation of an elbow after such injury is mandatory and often the orthopedic surgeon would appreciate better the instability while the evaluation is conducted under general anesthesia. The history may help in understanding the mechanism of injury, the ligamentous instability and the fracture pattern. The neurovascular bundles need to be assessed as well. Attention should be given to the shoulder and the forearm bones with their positions at impact, vis-a-vis the distal humerus and also especially the radial head. Often a Monteggia’s fracture (Olecranon process fracture with radial head dislocation) is seen with medial and collateral ligament disruption and radial head fracture. An attempt at reduction of the elbow followed with a CT scan examination is mandatory prior to any surgical planning.
Plate fixation of the proximal ulna (olecranon process) is preferable to the usual tension band wire fixation. Nice contoured plates are now available rendering the stabilization a little easier. The triceps insertion is preserved over the proximal ulna. Additional K wires fixation can be needed to secure a highly comminuted intra-articular fracture. The coronoid process may require stabilization as well in order to assure a functional return to daily activities. Any chosen surgical exposure must allow the operating surgeon to expose the radial head allowing a closed reduction versus an open reduction with internal fixation using screws or simply allowing the placement of a prosthetic replacement of the radial head. Ligamentous complex medially (MCL) or laterally (LCL) will need also to be exposed for possible repair if needed. Many recent systems of fixation have improved our armamentarium in designing contoured plates allowing us to insert cannulated screws or self-taping locking screws as well as standard screws cortical or cancellous. Occasionally a highly comminuted olecranon fracture may encourage the surgeon to lock the elbow by placing a K-wire or a Steinman pin across the olecranon process and the distal humerus avoiding any motion in the immediate post-operative. Otherwise, the elbow is immobilized in a posterior splint for a week to ten days until a progressive range of motion is allowed.
The stabilization of the olecranon process is the key for obtaining an acceptable outcome. Hardware failure, infection, non-union and poor rehabilitation may add to the poor result obtained through the bad fixation for a comminuted fracture dislocation of an elbow. The most common pattern of injury is a valgus posterolateral rotatory load when the fall is precipitated on an upper extremity held in extension at the elbow on a wrist hyperextended. The first structure to give-up is the lateral ulnar collateral ligament and then the medial collateral ligament.
The complexity of the bony and ligamentous structures renders the treatment of such injury very difficult and it is not recommended to a new comer in the practice of Orthopedics to handle such injuries. The radial head should be preserved whenever possible until a decision is taken to allow it replacement with a prosthetic device. An external fixator could be used when a residual instability is encountered but it should be used as a salvage or any desperate situation after failed surgical approaches.
Any complex fracture-dislocation of an elbow is a challenging problem that should not be approached by an unexperimented orthopedic surgeon, because often the first attempt at restoring the stability provide the best chances at resolving the problem. After failed previous approaches, rarely a late reconstructive procedure can restore some motion to a stiff joint. Joint debridement to remove overgrowth soft tissue or bone may be needed occasionally. Degenerative arthritis is the becoming of most of such joint which has undergone multiple procedures at restoring stability or in the goal at restoring range of motion.
When the battle is lost at reaching the best result, an elbow replacement may be the last solution at relieving pain and discomfort. Elbow fusion has lost in the recent decades the impact it used to have in the mind of the orthopedic surgeon but may be still reserved to patients with a failed arthroplasty or following post-operative infections etc. I can remember the time I was an orthopedic resident at the HUEH and the Fascia Lata was a popular structure to use in an interposition arthroplasty to improve the function of the elbow. I learned the hard way, these techniques from my mentors especially Drs Anthenor Miot who was a beneficiary of the Ford Foundation and Vatey Parisien who trained in the United States as a resident in the orthopedic services of Professor Milch. Unfortunately, although pain was relieved, this procedure did not provide enough stability to the joint and the incapability of such patient to handle heavy load was extremely limited. These procedures are rarely mentioned nowadays in our textbook.
Complex elbow injuries present always a challenge to the orthopedic surgeon. There are particular patterns of fractures, and depending on the mechanism of injury, a variation in the pathology is expected to influence the outcome. Fractures of the antero-medial facet of the Coronoid processes, the radial head and the medial epicondyle need to be given a special attention in the surgical planning. Proper fixation and reconstruction of different ligamentous injuries will play also an important role in the rehabilitation.
I hope I was able to bring a better understanding in the management of a complex fracture dislocation of the elbow to our lectors. I will always remember during the time of my orthopedic residency and my traumatology fellowship, the confusion in my mind while approaching such elbows. I felt also that same fear among the orthopedic residents whom I had the privilege to teach over the years as an attending in the United States and in Haiti or as a visiting professor during numerous medical missions in Ethiopia, Egypt, Panama, Equateur, Peru, Brazil etc when they were called upon to manage a complex fracture dislocation of an elbow. I hope they have learned and mastered the proper techniques to rendering a traumatized elbow, functional.
Maxime Coles MD
Boca Raton FL
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