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Outcomes after Surgical

Stabilization of Chronic Traumatic


Elbow Dislocations
Samantha L. Piper, MD, Jennifer Tangtiphaiboontana, MD
and Lisa L. Lattanza, MD

Current Orthopaedic Practice, Volume 27, No 2,


March/April 2016

Helmi Ismunandar

INTRODUCTION

Surgical Protocol

Because of the rarity of this condition, only small


case series exist to support each protocol

Because the ideal treatment for


chronic elbow dislocation, both
simple and complex, remains
inconclusive
In This
Journal

Explore the characteristics of injuries


that result in recurrent dislocation,
especially after an initial surgery has
failed
Evaluate the outcomes after our surgical
stabilization algorithm for chronic
posttraumatic elbow dislocations

Materials and
Methods

Exclusion criteria :
duration of dislocation of less
than 4wk or immediate
conversion to a total elbow
arthroplasty

Mean age of 38.7 yr


at the time of injury
(range 24-50 yr) ,
five women and five
men

Dislocation
duration of
greater than
4 wk + treat
surgical

Mechanisme Injury
Three motorcycle accidents
Two motor vehicle accidents
Two falls from standing height
One bicycle accident
One fall from a horse
One assault

One of the patients additional


injuries : Thoracic aorta injury,
burst fracture of T3-T4, L2
fracture, multiple facial and rib
fractures that required an
intensive care unit stay and
led to a delay in diagnosis of
the elbow injury

Complex dislocations, seven had coronoid fractures, six had radial head fractures,
and two had ulnar shaft fractures. Five of the coronoid fractures were
anteromedial, three were Morrey type III, two were Morrey type II, and two were
Morrey type I. Five patients had a terrible triad injury, three patients had a
Monteggia injury, and two patients had an Essex- Lopresti injury

Treatment
Six patients surgically
Four nonsurgically (two were closed reduced
and splinted and two were only splinted)
One in the intensive care unit for an extended
period

Surgically
Three with lateral ulnar collateral ligament (LUCL)
reconstruction or repair (one reconstruction with bone tunnels
and allograft
Two repairs with suture anchors
One of which failed and was revised to bone tunnels with
allograft)
One medial collateral ligament (MCL) repair (first suture
anchor, which failed and was revised to bone tunnels with
Three radial head interventions (one open reduction internal
allograft)
fixation,
one revision, one arthroplasty)
Two coronoid fixations (one with suture repair through bone
tunnels, one with repair with suture anchor)
Two with external fixation (one hinged external fixator for 4
wk, one transhumeral pin for 3 wk).

RESULT
Chronic elbow dislocations with a Morrey Type III
coronoid fracture that could not be reconstructed and
stabilization failed.
Three patients in this series presented with a Morrey
type III coronoid fracture. One was successfully treated
at an outside hospital and healed without further
intervention, but the elbow remained dislocated from
the outside hospital because of lack of recognition of
the ligamentous component to the instability.
The other two, one was treated with a patellar allograft
and buttress plate, and the other could not be

Average follow-up
was 26mo (range
4- 55 mo). At final
follow up, eight
elbows remained
concentrically
reduced
radiographically
FIGURE 1. Patient with an 11.9-week posttraumatic complex elbow dislocation. (A)
Radiographs at presentation. (B) After surgery at our institution. (C) At final follow-up. He
was treated with lateral ulnar collateral ligament and medial collateral ligament
reconstruction only and maintained a stable, concentrically reduced elbow joint at final
follow-up (54.6 mo)

Of the elbows that did


not remain
concentrically
reduced, one had
failure of the coronoid
allograft after an
aggressive physical
therapy session with
reabsorption of the
distal humerus

FIGURE 2. A patient with a 7.3-week posttraumatic elbow dislocation and terrible triad injury
with Morrey type III coronoid fracture and ulnar shaft fracture. (A) Radiographs at presentation.
(B) Treated at an outside hospital with open reduction and internal fixation, excision of the
radial head, and a transhumeral pin. (C and D) She was reated with a radial head arthroplasty,
coronoid patellar allograft reconstruction, and lateral ulnar collateral ligament and medial
collateral ligament reconstruction. (E) Her coronoid allograft failed, and ultimately this was

At final followup,
there was
significant
improvement in
average range of
motion, with the
eight patients
achieving a full
functional arc
with their native
elbow (>100
degrees)

FIGURE 3. Range of motion at final follow-up of the patient described


in Figure 1. He has functional and painless range of motion in the
operative elbow (at

Average preoperative flexion-extension arc was


43.6 degrees (range 0-70 degrees), and average
postoperative arc was 118.2 degrees (range 85145 degrees) (P0.001).
Average preoperative pronation-supination arc
was 102.1 degrees (range 40-160 degrees), and
average postoperative arc was 145.6 degrees
(range 100-180 degrees) (P0.04).
Nine patients had no pain in the elbow at final
follow-up. One patient had persistent pain only
with weight bearing.

Complication
One revised LUCL for failure 3wk after surgery, which
then subsequently maintained reduction,
Three superficial infections treated with oral antibiotics
alone
Three ulnar neurapraxias that resolved by final followup
Three patients developed heterotopic ossification after surgery
Two of which required resection to regain a functional range of
motion.

DISCUSSION

In this series, there was not a single injury


characteristic or pattern that consistently led to a
chronic posttraumatic elbow dislocation.

Chronic dislocation occurred after both simple and


complex dislocations, and after various types of
complex dislocation including terrible triad,
Monteggia, Essex-Lopresti, and varus posteromedial
types of injuries.
All of these are known to result in significant elbow
instability and the failure to correct all anatomic
components of the instability will increase the risk for
developing a chronic dislocation

In our protocol, the MCL was reconstructed if instability


persisted after treatment of osseous and LUCL
pathology.
The MCL has been reported in the literature to be
unnecessary to repair in simple elbow dislocations or
complex dislocations after open reduction and internal
fixation of fractures if the LUCL has been repaired or
reconstructed

In This study supports and suggests that


the MCL is more essential to elbow stability
than previously thought This may help to
prevent progression to chronic instability or
dislocation

Stabilization of elbows with a Morrey type III coronoid fracture that


could not be reconstructed failed.
Loss of the coronoid leads to a very unstable elbow, and every
attempt should be made to fix large coronoid fragments. When
fixation is not possible, an allograft may be used, although results
of reconstruction have been unreliable

In this study The size of the coronoid


fragment, rather than the location, was more
indicative of persistent instability if the MCL was
reconstructed

Several protocols
Jupiter and Ring --> Successfully stabilized five elbows with simple chronic
dislocations using open reduction and hinged external fixator only
Majima et al stabilized three elbows with simple and complex chronic dislocations
with open reduction, MCL and LUCL reconstruction, and longarm casting for 2 wk

Ivo et al stabilized complex chronic


dislocations in three elbows with open reduction,
revision of osseous fixation, and external fixation
only, without ligamentous reconstruction
In this
study

Able to restore a stable and concentrically reduced


joint with a painless, functional range of motion in
eight of 10 patients using their protocol.
The two patients who re-dislocated had Morrey type III
coronoid fractures that could not be reconstructed

Limitation
To obtain all records from outside hospitals
regarding treatment of patients before
arrival at this institution.
Average follow-up duration was 26 mo, one
patient had less than 6mo of follow-up, with
a minimum follow up at 4 mo.
Because of the small sample size, that
inclusion of this patient is important,
although it may introduce bias

CONCLUSION
The treatment of chronic, posttraumatic
elbow dislocation remains a challenge for the
orthopaedic surgeon
This should begin with repair or reconstruction
of osseous anatomy, especially large coronoid
fragments, followed by lateral and, when
necessary, medial ligamentous reconstruction
as indicated by intraoperative assessment of
stability.

A stable, painless and functional elbow joint


can be restored and maintained after a
chronic dislocation, but patients should be
warned of the complications associated
with this challenging procedure