- Email: [email protected]
Transverse divergent dislocation of the elbow
Case reports
279
Transverse divergent dislocation of the elbow T. B. McAuliffe Royal National
Orthopaedic
Hospital,
Stanmore,
Middlesex
D. Williams Robert Jones and Agnes Hunt Orthopaedic
Hospital,
INTRODUCTION
COMPLETEdisclocation of all three bones of the elbow is an uncommon injury and the transverse type is so rare that it has been described as a surgical curiosity (Rockwood and Green, 1984). In recent times there has only been one other description of this injury (DeLee, 1981). Two earlier reports (Warmont 1854; Wight 1893) had no radiographs nor any details on the long-term results of the injury. All these earlier reports stated that closed reduction of this injury is relatively straightforward. We report a second case with radiographs and follow-up. This case proved much less easy to treat than those in the earlier reports, although the eventual outcome was satisfactory.
Oswestry
Shropshire
injury there is complete disruption of most of the ligaments about the elbow. In accordance with this, most authors have found that reduction is easy and this was true in this case. However, where there is very severe disruption there will be few stabilizing soft tissue elements left intact and reduction will be difficult to maintain, as proved to be the case in this patient. Based on our experience in this case we would suggest that in
CASE REPORT A IO-year-old boy fell from a tree injuring his left elbow. Clinically he had an obviously dislocated elbow. There was no evidence of any neurovascular injury. Radiographs revealed a transverse divergent dislocation of the elbow (Figs. 1 and 2). Under a general anaesthetic the dislocation was reduced and the arm placed into an above-elbow plaster-of-Paris backslab after the reduction had been verified by an image intensifier. A radiograph performed the following day showed that the dislocation had recurred. A further attempt at closed reduction with screening under image intensification on the following day was unsuccessful because of the gross instability of the elbow. An open exploration of the elbow was therefore performed. At operation there was gross oedema around the joint. The ulnar nerve was exposed and found to be severely contused but otherwise intact. There was gross disruption of the capsule of the joint with a complete tear of the lateral ligament and a fracture of the coronoid process. An attempted reduction of the joint and internal fixation with Kirschner wires proved unsatisfactory due to the swelling and disruption of the soft tissues. The procedure was therefore abandoned. The limb was elevated until the swelling had settled. One week later at a second operation an open reduction was possible. The elbow was found to be stable in full supination and 90” of flexion and was immobilized in this position in a plaster-of-Paris splint. A radiograph confirmed a satisfactory reduction. Postoperatively the arm was splinted for I month. He then underwent a programme of physiotherapy involving active and passive movement. One year after the accident he had made a good functional recovery considering the severity of the injury. He lacked IO” of extension and could flex to IOS”. Supination could pronate only to 40”.
was full but he
DISCUSSION
Transverse divergent dislocation of the elbow is a rare injury and there is little in the literature to guide the surgeon on the best method of treatment and the likely outcome of such an injury. Inevitably in such a severe @ 1988Butterworth & Co (Publishers) Ltd 0020-1383/88/04027!M2
$0303
FQ. I. Anteroposterior dislocation of left elbow
radiograph of transverse in a child of 6 years.
divergent
280
Injury: the British Journal of Accident Surgery (1988) Vol. lS/No. 4
this potentially very unstable injury it would be wise to reduce this dislocation and hold it temporarily with percutaneous Kirschner wires. This should be done as early as possible before oedema makes it too difficult. As always, a compromise must then be sought between adequate immobilization to allow soft tissue healing and early mobilization to prevent stiffness. A period of 4 weeks’ immobilization proved sufficient in this case and would seem reasonable.
REFERENCES
DeLee J. (1981) Transverse divergent dislocation of the elbow in a child. J. Bone Joint Surg. 63A, 322. Rockwood C. A. and Green D. P. (1984) Fractures. Philadelphia, J. B. Lippincott Co. Warmont A. (1854) Luxation simultanee du cubitus en dedans et du radius en dehors, compliquee de fracture de Requests for reprints should be addressed to: T. B. McAuliffe
Fig. 2. Lateral radiograph
of the same patient.
l’avant bras. Mon. Hop., J. prog. med. chir prat., p. 961. Wight J. S. (1893) Dislocation of the bones of the right forearm backward, the radius being outward and the ulna being inward, and the head of the radius being dislocated from the base of the ulna. Phys. and Surg. 15, 67. Paper accepted 7 January 1988.
MA FRCS,
Royal National Orthopaedic Hospital, Brockley Way, Stanmore,
Middx.
Cullen’s sign: a new association with central dislocation of the hip joint R. D. Sayers and K. M. Porter Birmingham
Accident
Hospital
INTRODUCTION discoloration caused by haemorrhage is known eponymously as Cullen’s sign and was initially reported in association with ruptured ectopic pregnancy (Cullen, 1918), and subsequently in association with acute pancreatitis (Fallis, 1937). A similar discoloration in the flanks has been described in acute pancreatitis (Turner, 1920) and is known as Grey Turner’s sign. Cullen’s sign has also been reported in a few other conditions including hepatocellular carcinoma (Mabin and Gelfand, 1974), and after percutaneous liver biopsy (Capron et al., 1977). Cullen’s sign has not previously been reported in association with musculoskeletal injury. We report a new association of Cullen’s sign with central dislocation of the hip joint. PERIUMBILICAL
normal. His abdominal pain settled on a conservative regimen of restricted oral fluids, and his bruising resolved. The central dislocation of the hip joint was reduced satisfactorily under general anaesthetic and a Denham pin was inserted through the femoral condyles to allow skeletal traction. He remained on traction for 6 weeks and was then mobilized non-weight-bearing for a further 6 weeks.
DISCUSSION The most likely cause of this patient’s umbilical bruising was blood from a retroperitoneal haematoma secondary to his pelvic fracture, tracking through the tissue planes of his abdominal wall to reach the umbilicus. Retroperitoneal haematoma is a common complication of pelvic fractures because of the associated soft
CASE REPORT Following a fall a 79-year-old man complained of pain in his left hip region and an inability to bear weight. He was clinically shocked and required resuscitation with intravenous plasma expanders and blood. Radiographs revealed a central dislocation of his left hip joint (Fig. 1). He was treated initially with skin traction. Two days after admission he developed left iliac fossa pain and vomiting. Examination revealed a pulse rate of 90/min (atrial fibrillation) and a blood pressure of 130/90 mmHg. He was afebrile. There was extensive bruising over his left hip joint and periumbilical bruising (Cullen’s sign) (Fig. 2). His left iliac fossa was tender without guarding and his bowel sounds were quiet. A rectal examination was normal. Chest and abdominal radiographs were normal. Investigations revealed a haemoglobin of 12.1 g/d1 and a white cell count of 8.0~10”/1. The serum urea, electrolytes and amylase were normal. Examination of the urine was 0 1988 Butterworth & Co (Publishers) Ltd 0020-1383/88/04028C42
$0340
Fig. 1. Radiograph of the pelvis showing central dislocation of the left hip joint.
279
Transverse divergent dislocation of the elbow T. B. McAuliffe Royal National
Orthopaedic
Hospital,
Stanmore,
Middlesex
D. Williams Robert Jones and Agnes Hunt Orthopaedic
Hospital,
INTRODUCTION
COMPLETEdisclocation of all three bones of the elbow is an uncommon injury and the transverse type is so rare that it has been described as a surgical curiosity (Rockwood and Green, 1984). In recent times there has only been one other description of this injury (DeLee, 1981). Two earlier reports (Warmont 1854; Wight 1893) had no radiographs nor any details on the long-term results of the injury. All these earlier reports stated that closed reduction of this injury is relatively straightforward. We report a second case with radiographs and follow-up. This case proved much less easy to treat than those in the earlier reports, although the eventual outcome was satisfactory.
Oswestry
Shropshire
injury there is complete disruption of most of the ligaments about the elbow. In accordance with this, most authors have found that reduction is easy and this was true in this case. However, where there is very severe disruption there will be few stabilizing soft tissue elements left intact and reduction will be difficult to maintain, as proved to be the case in this patient. Based on our experience in this case we would suggest that in
CASE REPORT A IO-year-old boy fell from a tree injuring his left elbow. Clinically he had an obviously dislocated elbow. There was no evidence of any neurovascular injury. Radiographs revealed a transverse divergent dislocation of the elbow (Figs. 1 and 2). Under a general anaesthetic the dislocation was reduced and the arm placed into an above-elbow plaster-of-Paris backslab after the reduction had been verified by an image intensifier. A radiograph performed the following day showed that the dislocation had recurred. A further attempt at closed reduction with screening under image intensification on the following day was unsuccessful because of the gross instability of the elbow. An open exploration of the elbow was therefore performed. At operation there was gross oedema around the joint. The ulnar nerve was exposed and found to be severely contused but otherwise intact. There was gross disruption of the capsule of the joint with a complete tear of the lateral ligament and a fracture of the coronoid process. An attempted reduction of the joint and internal fixation with Kirschner wires proved unsatisfactory due to the swelling and disruption of the soft tissues. The procedure was therefore abandoned. The limb was elevated until the swelling had settled. One week later at a second operation an open reduction was possible. The elbow was found to be stable in full supination and 90” of flexion and was immobilized in this position in a plaster-of-Paris splint. A radiograph confirmed a satisfactory reduction. Postoperatively the arm was splinted for I month. He then underwent a programme of physiotherapy involving active and passive movement. One year after the accident he had made a good functional recovery considering the severity of the injury. He lacked IO” of extension and could flex to IOS”. Supination could pronate only to 40”.
was full but he
DISCUSSION
Transverse divergent dislocation of the elbow is a rare injury and there is little in the literature to guide the surgeon on the best method of treatment and the likely outcome of such an injury. Inevitably in such a severe @ 1988Butterworth & Co (Publishers) Ltd 0020-1383/88/04027!M2
$0303
FQ. I. Anteroposterior dislocation of left elbow
radiograph of transverse in a child of 6 years.
divergent
280
Injury: the British Journal of Accident Surgery (1988) Vol. lS/No. 4
this potentially very unstable injury it would be wise to reduce this dislocation and hold it temporarily with percutaneous Kirschner wires. This should be done as early as possible before oedema makes it too difficult. As always, a compromise must then be sought between adequate immobilization to allow soft tissue healing and early mobilization to prevent stiffness. A period of 4 weeks’ immobilization proved sufficient in this case and would seem reasonable.
REFERENCES
DeLee J. (1981) Transverse divergent dislocation of the elbow in a child. J. Bone Joint Surg. 63A, 322. Rockwood C. A. and Green D. P. (1984) Fractures. Philadelphia, J. B. Lippincott Co. Warmont A. (1854) Luxation simultanee du cubitus en dedans et du radius en dehors, compliquee de fracture de Requests for reprints should be addressed to: T. B. McAuliffe
Fig. 2. Lateral radiograph
of the same patient.
l’avant bras. Mon. Hop., J. prog. med. chir prat., p. 961. Wight J. S. (1893) Dislocation of the bones of the right forearm backward, the radius being outward and the ulna being inward, and the head of the radius being dislocated from the base of the ulna. Phys. and Surg. 15, 67. Paper accepted 7 January 1988.
MA FRCS,
Royal National Orthopaedic Hospital, Brockley Way, Stanmore,
Middx.
Cullen’s sign: a new association with central dislocation of the hip joint R. D. Sayers and K. M. Porter Birmingham
Accident
Hospital
INTRODUCTION discoloration caused by haemorrhage is known eponymously as Cullen’s sign and was initially reported in association with ruptured ectopic pregnancy (Cullen, 1918), and subsequently in association with acute pancreatitis (Fallis, 1937). A similar discoloration in the flanks has been described in acute pancreatitis (Turner, 1920) and is known as Grey Turner’s sign. Cullen’s sign has also been reported in a few other conditions including hepatocellular carcinoma (Mabin and Gelfand, 1974), and after percutaneous liver biopsy (Capron et al., 1977). Cullen’s sign has not previously been reported in association with musculoskeletal injury. We report a new association of Cullen’s sign with central dislocation of the hip joint. PERIUMBILICAL
normal. His abdominal pain settled on a conservative regimen of restricted oral fluids, and his bruising resolved. The central dislocation of the hip joint was reduced satisfactorily under general anaesthetic and a Denham pin was inserted through the femoral condyles to allow skeletal traction. He remained on traction for 6 weeks and was then mobilized non-weight-bearing for a further 6 weeks.
DISCUSSION The most likely cause of this patient’s umbilical bruising was blood from a retroperitoneal haematoma secondary to his pelvic fracture, tracking through the tissue planes of his abdominal wall to reach the umbilicus. Retroperitoneal haematoma is a common complication of pelvic fractures because of the associated soft
CASE REPORT Following a fall a 79-year-old man complained of pain in his left hip region and an inability to bear weight. He was clinically shocked and required resuscitation with intravenous plasma expanders and blood. Radiographs revealed a central dislocation of his left hip joint (Fig. 1). He was treated initially with skin traction. Two days after admission he developed left iliac fossa pain and vomiting. Examination revealed a pulse rate of 90/min (atrial fibrillation) and a blood pressure of 130/90 mmHg. He was afebrile. There was extensive bruising over his left hip joint and periumbilical bruising (Cullen’s sign) (Fig. 2). His left iliac fossa was tender without guarding and his bowel sounds were quiet. A rectal examination was normal. Chest and abdominal radiographs were normal. Investigations revealed a haemoglobin of 12.1 g/d1 and a white cell count of 8.0~10”/1. The serum urea, electrolytes and amylase were normal. Examination of the urine was 0 1988 Butterworth & Co (Publishers) Ltd 0020-1383/88/04028C42
$0340
Fig. 1. Radiograph of the pelvis showing central dislocation of the left hip joint.