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Chronic dislocation of elbow
CHRONIC M. Orthopedic
DISLOCATION THOMAS
Staff, Jefferson
HORWITZ,
MedicaI
OF ELBOW * M.D.
CoIIege and Jewish HospitaIs
PHILADELPHIA
L
l
R., aged thirty-seven years, injured her right eIbow by direct trauma on JuIy I, 1936. Roentgenogram faiIed to revea1
genographic pictures reveaIed unquestionabIe posterior disIocation of the right eIbow (Fig. 2). At this time, she compIained of sIight paresthe-
FIG. 2. JuIy 31, 1936, on admission; definite posterior disIocation Bf the radius and uIna with beginning osteopIastic formation anteriorly and posteriorly.
FIG. I. Lateral view taken on JuIy I, 1936, day of injury, showing negative findings.
any fracture or disIocation in this region (Fig. - I). After sIing immobiIization for three days, her eIbow was exercised daiIy by a visiting nurse unti1 nine days after injury, when undue deformity and increasing painful disabiIity of the right eIbow became apparent. She faiIed to seek immediate medica attention despite marked disabiIity of the right eIbow associated with an ahnost fixed extension deformity of the forearm. She was seen in the Out-Patient Department four and one-haIf weeks foIIowing the initia1 trauma, when the cIinica1 and roent-
sias in the fourth and fifth fingers of the right hand. She was admitted to the hospita1 and an attempt at cIosed reduction, under fIuoroscopic contro1, failed. Open reduction was performed August 7, 1936, by the method of Vangorder.3 Through . . a posterror mIdIme incision, the uInar nerve was isoIated in its groove, found sIightIy thickened and transposed anteriorIy. The triceps tendon was severed transverseIy $5 inch above the oIecranon process, the posterior space between this tendon, the Iower posterior
* From the service of Dr. Harry FinkeIstein, 118
Hospital
for Joint
Diseases,
New York.
NEW Saruss
VOL. XXXVII,
No.
I
Horwitz-Dislocation
humeral surface and the oIecranon incisura evacuated of considerable detritus and fibrous tissue, and reduction easiIy effected. With the
FIG. 3. August 8, 1936, foIIowing the first open procedure. Reduction compIete except for a marked hiatus between the trochlea and semilunar notch due to the severed triceps mechanism.
forearm at right angIes, the resulting z-inch gap in the triceps tendon was cIosed with a layer of transpIanted fascia Iata and the extremity immobifized in plaster-of-Paris bandage. Roentgenogram the foIIowing day reveaIed recurrence of the posterior disIocation as we11 as some IateraI dispIacement of the radius and uIna, not previousIy present. Correction was easily obtained under fluoroscopic control and plaster fixation reappIied. X-ray pIates reveaIed reduction of the dislocation in both planes, except for undue gaping between the trochlea and uInar semiIunar notch apparent on the IateraI view (Fig. 3), and this, despite thorough evacuation of the Iatter at the time of open reduction. During the ensuing week, she deveIoped early signs and symptoms of uInar nerve compression which subsided in a few days with sinusoida stimuIation through an aperture in the pIaster bandage.
of Elbow
American Journal or surgery
I 19
At the end of two weeks, active exercises were initiated, reveahng at first an exceIIent range of Aexion and extension, with compIete restora-
FIG. 4. October g, ‘936, compIete reduction present one month after the second open procedure. The hiatus is no Ionger present. Note moderate osteoplastic reformation anteriorly and posteriorly.
tion of the triceps mechanism. In the ensuing days, there was gradua1 Ioss in the range of one month postopffexion. Roentgenogram erativeIv revealed recurrence of the posterior dislocation. On September 9, 1936, two months after the initia1 injury, open correction was again performed, but through a IateraI approach, since the posterior one had aIready proved itseIf unsatisfactory and the media1 one, although preferabIe, seemed contraindicated by IocaIized induration, redness and tenderness in the course of the transposed uInar nerve. Considerable debris and calcific materia1 was evacuated from the anterior and posterior compartments of the eIbow joint, and reduction easiiy obtained without aItering the integrity of the triceps tendon or the IateraI Iigaments, and the forearm maintained in acute flexion.
120
American Journal of Surgery
Horwitz-DisIocation
Two weeks Iater, active exercises were again instituted with graduaIIy increasing range of extension from the acuteIy ffexed position. Roentgenogram taken one month foIIowing the second open procedure reveaIed maintenance of the reduction (Fig. 4)) with exceIIent aIinement of the bones of the arm and forearm. Six months foIIowing the second operation and eight months after the initia1 injury, the patient presents a painless, normal-appearing elbow with an exceIIent range of motion from complete ffexion to 155 degrees of extension and pronation of 65 degrees to aImost compIete supination. There is no IateraI instability. Except for fleeting paresthesias in the fifth finger of the right hand, there are no further evidences of uInar nerve involvement.
of Elbow
JULY,1937
ossifying periarticuIar changes, nerve injury and fracture.l 3. The inadequacy of the commonly advocated posterior approach2+ and the danger in the necessary severance of the triceps tendon. The latter procedure, as the above roentgenograms evidence, destroys the essentia1 components of the Jones’ position of acute flexion, i.e., the posterior sIing effect of the intact triceps tendon and its coaptating force approximating the trochIea within the semiIunar notch of the uIna, thus encouraging redislocation. The media1 incision wouId serve as a more idea1 approach. REFERENCES
DISCUSSION
This case presents numerous instructive phases. I. The danger of over-zeaIous activity
in a recentIy injured eIbow, despite negative x-ray findings, in the Iight of possible soft tissue Iaceration and pathoIogic joint effusion and the danger of secondary Iuxation. 2. The inadvisability of attempting cIosed reduction in cases of three weeks duration or older, in the face of almost certain faiIure, and the danger of increasing
P. D. Fractures and disIocations of the eIbow joint. Surg. Gynec. and Ok., 50: 335, 1933. 2. SPEED, J. J. Operation for unreduced posterior disLocation of elbow. Southern Med. Jour., 18: 193, 1. WILSON,
‘935.
3. VANGORDER,G. W. SurgicaI approach in oId posterior
disIocation
of elbow. Jour. Bone and Joint Surg.,
14: 127, 1932. 4. NOV&JOSSERAND and POUZET, F. RCsuItats eIoign&s
d’hemi-§ions et de resections pour Iuxation ancienne du coude. Lyon cbir., 29: 610, 1932. /I;. TAVERNIER. L. and POUZET. F. Le traitement des Iuxations’ anciennes du c&de. Technique de Ia reduction sanglante. Jour. de cbir., 43: 161, 1934. 6. VOCHEY, A. and DECHAUME, M. TransoIecranon route in surgica1 reduction of oId dislocations of the elbow. Rev. d’ortbop., 14: 193, 1927.
DISLOCATION THOMAS
Staff, Jefferson
HORWITZ,
MedicaI
OF ELBOW * M.D.
CoIIege and Jewish HospitaIs
PHILADELPHIA
L
l
R., aged thirty-seven years, injured her right eIbow by direct trauma on JuIy I, 1936. Roentgenogram faiIed to revea1
genographic pictures reveaIed unquestionabIe posterior disIocation of the right eIbow (Fig. 2). At this time, she compIained of sIight paresthe-
FIG. 2. JuIy 31, 1936, on admission; definite posterior disIocation Bf the radius and uIna with beginning osteopIastic formation anteriorly and posteriorly.
FIG. I. Lateral view taken on JuIy I, 1936, day of injury, showing negative findings.
any fracture or disIocation in this region (Fig. - I). After sIing immobiIization for three days, her eIbow was exercised daiIy by a visiting nurse unti1 nine days after injury, when undue deformity and increasing painful disabiIity of the right eIbow became apparent. She faiIed to seek immediate medica attention despite marked disabiIity of the right eIbow associated with an ahnost fixed extension deformity of the forearm. She was seen in the Out-Patient Department four and one-haIf weeks foIIowing the initia1 trauma, when the cIinica1 and roent-
sias in the fourth and fifth fingers of the right hand. She was admitted to the hospita1 and an attempt at cIosed reduction, under fIuoroscopic contro1, failed. Open reduction was performed August 7, 1936, by the method of Vangorder.3 Through . . a posterror mIdIme incision, the uInar nerve was isoIated in its groove, found sIightIy thickened and transposed anteriorIy. The triceps tendon was severed transverseIy $5 inch above the oIecranon process, the posterior space between this tendon, the Iower posterior
* From the service of Dr. Harry FinkeIstein, 118
Hospital
for Joint
Diseases,
New York.
NEW Saruss
VOL. XXXVII,
No.
I
Horwitz-Dislocation
humeral surface and the oIecranon incisura evacuated of considerable detritus and fibrous tissue, and reduction easiIy effected. With the
FIG. 3. August 8, 1936, foIIowing the first open procedure. Reduction compIete except for a marked hiatus between the trochlea and semilunar notch due to the severed triceps mechanism.
forearm at right angIes, the resulting z-inch gap in the triceps tendon was cIosed with a layer of transpIanted fascia Iata and the extremity immobifized in plaster-of-Paris bandage. Roentgenogram the foIIowing day reveaIed recurrence of the posterior disIocation as we11 as some IateraI dispIacement of the radius and uIna, not previousIy present. Correction was easily obtained under fluoroscopic control and plaster fixation reappIied. X-ray pIates reveaIed reduction of the dislocation in both planes, except for undue gaping between the trochlea and uInar semiIunar notch apparent on the IateraI view (Fig. 3), and this, despite thorough evacuation of the Iatter at the time of open reduction. During the ensuing week, she deveIoped early signs and symptoms of uInar nerve compression which subsided in a few days with sinusoida stimuIation through an aperture in the pIaster bandage.
of Elbow
American Journal or surgery
I 19
At the end of two weeks, active exercises were initiated, reveahng at first an exceIIent range of Aexion and extension, with compIete restora-
FIG. 4. October g, ‘936, compIete reduction present one month after the second open procedure. The hiatus is no Ionger present. Note moderate osteoplastic reformation anteriorly and posteriorly.
tion of the triceps mechanism. In the ensuing days, there was gradua1 Ioss in the range of one month postopffexion. Roentgenogram erativeIv revealed recurrence of the posterior dislocation. On September 9, 1936, two months after the initia1 injury, open correction was again performed, but through a IateraI approach, since the posterior one had aIready proved itseIf unsatisfactory and the media1 one, although preferabIe, seemed contraindicated by IocaIized induration, redness and tenderness in the course of the transposed uInar nerve. Considerable debris and calcific materia1 was evacuated from the anterior and posterior compartments of the eIbow joint, and reduction easiiy obtained without aItering the integrity of the triceps tendon or the IateraI Iigaments, and the forearm maintained in acute flexion.
120
American Journal of Surgery
Horwitz-DisIocation
Two weeks Iater, active exercises were again instituted with graduaIIy increasing range of extension from the acuteIy ffexed position. Roentgenogram taken one month foIIowing the second open procedure reveaIed maintenance of the reduction (Fig. 4)) with exceIIent aIinement of the bones of the arm and forearm. Six months foIIowing the second operation and eight months after the initia1 injury, the patient presents a painless, normal-appearing elbow with an exceIIent range of motion from complete ffexion to 155 degrees of extension and pronation of 65 degrees to aImost compIete supination. There is no IateraI instability. Except for fleeting paresthesias in the fifth finger of the right hand, there are no further evidences of uInar nerve involvement.
of Elbow
JULY,1937
ossifying periarticuIar changes, nerve injury and fracture.l 3. The inadequacy of the commonly advocated posterior approach2+ and the danger in the necessary severance of the triceps tendon. The latter procedure, as the above roentgenograms evidence, destroys the essentia1 components of the Jones’ position of acute flexion, i.e., the posterior sIing effect of the intact triceps tendon and its coaptating force approximating the trochIea within the semiIunar notch of the uIna, thus encouraging redislocation. The media1 incision wouId serve as a more idea1 approach. REFERENCES
DISCUSSION
This case presents numerous instructive phases. I. The danger of over-zeaIous activity
in a recentIy injured eIbow, despite negative x-ray findings, in the Iight of possible soft tissue Iaceration and pathoIogic joint effusion and the danger of secondary Iuxation. 2. The inadvisability of attempting cIosed reduction in cases of three weeks duration or older, in the face of almost certain faiIure, and the danger of increasing
P. D. Fractures and disIocations of the eIbow joint. Surg. Gynec. and Ok., 50: 335, 1933. 2. SPEED, J. J. Operation for unreduced posterior disLocation of elbow. Southern Med. Jour., 18: 193, 1. WILSON,
‘935.
3. VANGORDER,G. W. SurgicaI approach in oId posterior
disIocation
of elbow. Jour. Bone and Joint Surg.,
14: 127, 1932. 4. NOV&JOSSERAND and POUZET, F. RCsuItats eIoign&s
d’hemi-§ions et de resections pour Iuxation ancienne du coude. Lyon cbir., 29: 610, 1932. /I;. TAVERNIER. L. and POUZET. F. Le traitement des Iuxations’ anciennes du c&de. Technique de Ia reduction sanglante. Jour. de cbir., 43: 161, 1934. 6. VOCHEY, A. and DECHAUME, M. TransoIecranon route in surgica1 reduction of oId dislocations of the elbow. Rev. d’ortbop., 14: 193, 1927.