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Hinged external fixation for complex fracture-dislocation of the elbow in elderly people
G Model
JINJ-5922; No. of Pages 5 Injury, Int. J. Care Injured xxx (2014) xxx–xxx
Contents lists available at ScienceDirect
Injury journal homepage: www.elsevier.com/locate/injury
Hinged external fixation for complex fracture-dislocation of the elbow in elderly people P. Maniscalco a, A.L. Pizzoli b,*, L. Renzi Brivio b, M. Caforio a,** a b
Department of Orthopaedics and Traumatology, Guglielmo da Saliceto Hospital, Piacenza, Italy Department of Orthopaedics and Traumatology, C. Poma Hospital, Mantua, Italy
A R T I C L E I N F O
A B S T R A C T
Keywords: Hinged external fixator Elbow fracture in elderly Complex elbow fracture-dislocation
The authors report their experience of treating complex elbow fracture-dislocations in elderly people, using a minimally-invasive approach with a new articulated external fixator that is associated with minimal internal fixation. The clinical results for 19 patients are presented according to outcome factors, such as range of motion, pain and function, rate and type of complications, and reoperation rate. The results indicate that this treatment strategy should be considered as a good alternative to other treatment options reported in the literature, including conservative treatment, ORIF with angular stable plates and total elbow arthroplasty. ß 2014 Elsevier Ltd. All rights reserved.
Introduction The treatment and the risk–benefit evaluation of traumatic lesions of the elbow are based on a correct preoperative assessment of bone and/or soft tissue lesions to distinguish the different patterns of instability, and on the type of patient to be treated. The term ‘‘complex lesion of the elbow’’ identifies a possible clinical scenario of articular and periarticular mechanical instability because of bone, ligament and/or soft tissue lesions that is difficult to assess with the ordinary classifications [1,2]. Elbow dislocation is the second most common dislocation in adults, after the shoulder, with an annual estimated incidence of six in 100,000 [3]. Dislocation of the elbow can be simple, with no fractures, or complex, with bone structure involvement [4]. The most common elbow fracture sites are the olecranon, the coronoid process and the radial head. The latter two structures are the major bone stabilisers of the elbow. The incidence of fracture of these sites in patients with elbow dislocation is 36% for the radial head, 13% for the coronoid process and 4% for the olecranon [3]. The most common treatment of complex elbow fracture-dislocations is ORIF [5] and ligament repair (particularly lateral collateral ligaments [LCL]) with the aim to restore bone-articular surface and joint stability. Radial
* Corresponding author at: Ortopedia e Traumatologia Ospedale C. Poma, V. le Albertoni 1, 46100 Mantova, Italy. ** Corresponding author at: Ortopedia e Traumatologia Ospedale Guglielmo da Saliceto, Via Taverna 49, 29121 Piacenza, Italy. E-mail addresses: [email protected] (A.L. Pizzoli), [email protected] (M. Caforio).
head prosthesis is sometimes necessary when it is not possible to reconstruct this structure. A clinical examination at the end of surgery is mandatory to assess capsular and ligament structures and final stability. Instability or re-dislocation after surgery indicates the use of a hinged external elbow fixator [6–8] to enable early joint movement and prevent residual instability or stiffness. Although open surgery and ligament reconstruction have produced good results in common lesions, these procedures are often difficult and are sometimes associated with major complications, such as septic arthritis, wound failure or bone fragment necrosis, particularly in highly comminuted fractures and weak bone, like that in elderly people [8,9]. Elderly patients also often present with local or general risk factors that can be associated with increased complication rates when undergoing a standard approach, such as arthroplasty or ORIF. In these situations, a minimally-invasive surgery associated with an articulated external fixator should be considered as a possible alternative to other treatment options reported in the literature, including conservative treatment, ORIF with angular stable plates, and total elbow arthroplasty (TEA) [10,11]. The purpose of this prospective study is to evaluate whether the above strategy can guarantee early joint motion and good long-term function in elderly patients who often live alone and ask to be independent, and whether it minimises the risk of major complications. Materials and methods A total of 19 patients (13 women and 6 men) with an average age of 74.5 years were evaluated (Table 1). The inclusion criteria
http://dx.doi.org/10.1016/j.injury.2014.10.024 0020–1383/ß 2014 Elsevier Ltd. All rights reserved.
Please cite this article in press as: Maniscalco P, et al. Hinged external fixation for complex fracture-dislocation of the elbow in elderly people. Injury (2014), http://dx.doi.org/10.1016/j.injury.2014.10.024
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JINJ-5922; No. of Pages 5 P. Maniscalco et al. / Injury, Int. J. Care Injured xxx (2014) xxx–xxx
2
Table 1 General data relative to the patients, their lesions and their treatments. No.
Patient
Sex
Age
Kind of lesion
Treatment
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19
BA FM BL MM GB BA RV CD SV ME CF SI LM MG RF GT HA TD EG
Woman Woman Woman Woman Woman Woman Woman Woman Woman Woman Man Man Woman Man Man Man Man Woman Man
80 70 67 76 72 69 79 68 78 77 76 83 78 65 81 79 82 66 71
Open fracture AO 1.3 C2 AO 1.3 C2 AO 1.3 C2 AO 1.3 C2 AO 2.1 C3 terrible triad AO 1.3 C2 AO 1.3 C2 Unstable postero-lateral elbow dislocation AO 2.1 C3 + elbow posterior dislocation AO 1.3 C3 AO 1.3 B1 + dislocation Terrible triad AO 1.3 B1 + elbow posterior dislocation Open dislocation + neurovascular lesion Monteggia’s fracture Coronoid fracture and elbow posterior dislocation Open dislocation + coronoid + N/V lesion AO 1.3 C2 AO 2.1 C3
F4 F4 F4 F4 F4 F4 F4 F4 F4 F4 F4 F4 F4 F4 F4 F4 F4 F4 F4
were age over 65 years with no previous dysfunction of the injured elbow, and the clinical indication to use an articulated external fixator for a posttraumatic bone and/or ligament instability. All patients were treated with a new, radiolucent, hinged external fixator (F4 Motion Citieffe1), which was designed to allow full range of motion (ROM) and joint distraction with minimal fixation, at Mantua and Piacenza Hospitals from 2008 to 2011. When necessary, joint distraction was applied using the fixator itself. According to the postoperative protocol, almost all patients were permitted to move their elbow in flexion–extension and prono-supination, as far as tolerated, the day after surgery. Passive mobilisation was made twice daily by a physiotherapist until
external external external external external external external external external external external external external external external external external external external
fixator and cannulated screws fixator, Kirschner wires and cannulated screws fixator and cannulated screws fixator and cannulated screws fixator and capitellectomy fixator and cannulated screws fixator and cannulated screws fixator and capsular-internal ligament reconstruction fixator and olecranon plate fixator and cannulated screws fixator and cannulated screws fixator and capitellectomy fixator and cannulated screws fixator fixator and radial plate fixator fixator fixator and cannulated screws fixator and cannulated screws
discharge. Articular ROM was limited to between 708 and 1108 in two patients because of the complexity of the fracture and soft tissue lesions. Three weeks after surgery the hinged external fixator was unlocked, and full elbow flexion–extension was permitted in all patients. The rehabilitation programme, including active and passive mobilisation, was continued to achieve full ROM and to enable complete healing of the soft tissues involved in the injury. The duration and intensity of the programme were customised according to the specific needs of the patients. Patients were evaluated with a dedicated form that included items relating to the classification of the different types of bone and soft tissue lesions, the type of operation performed (Table 1), and the radiological and clinical outcomes at 3, 6, 9 and 12 weeks
Fig. 1. Case 14: AP and lateral radiographs (A1), and the clinical picture (A2) of a patient with coronoid fracture and open grade 3C elbow dislocation (neurovascular lesion). Case 1: AP and lateral radiographs (B1), and the clinical picture (B2) of a patient with a distal humeral AO 1.3 C2 grade 2 open fracture.
Please cite this article in press as: Maniscalco P, et al. Hinged external fixation for complex fracture-dislocation of the elbow in elderly people. Injury (2014), http://dx.doi.org/10.1016/j.injury.2014.10.024
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JINJ-5922; No. of Pages 5 P. Maniscalco et al. / Injury, Int. J. Care Injured xxx (2014) xxx–xxx
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Fig. 2. Postoperative X-ray controls: (A1 and A2) joint reduction and neurovascular + soft tissue repair + F4 motion application (case 14). (B) Percutaneous reduction and osteosynthesis + F4 motion with limited distraction used to neutralise flexion–extension forces of the elbow (case 1).
and long-term follow-up (12 months). X-ray and clinical examination to determinate ROM and joint stability were performed at all timepoints. Neurological evaluation was performed by a specialist. Pain at long-term follow-up was evaluated using the visual analogue scale (VAS, 0–10). Fixator screws were removed under local or general anaesthesia.
The hinged external fixator was removed after 8 weeks in case 14 and after 9 weeks in case 1. Physiotherapy was continued for at least another 6 weeks and was associated with good functional improvement, as shown at long-term follow-up (Fig. 4).
Clinical cases
The most common lesions presented in the study were comminuted articular fractures with weak bone or fracturedislocation; a few patients had open fractures with high risk of complications (cases 1, 14 and 17, Table 1). The average time of fixation was 7 weeks (range 6–12 weeks), the average ROM obtained with the fixator ranged between 208 and 1188 and was improved at follow-up (3–1208), and the average prono-supination ranged from 728 to 738. Two patients required plastic surgery and nerve transplant during the follow-up period. Adjunctive surgery during this period was not necessary in the remaining patients. There were no losses of reduction, residual instability or major complications (septic arthritis, osteitis, implant failure or posttraumatic deformity) in the study. The pin track infection rate was 3.8% and resolved with frequent local dressing and shortterm oral antibiotic therapy. One pin had to be removed from one patient because of early loosening; there was no consequent implant instability. There were no patient reports of limited tolerance to the external fixator, and none of the patients used
Two clinical cases are presented from first assessment (Fig. 1) to long-term follow-up (Fig. 4). The surgical approach in both cases was based on minimallyinvasive reduction and osteosynthesis with Kirshner wires or cancellous cannulated screws, followed by the application of an articulated external fixator (F4 Motion Citieffe1) (Fig. 2). This fixator has a radiolucent articulated unit to visualise, under image intensifier, the placement in the joint of 2 mm guide wires in the centre of rotation of the elbow to provide a correct articular movement. The distal arch of the fixator enables the placement of ulnar screws in the posterior aspect of the forearm without any soft tissue transfixion, thereby avoiding any limits for prono-supination. The day after surgery, patient 1 was permitted free motion of the joint while for patient 14, mobilisation was limited to a maximum of 1108 flexion and 608 extension. Prono-supination was free, as tolerated by pain: after 3 weeks free ROM was permitted in all patients (Fig. 3).
Results
Please cite this article in press as: Maniscalco P, et al. Hinged external fixation for complex fracture-dislocation of the elbow in elderly people. Injury (2014), http://dx.doi.org/10.1016/j.injury.2014.10.024
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JINJ-5922; No. of Pages 5 4
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Fig. 3. Postoperative free ROM: (A) case 14 and (B) case 1.
opioid drugs to control postoperative pain. The fixator screws were removed without any anaesthesia in 50% of the patients. At 12 months after surgery, only 10 patients reported low-level pain. There were no other reports of pain. Six patients had residual pain of level 1 on the VAS, three patients of level 2 and one patient
of level 3 (Table 2). There was no disability in daily activities and none of the patients regularly used drugs for pain relief. In only two patients (14 and 18), ligament tests were positive for residual laxity in valgus and varus, which was addressed with a functional elbow brace.
Fig. 4. Physical examination and X-ray films taken after removal of hinged external fixator: (A) case 14 at the moment of screw removal and (B) case 1 at 12 months after the trauma.
Please cite this article in press as: Maniscalco P, et al. Hinged external fixation for complex fracture-dislocation of the elbow in elderly people. Injury (2014), http://dx.doi.org/10.1016/j.injury.2014.10.024
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JINJ-5922; No. of Pages 5 P. Maniscalco et al. / Injury, Int. J. Care Injured xxx (2014) xxx–xxx
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Table 2 Clinical results at 12 month after surgery. No.
Patients and age
Pain (0–10)
ROM (flex–exten)
ROM (prono-sup)
Valgus stress
Varus stress
Valgus deformity
Varus deformity
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19
BA woman 80 years old FM woman 70 years old BL woman 67 years old MM woman 76 years old GB woman 72 years old BA woman 69 years old RV woman 79 years old CD woman 68 years old SV woman 78 years old ME woman 77 years old CF woman 71 years old SI woman 65 years old LM man 73 years old MG man 78 years old RF man 81 years old GT man 79 years old HA man 82 years old TD woman 66 years old EG man 71 years old
0 0 1 0 1 0 1 0 0 1 2 0 2 3 1 0 2 0 1
0–1308 0–1208 5–1108 0–1308 0–1308 0–1408 0–1208 0–1408 5–1108 5–120 0–1208 0–1358 5–1258 0–1308 0–1008 5–1358 7–1308 15–1208 10–1158
80–808 80–708 60–708 70–708 60–708 90–908 60–708 80–808 60–508 70–708 80–708 70–708 75–758 70–808 80–708 70–608 70–708 70–608 80–608
None None None None None None None None None None
None None None None None None None None None None
None None None None None None None None None None None 38 58 78 None 58 None 58 None
None None None None None None None None None None None None None None 58 None None None None
Discussion Articulated external fixation of the elbow is a relatively old procedure that was introduced by Volkov and Oganesian in the late 1970s as a support to articular surface reconstruction in the treatment of stiff joints. In the last two decades, the indications for articulated external fixation have developed not only in the field of reconstruction, but also in trauma surgery [8,11,12]. Current indications include acute and recurrent instability after osteosynthesis with or without ligament repair, chronic dislocations, distraction arthroplasty, open articular fractures around the elbow or complex fracture-dislocations in non-compliant patients [13]. Another possible indication for articulated external fixation of the elbow is complex lesions in elderly people. This patient population often presents with local or general risk factors that can be associated with an increased complication rate when using a standard approach, such as arthroplasty or ORIF. The weak bone (osteoporotic or osteopenic) or unstable soft tissues (open lesions or bad skin) often presented by elderly patients can compromise the stability of the osteosynthesis or the ligament reconstruction. In these cases, the articulated external fixator is the only device that can guarantee joint stability and early joint movement. Moreover, it is possible to limit the surgical approach to obtain optimal joint reduction with minimal internal fixation and a simple alignment of the metaphyseal fragments (case 1) because the fixator, if properly applied, can neutralise all the dislocating forces around the elbow. This mechanical support, as shown by the results of the current study and the literature [9,10,12], can guarantee bone and soft tissue healing while avoiding secondary displacement or residual deformities. This facilitates the postoperative rehabilitation phase (less pain and protected motion) and limits the risk of early or late complications (infection, re-dislocation, stiffness or chronic instability). The long-term ROM and functional results shown in this study support the validity of this strategy in elderly patients who frequently live alone and ask to be independent even during their convalescence. The good tolerance of the fixator and the low
+ +
pin-tract infection rate confirm that the potential complications with external fixation are limited. Nevertheless, only a precise technique of application and a specific follow-up protocol can guarantee good short- and long-term outcomes.
Conflicts of interest The authors have no conflict of interest.
References [1] Tarassoli P, McCann P, Amirfeyz R. Complex instability of the elbow. Injury 2013 [Epub ahead of print]. [2] Giannicola G, Polimanti D, Bullitta G, Sacchetti FM, Cinotti G. Critical time period for recovery of functional range of motion after surgical treatment of complex elbow instability: prospective study on 76 patients. Injury 2014;45(3):540–5. [3] Josefsson PO, Nilsson BE. Incidence of elbow dislocation. Acta Orthop Scand 1986;57:537–8. [4] Hildebrand KA, Patterson SD, King GJ. Acute elbow dislocations: simple and complex. Orthop Clin North Am 1999;30:63–79. [5] Ring D, Jupiter JB. Fracture-dislocation of the elbow. J Bone Joint Surg Am 1998;80:566–80. [6] Stavlas P, Gliatis J, Polyzois V, Polyzois D. Unilateral hinged external fixator of the elbow in complex elbow injuries. Injury 2004;35:1158–66. [7] McKee MD, Bowden SH, King GJ, Patterson SD, Jupiter JB, Bamberger HB, et al. Management of recurrent, complex instability of the elbow with a hinged external fixator. J Bone Joint Surg Br 1998;80:1031–6. [8] Tan V, Daluiski A, Capo J, Hotchkiss R. Hinged elbow external fixators: indications and uses. J Am Acad Orthop Surg 2005;13(8):503–14. [9] Jupiter J, Ring D. Treatment of unreduced elbow dislocations with hinged external fixation. J Bone Joint Surg Am 2002;84-A(9):1630–5. [10] Deuel C, Wolinsky P, Schepherd E, Hazelwood SJ. The use of hinged external fixation to provide additional stabilization for fractures of the distal humerus. J Orthop Trauma 2007;21(5):323–9. [11] Nielsen D, Nowinsky RJ, Bamberger HB. Indications alternatives and complications of external fixation about the elbow. Hand Clin 2002;18(1):87–9. [12] Pennig D, Gausepohl T, Mader K. Transarticular fixation with the capacity for motion in fracture dislocations of the elbow. Injury 2000;31(Suppl. 1): 35–44. [13] Berendes S, Zilkens C, Anastasiadis A, Graf M, Muhr G, Kalicke T. Additional external hinged fixator after open repositioning and internal fixation of acute elbow instability in non-compliant patients. Orthop Rev 2010;2:e21.
Please cite this article in press as: Maniscalco P, et al. Hinged external fixation for complex fracture-dislocation of the elbow in elderly people. Injury (2014), http://dx.doi.org/10.1016/j.injury.2014.10.024
JINJ-5922; No. of Pages 5 Injury, Int. J. Care Injured xxx (2014) xxx–xxx
Contents lists available at ScienceDirect
Injury journal homepage: www.elsevier.com/locate/injury
Hinged external fixation for complex fracture-dislocation of the elbow in elderly people P. Maniscalco a, A.L. Pizzoli b,*, L. Renzi Brivio b, M. Caforio a,** a b
Department of Orthopaedics and Traumatology, Guglielmo da Saliceto Hospital, Piacenza, Italy Department of Orthopaedics and Traumatology, C. Poma Hospital, Mantua, Italy
A R T I C L E I N F O
A B S T R A C T
Keywords: Hinged external fixator Elbow fracture in elderly Complex elbow fracture-dislocation
The authors report their experience of treating complex elbow fracture-dislocations in elderly people, using a minimally-invasive approach with a new articulated external fixator that is associated with minimal internal fixation. The clinical results for 19 patients are presented according to outcome factors, such as range of motion, pain and function, rate and type of complications, and reoperation rate. The results indicate that this treatment strategy should be considered as a good alternative to other treatment options reported in the literature, including conservative treatment, ORIF with angular stable plates and total elbow arthroplasty. ß 2014 Elsevier Ltd. All rights reserved.
Introduction The treatment and the risk–benefit evaluation of traumatic lesions of the elbow are based on a correct preoperative assessment of bone and/or soft tissue lesions to distinguish the different patterns of instability, and on the type of patient to be treated. The term ‘‘complex lesion of the elbow’’ identifies a possible clinical scenario of articular and periarticular mechanical instability because of bone, ligament and/or soft tissue lesions that is difficult to assess with the ordinary classifications [1,2]. Elbow dislocation is the second most common dislocation in adults, after the shoulder, with an annual estimated incidence of six in 100,000 [3]. Dislocation of the elbow can be simple, with no fractures, or complex, with bone structure involvement [4]. The most common elbow fracture sites are the olecranon, the coronoid process and the radial head. The latter two structures are the major bone stabilisers of the elbow. The incidence of fracture of these sites in patients with elbow dislocation is 36% for the radial head, 13% for the coronoid process and 4% for the olecranon [3]. The most common treatment of complex elbow fracture-dislocations is ORIF [5] and ligament repair (particularly lateral collateral ligaments [LCL]) with the aim to restore bone-articular surface and joint stability. Radial
* Corresponding author at: Ortopedia e Traumatologia Ospedale C. Poma, V. le Albertoni 1, 46100 Mantova, Italy. ** Corresponding author at: Ortopedia e Traumatologia Ospedale Guglielmo da Saliceto, Via Taverna 49, 29121 Piacenza, Italy. E-mail addresses: [email protected] (A.L. Pizzoli), [email protected] (M. Caforio).
head prosthesis is sometimes necessary when it is not possible to reconstruct this structure. A clinical examination at the end of surgery is mandatory to assess capsular and ligament structures and final stability. Instability or re-dislocation after surgery indicates the use of a hinged external elbow fixator [6–8] to enable early joint movement and prevent residual instability or stiffness. Although open surgery and ligament reconstruction have produced good results in common lesions, these procedures are often difficult and are sometimes associated with major complications, such as septic arthritis, wound failure or bone fragment necrosis, particularly in highly comminuted fractures and weak bone, like that in elderly people [8,9]. Elderly patients also often present with local or general risk factors that can be associated with increased complication rates when undergoing a standard approach, such as arthroplasty or ORIF. In these situations, a minimally-invasive surgery associated with an articulated external fixator should be considered as a possible alternative to other treatment options reported in the literature, including conservative treatment, ORIF with angular stable plates, and total elbow arthroplasty (TEA) [10,11]. The purpose of this prospective study is to evaluate whether the above strategy can guarantee early joint motion and good long-term function in elderly patients who often live alone and ask to be independent, and whether it minimises the risk of major complications. Materials and methods A total of 19 patients (13 women and 6 men) with an average age of 74.5 years were evaluated (Table 1). The inclusion criteria
http://dx.doi.org/10.1016/j.injury.2014.10.024 0020–1383/ß 2014 Elsevier Ltd. All rights reserved.
Please cite this article in press as: Maniscalco P, et al. Hinged external fixation for complex fracture-dislocation of the elbow in elderly people. Injury (2014), http://dx.doi.org/10.1016/j.injury.2014.10.024
G Model
JINJ-5922; No. of Pages 5 P. Maniscalco et al. / Injury, Int. J. Care Injured xxx (2014) xxx–xxx
2
Table 1 General data relative to the patients, their lesions and their treatments. No.
Patient
Sex
Age
Kind of lesion
Treatment
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19
BA FM BL MM GB BA RV CD SV ME CF SI LM MG RF GT HA TD EG
Woman Woman Woman Woman Woman Woman Woman Woman Woman Woman Man Man Woman Man Man Man Man Woman Man
80 70 67 76 72 69 79 68 78 77 76 83 78 65 81 79 82 66 71
Open fracture AO 1.3 C2 AO 1.3 C2 AO 1.3 C2 AO 1.3 C2 AO 2.1 C3 terrible triad AO 1.3 C2 AO 1.3 C2 Unstable postero-lateral elbow dislocation AO 2.1 C3 + elbow posterior dislocation AO 1.3 C3 AO 1.3 B1 + dislocation Terrible triad AO 1.3 B1 + elbow posterior dislocation Open dislocation + neurovascular lesion Monteggia’s fracture Coronoid fracture and elbow posterior dislocation Open dislocation + coronoid + N/V lesion AO 1.3 C2 AO 2.1 C3
F4 F4 F4 F4 F4 F4 F4 F4 F4 F4 F4 F4 F4 F4 F4 F4 F4 F4 F4
were age over 65 years with no previous dysfunction of the injured elbow, and the clinical indication to use an articulated external fixator for a posttraumatic bone and/or ligament instability. All patients were treated with a new, radiolucent, hinged external fixator (F4 Motion Citieffe1), which was designed to allow full range of motion (ROM) and joint distraction with minimal fixation, at Mantua and Piacenza Hospitals from 2008 to 2011. When necessary, joint distraction was applied using the fixator itself. According to the postoperative protocol, almost all patients were permitted to move their elbow in flexion–extension and prono-supination, as far as tolerated, the day after surgery. Passive mobilisation was made twice daily by a physiotherapist until
external external external external external external external external external external external external external external external external external external external
fixator and cannulated screws fixator, Kirschner wires and cannulated screws fixator and cannulated screws fixator and cannulated screws fixator and capitellectomy fixator and cannulated screws fixator and cannulated screws fixator and capsular-internal ligament reconstruction fixator and olecranon plate fixator and cannulated screws fixator and cannulated screws fixator and capitellectomy fixator and cannulated screws fixator fixator and radial plate fixator fixator fixator and cannulated screws fixator and cannulated screws
discharge. Articular ROM was limited to between 708 and 1108 in two patients because of the complexity of the fracture and soft tissue lesions. Three weeks after surgery the hinged external fixator was unlocked, and full elbow flexion–extension was permitted in all patients. The rehabilitation programme, including active and passive mobilisation, was continued to achieve full ROM and to enable complete healing of the soft tissues involved in the injury. The duration and intensity of the programme were customised according to the specific needs of the patients. Patients were evaluated with a dedicated form that included items relating to the classification of the different types of bone and soft tissue lesions, the type of operation performed (Table 1), and the radiological and clinical outcomes at 3, 6, 9 and 12 weeks
Fig. 1. Case 14: AP and lateral radiographs (A1), and the clinical picture (A2) of a patient with coronoid fracture and open grade 3C elbow dislocation (neurovascular lesion). Case 1: AP and lateral radiographs (B1), and the clinical picture (B2) of a patient with a distal humeral AO 1.3 C2 grade 2 open fracture.
Please cite this article in press as: Maniscalco P, et al. Hinged external fixation for complex fracture-dislocation of the elbow in elderly people. Injury (2014), http://dx.doi.org/10.1016/j.injury.2014.10.024
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Fig. 2. Postoperative X-ray controls: (A1 and A2) joint reduction and neurovascular + soft tissue repair + F4 motion application (case 14). (B) Percutaneous reduction and osteosynthesis + F4 motion with limited distraction used to neutralise flexion–extension forces of the elbow (case 1).
and long-term follow-up (12 months). X-ray and clinical examination to determinate ROM and joint stability were performed at all timepoints. Neurological evaluation was performed by a specialist. Pain at long-term follow-up was evaluated using the visual analogue scale (VAS, 0–10). Fixator screws were removed under local or general anaesthesia.
The hinged external fixator was removed after 8 weeks in case 14 and after 9 weeks in case 1. Physiotherapy was continued for at least another 6 weeks and was associated with good functional improvement, as shown at long-term follow-up (Fig. 4).
Clinical cases
The most common lesions presented in the study were comminuted articular fractures with weak bone or fracturedislocation; a few patients had open fractures with high risk of complications (cases 1, 14 and 17, Table 1). The average time of fixation was 7 weeks (range 6–12 weeks), the average ROM obtained with the fixator ranged between 208 and 1188 and was improved at follow-up (3–1208), and the average prono-supination ranged from 728 to 738. Two patients required plastic surgery and nerve transplant during the follow-up period. Adjunctive surgery during this period was not necessary in the remaining patients. There were no losses of reduction, residual instability or major complications (septic arthritis, osteitis, implant failure or posttraumatic deformity) in the study. The pin track infection rate was 3.8% and resolved with frequent local dressing and shortterm oral antibiotic therapy. One pin had to be removed from one patient because of early loosening; there was no consequent implant instability. There were no patient reports of limited tolerance to the external fixator, and none of the patients used
Two clinical cases are presented from first assessment (Fig. 1) to long-term follow-up (Fig. 4). The surgical approach in both cases was based on minimallyinvasive reduction and osteosynthesis with Kirshner wires or cancellous cannulated screws, followed by the application of an articulated external fixator (F4 Motion Citieffe1) (Fig. 2). This fixator has a radiolucent articulated unit to visualise, under image intensifier, the placement in the joint of 2 mm guide wires in the centre of rotation of the elbow to provide a correct articular movement. The distal arch of the fixator enables the placement of ulnar screws in the posterior aspect of the forearm without any soft tissue transfixion, thereby avoiding any limits for prono-supination. The day after surgery, patient 1 was permitted free motion of the joint while for patient 14, mobilisation was limited to a maximum of 1108 flexion and 608 extension. Prono-supination was free, as tolerated by pain: after 3 weeks free ROM was permitted in all patients (Fig. 3).
Results
Please cite this article in press as: Maniscalco P, et al. Hinged external fixation for complex fracture-dislocation of the elbow in elderly people. Injury (2014), http://dx.doi.org/10.1016/j.injury.2014.10.024
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Fig. 3. Postoperative free ROM: (A) case 14 and (B) case 1.
opioid drugs to control postoperative pain. The fixator screws were removed without any anaesthesia in 50% of the patients. At 12 months after surgery, only 10 patients reported low-level pain. There were no other reports of pain. Six patients had residual pain of level 1 on the VAS, three patients of level 2 and one patient
of level 3 (Table 2). There was no disability in daily activities and none of the patients regularly used drugs for pain relief. In only two patients (14 and 18), ligament tests were positive for residual laxity in valgus and varus, which was addressed with a functional elbow brace.
Fig. 4. Physical examination and X-ray films taken after removal of hinged external fixator: (A) case 14 at the moment of screw removal and (B) case 1 at 12 months after the trauma.
Please cite this article in press as: Maniscalco P, et al. Hinged external fixation for complex fracture-dislocation of the elbow in elderly people. Injury (2014), http://dx.doi.org/10.1016/j.injury.2014.10.024
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Table 2 Clinical results at 12 month after surgery. No.
Patients and age
Pain (0–10)
ROM (flex–exten)
ROM (prono-sup)
Valgus stress
Varus stress
Valgus deformity
Varus deformity
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19
BA woman 80 years old FM woman 70 years old BL woman 67 years old MM woman 76 years old GB woman 72 years old BA woman 69 years old RV woman 79 years old CD woman 68 years old SV woman 78 years old ME woman 77 years old CF woman 71 years old SI woman 65 years old LM man 73 years old MG man 78 years old RF man 81 years old GT man 79 years old HA man 82 years old TD woman 66 years old EG man 71 years old
0 0 1 0 1 0 1 0 0 1 2 0 2 3 1 0 2 0 1
0–1308 0–1208 5–1108 0–1308 0–1308 0–1408 0–1208 0–1408 5–1108 5–120 0–1208 0–1358 5–1258 0–1308 0–1008 5–1358 7–1308 15–1208 10–1158
80–808 80–708 60–708 70–708 60–708 90–908 60–708 80–808 60–508 70–708 80–708 70–708 75–758 70–808 80–708 70–608 70–708 70–608 80–608
None None None None None None None None None None
None None None None None None None None None None
None None None None None None None None None None None 38 58 78 None 58 None 58 None
None None None None None None None None None None None None None None 58 None None None None
Discussion Articulated external fixation of the elbow is a relatively old procedure that was introduced by Volkov and Oganesian in the late 1970s as a support to articular surface reconstruction in the treatment of stiff joints. In the last two decades, the indications for articulated external fixation have developed not only in the field of reconstruction, but also in trauma surgery [8,11,12]. Current indications include acute and recurrent instability after osteosynthesis with or without ligament repair, chronic dislocations, distraction arthroplasty, open articular fractures around the elbow or complex fracture-dislocations in non-compliant patients [13]. Another possible indication for articulated external fixation of the elbow is complex lesions in elderly people. This patient population often presents with local or general risk factors that can be associated with an increased complication rate when using a standard approach, such as arthroplasty or ORIF. The weak bone (osteoporotic or osteopenic) or unstable soft tissues (open lesions or bad skin) often presented by elderly patients can compromise the stability of the osteosynthesis or the ligament reconstruction. In these cases, the articulated external fixator is the only device that can guarantee joint stability and early joint movement. Moreover, it is possible to limit the surgical approach to obtain optimal joint reduction with minimal internal fixation and a simple alignment of the metaphyseal fragments (case 1) because the fixator, if properly applied, can neutralise all the dislocating forces around the elbow. This mechanical support, as shown by the results of the current study and the literature [9,10,12], can guarantee bone and soft tissue healing while avoiding secondary displacement or residual deformities. This facilitates the postoperative rehabilitation phase (less pain and protected motion) and limits the risk of early or late complications (infection, re-dislocation, stiffness or chronic instability). The long-term ROM and functional results shown in this study support the validity of this strategy in elderly patients who frequently live alone and ask to be independent even during their convalescence. The good tolerance of the fixator and the low
+ +
pin-tract infection rate confirm that the potential complications with external fixation are limited. Nevertheless, only a precise technique of application and a specific follow-up protocol can guarantee good short- and long-term outcomes.
Conflicts of interest The authors have no conflict of interest.
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Please cite this article in press as: Maniscalco P, et al. Hinged external fixation for complex fracture-dislocation of the elbow in elderly people. Injury (2014), http://dx.doi.org/10.1016/j.injury.2014.10.024