Non-splinting treatment of elbow joint injuries

NON4PLINTING

TREATMENT

A REPORT

THOMAS A. SurgicaI Resident,

OF ELBOW JOINT INJURIES*

OF ITS USE IN TWENTY

-BOUTROUS, M.D.,

CASES

ALEXANDER

Redford Receiving Hospital

BLAIN

III,

M.D.

FelIow in Medicine, Wayne University College of Medrcine AND

W. Attending

A.

CHIPMAN,

M.D.

Surgeon, Redford Branch of Detroit Receiving Hospital DETROIT,

MICHIGAN

C

ONVENTIONAL methods of treating injuries and fractures about the eIbow joint Ieave much to be desired. These injuries are often foIIowed by undesirabIe sequeIae ranging from various degrees of dysfunction to the dreaded ischemic contractures of Volkman. Downer’ states that “at the AIexander BIain Hospita1 conventiona spIinting of eIbow joint fractures has not Ied to entirely satisfactory resuIts by any means.” This is true in the experience of numerous other surgeons. GouId,2 as quoted by Neuwrith, beIieves that these compIications are often due to the generaIIy accepted methods of treatment. He says : “The most successful treatment is prevention, and this means avoidance of circuIar bandages and avoidance of acute ffexion in the presence of sweIIing.” Neuwrith,3 in 1942, presented five cases of fractures about the elbow joint treated by pIacing the arm in a sIing and by encouraging earIy active and passive motion. He was stimuIated to attempt this unaccepted method of treatment by the poor resuIts obtained in a case in which the usua1 spIinting procedure was used. The foIIowing types of fracture were treated with exceIIent resuIts in his series: Case I. (a) A cornminuted fracture of the IateraI condyIe with sIight dispIacement upward, IateraIIy and backward extending through the IateraI portion of the capiteIIum into the joint proper. (b) SimpIe * From the Redford Branch of Detroit 212

avuIsion fracture, media1 epicondyIe, with dispIacement downward and backward. Case 2. SimpIe cornminuted fracture through the base of the oIecranon process of the Ieft uIna, the fragments being in good position. Case 3. SimpIe cornminuted fracture of right cIavicIe and simpIe cornminuted fracture of the olecranon process of the right ulna. Case 4. SimpIe compIete fracture of the epicondyIe of the Ieft humerus and simpIe complete dislocation of the left eIbow. Case 3. Cornminuted fracture through the head of the Ieft radius with no appreciabIe separation of fragments. On the basis of these cases he said: “It is my opinion that the non-fixing type of treatment in fractures of the elbow may be appIied in a11 cases with profit and with greater restoration of norma function and should be the ruIe, with fixation and spIinting the exception.” His concIusions were these: (I) Since the fractured segments in fractures of the elbow are not Iong enough to be manipulated in reduction, the non-fixing methods shouId be the treatment of choice. (2) Interference with the circuIation about the elbow, brought about by the appIication of pIaster casts, tight bandages, and the Iike, is responsible for many of the compIications and the high degree of dysfunction resuIting from the fixation treatment. (3) Greater restoration of function was attained by this method in the series of cases presented. (4) The Receiving HospitaI, Detroit,

Mich.

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method may be used in the treatment children as we11 as adults. O’Donoghue 4 has taken exception these conclusions and beIieves that

of to

a11 eIbow joint injuries cannot be Iumped together and be treated by this method routinely. It is his opinion that five cases is not a large enough series upon which to base such broad concIusions and that the treatment of these injuries shouId not be oversimplified. He says: “It may we11 be that nonsplinting may be the answer to many types of fracture of the eIbow. Certainly, I beheve that there are many types of fractures to which it will not appIy. Let us hope that it wiI1 not be adopted indiscriminateIy unti1 more research has been carried out as to its indications and advantages.” The folIowing is a report of twenty cases to which the principIe of non-sphnting has been appIied, either to the exclusion of or in conjunction with other therapy. We believe that our resuIts in these cases have been astonishing as compared with the resuIts in patients whom we have treated with splinting methods. The series was started independentIy of Neuwrith’s work because of the following experience

of one of us (T.A.B.): CASE

REPORTS

In September, 1941, a seventy-nine year old white maIe was admitted to the Redford Branch of the Detroit Receiving Hospital with a compound cornminuted fracture of the lower end of the humerus caused by a fall down the stairs. The x-ray report was as follows:-“there is a ‘T’ fracture of the lower end of the humerus. In the AP view there is considerabIe widening of the joint because of separation of the condyIes. In the IateraI view the shaft of the humerus is dispIaced backward about 600/,. The position is not good.” The patient was taken to the operating room and the wound was thoroughIy debrided and irrigated under IocaI anesthesia. This was used because the patient was elderly and in shock. The wound was dressed without suturing after small spicules of the bone were removed. Because of the patient’s poor condition, the

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fragments were not readjusted. The neuroIogicaI examination was entireIy negative. The patient was given combined antitetanic and gas bacillus serum and sent to bed with his arm in a sIing. The foIIowing day a check ray was taken and there was a question of Bacillus Welchi infection. Consequently, splinting was delayed unti1 the possibility of BaciIIus Welchii infection was ruled out. It had been decided upon reviewing the origina x-rays that a splint wouId be applied in the position of optimal use and the joint be aIIowed to ankylose. However, after several days had elapsed and the possibiIity of Bacillus Welchii infection had been ruled out, it was noted that there was some voluntary active motion of the injured elbow on the part of the patient. Therefore, he was urged to continue both active and passive motion and was observed cIoseIy in the hospital and in the out-patient department for a considerable period of time. The patient was discharged to the out-patient department on September 17, 1941. An x-ray taken on January 30, 1943, showed : “Right elbow-there is an old compIeteIy healed ‘T’ fracture of the lower end of the humerus. Fragments are in good position and alignment.” The function in this joint was about go per cent perfect. The folIowing pictures ilIustrate the range of motion obtained. (Figs. I to 4.) While the patient was still in the hospital, it was decided to use the non-splinting method of treatment for other fractures about the elbow joint because of the exceIIent results noted, and because of the dysfunction so often encountered in the past with splinting methods. In a11the followingcases itwas obviousduring the first few days that the patients were timid about active and passive motion. Consequently, especially in the younger age group, AI1 the close observation was necessary. patients were encouraged to take the arm out of the sling four or five times a day and carry out either active and/or passive motion (a11 positions). The earlier the motion the better and more rapid was the restoration of function. A triangular sIing (Vernon5) was used for a11 the injuries about the elbow joint. Splinting methods were used in only four cases in this series, two of these being cases in which open reduction was necessitated. For the sake of convenience these cases are divided into two groups. Group I is composed of cases in which the displacement of fragments was minimal

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or absent and in which the non-splinting treatment was used exclusively. Group II is composed of the more comphcated cases.

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joint was exquisitely tender and surrounded by marked ecchymosis. The x-ray report was elbow-there is a supraas follows : “Right

FIG. I.

FIG.

2.

FIG. I. Pronation. FIG. 2. Supination. GROUP I-CASE I. B. H., a seventeen year old white female, was admitted on May 3, 1942, after injuring her right eIbow in a faII while ice skating. An x-ray revealed: “CompIete Iinear fracture of the head of the radius with fragments in perfect position.” She was followed for a period of severa months in the out-patient department and discharged with perfect function. CASE II. J. L., a six year old white femaIe, was seen on June 21, 1942, after having fallen, injuring her elbow, while at home. The elbow

condylar fracture of the humerus in perfect position.” The patient was seen several times in the out-patient department and was discharged on July 24, 1942, with perfect function. CASE III. C. S., a six year old white male, was seen on August 2, 1942, after having injured his left elbow in a faI1 from a tree. “Left elbow-there is The x-ray revealed: a juxtaepiphyseal supracondylar fracture of the latera condyle of the humerus with slight anterior anguIation of the dista1 fragment and the epiphysis of the capiteIIum.”

Boutrous

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The patient department

time

was followed until October

he was discharged

et a&Injuries

in the out-patient 17, 1942 at which

with perfect

function.

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sion of the lateral condyle of the humerus. This does not exclude a possible epiphyseal He was followed in the out-patient injury.”

FIG. 3.

FIG. 4.

FIG. 3. Extension. FIG. 4. Flexion. CASE IV. J. W., a fourteen year old white male, was seen on January 14, 1944, after having fallen, injuring his left elbow. The x-ray showed: “Left elbow-incomplete avulsion fracture of the lateral epicondylar epiphysis.” Th e patient was followed in the out-patient department until February 2, I 944, when he was discharged with perfect function. CASE v. R. B., a fifteen year old white maIe, was seen on October 23, 1943, after having injured his right elbow while wrestling. The x-ray showed: “Right elbow-small avul-

department until November 13, 1943, when he was discharged with complete function. C.4SE VI. C. D., a thirteen year old white male, was seen on October 6, 1943, after having injured his right elbow while playing football. The x-ray revealed: “ Right elbow-no apparent fracture. This does not exclude epiphyseal injury.” The patient had exquisite tenderness over the medial epicondyle on slightest paIpation. The clinical diagnosis was epiphyseal injury. He was discharged on October 20, 1943, with perfect function.

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D. S., a sixteen year old female, CASE VII. was seen on March 6, 1942, after having injured her left elbow in a faII from a porch. The x-ray showed: “Left eIbow-there is a minute avuIsion type of fracture of the coronoid of the uIna in exceIIent position.” She was foIlowed in the out-patient department and discharged in four weeks with perfect function. W. R., a sixteen year old female CASE VIII. was seen on October 7, 1942, after a faII whiIe injuring her elbow. The riding a bicycIe, “Right elbow-there is no x-ray showed: apparent fracture. This does not exclude epiThe clinical diagnosis was physea1 injury.” epiphysea1 injury on the basis of exquisite tenderness. She was seen in the out-patient department for four weeks, at which time she was discharged with perfect function. CASE IX. R. G., a tweIve year old maIe, was seen on August 17, 193.2, after having injured his Ieft elbow while at play. The x-ray fracture metashowed : “Left elbow-oblique physia1 portion of the externa1 condyle of the humerus with fragments in good position.” The patient was seen on January 30, 1943, after having been followed in the out-patient department, and was discharged with approximately 95 per cent function, there being some limitation of extension. Pronation, supination, and flexion were excellent. CASE x. J. K., a six year old male, was seen on September 30, 1942, after having injured his right elbow whiIe at pIay. The eIbow-there is a x-ray showed : “Right supracondylar fracture of the humerus with fragments in exceIIent position.” The patient was followed in the out-patient department until January 30, 1943, at which time he was discharged with perfect function. CASE XI. J. V., a six year oId female, was seen on December 3 I, 1941, after having injured her left arm while at pIay. The x-ray is sIight sepashowed : “Left elbow-there ration of the media1 epicondyIe of the left humerus.” The patient was followed in the out-patient department LntiI March 21, 1942, at which time she was discharged with perfect function. CASE XII. B. K., a fifteen year oId white femaIe was seen on January 7, 1943, after having sustained injury to the Ieft eIbow. The x-ray was reported thus: “Left eIbow-chip fracture of posterior surface of the Iower end of the humerus which has been dispIaced into the

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elbow joint.” She was folIowed for four weeks in the out-patient department and was discharged with perfect function. GROUP II. Cases in this group were of a more complex nature and four required some degree of splinting. CASE I. This was the seventy-nine year oId maIe, mentioned previousIy in this article. AIthough there was considerabIe dispIacement of the fragments, he was treated soIeIy by placing the arm in a triangular sIing. As can be seen from Figures I, 2, 3 and 4 and his x-ray report on January 30, 1943, his fina resuIt was excellent. CASE II. C. B., a white female, age fiftyseven, was admitted to the hospita1 on March I, 1943, after faIIing on and injuring her Ieft eIbow. She was obese and had hypertension (220/1 I 0). Physical examination reveaIed the patient holding her Ieft arm with about 90 degrees flexion of the eIbow. There was much ecchymosis and swelling with slight deformity and extreme tenderness over the olecranon process. The x-ray showed: “There is a badly comminuted fracture of the upper end of the ulna running obIiqueIy from the base of the coronoid process backward for the posterior-most corner of the ulna. The coronoid process is shattered and both, it and the olecranon, are dispIaced mesially, while the shaft of the ulna is dispIaced slightiy laterally. The fragments are in poor position.” On March 2, 1943, an attempt at reduction was made under sodium pentothal anesthesia. An x-ray showed some improvement in position, but stiI1 imperfect reduction. The second attempt at reduction on March 4, 1943, under gas and nitrous oxide anesthesia, was completely successful, and she was discharged to the out-patient department on March I 2, 1943. She was seen at three day intervaIs for several months. On her Iast visit, JuIy, 1943, there was 90 per cent fIexion and extension and perfect pronation and supination. In addition to the reduction of the fragments, the non splinting method was used. CASE III. F. R., a white male, age fourteen, was admitted January 25, 1943, after faIIing and injuring his Ieft elbow while playing at school. Physical examination reveaIed deformity of the Ieft elbow and there was extreme tenderness on the slightest paIpation. The x-ray showed : “Left elbour-anterior dislocation of the Iower end of the humerus at elbow joint. In addition there is a transverse fracture of the radius at the junction of the upper and

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middIe thirds with slight anterior anguIation.” The dislocation was reduced under inhalation anesthesia and a check x-ray showed:-“Reduction of dislocation at elbow joint accomplished. Fragments of radius are in good apposition and aIignment.” Because of associated fracture of the radius, some immobilization was deemed advisabIe. A posterior mold was applied from the middIe third of the humerus to the finger tips. The patient was discharged to the out-patient department on January 27, 1943. On January 30, 1943, the mold was removed and a short posterior moId, not including the elbow, was applied to the forearm. Active and passive motion was instituted. No vigorous exercises were possible because of the fractured radius. On February 20, 1943 the short mold was removed and vigorous exercises commenced; improvement was gradual. He was discharged on April 17, 1943, with excehent pronation and supination, complete flexion, and about 90 per cent extension. CASE IV. W. M., a white maIe, age twelve, was admitted June 16, 1943, after injuring his left eIbow in a fall from a tree. Physical examination revealed deformity and pain on palpation in the region of the left elbow. The x-ray revealed: “Left elbow-distal end of humerus is dislocated laterally at the elbow joint. There is a Iinear caIcium shadow under the distal end of the humerus which could represent an avulsion fracture but from the present films the donor site cannot be visualized. The possibiIity of epiphyseal injury cannot be excluded at this time.” Reduction, with inhalation anesthesia, under the fIuoroscope was done and a posterior mold applied. A check x-ray after reduction showed that almost perfect relationship had been re-established. He was discharged to the out-patient department on June 17, 1943, and on June 19, 1943, the posterior mold was removed. Active and passive motion was started, and he was discharged on July 24, 1943, with perfect function. CASE v. B. T., a white maIe, age thirteen, was admitted on June 12, 1943, after falling from a bicycle and injuring his left elbow, PhysicaI examination showed swelling with apparent deformity and the hand held in pronation. The x-ray showed: “Left eIbow-AP and IateraI views show compIete transverse fracture through the distal end of the shaft of the lateral portion of the humerus, with detachment of supracondyIar fragment and capiteIlar epiphysis and displacement of frag-

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ment upward, IateraIIy, and posteriorly.” Reduction was carried out under genera1 anesthesia and a posterior moId applied from the middle third of the humerus to the wrist. A check x-ray showed: “After reduction, an excehent anatomica realignment has been obtained.” The patient was discharged to the out-patient department on June 14, 1943. The spIint was removed on June 19, 1943, and active and passive motion begun. He was discharged on September I I, 1943, asymptomatic and with compIete function. In this case a splint was used for seven days. CASE VI. K. L., a white maIe, age sixteen, was admitted on December 27, 1943, after having injured his left elbow in a faI1 while ice skating. The physical examination showed exquisite tenderness over the area of the Ieft medial epicondyIe. An x-ray reveaIed: “Left elbow-there is an avuIsion fracture of the media1 epicondyle of the humerus which is displaced about 0.3 cm.” Management consisted of open reduction and re-alignment of the fragments by use of the singIe Sherman vitaIIium screw (I s/4 in.). The postoperative course was uneventfu1. There was no immobilization, active and passive motion being started immediateIy. He was discharged to the outpatient department on January I, 1944, and was followed until February 19, 1944, at which time he was discharged with compIete union and perfect function. CASE VII. F. F., a white maIe, age five, was admitted on January 8, 1944, after having injured his right eIbow in a fail from a bicycle. The physical examination reveaIed obvious disalignment of the eIbow joint with ecchymosis, swelling, etc. An x-ray showed: “Right elbow-there is a trans-condylar fracture of the humerus with almost compIete anterior displacement of the shaft of the huClosed reduction was done under merus.” genera1 anesthesia. A check x-ray showed the fragments in good position. A posterior mold was applied folIowing the open reduction. He was discharged to the out-patient department on January 9, 1944. The mold was removed on January 22, 1944, thirteen days later, and active and passive motion started. He was last seen on February 19, 1944, at which time excellent pronation and supination was exhibited-about 90 per cent flexion and 70 per The patient is still under cent extension. observation. (Note: The mold was used for thirteen days due to an oversight.)

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CASE VIII. hl. I\il., a white female, age thirty-seven, was admitted on July 22, 1942, after having injured her right elbow in fal!ing from a chair. The physical examination revealed a badly swollen, extremely tender elbow with obvious deformity. The x-ray showed: “ Right elbow-examination reveals a complete lateral disIocation of the forearm. There has been a badly cornminuted fracture of the lateral condyle of the humerus with about 2 cm. posterior displacement.” Reduction was done under general anesthesia. A check ?c-ray showed : “The latera dislocation of the forearm has been compIeteIy reduced. The com-

open reduction was necessary in two cases and temporary spIinting in four cases. However, the principles of early active and passive motion were employed in al1 of these cases with resufts, which we consider to be superior to the oIder method. In a11 cases eventual function of the elbow joint was excellent, and in a11 cases a trianguIar sIing was used. It is our observation that pronation and supination are the functions which return first. FIexion is next and extension returns last.

minuted fragments show wide separation and rotation. In the cubital fossa there is now a deposit of bony density (I by I cm.) which is

CONCLUSIONS

thought to be an avulsion chip off the media1 condyle as it is on the medial side. There is some posterior displacement of the lateral chip.” (The patient was discharged to the outpatient department on July 30, 1942, for observation.) Active and passive motion was commenced but the results were discouraging and open reduction was done on September 30, 1942. The fragment was removed, and nonsphnting treatment was continued. She was Iast seen on January 30, 1943, at which time there was excellent pronation, about 75 per cent supination and flexion and 80 per cent extension. COMMENTS

In a series of twenty cases of injuries of the eIbow joint, temporary immobiIization was empIoyed in onIy four cases. In these four cases, periods of immobiIization averaged 6.75 days. This average is too high because of the oversight in the case in which the moId was Ieft on inadvertentIy for thirteen days. In the tweIve cases of group I, in which there was IittIe or no dispIacement of fragments, non-sphnting with the trianguIar sIing was used exclusiveIy with exceIlent resuIts. In addition to these tweIve cases, five cases of Neuwrith’s3 are cited. In the eight cases of group II, in which the fractures are more compIex,

I. A series of twenty cases, injuries and fractures about the elbow joint, is presented in which exceIIent results were obtained in a11 age groups by the use of the non-spIinting method. 2. In fractures and epiphysea1 injuries about the elbow joint without dispIacement of fragments, this is the method of choice. 3. In fractures requiring reduction, occasional splinting was desired for rather brief periods of time (usuaIIy under one week) 4. It is recommended that the nonspIinting method of treating fractures and injuries about the elbow joint be more wideIy employed and the resuIts studied. Our resuIts lead us to the enthusiastic support of its use. However, we wouId caution against the indiscriminate use of the non-spIinting method in those complicated cases requiring reduction. REFERENCES I. DOWNER, IRA G. Persona1 communication. 2. GOULD, A. L. A neglected danger in the treatment of elbow fractures. Maine M. J., 27: I 16. 1036. 3. NEUWRITH, A. A. Nonsplinting t;eatm&tT,f frac-

tures of the elbow joint. J. A. M. A., I 18:

4. 5.

1942.

971,

D. H. Correspondence concerning ref. 3. J. A. M. A., 119: 746. 1942. VERNON, SIDNEY. Mod&cd sling for fractures about the eIbow. Am. J. Surg., 23: 335, 1934. O’DONAGHUE,