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Recurrent dislocation of the elbow in identical twins
CASE REPORTS
Recurrent dislocation of the elbow in identical twins Umberto G. Fazzi, FRCS, and Lech A. Rymaszewski, MSc, FRCS,
Glasgow, Scotland In 1966 Osborne and Cotterill 4 stated that the essential pathologic defect causing recurrent dislocation of the elbow is the failure of the posterolateral ligamentous and capsular structures to become reattached after being torn or stretched at the time of the initial traumatic dislocation. A pocket is therefore formed into which the head of the radius dislocates and the ulna follows. They reported no recurrences in eight cases after reattaching the posterolateral ligament and plicating the capsule. Symeonides et al. r and Hassman et al. 1 agreed with this explanation and together treated seven cases with lateral soft-tissue repair From the Department of Orthopaedic Surgery, Stobhill NHS Trust. Reprint requests: Umberto G. Fazzi, FRCS, 84 Mansionhouse Gardens, Langside, Glasgow G41 3DP, Scotland J SHOULDERELBOWSURG 1996;5:401-3. Copyright 9 1996 by Journal of Shoulder and Elbow Surgery Board of Trustees. 1058-2746/96/$5.00 + 0 3 2 / ! / 7 1 6 3 2
with no recurrences. These series concluded that inadequate immobilization after a simple dislocation prevents the soft tissues from healing and predisposes the elbow to recurrent dislocation. They recommended that after reduction of a simple dislocation, the elbow should be immobilized for at least 3 weeks to allow healing. This method of treatment is widely used. However, series published by Protzman 5 and Mehloff et a17 demonstrated a more rapid recovery with less stiffness, if immobilization was limited to a few days to overcome the acute pain. They had no problems with instability or recurrent dislocations. We report identical twins with recurrent dislocation of their right elbows who have additional features of this uncommon condition.
CASE REPORTS Case 1. A 14-year-old identical twin had six recurrent episodes of posterolateral dislocation of
Figure 1 Posteriorsubluxation of unaffected elbow. 401
402
Fazzi and Rymaszewski
J. ShoulderElbow Surg. September~October 1996
Figure 2 Articular defect on posterior aspect of capitellum (capitellum to left and radial head to right). her right elbow; the initial injury had occurred when she was 11 years old. Clinical examination revealed bilateral cubitus varus of 10 ~ and bilateral hyperextension of 20 ~ with flexion to 150 ~ Plain x-ray films were normal. No evidence of hypermobility of any other joints was seen. A computed tomography arthrogram performed before the operation showed a lax capsule. Examination with the patient under anesthesia revealed an easily dislocatable elbow at 25 ~ of flexion. On examination of the elbow with no symptoms it was also possible to subluxate it (Figure 1). Arthrotomy of the right elbow showed a lax capsule but no stripping of the lateral ligament from the posterior aspect of the lateral condyle. Some incongruity of the radial head was seen posteriorly. The lateral structures were dissected from the capitellum, tightened, and reattached in a manner similar to that described by Osborne and Cotterill. 4 The elbow was then immobilized for 4 weeks. At review 2 years after the operation both elbows have no symptoms, and no further episodes of dislocation have occurred. Case 2. The previously mentioned patient's sister had had approximately 12 dislocations of her right elbow; the first had occurred at the age of 10 years. Clinical examination was similar to that of the patient's sister. She had a carrying angle of 10 ~ varus bilaterally. She was able to hyperextend both elbows 15 ~ with flexion to 150 ~. Plain x-ray films were normal. She had no other hypermobile
joints. A computed tomography arthrogram was also performed on this twin. Examination with the patient under anesthesia confirmed that dislocation occurred in a similar position to that of her sister. The elbow with no symptoms was also found to be unstable. Arthrotomy again showed a lax capsule with some irregularity of the radial head posteriorly. There was also a flattened area on the posterior aspect of the capitellum, where the radial head had rested when dislocated (Figure 2). The soft tissues were repaired with a similar technique used with her sister. Her elbow was then immobilized for 4 weeks. She has now been reviewed for 2 years since surgery and has had one episode of dislocation after significant trauma. DISCUSSION Morrey and An 3 demonstrated that the elbow is an inherently stable joint, and this stability is due in virtually equal measure to the congruous articular surfaces and the soft tissues. This explains the stability after a simple dislocation and why recurrent instability problems are rare. The question of why they occur in certain cases does not seem to have been fully explained. Patients with hypermobility syndromes are more likely to have recurrent dislocations of their joints, and many of these patients can be easily identified on clinical evaluation. None of the reports concerning recurrent elbow dislocation mentions whether this was a contributing factor. Although
J. Shoulder Elbow Surg. Volume 5, Number 5
the twins did not have generalized joint laxity, their unaffected elbows could be subluxated while they were under general anesthesia. This finding in identical twins suggests that a genetic factor may predispose some individuals to recurrent elbow dislocation irrespective of the duration of immobilization, and this certainly merits further investigation. REFERENCES 1. Hassman GC, Brunn F, Neer CS. Recurrent dislocation of the elbow. J Bone Joint Surg Am 1975;57A: 1080-4.
Fazzi and Rymaszewski
403
2. Mehlhoff TL, Noble PC, BennetjB, Tullos HS. Simple dislocation of the e)bow in the adult. Results after closed treatment. J Bone Joint Surg Am 1988;70A:244-9. 3. Morrey BF, AN K-N. Articular and ligamentous cantribution to the stability of the elbow joint. Am J Sports Med 1983;11 : 315-9. 4. Osborne G, Cotterill I~ Recurrent dislocation of the elbow. J Bone Joint Surg Br 1966;488:340-6. 5. Protzman RR. Dislocation of the elbow ioint. J Bone Joint Surg Am 1978;60A:539-41. 6. Symeonides PP, Paschaloglou C, Stavrou Z, Pangalides TH. Recurrent dislocation of the elbow. Report of three cases. J Bone Joint Surg Am 1975;57A; 1084-6.
Recurrent dislocation of the elbow in identical twins Umberto G. Fazzi, FRCS, and Lech A. Rymaszewski, MSc, FRCS,
Glasgow, Scotland In 1966 Osborne and Cotterill 4 stated that the essential pathologic defect causing recurrent dislocation of the elbow is the failure of the posterolateral ligamentous and capsular structures to become reattached after being torn or stretched at the time of the initial traumatic dislocation. A pocket is therefore formed into which the head of the radius dislocates and the ulna follows. They reported no recurrences in eight cases after reattaching the posterolateral ligament and plicating the capsule. Symeonides et al. r and Hassman et al. 1 agreed with this explanation and together treated seven cases with lateral soft-tissue repair From the Department of Orthopaedic Surgery, Stobhill NHS Trust. Reprint requests: Umberto G. Fazzi, FRCS, 84 Mansionhouse Gardens, Langside, Glasgow G41 3DP, Scotland J SHOULDERELBOWSURG 1996;5:401-3. Copyright 9 1996 by Journal of Shoulder and Elbow Surgery Board of Trustees. 1058-2746/96/$5.00 + 0 3 2 / ! / 7 1 6 3 2
with no recurrences. These series concluded that inadequate immobilization after a simple dislocation prevents the soft tissues from healing and predisposes the elbow to recurrent dislocation. They recommended that after reduction of a simple dislocation, the elbow should be immobilized for at least 3 weeks to allow healing. This method of treatment is widely used. However, series published by Protzman 5 and Mehloff et a17 demonstrated a more rapid recovery with less stiffness, if immobilization was limited to a few days to overcome the acute pain. They had no problems with instability or recurrent dislocations. We report identical twins with recurrent dislocation of their right elbows who have additional features of this uncommon condition.
CASE REPORTS Case 1. A 14-year-old identical twin had six recurrent episodes of posterolateral dislocation of
Figure 1 Posteriorsubluxation of unaffected elbow. 401
402
Fazzi and Rymaszewski
J. ShoulderElbow Surg. September~October 1996
Figure 2 Articular defect on posterior aspect of capitellum (capitellum to left and radial head to right). her right elbow; the initial injury had occurred when she was 11 years old. Clinical examination revealed bilateral cubitus varus of 10 ~ and bilateral hyperextension of 20 ~ with flexion to 150 ~ Plain x-ray films were normal. No evidence of hypermobility of any other joints was seen. A computed tomography arthrogram performed before the operation showed a lax capsule. Examination with the patient under anesthesia revealed an easily dislocatable elbow at 25 ~ of flexion. On examination of the elbow with no symptoms it was also possible to subluxate it (Figure 1). Arthrotomy of the right elbow showed a lax capsule but no stripping of the lateral ligament from the posterior aspect of the lateral condyle. Some incongruity of the radial head was seen posteriorly. The lateral structures were dissected from the capitellum, tightened, and reattached in a manner similar to that described by Osborne and Cotterill. 4 The elbow was then immobilized for 4 weeks. At review 2 years after the operation both elbows have no symptoms, and no further episodes of dislocation have occurred. Case 2. The previously mentioned patient's sister had had approximately 12 dislocations of her right elbow; the first had occurred at the age of 10 years. Clinical examination was similar to that of the patient's sister. She had a carrying angle of 10 ~ varus bilaterally. She was able to hyperextend both elbows 15 ~ with flexion to 150 ~. Plain x-ray films were normal. She had no other hypermobile
joints. A computed tomography arthrogram was also performed on this twin. Examination with the patient under anesthesia confirmed that dislocation occurred in a similar position to that of her sister. The elbow with no symptoms was also found to be unstable. Arthrotomy again showed a lax capsule with some irregularity of the radial head posteriorly. There was also a flattened area on the posterior aspect of the capitellum, where the radial head had rested when dislocated (Figure 2). The soft tissues were repaired with a similar technique used with her sister. Her elbow was then immobilized for 4 weeks. She has now been reviewed for 2 years since surgery and has had one episode of dislocation after significant trauma. DISCUSSION Morrey and An 3 demonstrated that the elbow is an inherently stable joint, and this stability is due in virtually equal measure to the congruous articular surfaces and the soft tissues. This explains the stability after a simple dislocation and why recurrent instability problems are rare. The question of why they occur in certain cases does not seem to have been fully explained. Patients with hypermobility syndromes are more likely to have recurrent dislocations of their joints, and many of these patients can be easily identified on clinical evaluation. None of the reports concerning recurrent elbow dislocation mentions whether this was a contributing factor. Although
J. Shoulder Elbow Surg. Volume 5, Number 5
the twins did not have generalized joint laxity, their unaffected elbows could be subluxated while they were under general anesthesia. This finding in identical twins suggests that a genetic factor may predispose some individuals to recurrent elbow dislocation irrespective of the duration of immobilization, and this certainly merits further investigation. REFERENCES 1. Hassman GC, Brunn F, Neer CS. Recurrent dislocation of the elbow. J Bone Joint Surg Am 1975;57A: 1080-4.
Fazzi and Rymaszewski
403
2. Mehlhoff TL, Noble PC, BennetjB, Tullos HS. Simple dislocation of the e)bow in the adult. Results after closed treatment. J Bone Joint Surg Am 1988;70A:244-9. 3. Morrey BF, AN K-N. Articular and ligamentous cantribution to the stability of the elbow joint. Am J Sports Med 1983;11 : 315-9. 4. Osborne G, Cotterill I~ Recurrent dislocation of the elbow. J Bone Joint Surg Br 1966;488:340-6. 5. Protzman RR. Dislocation of the elbow ioint. J Bone Joint Surg Am 1978;60A:539-41. 6. Symeonides PP, Paschaloglou C, Stavrou Z, Pangalides TH. Recurrent dislocation of the elbow. Report of three cases. J Bone Joint Surg Am 1975;57A; 1084-6.