- Email: [email protected]
Treatment of old unreduced dislocation of the elbow
39
Injury. 8, 39-42
Treatment of old unreduced of the elbow S. Krishnamoorthy, Department
K. Bose and K. P. Wong
of Orthopaedic
Surgery, Singapore General Hospital
Summary
Twenty-six patients with old unreduced dislocation of the elbow treated by open reduction were reviewed. All patients improved after surgery. It is felt that any patient with an elbow dislocation which is less than 3 months old should be treated by open reduction. The operative technique using a medial and lateral approach and keeping the dissection extraperiosteal is described.
INTRODUCTION THE MANAGEMENT of old unreduced dislocation of the elbow is a challenging problem to orthopaedic surgeons, especially to those practising in developing countries. There is little literature dealing with this problem (Silva, 1958; Battacharya, 1964). Silva pointed out the problems andemphasized thepoor resultsof openreduction. The object of this paper is to review the results of open reduction for old unreduced dislocation of the elbow by the technique of extraperiosteal dissection, which has been used at the Singapore General Hospital over the last 10 years.
MATERIAL
AND
dislocation
METHODS
Twenty-six patients with old unreduced dislocation of the elbow seen over a lo-year period between 1965 and 1974 were reviewed (Table Z). There were 20 male and 6 female patients. Their ages ranged from 6 to 60 years but the majority were between 10 and 30 years. The elbow dislocation in all the patients was either posterior or posterolateral. In 9 there were associated fractures of the medial epicondyle (Cases 1, 2, 25 and 26) of the coronoid process (Cases 10, 15 and 18), of the capitulum (Case 3) and of the trochlear (Case 7).
All patients had been treated initially by medically unqualified bone-setters. The time interval between the injury and the operation is shown in Table If. This varied from 2 weeks to 8 months, the average being about 7 weeks.
OPERATIVE
TECHNIQUES
The patients in this series were operated on by different surgeons using the same basic technique. In 8 patients the approach was posterolateral and in the remaining 18 patients combined medial and lateral incisions were used. The patient lay supine with the forearm across the chest. A lateral incision of lo-12cm was made parallel to the lateral margin of the triceps, exposing the tip of the lateral epicondyle. The interval between the triceps posteriorly and the origins of the extensor carpi radialis longus and brachioradialis was developed. The radial nerve was protected in the proximal part of the wound. With a scalpel the common origin of the extensor was detached to expose the radiohumeral joint. Brachioradialis and extensor carpi radialis longus were separated by sharp dissection to expose the lateral aspect of the joint. The medial side of the joint was then approached by a medial incision about IO-12cmlong,behind themedialepicondyle. The ulnar nerve was isolated and retracted posteriorly. Soft tissues were dissected from the medial epicondyle by blunt dissection, and the anterior part of the capsule was exposed. Thickened capsule, fibrous tissue and myositic new bone was removed especially along the trochlear notch, olecranon fossa and coronoid fossa. The proper clearance of these sites was essential in achieving a stable reduction but care was taken not to damage the articular cartilage. It was
40
Injury:
Table 1. Old unreduced Case
dislocation
Age (years)
Sex
2 3 4 5 6 7 8 9 10 11 12 13 14 15
14 14 41 6 21 13 59 60 16 33 42 51 12 31 44
16 17
18 12
18 19 20 21 22 23 24 25 26
25 14 30 24 30 16 12 50 17
M M M F M F F F M M M M M F M M M M
no.
1
*FF =
fixed
Duration of injury
4 4 6 11
8 9 4 6 8 3
4 2 2 4 2
6 12 5 32 6 4 32 8 8
Duration of follow-up 32
weeks year 5 weeks 2 years 8f years
1
28 weeks 6; years 7 weeks 4 weeks 8 weeks 1 year 1 year 16 weeks 12 weeks 24 weeks 20 weeks 4 weeks 20 weeks 12 weeks 2 years 1; years 3 years 2 years 28 weeks 32 weeks 20 weeks
of
injury
Weeks
No. of cases
l-4 5-8 9-12 >I2
12 9 3 2
Surgery
Vol. ~/NO. 1
Elbow flexion (%) At last Preop. follow-up IO-15 O-70 20-50 O-40 ? 20-25 20-40 15-35 O-l 0 0 0 1 O-20 o-5 0
0 O-l 5 O-20 0 0 5-l 0 45-55 o-5 O-l 0 20-30 O-l 0 o-1 0
25-l 35 O-l 25 ? 30-90 40-I 30 60-I 30 50-I 40 ? ? 30-90 50-l 35 45-l 20 40-I 20-I
30 30
30-90 O-l 30 70-l 00 45-l 20 90’ FF* 15-l 40 30-I 40 O-l 30 35-l 05 45-90 20-I 35 25-l 20
deformity.
necessary to excise the radial head in 4 patients (all adults) to facilitate reduction. Transposition of the ulnar nerve was not necessary in any patient. The wounds were closed in layers and suction drainage was used for 2448 hours. Hydrocortisone instillation was not used in any patient. Table II. Duration
of Accident
of the elbow
(weeks)
flexion
the British Journal
Postoperatively
the elbow was immobilized in before active exercises were started. No elbow was manipulated during the postoperative period. The only significant postoperative complication encountered was nerve palsy. In 1 patient the 90” of flexion for 24weeks
radial nerve was involved and in 2 other patients the ulnar nerves were involved. A11 the nerve palsies recovered within 6 weeks.
RESULTS In classifying the results, emphasis was placed on the active range of movement and on the stability of the elbow. The return of elbow function was graded as follows: Good: flexion range 90” or more; loss of extension 30” or less; no pain or instability (Fig. 1). Fair: flexion range 60” or more; loss of extension 30-60”; no pain or instability (Fig. 2). Poor: flexion range less than 60”; all cases with pain and instability. Of 26 patients, 3 were excluded because of inadequate documentation and follow-up. Of the 23 patients, 9 had good results, 11 had fair results and 3 had poor results (Tab/e III). The follow-up ranged from 4 weeks to 8 years, the average being I5 weeks. All patients had improved on their preoperative range and all elbows were found to be stable and painless.
Krishnamoorthy
et al.
: Unreduced
Dislocation
41
of Elbow
Fig. 1. Dislocated for 8 weeks before operation. radiographs. Below, 8 months after open reduction.
Fig. 2. Dislocated for 10 weeks before operation. graphs. Below, 3 months after open reduction.
Good
result.
Above,
preoperative
Fair result. Above, preoperative
DISCUSSION Stiffness of the elbow resulting from old unreduced dislocation causes considerable functional disability. In most of these patients the elbow was fixed in extension or with only a few degrees of flexion. In the present series the preoperative range was between 10” and 15”. The aim of treating old unreduced dislocation of the elbow should be to secure reduction with as much restoration of elbow function as possible. Open reduction performed by the technique described
and postoperative
and postoperative
radio-
gave uniformly satisfactory results. No patient was made worse by operation. Silva (1958) emphasized the poor result of open reduction in old unreduced dislocation and advocated replacement arthroplasty. It is difficult to compare the present series with his because in most of his patients the dislocations were of longer duration. In the present series 24 patients were seen within 3 months of the injury, and the 2 patients in whom the dislocations were 8 months old had good and poor results respectively.
42
Injury:
Tab/e ///.
the British Journal of Accident Surgery Vol.. ~/NO.
Duration of injury and results
Duration of injury (weeks)
No. of cases
Good
12 6
4 4
7 2
1 -
9-l 2 _>I 2
3 2
1
2 _
1 1
Total
23
9
11
3
l-4 5-8
Fair
Open reduction using the medial and lateral approach and keeping the dissection extraperiosteal had given encouraging results, especially in patients in whom the dislocation was less than 3 months old. It is felt that even in dislocations which are of longer duration, open reduction according to the technique described should be given a trial before embarking on major arthroplasties. Acknowledgements Our thanks are due to the orthopaedic surgeons both in the Government and in the University
RPQ,C~~~ Hospital,
1
fir reprints should be uddi-essed to: Outram Road, Singapore 3, Republic
Dr S. Krishnamoorthy, of Singapore.
Poor
Unit for allowing us to review their cases. We would also like to thank Miss Janet Soh for her secretarial help and Mr S. H. Tow, ARPS, for the photography.
REFERENCES Battacharya S. (1964) New management in posttraumatic stiffness of the elbow and old unreduced dislocation of the elbow joint. Singupore Med. J. 5, 220.
Silva J. F.
(1958) Old dislocation R. CON. Srrg. Engl. 22, 363.
of the elbow. Ann.
Department of orthopaedic surgery,
Singapore
General
Injury. 8, 39-42
Treatment of old unreduced of the elbow S. Krishnamoorthy, Department
K. Bose and K. P. Wong
of Orthopaedic
Surgery, Singapore General Hospital
Summary
Twenty-six patients with old unreduced dislocation of the elbow treated by open reduction were reviewed. All patients improved after surgery. It is felt that any patient with an elbow dislocation which is less than 3 months old should be treated by open reduction. The operative technique using a medial and lateral approach and keeping the dissection extraperiosteal is described.
INTRODUCTION THE MANAGEMENT of old unreduced dislocation of the elbow is a challenging problem to orthopaedic surgeons, especially to those practising in developing countries. There is little literature dealing with this problem (Silva, 1958; Battacharya, 1964). Silva pointed out the problems andemphasized thepoor resultsof openreduction. The object of this paper is to review the results of open reduction for old unreduced dislocation of the elbow by the technique of extraperiosteal dissection, which has been used at the Singapore General Hospital over the last 10 years.
MATERIAL
AND
dislocation
METHODS
Twenty-six patients with old unreduced dislocation of the elbow seen over a lo-year period between 1965 and 1974 were reviewed (Table Z). There were 20 male and 6 female patients. Their ages ranged from 6 to 60 years but the majority were between 10 and 30 years. The elbow dislocation in all the patients was either posterior or posterolateral. In 9 there were associated fractures of the medial epicondyle (Cases 1, 2, 25 and 26) of the coronoid process (Cases 10, 15 and 18), of the capitulum (Case 3) and of the trochlear (Case 7).
All patients had been treated initially by medically unqualified bone-setters. The time interval between the injury and the operation is shown in Table If. This varied from 2 weeks to 8 months, the average being about 7 weeks.
OPERATIVE
TECHNIQUES
The patients in this series were operated on by different surgeons using the same basic technique. In 8 patients the approach was posterolateral and in the remaining 18 patients combined medial and lateral incisions were used. The patient lay supine with the forearm across the chest. A lateral incision of lo-12cm was made parallel to the lateral margin of the triceps, exposing the tip of the lateral epicondyle. The interval between the triceps posteriorly and the origins of the extensor carpi radialis longus and brachioradialis was developed. The radial nerve was protected in the proximal part of the wound. With a scalpel the common origin of the extensor was detached to expose the radiohumeral joint. Brachioradialis and extensor carpi radialis longus were separated by sharp dissection to expose the lateral aspect of the joint. The medial side of the joint was then approached by a medial incision about IO-12cmlong,behind themedialepicondyle. The ulnar nerve was isolated and retracted posteriorly. Soft tissues were dissected from the medial epicondyle by blunt dissection, and the anterior part of the capsule was exposed. Thickened capsule, fibrous tissue and myositic new bone was removed especially along the trochlear notch, olecranon fossa and coronoid fossa. The proper clearance of these sites was essential in achieving a stable reduction but care was taken not to damage the articular cartilage. It was
40
Injury:
Table 1. Old unreduced Case
dislocation
Age (years)
Sex
2 3 4 5 6 7 8 9 10 11 12 13 14 15
14 14 41 6 21 13 59 60 16 33 42 51 12 31 44
16 17
18 12
18 19 20 21 22 23 24 25 26
25 14 30 24 30 16 12 50 17
M M M F M F F F M M M M M F M M M M
no.
1
*FF =
fixed
Duration of injury
4 4 6 11
8 9 4 6 8 3
4 2 2 4 2
6 12 5 32 6 4 32 8 8
Duration of follow-up 32
weeks year 5 weeks 2 years 8f years
1
28 weeks 6; years 7 weeks 4 weeks 8 weeks 1 year 1 year 16 weeks 12 weeks 24 weeks 20 weeks 4 weeks 20 weeks 12 weeks 2 years 1; years 3 years 2 years 28 weeks 32 weeks 20 weeks
of
injury
Weeks
No. of cases
l-4 5-8 9-12 >I2
12 9 3 2
Surgery
Vol. ~/NO. 1
Elbow flexion (%) At last Preop. follow-up IO-15 O-70 20-50 O-40 ? 20-25 20-40 15-35 O-l 0 0 0 1 O-20 o-5 0
0 O-l 5 O-20 0 0 5-l 0 45-55 o-5 O-l 0 20-30 O-l 0 o-1 0
25-l 35 O-l 25 ? 30-90 40-I 30 60-I 30 50-I 40 ? ? 30-90 50-l 35 45-l 20 40-I 20-I
30 30
30-90 O-l 30 70-l 00 45-l 20 90’ FF* 15-l 40 30-I 40 O-l 30 35-l 05 45-90 20-I 35 25-l 20
deformity.
necessary to excise the radial head in 4 patients (all adults) to facilitate reduction. Transposition of the ulnar nerve was not necessary in any patient. The wounds were closed in layers and suction drainage was used for 2448 hours. Hydrocortisone instillation was not used in any patient. Table II. Duration
of Accident
of the elbow
(weeks)
flexion
the British Journal
Postoperatively
the elbow was immobilized in before active exercises were started. No elbow was manipulated during the postoperative period. The only significant postoperative complication encountered was nerve palsy. In 1 patient the 90” of flexion for 24weeks
radial nerve was involved and in 2 other patients the ulnar nerves were involved. A11 the nerve palsies recovered within 6 weeks.
RESULTS In classifying the results, emphasis was placed on the active range of movement and on the stability of the elbow. The return of elbow function was graded as follows: Good: flexion range 90” or more; loss of extension 30” or less; no pain or instability (Fig. 1). Fair: flexion range 60” or more; loss of extension 30-60”; no pain or instability (Fig. 2). Poor: flexion range less than 60”; all cases with pain and instability. Of 26 patients, 3 were excluded because of inadequate documentation and follow-up. Of the 23 patients, 9 had good results, 11 had fair results and 3 had poor results (Tab/e III). The follow-up ranged from 4 weeks to 8 years, the average being I5 weeks. All patients had improved on their preoperative range and all elbows were found to be stable and painless.
Krishnamoorthy
et al.
: Unreduced
Dislocation
41
of Elbow
Fig. 1. Dislocated for 8 weeks before operation. radiographs. Below, 8 months after open reduction.
Fig. 2. Dislocated for 10 weeks before operation. graphs. Below, 3 months after open reduction.
Good
result.
Above,
preoperative
Fair result. Above, preoperative
DISCUSSION Stiffness of the elbow resulting from old unreduced dislocation causes considerable functional disability. In most of these patients the elbow was fixed in extension or with only a few degrees of flexion. In the present series the preoperative range was between 10” and 15”. The aim of treating old unreduced dislocation of the elbow should be to secure reduction with as much restoration of elbow function as possible. Open reduction performed by the technique described
and postoperative
and postoperative
radio-
gave uniformly satisfactory results. No patient was made worse by operation. Silva (1958) emphasized the poor result of open reduction in old unreduced dislocation and advocated replacement arthroplasty. It is difficult to compare the present series with his because in most of his patients the dislocations were of longer duration. In the present series 24 patients were seen within 3 months of the injury, and the 2 patients in whom the dislocations were 8 months old had good and poor results respectively.
42
Injury:
Tab/e ///.
the British Journal of Accident Surgery Vol.. ~/NO.
Duration of injury and results
Duration of injury (weeks)
No. of cases
Good
12 6
4 4
7 2
1 -
9-l 2 _>I 2
3 2
1
2 _
1 1
Total
23
9
11
3
l-4 5-8
Fair
Open reduction using the medial and lateral approach and keeping the dissection extraperiosteal had given encouraging results, especially in patients in whom the dislocation was less than 3 months old. It is felt that even in dislocations which are of longer duration, open reduction according to the technique described should be given a trial before embarking on major arthroplasties. Acknowledgements Our thanks are due to the orthopaedic surgeons both in the Government and in the University
RPQ,C~~~ Hospital,
1
fir reprints should be uddi-essed to: Outram Road, Singapore 3, Republic
Dr S. Krishnamoorthy, of Singapore.
Poor
Unit for allowing us to review their cases. We would also like to thank Miss Janet Soh for her secretarial help and Mr S. H. Tow, ARPS, for the photography.
REFERENCES Battacharya S. (1964) New management in posttraumatic stiffness of the elbow and old unreduced dislocation of the elbow joint. Singupore Med. J. 5, 220.
Silva J. F.
(1958) Old dislocation R. CON. Srrg. Engl. 22, 363.
of the elbow. Ann.
Department of orthopaedic surgery,
Singapore
General