Complications related to simple dislocations of the elbow

Ipsilateral Shoulder and Elbow Dislocation

BACKGROUND

Shoulder dislocations and elbow dislocations are common presentations to the emergency department (ED). Simultaneous ipsilateral elbow and shoulder dislocations are rarely reported and typically occur secondary to trauma.

CASE REPORT

A 45-year-old female presented to the ED after a fall from standing and complained of upper right extremity pain. Radiographs revealed posterior dislocation of the right elbow and anterior dislocation of the right shoulder without fractures. Successful reduction of the elbow and shoulder were both achieved, and the patient was placed in a long-arm splint and sling. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: This case describes the unique mechanism of injury of a simultaneous ipsilateral shoulder and elbow dislocation without trauma.

Thrombosis of the Brachial Artery After Closed Elbow Dislocation

Posterior dislocation of the elbow joint is the second commonest large joint dislocation that can be experienced due to various traumatic incidents. Although it may be associated with fractures and vascular lesions, in this case report, we describe a patient who encountered a posterolateral elbow dislocation following a fall on their arm with an extended elbow. This dislocation was followed by delayed thrombosis of the brachial artery, necessitating a revascularization surgery. For optimal patient care, physicians should remain vigilant, being cautious about potential vascular injuries both before and after performing a closed reduction of the elbow joint. The suspicion of vascular injury should be even more pronounced when bony lesions or open injuries are present. Effective management of such cases requires a collaborative effort between orthopedic and vascular surgeons. The preferred surgical approach involves the utilization of a saphenous graft, with the essential prerequisite of achieving a stable elbow joint before proceeding with revascularization.

Thrombosis of the brachial artery - a rare and devastating complication after a simple closed posterolateral elbow dislocation

Dislocation of the elbow joint is the second most common dislocation after the shoulder joint. Although this pathology is relatively common, concomitant vascular injuries are rare. We present a case of a patient who sustained a fall on his arm with an outstretched elbow that resulted in a closed simple posterolateral elbow dislocation and delayed thrombosis of the brachial artery followed by two revascularisation surgeries. The physician must always maintain a high index of suspicion for a concomitant vascular injury before and after closed reduction of the elbow joint and have in mind that complete ischemia without any pulsations could be absent because the elbow is surrounded by rich collateral anastomoses. Suspicion should be even stronger in the presence of bony lesions or open injuries. A team of trauma and vascular surgeons has to work hand in hand as surgical treatment with a saphenous graft or direct suture is the first method of choice with the prior requirement of a stable elbow joint.

Elbow Posterolateral Dislocation Accompanying Flexor Group Origo Rupture without Fracture - A Case Report

INTRODUCTION

We wished to present a case that had elbow posterolateral dislocation accompanying complete medial collateral ligament rupture(MCLR) and complete flexor group origo rupture (FGOR) without fracture.

CASE REPORT

A30-year-old man came to emergency department after falling on the outstretched palm. After first physical examination and radiologic searches, elbow joint posterolateral dislocation was diagnosed. Together with sedoanalgesia, elbow dislocation was reduced, and instability evaluation by applying varus and valgus stress tests was performed. Positive valgus stress test and palpation sign which indicated soft tissue damage on the medial side of elbow were determined. Control roentgenograms showed no osseous pathology. By magnetic resonance imaging, elbow dislocation diagnosis accompanying MCLR and FGOR without fracture was confirmed. Using medial approach, ruptured MCL and elbow FGO repairing procedures were performed.

CONCLUSION

The complications of elbow dislocation without fracture, which is barely seen, should be treated through appropriate treatment strategies after meticulous physical examination and radiologic evaluation. Hence, possible sequelae could be prevented or satisfactory results could be obtained.

Complications of Elbow Trauma

The elbow is a highly congruent trochoginglymoid joint allowing motion in both flexion-extension and pronosupination across 3 articulations. Therefore, treatment of fractures of the elbow can be technically challenging to manage, even after initial surgery. The posttraumatic elbow is prone to complications such as stiffness associated with heterotopic ossification, instability or subluxation (posterolateral rotatory instability and varus posteromedial instability patterns), and wound complications. This article discusses the pathoanatomy, prevention, and treatment of these complications.

Unstable Simple Elbow Dislocation Treated with the Repair of Lateral Collateral Ligament Complex

Background

Unstable simple elbow dislocation (USED) repair is challenged by the maintenance of joint reduction; hence, primary repair or reconstruction of disrupted ligaments is required to maintain the congruency and allow early motion of the elbow. We evaluated the effectiveness and the outcome of lateral collateral ligament (LCL) complex repair with additional medial collateral ligament (MCL) repair in cases of USED.

Methods

We retrospectively reviewed 21 cases of diagnosed USED without fractures around the elbow that were treated with primary ligament repair. In all cases, anatomical repair of LCL complex with or without common extensor origin was performed using suture anchor and the bone tunnel method. Next, the instability and congruency of elbow for a full range of motion were evaluated under the image intensifier. MCL was repaired only if unstable or incongruent elbow was observed. Clinical outcomes were evaluated using the Mayo elbow performance score (MEPS) and radiographic outcomes on last follow-up images.

Results

All cases achieved a stable elbow on radiographic and clinical results. LCL complex repair alone was sufficient to obtain the stable elbow in 17 of 21 cases. Four cases required additional MCL repair after restoration of the LCL complex. The overall mean MEPS was 91 (range, 70 to 100): excellent in 12 cases, good in 7 cases, and fair in 2 cases. All 17 cases with LCL complex repair only and 2 of 4 cases with additional MCL repair had excellent or good results by MEPS.

Conclusions

USED requires surgical treatment to achieve a congruent and stable joint. If the repair of lateral stabilizer such as LCL complex acquires enough joint stability to maintain a full range of motion, it may not be necessary to repair the medial stabilizer in all cases of USED.

The epidemiology of closed reduction for simple elbow dislocations and the incidence of early subsequent open reduction

BACKGROUND

Simple elbow dislocations are often treated with closed reduction (CR); however, the rate of CR failure and factors that may predict failure have been largely underinvestigated. The objectives of this study were (1) to determine the incidence of elbow dislocations treated by CR in a universal health care system and (2) to identify patient characteristics associated with failed CR, defined as the subsequent need for open reduction.

METHODS

Patients ≥16 years old who underwent elbow CR by a physician between 1994 and 2010 were identified from administrative databases. Concurrent elbow fractures were excluded. The incidence density rate (IDR) of CR per 100,000 eligible person-years among the general population was calculated. Failed CR was defined as subsequent open reduction with or without ligament repair or reconstruction within 90 days. Patient and provider characteristics were modeled in a multivariate logistic regression for failure.

RESULTS

The cohort consisted of 4878 patients (median age, 41 years) who underwent CR (IDR, 2.65 per 100,000 person-years), and 75 (1.5%) underwent subsequent open reduction with or without ligament repair or reconstruction (median time, 15 days). Young men (≤20 years) had the highest IDR (7.45 per 100,000 person-years), twice that of young women (P = .005). Patient characteristics associated with failed CR included older age (P = .001), admission to the hospital (P < .0001), >1 attempted CR (P = .001), and new orthopedic consultation in the 4 weeks after the CR (P = .02).

CONCLUSION

Young men are at highest risk for CR for simple elbow dislocations; however, older patients are more likely to require open intervention, as are those with markers of a difficult reduction signifying potentially greater soft tissue damage. A comprehensive understanding of the epidemiology of simple elbow dislocation will aid management decisions.

Atypical Essex-Lopresti injury of the forearm: a case report

The Essex-Lopresti injury of the forearm is difficult to diagnose. A missed diagnosis can lead to persistent pain and instability of the wrist. We report a 33-year-old man with a pre-existing cubital varus deformity who sustained an atypical Essex-Lopresti injury after a fall on his elbow. Accurate diagnosis requires understanding of force transmission and anatomy of the radius and ulna, as well as the proximal and distal radioulnar joints as a unit.

Open surgical treatment of posttraumatic elbow contractures in children

Posttraumatic elbow stiffness in children can be a severe obstacle to accomplishing basic activities of daily living, including dressing, and participating in recreational activities. The etiology of this stiffness is typically extrinsic or instrinsic pathology caused by an earlier supracondylar humerus fracture, elbow dislocation, or elbow fracture-dislocation. Children with functional limitations, typically associated with flexion contractures greater than 30 degrees or less than a functional arc (30 to 130 degrees) can benefit from surgical contracture release, which consistently improves range of motion.

Risk of symptomatic heterotopic ossification following plate osteosynthesis in multiple trauma patients: an analysis in a level-1 trauma centre

BACKGROUND

Symptomatic heterotopic ossification (HO) in multiple trauma patients may lead to follow up surgery, furthermore the long-term outcome can be restricted. Knowledge of the effect of surgical treatment on formation of symptomatic heterotopic ossification in polytrauma is sparse. Therefore, we test the effects of surgical treatment (plate osteosynthesis or intramedullary nailing) on the formation of heterotopic ossification in the multiple trauma patient.

METHODS

We retrospectively analysed prospectively documented data of blunt multiple trauma patients with long bone fractures which were treated at our level-1 trauma centre between 1997 and 2005. Patients were distributed to 2 groups: Patients treated by intramedullary nails (group IMN) or plate osteosynthesis (group PLATE) were compared. The expression and extension of symptomatic heterotopic ossifications on 3-6 months follow-up x-rays in antero-posterior (ap) and lateral views were classified radiologically and the maximum expansion was measured in millimeter (mm). Additionally, ventilation time, prophylactic medication like indomethacine and incidence and correlation of head injuries were analysed.

RESULTS

101 patients were included in our study, 79 men and 22 women. The fractures were treated by intramedullary nails (group IMN n = 50) or plate osteosynthesis (group PLATE n = 51). Significantly higher radiologic ossification classes were detected in group PLATE (2.9 +/- 1.3) as compared to IMN (2.2 +/- 1.1; p = 0.013). HO size in mm ap and lateral showed a tendency towards larger HOs in the PLATE group. Additionally PLATE group showed a higher rate of articular fractures (63% vs. 28% in IMN) while IMN demonstrated a higher rate of diaphyseal fractures (72% vs. 37% in PLATE; p = 0.003). Ventilation time, indomethacine and incidence of head injuries showed no significant difference between groups.

CONCLUSION

Fracture care with plate osteosynthesis in polytrauma patients is associated with larger formations of symptomatic heterotopic ossifications (HO) while intramedullary nailing was associated with a higher rate of remote HO. For future fracture care of multiply injured patients these facts may be considered by the responsible surgeon.