Neglected elbow dislocation in a young man: treatment by open reduction and elbow fixator

Abstract

A 22-year-old man fell 4 floors during a fire. He had 20% burns and multiple injuries. The Injury Severity Score on admission was 44. The Glasgow Coma Score was 11/15. He had a fractured pelvis and bilateral open fractures of the os calcis and required subsequent left belowknee amputation. He had also a left intracerebral hemorrhage resulting in a right hemiplegia and dysphasia. Several attacks of convulsions occurred. The patient presented to us 1 month after injury because of left elbow pain. The left elbow was posteriorly dislocated and was fixed in full extension. There was no nerve palsy in the left upper limb, particularly the ulnar nerve. Radiographs confirmed posterior dislocation of the left elbow with no fracture (Figure 1). Open reduction was performed by the posterior approach. The operative findings were as follows: dense fibrous tissue in the olecranon fossa, a contracted fibrotic triceps, contracted collateral ligaments, preserved articular cartilage, and a fairly normal-looking ulnar nerve. Reduction was achieved after excision of the fibrous tissue remnants of the capsule, release of both collateral ligaments, and clearance of the olecranon fossa. The reduction was concentric and not particularly difficult but with only fair stability. The ulnar nerve was inspected and decompressed at the cubital tunnel. The continuity of the triceps mechanism was carefully preserved, and there was limited flexion of the reduced elbow. The center of rotation of the elbow through the anteroinferior aspect of the medial epicondyle and the center of the lateral epicondyle was identified.2 A 2-mm Kirschner wire was inserted in the axis of rotation, with the position confirmed by image intensifier. The central connecting unit with the humeral and ulnar frames was slid over the wire, and the fixator used as its own template. Humeral screws (6/5 mm) were inserted from lateral to the mid humerus with care taken to avoid the radial nerve. Ulnar screws (4.5/3.5 mm) were applied from the dorsal side at the subcutaneous border so as to allow maximum forearm rotation. The elbow was then flexed and extended to confirm correct alignment and concentric reduction. The Kirschner wire was removed. The reduction was stable, and passive range was 0° to 70° because of limitation from the tight triceps. The postoperative regimen included active mobilization of the elbow and alternate passive stretching in flexion and extension by the compression-distraction device that accompanied the elbow fixator (Figure 2). This allowed slow stretching of the contracted triceps without the risk of overloading the articular cartilage of the elbow joint. The fixator was removed at 6 weeks, and active range on removal was 40° to 125°. The young man was well motivated and had active mobilization with passive stretching by therapists. He achieved 20° to 135° flexion range after 1 more month. At 1-year follow-up, the patient had full range in flexion/ extension and rotation (Figure 3). Radiographs of the left elbow did not show heterotopic ossification or degenerative changes (Figure 4). The Mayo elbow functional score8 was 100, and he was very satisfied, as he could use his left upper limb to maneuver his wheelchair single-handedly.