Treatment of Unstable Elbow Injuries with a Hinged Elbow Fixator: Subjective and Objective Results

Abstract

Introduction: Injuries around the elbow pose a challenging problem for orthopaedic surgeons. The complex bony architecture of the joint should be restored and the thin soft tissue envelope needs to be handled with meticulous care. Elbow instability is a complication seen after dislocations and fractures of the elbow and remains a treatment challenge. The purpose of this study was to provide subjective and objective results following the surgical treatment of unstable elbow dislocations with an external hinged fixation technique.

Methods: Forty-six consecutive patients with complex trauma of the elbow with instability after ligament reconstruction were enrolled between January 2017 and December 2019. The parameters used to quantify the subjective and objective functional results were the Mayo Elbow Score (MES, objective) and Oxford Elbow Score (OES, subjective), and clinical stability of the elbow joint. We also performed a radiological follow-up of the fractures.

Results: The mean MES and OES scores were good at the 12-month follow-up. We had 38 patients with stable joints and 8 patients with minor instability. Using the stress test, we saw a significant difference in the affected joint under varus stress (6.7 ± 1.8 mm) compared to the healthy joint (5.8 ± 1.2 mm) laterally. Furthermore, medially the gap was significantly larger (5.8 ± 0.8 mm, treated elbow) than the contralateral gap under valgus stress (4.3 ± 0.8 mm) (p <0.001). Twenty-one complications occurred in 46 patients (46%): Seven patients had a clinical change of elbow axis: Three valgus (6%), four varus (9%); Superficial wound infection occurred in one case (2%) and ulnar nerve dysfunction in two (4%). The most common medium-term complication was post-traumatic osteoarthritis in eight cases (17%). Heterotopic ossification occurred in five patients (11%) and elbow stiffness in five cases (11%).

Conclusion: The use of the hinged elbow external fixator in the treatment of complex elbow trauma is a valid therapeutic adjunct to ligamentous reconstruction showing encouraging results with acceptable complications.

How to cite this article: Meccariello L, Caiaffa V, Mader K, et al. Treatment of Unstable Elbow Injuries with a Hinged Elbow Fixator: Subjective and Objective Results. Strategies Trauma Limb Reconstr 2022;17(2):68-73.

Keywords: Complications; Dislocation; Fracture; Hinged external fixator; Instability; Ligament; Outcomes.

Figs 1A to M

(A to C) Clinical photographs of a 48-year-older man with an open elbow injury, radial nerve palsy and metacarpal injuries on the left side; (D and E) The 3D-angio CT showed the elbow dislocation without arterial injuries; (F and G) The hinged external fixator is in place with an extension to the wrist; (H to J) The postoperative CT showed the reduction of radio-humeral and ulnar-humeral joints; (K) After 2 weeks we unlocked the hinged external fixation from the wrist external fixation; (L and M) Radiographs showing good reduction after 6 weeks of use

Figs 2A to E

(A and B) Twelve months after surgery on the left side, the radiographs showed fracture healing of the elbow and wrist and little bone metaplasia around the MCL and LCL; (C to E) The elbow had a good range of motion, yet the radial nerve palsy persisted

Figs 3A to M

(A) Seventy-year-old female had a left elbow posterolateral dislocation with an intra-articular fracture of the capitellum after a low energy trauma; (B and C) After reduction and casting in the emergency department, the CT showed the fracture and persistent elbow dislocation; (D to F) In the acute setting, we performed surgery with osteosynthesis, and applied a hinged external fixator; (G) Postoperative clinical image; (H and I) After 12 months radiographs showed good elbow alignment without osteoarthritis; (J to M) Excellent clinical outcomes after 12 months