Persistent elbow dislocation

Abstract

Acute elbow dislocation is a common injury with an incidence in the general population estimated at around 5/100,000. Persistent (or static) elbow dislocation is a relatively rare problem but might occur due to inappropriate assessment or treatment of acute simple or complex elbow dislocations. Persistent elbow dislocation can be an invalidating and painful condition with a more ominous prognosis than an acute elbow dislocation with appropriate treatment. Surgical treatment of persistent elbow dislocation is a complex intervention that requires extended surgical exposure and arthrolysis in combination with circumferential ligamentous and osseous stabilization. Satisfactory results are described, but complication and reintervention rates are high. After-treatment with a dynamic external fixator is often necessary.

Keywords: Coronoid fracture; Instability; Ligament reconstruction; Persistent elbow dislocation; Radial head fracture; Terrible triad.

Figure 1

Radiographs showing posterolateral simple elbow dislocation in an 80-year-old overweight female (A). The patient was treated with a cast. After five months, the MCL and LCL reconstruction was performed because of persistent instability and recurrent dislocations. Reconstruction of the collateral ligaments failed and persistent elbow dislocation was present after nine months (B) and (C). Authors believe that the increased loading of the collateral ligaments by the increased weight of the forearm and relative abducted position of the shoulder (D) in this overweight patient is a significant risk factor for failed treatment and persistent elbow dislocation. MCL, medial or ulnar collateral ligament; LCL, lateral collateral ligament.

Figure 2

Radiographs (A) and CT scan (B) showing dysplasia of the greater sigmoid notch in a 27-year-old female with severe instability and persistent elbow dislocations. Coronoid height in this patient is around 6.4 mm (normal values between 13 and 19.6 mm) and olecranon-coronoid angle in this patient is −2.8° (normal value varies between 18° and 28°), indicating severe dysplasia.CT, computed tomography.

Figure 3

(A) Radiographs of the Right elbow of a 70-year-old female showing a posterolateral dislocation of the elbow with a radial head fracture and a coronoid fracture, suggesting a terrible triad injury. The patient was initially treated with closed reduction and a cast at the emergency department. After two weeks, the elbow was reduced under fluoroscopy because of persistent dislocation in the cast. (B) Persistent dislocation after four weeks in a cast. (C) CT scan after months shows persistent posterolateral position of the radial head relative to the capitellum and heterotopic ossification (arrow) after two months. (D) Severe degeneration of the ulnohumeral joint after five months of persistent elbow subluxation. CT, computed tomography.

Figure 4

A radiograph (A) and CT scan (B) of the Right elbow of a 61-year-old female with a comminuted radial head fracture and a coronoid fracture of the anterolateral facet with extension in the anteromedial facet following a posterolateral dislocation of the elbow, suggesting a terrible triad injury. The patient was treated with radial head replacement combined with refixation of the LCL. The coronoid fracture was not fixed. After one year, the patient was referred to an elbow expertise Center with severe persistent posterolateral and valgus instability and subluxation (C) and (D). CT, computed tomography; LCL, lateral collateral ligament.

Figure 5

3D reconstruction of a CT scan of the Left elbow of a 44-year-old female with an anteromedial facet fracture of the rim and the tip of the coronoid (subtype-II) and a small fragment at the lateral side of the distal humerus (arrow), suggesting a humeral avulsion of the LCL. 3D, three dimensional; CT, computed tomography; LCL, lateral collateral ligament.

Figure 6

3D reconstruction of a CT scan of the Right elbow of a 54-year-old male with a transolecranon elbow dislocation with a comminuted olecranon fracture extending in the coronoid and a comminuted radial head fracture (A). The patient was initially treated in a local hospital with plate fixation of the olecranon, radial head replacement, and LCL refixation (B). After five months, the patient was referred to an elbow expertise Center with complaints of persistent pain and decreased range of motion. Physical examination demonstrated persistent instability and subluxation of the elbow. A CT scan showed nonunion of the large coronoid fragment (C). The patient was treated with an extended arthrolysis by a posterior approach. A revision of the radial head replacement was performed because of loosening. The olecranon plate was removed, and the coronoid fracture was reduced and fixed with two lag screws. The olecranon was incompletely healed and fixed again with plate osteosynthesis (D). CT, computed tomography; LCL, lateral collateral ligament.

Figure 7

Supine overhead gravity-assisted exercises.