Management of recurrent, complex instability of the elbow with a hinged external fixator

Abstract

We have treated 16 patients with recurrent complex elbow instability using a hinged external fixator. All patients had instability, dislocation or subluxation of the ulnohumeral joint. The injuries were open in eight patients and were associated with 20 other fractures and five peripheral nerve injuries. Two patients had received initial treatment from us; 14 had previously had a mean of 2.1 unsuccessful surgical procedures (1 to 6). The fixator was applied at a mean of 4.8 weeks (0 to 9) after the injury and remained on the elbow for a mean of 8.5 weeks (6 to 11). After treatment we found the mean range of flexion-extension to be 105° (65 to 140). At a final follow-up of 23 months (14 to 40), the mean Morrey score was 84 (49 to 96): this translated into one poor, three fair, ten good and two excellent results.Complications included one fractured humeral pin, one temporary palsy of the radial nerve, one recurrent instability, one wound infection, one severe pin-track infection and one patient with reflex sympathetic dystrophy. Although technically demanding, the use of the fixator is an important advance in the management of recurrent complex elbow instability after failure of conventional treatment.

Die Operation von Ellenbogenluxationen mit Radiuskopf- und Processus-coronoideus-Frakturen

“…Oft erreichen die Patienten nach dieser Verletzung aufgrund einer Arthrose, wiederauftretenden Instabilität oder Steifigkeit nach langer Ruhigstellung [1,5,6] nur eine sehr schlechte Ellenbogenfunktion. In der Literatur findet sich keine Studie, die diese spezielle Problematik gezielt beschreibt; nur aus größeren Serien von Ellenbogenverletzungen können Patienten mit diesem Unfallmechanismus und Verletzungsmuster herausgesucht werden [5,7,8].…”

“…At an average follow-up of 31 months, 80% of this series of 41 patients (mean age 42 years) had a good or excellent result. [2,8]. Allerdings ist eine erfolgreiche primäre Therapie der Anlage eines Bewegungsfixateurs, die ein spezielles technisches Vorgehen erfordert, vorzuziehen.…”

“…Elbow function is often poor due to arthrosis, recurrent instability and/or stiffness from prolonged immobilization [1,5,6] and the title "terrible triad" is well deserved. There is no single landmark study in the literature that specifically describes this condition, and, what is available, must be extrapolated from patients with this injury that are included in other larger series [5,7,8].…”

“…Both McKee et al and Cobb & Morrey described application of a hinge fixator to the elbow to restore concentric stability and allow early motion in a series of unstable elbow fracture-dislocations that had failed initial management [2,8]. However, this is a specialized technique, and successful primary management is preferable.…”

“…The incision is closed. The frame is applied through two half-pins in the humerus and two in the ulna both inserted from posterior[8]. The Steinmann pin is now removed.…”