CHRONIC ELBOW DISLOCATION:

EVALUATION AND MANAGEMENT

Kenneth W. Donohue, MD; Thomas L. Mehlhoff, MD
J Am Acad Orthop Surg 2016;24:413-423

Ni Luh Putu Julita Yanti

Supervisor
dr. Anak Agung Gde Yuda Asmara, Sp.OT(K)
• The elbow is the second most common major joint
dislocation in adults, after the shoulder.
• 7,000 per year in United States
• 80% Posterior and posterolateral dislocations
• In children, the elbow is the most common major joint
dislocation, usually occurring in those >10 years of age.
• Most dislocations are posterolateral, and frequently an
associated fracture is present.
CHRONIC ELBOW DISLOCATION

A dislocation that has remained

unreduced for >2 weeks
• Speed (1925)  the duration of dislocation and patient age
were the two most important predictors of outcome.
• Allende and Freytes (1944)  dislocations of .6 months’
duration had too much articular damage for successful open
reduction.
• Mahaisavariya and Laupattarakasem (2005)  no correlation
between the duration of dislocation and the postoperative arc of
motion.
• Naidoo (1982)  no difference in the postoperative function or
the amount of articular surface damage in 23 patients treated
between 1 month and 2 years after dislocation.
• Mehta (2007)  no difference in the outcome of patients who
underwent surgical reduction between 2 and 6 months after
injury.
EVALUATION
• Complete hystory
• The date of initial injury
• Any prior treatment
• Chronic elbow dislocation must not be confused with chronic
elbow instability
• The diagnosis of instability suggests collateral ligament and
soft-tissue insufficiency that may require reconstruction.
• The diagnosis of chronic dislocation implies thick intraarticular
fibrosis and soft-tissue contracture that requires débridement
and release.
 ..EVALUATION

• 20% of patients had a painless functional arc of motion.

• The range of motion of the elbow is substantially reduced.
• It is important to assess active and passive motion before
surgical treatment.
• Decreased passive flexion
• increased contracture of the ulnar collateral ligament (UCL)
and the triceps
• greater intra-articular fibrosis
• Ulnar nerve symptoms are present in approximately 15% of
patients with chronic elbow dislocation..
PREOPERATIVE IMAGING

• AP, Lateral, and Oblique radiographs of the elbow

• CT imaging with three-dimensional reconstruction
is helpful to assess dislocations with intra-articular
fracture, heterotopic ossification, or arthritic
change.
• MRI of the elbow is usually of limited value in
these patients because extensive scar tissue
obscures the resolution of adjacent structures.
MANAGEMENT

• Before surgical reduction is performed, it is important to

consider the patient’s general health, functional goals,
and willingness to tolerate a lengthy course of
postoperative rehabilitation
 Approach

The triceps- The paratricipital

reflecting
approach approach
REDUCTION
• Chronic dislocation produces extensive fibrosis around the injured joint.
• Intra-articular granulation tissue is consistently present and must be removed from
the sigmoid notch, coronoid fossa, and olecranon fossa to allow reduction
• Release or resection of the anterior and posterior capsule is also recommended
• In a series of 22 patients with dislocation, Coulibaly et al found that 13 patients
required LCL release, and 8 patients required additional triceps lengthening to
achieve reduction.
• In a series of five patients with chronic dislocation, Jupiter and Ring found that all
patients required release of the brachialis, brachioradialis, radial wrist extensors, and
triceps from the distal humerus.
• Allende and Freytes described a radiohumeral horn in all 35 patients in their series
and emphasized that excision of this ossification was essential for joint reduction.
• Other authors have reported successful reduction without excision of heterotopic
ossification.
TRICEPS LENGTHENING
• Triceps lengthening can facilitate joint reduction, decrease pressure across
the damaged articular surface, and increase postoperative flexion.
• Relative indications for triceps lengthening include:
• dislocation of.3 months’ duration
• >1000 of intraoperative elbow flexion
• > 5 cm of overlap between the humerus and the olecranon on AP
radiographs of the elbow.
• Triceps lengthening is most commonly accomplished by means of V-Y triceps
plasty.
• The authors emphasized that reduction of the radiohumeral joint with
detachment of the extensor muscles is the key to success in avoiding triceps
lengthening.
ULNAR NERVE TRANSPOTITION

• Most studies using the Speed technique or Paratricipital

approach include ulnar nerve release in order to protect the
nerve and access the medial joint
• The indications for subsequent ulnar nerve transposition are
less clear.
• Proposed indications for nerve transposition include
preoperative ulnar nerve symptoms, visible nerve fibrosis or
edema, or excessive nerve tension after joint reduction
STABILIZATION

Ligament reconstruction
Hinged external fixator
SALVAGE PROCEDURES

• Total elbow arthroplasty may be an alternative to open

reduction in older patients (aged >65 years).
• Salvage options for younger patients (aged ,65 years)
include arthrodesis, as well as distraction or
interposition arthroplasty.
• Arthrodesis is poorly tolerated and is usually reserved
for patients in whom previous salvage procedures have
been unsuccessful.
AUTHORS’ PREFERRED TECHNIQUE
• The patient is positioned supine with the arm across the chest.
• General anesthesia is used because of the expected duration
and complexity of the procedure.
• A longitudinal posterior incision is made.
• Large fullthickness subcutaneous medial and lateral skin flaps
are elevated for extensile exposure of the elbow.
• The ulnar nerve is identified, released from the cubital tunnel,
and protected.
• If the elbow has been locked in a position of extension for a
prolonged period, anterior subcutaneous transposition of the
ulnar nerve will be needed to prevent traction neuritis after the
release.
OUTCOMES
• Most adult patients will have an active arc of motion of approximately 100° after open
reduction.
• Motion is reduced when the triceps is surgically lengthened or when the elbow is
mmobilized for .2 weeks
• The most common complications after surgical reduction include:
• pin tract infection,
• fracture,
• heterotopic ossification,
• ulnar neuritis,
• stiffness.
• Despite successful open reduction, the risk of progressive arthritis will remain elevated
throughout the patient’s life.
 SUMMARY
• Management of chronic elbow dislocation is
challenging.
• Each patient must be considered individually in the
context of age, activity level, and goals.
• Successful treatment hinges on the surgeon’s ability to
anticipate the common obstacles to reduction and tailor
the procedure to each patient.
THANKYOU