Abstract

---

Posteromedial elbow dislocation is a rare injury when compared to posterolateral elbow dislocations.In developing countries like India old unreduced dislocations are not uncommon due to lack of medical facilities in villages. When elbow dislocation are old, management options include conservative, closed or open reduction, arthrodesis, excision arthroplasty and total elbow replacement. Treatment option depends mainly duration of injury, available functional range of movement and nature of articular surfaces. This is a case report of such old unreduced elbow dislocation which was posteromedial in 49 year old female who initially got treated with traditional bonesetter resulting in stiffness and pain . We managed patient with open reduction of elbow through posterior approach and strict postoperative rehabilitation. Functional assessment with Mayo Elbow Performance Score showed excellent results.    

Introduction

---

Elbow dislocations are common injuries in adults. They are usually posterior. Among  them posterolateral dislocations comprise major part of dislocations(80%)[1]. Posteromedial elbow dislocations are rare when compared to posterolateral dislocations. Posterior  elbow dislocations can be associated with fractures around  elbow which are called ‘complex dislocations’ or can be ‘simpler dislocations’ without any fractures[2] . Most common associated fractures with elbow dislocations among adults are epicondylar fractures which could be either medial or lateral epicondyle fractures,radial head fractures or coronoid fractures[3]. Most of the elbow dislocations are stable injuries unless associated with concurrent fractures no matter how small they are which makes them inherently unstable like in terrible triad of elbow[4] . Management wise too, elbow dislocations are easily reducible  in cases of simple dislocations  under sedation or general anaesthesia unless there are soft tissue interpositions or entrapment of fractured bony fragments in the joint. However, all these medical treatment would be possible in hospital setup with all available facilities and trained medical faculty. Most places of developing countries like India, major bony injuries are treated with traditional bonesetters in village areas due to lack of easily accessible medical facilities. Hence most of injuries are improperly treated   resulting in hazardous complications. In this article, we report about such  case of unreduced posteromedial elbow dislocation which was of six month old without fracture around elbow which is rare injury and how we managed it surgically to get good anatomical reduction  and functional outcome as assessed by Mayo Elbow Performance Score.

Case report

---

49 year old female came  to our institute Sri Lakshmi Narayan Institute of Medical Science, in July 2014 with a history of injury around left elbow around six months back. On proper history elicitation we found mode of injury was fall on outstretched hand in a bathroom. Immedietly after the injury patient underwent treatment with traditional bonesetters where bandages were applied for a period a month. She later continued to have pain and stiffness which brought her to our institute after six months post trauma. On examination there was swelling and deformity with tenderness at elbow joint. Three point bony relations between tip of olecranon, lateral and medial epicondyle were altered. There was 30° of flexion deformity with further flexion upto 60°. Supination-pronation movements were 20° each. Skin condition around elbow appeared good and there was no distal neurovascular deficit. X-ray showed posteromedial dislocation of elbow joint( Figure 1). Computed tomography(CT) scan(Figure 2) showed no features of old malunited fracture. Patient was posted for open reduction after thorough preoperative workup. Posterior aproach to elbow was applied. Without triceps splitting elbow joint was approached from medial and lateral side of triceps. Ulnar nerve was isolated. Coronoid, radial and olecranon fossae were filled up with fibrous tissues and were removed.There was no articular irregularities. We were able to achieve congruent open reduction without triceps lengthening. To achieve stability thick radiocapitellar  Kirschner-wire was passed. Limb was immobilized for three weeks postoperatively with plaster of paris. Mobilization was started at three weeks after Kirschner-wire removal. Patient was put on vigorous active and active assisted range of movement exercises. Functional assessment with Mayo  Elbow Performance score at six months showed a score of 95(excellent)(Figure 3). Radiological assessment at at 4, 12 and 36 weeks showed no signs of resubluxation of joint or myositis ossificans (Figure 4).  

Discussion

---

Elbow joint is  second most commonly dislocated joint after shoulder[5,6]. Elbow dislocations are classified as posterior, anterior ,lateral, medial or divergent depending on ulnar relation to distal humerus. Posteromedial elbow are very rare compared to posterolateral dislocations. That too old unreduced posteromedial dislocations are less reported. Elbow dislocations are also classified as simple or complex injuries depending on associated fractures around elbow[2]. Associated fractures becomes increasingly important for management since they increase instability. ‘Terrible triad’ involves  a radial head fracture, a coronoid tip fracture and a dislocation of the elbow and that’s when elbow will be highly unstable[4]. Mechanism of injury involves fall on outstretched hand when a combination of axial loading  supination/external rotation of the forearm with posterolateral based valgus force results in elbow dislocation which is commonly seen in posterolateral elbow dislocation. In case of posteromedial elbow dislocation, a varus posteromedial force is responsible. In our case too patient fell on her outstretched hand in a bathroom with probable varus posteromedial force  which resulted in posteromedial elbow dislocation.

Neglected and unreduced elbow dislocations are not uncommon in developing countries like India[7,8]. There is a habit of people approaching to traditional bone setters immedietly after trauma because of easy accessibility of those in villages and lack of education on health issues. In our case too patient approached to local bone setter immedietly after trauma and continued treatment there for a month. In fresh fractures CT is useful investigation especially to identify minute fractures which will be missed in plain radiographs. In older dislocations too, CT plays important role in identifying malunited fractures and to know articular irregularities. In our case, there were no such findings. Treatment options for old unreduced elbow dislocation depends mainly on duration of injury, available range of movements and nature of articular surfaces[9,10,11,12,13]. Treatment options include  conservative management, closed or open reduction, arthrodesis, excisional arthoroplasty or total elbow replacement. Conservative management can be tried if patient has got functional range of movements from 30°-130° with a arc of 100°[11]. Our patient had flexion deformity of 30° with further flexion upto 60°(arc of only 30°). Hence we decided for surgical management. Closed reduction is generally indicated  till three weeks post trauma. After 3 weeks, closed reduction will be difficult due to surrounding soft tissue contractures and also has increased chance of fracture while manipulation due to juxtaarticular osteoporosis. Hence open reduction is advised in such cases[9,10]. Most studies suggest  open reduction for elbow dislocation up to 3 months and other studies shows that it can be done till two years[14,15]. In older dislocation with damaged articular surfaces other surgical options have to be considered like elbow arthroplasty, excisional arthroplasty, or arthrodesis[9,11,12,13].Total elbow arthroplasty is to be considered in elderly patients since it has  limited life span and is cost-prohibitive. Excision arthroplasty is easy option but it will give highly untable elbow and hence discouraged now a days. In our patient duration of injury was six months and intraoperatively we found out articular surfaces to be in good condition and hence we decided to go ahead with open reduction procedure.

Different surgical approaches have been described for open reduction of elbow in case of old dislocations. Most commonly used is Speed’s posterior approach  with triceps lengthening procedures like V-Y plasty to facilitate reduction[16]. Krishnamooorthy et al[17] showed combined medial and lateral approach without triceps lengthening is better alternative to posterior approach. We used posterior approach without triceps lengthening since it was not required for us to facilitate reduction. We opened both medial and lateral side of the joint with aggressive dissection without triceps splitting since studies shows that triceps splitting approach may cause fibrosis in the muscle restricting flexion in the future.

Conclusion

---

Posteromedial elbow dislocation is one rare injury. Old unreduced posteromedial  elbow dislocation when properly managed with open reduction and strict postoperative physiotherapy protocol it is possible to achieve good functional elbow. This case report also highlights lack of knowledge on health issues and poor avilabilites of medical facilities in developing countries like India which will cause increase in morbidities among patients and also give tougher challenges to surgeons dealing with them later.

References

---

1.Eygendaal D, Verdegaal SHM, Obermann WR, Van Vugt AB, Poll RG, Rozing PM. Posterolateral dislocation of the elbow joint: relationship to medial instability. J of Bone and Joint Surg. 2000; 82-A(4): 555-560

2. Hildebrand KA, Patterson SD, King GJ. Acute elbow dislocations:simple and complex. Orthop Clin North Am. 1999; 30: 63-79.

3. O’Driscoll SW, Jupiter JB, King GJW, Hotchkiss RN, Morrey BF. The unstable elbow. J Bone Joint Surg. 2000;82-A(5):724-738.

4. Sotereanos DG, Darlis NA, Wright TW, et al.: Unstable fracture-dislocations of the elbow.

Instr Course Lect. 2007; 56:369-76

5.Haan J, Schep NWL, Tuinebreijer WE, Patka P, Hartog D. Simple elbow dislocations: a systematic review of the literature. Arch Orthop Trauma Surg. 2010;130:241-249.

6.Blackard D, Sampson J. Management of an uncomplicated posterior elbow dislocation. J Athl Training. 1997;32:63-67.

7. Seth M, Flores M. Management of neglected dislocation of elbow. Indian J Orthop 1986;20:177-81. 

8. Bhattacharya D. Open reduction for old unreduced posterior dislocation of the elbow-a review of results. Indian J Orthop 1979;13:34-8. 

9. Freeman BL III. Old unreduced dislocations. In: Crenshaw AH, editor. Campbell’s operative orthopaedics. Vol I, 9th ed. StLouis: Mosby; 1998:2673–4.

10. Naidoo KS. Unreduced posterior dislocations of the elbow. J Bone Joint Surg Br 1982;64:603–6.

11. Fowles JV, Kassab MT, Douik M. Untreated posterior dislocation of the elbow in children. J Bone Joint Surg Am. 1984;66:921–6.

12. Bruce C, Laing P, Dorgan J, Klenerman L. Unreduced dislocation of the elbow: case report and review of the literature. J Trauma 1993;35:962–5.

13. Allende G, Freytes M. Old dislocation of the elbow. J Bone Joint Surg 1944;26:691–706.

14. Devnani AS. Outcome of longstanding dislocated elbows treated by open reduction and excision of collateral ligaments. Singapore Med J 2004;45:14-9.   

15.Mehta S, Sud A, Tiwari A, Kapoor SK. Open reduction for late-presenting posterior dislocation of the elbow. J Orthop Surg (Hong Kong) 2007;15:15-21.

16. Speed JS. An operation for unreduced post dislocation of elbow. South Med J 1925;18:193. 

17. Krishnamoorthy S, Bose K, Wong KP. Treatment of old unreduced dislocation of elbow. Injury. 1976;8:39-42.

Source(s) of Funding

---

None

Competing Interests

---

None