We have previously reported on the medium-term outcomes following a non-operative protocol of a short period of splinting followed by early movement to treat simple dislocations of the elbow. We undertook extended follow up of our original patient study group to determine whether the excellent results previously reported were maintained in the very long-term. A secondary question was to determine the rate and need for any late surgical intervention. We attempted to contact all patients in the original patient study group. Patients were requested to complete the Oxford elbow score (OES), the Disabilities of the Arm, Shoulder and Hand (DASH) questionnaire and a validated patient satisfaction questionnaire. Patients were requested to attend a face-to-face assessment where they underwent a clinical examination including neurovascular assessment, range-of-motion and an assessment of ligamentous stability. Seventy-one patients (65%) from the original patient study group agreed to participate in the study. The mean duration of follow-up was 19.3 years. At final follow-up patients reported excellent functional outcome scores and a preserved functional range of movement in the injured elbows. The mean DASH score was 5.22 points and the mean Oxford Elbow Score was 91.6 points. The mean satisfaction score was 90.9 points. Our study shows that the excellent outcomes following treatment with a protocol of a short period of splinting and early movement remain excellent and are maintained into the very long term. These findings support our hypothesis that this treatment protocol is appropriate and suitable for most patients with simple dislocations of the elbow. The role for primary ligamentous repair for this patient group should be carefully considered. Work to more clearly define the anticipated benefits of surgery for specific patient groups or injury patterns would help to support informed decision making

This study describes the long term clinical and patient reported outcomes following simple dislocation of the elbow. We identified all adult patients treated at our trauma centre for a simple dislocation of the elbow over 10 years. 140 patients were identified and 110 (79%) patients were reviewed at a mean of 88 (95% CI 80–96) months after injury. This included clinical examination, the Disabilities of the Arm, Shoulder and Hand (DASH) questionnaire, an Oxford Elbow questionnaire and a patient satisfaction questionnaire. Patients reported long-term residual deficits in range of movement. The mean DASH score was 6.5 (95% CI 4 to 9). The mean Oxford Elbow score was 43.5 (95% CI 42.2 to 44.8). The mean satisfaction score was 85.6 (95% CI 82.2 to 89). Sixty-two patients (56%) reported persistent subjective stiffness of the elbow. Nine (8%) reported subjective instability and 68 (62%) complained of continued pain. The DASH, Oxford Elbow and satisfaction scores all showed good correlation with absolute range of movement in the injured elbow. After multivariate analysis, a larger elbow flexion contracture and female gender were both independent predictors of worse DASH scores. Poorer Oxford Elbow scores and overall satisfaction ratings were predicted by reduced flexion-extension arc of movement. Patients report good long term functional outcomes after simple dislocations of the elbow. These are not entirely benign injuries. There is a high rate of residual pain and stiffness. Functional instability is less common and does not often limit activities

To evaluate the results of open reduction in unreduced posterior dislocation of the elbow, done irrespective of the time since injury or age of the patient. Ten such cases in which the dislocation had been unreduced for more than 3 weeks since injury were included. Stiffness of the elbow was the main indication for the operation. Average age of the patient was 34.3 years (range 13 years to 65 years). Average time since injury was 3.9 months (range 2 month to 6 months). 3 patients had associated fractures around the elbow joint. All the patients had non functional elbow motion to perform any activity of daily living. We used speed’s procedure in all cases. At an average follow up of 18.5 months (range from 11 to 28 months), 8 patients achieved functional range of motion for activities of daily living and maintained an average arc of flexion(median) of 100 degrees and an average supination – pronation arc of 139.5 degrees. According to the Mayo Elbow Performance Index 5 patients achieved excellent results, 3 achieved good results and 2 achieved poor results. Complications included 2 cases of pin site infection, 1 case of ulnar neuritis and 1 case of delayed wound healing. We conclude that open reduction can provide painless, stable and functional elbow even in cases which are unreduced up to 6 months after the original injury

Dislocation of the elbow with associated fractures of the radial head and the coronoid process of the ulna have been referred to as the “terrible triad of the elbow” because of the difficulties in treating this injury and the poor outcomes. The orthopaedic database, Orthoscope, was used to identify all patients with dislocation of the ulnohumeral joint and fracture of both the head of the radius and the coronoid process of the ulna, seen and treated at Auckland City Hospital since 1998. All patients were invited to follow up appointments to evaluate the outcomes achieved. The research protocol was approved by the local research committee. Follow up appointments consisted of clinic al examination, assessing the range of elbow motion, an elbow radiograph and a functional assessment, using the DASH score and the American Shoulder and Elbow Society scoring systems. There were 32 patients identified, from Orthoscope, and invited for follow up. Six patients, who had moved overseas, were lost to follow up and two others declined follow up. 23 patients (24 elbows) remained for evaluation. All patients returned for the described assessment protocol. There were 10 male patients and 13 female patients, with a mean age of 46.9 (range, 29 to 67 years). The average arc of ulnohumeral motion was 122 degrees (range; 110 degrees to 140 degrees) and that of forearm rotation was 138 degrees (range, 35 degrees to 170 degrees). The radial head component was fixed in a standard fashion with repair, or replacement, and no radial head excisions were undertaken. Coronoid fractures were treated with screw fixation or suturing, with drill holes or anchors. To augment stability, a lateral ligament repair was undertaken in most patients. All patients, except one, would undergo the procedure again if needed. Elbow fracture-dislocations are historically very unstable and are prone to numerous complications. With operative treatment of the radial head, with repair or replacement, to restore stability through radiocapitellar contact, coronoid and lateral ligament repair, good range of movement and stability can be achieved

Introduction. The action of the radial head in the stability of the elbow is currently admitted. Its conservation is not always possible in complex fractures. The association with a posterolateral dislocation of the elbow leads to a higher risk of instability of the elbow joint and also at a longer term to degenerative changes. Some authors recommend the use of metallic radial head implant, acting as a spacer. The results seems encouraging but should the resection arthroplasty associated with the repair of the medial collateral ligament be abandoned?. Material and methods. In an amount of 35 consecutive patients who were taken in charge for an elbow dislocation 26 were included in this retrospective study, 13 of them had the association of a dislocation and a fracture of the radial head. In all 13 cases the radial head was considered as inadequate with a conservative treatment and was resected. The patients were assessed clinically according to the American Shoulder and Elbow Surgeons score (ASES) and the Mayo elbow performance index with a mean follow-up of 13 years (ranging from 5 to 15). The degenerative changes were assessed on plan × rays and an additional axial view according to the 4 stages described by Morrey. Results. No redislocation occurred. According to the Broberg/Morrey index 92% of the patients were considered as having a good result. They returned to work with no hindering. Signs of osteoarthritis grade 1 or 2 were observed and were clinically well tolerated. There was no difference for this item between the patients who conserved their radial head and those who sustained a resection. All patients were satisfied although they were protecting their joint against overuse while working. Discussion. The studies about the use of prosthesis of the radial head offer similar functional results. Degenerative changes on the trochleo ulnar joint are identical in all type of treatment. In order to prevent stiffness in the elbow joint an early post operative rehabilitation is recommended, it justifies a surgical stabilization associated with the use of an adapted dynamic splint. Conclusion. In case of elbow dislocation with a fracture of the radial head when its preservation is impossible, the resection without any prosthetic replacement remains a reasonable option if associated with a repair of the medial collateral ligament. At long term the functional results are still good with mild signs of osteoarthritis eliminating ipso facto the problem of an implant survivorship

Aims. The management of fractures of the medial epicondyle is one of the greatest controversies in paediatric fracture care, with uncertainty concerning the need for surgery. The British Society of Children’s Orthopaedic Surgery prioritized this as their most important research question in paediatric trauma. This is the protocol for a randomized controlled, multicentre, prospective superiority trial of operative fixation versus nonoperative treatment for displaced medial epicondyle fractures: the Surgery or Cast of the EpicoNdyle in Children’s Elbows (SCIENCE) trial. Methods. Children aged seven to 15 years old inclusive, who have sustained a displaced fracture of the medial epicondyle, are eligible to take part. Baseline function using the Patient-Reported Outcomes Measurement Information System (PROMIS) upper limb score, pain measured using the Wong Baker FACES pain scale, and quality of life (QoL) assessed with the EuroQol five-dimension questionnaire for younger patients (EQ-5D-Y) will be collected. Each patient will be randomly allocated (1:1, stratified using a minimization algorithm by centre and initial elbow dislocation status (i.e. dislocated or not-dislocated at presentation to the emergency department)) to either a regimen of the operative fixation or non-surgical treatment. Outcomes. At six weeks, and three, six, and 12 months, data on function, pain, sports/music participation, QoL, immobilization, and analgesia will be collected. These will also be repeated annually until the child reaches the age of 16 years. Four weeks after injury, the main outcomes plus data on complications, resource use, and school absence will be collected. The primary outcome is the PROMIS upper limb score at 12 months post-randomization. All data will be obtained through electronic questionnaires completed by the participants and/or parents/guardians. The NHS number of participants will be stored to enable future data linkage to sources of routinely collected data (i.e. Hospital Episode Statistics). Cite this article: Bone Jt Open 2024;5(1):69–77

Thirty-four acute traumatic dislocations in children aged 5 to 13 years, treated between 1994 and 2002, were reviewed retrospectively. All injuries were caused by a fall. Two injuries were compound. Two children had ulnar nerve injuries, one a radial nerve injury, and one median nerve and brachial artery injury. Posterolateral dislocations were seen in 22 children, posteromedial in eight, posterior in one, anteromedial in two and anterolateral in one. Pure dislocations occurred in eight children and 26 had associated elbow injuries, including 11 medial epicondyle, five lateral mass, one olecranon, one radial head and eight combined injuries. In the combined group, six children had associated fractures and two had divergent dislocation of the proximal radio-ulnar joint. Twenty required open reduction. The injury was initially missed in eight.

The child with vascular and median nerve injury had not recovered by four months. Among the others, at follow-up of 4 to 48 months 22 results were excellent to good, 10 fair and one poor. Complications included pseudarthrosis of the medial epicondyle in one child and loss of flexion and rotation of 10° to 30° in 15. Radial and ulnar nerve injuries recovered. A high index of suspicion, good clinical examination and compared radiographs are recommended to avoid missed injuries.

Anterior elbow dislocations often occur as a fracture-dislocation in which the distal humerus is driven through the olecranon, causing either a simple oblique fracture of the olecranon or a complex, comminuted fracture of the proximal ulna. The purpose of this study was to characterise the morphology and to evaluate the surgical treatment of this injury. Thirteen patients (8 women and 5 men) with a mean age of 42 years were included in this study. Four patients had a simple, oblique fracture of the olecranon and 9 a complex, comminuted fracture of the proximal ulna. Six patients had an associated fracture of the coronoid process which was detached as a large fragment and 7 an additional fracture of the radial head. In all cases the collateral ligaments were found intact. All fractures were treated by open reduction and internal fixation through a midline dorsal approach. Simple fractures of the olecranon were treated with tension-band wiring while comminuted fractures were fixed with a plate and screws. Fractures of the coronoid process were stabilised by interfragmentary screws or small plates. The concomitant radial head fractures were treated by excision of small fragments, internal fixation or radial head replacement. The average follow up was 71 months. According to the functional scale of Broberg and Morrey, the results were excellent in 8 patients, good in 2, and poor in 3. Mild arthritis was observed in one patient. Transolecranon fracture –dislocation of the elbow is often misidentified as an anterior Monteggia lesion or a simple fracture of the olecranon. Differential diagnosis between these lesions is imperative. Consequently, anatomical restoration of the trochlear notch in cases of transolecranon fracture –dislocations can be achieved leading to good long-term results

With the aim of identifying appropriate treatment and diagnosis, this paper discusses 12 of 107 elbow dislocations and 56 elbow fracture dislocations seen over four years. One patient presented with arterial injury, two with olecranon fractures and dislocation, and three with radial head, olecranon and coronoid fractures. One patient had an intra-articular fracture, two had collateral ligamentous injuries and two had radial head fractures and dislocations. Depending on treatment, the results can be very poor or excellent. An awareness of the pitfalls in dislocations and fracture dislocations of the elbow is necessary to prevent poor outcomes

Introduction. We present the results of the management of irreducible dislocation or fracture / dislocation of the elbow using the “Orthofix” external fixator in cases where the condition of the soft tissues was contraindicated for extensile surgical approaches or the internal fixation would not be stable enough to permit safe joint mobilization postoperatively. Materials and methods. Twelve (12) patients were treated using elbow external fixation,5 with supracondylar fracture and severe osteoporosis and 7 with fracture / dislocation of the elbow and excessive soft tissue impairment (two of them with open fracture). For the patients with fracture, we performed minimal internal fixation using small incisions and minor soft tissue detachments and then we applied the elbow external fixator for the neutralization of the fixation. This permitted the immediate active assisted joint mobilization postoperatively without interfering with the stability of the joint and of the fixation. The same happened for the patients that their elbow remained unstable after reduction of traumatic dislocation, where the external fixation maintained the reduction of the joint. Prerequisite for the safe mobilization of the joint was the application of the external fixation at the center of rotation of the elbow which is the transepicondylar axis, in order to comply with the biomechanics of the joint. Results. The fixator was applied for a mean of 10 weeks (6 – 16 weeks). All the fractures united and no instability of the joint was noted. The range of motion was between useful limits with lack of extension less than 30 degrees and flexion more than 130 degrees, pronation 60 degrees and supination 55 degrees (mean values). Pin track infection was presented in 3 patients and the treatment was local care and antibiotics. One patient had radial nerve palsy immediately after the operation, who recovered totally after four months without any treatment. Conclusions. The external fixation of the elbow provides sufficient stability permitting the immediate mobilization of the joint postoperatively and in combination with the minimal soft tissue damage during the operation prevents the postoperative stiffness. It is a safe alternative solution when the condition of soft tissues around the elbow do not permit a thorough open procedure

Proximal Radius – Fractures of the proximal radius in children account for slightly more than 1% of all children’s fractures, represent 5 to 10% of all elbow fractures and accounts for 5% of all fractures involving the growth plate. The average age in the literature is 10 years (4 to 16 years) with no difference between boys and girls. The anatomical aspects should be emphasized for the comprehension of this fracture: 1) the radial head of the child only starts to ossify at age 5 so it is very rare to have a fracture before this age since all the head is cartilaginous and therefore more resistant to trauma. At the same time it makes more difficult the diagnosis because of the absence of ossification of the epiphysis. 2) There is a valgus angulation of 12.5° between the radial head and the shaft of the radius in the AP plan and an anterior angulation of 3° on the lateral plane that should not be misinterpreted as fractures. 3) The radial head is intrarticular in a similar way like the femoral head and trauma to this region may lead to AVN as a result of damage to the vascular supply of the epiphysis. 4) The proximal radioulnar joint has a very intimate continuity contributing to exact congruence of the articular surfaces. The axis of rotation lies directly in the center of the radial neck. Any deviation of the epiphysis over the neck has a major reflect over the axis of rotation causing a “cam” effect when the radial head rotates with loss of pronosupination. The mechanism of injury responsible for this injury result from a fall on the outstretched upper extremity in which the elbow is extended and a valgus force is applied to the elbow joint. In more rare cases it result from direct pressure to the radial head during dislocation of the elbow. There are different classifications mostly based on the anatomical lesion or degree of deformity. Wilkins divides this fracture in two major groups: Group I (valgus fracture) subdivided in three types: type A – the Salter-Harris type I and II, type B – Salter-Harris type IV and type C – fractures involving only the proximal radial metaphysis and Group II (fractures associated with elbow dislocation) subdivided in two types: type D – reduction injuries and type E – dislocation injuries. O’Brien divides the common valgus injury in three types according to the degree of angulation between the radial head and the axis of the radius: Type I (0 to 30° angulation) Type II (between 30° and 60°) and Type III (more than 60°). The clinical symptoms may vary according to the magnitude of the injury. The child will mostly complaint of pain and tenderness on the lateral side of the joint. In young children pain may first be referred to the wrist. The pain usually increases with pronosupination and extension of the elbow. The diagnosis relies mostly on the x-ray view (AP and lateral) and the fracture will be easily visualized in either film. In the cases where the fracture line is superimposed over the ulna an oblique view will be necessary. In the young child, whereas the epiphysis is still not ossified, an ultrasound may be helpful differentiating the position of the radial head. An arthrogram may also be of benefit especially during the process of reduction to check the accuracy of the treatment. The prognosis of this lesion depends on several factors. A poor result can be expected if the fracture is associated with other injuries such as elbow dislocation and ulna or medial epicondylar fractures. A residual tilt of the radial head, provided is not superior to 30°, is more tolerable than a translocation of the radial head superior to 4mm. Age is also an important factor since the older the child the less remodeling it will have. The treatment has also an important role in the prognosis of this injury since it is unanimous acceptable that an open reduction is associated with poor results. Therefore the treatment of a young child with an isolated minimal displaced fracture-separation of the proximal radius (less than 30°) should be a simple long arm cast. In a more displaced fracture (more than 30° of tilt) a closed reduction should be performed under general anesthesia as suggested by Patterson. If the maneuver is not successful other attempts should be made with lateral pin compression applied directly to the radial head as suggested by Pesudo or an indirect reduction by an intramedullary kirschner wire as suggested by Metaizeau. Open reduction should be only reserved for dislocated Grade IV Salter-Harris type fractures, incarcerated radial head or in the presence of failure of closed treatment. The incidence of complications especially if associated with a dislocation of the elbow or other fractures can be high. The most common are loss of motion, radial head overgrowth usually with no clinical significance, notching of the radial neck and premature physeal closure. Avascular necrosis of the radial head is most commonly associated with open reduction. Distal Radius – It is the most common fracture separation in children and represent 46% of all fractures involving the growth plate. A fracture of the ulna is associated in 6 to 11% of the injuries. The average age is 12 years with a minimum of 7 and a maximum of 16 years. Although this high incidence it is very uncommon subsequent growth disturbance. The usual mechanism of injury is similar to the proximal radius injury and result from a fall on the outstretched upper extremity with the wrist hyperextended. This type of injury is classified by the Salter-Harris classification for physeal fractures and the most commons are the types I and II. The clinical symptoms vary from mild tenderness over the fracture site to a noticeable deformity most often with the apex volar. Attention should be given to the possibility of vascular and neural injury associated, mostly from the time of the acute deformation, and the diagnosis is made by x-ray view (AP and lateral) with the fracture well visualized. The prognosis is in general good since even in the presence of a markedly displaced fracture it can be expected a remarkably remodeling even in an older child. Treatment in a nondisplaced fracture only requires a below elbow cast for 4 weeks. In a displaced fracture a closed reduction should be performed under hematoma block or general anesthesia (in a young child). The reduction is stable most of the times in a plaster with the wrist in slight flexion. The incidence of complications is very rare

Radial head fractures are the most common fractures occurring around the elbow and are often associated with other fractures or soft tissue injuries in the elbow. The purpose of this study was to characterise the morphology and to evaluate the outcome of the surgical management of radial head fractures in complex elbow injuries. Nineteen patients with this pattern of injury underwent surgical treatment in our unit. In addition, seven patients had posterior dislocation of the elbow, 2 medial collateral ligament rupture, one capitellar fracture, 3 posterior Monteggia, 1 Essex-Lopresti lesion and 5 coronoid fracture plus posterior dislocation. Non comminuted radial head fractures were treated by open reduction and internal fixation or simple excision of small fragments. Patients with comminuted, displaced radial head fractures underwent radial head replacement. The average follow up was 44 months. Two patients developed post-traumatic elbow contractures, one elbow instability and 2 mild arthritis. Overall, according to the DASH Outcome Measure, the results were excellent in 12 patients, fair in 3 and poor in 4. In complex injuries of the elbow the characteristics of the radial head fracture and in particular the comminution, the fragment number, the displacement as well as the age of the patient should determine the appropriate surgical technique which will lead to satisfactory long-term results. Anatomical restoration and maintenance of elbow stability will allow early mobilisation of the elbow joint and should be the goals of surgical management

Purpose. Evaluation of our experience on the treatment of comminuted, radial head fractures, and of the outcomes of pyrocarbon prosthetic replacement in such cases. Materials and Methods. We evaluated 47 cases of prosthetic replacement, performed from May 2003 to July 2008. There were 18 males and 29 females with an average follow-up of 48 months (12 to 60). The Hotchkiss classification was used to characterize the fractures. The indicators for the procedure were type III fractures in 27 cases, type IV fractures in 10 cases, comminuted radial head fractures (associated with disruption in medial collateral ligament) in 3 cases, Monteggia variant in 5 cases, and Essex Lopresti in 2 cases. Functional outcomes were assessed using the Mayo Elbow Performance Index and the Visual Analog Scales (VAS) of pain, joint motion, and stability. Results. The mean VAS score for elbow pain was 1 (0.5–2.1). Patients showed an average arch of motion from 6 degrees to 140, with 75 degrees of pronation, and 67 of supination. By the Mayo Elbow Performance Index, 42 patients had good to excellent results, 3 fair, and 2 poor. The complications that we have encountered were: implant dislocations (2 cases), elbow stiffness (1), implant dissociation (1), stem rupture (1), and transient PIN palsy (2 cases with complete recovery of nervous function at 5 and 8 weeks). There was no persistent instability, infection, synosthosis, severe degenerative changes, or impingement. Conclusion. The pyrocarbon implants are a good treatment option in complicated, radial head fractures, but the outcome depends on the severity of the initial fracture and the associated lesions. We have also encountered a tendency towards overestimating the prosthesis size, causing restriction of motion, impingement, overstuffing, or dislocation. For these results we are now using the non-modular prosthesis in our center, but further studies are required

Purpose of the study: Fracture dislocations are complex injuries compromising elbow stability and functional potential. The treatment of these injuries should restore the exact anatomy of the joint, the only guarantee for a good functional outcome. The purpose of our work was to analyse our results and review the literature in order to establish an evidence-based therapeutic algorithm essentially based on the type of associated fracture. Material and methods: This was a retrospective analysis of 15 cases (12 men, 3 women) reviewed at mean 18 months. The causal event was a fall in most patients, followed by traffic and sports accidents. This was a first-intention treatment for 12 patients and a second-intention intervention for three. Initially, none of the patients presented vessel or nerve injury. There were three open fractures. The most common fracture was: radial head (n=12), coronoid process (n=9). One or two approaches were used, depending on the type of associated fracture. Treatment consisted in fixation of the radial head (n=8) and arthroplasty (n=4).. The coronoid process was fixed in six cases. All ligament tears were repaired. An articulated external fixator was used in four cases. Results: All patients had a stable elbow. Mean flexion was 125, extension -16, pronation 72 and supination 63. Wrist force was 80% compared with the controlateral side. The Mayo Clinic function score was 84 points. Discussion: Reconstruction of the lateral osteoligament column, associated with fixation of the coronoid, restores stability in the majority of elbows. For very high energy injuries with complex bone and ligament damage, addition of an articulated external fixator is indispensable to enable early mobilization. Stiffness and instability are the most common complications after traumatic injury. Conclusion: Fracture dislocations of the elbow are complex injuries requiring adequate emergency care, with surgery as needed, for all lesions at the same time via one or two approaches followed by early rehabilitation. The function outcome depends on the intraoperative stability achieved and early mobilization

Background: Posterior dislocation of the elbow with fractures of the radial head and coronoid process is a rare injury which, when treated conservatively, has a high redislocation rate and poor results (7/11 in the largest published series). Methods: Six patients with this injury were treated with triple reconstruction, involving exploration of the joint via a lateral approach with insertion of a radial head prosthesis. The coronoid fracture and anterior capsule was repaired (using an in-to-out technique) and the lateral collateral ligament was reat-tached, using Mitek Super Anchors. All patients were evaluated prospectively. Results: The average age was 52 years (37–75y). At one year follow up all elbows remained in joint and all were pain free or causing slight pain only. The average range of ulno-humeral movement was 55 degrees (range 38–68) and the average forearm rotation was 67 degrees (range 18–104). Functional assessment showed an average Liverpool score of 23/36 (range 17–29) and average Broberg and Morrey score of 74/100 (range 68–84). Conclusions: Triple reconstruction recognises and remedies the three elements of this devastating injury. All of these must be addressed in order to fulþll the short-term goal of restoring and maintaining stability. Our patients have a stable, pain free, though stiff, elbow in contrast to the poor results reported from previous conservative and operative treatments

The causes of a stiff elbow are numerous including: post-traumatic elbow, burns, head injury, osteoarthritis, inflammatory joint disease and congenital. Types of stiffness include: loss of elbow flexion, loss of elbow extension and loss of forearm rotation. All three have different prognoses in terms of the timing of surgery and the likelihood of restoration of function. Contractures can be classified into extrinsic and intrinsic (all intrinsic develop some extrinsic component). Functional impairment can be assessed medicolegally; however, in clinical practice the patient puts an individual value on the arc of motion. Objectively most functions can be undertaken with an arc of 30 to 130 degrees. The commonest cause of a Post-traumatic Stiff elbow is a radial head fracture or a complex fracture dislocation. Risk factors for stiffness include length of immobilisation, associated fracture with dislocation, intra-articular derangement, delayed surgical treatment, associated head injury, heterotopic ossification. Early restoration of bony columns and joint stability to allow early mobilisation reduces incidence of joint stiffness. Heterotopic ossification (HO) is common in fracture dislocation of the elbow. Neural Axis trauma alone causes HO in elbows in 5%. However, combined neural trauma and elbow trauma the incidence is 89%. Stiffness due to thermal injury is usually related to the degree rather than the site. The majority of patients have greater than 20% total body area involved. Extrinsic contractures are usually managed with a sequential release of soft tissues commencing with a capsular excision (retaining LCL/MCL), posterior bundle of the MCL +/− ulna nerve decompression (if there is loss of flexion to 100 degrees). This reliably achieved via a posterior incision, a lateral column exposure +/− ulna nerve mobilisation. A medial column exposure is a viable alternative. Arthroscopic capsular release although associated with a quicker easier rehabilitation is associated with increased neural injury. Timing of release is specific to the type of contracture, i.e. flexion contractures after approx. six months, extension contractures ASAP but after four months, loss of forearm rotation less 6 to 24 months. The use of Hinged Elbow Fixators is increasing. The indications include reconstructions that require protection whilst allowing early movement, persistent instability or recurrent/late instability or interposition arthroplasty. Post-operative rehabilitation requires good analgesia, joint stability and early movement. The role of CPM is often helpful but still being evaluated

In the treatment of acute elbow dislocation promising clinical results have been reported on articulated external fixation and surgical reconstruction of major joint stabilizers. However, it remains unclear whether or not surgical reconstruction of the major joint stabilizers sufficiently stabilizes the elbow joint or if augmentation by a hinged elbow fixator is beneficial to provide early stability and motion capacity. The aim of the present study was to compare the stabilizing potential of surgical reconstruction versus augmentation by a hinged external elbow in a model of sequentially induced intability of the elbow. Materials and Methods: 8 unpreserved human upper extremities were mounted to a testing apparatus which was integrated within a material testing machine. In a first series, varus and valgus moments were induced to the intact elbow joint at full extension, as well as at 30°, 60°, 90° and 120° of flexion and the mean angular displacement at 2.5, 5, an 7.5 Nm was calculated. Instability was then induced by sequentially dissecting the lateral and the medial collateral ligament, the radial head, and the posterior capsule. The elbow joint was then sequentially restabilized by osteosynthesis of the radial head and refixation of the lateral and medial collateral ligament using bone anchors. In each sequence, elbow stability was tested with and without augmentation by a hinged external fixator according to the first testing series described above. Biomechanical data of surgical reconstruction alone and surgical reconstruction augmented by external fixation were compared using an analysis of variance. Results: In the intact elbow, varus-valgus displacement with 7.5 Nm ranged from 8,3 ± 2,4° (0°) to 11,4 ± 4,2° (90°). With the fixator applied, varus-valgus displacement was significantly lower and ranged from 4,2 ± 1,3° (0°) to 5,3 ± 2,2° (90°). After complete destabilization of the elbow joint, maximum varus-valgus displacement ranged from 17,4 ± 5,3° (0°) to 23,6 ± 6,4° (90°). Subsequent reconstruction of the collateral ligaments, the posterior capsule, and the radial head proved to stabilize the elbow joint compared with the unstable situation, however, mean varus-valgus displacement remained significantly higher when compared to the intact elbow joint. During each sequence of instability, the hinged external fixator provided constant stability not significantly different to the intact elbow joint while guiding the elbow through the entire range of motion. Conclusion: The stabilizing potential of surgical reconstruction alone is inferior to augmentation of a hinged external elbow fixator. In order to proved primary stability and early motion capacity, augmentation of a hinged external elbow fixator in the treatment of acute dislocation of the elbow is recommended

Fracture dislocations of the elbow are complex injuries that have a significant risk of long term instability and loss of function. The more severe injuries are fortunately rare and the published series are relatively small. This in turn means that there is less precise evidence and guidance as to the optimal treatment. With the improvements in the understanding of this injury we consider that the prognosis is not necessarily as poor as has been previously reported and we have attempted to quantify this in a prospective, single surgeon series with standard surgical and rehabilitation protocols using dedicated upper limb physiotherapists. Methods All patients presenting to the hospital with a terrible triad injury were seen by the senior author for assessment and treatment. Early surgical reconstruction was performed under general anaesthetic by the senior author. Radial head fractures were treated by fixation or prosthetic replacement. Ligament reconstruction or reinforcement was performed where needed. Following surgery early mobilisation was performed using dedicated upper limb physiotherapists. Information was collected prospectively recording function and stability. All patients were assessed with the Mayo clinic elbow score and the AAOS Disability of the Arm Shoulder and Hand score (DASH). Results Eleven patients were admitted with a terrible triad injury to their elbow. All were the result of an acute traumatic episode. Follow up was for a mean of 21 months and no patients were lost to follow up. All fractures had united and there were no cases of migration or failure of metal fixation devices. There were no cases of symptomatic instability and no patient had signs of instability when assessed at clinically. A mean flexion arc of 106 degrees was recorded (range 60–145) with a mean extension limit of 23 degrees (range 0–40). Pronation and supination arcs were recorded with a mean of 127 degrees of rotation (range 0–160). There were no reoperations for infection or instability amongst this group of patients. Mayo clinic performance index for the elbow produced a mean score of 91.5 with a range of 85–100 which equates to a good or excellent outcome for all patients. Conclusion We have demonstrated that with a combination of early surgical stabilisation of bony injuries and restoration of ligamentous stability coupled with a specialised rehabilitation programme can give excellent results in what was once felt to be a catastrophic injury

Introduction Complex fracture dislocation of the elbow can often be either irreducible or unstable with inability to hold the reduction or delayed subluxation or dislocation. This study looks at the aetiology of the instability, bony and ligamentous, and the results following stabilisation with a combination of internal fixation, ligament repair, radial head arthroplasty and or hinged external fixation. Methods Twenty-one consecutive unstable elbows referred to three tertiary centres were prospectively recruited for this study. All cases had fine-cut CT scans with sagittal, coronal and 3D reconstructions. All elbows were approached using a posterior ‘global’ incision. Ulnar neurolysis was routinely performed. Medial and lateral ligament complexes were inspected and repaired. Internal fixation of the radial head was attempted where indicated, or a radial head arthroplasty was performed. The coronoid-brachialis complex was repaired using pull-through sutures. Elbow stability was tested and a hinged external fixator used where indicated. The fixator was removed at six weeks. Indomethacin prophylaxis against heterotopic ossification was used routinely. Follow-up range of motion, articular congruity and DASH score were assessed at one year. All cases required a repair of the coronoid-brachialis complex. Radial head reconstruction was attempted in four cases, but abandoned in three. The radial head was replaced in 13 cases. A lateral repair alone was required in 12 cases, a medial repair alone in two cases and a combined medial and lateral repair in seven cases. Eighteen cases required a hinged device (nine Compass hinges and nine OpteROM distractors). Results The mean less of extension at one year was 12° (range 0 to 20) and the mean loss of flexion was 14° (range 0 to 20). All cases achieved at least a functional arc of motion from 30° to 130°. Three cases achieved a full range of motion. Despite Indomethacin prophylaxis three cases developed minor heterotopic ossification. The average DASH score was 23. Conclusions If managed appropriately, a very good anatomical and functional outcome can be achieved in difficult unstable elbows post fracture dislocation. Repair of the coronoid-brachialis complex is the key to stability, along with radial head reconstruction or replacement. A hinged external fixation device allows early mobilisation

Dislocation and carpal fracture-dislocation are a rare injury, interesting capsula and ligaments, with a variable damage of the vascularization. Classification is difficult for the complexity on this lesion. The aim of our work is to underline how the best final clinical result is achieved after an immediate treatment of reduction and stabilization of bone injury. We considered two groups:. A: 8 patients, who have been observed since july ’93 until 1996 ; all the patients were men who had work or car accidents, with outstretched upper extremity. The ages of the patients ranged from 19 to 34 years.. All patients were followed for an average of 8 years. B: Another group is at short term is since luglio 2002 until today and is in 10 patients with 11 wrists with a total of 14 surgical treatment. 1 is bilateral. 3 wrists reoperated for lacking initial reduction or for the general initial condition. Assesment of the patients includeds clinical rating and roentgenografich analysis. The clinical scoring included pain, functional status, range of motion and grip strength. Among the various classifications, we took into account the one proposed by Allieu, based on the radio-lunate ligament, consequently this classification offers an important prognostic factor. In one of our cases there was assocciated a fracture of the radial stiloid, and in other one a posterior dislocation of the elbow. We treated all the patients with a volar approach, the stabilitation of the carpus and scaphoid was achieved utilizing K wires in four cases, microscrew in two patients for scaphoid’s fracture and in other one the Herbert screw in the A group. In the B recent group we used in all cases K wiring, and herbert screw in 8 wrists, microscrews in one , and internal capsulodesis in the 2 last for perilunate isolated dislocation. The initial failing of reduction is due to an unstable reduction in very injured patient ( we use only k wire for the navicular). 10 patients in the second B group have been treated by the same first Author. After surgery treatment, the wrist was immobilizated in a splint for 6 weeks, then a careful mobilitation was started. Finally we think that is necessary, to avoid the instability and pseudoartrosis on the scaphoid, to treat all the transcapho-lunate dislocation with open reduction and stabilitation, as agreed with literature