Objectives. To evaluate management, direct-medical-costs and clinical outcome profile of a large trauma unit with respect to simple elbow dislocations. Methods. All simple elbow dislocations that were defined as not requiring acute surgical intervention, post-reduction, were considered between Jan-2008 and Dec-2010. Inclusion criteria consisted of age greater than 13; absence of major associated fractures, successful closed reduction, and follow-up as an outpatient. The management of these patients was classified in terms of immobilisation time into: short (< 2weeks), standard (2–3weeks) and prolonged (>3weeks). Direct-medical-costs were calculated based on current tariff rates associated with radiology, admission, theatre time (for reductions and recovery) and outpatient attendances. Clinical outcome was evaluated with respect to complications, secondary procedures, and time before discharge from clinic. Results. Of 81 patients in total, 6% required reduction in theatre, 17% admission, 9% were referred to a specialist or had a complication and 42% DNA their final appointment. The mean length-of-immobilisation was 2.25weeks (range 0–6weeks). The median direct-medical-cost was £893 per patient (range £418-£2,693). The median duration of patients' engagement with hospital services was 57days (range 3–831). There was no statistically significant relationship between length-of-immobilisation and time-before-discharge (p=0.42), or associated direct-medical-cost (p=0.586). In terms of clinical outcome the prolonged immobilisation group had a statistically significant worse outcome in comparison to the short (p=0.30) and the standard (p=0.01). The comparison between standard immobilisation and short resulted in a marginally (p=0.08) significant advantage of the first. Conclusion. Prolonged elbow immobilisation is generally associated with increased stiffness and a higher rate of complications. For simple elbow dislocations time-to-mobilisation was variable, as well as the mode of follow-up. The use of standardised protocols of treatment is essential in these type of injuries that are usually managed in an outpatient basis, to minimise the variability between clinical teams, improve outcome, and minimise costs

Introduction. The elbow is the second most common site of non prosthetic joint dislocation. Simple elbow dislocation alone contributes to 11-28% of all elbow injuries. Post-reduction treatment methods include traditional plaster of Paris (POP) immobilisation followed by physiotherapy, sling application followed by early mobilisation and rapid motion. The aim of the study was to evaluate the final outcome and cost-effectiveness of the pop and the sling groups. Study Design. Retrospective cohort study. Methods. We reviewed 42 simple elbow dislocations treated between 1998-2003. 20 patients in POP group and 22 patients in the sling group were assessed at a minimum follow-up of two years. The data collected consisted of age, gender, duration of immobilisation, length of physiotherapy, and return to work. All were assessed using MEPI (Mayo Elbow Performance Index) score and Quick DASH questionnaire. The final outcome was graded as excellent, good, fair and poor. Results. The final functional outcome in the POP group was 10 excellent, 3 good, 4 fair and 3 poor. In the sling group, we had 19 excellent, 1 good and 2 fair results. The mean MEPI scores in the POP and sling group were 89.2 and 98.2 respectively (p<0.05). The mean quick DASH scores in the POP and sling group were 12.8 and 2.7 respectively (p<0.05). The final functional outcome is directly dependent on the length of immobilisation (R=0.91). The mean time to return to work in POP group and sling groups was 6.6 and 3.2 weeks respectively (p<.001). Conclusion. Sling and early mobilisation is a safe and cost-effective method of treatment for simple elbow dislocation. The length of physiotherapy and time taken to return to work were significantly shorter in the sling group. Early mobilisation did not result in redislocation or late instability. The final outcome of the sling and early mobilisation group was significantly better than POP immobilisation group

Heterotopic ossification (HO) is a well-known complication of traumatic elbow injuries. The reported rates of post-traumatic HO formation vary from less than 5% with simple elbow dislocations, to greater than 50% in complex fracture-dislocations. Previous studies have identified fracture-dislocations, delayed surgical intervention, and terrible triad injuries as risk factors for HO formation. There is, however, a paucity of literature regarding the accuracy of diagnosing post-traumatic elbow HO. Therefore, the purpose of our study was to determine the inter-rater reliability of HO diagnosis using standard radiographs of the elbow at 52 weeks post-injury, as well as to report on the rate of mature compared with immature HO. We hypothesized inter-rater reliability would be poor among raters for HO formation. Prospectively collected data from a large clinical trial was reviewed by three independent reviewers (one senior orthopedic resident, one senior radiology resident, and one expert upper extremity orthopedic surgeon). Each reviewer examined anonymized 52-week post-injury radiographs of the elbow and recorded: 1. the presence or absence of HO, 2. the location of HO, 3. the size of the HO (in cm, if present), and 4. the maturity of the HO formation. Maturity was defined by consensus prior to image review and defined as an area of well-defined cortical and medullary bone outside the cortical borders of the humerus, ulna, or radius. Immature lesions were defined as an area of punctate calcification with an ill-defined cloud-like density outside the cortical borders of the humerus, ulna or radius. Data were collected using a standardized online data collection form (CognizantMD, Toronto, ON, CA). Inter-rater reliability was calculated using Fleiss’ Kappa statistic and a multivariate logistic regression analysis was performed to identify risk factors for HO formation in general, as well as mature HO at 52 weeks post injury. Statistical analysis was performed using RStudio (version1.4, RStudio, Boston, MA, USA). A total of 79 radiographs at the 52-week follow-up were reviewed (54% male, mean age 50, age SD 14, 52% operatively treated). Inter-rater reliability using Fleiss’ Kappa was k= 0.571 (p = 0.0004) indicating moderate inter-rater reliability among the three reviewers. The rate of immature HO at 52 weeks was 56%. The multivariate logistic regression analysis identified male sex as a significant risk factor for HO development (OR 5.29, 1.55-20.59 CI, p = 0.011), but not for HO maturity at 52 weeks. Age, time to surgery, and operative intervention were not found to be significant predictors for either HO formation or maturity of the lesion in this cohort. Our study demonstrates moderate inter-rater reliability in determining the presence of HO at 52 weeks post-elbow injury. There was a high rate (56%) of immature HO at 52-week follow-up. We also report the finding of male sex as a significant risk factor for post traumatic HO development. Future research directions could include investigation into possible male predominance for traumatic HO formation, as well as improving inter-rater reliability through developing a standardized and validated classification system for reporting the radiographic features of HO formation around the elbow

The patterns of nerve and associated skeletal injury were reviewed in 84 patients referred to the brachial plexus service who had damage predominantly to the infraclavicular brachial plexus and its branches. Patients fell into four categories: 1. Anterior glenohumeral dislocation (46 cases); 2. ‘Occult’ shoulder dislocation or scapular fracture (17 cases); 3. Humeral neck fracture (11 cases); 4. Arm hyperextension (9 cases). The axillary (38/46) and ulnar (36/46) nerves were most commonly injured as a result of glenohumeral dislocation. The axillary nerve was ruptured in only 2 patients who had suffered high energy trauma. Ulnar nerve recovery was often incomplete. ‘Occult’ dislocation refers to patients who had no recorded shoulder dislocation but the history was suggestive that dislocation had occurred with spontaneous reduction. These patients and those with scapular fractures had a similar pattern of nerve involvement to those with known dislocation, but the axillary nerve was ruptured in 11 of 17 cases. In cases of humeral neck fracture, nerve injury resulted from medial displacement of the humeral shaft. Surgery was performed in 7 cases to reduce and fix the fracture. Arm hyperextension cases were characterised by injury to the musculocutaneous nerve, with the nerve being ruptured in 8 of 9. Five had humeral shaft fracture or elbow dislocation. There was variable involvement of the median and radial nerves, with the ulnar nerve being least affected. Most cases of infraclavicular brachial plexus injury associated with shoulder dislocation can be managed without operation. Early nerve exploration and repair should be considered for:. Axillary nerve palsy without recorded shoulder dislocation or in association with fracture of the scapula. Musculocutaneous nerve palsy with median and/or radial nerve palsy. Urgent operation is necessary for nerve injury resulting from fracture of the humeral neck to relieve ongoing pressure on the nerves

Introduction:. Distal humerus fractures as well as elbow fracture dislocation are often accompanied by soft tissue damage that warrants early fixation with an external fixator. The distal humerus is a hazardous area for placement of an external fixator due to the close proximity of the radial nerve to the humerus in this area. No known safe zone has been identified on the lateral border of the humerus to avoid radial nerve damage. The aim of this study was to record the incidence of radial nerve damage by placing two 4 mm pins into the humerus and to note the relation of the nerve to the pins. Methods:. Two 4 mm pins used to fix an external fixator were drilled into the lateral border of the humerus at points 100 mm and 70 mm proximal to the lateral epicondyle of both arms of 39 cadavers. The 30 mm interval between the pins is the interval between the pins in a pinblock of a commonly-used external fixator. The arms were dissected by medical students and the incidence of radial nerve damage was recorded. Statistical analysis was done using a Fischer's exact test to identify the incidence of nerve damage relative to pin insertion. The number of damaged nerves was compared to the number of non-damaged nerves. A design based Chi Square test was carried out to test left and right arms. The proportions of interest were estimated along a 95% confidence interval. Results:. The radial nerve was hit (damaged) by 56.4% of the proximal and 20.5% of the distal pins. The radial nerve ran posterior to the proximal pin in 2.57% of arms and 0% to the distal pin. Conclusion:. Although no clear safe zone could be established, pins should be placed closer than 100 mm from the lateral epicondyle and as posterior on the humerus as possible to minimize the risk for radial nerve damage. Keywords: Radial nerve, external fixation, humerus fractures