Midcarpal instability is an uncommon but troublesome problem. Patients have loss of dynamic control of the wrist in pronation and ulnar deviation due to laxity of the volar wrist ligaments that is often congenital or due to minor trauma. For those in whom conservative measures fail, open ligament reconstruction or fusions have been described. We prospectively studied a series of fourteen patients who underwent arthroscopic thermal capsular shrinkage for midcarpal instability.Introduction
Aim
A prospective study of early operative treatment of unstable elbow dislocations using a surgical algorithm, we present the early results of nine such injuries including five terrible triads of the elbow and four elbows which redislocated in plaster. All except two were high energy injuries. The lateral collateral ligament complex was found to be avulsed proximally in all cases and was reattached using a bone anchor. The common extensor origin was also torn to a variable extent in all cases and was repaired end to end. In the terrible triads, the coronoid fracture as fixed with a transosseous suture and the radial head reconstructed or, in one case with gross comminution, replaced. In the four redislocations, full stability was only restored when the medial collateral ligament was also reattached. Mobilization without a hinged external fixator was allowed from day one, but the elbows were protected in a hinged splint in between exercise sessions. Patients were assessed for stability, ROM, and functional disability using the DASH score at an average of 12 months. No elbows redislocated post-operatively and no patients complained of instability. Mean extension was 18° (95% CI 7° – 28°), flexion 131° (124° – 137°), pronation 76° (56° – 96°), and supination 82° (75° – 90°). Mean DASH score was 14.6 (95% CI 0.7 – 28.5) though this result was skewed by one patient who developed RSD and had a DASH score of 67.2. This was however the only complication. Early operative intervention with reconstruction of unstable elbow dislocations, including the terrible triad, prevents the poor results which are commonly found following non-operative treatment of such injuries. An external fixator is not usually required in the acute setting.
Efficient utilisation of the trauma list is an important aspect of trauma care in the NHS. An audit of the trauma theatre time utilisation was done from April 1999 to March 2000. Ideally the first case should start at 8:30 am. However, we found that the first patient was on the operating table only by 9:40 am (mean). The main reasons for the delay were the time required for the anaesthetist to see the patient and the other staff to set up the necessary equipments. We decided to identify the first case of the trauma list the day before, so that the anaesthetist can review the patient the previous day. We felt that this would also give adequate time for the theatre staff to set up their instruments. However, this did not improve the theatre timings. We introduced the novel idea of performing a carpal tunnel decompression at the beginning of each trauma list to make use of the redundant time without an extra financial burden to the hospital. Carpal tunnel decompression can be performed under local anaesthetic by a basic grade surgeon. This would also give time for the anaesthetist and the consultant surgeon to review the patients on the trauma list. The theatre time utilisation was re-audited a year following the introduction of carpal tunnel release. The patient for carpal tunnel decompression was on table at 8:44 am (mean). The first trauma case was on operating table at 9:46 am (mean). Therefore, in spite of performing an additional surgery on the list, there was a delay of only 6 minutes. This simple idea has helped us to do an additional case every day with only a 6 minute delay to the trauma list.
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.
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).
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.
