Session I - Upper Extremity

Unstable Elbow Dislocations and Fracture-Dislocations: Temporary Transarticular Fixation

Kathryn E. Cramer, MD; Berton R. Moed, MD; David E. Karges, DO; J. Tracy Watson, MD, Wayne State University, Detroit, MI

Introduction: Instability after an elbow dislocation or fracture-dislocation is unusual but very difficult to treat effectively. Despite reduction and fixation of associated fractures, significant soft-tissue injury that occurs as a result of dislocation may result in residual instability. This study evaluates the technique and results of temporary transarticular fixation of the unstable elbow, a previously unreported acute treatment method, in a group of patients with a varied spectrum of injury.

Methods and Materials: Beginning in 1990, a prospective protocol was instituted for stabilization of unstable elbow injuries. Inclusion criteria included skeletally mature patients with elbow dislocations or fracture dislocations that were persistently unstable after reduction and fixation of all amenable associated fractures. Unstable joints were anatomically reduced and temporarily fixed with a smooth Steinmann pin or screw passing from the olecranon into the distal humerus, exiting the posterior humeral cortex in order to allow easy retrieval in the event of breakage. The arm was then immobilized in a long-arm cast. After soft-tissue healing, the cast and transarticular fixations were removed and a progressive physical therapy program, directed towards regaining motion, was begun. Over a six-year period, 17 patients (9 male, 8 female) with an average age of 47 years (range 24­75) underwent temporary transarticular screw, or Steinmann pin fixation, for persistent elbow instability after an elbow or fracture dislocation. Associated fractures included 13 radial-head fractures (7 Type II fractures were treated with ORIF; 6 Type III fractures were excised). One of the excised radial heads had a Silastic spacer placed acutely. Two articular olecranon fractures were treated with ORIF. Eleven small coronoid avulsions were documented (6 Type I; 5 Type II); none were internally fixed. Using the AO fracture classification, there were three 21B1, four 21B2, five 21C1, three 21C2, and one 21C3 injuries. One patient had an isolated elbow dislocation without associated fracture. A temporary transarticular smooth Steinmann pin was used in 4 patients while a screw was used in the remaining 13 (average time to removal, 3 weeks; range, 10 days to 6 weeks). Seven patients were treated acutely for instability, while 10 were treated delayed (average, 3 weeks; range, 2 to 4 weeks). Follow-up data included assessment of pain, functional status, range of motion and stability, and return to work. Complications were identified and documented.

Results: Follow-up ranged from 6­36 months (average, 17 months). Only four patients had less than 12-months follow-up. Four patients had slight or minimal pain, while 13 were pain free. Fourteen patients had no limitation of ADL, while two had minimal and one had significant limitation. Range of motion averaged 125 degrees of flexion (range 100­145), -23 degrees of extension (range ­45­0). Six patients lost more than 30 degrees of pronation and eight patients lost more than 30 degrees of supination. Decreased range of motion correlated with increased time of immobilization. No elbows were unstable. Fifteen patients returned to their previous occupation. Complications included two superficial pin tract infections, one case of heterotopic ossification requiring excision and one case of screw breakage (removed without difficulty).

Discussion: Previously proposed procedures for the persistently unstable elbow require extensive dissection, bony procedures or the placement of complicated external frames to an already severely traumatized joint. Most exist as case reports, and the largest published series contains twelve cases. The technique reported here is controversial but conforms to the standards of contemporary fracture care: stable fixation, minimal surgical trauma and preservation of soft tissue. Despite the brief period of immobilization, an average flexion arc of 100 degrees was obtained, and 94 percent of patients had minimal or no limitation of function.

Conclusion: Temporary transarticular fixation for elbow instability following elbow dislocation or fracture dislocation is safe, simple and effective and avoids further soft-tissue injury. Screw fixation is preferable to Steinmann pin fixation, and length of immobilization should not exceed three weeks. Preliminary functional results are favorable and comparable to other reported methods; however, longterm follow-up is necessary.

REFERENCES

1. Cobb, T.K. and Morrey, B.F.: Use of distraction arthroplasty in unstable fracture dislocations of the elbow. Clin Orthop, 312:201­210, 1995.

2. Gil, D.E.; Delgado,G. and Alonso-Llamas, M.: Recurrent dislocations of the elbow. International Orthop, 14:41­45, 1990.