Download RECURRENT DISLOCATION OF THE ELBOW method of treatment

RECURRENT
GEOFFREY
Recurrent
have
been
of the elbow
through
pathology
of the
a constant
anatomy,
dislocation
dislocation
dislocations
condition
THE
COTTERILL,
is uncommon,
but
not
been
of injury
and
ELBOW
BIRMINGHAM,
in the past
of colleagues
has
of
with
the
of the
the articular
dislocation
their humeral
ENGLAND
three
years
in Liverpool,
well
described
ligaments
able
than
to
eighteen
cases
Birmingham
nor
is there
and
a standard
shoulder.
is found
hyperextend
stability
common
of the
posterior
hand
forearm
of the humerus.
trochlea,
by a
valgus
strain.
laterally,
Eight
elbows
1936).
in children
been
treated
joint,
but
dislocation
that
there
that
occur
during
the
past
dislocation,
but there
recurrent
spontaneous
Furthermore,
both
simple
and adolescents,
in whom
It is interesting
against
to those
traumatic
bilateral
the
elbow
suggested
analogous
have
in adults.
elbow
features
changes
that
most
gradually
recurrent
is greater
children
lose
is provided
and
there
this
partly
under
ability
by the
the
during
shape
of
surfaces
but also by the triangular
collateral
ligaments.
In flexion,
posterior
is prevented
by the impaction
of the radial
head
and coronoid
process
against
articulations,
but in full extension,
dislocation
is prevented
solely by the ligaments.
outstretched
the
clinical
articular
to repair
the capsular
defect.
of the elbow
usually
follows
simple
of the capsule
in some
cases,
and
SIMPLE
The
secondary
has
been
reported
(Much
of the elbow
are commonest
age of ten are
adolescence.
The natural
up
PAUL
cooperation
mechanism
defect
years by an operation
Recurrent
dislocation
be congenital
laxity
laxity
the
of this
capsular
in recurrent
may
and
OF
of treatment.
A study
three
LIVERPOOL,
dislocation
The
method
was
OSBORNE,
discovered
Oswestry.
DISLOCATION
with
to the
“
DISLOCATION
or postero-lateral
the elbow
incompletely
trochlear
notch
and
OF
THE
ELBOW
dislocation
of the elbow
extended.
The
coronoid
process
force
is caused
ofthe
which
by a fall on the
fall is first
strike
against
transmitted
the
trochlea
In this position
the laterally
sloping
surface
of the inner
two-thirds
of the
cam
action,
converts
the vertical
thrust
into a lateral
rotation
and partly
The upper
ends
of the radius
and ulna
are displaced
backwards
and then
swinging
“
on the
intact
biceps
tendon.
The
greatest
movement
is on the
outer
side
of
the joint
where
the lateral
ligament
is stripped
superiorly
and the postero-lateral
capsule
torn,
allowing
the radial
head to rotate
backwards
from the capitular
surface
(Figs.
1 and 2).
In simple
dislocation,
damage
also
occurs
to the medial
side
of the capsule,
and
considerable
bruising
and swelling
is often
present
on the inner
side of the joint.
The medial
epicondyle
reduction,
indicates
has
not
may be detached
in children
and the medial
however,
it is not always
possible
to strain
that the ligament
been stripped
off the
contribute
significantly
remains
in continuity
ligament
the joint
stretched
to open
with the periosteum,
bone,
usually
superiorly.
to the stability
of the
The
joint,
or ruptured.
into valgus,
although
weak
anterior
is necessarily
its
ligament,
damaged
After
which
attachment
which
does
in posterior
dislocation.
through
Greater
damage
occurs
a greater
arc during
often
with detachment
capsule,
particularly
to the lateral
dislocation.
ligament
because
the lateral
The lateral
ligament
is torn
of a fragment
of the lateral
epicondyle.
where
it lies behind
the lateral
ligament,
side of the joint
moves
at its upper
attachment,
The posterior
is torn
from
part of the
its superior
attachment.
340
THE
JOURNAL
OF
BONE
AND
JOINT
SURGERY
RECURRENT
Knowledge
the
coronoid
in some
this
of
dislocated
elbow
process.
cases
can
Figure
Figure
DISLOCATION
lateral
rotation
displacement
joint.
Initial
hypersupination
is necessary.
be achieved
Fio.
I-Normal
2-Primary
Forward
without
an
1
disposition
dislocation
separation
flexion
with
anaesthetic.
341
OF THE ELBOW
mechanism
to free the
traction
is useful
in the reduction
head
of the radius
and
then
complete
reduction,
of
the
which
FIG. 2
and lateral
ligaments
of the elbow.
detachment
of medial
ligament
and
ligament with fragment
of bone.
of medial
showing
of lateral
FIG. 3
FIG. 4
Pathology
of recurrent
dislocation
of the elbow.
The medial
ligament
is lax and
longer
than normal.
There has been incomplete
healing
of lateral
ligament
and
postero-lateral
capsule
with an ununited
lateral epicondylar
fragment
(Fig. 3). The
defect at the back of capitulum
is illustrated
(Fig. 4).
Associated
childhood
process
fractures
and
do
may
fractures
not
ofthe
predispose
PATHOLOGY
The
essential
pathological
occur,
head
to recurrent
OF
defect
48 B,
NO.
2,
MAY
1966
the separated
in adults.
medial
Ununited
epicondylar
fractures
OF
ELBOW
ofthe
epiphysis
in
coronoid
dislocation.
RECURRENT
the postero-lateral
ligamentous
and
initial
simple
traumatic
dislocation,
VOL.
including
ofthe
radius
causing
DISLOCATION
recurrent
capsular
structures,
to become
reattached.
dislocation
torn
THE
of the
elbow
or stretched
at the
A pocket
of capsule
is failure
of
time of an
is created
342
G.
FIG.
Case
1.
capitulum
Case
2.
OSBORNE
AND
P.
COTTERILL
5
Figure
5-Recurrent
dislocation
of elbow joint showing
a defect at the back of the
and an epicondylar
fragment.
Figure 6-The
dislocation
has been reduced
but the
deformity
of the rim of the radial head, and the bone fragment,
are shown.
Figure
7-The
marginal
defect
of the
radial
when the forearm
head
is shown.
Figure
FIG.
Figure
head.
9-Case
Figure
3. A small capitular
10-Case
4. Subluxation
fragment
is shown.
of the elbow with
defect
8-Dislocation
occurs
is pronated.
There is also
slight capsular
10
osteochondritis
ossification
and
of the radial
a capitular
is shown.
THE
JOURNAL
OF
BONE
AND
JOINT
SURGERY
RECURRENT
into
which
The
intact
the
head
of the
lateral
attachment
has
longer
obliged
slipping
of
radius
ligament
been
is received
would
stripped
OF THE
as it slides
normally
prevent
forearm
343
ELBOW
off its articulation
this
with
displacement,
or if it is more lax than normal,
the curve
of the capitulum
and at some
bones
occurs.
The medial
to follow
the
DISLOCATION
up,
the capitulum.
but
if its
superior
the head of the radius
is no
point
in extension
backward
ligament
may also have a laxity
which
contributes
to
instability
of the joint.
A sinlple
vertical
thrust,
as in leaning
on the arm,
will force
the coronoid
process
against
the laterally
sloping
surface
of the
postero-lateral
process
and
the
and
head
of the
through
displaces
4).
Damage
significant
strike
of
the
occur
lies
in
radius,
to
to it a
The
coronoid
travels
arc than the
the
humerus
the
osteochondral
dislocation
surfaces
radius
displaces
abrade
the posterior
or
the
An
joint.
its edge
margin
fracture
of bone
capsule
of this
is often
elbow
backwards,
or lateral
osteochondral
of a fragment
postero-lateral
of union
farther,
ulna,
which
(Figs.
3
of the
ofthe
capitulum.
with detachment
Failure
imparts
therefore,
a greater
behind
in recurrent
As the head
can
which
movement.
disengaged
from
under
the trochlea
and
forearm
then rides posteriorly.
The lateral
are more
lax than
the medial
structures
is
the whole
structures
rotating
simply
trochlea,
rotation
(Figs.
fragment,
can
which
5 and
possibly
6).
because
of the inhibiting
effect of the synovial
fluid, increases
the capsular
laxity
on the outer
side of the joint.
Such small intracapsular
bone fragments
are common
after
ligamentous
subsequently
crater
injuries
increase
of
in size.
in the postero-lateral
and,
with
radial
head
occurs,
the
margin
lesions
coincide,
the radial
head
because
or
with
“
dislocation
can slide
and
may
defect
or
the
of
repeated
dislocation,
can
become
similarly
sometimes
with
a crater
(Figs.
7 and
8).
When,
articular
the elbow
A permanent
capitulum
the
shovel-like
rotation,
edge of
damaged,
defect
“
these
occurs
into the
two
with ease
capitular
defect.
Radiographs
of the
often
head
reduction
under
and
show
abnormality
capitulum,
but
ofthe
shape
The
anaesthesia.
the lesions
lax medial ligament
and a postero-lateral
capsular pocket are present with an avulsion
fracture.
Figure
12 compares
the shoulder
with a defect of the anterior
margin
of the
glenoid,
and a posterior
impaction
fracture
of head of humerus.
There is anterior
capsular laxity with a detached
labrum.
Figure
I 3 shows the features apparent
in a recurrent
dislocation
of any
of both
convex
present,
with
diathrodial
and
capsular
joint.
concave
pockets
Defect
surfaces
and
are
laxity
with avulsion
of the rim or attachments
of
ligaments.
Figure 14 shows the general
principles of repair
of a recurrent
dislocation.
The capsule
is shortened
and attached
to
may
the articular
margin,
redundant
capsule
being excised
or overlapped.
be confined
to the cartilaginous
surfaces
and
are
therefore
transradiant.
Osteochondritis
dissecans
of
the capitulum
can occur
in association
with
recurrent
dislocation
of the elbow
and one
patient
had osteochondritis
dissecans
of the radial
head (Fig. 9). A shallow
trochlea
notch
has been described
as a predisposing
factor
but it may be a result
of repeated
dislocation.
Not all patients
with recurrent
dislocation
of the elbow
have complete
dislocation,
or
need
radial
FiG.
13
FIG.
14
The comparative
pathology
of recurrent
dislocation.
Figure
1 1 illustrates
an elbow
with capitular
flattening
and a matching
“
shovel-like
“
defect of the radial head.
A
radial
head
may
subluxate
defect
or capsular
pocket
and can be reduced
easily by the patient
of
locking
and
in the radiograph
capsular
bone fragments
“
lead
VOL.
“
to
48 B,
a mistaken
NO.
2.
MAY
diagnosis
1966
of
osteochondritis
dissecans.
momentarily
into
acapitular
(Fig. 10) who may complain
resembling
loose
bodies
may
Two
such
patients
have
been
344
G.
encountered
with vague
recently
instability
and recurrent
or locking
It is interesting
and
and
(Figs.
glenoid
in recurrent
of repair.
dislocation
TREATMENT
Not
childhood
of
the
capsule
Occasional
and
ofany
Figure
lesion
and
the
in recurrent
joint,
always
be considered
dislocation
and
DISLOCATION
If
of the shoulder
Figure
OF
may
years
be expected
features
14 the
THE
are
less
for
elbow may cease
juvenile
tendency
elbow
when
and
operation,
in
cease.
and
to dislocate
after
to hyperextension
joint
Surgical
as is usual
cause tightening
frequent
an indication
of the
surgical
ELBOW
become
not
head
head
to develop
which
may
possible
the dislocation,
occurring
processes
of growth
may
normal
dislocations
of a few
should
ball and socketjoint
could
13 suggests
the pathological
RECURRENT
at intervals
joint
fracture
of the back of the humeral
defects
of the capitulum
and radial
diarthrodial
surgical
treatment.
is infrequent,
the
ligaments
dislocations
of the elbow
The impaction
resemble
the
of any
OF
all elbows
need
or adolescence,
P. COTTERILL
the pathological
1 1 and 12).
flattening
respectively,
and recurrent
dislocation
similar
capsular
and articular
lesions.
be found
methods
AND
subluxation
of the elbow.
to compare
of the elbow
the anterior
OSBORNE
an
the
disappears.
treatment
dislocations
is indicated
occur
frequently
with trivial
violence
in the older adolescent
or adult
patient.
The operation
suggested
and
sular
is a repair
ligamentous
of the cap-
laxity.
Usually
a capsular
repair
only on the lateral
side of thejoint
is adequate,
but when
15
F1G.
The suggested
operation
for repair
in recurrent
of the lateral
dislocation
and
16).
capsular
occur
damage
the
cylinder
patient
is
is applied
allowed
when
dislocations
there
laxity
is much
repair
of
the
medial
medial
ligament
should
also be done.
on the lateral
side of the elbow
from the lateral
epicondylar
The elbow
is opened
behind
the lateral
ligament
and any
from
the postero-lateral
part of the capsule.
The bone
of
of the lateral
side of the capitulum
is cleared
of soft tissue
and
One or two transverse
holes are drilled
with an awl, and catgut
is
passed
through
the bone and through
the postero-lateral
down
tightly
so that it will adhere
to the bone of the lower
articular
margin
as possible.
A similar
repair
of the medial
A plaster
spontaneous
and
ligament
of the elbow.
Technique-An
incision
is made
ridge
to the annular
ligament.
fragments
of bone
are removed
the lateral
epicondyle
scarified
(Figs.
15 and
frequent
16
FIG.
with
to recover
the
elbow
movements
at about
capsule
in order
to tie the capsule
end of the humerus
as close to the
ligament
is done if it is necessary.
40 degrees
for
four
weeks,
after
which
we have
found
gradually.
DISCUSSION
Recurrent
dislocation
ofthe
elbowjoint
was
reported
by Albert
(1881)
and
reports
of thirty
other
cases.
Except
in two cases
(Heusner
1894,
Rehn
1924)
all the
dislocations
have been posterior
or postero-lateral.
The age when
the first dislocation
occurred
was recorded
in twenty-four
cases.
The ages
ranged
from nine months
to twenty-nine
years ; and 80 per cent of patients
were under
fifteen.
Of twenty-six
cases
in which
the sex was stated,
over 80 per cent were in males.
Recurrent
bilateral
dislocation
1947, Kapel
of the
elbow
has
been
described
in three
cases
(Milch
1936,
Reichenheim
1951).
THE
JOURNAL
OF
BONE
AND
JOINT
SURGERY
RECURRENT
DISLOCATION
OF THE
A record
of the physical
examination
of the joint
In three
the joint
appeared
normal.
In twelve
excessive
in lateral
mobility
or hyperextension
were found.
Radiographs
in eight,
notch
four.
In one
before
fracture
a flake
operation
of the tip
ofbone
FIG.
surgical
elbow.
Figure
tendon
operation.
Artificial
through
Treatment
ofthe
little
immobilisation
that
treatment
seems
to
given
The
the
some
operations
resemble
and
the
that,
as with the
it recurring
generally
successful
prevent
VOL.
48 B,
scar
NO.
2,
recurrent
20
unsuccessful
of
Transplantation
and olecranon
Reconstruction
shadow
reported
a defect
in the joint
were
18
dislocation
the
of biceps
Wainwright’s
operation.
tendon
which
fossa.
Figure
20ofthe medial ligament.
was not clear for most patients.
the first injury
to the joint
consistently
The
impression
later
and
in helping
was
that
the
gained
conservative
established
recurrent
be classified
broadly
into four groups
(Figs.
17 to 20).
All have
although
less than ten cases ofany
one method
can be reviewed.
those
performed
on the shoulder
before
Bankart
(1938)
described
pathological
capsular
repairs,
elbow
was usually
lesion
of recurrent
but no method
used but never
dislocation.
They
consisted
of slings,
was invariably
successful.
An anterior
a posterior
one.
It appeared,
however,
shoulder,
any method
that blocked
the pathway
of the dislocation
would
and, with a joint
as inherently
stable
as the elbow,
all methods
were more
than was the case with the shoulder
joint.
Transplantation
of the biceps
tendon
to the coronoid
the coronoid
(Milch
subsequent
operation.
an osseous
can
results,
essential
bone
blocks
approach
to
been
for
coronoid.
Figure
18-Milch’s
and
block
of coronoid.
Figure
19-Kapel’s
formed
from
strips
of biceps
and triceps
injury
showed
FIG.
suggested
through
the coronoid
and Spring’s
operation.
have
successful
original
the
followed
dislocation
of the elbow.
Previous
operations
other
1947, King
1953)
and loose
bodies
FIG.
17-Reichenheim’s
initial
one
(Reichenheim
dissecans,
17
procedures
Bone
ligaments
are passed
Knoflach’s
and
in half of the thirty
cases.
laxity
of ligaments,
increase
in six joints,
a shallow
trochlear
and fracture
of the epicondyles
in
19
FIG.
Previous
to thejoint
Two authors
to osteochondritis
to
is available
mobility,
showed
no abnormality
of the coronoid
in four
lay anterior
the lateral
epicondyle.
of the trochlea
possibly
due
recorded
by Spring
(1953).
close
345
ELBOW
process
(Reichenheim
1936,
Wainwright
1947)
tissue
MAY
formation)
1966
with
1947)
both
a mechanical
or the
combine
effect
insertion
of a bone
block
an anterior
approach
on
the
coronoid
to
prevent
into
(with
its
346
G. OSBORNE
disengagement
anterior
under
approach
the
trochlea-the
to the
elbow
AND
P. COTTERILL
initial
joint,
step
however,
in dislocation
of the
is technically
difficult
elbow
joint.
the
intra-articular
and
tendinous
slings described
by Kapel
(1951) are formidable
technical
procedures.
(1935) and Spring
(1953) used either
fascial
strips or tendinous
strips to reinforce
ligaments
and Sorrel
(1935)
used a bone block
projecting
from the lateral
side
to achieve
this
Eight
years.
four
strained
elbow
Both Knoflach
the collateral
of the humerus
effect.
patients
There
the
Any
have been treated
surgically
has been no recurrence.
One
elbow,
movement
but
and
redislocation
used
the
did
elbow
not
normally
by the method
described
here during
boy, playing
football,
fell on the right
the last
arm and
occur.
range
All
without
patients
recovered
a full
of
restriction.
SUMMARY
1 Recurrent
dislocation
secondary
damage
to the
.
2.
3.
of the elbow
is caused
primarily
capitulum
and head of radius.
The pathological
changes
Subluxation
or instability
and deserves
4. A simple
by collateral
resemble
those
of recurrent
of the radial
head is often
dislocation
associated
wider
recognition
because
it may be confused
method
of soft-tissue
repair
has successfully
ligament
laxity
with
of the shoulder.
with capsular
ossification
with osteochondritis
dissecans.
prevented
redislocation
of eight
elbows.
We wish to thank
Mr Norman
Roberts
for helpful
advice in the preparation
of this paper.
We are grateful
to
Mr H. G. A. Almond,
Mr T. S. Donovan,
Mr F. C. Dwyer,
Mr M. H. M. Harrison,
Professor
Robert
Roaf
and Mr Douglas Savill for permission
to use their cases.
REFERENCES
E. (1881):
ALBERT,
Lehrbuch
der Chirurgie
und
Operationslehre.
Zweite
Band
Auflage.
2, 377.
Wien:
Urban
& Schwarzenberg.
A.
BANKART,
British
S. B. (1938):
Journal
L.
HEUSNER,
(1 894) : Em
funfzigjahrigen
Jubil#{228}ums des
0. (1951):
KAPEL,
The Pathology
and
26, 23.
Fall von habitueller
of Surgery,
Operation
Vereins
for Habitual
der
Treatment
of Recurrent
Luxation
des
des
Regierungsberzirks
Aerzte
Dislocation
Dislocation
Ellenbogens.
In
of the
Festschrift
Journal
ofBone
zur
Feler
des
Wiesbaden.
D#{252}sseldorf
of the Elbow.
Shoulder-joint.
andJoint
33-A,
Surgery,
707.
KING,
Recurrent
KNOFLACH,
T. (1953):
J. G.
MILCH,
H. (1936):
18, 777.
REHN,
E. (1924):
REICHENHEIM,
P.
of the Elbow.
SORREL,
E. (1935):
(1935):
Nationale
SPRING,
W.
Surgery,
WAINWRIGHT,
Medicine
de
E.
Zur
Bilateral
Dislocation
Operation
Recurrent
of the Elbow.
Journal
of Bone and Joint
Surgery,
der habituellen
Ellbogenluxation.
Zentralblattfur
Dislocation
ofthe
Ulna at the Elbow.
JournalofBone
Gelenkkapselplastik
bei habitueller
Ellbogenluxation.
Neue
Deutsche
P. (1947):
Transplantation
of the Biceps Tendon
as a Treatment
for
British Journal
of Surgery,
35, 201.
Luxation
Chfrurgie,
(1953):
35-B, 55.
D. (1947):
(Section
r#{233}cidivante du coude.
61, 790.
Report
of a Case
Recurrent
of Orthopaedics),
Operation.
of Recurrent
Dislocation
40, 885.
of the
Gu#{233}rison.
Dislocation
of the
Elbow-joint.
THE
Bulletins
50.
62, 2897.
Chirurgie.
andJoint
Surgery,
Chirurgie,
26-B,
Recurrent
Dislocation
522.
et M#{233}moires de la Soci#{233}t#{233}
Elbow.
Journal
Proceedings
JOURNAL
35-B,
of
OF
BONE
of
the
Bone
Royal
AND
JOINT
and
Joint
Society
SURGERY
of