Introduction. The stability of the elbow joint following an acute elbow dislocation is dependent on associated injuries. The ability to identify these concomitant injuries correctly directs management and improves the chances of a successful outcome. Interpretation of plain radiographs in the presence of either a dislocation or post-reduction films with plaster in-situ is difficult. This study aimed to assess the ability of orthopaedic registrars to accurately identify associated bony injuries on initial plain radiographs using CT as the gold standard for comparison. Methods. Patients over the age of 16 years undergoing an elbow CT scan within one week of a documented elbow dislocation between 1st June 2010 and 1st June 2014 were included in the study. Three orthopaedic registrars independently reviewed both the initial dislocation and immediate post reduction plain radiographs to identify any associated bony injuries. This radiograph review was repeated by each registrar after two weeks. The incidence of associated injuries as well as the inter- and intra-observer variability was calculated. Results. 28 patients were included in the study. 54% of the patients were female and the mean age was 45 years (range 16 to 90 years). The incidence of a radial head fracture was 54%, coronoid fracture 43% and epicondyle avulsion 18% on CT. The inter-observer reliability was only shown to be fair amongst registrars and the intra-observer variability moderate. Conclusions. Computerised tomography is a useful adjunct in the assessment of associated osseous injuries following an elbow dislocation due to the presence of a high number of injuries. Plain radiographs alone have been shown to have only a fair and moderate inter and intra-observer variability respectively, therefore a low threshold to obtain further 3D imaging should be practised. Level of Evidence. IV

The April 2024 Children’s orthopaedics Roundup. 360. looks at: Ultrasonography or radiography for suspected paediatric distal forearm fractures?; Implant density in scoliosis: an important variable?; Gait after paediatric femoral shaft fracture treated with intramedullary nail fixation: a longitudinal prospective study; The opioid dilemma: navigating pain management for children’s bone fractures; 12- to 20-year follow-up of Dega acetabuloplasty in patients with developmental dysplasia of the hip; Physeal fractures of the distal ulna: incidence and risk factors for premature growth arrest; Analysis of growth after transphyseal anterior cruciate ligament reconstruction in children; Management of lateral condyle humeral fracture associated with elbow dislocation in children: a retrospective international multicentre cohort study

Aims: To review paediatric elbow dislocations treated in our institution over a ten year period in terms of incidence, aetiology, management and follow up. Methods: Prospective data collected on elbow injuries in our unit was used to identify elbow injuries and elbow dislocations over a ten year period. This was followed by a case note and x ray review. Results: 1761 elbow injuries exclusively treated in our unit in a ten year period. Of these patients 63 had elbow dislocations. We found a male to female preponderance of around 2:1 (44:19), left more common than right (37:26). There was a seasonal variation with more injuries in the summer months. 80% of all dislocations occurred as a result of a low fall or simple sporting injury. 60 of the 63 dislocations were posterior with 2 anterior and 1 divergent dislocation. Associated fractures were common with 33% of patients having a medial epicondylar fracture in association with their dislocation, other fractures were rare. 2 dislocations were open; there were 2 neuropraxias and no vascular complications. 12 cases were reduced with sedation and analgesia with the remainder undergoing general anaesthetic. Closed reduction was possible in all cases Those patients with associated fractures of the medial epicondyle who underwent reduction under sedation had a much higher requirement of open reduction of the fragment (3 out of 4) compared with those having reduction under general anaesthesia (4 out of 16). Post operative management consisted on average of 3 weeks in plaster. In the timeframe used there were no - recurrent dislocations, no patients re referred for assess- ment of ongoing elbow problems and no complaints of ongoing stiffness. Conclusions: Paediatric elbow dislocations represent around 3.5% of all paediatric elbow injuries, are more common in boys and on the left. They generally arise from low energy trauma and are usually posterior. Closed reduction we found always to be possible but if there was an associated fracture then reduction is probably best carried out under general anaesthesia since this appears to aid reduction of associated fragments

Introduction and Aims: To review paediatric elbow dislocations treated in our institution over a ten year period and assess outcome. Method: Prospective data collected on elbow injuries in our unit was used to identify elbow injuries and elbow dislocations over a ten-year period. Thereafter, a comprehensive case note and radiological review was performed. Results: 1761 elbow injuries exclusively treated in our unit in a ten-year period. Sixty-three elbow dislocations were identified. Male to female preponderance of around 2:1 (44:19), left more common than right (37:26). There was a seasonal variation. Eighty percent of all dislocations occurred as a result of a low fall or simple sporting injury. Sixty of the 63 dislocations were posterior with two anterior and one divergent dislocation. Associated fractures were common (46%), with 33% of patients having a medial epicondylar fracture in association with their dislocation, other fractures were rare. Two dislocations were open; there were two neuropraxias and no vascular complications. Twelve cases were reduced with sedation and analgesia with the remainder undergoing general anaesthetic. Closed reduction was possible in all cases. Reduction of fracture dislocations under sedation was associated with a higher incidence of medial epicondyle entrapment in the joint compared with general anaesthetic reduction. Post-operative management consisted on average of three weeks in plaster. No significant long-term loss of movement occurred in any patient. In the timeframe used there was one re-dislocation and no re-referrals for ongoing instability. Conclusions: Paediatric elbow dislocations represent around 3.5% of all paediatric elbow injuries. Although closed reduction is almost always possible, fracture dislocations should be reduced under general anaesthesia. Unlike in adults there appears to be problem with immobilisation for up to five weeks and the results of conservative treatment are excellent

Purpose of the study: Elbow dislocation is a frequent traumatic injury. Management is well described. An associated vascular lesion is exceptional, but must be searched for systematically. We report a short series and describe our therapeutic strategy for these complicated dislocations. Material and methods: Between 1999 and 2004, our emergency unit cared for 357 cases of elbow dislocation. For six, injury to the brachial artery was present. This series included four men and one woman, mean age 34.7 years. The causal trauma was a traffic accident for four, and a fall four two. The dislocation was open in three. The radial pulse could not be palpated in any of the patients but blood supply to the hand persisted in five. There was a clinically detected neurological deficit in three. After obtaining the necessary x-rays, the elbows were reduced in the emergency room. The radial pulse remained impalpable in all patients and arteriography was performed and revealed a rupture of the brachial artery in five and an arterial spasm in one. Vascular repair was undertaken in all six cases using an reversed venous graft. The elbow was stabilized with an external fixator in three patients. For the others, the elbow was immobilized for 21 days on average before remobilization. Results: AT 23 months follow-up, the overall outcome has been average with a Mayo clinic score of 69.2 points. Only four elbows were functional. Only one patient had a pain free elbow. Stiff joint was the most frequent functional impairment: mean flexion was 111.7° with a 41.7° extension deficit. The blood supply to the hand was correct in all cases, but one of the graft bridges became obstructed by a thrombus, the distal vascularization being supplied by the collateral circulation. The initial neurological lesions recovered partially. Discussion: Elbow dislocation with vascular injury is exceptional but must be systematically detected. Emergency management associates reduction of the dislocation, a vascular work-up and rapid surgical management of the elbow, using an articulated external fixator when necessary, to limit as much as possible posttraumatic stiffness

Elbow dislocations are difficult to treat because of the high incidence of short- (vascular and neurological lesions) and long-term (decreased range of motion and instability) complications. We report the results obtained in 20 elbow dislocations treated with hinged cast tutorisation or hinged external fixator. We treated 20 patients with an average age of 45 years (range 16– 62 years). The average follow-up was 7 months (range 5–18 months). We divided the patients into two groups: patients treated by a hinged tutor for 4 weeks (group A), patients treated by hinged external fixator, removed after 5 weeks (group B). All the patients were evaluated clinically using the “Mayo elbow performance score” after 3 weeks, 1 month and 1 year. Results were excellent in six elbows and good in 14; none of the patients had an insufficient or poor score. We observed deficit in prono-supination in three patients and deficit in flexion and extension in six patients; three patients complained of epicondylar pain when carrying something. At the end of the treatment none of the patients complained of instability. According to our data normal function can be restored after early mobilisation. Our experience suggests that the most important aspect in the choice of treatment is the evaluation of joint stability after reduction. The results obtained with the external fixator are very good in terms of restoring function; the incidence of complications is very low and was equally distributed between the two groups

Introduction – Elbow dislocation in children is a rare lesion and most of the times is associated with a fracture of the medial epicondyle. When there is a fracture of the radial neck it is even more rare and usually represents a major instability with large soft tissue disruption. Methods – Between 1984 and 2003, 56 patients with unilateral elbow dislocations were identified ranging from 4 to15 years of age. In 8 patients a radial neck fracture was associated and in two there was a radio ulnar translocation . All these patients were treated the same way: closed reduction of the fracture dislocation under general anesthesia, evaluation of the instability and fracture fixation by closed means (Metaizeau technique). No ligamentous reconstruction was performed even in the presence of severe instability after bone reconstruction. A plaster was applied for two weeks followed by active mobilization. Results – All fractures healed with no complications. All patients except one regained full range of motion. The patient with a loss of extension (20°) complaints of pain on the lateral side during sports activity and has a minor instability test positive for the lateral collateral ligament. Discussion – This is a rare lesion in children not well documented in the literature. In the adult population there is an emphasis on the necessity of a repair of the soft-tissue structures as an integral part of the surgical strategy for elbow dislocation that require operative treatment (Mckee et al. J Shoulder Elbow Surg. 2003 Jul–Aug;12(4):391–6). In this small series we found no major instability in a long follow-up study even without reconstruction of the soft-tissues. Conclusion – We concluded that in this particular type of lesion, a close anatomical reduction of the articular surfaces with restoration of the normal relationship around the elbow was fundamental to restore elbow stability with no need for soft-tissue reconstruction

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

The purpose of this study was to present long-term results of elbow dislocation in children. Eleven patients (10 male) with elbow dislocation (mean age 10.4 years old) were re-evaluated with mean follow up 85 months (24 – 186). Active range of motion and instability were clinically evaluated. Osteoarthritic changes, position and shape of medial epicondyle were radiographically recorded. Functional evaluation was made with Hospital for Special Surgery Elbow Assessment protocol (up to 100). All cases were treated with closed reduction under general anaesthesia. Three patients were treated surgically with KW for fractures of medial epicondyle. Lack of extension (5° – 15°) was detected in 3 patients two of which had fractures (1 osteochondral and 1 of medial epicondyle). 4 patients were presented with flexion deficit (5° – 10°) while 1 patient had reduction both for supination and pronation (fx of medial epicondyle). Decreased pronation was recorded in two more patients (5° — 10°). Radiologically we found a patient with medial and lateral epicondyle alteration, a patient with osteochondral fracture and another one with ossification of LCL. Functionally the overall result was excellent (subjectively) while mean HSS Elbow Assessment score was 99.1 (96–100)

Simple posterior elbow dislocations are often being treated with strict immobilization after reduction. We performed a study in order to investigate if a functional protocol of rehabilitation, allowing early motion, would be more effective. We prospectively followed twenty five consecutive patients for simple posterior elbow dislocation in a non-randomized study. Patients were divided in two groups. Group A (twelve cases) was treated with immobilization using a cast in 90 degrees of flexion and neutral rotation for three weeks. Group B (thirteen cases) was treated according to a functional rehabilitation program that allowed early controlled mobilization starting on the 2nd post-traumatic day, consisting of immediate flexion from 90° and gradual extension after the 2nd week. Follow-up of the patients was recorded at six weeks and three months. The functional scores used were Mayo Clinic Performance Index, Liverpool Elbow score and Broberg and Morey. None of the patients had an incident of redislocation. Patients of group B had statistically significant better (p< 0.05) functional scores at six weeks and better no statistically significant in three months: group B/group A: Mayo: 91.6/65.5, Liverpool: 8.8/6.1, Broberg and Morey: 89.1/73.3. It seems that a functional rehabilitation program gives the same result in terms of stability offering at the same time patients a better range of motion and functional score at least at six weeks and three months

This retrospective study of 196 cases of children’s elbow dislocation had for objectives to check literature’s epidemiological data and to compare the various therapeutic protocols used over a 32 years period. The average age was 11 years, boys (117) were more frequently affected than girls (79). Both sides were almost equally affected. Most dislocations were posterior or postero-lateral (176). An associated fracture has been found in 104 cases, in 64 cases it was a medial epicondyle’s fracture. Nervous or vascular complications have been found in 8 cases and have immediately been reversed following reduction of the dislocation. 153 patients have been reviewed, 134 patients reported good results, 12 results were average and 7 results were poor. Radiological calcifications have been found in 37 cases (24%). We have shown significant statistical link between the occurrence of elbow stiffness and 2 factors: the carrying out of late kinesitherapy and the appearance of posttraumatic calcifications. We haven’t found any factor favoring the appearance of calcification. This large series has confirmed the epidemiological data found in literature and allowed us to initiate a simple therapeutic stance combining an early reduction under general anesthesia, the carrying out of an osteosynthesis each time it is necessary and a plastered immobilization of 4 weeks followed by a self rehabilitation

After dislocation of the elbow with avulsion of the medial epicondyle, the management of the latter is controversial. Of 28 children followed up after initial closed reduction of the elbow, 19 had a satisfactory closed reduction of the epicondyle and were treated in plaster. At follow-up, 11 children had a normal elbow and eight had lost an average of 15 degrees of flexion. Nine children had had open reduction and internal fixation of the fragment, one for an open injury, three for displacement of the epicondyle and six for intra-articular entrapment of the fragment. Five of these children had ulnar nerve contusion or compression, four requiring anterior transposition of the nerve. At review, only three had normal elbows and six had lost an average of 37 degrees of flexion. We agree with other authors that surgery is indicated only for children in whom the epicondyle is trapped in the joint or is significantly displaced after closed reduction.

Purpose of the study: Although the role of the radial head is clearly established regarding elbow stability, it cannot always be preserved after complex fractures. Association with a posteriolateral dislocation, besides the risk of short-term recurrent dislocation, raises the problem of long-term osteoarthritic degeneration. Certain authors advocate a metal prosthesis which works like a spacer in lieu of the head; their mid-term results have been encouraging, but should complete resection with suture of the medial ligament plane be ruled out definitively?

Material and methods: We reviewed 13 files of patients who had had an initial resection of the radial head after trauma. For seven of these patients, there was an associated dislocation; the medial ligament structures were sutured. All patients were reviewed with mean 13 years follow-up (5–15) and evaluated clinically with the American Shoulder and Elbow Surgeon (ASES) system to establish the Mayo Clinic Elbow Performance (MCEP) score. Osteoarthritis of the ulnar trochlea was analysed on the plain x-rays, completed by an axial view, using the Morrey radiographic classification of 4 stages.

Results: There were not cases of recurrent dislocation. According to the Broberg and Morrey index, 92% of patients had good outcome with total resumption of occupational activities; there was no difference between patients with and without dislocation. All patients developed grade 1 or 2 osteoarthritis, with very good clinical tolerance. All were satisfied with their operation despite efforts to spare joint movements.

Discussion: The studies evaluating the use of radial head prostheses have reported similar findings for functional outcome. Radiographic degeneration of the ulnar trochlea is also comparable. Immediate rehabilitation is necessary to prevent loss of range of motion and warrants surgery to stabilize the joint as wells as possible use of an adapted dynamic orthesis.

Conclusion: Resection of the radial head without prosthetic reconstruction remains a reasonable option when the head cannot be saved. Associated dislocation implies repair of the medical collateral ligament. At long-term, the functional impairment is minimal despite the moderate osteoarthritis; the problematic of implant survival is avoided.

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

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 aim of our study is to report on our experience with elbow dislocations in childhood, the spectrum of the associated injuries and the various treatment modalities used. In a period of 18 years, 52 children (33 male and 12 female) with elbow dislocations were treated in our clinic. 45 patients were followed-up with an average time of 7.2 years. 13(29%) dislocations were pure while associated injuries were present in 32(71%). Three had compound injuries. 23 of the associated injuries involved medial epicondyle fractures, 6 radial head fractures, 2 coronoid fractures, 2 lateral humerus condyle fractures, 1 ulnar diaphysis fracture and 1 radial peripheral metaphysic fracture. 27 patients treated conservatively while 18 patients treated surgically. At the final re-examination, according to Roberts PH criteria, the clinical results were excellent in 24(56%) patients, good in 11(27%) patients, fair in 4(13%) and poor in 2 (4%) patients. A transit ulnar nerve paresis was perceived in 1 patient. The x-ray findings demonstrated 6 patients with medial epicondyle pseudartrosis and 6 patients with ectopic ossification. Most elbow dislocations are associated with elbow fractures, therefore examination for an associated fracture is necessary. Closed reduction is the treatment of choice for elbow dislocations. Surgical treatment is indicated in elbow dislocations that are not reduced closely, in open injuries and in the presence of associated injuries that demand surgical treatment. The clinical and x-ray results are usually excellent. The presence of associated fractures, especially fractures of the radial head tent to lead in poor results

The August 2014 Children’s orthopaedics Roundup. 360 . looks at: Conservative treatment still OK in paediatric clavicular fractures; Femoral anteversion not the usual suspect in patellar inversion; Shoulder dislocation best treated with an operation; Perthes’ disease results in poorer quality of adult life; Physiotherapy little benefit in supracondylar fractures; Congenital vertical talus addressed at the midtarsal joint; Single-sitting DDH surgery worth the effort; and cubitus valgus associated with simple elbow dislocation

A particular pattern of complex instability of the elbow is “the terrible triad”, in which elbow dislocation is associated with fractures of the coronoid and radial head. Other frequent patterns are the variant of Monteggia lesions (Bado II) described by Jupiter which is characterized by ulnar fracture associated with fracture-dislocation of proximal radius, and the articular fracture of the distal humerus associated with elbow dislocation. The goal of treatment is to restore the primary stabilizers of the elbow such as the coronoid process, olecranon and both collateral ligaments by internal fixation and reconstruction of the ligaments. If elbow stability obtained at operation is unsatisfactory or internal fixation not enough stable, there an indication for applying a dynamic external fixator (DEF). The latter allows:. the articular congruence to be maintained and the ligaments to heal in adequate tension and position,. internal fixation and ligaments reconstruction to be protected, and. immediate joint motion to be carried out. From 2005 to 2008, we treated surgically 31 patients with complex instability of the elbow. DEF was applied in 38% of cases, namely 3 terrible triads, 5 fracture-dislocations of Monteggia and 4 articular fractures of the humerus associated with elbow dislocation. The mean age of patients was 44 years (range 30–74). All patients underwent ORIF, reconstruction of ligaments and dynamic external fixation. The OptiROM elbow fixator was used In 2 patients, the Orthofix fixator in 1 and the DJD fixator in 9. In all cases, active elbow motion was allowed without restrictions from the second postoperative day. Indomethacin was consistently administered for 5 weeks to prevent heterotopic ossifications. The DEF was removed after 6 weeks. The mean follow-up was 25 months (range 5–44 months). At last follow-up, the clinical results, evaluated according to the MEPS, were excellent in 10 patients (83%), who had had a fast recovery of range of motion (ROM). The elbow was painless in all patients and stable in all but 1. Moderate osteoarthrosis was found in 60% of cases. Complications included: 1 elbow stiffness, 1 pseudarthrosis of capitulum humeri and trochlea, 1 transitory radial nerve palsy, and 1 superficial pin tract infection. In conclusion, DEF is a helpful tool for treatment of complex elbow instability, particularly when stable internal fixation cannot be obtained or instability persists after ligaments reconstruction. However, DEF increases morbidity, and implies a longer operative time and prolonged exposure to radiation