Skip to main content
SpringerLink
Log in

Good Functional Recovery of Complex Elbow Dislocations Treated With Hinged External Fixation: A Multicenter Prospective Study

  • Clinical Research
  • Published:
Clinical Orthopaedics and Related Research®

A CORR Insights to this article was published on 07 November 2014

Abstract

Background

After a complex dislocation, some elbows remain unstable after closed reduction or fracture treatment. Function after treatment with a hinged external fixator theoretically allows collateral ligaments to heal without surgical reconstruction. However, there is a lack of prospective studies that assess functional outcome, pain, and ROM.

Questions/purposes

We asked: (1) In complex elbow fracture-dislocations, does treatment with a hinged external fixator result in reduction of disability and pain, and in improvement in ROM, function, and quality of life? (2) Does delayed treatment (7 days or later) have a negative effect on ROM after 1 year? (3) What are the complications seen after external fixator treatment?

Methods

During a 2-year period, 11 centers recruited 27 patients 18 years or older who were included and evaluated at 2 and 6 weeks and at 3, 6, and 12 months after surgery as part of this prospective case series. During the study period, the participating centers agreed on general indications for use of the hinged external fixator, which included persistent instability after closed reduction alone or closed reduction combined with surgical treatment of associated fracture(s), when indicated. Functional outcome was evaluated using the Quick Disabilities of the Arm, Shoulder and Hand (QuickDASH; primary outcome) score, the Mayo Elbow Performance Index (MEPI), the Oxford Elbow Score, and the level of pain (VAS). ROM, adverse events, secondary interventions, and radiographs also were evaluated. A total of 26 of the 27 patients (96%) were available for followup at 1 year.

Results

All functional and pain scores improved. The median QuickDASH score decreased from 30 (25th–75th percentiles [P25–P75], 23–40) at 6 weeks to 7 (P25–P75, 2–12) at 1 year with a median difference of −25 (p < 0.001). The median MEPI score increased from 80 (P25–P75, 64–85) at 6 weeks to 100 (P25–P75, 85–100) at 1 year with a median difference of 15 (p < 0.001). The median Oxford Elbow Score increased from 60 (P25–P75, 44–68) at 6 weeks to 90 (P25–P75, 73–96) at 1 year with a median difference of 29 (p < 0.001). The median VAS decreased from 2.8 (P25–P75, 1.0–5.0) at 2 weeks to 0.5 (P25–P75, 0.0–1.9) at 1 year with a median difference of −2.1 (p = 0.001). ROM also improved. The median flexion-extension arc improved from 50° (P25–P75, 33°–80°) at 2 weeks to 118° (P25–P75, 105°–138°) at 1 year with a median difference of 63° (p < 0.001). Similarly, the median pronation-supination arc improved from 90° (P25–P75, 63°–124°) to 160° (P25–P75, 138°–170°) with a median difference of 75° (p < 0.001). At 1 year, the median residual deficit compared with the uninjured side was 30° (P25–P75, 5°–35°) for the flexion-extension arc, and 3° (P25–P75, 0°–25°) for the pronation-supination arc. Ten patients (37%) experienced a fixator-related complication, and seven patients required secondary surgery (26%). One patient reported recurrent instability.

Conclusions

A hinged external elbow fixator provides enough stability to start early mobilization after an acute complex elbow dislocation and residual instability. This was reflected in good functional outcome scores and only slight disability despite a relatively high complication rate.

Level of Evidence

Level IV, therapeutic study.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Log in via an institution

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Institutional subscriptions

Fig. 1
Fig. 2A–B
Fig. 3A–B
Fig. 4A–F
Fig. 5A–B

Similar content being viewed by others

References

  1. Anakwe RE, Middleton SD, Jenkins PJ, McQueen MM, Court-Brown CM. Patient-reported outcomes after simple dislocation of the elbow. J Bone Joint Surg Am. 2011;93:1220–1226.

    Article  PubMed  Google Scholar 

  2. Beaton DE, Katz JN, Fossel AH, Wright JG, Tarasuk V, Bombardier C. Measuring the whole or the parts? Validity, reliability, and responsiveness of the Disabilities of the Arm, Shoulder and Hand outcome measure in different regions of the upper extremity. J Hand Ther. 2001;14:128–146.

    Article  CAS  PubMed  Google Scholar 

  3. Cheung EV, O’Driscoll SW, Morrey BF. Complications of hinged external fixators of the elbow. J Shoulder Elbow Surg. 2008;17:447–453.

    Article  PubMed  Google Scholar 

  4. Dawson J, Doll H, Boller I, Fitzpatrick R, Little C, Rees J, Jenkinson C, Carr AJ. The development and validation of a patient-reported questionnaire to assess outcomes of elbow surgery. J Bone Joint Surg Br. 2008;90:466–473.

    Article  CAS  PubMed  Google Scholar 

  5. Duckworth AD, Ring D, Kulijdian A, McKee MD. Unstable elbow dislocations. J Shoulder Elbow Surg. 2008;17:281–286.

    Article  PubMed  Google Scholar 

  6. Egol KA, Immerman I, Paksima N, Tejwani N, Koval KJ. Fracture-dislocation of the elbow functional outcome following treatment with a standardized protocol. Bull NYU Hosp Jt Dis. 2007;65:263–270.

    PubMed  Google Scholar 

  7. Floor S, Overbeke AJ. [Questionnaires on the quality of life in other than the Dutch language used in the Nederlands Tijdschrift voor Geneeskunde (Dutch Journal of Medicine): the translation procedure and arguments for the choice of the questionnaire] [in Dutch]. Ned Tijdschr Geneeskd. 2006;150:1724–1727.

    CAS  PubMed  Google Scholar 

  8. Forthman C, Henket M, Ring DC. Elbow dislocation with intra-articular fracture: the results of operative treatment without repair of the medial collateral ligament. J Hand Surg Am. 2007;32:1200–1209.

    Article  PubMed  Google Scholar 

  9. Foruria AM, Augustin S, Morrey BF, Sanchez-Sotelo J. Heterotopic ossification after surgery for fractures and fracture-dislocations involving the proximal aspect of the radius or ulna. J Bone Joint Surg Am. 2013;95:e66.

    Article  PubMed  Google Scholar 

  10. Garrigues GE, Wray WH 3rd, Lindenhovius AL, Ring DC, Ruch DS. Fixation of the coronoid process in elbow fracture-dislocations. J Bone Joint Surg Am. 2011;93:1873–1881.

    Article  PubMed  Google Scholar 

  11. Hefti F, Stoll TM. [Healing of ligaments and tendons][in German]. Orthopade. 1995;24:237–245.

    CAS  PubMed  Google Scholar 

  12. Hudak PL, Amadio PC, Bombardier C. Development of an upper extremity outcome measure: the DASH (disabilities of the arm, shoulder and hand) [corrected]. The Upper Extremity Collaborative Group (UECG). Am J Ind Med. 1996;29:602–608.

    Article  CAS  PubMed  Google Scholar 

  13. Ivo R, Mader K, Dargel J, Pennig D. Treatment of chronically unreduced complex dislocations of the elbow. Strategies Trauma Limb Reconstr. 2009;4:49–55.

    Article  PubMed Central  PubMed  Google Scholar 

  14. Johnston GW. A follow-up of one hundred cases of fracture of the head of the radius with a review of the literature. Ulster Med J. 1962;31:51–56.

    PubMed Central  CAS  PubMed  Google Scholar 

  15. Josefsson PO, Gentz CF, Johnell O, Wendeberg B. Surgical versus non-surgical treatment of ligamentous injuries following dislocation of the elbow joint: a prospective randomized study. J Bone Joint Surg Am. 1987;69:605–608.

    CAS  PubMed  Google Scholar 

  16. Jupiter JB, Ring D. Treatment of unreduced elbow dislocations with hinged external fixation. J Bone Joint Surg Am. 2002;84:1630–1635.

    PubMed  Google Scholar 

  17. Maripuri SN, Debnath UK, Rao P, Mohanty K. Simple elbow dislocation among adults: a comparative study of two different methods of treatment. Injury. 2007;38:1254–1258.

    Article  PubMed  Google Scholar 

  18. McKee MD, Bowden SH, King GJ, Patterson SD, Jupiter JB, Bamberger HB, Paksima N. Management of recurrent, complex instability of the elbow with a hinged external fixator. J Bone Joint Surg Br. 1998;80:1031–1036.

    Article  CAS  PubMed  Google Scholar 

  19. McKee MD, Pugh DM, Wild LM, Schemitsch EH, King GJ. Standard surgical protocol to treat elbow dislocations with radial head and coronoid fractures. Surgical technique. J Bone Joint Surg Am. 2005;87(suppl 1):22–32.

    PubMed  Google Scholar 

  20. Mehlhoff TL, Noble PC, Bennett JB, Tullos HS. Simple dislocation of the elbow in the adult. Results after closed treatment. J Bone Joint Surg Am. 1988;70:244–249.

    CAS  PubMed  Google Scholar 

  21. Morrey BF. The Elbow and Its Disorders. 2nd ed. Philadelphia, PA: WB Saunders; 1993.

    Google Scholar 

  22. Morrey BF. Current concepts in the treatment of fractures of the radial head, the olecranon, and the coronoid. J Bone Joint Surg Am. 1995;77:316–327.

    Google Scholar 

  23. Morrey BF, Askew LJ, Chao EY. A biomechanical study of normal functional elbow motion. J Bone Joint Surg Am. 1981;63:872–877.

    CAS  PubMed  Google Scholar 

  24. Mughal M, Mathew P, Hastings H 2nd. Iatrogenic injury to the ulnar nerve during primary repair of medial ulnar collateral ligament in complex elbow fracture dislocations. J Hand Surg Eur Vol. 2013;38:686–687.

    Article  CAS  PubMed  Google Scholar 

  25. O’Driscoll SW, Bell DF, Morrey BF. Posterolateral rotatory instability of the elbow. J Bone Joint Surg Am. 1991;73:440–446.

    PubMed  Google Scholar 

  26. Pollock JW, Pichora J, Brownhill J, Ferreira LM, McDonald CP, Johnson JA, King GJ. The influence of type II coronoid fractures, collateral ligament injuries, and surgical repair on the kinematics and stability of the elbow: an in vitro biomechanical study. J Shoulder Elbow Surg. 2009;18:408–417.

    Article  PubMed  Google Scholar 

  27. Protzman RR. Dislocation of the elbow joint. J Bone Joint Surg Am. 1978;60(4):539–541.

    CAS  PubMed  Google Scholar 

  28. Pugh DM, Wild LM, Schemitsch EH, King GJ, McKee MD. Standard surgical protocol to treat elbow dislocations with radial head and coronoid fractures. J Bone Joint Surg Am. 2004;86:1122–1130.

    PubMed  Google Scholar 

  29. Rafai M, Largab A, Cohen D, Trafeh M. [Pure posterior luxation of the elbow in adults: immobilization or early mobilization: a randomized prospective study of 50 cases][in French]. Chir Main. 1999;18:272–278.

    CAS  PubMed  Google Scholar 

  30. Regan W, Morrey B. Fractures of the coronoid process of the ulna. J Bone Joint Surg Am. 1989;71:1348–1354.

    CAS  PubMed  Google Scholar 

  31. Ring D, Bruinsma WE, Jupiter JB. Complications of hinged external fixation compared with cross-pinning of the elbow for acute and subacute instability. Clin Orthop Relat Res. 2014;472:2044–2048.

    Article  PubMed  Google Scholar 

  32. Ring D, Hannouche D, Jupiter JB. Surgical treatment of persistent dislocation or subluxation of the ulnohumeral joint after fracture-dislocation of the elbow. J Hand Surg Am. 2004;29:470–480.

    Article  PubMed  Google Scholar 

  33. Ring D, Jupiter JB, Zilberfarb J. Posterior dislocation of the elbow with fractures of the radial head and coronoid. J Bone Joint Surg Am. 2002;84:547–551.

    PubMed  Google Scholar 

  34. Ruch DS, Triepel CR. Hinged elbow fixation for recurrent instability following fracture dislocation. Injury. 2001;32(suppl 4):SD70–78.

    Article  PubMed  Google Scholar 

  35. Savoie FH 3rd, Trenhaile SW, Roberts J, Field LD, Ramsey JR. Primary repair of ulnar collateral ligament injuries of the elbow in young athletes: a case series of injuries to the proximal and distal ends of the ligament. Am J Sports Med. 2008;36:1066–1072.

    Article  PubMed  Google Scholar 

  36. Schep NWL, De Haan J, Iordens GIT, Tuinebreijer WE, Bronkhorst MWGA, De Vries MR, Goslings JC, Ham SJ, Rhemrev S, Roukema GR, Schipper IB, Sintenie JB, Van der Meulen HGWM, Van Thiel TPH, Van Vugt AB, Verleisdonk EJMM, Vroemen JPAM, Wittich P, Patka P, Van Lieshout EMM, Den Hartog D. A hinged external fixator for complex elbow dislocations: a multicenter prospective cohort study. BMC Musculoskelet Disord. 2011;12:130.

    Article  PubMed Central  PubMed  Google Scholar 

  37. Schippinger G, Seibert FJ, Steinbock J, Kucharczyk M. Management of simple elbow dislocations: does the period of immobilization affect the eventual results? Langenbecks Arch Surg. 1999;384:294–297.

    Article  CAS  PubMed  Google Scholar 

  38. Sorensen AK, Sojbjerg JO. Treatment of persistent instability after posterior fracture-dislocation of the elbow: restoring stability and mobility by internal fixation and hinged external fixation. J Shoulder Elbow Surg. 2011;20:1300–1309.

    Article  PubMed  Google Scholar 

  39. Stavlas P, Gliatis J, Polyzois V, Polyzois D. Unilateral hinged external fixator of the elbow in complex elbow injuries. Injury. 2004;35:1158–1166.

    Article  CAS  PubMed  Google Scholar 

  40. Ware JE Jr, Sherbourne CD. The MOS 36-item short-form health survey (SF-36): I. Conceptual framework and item selection. Med Care. 1992;30:473–483.

    Article  PubMed  Google Scholar 

  41. Yu JR, Throckmorton TW, Bauer RM, Watson JT, Weikert DR. Management of acute complex instability of the elbow with hinged external fixation. J Shoulder Elbow Surg. 2007;16:60–67.

    Article  PubMed  Google Scholar 

  42. Zeiders GJ, Patel MK. Management of unstable elbows following complex fracture-dislocations: the “terrible triad” injury. J Bone Joint Surg Am. 2008;90(suppl 4):75–84.

    Article  PubMed  Google Scholar 

Download references

Acknowledgments

We thank the Oxford and Isis Outcomes, part of Isis Innovation Limited, for their kind support. We also thank Mr. Kiran C. Mahabier, MD (Trauma Research Unit, Department of Surgery, Erasmus MC, Rotterdam, The Netherlands) and Mr. Harold Goei, Mr. Gerben De Resu, and Mrs. Liza van Loon (Trauma Research Unit Department of Surgery, Erasmus MC, Rotterdam, The Netherlands) for assistance with data collection.

Author information

Authors and Affiliations

  1. Trauma Research Unit, Department of Surgery, Erasmus MC, University Medical Center Rotterdam, PO Box 2040, 3000 CA, Rotterdam, The Netherlands

    Gijs I. T. Iordens MD, Dennis Den Hartog PhD, Esther M. M. Van Lieshout PhD, Wim E. Tuinebreijer PhD, Peter Patka PhD & Michael H. J. Verhofstad PhD

  2. Department of Surgery, Westfriesgasthuis, Hoorn, The Netherlands

    Jeroen De Haan PhD

  3. Trauma Unit, Department of Surgery, Academic Medical Center, Amsterdam, The Netherlands

    Niels W. L. Schep PhD

Authors
  1. Gijs I. T. Iordens MD
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Dennis Den Hartog PhD
    View author publications

    You can also search for this author in PubMed Google Scholar

  3. Esther M. M. Van Lieshout PhD
    View author publications

    You can also search for this author in PubMed Google Scholar

  4. Wim E. Tuinebreijer PhD
    View author publications

    You can also search for this author in PubMed Google Scholar

  5. Jeroen De Haan PhD
    View author publications

    You can also search for this author in PubMed Google Scholar

  6. Peter Patka PhD
    View author publications

    You can also search for this author in PubMed Google Scholar

  7. Michael H. J. Verhofstad PhD
    View author publications

    You can also search for this author in PubMed Google Scholar

  8. Niels W. L. Schep PhD
    View author publications

    You can also search for this author in PubMed Google Scholar

Consortia

Dutch Elbow Collaborative

Corresponding author

Correspondence to Dennis Den Hartog PhD.

Additional information

The institution of one or more of the authors (GITI, DDH, EMMVL, PP, MHJV) has received, during the study period, funding from the Osteosynthesis and Trauma Care (OTC) Foundation (Zuchwil, Switzerland) (No. 2009-NSPP) and from Orthofix SRL (Bussolengo, Italy).

All ICMJE Conflict of Interest Forms for authors and Clinical Orthopaedics and Related Research ® editors and board members are on file with the publication and can be viewed on request.

Each author certifies that his or her institution approved the human protocol for this investigation, that all investigations were conducted in conformity with ethical principles of research, and that informed consent for participation in the study was obtained.

Clinical Orthopaedics and Related Research ® neither advocates nor endorses the use of any treatment, drug, or device. Readers are encouraged to always seek additional information, including FDA-approval status, of any drug or device prior to clinical use.

Dutch Elbow Collaborative: M. W. G. A. Bronkhorst (Bronovo Hospital, Den Haag, The Netherlands), M. R. De Vries (Reinier de Graaf Groep, Delft, The Netherlands), J. C. Goslings (AMC, Amsterdam, The Netherlands), S. J. Rhemrev (MC Haaglanden, Den Haag, The Netherlands), G. R. Roukema (Maasstad Ziekenhuis, Rotterdam, The Netherlands), H. G. W. M. Van der Meulen Haga Ziekenhuis, Den Haag, The Netherlands), E. J. M. M. Verleisdonk (Diakonessenhuis, Utrecht, The Netherlands), J. P. A. M. Vroemen (Amphia Ziekenhuis, Breda, The Netherlands), Ph. Wittich (St. Antonius Ziekenhuis, Nieuwegein, The Netherlands).

About this article

Check for updates. Verify currency and authenticity via CrossMark

Cite this article

Iordens, G.I.T., Den Hartog, D., Van Lieshout, E.M.M. et al. Good Functional Recovery of Complex Elbow Dislocations Treated With Hinged External Fixation: A Multicenter Prospective Study. Clin Orthop Relat Res 473, 1451–1461 (2015). https://doi.org/10.1007/s11999-014-3959-1

Download citation

  • Received:

  • Accepted:

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1007/s11999-014-3959-1

Keywords

Search

Navigation