Neglected elbow joint details in referance to orthopedics Maheshwar

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Here is a comprehensive account of neglected elbow joint as discussed in orthopedics (with emphasis on the Maheshwari context — a standard Indian orthopedics textbook reference):

Neglected Elbow Joint — Orthopedic Overview

1. Definition

A neglected elbow dislocation (also called old/chronic/unreduced elbow dislocation) refers to an elbow dislocation that has remained unreduced for more than 3 weeks (some sources say >2 weeks). It is commonly seen in developing countries due to delayed presentation, traditional medicine use, or missed diagnosis.

2. Anatomy Relevant to Elbow Dislocations

The elbow is a complex hinge joint composed of three articulations within a single synovial cavity (Bailey & Love's, p. 558):

Articulation	Bones Involved	Movement
Ulnohumeral	Trochlea + Olecranon fossa	Flexion / Extension
Radiocapitellar	Capitellum + Radial head	Flexion + Rotation
Proximal Radioulnar (PRUJ)	Radial head + Radial notch of ulna	Pronation / Supination

Neurovascular relations (anterior, medial to lateral): Median nerve → Brachial artery → Radial nerve
Posterior: Ulnar nerve lies just behind the medial epicondyle.

3. Classification of Elbow Dislocations

By Direction:

Type	Description	Frequency
Posterior	Most common (~90%)	Olecranon displaced posteriorly
Posterolateral	Most frequent subtype	Common in adults
Posteromedial	Less common	—
Anterior	Rare	High-energy mechanism
Divergent	Very rare	Radioulnar joint disrupted

By Timing:

Acute: < 2–3 weeks
Neglected/Old: > 3 weeks (fibrosis, heterotopic ossification, contracture established)

4. Pathological Changes in Neglected Elbow

With time, several irreversible changes develop that make reduction increasingly difficult:

Fibrosis of the joint capsule and collateral ligaments — capsule becomes contracted and scarred
Heterotopic ossification (myositis ossificans) — ectopic bone forms in periarticular soft tissues
Disuse osteoporosis — regional osteopenia due to immobilization (visible on X-ray as decreased bone density)
Contracture of muscles — biceps, brachialis, and triceps become shortened
Neurovascular adaptation — nerves (especially ulnar) may migrate or become embedded in scar tissue
Loss of articular cartilage — joint surface degenerates if untreated for months
Degenerative changes — secondary osteoarthritis in longstanding cases

The image below shows the classic radiographic findings of a neglected elbow dislocation:

AP and lateral radiographs showing: complete loss of normal articulation, posterior displacement of olecranon, heterotopic ossification (circled areas), and regional osteopenia.

5. Clinical Features

History:

Prior trauma (fall on outstretched hand / valgus stress)
Delayed or no treatment received

Symptoms:

Pain (may be mild in chronic cases)
Restricted elbow movement (flexion-extension + forearm rotation both affected)
Deformity — apparent posterior prominence of olecranon

Signs:

Loss of normal bony triangle (olecranon, medial, and lateral epicondyle relationship)
Fixed flexion deformity (typically 30–60°)
Reduced carrying angle
Palpable posterior displacement of olecranon
Check for ulnar nerve involvement (ring and little finger numbness/weakness)

6. Investigations

Investigation	Findings
X-ray (AP + Lateral)	Posterior displacement, heterotopic ossification, osteopenia, joint space narrowing
CT scan	Detailed bony architecture, degree of ossification, articular surface damage
MRI	Soft tissue contracture, ligament status, cartilage damage
EMG/NCV	If ulnar nerve involvement suspected

7. Management

A. Non-surgical (Limited Role)

Physiotherapy and gentle manipulation under anesthesia (MUA) — only within 3–6 weeks of dislocation
Serial splinting/casting in early neglected cases

B. Surgical Management

The choice depends on duration, age, bone quality, and joint status:

i. Open Reduction (Preferred if articular cartilage preserved)

Timing: 3 weeks to ~3 months — best window
Approach: Posterior approach (Bryan-Morrey or triceps-splitting)
Steps:
1. Release of posterior capsule
2. Excision of heterotopic bone/scar tissue
3. Gradual reduction of the joint
4. Repair/reconstruction of collateral ligaments
5. Post-op: early mobilization in a hinged brace

ii. Interposition Arthroplasty

Used when joint surface is damaged but patient is young/active
Interposes fascia or silicone between joint surfaces

iii. Total Elbow Arthroplasty (TEA)

For elderly patients with advanced articular damage
Provides pain relief and acceptable range of motion

iv. Elbow Arthrodesis

Rarely indicated — loss of rotation is a major functional deficit
Reserved for failed arthroplasty or severe septic destruction

8. Complications

Complication	Notes
Ulnar nerve injury	Most common nerve affected; may need anterior transposition
Redislocation	If ligament reconstruction inadequate
Heterotopic ossification	May recur post-surgery; managed with indomethacin/radiation prophylaxis
Stiffness / loss of ROM	Expected to some degree; goal is functional arc (30–130°)
Avascular necrosis	Of capitellum or trochlea in severe cases
Post-traumatic arthritis	Long-term sequela

9. Prognosis

Results are inversely proportional to duration of neglect
If treated within 3 months: good to excellent functional outcomes possible
If treated after 6 months: guarded prognosis; full ROM rarely restored
Goal: achieve functional arc of 30–130° flexion and 50° each of pronation/supination

10. Key Points (Maheshwari / Indian Orthopedics Perspective)

Neglected dislocations are common in India due to late presentation
Always assess ulnar nerve pre- and post-operatively
Posterior approach is the workhorse for open reduction
Avoid forceful manipulation — risk of fracture in osteoporotic bone
Heterotopic ossification prophylaxis (indomethacin 75 mg/day × 6 weeks or single-dose radiation) is recommended post-surgery
Hinged external fixator may be used for stability post-reduction in unstable elbows

Sources: Bailey & Love's Short Practice of Surgery, 28th Ed. (p. 558); Maheshwari's Essential Orthopedics (standard Indian orthopedic reference); Clinical VQA radiographic database.

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