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neglected chronic elbow dislocation surgical treatment

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elbow dislocation open reduction ligament reconstruction outcome

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DISCUSSION

Neglected elbow dislocation - defined as an unreduced dislocation persisting beyond 3 weeks - is an uncommon but challenging entity in orthopaedic practice. The present case highlights several key issues: the epidemiology and pathoanatomy of chronic elbow dislocation, the diagnostic approach, surgical planning, and the reconstructive strategy employed.

Epidemiology and Definition

The elbow is the second most commonly dislocated major joint in adults, with a reported incidence of 5.2 per 100,000 person-years in the United States.1 Posterior and posterolateral dislocations account for the vast majority. While acute elbow dislocations are well-described, neglected or chronic unreduced dislocations remain a clinical problem predominantly in developing countries, where patients initially seek treatment from traditional bonesetters, leading to delayed or inadequate management.2 In our patient, a 70-year-old female, initial treatment consisted of above-elbow slab immobilization for six weeks without confirmed reduction, resulting in a chronic unreduced posterolateral dislocation at the time of definitive presentation - an interval of approximately three months.

Mechanism of Injury and Pathoanatomy

As described by O'Driscoll et al. and detailed in Rockwood and Green's Fractures in Adults, simple elbow dislocations typically result from a fall on an outstretched hand with a valgus, axial, and posterolateral rotatory force applied to the joint.1 The soft tissue injury follows a predictable progression: the lateral ulnar collateral ligament (LUCL) fails first, followed by the anterior and posterior capsule, and finally the medial collateral ligament (MCL). In many cases the MCL may be partially preserved. In our case, the mechanism was a fall on an outstretched hand, consistent with this well-established pattern.
In chronic dislocations, the pathoanatomy becomes considerably more complex. Over time, fibrous tissue and scar formation fill the joint space, the surrounding musculature contracts, heterotopic ossification or "ossific densities" may develop around the joint (as noted on imaging in our patient), and the capsulo-ligamentous structures lose their normal anatomy.1,2 This fibrosis renders closed reduction impossible and makes open surgical intervention both necessary and technically demanding.

Clinical Presentation and Diagnosis

The classic clinical triad of a neglected elbow dislocation includes painful restriction of motion, distortion of the normal bony landmarks (the three-point relationship between the olecranon, medial epicondyle, and lateral epicondyle), and a prominently palpable olecranon posteriorly.1 Our patient presented with exactly these features: the elbow fixed at 90 degrees of flexion, only 20-30 degrees of flexion-extension available, complete restriction of pronation and supination, distorted three-point relationship, and a posteriorly prominent olecranon - all without neurovascular deficit.
Radiographic findings of complete loss of ulnohumeral congruity with radiocapitellar dislocation, soft tissue thickening, and ossific densities around the joint are characteristic of a chronic neglected dislocation.2 These ossific densities may represent early heterotopic ossification or organized hematoma and are important prognostic markers for post-operative stiffness.1 Per Campbell's Operative Orthopaedics, the most common complications of elbow dislocation are elbow stiffness and loss of motion, and the surgeon must confirm concentric reduction of the ulnohumeral joint after any reduction - with CT scan if uncertain.3

Surgical Approach and Technique

The posterior triceps-sparing approach used in our case is a well-recognized exposure for the elbow, preserving the triceps mechanism and facilitating early rehabilitation. Medial and lateral flaps were elevated, and the ulnar nerve was formally identified and released - a mandatory step, as the ulnar nerve is the most commonly injured nerve following elbow dislocation and is at particular risk during open reduction of chronic cases due to scarring and altered anatomy.1,3
Soft tissue release in neglected dislocations requires meticulous excision of fibrotic and scar tissue from the joint, and reduction is confirmed under image intensifier (C-arm) to ensure concentric ulnohumeral and radiocapitellar articulation - consistent with recommendations in both Rockwood and Green's and Campbell's Operative Orthopaedics.1,3
The annular ligament reconstruction using the Bell-Tawse technique - which employs a strip of the triceps tendon routed around the radial neck - is the established method for restoring radiocapitellar stability when the native annular ligament is deficient or cannot be repaired primarily.4 This technique was originally described by Bell Tawse in 1965 and remains the most commonly referenced procedure for annular ligament reconstruction in chronic elbow dislocation settings, as referenced in Rockwood and Green's.1
Ulnar collateral ligament (UCL) reconstruction using the Tommy John technique (free tendon graft, figure-of-eight or docking construct through bone tunnels in the medial epicondyle and proximal ulna) addresses medial instability and is well-supported by the literature.1,3 In neglected dislocations with multidirectional instability, reconstruction of both medial and lateral ligament complexes is often required to achieve a stable, concentric reduction - as demonstrated in published case series reporting excellent Mayo Elbow Performance Scores (MEPS) with circumferential or combined ligamentous reconstruction approaches.5,6

Comparison with Published Literature

Prasetia et al. (2021) reported two cases of very late-presenting unreduced posterior elbow dislocation (12-18 months) treated with open reduction and VY triceps lengthening, with functional restoration achieved in both.2 They concluded that open reduction remains a viable option regardless of chronicity or patient age. Laumonerie et al. (2025) described the "French Elbow Connection" technique combining open reduction with triple ligamentoplasty in 12 patients with chronic elbow dislocation, reporting a median MEPS of 90 points and median flexion-extension arc of 145 degrees at short-term follow-up.7 These results underscore that aggressive surgical reconstruction with simultaneous ligament repair can yield satisfactory functional outcomes.
Negi et al. (2024) reported that neglected complex elbow dislocations require reconstruction of both ligamentous and osseous structures for good functional outcomes, performing open reduction, corrective osteotomy, MCL and annular ligament reconstruction, and LCL repair in a combined procedure.4 Krishna et al. (2023) demonstrated excellent MEPS following circumferential ligamentous reconstruction with a gracilis tendon graft, reducing the need for external fixation and permitting early mobilization.5
A systematic review by Pott et al. (2024) analyzing 1,081 elbow dislocation cases noted that while good to excellent outcomes are achievable, residual stiffness and pain are common - emphasizing the importance of early and appropriate treatment to prevent chronicity.8

Rehabilitation and Outcomes

Post-operative rehabilitation must begin early to counter the tendency toward stiffness that is inherent in this condition. As Rockwood and Green's emphasizes, immobilization greater than three weeks is associated with increased incidence of stiffness and poorer functional outcomes.1 Our patient demonstrated significant improvement in range of motion at four months post-operatively, consistent with the expected trajectory following combined open reduction and ligamentous reconstruction.
The absence of pre-operative neurovascular deficit in our patient - despite the chronic nature of the dislocation - is a favorable prognostic factor. Post-operative ulnar nerve monitoring is, however, mandatory given the nerve release performed, and any new-onset ulnar neuropathy must be investigated promptly.

Key Learning Points

  1. Neglected elbow dislocation beyond three weeks mandates open surgical reduction due to progressive fibrosis and soft tissue contracture.
  2. Distortion of the olecranon-epicondyle three-point relationship and ossific densities on imaging are hallmarks of chronicity.
  3. The posterior triceps-sparing approach with formal ulnar nerve release, aggressive soft tissue debridement, and C-arm-confirmed reduction is the surgical standard.
  4. Bell-Tawse annular ligament reconstruction and UCL Tommy John repair address the essential ligamentous deficiencies in posterolateral dislocation.
  5. Early supervised physiotherapy is the cornerstone of post-operative management, and functional outcomes are favorable when reconstruction is comprehensive.

References

  1. Rockwood and Green's Fractures in Adults, 10th ed., 2025. Chapter 40: Simple Elbow Dislocation. pp. 1648-1654.
  2. Prasetia R, Mahyudin, Rasyid HN. Open Reduction on very late-presenting unreduced posterior elbow dislocation: Still promising treatment option. Int J Surg Case Rep. 2021;83:106056. [PMID: 34118556]
  3. Campbell's Operative Orthopaedics, 15th Ed., 2026. Chapter: Complications of Elbow Dislocation.
  4. Negi DK, Aduri TT, Thami T, Bhayana H. Corrective Osteotomy and Ligamentous Reconstruction in a Neglected Elbow Dislocation with Radial Neck Malunion: A Case Report. JBJS Case Connect. 2024. [PMID: 38422194]
  5. Krishna SV, Ballal M, Br V, Hs C. Multidirectional Instability in a Neglected Elbow Dislocation Managed with Circumferential Ligament Reconstruction. Rev Bras Ortop. 2023. [PMID: 36969788]
  6. Donohue KW, Mehlhoff TL. Chronic elbow dislocation: evaluation and management. J Am Acad Orthop Surg. 2016.
  7. Laumonerie P, Ciais G, Barret H, et al. Chronic elbow dislocations: short-term results of the "French elbow connection" technique. Int Orthop. 2025. [PMID: 39945805]
  8. Pott CMJM, de Klerk HH, Priester-Vink S, et al. Treatment Outcomes of Simple Elbow Dislocations: A Systematic Review of 1,081 Cases. JBJS Rev. 2024. [PMID: 38181107]
This discussion is grounded in Rockwood and Green's Fractures in Adults (10th ed., 2025) and Campbell's Operative Orthopaedics (15th ed., 2026) as the primary orthopedic references, supplemented by current peer-reviewed literature. All references cited are real and retrievable. If you want this formatted for a specific journal style (e.g., JBJS, Injury, IJOCR), just let me know.
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