Give me maps score and post op findings in this case of neglected elbow discs
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MAPS score neglected elbow dislocation outcome scoring system
The image shows a case report of a neglected elbow dislocation (not "discs" — likely a transcription error). The scoring system referenced is MAPS, which in elbow literature typically refers to the Mayo Elbow Performance Score (MEPS/MEPI). Here is a full breakdown based on the case:
MAPS (Mayo Elbow Performance Score) — Pre-op Assessment
The MEPI has 4 domains (total 100 points):
| Domain | Max Points | Pre-op Status from Case |
|---|---|---|
| Pain | 45 | Painful left elbow → likely moderate/severe pain → ~15–20 pts |
| Motion | 20 | Only 20–30° flexion/extension; supination & pronation completely restricted → ~5 pts |
| Stability | 10 | 3-point relationship distorted; posterolateral dislocation → grossly unstable → 0 pts |
| Function | 25 | Severely limited ADLs → ~5–10 pts |
| Estimated Pre-op MAPS | 100 | ~25–35 (Poor — <60) |
4-Month Post-Op Findings
From the case image:
| Parameter | Findings |
|---|---|
| Radiograph | Concentric ulnohumeral and radiocapitellar joint reduction achieved, confirmed on post-op X-ray |
| ROM | Significant improvement in flexion-extension arc; patient shown touching face/head (suggesting ~100–120° flexion arc) |
| Supination/Pronation | Partially recovered |
| Neurovascular status | No new deficit; ulnar nerve released intra-op (no neuropathy) |
| Stability | Restored via Bell Tawse annular ligament reconstruction + Tommy John UCL repair |
| Functional activities | Patient able to perform self-care activities (shown feeding self, touching head) |
Estimated Post-op MEPI Score (4 months)
| Domain | Estimated Post-op Score |
|---|---|
| Pain | Mild residual → ~35–40 pts |
| Motion | Improved arc ~100–120° → ~15 pts |
| Stability | Stable after ligament reconstruction → 10 pts |
| Function | Can perform most ADLs → ~20 pts |
| Total Estimated | ~80–85 → Good (75–89) |
MEPI Grading Scale (for reference)
| Score | Grade |
|---|---|
| 90–100 | Excellent |
| 75–89 | Good |
| 60–74 | Fair |
| <60 | Poor |
Summary: This 70-year-old female with a 3-month neglected posterolateral elbow dislocation had a pre-op MEPI in the Poor range (~25–35). At 4 months post-op (following open reduction, soft tissue release, Bell Tawse annular ligament reconstruction, and Tommy John UCL repair via posterior triceps-sparing approach), she achieved a Good outcome (~80–85 MEPI) — consistent with published literature on neglected elbow dislocations where 80–97% of surgical cases achieve good-to-excellent MEPI scores (PMC study, low-resource setting series).
What are the likely questions that can be asked while presenting this poster and how to present this poster
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neglected elbow dislocation surgical management Bell Tawse Tommy John UCL outcomes
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Here is a complete guide — how to present the poster and every likely question you may face.
How to Present This Poster
Opening Statement (30 seconds)
"We present a case of a 70-year-old female with a chronic unreduced posterolateral elbow dislocation of 3 months' duration — a condition often termed 'neglected elbow dislocation.' Despite initial immobilization, the elbow remained dislocated, and the patient presented with a painful, stiff elbow with near-complete loss of motion. We managed her surgically using a posterior triceps-sparing approach with soft tissue release, Bell Tawse annular ligament reconstruction, and Tommy John UCL repair — achieving concentric reduction and significant functional recovery at 4 months."
Presentation Flow (3–5 minutes)
Walk the listener left to right through the poster:
- Case Report panel — Introduce the patient: age, sex, mechanism (FOOSH), 3-month delay, prior treatment (above-elbow slab × 6 weeks), and why she still presented with a dislocated elbow.
- Findings panel — Highlight the key clinical findings: elbow held in 90° flexion, distorted 3-point relationship, olecranon palpable posteriorly, ROM only 20–30° flex/ext, no supination/pronation, no neurovascular deficit.
- Investigations panel — Describe the X-ray: complete loss of ulnohumeral congruity, radiocapitellar dislocation, ossific densities (early heterotopic ossification), soft tissue thickening.
- Diagnosis — Chronic unreduced posterolateral elbow dislocation.
- Management panel — Walk through the surgical steps: lateral decubitus position, posterior triceps-sparing approach, medial and lateral flaps, ulnar nerve identification and release, soft tissue release of contracted structures, joint reduction confirmed under C-arm, Bell Tawse annular ligament reconstruction for lateral stability, Tommy John UCL repair for medial stability.
- 4-Month Post-op panel — Show the clinical photos (patient touching head, feeding herself) and post-op X-ray showing concentric reduction. Mention significant ROM improvement and functional recovery.
- Close — Summarize the learning point: "Even in elderly patients with a 3-month neglected dislocation, meticulous surgical release and ligament reconstruction can restore a functional elbow."
Likely Questions and How to Answer Them
1. Why is this called a "neglected" dislocation?
Answer: A neglected (or chronic unreduced) elbow dislocation is defined as one that remains unreduced beyond 3–4 weeks from the time of injury. In this patient, the joint had been dislocated for 3 months before definitive treatment. During this period, fibrous and ossific tissue fills the joint space, the capsule contracts, and the collateral ligaments shorten — making closed reduction impossible.
2. Why did the initial above-elbow slab fail?
Answer: The slab was applied without confirming concentric reduction. In a complete posterolateral dislocation, immobilization in a dislocated position simply allows fibrous tissue to organize around the dislocated joint. The failure highlights the importance of confirming reduction under imaging (X-ray or fluoroscopy) before any immobilization.
3. Why was a posterior triceps-sparing approach chosen over a medial or lateral approach?
Answer: The posterior approach provides 360° access to the elbow joint — allowing simultaneous medial and lateral releases, ulnar nerve identification, and ligament reconstruction from a single incision. The triceps-sparing modification (elevating medial and lateral flaps without detaching the triceps) preserves the extensor mechanism, reduces post-op weakness, and allows earlier rehabilitation compared to a triceps-splitting or olecranon osteotomy approach.
4. What structures were released during soft tissue release?
Answer: In a neglected dislocation, the following are typically released:
- Anterior and posterior capsule (severely contracted)
- Collateral ligaments (scarred and shortened)
- Heterotopic ossific tissue / ossific densities within the joint
- Brachialis and common flexor/extensor origins (if fibrosed)
- The ulnar nerve was released (not just identified) to prevent traction neuropathy after restoration of normal anatomy.
5. What is the Bell Tawse procedure?
Answer: The Bell Tawse procedure is a reconstruction of the annular ligament using a strip of triceps fascia or local tissue to stabilize the radial head. In this case, the annular ligament was either absent or disrupted due to chronic dislocation, and the Bell Tawse reconstruction restored the radiocapitellar containment, preventing re-dislocation of the radial head.
6. Why was Tommy John (UCL) repair done in a 70-year-old non-athlete?
Answer: In the context of a chronic dislocation, the medial ulnar collateral ligament (UCL) undergoes stretching, scarring, or rupture. Unlike the athlete scenario where UCL reconstruction uses a tendon graft, here the UCL repair (primary repair or imbrication of the residual ligament) was done to restore medial stability and prevent valgus instability post-reduction — which is critical for maintaining concentric reduction in the long term.
7. Was there any concern about the ulnar nerve?
Answer: Yes — the ulnar nerve was identified and released intraoperatively. In chronic elbow dislocations, the ulnar nerve can be tethered, kinked, or compressed by scar tissue as the anatomy is restored. Prophylactic neurolysis (and sometimes transposition) prevents post-op ulnar nerve paresthesia. The patient had no pre-op neurovascular deficit, and this was maintained post-operatively.
8. What is the post-op rehabilitation protocol?
Answer: Standard protocol includes:
- 0–2 weeks: Splint immobilization (at ~90° flexion) for wound healing
- 2–3 weeks: Active-assisted ROM exercises initiated
- 6 weeks: Progressive ROM and muscle strengthening
- 3 months: Full ADL functional use expected
- The patient showed significant ROM recovery at 4 months, able to touch her face and perform self-care tasks.
9. What were the post-op X-ray findings?
Answer: The post-op X-ray showed:
- Concentric ulnohumeral reduction restored
- Radiocapitellar alignment re-established
- No evidence of avascular necrosis or hardware failure
- Ossific densities (heterotopic ossification) may still be visible but the joint space is congruent
10. What is the MEPI score and what was the expected outcome?
Answer: The Mayo Elbow Performance Index (MEPI) scores pain (45 pts), motion (20 pts), stability (10 pts), and function (25 pts) — total 100. Pre-operatively this patient was likely in the Poor range (<60) given her near-complete loss of motion, pain, and instability. At 4 months post-op, with improved ROM, pain relief, and stable joint, the expected score is in the Good range (75–89), consistent with published series on neglected elbow dislocations where 80–97% achieve good-to-excellent outcomes.
11. What complications could have occurred?
Answer:
| Complication | Risk |
|---|---|
| Heterotopic ossification (HO) | Moderate — ossific densities were already present pre-op |
| Ulnar nerve palsy | Managed by intra-op neurolysis |
| Re-dislocation / instability | Mitigated by Bell Tawse + UCL repair |
| Stiffness | Residual risk; managed by early physio |
| Avascular necrosis of capitellum | Low but possible |
| Wound complications | Low |
12. Why not attempt closed reduction first?
Answer: After 3 weeks, closed reduction becomes virtually impossible due to fibrous ankylosis and periarticular contracture. At 3 months, the joint cavity is completely obliterated with fibrotic tissue and ossific deposits — making open surgical release the only viable option.
13. What is the learning message / take-home point?
Answer: "Neglected elbow dislocations are a preventable problem — timely diagnosis and confirmed reduction on day one could have avoided this entire surgical episode. However, even in a 70-year-old with a 3-month neglected dislocation, systematic open reduction, soft tissue release, and anatomical ligament reconstruction can restore a functional, stable elbow with good long-term outcomes."
Tip for presenting: Keep your hands free to point to relevant sections of the poster. Speak to the examiner, not the poster. Lead with the clinical problem, not the surgical technique — the surgery is the solution to the problem you've framed.
How to Tommy John and bell tawse procedure done referance of standard textbook
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Bell Tawse procedure annular ligament reconstruction technique steps elbow radial head dislocation
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Bell Tawse procedure surgical technique steps annular ligament reconstruction
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