Chronic (3-Month) Unreduced Posterolateral Elbow Dislocation - Treatment Options

Pathological Findings (Why It's Difficult)

• Posterolateral dislocation is the most common type; the arm is fixed in extension or slight flexion
• Pronation and supination are limited (pronation more so, as the biceps pulls the forearm into supination)
• Pathological changes include:
  • Extensive heterotopic ossification around the joint
  • Marked shortening of the triceps muscle and collateral ligaments
  • Tightening of the ulnar nerve with attempts at flexion
  • Ossification or dense fibrous thickening of the joint capsule
  • Possible ankylosis
  • Dense fibrous tissue filling the olecranon and coronoid fossae
  • "Radial humeral horn" - ossification of the periosteal hematoma near the radial head

Treatment Options (in Order of Severity/Duration)

1. Closed Reduction (Not Applicable at 3 Months)

"Most authors agree that closed reduction of the elbow is virtually impossible after 3 weeks. By that time, soft-tissue contracture and localized osteopenia are sufficient to make closed reduction hazardous; the bone may fracture or the articular surfaces may be damaged."

• At 3 months, closed reduction is contraindicated
• If attempted (in borderline cases under GA with complete muscle relaxation), must be done gently

2. Open Reduction - PRIMARY OPTION at 3 Months

"Although the results of open reduction of the elbow, if undertaken within 3 months, are acceptable, a normal functioning elbow should not be expected."

What Must Be Done During Open Reduction:

1. Lengthen the shortened triceps muscle (V-Y technique - see Technique 66.11/Speed)
2. Release the shortened medial and lateral collateral ligaments
3. Remove fibrous tissue between distal humerus and ulna
4. Divide the radial humeral horn if present
5. Decompress/transpose the ulnar nerve (low threshold for transposition)

After Reduction - Dealing with Instability:

• The elbow frequently remains unstable after reduction
• ~30% recurrent dislocation rate after ligamentous repair alone

Stabilization Options Post-Reduction:

a) Hinged External Fixator (historical standard)

• Allows early range of motion (theoretically improves results)
• Protects repair, maintains reduction, permits motion, enhances tendon stretching
• Left in place for 8 weeks with active and passive ROM exercises
• Jupiter and Ring: stable/mobile joint in 5 patients at average 11 weeks post-injury

b) Internal Joint Stabilizer (IJS) - Current Preference

"In this author's perspective, the IJS has largely supplanted the need to perform hinged elbow external fixation."

• Provides sufficient stability to initiate immediate range of motion despite wide soft-tissue resection
• Serves dual functions: maintaining congruent ROM while protecting ligament reconstruction
• Elective implant removal at 4-6 months
• Correct application defines the axis of rotation, allowing concentric flexion-extension

c) Steinmann Pins/Kirschner Wires

• Transfixing the olecranon to the humerus at 90° if no other fixation used
• Pins removed at ~14 days
• Splint worn; gentle active motion exercises several times daily thereafter

d) Open Reduction + Soft-tissue Release Alone (Anderson et al., 32 patients)

• Open reduction, complete soft-tissue release, intraarticular scar excision, ulnar nerve transposition
• Triceps tendon left intact (25% required needle barbotage to incrementally lengthen it)
• No ligament reconstruction, no external fixation, no Steinmann pins
• 97% good to excellent results (Mayo Elbow Performance Index) at mean ~2-year follow-up

3. Speed Technique: Open Reduction + V-Y Lengthening of Triceps (Technique 66.11)

1. Posterolateral incision; expose triceps aponeurosis
2. Isolate and protect ulnar nerve (decompress/transpose)
3. Reflect triceps aponeurosis distally as a flap (V-Y lengthening)
4. Incise triceps muscle in midline, 7.5 cm proximal to joint, curving around lateral olecranon
5. Strip all muscles subperiosteally from distal humerus (anterior and posterior)
6. Release capsule and collateral ligaments from humeral condyles
7. Remove callus from posterior humerus and olecranon fossa
8. Clear the trochlear notch of the ulna
9. Rotate forearm, press on capitellum anteriorly to bring radial head into position
10. Reduce the coronoid process over the trochlea
11. If unstable: transfix olecranon to humerus with Steinmann pins at 90°
12. Suture periosteum and triceps; close

"If a dislocation has been present for a long time, the best functional results can be obtained only by continuing exercises for a long time."

4. Interposition Arthroplasty

• Distraction interposition arthroplasty using fascia lata or similar graft
• Multiple authors have described this technique
• Detailed technique described in Chapter 15 of Campbell's

5. Total Elbow Arthroplasty (TEA)

"Many authors suggest that an adult elbow that has remained unreduced for longer than 3 to 6 months may require some type of elbow arthroplasty or perhaps arthrodesis."

• Appropriate for older patients with significant joint degeneration
• Technique described in Chapter 15 of Campbell's

6. Elbow Arthrodesis

• Last resort - reserved when arthroplasty is not feasible or patient declines
• Technique in Chapter 15 of Campbell's

7. Intraarticular "Cruciate" Ligament Reconstruction (Arafiles Technique)

• Creation of an intraarticular cruciate-type ligament using a tendon graft
• Stabilizes the joint and allows early flexion-extension exercises
• Based on the technique of Arafiles (1987): slot in trochlea with drill holes guiding the tendon graft course

Special Considerations

Summary Algorithm for 3-Month Posterolateral Elbow Dislocation

Chronic (3-month) Posterolateral Elbow Dislocation
              ↓
         Open Reduction
    (Speed/V-Y technique)
         ↓
Post-reduction stability?
   ├── Stable → Splint + early motion
   └── Unstable → IJS (preferred) or Hinged Ext. Fixator
              ↓
   Significant articular degeneration?
   ├── Young patient → Interposition Arthroplasty
   └── Older patient → Total Elbow Arthroplasty
              ↓
   All options failed/declined → Arthrodesis