E ORIGINAL ARTICLE Elbow dislocation and articular fracture of the distal humerus

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1 Shoulder & Elbow. ISSN E ORIGINAL ARTICLE Elbow dislocation and articular fracture of the distal humerus Thierry G. Guitton,AndrewD.Duckworth, Margaret M. McQueen, Peter Kloen &DavidRing Harvard Medical School, Orthopedic Hand and Upper Extremity Service, Massachusetts General Hospital, Boston, MA, USA Edinburgh Orthopaedic Trauma Unit, Royal Infirmary of Edinburgh, Edinburgh, UK Department of Orthopaedic Surgery, Academic Medical Center, Amsterdam, the Netherlands Received Received 7 June 2009; accepted 23 December 2009 Keywords Capitellum, distal humerus, dislocations, elbow, fracture, trochlea Conflicts of Interest The authors did not receive any outside funding or grants in support of their research fororduringthepreparationofthiswork. Correspondence David Ring, Massachusetts General Hospital, Yawkey Center, Suite 2100, 55 Fruit Street, Boston, MA 02114, USA. Tel.: Fax: dring@partners.org DOI: /j x ABSTRACT Background The present report describes subluxation and dislocation of the elbow with articular fracture of the distal humerus and injury to the medial collateral ligament, a type of elbow fracture-dislocation about which little is available in the literature. Methods Twenty-two patients with subluxation or dislocation of the elbow (with injury to the medial collateral ligament) anda fracture of the distal humerusarticular surface(capitellum/trochlea) were identified. Seventeen patients had a minimum of 12 months follow-up and eight patients returned for a long-term follow-up at a median of 36 months (range 12 months to 154 months) after injury. Results Nine patients had one or more subsequent surgeries. Seven patients had surgery to address complications and two had a planned implant removal. The final median arc of elbow flexion was 120 (range 100 to 145 ) and the median arc of forearm rotation was 175 (range 150 to 180 ). The median Broberg and Morrey score was 88 points (range 63 points to 100 points) and the median Disabilities of the Arm Shoulder and Hand score was 9 points (range 1 point to 43 points). Discussion Some elbow dislocations and subluxations are associated with osteochondral fractures of the distal humeral articular surface. INTRODUCTION The definition of an elbow fracture-dislocation has been expressed as either a dislocation of the elbow with fracture of the radial head [1] or a dislocation of the elbow with intra-articular fracture [2,3]; however, reports of elbow dislocation or subluxation with associated fracture of the distal humerus are uncommon in adults [4 6] where fractures of the proximal radius and ulna are emphasized [7 9]. In children, dislocation of the elbow is most frequently associated with fracture of the medial or lateral epicondyle [10]. Very little mention has been made of dislocation or subluxation of the elbow associated with intra-articular fracture of the distal humerus in either age group [11,12]. We describe 22 adult patients with subluxation or dislocation of the elbow and articular fracture of the distal humerus (capitellum/trochlea) with injury to the medial collateral ligament documented by direct operative inspection or valgus stress testing with the aim of highlighting this variation of traumatic elbow instability. MATERIALS AND METHODS Inclusion and exclusion criteria (Tables 1 and 2) All fractures at one of our institutions were entered into a prospective database organized according to the AO Comprehensive Classification of Fractures [13] between 1974 and Among Table 1 Patients Institution 1 4 Institution 2 13 Institution 3 5 Total 22 Table 2 Patient details RSFU 8 Dead 4 Opt. out 3 Refused 1 Lost to FU 6 Total 22 Included RSFU 8 NO RSFU >12 FU 9 Total 17 RSFU, Research specific follow-up; NO RSFU >12 FU, no research specific follow-up but >12 months follow-up available in medical record. 264 adult patients with a fracture of the distal humerus, four had an associated elbow dislocation or subluxation. N Journal Compilation 2010 British Elbow and Shoulder Society. Shoulder & Elbow , pp

2 (a) (b) (c) (d) (e) (f) (g) (h) (i) (j) (k) (l) Figure 1: Legend on next page. 112 Journal Compilation 2010 British Elbow and Shoulder Society. Shoulder & Elbow , pp

3 At a second institution, between 1997 and 2007, two surgeons treated an additional 13 patients with articular fractures of the distal humerus with additional dislocation or subluxation, many of whom had been referred from other institutions. At the third institution, one surgeon treated an additional five patients with articular fractures of the distal humerus with additional dislocation or subluxation. At all three institutions, we defined a dislocation as either complete loss of apposition of the articular surfaces of the humerus and the ulna, or substantial subluxation necessitating injury to the medial collateral ligament with confirmation of ligament injury by stress examination after fracture fixation in the operating room or after closed reduction in the three patients treated non-operatively. Eighteen patients were treated operatively and four patients were treated non-operatively. Two patients had an ipsilateral minimally displaced radial head fracture, one patient had an additional distal radius fracture and one patient had an ipsilateral metacarpal phalangeal joint fracture. The medical records were reviewed retrospectively and patients were invited to return for a comprehensive long-term follow-up under a protocol approved by each Institutional Review Board. Four patients were dead, one patient became paraplegic and refused further investigation, three patients opted out and six patients could not be contacted. The four patients that were deceased at the time of the study had a median age of 70 years (range 25 years to 80 years) at the time of injury. Eight patients underwent a research specific comprehensive long-term evaluation performed by independent observers. Among the 14 patients who did not return for a study-specific long-term evaluation, nine had adequate records a minimum of 12 months after surgery and were evaluated based upon data from the medical record alone. Therefore, a total of 17 patients were included in the study: nine that had adequate records a minimum of 12 months after surgery and eight patients with a comprehensive long-term evaluation. The median interval between injury and final evaluation was 36 months (range 12 months to 154 months). Classification The distal humerus fractures were classified based on radiographs taken immediately after injury and intra-operative findings according the classifications of Ring et al. [11] and Dubberley et al. [14] (Fig. 1). According to the classification of capitellum/trochlea fractures used by Ring et al. [11] (Fig. 2), there was one Type 1 (i.e. single fragment involving the capitellum and lateral portion of the trochleaonly), threetype 2 (i.e. Type 1 fracture also involving the lateral epicondyle), five Type 3 (i.e. Type 2 fracture also involving the posterior part from the metaphyseal bone of the lateral column), four Type 4 (i.e. Type 3 fracture also involving a fracture of the posterior trochlea) and four Type 5 (i.e. Type 4 fracture also involving a fracture of the medial epicondyle) fractures. According to the classification of Dubberley et al. [14], four patients had Type 1A fractures (i.e. involving the capitellum and a small portion of lateral trochlea without involvement of the posterior aspect of the distal humerus), one Type 1B (i.e. similar to 1A with posterior fracture/impaction), five Type 2B (i.e. more extensive involvement of the lateral trochlea with posterior fracture), two Type 3A (i.e. fractures of both the capitellum and the trochlea as separate fragments) and five Type 3B (i.e. more extensive involvement of the trochlea with more than one fragment and with posterior fracture) (Table 1). All patients had subluxation or dislocation of the elbow in addition to their distal humerus fracture. Patients Among the 17 patients with at least 1 year of follow-up, there were six men and 11 women with a median age of 50 years (range 21 years to 80 years) at the time of surgery. Six patients were known to be employed at the time of injury: one was a homemaker and five were retired. From five patients the occupation was unknown. Open reduction and internal fixation was performed in 13 patients a median of 1 day (range 0 day to 7 days) after injury. Operative technique At least six different surgeons participated in the care of these fractures and no standard protocols were used. Thirteen patients were treated operatively with open reduction and internal fixation and three patients were treated non-operatively. All three patients treated non-operatively underwent immediate reduction and then cast immobilization for 10 days to 14 days. One patient was treated operatively but the fracture fragments were excised. A lateral skin incision was used in eight patients, a posterior incision in five patients and one fracture was addressed through an Fig. 1 A 31-year-old man sustained a left injury with complex fracture of the capitellum, trochlea and lateral epicondyle, and subluxation consistent with injury to the medial collateral ligament dislocation when skiing (Patient 1). (A, B) Anteroposterior and lateral radiographs and (C) computed tomography, including three-dimensional reconstructions, demonstrated a complex articular fracture involving the capitellum, the anterior portion of the lateral trochlea, part of the lateral column posterior to the capitellum, and the lateral epicondyle. (D) Operative treatment revealed numerous small osteochondral fragments. The larger articular fragments were repaired and the smaller fragments were discarded or used as bone graft. (E, F) Anteroposterior and lateral radiographs taken a few weeks after surgery show fixation with a combination of countersunk headless variable pitch screws and small threaded Kirschner wires. The lateral epicondyle was repaired with a tension band wire engaging the soft tissue attachments. After fixation ofthe fracture,valgusstress confirmedinjuryto the medialcollateralligament,but it was not repaired. (G, H) Seven months after the operation, anteroposterior and lateral radiographs detected avascular necrosis and non-union of some of the capitellar fragments with loose hardware. He returned to the operating room for removal of loose wires and ununited fragments and repeat fixation of the lateral epicondyle. (I, J) Anteroposterior and lateral radiographs taken at the final evaluation 24 months after the injury demonstrated stable concentric reduction of the ulnohumeral joint with a stable non-union (possibly a fibrous non-union) of the lateral epicondyle, and no signs of progressive arthritis. (K, L) He regained near full flexion and extension, worked as a musician and remained active in sports. Journal Compilation 2010 British Elbow and Shoulder Society. Shoulder & Elbow , pp

4 (a) (b) (c) (d) (e) Fig. 2 A 28-year-old man sustained a very high-energy open elbow dislocation in a motorcycle crash. (A, B) Anteroposterior and lateral radiographs demonstrate an extensive anteromedial wound (Gustilo Type III B) and a very complex fracture of the distal humerus involving the articular surface and the medial and lateral epicondyles, but not the columns of the distal humerus. The fracture fragments are dislocated from the ulnohumeral joint. Operative exploration disclosed fracture of the lateral epicondyle and avulsion of the medial collateral ligament origin. (C, D) Anteroposterior andlateral radiographs demonstrate open reduction and internal fixation after two initial debridements. Extensive heterotopic ossification is present one month after injury. (E) Lateral radiograph 2 years after debridement of infection, there was a bony ankylosis asa result of the heterotopic ossification. 114 Journal Compilation 2010 British Elbow and Shoulder Society. Shoulder & Elbow , pp

5 extension of an open wound. An olecranon osteotomy was used in a single patient. Internal fixation was performed with 3.5 mm or 2.7 mm screws in two fractures, Kirschner wires alone in two fractures and plate and screws (3.5 mm) in eight fractures (one with additional use of tension band wiring for the lateral epicondyle, one with an additional kirschner wire). Screws (3.5 mm) and Kirschner wires were used in one case. The olecranon osteotomy was secured with figure-of-eight tension band wiring. Twelve elbows were immobilized for a median of 14 days (range 4 days to 30 days). Three patients started elbow exercises the first day after surgery. Postoperative management was not clearly documented for two patients. For all patients, active assisted range of motion exercises were initiated at the time the splint was discontinued. Evaluation All of the patients were evaluated according to the system of Broberg and Morrey [1]. The eight patients that returned for a long-term study-specific evaluation were also evaluated according the Disabilities of the Arm Shoulder and Hand (DASH) [15,16] questionnaire to measure upper extremity specific disability, which runs from 0 representing no disability to 100 representing maximum disability. The range of elbow motion was measured using a hand-held goniometer. Anteroposterior and lateral radiographs of the involved elbow were evaluated for arthrosis by an independent observer according to the system of Broberg and Morrey: Grade 0, no arthrosis; Grade 1, slight joint-space narrowing with minimum osteophyte formation;grade2,moderatejoint-spacenarrowingwithmoderate osteophyte formation; and Grade 3, severe degenerative change with gross destruction of the joint [1]. RESULTS Subsequent procedures Among the cohort of 17 patients, 10 patients (59%) had one or more subsequent surgeries. Eight patients had surgery to address complications and one had a planned implant removal. Implant removal was routine at one institution during the study period but was not recommended when the implants were buried in bone. Complications (Table 3) Four patients had postoperative instability. One had subluxation immediately after surgery and did not correct with exercises. In another patient, subluxation was noted 5 days after surgery and treated with closed reduction under anaesthesia and cast immobilization. This patient developed complete bony ankylosis with heterotopic ossification that was resected 3 months after the initial injury. In the third patient, loss of fixation of the fracture and dislocation of the elbow led to an elbow arthrodesis. This fracture was counted as a failure and otherwise excluded from the final analysis of motion and function. A fourth patient had a second elbow fracture-dislocation that involved the radial head rather than the distal humerus and led to problems of recurrent instability. Table 3 Patient complications and additional procedures Patient Complication 1 Postoperative instability, bony ankylosis with HO 2 Postoperative instability 3 Planned ROM 4 5 Postoperative instability, second elbow fracture-dislocation radial head 6 7 Infection, superficial cellulitis 8 9 Infection, ORIF olecranon osteotomy non-union 10 Osteonecrosis of the capitellum, non-union of the lateral epicondyle, ROM + repeat fixation Infection, elbow stiffness and HO, ROM Osteonecrosis of the capitellum, non-union of the lateral epicondyle, ROM + repeat fixation Postoperative instability, arthrodesis 17 Infection, resection arthroplasty, HO arthrodesis HO, Heterotopic Ossification; DOI, date of injury; ROM, removal of osteosynthesis material; ORIF, open reduction internal fixation. The index surgery was complicated by infection in four patients: one was a superficial cellulitis treated with oral antibiotics and the other three were deep infections that were treated with one or more surgeries for debridement followed by parenteral antibiotics. Amongthesepatients,onealsohadasubsequentsurgeryforelbow stiffness and heterotopic ossification, another had open reduction internal fixation of an olecranon osteotomy non-union 4 months after the initial surgery, one had eventual implant removal and one had resection arthroplasty as part of the debridement and was left with an arthrodesis from extensive heterotopic ossification. Two patients had osteonecrosis of the capitellum, non-union of the lateral epicondyle, and migration of implants treated with removal of the loose bone and implants and repeat fixation of the lateral epicondyle 7 months and 10 months after the initial injury respectively. Final outcomes (Table 4) Six patients had excellent (40%), five had good (33%) and four had fair (27%) results out of 15 on the Broberg and Morrey rating. Among the eight patients that returned for a research specific follow-up, the median DASH score was nine points (range 1 point to 43 points). Nine elbows (60%) out of 15 had radiographic signs of arthrosis: rated Grade 1 in four elbows (45%), Grade 2 in three elbows (33%) and Grade 3 in two elbows (22%) at final follow-up. One patient had crepitation with elbow motion and none of the patients had symptoms or signs of ulnar neuropathy. DISCUSSION Dislocations of the elbow that are not associated with intraarticular fractures are best treated with early active range of Journal Compilation 2010 British Elbow and Shoulder Society. Shoulder & Elbow , pp

6 Table 4 Patient results Pt Sex FU Age FU Flex Ext FE arc Pro Sup SP arc B&M score B&M outcome DASH Arth score 1 F Excellent F Excellent 3 3 F Good 0 4 F Good 0 5 M Good 1 6 F Excellent F Fair F Fair M Fair 1 10 M Excellent F Excellent M Good 3 13 F Fair M Good 0 15 F Excellent 0 16 F M 2 30 Total Min Max FU, Follow up (years); Flex, flexion; Ext, extension; FE arc, flexion extension arc; Pron, pronation; Sup, supination; SP arc, supination pronation arc; B&M score, Broberg and Morrey score; B&M outcome, Broberg and Morrey outcome; DASH, Disabilities of Arm Shoulder and Hand Qeustionnaire; Arth, arthrosis rating. motion [17,18]. When at least one of the articular or osseous components that contributes to this inherent stability of the elbow is disrupted, the risks of instability, malalignment and arthrosis are increased [19,20]. Elbow fracture-dislocations involving the distal humerus are uncommon in adults and are usually considered to involve an avulsion fracture of the medial epicondyle, most likely an alternative to the usual ligament avulsion from the epicondyle. Dislocation or subluxation of the elbow with articular fracture of the distal humerus is rarely discussed [5,12]. The limitations of the present study include its retrospective design and therefore its heavy reliance on medical records, including the availability of only nine of 22 patients for comprehensive long-term evaluation. However, given the relative infrequency of theseinjuries, wefeelthatitisusefultopointoutthatdistalhumerus fractures can be associated with collateral ligament injuries and elbow dislocation or subluxation, as well as to obtain an idea of how these fractures perform within the first year of treatment. All of our patients had a complex lateral articular and lateral epicondyle fractures. The complex fracture of the anterolateral articular surface may represent an alternative to fracture of the radial head [i.e. an alternative lateral column (radiocapitellar) failure]. The fracture of the lateral epicondyle represents an alternative to lateral collateral ligament avulsion from the lateral epicondyle. The medial collateral ligament was also injured in every patient. The part of the injury that is more troublesome and distinctive from fracture-dislocations involving the radial head is that the fracture of the capitellum includes the lateral lip of the trochlea. This lateral lip is a critical part of the ulnohumeral articulation. Failure to adequately restore this lip may compromise the stability, function and durability of the elbow, particularly in the absence of radiocapitellar contact. This is in contrast to a fracture-dislocation of the elbow with associated fracture of the radial head, in which resection of the radial head is consistent with good short-term results [20], although the affect of radial head resection on the long term durability of the elbow has been questioned [21]. Two of our patients had an extremely complex injury that included both fracture and dislocation of the articular surface and both fracture and ligament avulsion from the epicondyles. This is most likely just an extremely high energy version of an articular fracture-dislocation involving thedistalhumerus. Thecombination of an open,contaminated wound and devitalized articular fractures proved devastating in one patient, although we have had success retaining devascularized articular fragments with open fracture of the distal humerus and would still consider this the best option in a young, active patient. When the lateral lip of the trochlea, the capitellum and the lateral collateral ligament/lateral epicondyle can be repaired, stability is usually restored without the need to repair the medial collateral ligament.if the capitellum cannot be repaired, the surgeon should probably consider repairing the medial collateral ligament. The decision to immobilizetheelbowafter operation is based upon the complexity of the articular fracture and the relatively tenuous fixation; there were no concerns about elbow stability after the repairs. As long as the lateral lip of the trochlea is restored and the fixation of the capitellum holds long enough for the capsuloligamentous structures to heal, the elbow will be stable, even if the capitellum 116 Journal Compilation 2010 British Elbow and Shoulder Society. Shoulder & Elbow , pp

7 ultimately fails to heal or there is osteonecrosis, as occurred in two patients. Some elbow dislocations and subluxations are associated with osteochondral fractures of the distal humeral articular surface. Restoration of the articulation of the trochlea and the trochlear notch is paramount, although radiocapitellar articulation and restoration of the lateral collateral ligament are also helpful. The injured medial collateral ligament will heal if the elbow remains concentrically reduced [11] and does not routinely need repair. These are complex injuries with a high rate of recurrent dislocation or subluxation (four of 17; 23%) and complications. It is our hope that increased awareness of these injuries and their pitfalls will contribute to improved outcomes. References 1. Broberg MA, Morrey BF. Results of delayed excision of the radial head after fracture. J Bone Joint Surg Am 1986; 68: Broberg MA, Morrey BF. Resultsoftreatmentoffracture-dislocations of the elbow. Clin Orthop Relat Res 1987; 216: Josefsson PO, Johnell O, GentzCF. Long-term sequelae of simple dislocation of the elbow. J Bone Joint Surg Am 1984; 66: McKee MD, Jupiter JB, Bamberger HB. Coronal shear fractures of the distal end of the humerus. J Bone Joint Surg Am 1996; 78: Inoue G, Horii E. Combined shear fractures of the trochlea and capitellum associated with anterior fracture-dislocation of the elbow. J Orthop Trauma 1992; 6: Jupiter JB, Barnes KA, Goodman LJ, Saldana AE. Multiplane fracture of the distal humerus. J Orthop Trauma 1993; 7: An KN, Moorey BF. Biomechanics of the elbow. In: Morrey BF, ed. The elbow and its disorders. Philadelphia: WB Saunders, 1993: Morrey BF. Anatomy of the elbow joint. In: Morrey BF, ed. The elbow and its disorders. Philadelphia: WB Saunders, 1993: Morrey BF, An KN. Functional anatomy of the ligaments of the elbow. Clin Orthop 1985; 201: Rasool MN. Dislocations of the elbow in children. J Bone Joint Surg Br 2004; 86: Ring D, Jupiter JB, Gulotta L. Articular fractures of the distal part of the humerus. J Bone Joint Surg Am 2003; 85-A: GuittonTG, Doornberg JN, Raaymakers EL, Ring D, KloenP. Fractures of the capitellum and trochlea. J Bone Joint Surg Am 2009; 91: Müller ME, Nazarian S, Koch P, Chatzker J. The comprehensive classification of fractures of long bones. Berlin: Springer-Verlag, Dubberley JH, Faber KJ, Macdermid JC, Patterson SD, King GJ. Outcome after open reduction and internal fixation of capitellar and trochlear fractures. J Bone Joint Surg Am 2006; 88: 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: Veehof MM, Sleegers EJ, van Veldhoven NH, Schuurman AH, van Meeteren NL. Psychometric qualities of the Dutch language version of the Disabilities of the Arm, Shoulder, and Hand questionnaire (DASH-DLV). JHandTher2002; 15: Mehlhoff TL, NoblePC, Bennett JB, Tullos HS. Simple dislocation of the elbow in the adult. Results after closed treatment. J Bone Joint Surg Am 1988; 70: Protzman RR. Dislocation of the elbow joint. J Bone Joint Surg Am 1978; 60: Josefsson PO, Gentz CF, Johnell O, Wendeberg B. Dislocations of the elbow and intraarticular fractures. Clin Orthop 1989; 246: Broberg MA, Morrey BF. Resultsoftreatmentoffracture-dislocations of the elbow. Clin Orthop 1987; 216: Sanchez-Sotelo J, Romanillos O, Garay EG. Resultsof acuteexcision of the radial head in elbow radial head fracture-dislocations. JOrthop Trauma 2000; 14: Journal Compilation 2010 British Elbow and Shoulder Society. Shoulder & Elbow , pp