Initial Patient Presentation
A twenty-nine-year-old right-hand-dominant man presented to our emergency department after landing on the outstretched left upper extremity following a 15-foot fall from a ladder. Initial physical examination of the extremity revealed gross deformity of the midhumerus and swelling of the left elbow. A 2-cm wound over the lateral part of the elbow communicated with the radiocapitellar joint. Carpal bones were extruded through a second wound over the volar aspect of the wrist on the same extremity. The patient’s hand was well-perfused with palpable pulses. He reported paresthesias in the median nerve distribution.
Radiographs demonstrated a displaced mid-diaphyseal humeral fracture and an open divergent elbow dislocation (Figs. 1-A and 1-B). Distally, the patient had an open trans-scaphoid perilunate dislocation, fracture of the trapezium, and left fourth and fifth metacarpal fractures (Figs. 2-A and 2-B). Additional injuries included fractures of the lumbar transverse processes, ribs, superior and inferior pubic rami, iliac wing, and sacral ala, as well as widening of the sacroiliac joint. The patient also sustained low-grade injuries to the spleen and right adrenal gland, which were managed nonoperatively.
Initial Treatment
The elbow was provisionally reduced with axial traction. Pressure was then applied to the proximal part of the forearm to converge the radius and ulna. This reduced the dislocation, and a temporary splint was applied. Shortly thereafter, the patient was taken to the operating room for treatment of the left upper extremity. First, the traumatic wounds were irrigated and debrided. Next, open reduction and plate fixation of the humeral shaft was performed through an anterolateral approach. After closure of the anterolateral incision, the elbow was examined under anesthesia. The elbow remained stable through an arc of 0° to 110° of flexion and full pronosupination. Because of the excessively comminuted scaphoid fracture and lack of soft-tissue attachment to the lunate bone, immediate proximal row carpectomy and carpal tunnel release were performed.
Because of marked radiocapitate instability, the radiocarpal reduction was stabilized with two 0.062-in Kirschner wires through the radius into the capitate (Figs. 3-A and 3-B). All wounds were closed primarily, and a well-padded posterior splint with a sugar tong was applied. Postoperative radiographs demonstrated that the elbow remained reduced in the splinted position (Figs. 4-A and 4-B).
Postoperative Course
Postoperatively, the patient was carefully monitored for signs of compartment syndrome, which did not occur. Supervised forearm rotation and gentle active elbow flexion and extension were initiated after two weeks of immobilization. Terminal extension was not aggressively pursued until five weeks postoperatively. At that time, the splint immobilization was discontinued and the Kirschner wires were removed from the wrist. He continued to work on range of motion with biweekly physical therapy. At four months postoperatively, the patient had an elbow flexion-extension arc of 30° to 145°. Forearm rotation was restricted to 30° of supination and 5° of pronation.
At nine weeks postoperatively, heterotopic ossification had been noted surrounding the proximal parts of the radius and ulna. Computed tomography at five months confirmed that the heterotopic ossification was likely responsible for the restriction in forearm rotation. Excision of the heterotopic ossification was recommended at that time, and the patient underwent surgery eleven months after the initial procedure.
Heterotopic Ossification Excision
The mass of heterotopic ossification was approached through an anterior Henry approach. With complete excision of the heterotopic bone, intraoperative supination was full, but pronation was incompletely restored (30°). Postoperatively, the patient began indomethacin therapy (25 mg three times daily for one month) as prophylaxis against additional heterotopic ossification.
Functional Outcome
At three years following the second surgical procedure (four years after the initial injury), the patient’s elbow flexed from 20° to 140° (Figs. 5-A and 5-B). He eventually recovered 80° of supination and 30° of pronation (Figs. 6-A and 6-B). He was able to extend the wrist to 25° and flex it to 80°. Grip strength was 36 kg on the injured side and 64 kg on the uninjured side. Anteroposterior and lateral radiographs showed no recurrence of the excised heterotopic ossification (Figs. 7-A and 7-B). The patient returned to office-based work, and he expressed satisfaction with the functional result. Patient-rated disability remained minimal by the Quick Disabilities of the Arm, Shoulder and Hand (QuickDASH) score (16 of 100: low score equals less disability).
Despite the apparent complexity of the elbow injury and the likelihood of extensive ligamentous injury in our patient, the fundamental treatment principles for elbow dislocation were upheld. In the absence of persistent elbow instability, it was possible to congruously restore the elbow joint with a closed reduction and pursue early mobilization with limited permanent elbow impairment.
Disclosure: None of the authors received payments or services, either directly or indirectly (i.e., via his or her institution), from a third party in support of any aspect of this work. One or more of the authors, or his or her institution, has had a financial relationship, in the thirty-six months prior to submission of this work, with an entity in the biomedical arena that could be perceived to influence or have the potential to influence what is written in this work. No author has had any other relationships, or has engaged in any other activities, that could be perceived to influence or have the potential to influence what is written in this work. The complete Disclosures of Potential Conflicts of Interest submitted by authors are always provided with the online version of the article.