RECURRENT GEOFFREY Recurrent have

been

of the elbow through

pathology of the

a constant

anatomy,

dislocation

dislocation dislocations

condition

THE

COTTERILL,

is uncommon,

but

not

been

of injury

and

ELBOW

BIRMINGHAM,

in the past

of colleagues has

of

with the

of the

the articular dislocation their humeral

ENGLAND

three

years

in Liverpool,

well

described

ligaments able

than to

eighteen

cases

Birmingham

nor

is there

and

a standard

shoulder.

is found

hyperextend

stability

common

of the

posterior

hand forearm

of the humerus. trochlea, by a valgus strain. laterally,

Eight

elbows

1936). in children

been

treated

joint,

but

dislocation

that

there

that

occur

during

the

past

dislocation, but there recurrent spontaneous

Furthermore, both simple and adolescents, in whom

It is interesting

against

to those

traumatic bilateral

the elbow

suggested

analogous

have

in adults. elbow

features

changes

that

most

gradually

recurrent is greater

children

lose

is provided

and there

this

partly

under

ability by the

the

during shape

of

surfaces but also by the triangular collateral ligaments. In flexion, posterior is prevented by the impaction of the radial head and coronoid process against articulations, but in full extension, dislocation is prevented solely by the ligaments.

outstretched the

clinical

articular

to repair the capsular defect. of the elbow usually follows simple of the capsule in some cases, and

SIMPLE The

secondary

has been reported (Much of the elbow are commonest

age of ten are adolescence. The natural

up

PAUL

cooperation

mechanism

defect

years by an operation Recurrent dislocation be congenital laxity

laxity

the

of this

capsular

in recurrent

may

and

OF

of treatment.

A study

three

LIVERPOOL,

dislocation The

method was

OSBORNE,

discovered

Oswestry.

DISLOCATION

with to the

“

DISLOCATION

or postero-lateral

the elbow

incompletely

trochlear

notch

and

OF

THE

ELBOW

dislocation

of the elbow

extended.

The

coronoid

process

force

is caused

ofthe

which

by a fall on the

fall is first

strike

against

transmitted the

trochlea

In this position the laterally sloping surface of the inner two-thirds of the cam action, converts the vertical thrust into a lateral rotation and partly The upper ends of the radius and ulna are displaced backwards and then

swinging

“

on the

intact

biceps

tendon.

The

greatest

movement

is on the

outer

side

of

the joint where the lateral ligament is stripped superiorly and the postero-lateral capsule torn, allowing the radial head to rotate backwards from the capitular surface (Figs. 1 and 2). In simple dislocation, damage also occurs to the medial side of the capsule, and considerable bruising and swelling is often present on the inner side of the joint. The medial epicondyle reduction,

indicates has not

may be detached in children and the medial however, it is not always possible to strain

that the ligament

been stripped off the contribute significantly

remains

in continuity

ligament the joint

stretched to open

with the periosteum,

bone, usually superiorly. to the stability of the

The joint,

or ruptured. into valgus,

although

weak anterior is necessarily

its

ligament, damaged

After which

attachment

which does in posterior

dislocation. through

Greater damage occurs a greater arc during

often with detachment capsule, particularly

to the lateral dislocation.

ligament because the lateral The lateral ligament is torn

of a fragment of the lateral epicondyle. where it lies behind the lateral ligament,

side of the joint moves at its upper attachment,

The posterior is torn from

part of the its superior

attachment. 340

THE

JOURNAL

OF

BONE

AND

JOINT

SURGERY

RECURRENT Knowledge

the

coronoid in some

this

of

dislocated

elbow

process. cases

can

Figure Figure

DISLOCATION

lateral rotation displacement joint. Initial hypersupination

is necessary. be achieved

Fio. I-Normal 2-Primary

Forward without

an

1 disposition dislocation

separation

flexion with anaesthetic.

341

OF THE ELBOW

mechanism to free the traction

is useful in the reduction head of the radius and

then

complete

reduction,

of the

which

FIG. 2 and lateral ligaments of the elbow. detachment of medial ligament and ligament with fragment of bone.

of medial showing

of lateral

FIG. 3 FIG. 4 Pathology of recurrent dislocation of the elbow. The medial ligament is lax and longer than normal. There has been incomplete healing of lateral ligament and postero-lateral capsule with an ununited lateral epicondylar fragment (Fig. 3). The defect at the back of capitulum is illustrated (Fig. 4).

Associated

childhood process

fractures

and do

may

fractures

not

ofthe

predispose

PATHOLOGY

The

essential

pathological

occur,

head

to recurrent

OF

defect

48 B,

NO.

2,

MAY

1966

the separated in adults.

medial Ununited

epicondylar fractures

OF

ELBOW

ofthe

epiphysis in coronoid

dislocation.

RECURRENT

the postero-lateral ligamentous and initial simple traumatic dislocation, VOL.

including ofthe radius

causing

DISLOCATION

recurrent

capsular structures, to become reattached.

dislocation torn

THE

of the

elbow

or stretched at the A pocket of capsule

is failure

of

time of an is created

342

G.

FIG.

Case

1. capitulum

Case

2.

OSBORNE

AND

P.

COTTERILL

5

Figure 5-Recurrent dislocation of elbow joint showing a defect at the back of the and an epicondylar fragment. Figure 6-The dislocation has been reduced but the deformity of the rim of the radial head, and the bone fragment, are shown.

Figure

7-The

marginal

defect

of the

radial

when the forearm

head

is shown.

Figure

FIG. Figure

head.

9-Case Figure

3. A small capitular 10-Case 4. Subluxation

fragment is shown. of the elbow with

defect

8-Dislocation

occurs

is pronated.

There is also slight capsular

10

osteochondritis ossification

and

of the radial a capitular

is shown. THE

JOURNAL

OF

BONE

AND

JOINT

SURGERY

RECURRENT

into

which

The

intact

the

head

of the

lateral

attachment

has

longer

obliged

slipping

of

radius

ligament been

is received

would

stripped

OF THE

as it slides

normally

prevent

forearm

343

ELBOW

off its articulation this

with

displacement,

or if it is more lax than normal, the curve of the capitulum and at some bones occurs. The medial

to follow the

DISLOCATION

up,

the capitulum.

but

if its

superior

the head of the radius is no point in extension backward

ligament may also have a laxity which contributes to instability of the joint. A sinlple vertical thrust, as in leaning on the arm, will force the coronoid process against the laterally sloping

surface

of the

postero-lateral process

and

the

and

head

of the

through displaces

4). Damage

significant strike

of

the

occur lies

in

radius,

to

to it a

The

coronoid

travels

arc than the the humerus

the

osteochondral dislocation

surfaces

radius displaces abrade the posterior

or

the

An

joint. its edge margin

fracture of bone

capsule

of this

is often elbow

backwards, or lateral

osteochondral of a fragment

postero-lateral

of union

farther,

ulna, which (Figs. 3

of the

ofthe

capitulum. with detachment

Failure

imparts

therefore,

a greater behind

in recurrent

As the head can

which

movement.

disengaged from under the trochlea and forearm then rides posteriorly. The lateral are more lax than the medial structures

is

the whole structures rotating simply

trochlea,

rotation

(Figs.

fragment,

can which

5 and

possibly

6).

because

of the inhibiting effect of the synovial fluid, increases the capsular laxity on the outer side of the joint. Such small intracapsular bone fragments are common after

ligamentous

subsequently

crater

injuries

increase

of

in size.

in the postero-lateral and, with radial head

occurs,

the

margin

lesions coincide, the radial head

because

or with

“

dislocation can slide

and may defect or

the

of

repeated dislocation, can become similarly

sometimes with a crater (Figs. 7 and 8). When, articular

the elbow A permanent

capitulum the

shovel-like rotation,

edge of damaged, defect

“

these

occurs into the

two

with ease capitular

defect. Radiographs

of the

often

head

reduction

under

and

show

abnormality

capitulum,

but

ofthe

shape

The

anaesthesia.

the lesions

lax medial ligament and a postero-lateral capsular pocket are present with an avulsion fracture. Figure 12 compares the shoulder with a defect of the anterior margin of the glenoid, and a posterior impaction fracture of head of humerus. There is anterior capsular laxity with a detached labrum. Figure I 3 shows the features apparent in a recurrent dislocation

of any

of both

convex

present,

with

diathrodial

and capsular

joint.

concave pockets

Defect

surfaces and

are laxity

with avulsion of the rim or attachments of ligaments. Figure 14 shows the general principles of repair of a recurrent dislocation. The capsule is shortened and attached to

may the articular margin, redundant capsule being excised or overlapped. be confined to the cartilaginous surfaces and are therefore transradiant. Osteochondritis dissecans of the capitulum can occur in association with recurrent dislocation of the elbow and one patient had osteochondritis dissecans of the radial head (Fig. 9). A shallow trochlea notch has been described as a predisposing factor but it may be a result of repeated dislocation. Not all patients with recurrent dislocation of the elbow have complete dislocation, or need

radial

FiG. 13 FIG. 14 The comparative pathology of recurrent dislocation. Figure 1 1 illustrates an elbow with capitular flattening and a matching “ shovel-like “ defect of the radial head. A

radial

head

may

subluxate

defect or capsular pocket and can be reduced easily by the patient of locking and in the radiograph capsular bone fragments “

lead VOL.

“

to 48 B,

a mistaken NO.

2.

MAY

diagnosis 1966

of

osteochondritis

dissecans.

momentarily

into

acapitular

(Fig. 10) who may complain resembling loose bodies may Two

such

patients

have

been

344

G.

encountered with vague

recently instability

and recurrent or locking

It is interesting and and

(Figs. glenoid

in recurrent of repair.

dislocation

TREATMENT

Not childhood of

the

capsule

Occasional

and

ofany Figure

lesion

and

the

in recurrent

joint,

always

be considered

dislocation

and

DISLOCATION

If

of the shoulder

Figure

OF

may

years

be expected features 14 the

THE

are

less

for

elbow may cease juvenile tendency elbow

when

and

operation,

in

cease. and

to dislocate after to hyperextension

joint

Surgical

as is usual cause tightening

frequent

an indication

of the

surgical

ELBOW

become

not

head head

to develop which may

possible

the dislocation, occurring processes of growth may

normal

dislocations

of a few

should

ball and socketjoint could 13 suggests the pathological

RECURRENT

at intervals

joint

fracture of the back of the humeral defects of the capitulum and radial

diarthrodial

surgical treatment. is infrequent, the

ligaments

dislocations

of the elbow

The impaction resemble the

of any

OF

all elbows need or adolescence,

P. COTTERILL

the pathological

1 1 and 12). flattening

respectively, and recurrent dislocation similar capsular and articular lesions. be found methods

AND

subluxation of the elbow.

to compare

of the elbow the anterior

OSBORNE

an the

disappears.

treatment

dislocations

is indicated

occur

frequently

with trivial violence in the older adolescent or adult patient. The operation

suggested and

sular

is a repair

ligamentous

of the cap-

laxity.

Usually

a capsular repair only on the lateral side of thejoint is adequate, but when 15

F1G.

The suggested

operation

for repair

in recurrent

of the lateral

dislocation

and 16).

capsular

occur

damage

the

cylinder

patient

is

is applied

allowed

when

dislocations

there

laxity

is much

repair

of

the

medial medial

ligament should also be done. on the lateral side of the elbow from the lateral epicondylar The elbow is opened behind the lateral ligament and any from the postero-lateral part of the capsule. The bone of

of the lateral side of the capitulum is cleared of soft tissue and One or two transverse holes are drilled with an awl, and catgut is

passed through the bone and through the postero-lateral down tightly so that it will adhere to the bone of the lower articular margin as possible. A similar repair of the medial A plaster

spontaneous and

ligament

of the elbow.

Technique-An incision is made ridge to the annular ligament. fragments of bone are removed the lateral epicondyle scarified (Figs. 15 and

frequent

16

FIG.

with

to recover

the

elbow

movements

at about

capsule in order to tie the capsule end of the humerus as close to the ligament is done if it is necessary.

40 degrees

for

four

weeks,

after

which

we have

found

gradually.

DISCUSSION

Recurrent

dislocation

ofthe

elbowjoint

was

reported

by Albert

(1881)

and

reports of thirty other cases. Except in two cases (Heusner 1894, Rehn 1924) all the dislocations have been posterior or postero-lateral. The age when the first dislocation occurred was recorded in twenty-four cases. The ages ranged from nine months to twenty-nine years ; and 80 per cent of patients were under fifteen. Of twenty-six cases in which the sex was stated, over 80 per cent were in males. Recurrent bilateral

dislocation

1947, Kapel

of the

elbow

has

been

described

in three

cases

(Milch

1936,

Reichenheim

1951). THE

JOURNAL

OF

BONE

AND

JOINT

SURGERY

RECURRENT

DISLOCATION

OF THE

A record of the physical examination of the joint In three the joint appeared normal. In twelve excessive in lateral mobility or hyperextension were found. Radiographs in eight,

notch four.

In one

before fracture a flake

operation of the tip

ofbone

FIG.

surgical

elbow.

Figure

tendon operation. Artificial

through

Treatment ofthe little immobilisation

that treatment

seems

to

given

The the

some

operations

resemble and the

that,

as with the it recurring generally successful prevent

VOL.

48 B,

scar NO.

2,

recurrent

20

unsuccessful

of

Transplantation

and olecranon Reconstruction

shadow

reported a defect in the joint were

18

dislocation

the

of biceps Wainwright’s operation. tendon which

fossa. Figure 20ofthe medial ligament.

was not clear for most patients. the first injury to the joint

consistently

The

impression later

and

in helping

was

that the

gained

conservative

established

recurrent

be classified broadly into four groups (Figs. 17 to 20). All have although less than ten cases ofany one method can be reviewed. those performed on the shoulder before Bankart (1938) described

pathological

capsular repairs, elbow was usually

lesion

of recurrent

but no method used but never

dislocation.

They

consisted

of slings,

was invariably successful. An anterior a posterior one. It appeared, however,

shoulder, any method that blocked the pathway of the dislocation would and, with a joint as inherently stable as the elbow, all methods were more than was the case with the shoulder joint. Transplantation of the biceps

tendon to the coronoid the coronoid (Milch subsequent

operation.

an osseous

can

results,

essential

bone blocks approach to

been

for

coronoid. Figure 18-Milch’s and block of coronoid. Figure 19-Kapel’s formed from strips of biceps and triceps

injury

showed

FIG.

suggested

through the coronoid and Spring’s operation.

have

successful

original

the

followed

dislocation of the elbow. Previous operations

other

1947, King 1953) and loose bodies

FIG.

17-Reichenheim’s

initial

one

(Reichenheim dissecans,

17

procedures

Bone ligaments

are passed Knoflach’s

and

in half of the thirty cases. laxity of ligaments, increase

in six joints, a shallow trochlear and fracture of the epicondyles in

19

FIG.

Previous

to thejoint

Two authors to osteochondritis

to

is available mobility,

showed no abnormality of the coronoid in four

lay anterior

the lateral epicondyle. of the trochlea possibly due recorded by Spring (1953).

close

345

ELBOW

process (Reichenheim 1936, Wainwright 1947)

tissue MAY

formation) 1966

with

1947) both

a mechanical

or the combine effect

insertion of a bone block an anterior approach on

the

coronoid

to

prevent

into (with its

346

G. OSBORNE

disengagement anterior

under

approach

the

trochlea-the

to the

elbow

AND

P. COTTERILL

initial

joint,

step

however,

in dislocation

of the

is technically

difficult

elbow

joint.

the

intra-articular

and

tendinous slings described by Kapel (1951) are formidable technical procedures. (1935) and Spring (1953) used either fascial strips or tendinous strips to reinforce ligaments and Sorrel (1935) used a bone block projecting from the lateral side to achieve

this

Eight years.

four

strained elbow

Both Knoflach the collateral of the humerus

effect.

patients There the

Any

have been treated surgically has been no recurrence. One

elbow,

movement

but and

redislocation

used

the

did

elbow

not

normally

by the method described here during boy, playing football, fell on the right

the last arm and

occur.

range

All

without

patients

recovered

a full

of

restriction.

SUMMARY

1 Recurrent dislocation secondary damage to the .

2. 3.

of the elbow is caused primarily capitulum and head of radius.

The pathological changes Subluxation or instability

and deserves 4. A simple

by collateral

resemble those of recurrent of the radial head is often

dislocation associated

wider recognition because it may be confused method of soft-tissue repair has successfully

ligament

laxity

with

of the shoulder. with capsular ossification

with osteochondritis dissecans. prevented redislocation of eight

elbows. We wish to thank Mr Norman Roberts for helpful advice in the preparation of this paper. We are grateful to Mr H. G. A. Almond, Mr T. S. Donovan, Mr F. C. Dwyer, Mr M. H. M. Harrison, Professor Robert Roaf and Mr Douglas Savill for permission to use their cases.

REFERENCES E. (1881):

ALBERT,

Lehrbuch

der Chirurgie

und

Operationslehre.

Zweite

Band

Auflage.

2, 377.

Wien:

Urban

& Schwarzenberg.

A.

BANKART,

British

S. B. (1938):

Journal

L.

HEUSNER,

(1 894) : Em

funfzigjahrigen

Jubil#{228}ums des

0. (1951):

KAPEL,

The Pathology and 26, 23. Fall von habitueller

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Operation

Vereins

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der

Treatment

of Recurrent

Luxation

des

des

Regierungsberzirks

Aerzte

Dislocation

Dislocation

Ellenbogens.

In

of the Festschrift

Journal

ofBone

zur

Feler

des

Wiesbaden.

D#{252}sseldorf

of the Elbow.

Shoulder-joint.

andJoint

33-A,

Surgery,

707. KING,

Recurrent

KNOFLACH,

T. (1953): J. G. MILCH, H. (1936): 18, 777. REHN, E. (1924): REICHENHEIM, P. of the Elbow. SORREL, E. (1935):

(1935):

Nationale SPRING,

W.

Surgery, WAINWRIGHT,

Medicine

de E.

Zur

Bilateral

Dislocation Operation Recurrent

of the Elbow. Journal of Bone and Joint Surgery, der habituellen Ellbogenluxation. Zentralblattfur Dislocation ofthe Ulna at the Elbow. JournalofBone

Gelenkkapselplastik bei habitueller Ellbogenluxation. Neue Deutsche P. (1947): Transplantation of the Biceps Tendon as a Treatment for British Journal of Surgery, 35, 201. Luxation Chfrurgie,

(1953):

35-B, 55. D. (1947): (Section

r#{233}cidivante du coude.

61, 790. Report of a Case Recurrent

of Orthopaedics),

Operation.

of Recurrent

Dislocation 40, 885.

of the

Gu#{233}rison.

Dislocation

of the

Elbow-joint.

THE

Bulletins

50. 62, 2897.

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Surgery,

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26-B,

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522.

et M#{233}moires de la Soci#{233}t#{233}

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Journal

Proceedings

JOURNAL

35-B,

of

OF

BONE

of the

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Royal

AND

JOINT

and

Joint

Society

SURGERY

of