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Chronic Unreduced Elbow Dislocation
Introduction
Instability is a major problem at the elbow and some forms of the problem are reviewed in Chapter 32, Chapter 35, Chapter 36, Chapter 41, Chapter 49 . Chronic unreduced dislocation discussed herein is very uncommon in the United States and is principally seen in and discussed in the literature from Third World nations. Since the last edition of this book, little has changed regarding the management of this condition, but possibly some improvement in outcomes is to be expected.
Chronic Unreduced Elbow Joint
Chronic unreduced dislocation is to be distinguished from chronic subluxation due to coronoid deficiency (see Chapter 49 ) and from recurrent instability associated with ligament deficiency. The chronically unreduced complete dislocation is not common, so few have much experience dealing with it, except, as mentioned earlier, in underdeveloped countries.
Presentation
Of interest, occasionally the patient will not recall the exact injury. If this is the case, consider a neurotrophic process (see Chapter 82 ). Typically, the chronic unreduced complete dislocation has the following characteristics: (1) gross deformity ( Fig. 52.1 ); (2) a concurrent fracture is common but is often not the major problem; (3) variable motion from complete ankylosis in approximately one third of cases to a near-functional arc of motion of greater than 40 degrees in one third and motion between 0 and 40 degrees in the remaining one third ; and (4) pain ranges from minimal to significant depending on the duration of the dislocation with marked individual variation.
Occurrence and Clinical Presentation
At presentation, about two thirds of patients have unacceptable function due to stiffness, instability, or pain, or a combination of the three. The frequency is highly dependent on the local medical customs dealing with the initial dislocation and patient expectations. The presence of traditional medical care (bone setters) explains reports from Africa documenting upward of 80 cases over a 10-year period. In Thailand, 135 patients were reported in a 15-year period from three hospitals. The deformity may occur both in children and in adults. About 50% will have sustained an associated fracture. Surprisingly, most have no neurologic deficit at presentation, but if there is neural impairment, the ulnar nerve is most commonly involved. Vascular compromise is extremely rare.
Treatment
Treatment is based on age, duration, and the level of expectation of successful intervention. The full spectrum of reconstructive options has been suggested as a treatment for the neglected dislocation. These options include reduction and interposition ( Chapter 114 ), fusion ( Chapter 115 ), and replacement ( Chapter 97 ). Resection is not a viable option today. In most practices and circumstances, fusion might be considered, but this is a poorly functioning salvage and is not usually considered in the United States. An attempt at closed reduction is reasonable at all ages for dislocations of less than 3 weeks' duration. Today, this is possibly more effective with the added stability provided by an external fixation. Although fusion and resection have both been considered for the chronic condition, by far the most logical and accepted approach is open reduction. The results of this option are actually quite good and durable and, as such, are better than other options.
Here we will review only the treatment strategy for open reduction. The use of an external fixation is discussed in Chapter 48 . Joint replacement is recommended for stiffness in some instances and in patients older than 60 years of age and is discussed in Chapter 97 .
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