CLINICAL ORTHOPAEDICS AND RELATED RESEARCH
Number 431, pp. 21–25
Neglected Dislocation of the Elbow
Banchong Mahaisavariya, MD*; and Wiroon Laupattarakasem, MD†
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We retrospectively review the intermediate-term to long-
term results of 24 patients treated after late open reduction
of neglected posterior elbow dislocation in terms of the el-
bow, particularly noting joint mobility. The mean interval
from injury to operation was 7.9 months (range, 1–60
months). The posterior approach with V-Y muscleplasty was
used in most patients with 2 to 3 weeks postoperative immo-
bilization. The average preoperative arc of elbow flexion was
from 17° with an average maximum flexion of 27° (range,
5–60°) and an average flexion contracture of 10° (range, 0–
30°). The mean followup was 48.3 months (range, 12–132
months). At the time of final followup, the average arc of
elbow flexion was 82° with an average of maximum flexion of
122° (range, 90–150°) and an average flexion contracture of
40° (range, 0–75°). There was no correlation between the
postoperative arc of elbow motion and preoperative param-
eters including patient age, preoperative arc of elbow mo-
tion, or duration of untreated dislocation.
Treatment of neglected elbow dislocation is a challenging
problem to orthopaedic surgeons in developing countries
and little information has been written in the standard
textbooks. Elbow joint mobility after operative treatment
is variable, and considered related to several factors in-
cluding the age of the patient, the duration of the untreated
dislocation, the method of open reduction with or without
triceps lengthening, the collateral ligament reconstruction,
and postoperative mobilization with or without hinge ex-
ternal fixation.1,3,4,7 We present our experiences of the
From the *Faculty of Medicine Siriraj Hospital, Mahidol University,
Bangkok; and the †Faculty of Medicine, Khon Kaen University, Khon Kaen,
Thailand.
Each author certifies that his institution has waived approval for the human
protocol for this investigation and that all investigations were conducted in
conformity with ethical principles of research.
Each author certifies that he has no commercial associations (eg, consultan-
cies, stock ownership, equity interest, patent/licensing arrangements etc) that
might pose a conflict of interest in connection with the submitted article.
Correspondence to: Prof. B. Mahaisavariya, MD, Department of Orthopaedic
Surgery, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok
10700, Thailand. Phone: 662-4197968; Fax: 662-4128172 ; E-mail: sibmh@
mahidol.ac.th.
DOI: 10.1097/01.blo.0000152440.62369.f7
21
© 2005 Lippincott Williams & Wilkins
intermediate-term to long-term results of elbow joint mo-
bility after open reduction of neglected elbow dislocation.
MATERIALS AND METHODS
We retrospectively identified 72 patients with unreduced poste-
rior elbow dislocation for more than 1 month. The patients were
operated on in two hospitals for late open reduction from 1980 to
1999. Of these, 24 patients who could be followed up for at least
2 years were reviewed (Table 1). There were 18 men and six
women whose ages ranged from 7 to 60 years (average, 24.6
years). The duration of untreated dislocation ranged from 1 to 60
months (average, 7.9 months). There were three patients who
had associated medial epicondylar fractures (Patients 10, 12, and
16). The range of elbow flexion was measured preoperatively.
An open reduction was done with no attempt of closed re-
duction by manipulation. In all except two patients in this study,
the operation was done using Speed’s posterior approach9 with
some modifications. A posterior longitudinal incision was made
with a distal J-shaped curve so that the radial head could be
exposed. Having developed the triceps tongue flap, it was crucial
to identify the ulnar nerve before splitting the triceps to expose
the posterior surface of the distal humerus. Gentle passive flex-
ion of the elbow would be helpful in guiding sites of contracted
tissue to be released, and sharp dissection was preferred. The
dislocated radial head and its collateral ligament, which usually
were displaced cephalad into a lump of fibro-osseous tissue,
should carefully be identified and dissected to free the radial
head from the surrounding tissue. Any tension at the medial
collateral ligament should be released and at the same time, any
fibro-osseous tissue filling in the olecranon and coronoid fossae
should be removed to facilitate the reduction. The olecranon and
the radial head could then be gently pried reduced using a peri-
osteal elevator. Stability of the joint was tested; if redislocation
occurred, a temporary pin (either a humeroulnar or humeroradial
transfixing pin) was used with the elbow positioned in 90° of
flexion. Choosing the type of transfixing pin depended on the
convenience of the surgeon. Anterior transposition of the ulnar
nerve was done in only four cases. This was because the nerve
was obviously stretched during soft tissue release and passive
flexion of the elbow to 90°. In most cases, the articular surface
was covered by fibrosis. For patients who had dislocations for
more than 3 months, various degrees of degeneration had oc-
curred. This could be observed from the unhealthy appearance of
the cartilage, including nonshiny yellowish surface, less smooth-
ness, and some focal areas of superficial erosion of the articular
 Clinical Orthopaedics
22 Mahaisavariya and Laupattarakasem and Related Research

TABLE 1. Clinical Details of the Patients and Results after Open Reduction of Neglected Posterior
Dislocation of the Elbow
Arc of
Preoperative ROM Arc of Motion Final ROM Motion
Duration Preoperative Followup Final
Patient Side Age Gender (weeks) Extension Flexion (degrees) (months) Extension Flexion (degrees)
1 R 14 M 2 −10 20 10 132 −10 135 125
2 L 7 M 1 0 5 5 78 −75 105 30
3 R 57 M 2 0 10 10 78 −5 140 135
4 L 25 F 60 −5 30 25 60 −30 135 105
5 L 38 M 4 −10 10 0 48 −25 120 95
6 L 25 M 3 0 10 10 42 −50 115 65
7 R 19 M 6 −10 40 30 60 −60 90 30
8 R 10 M 7 −5 60 55 38 −30 120 90
9 R 38 F 2 −10 30 20 66 −55 135 80
10 L 11 F 2 0 10 10 30 −60 130 70
11 L 12 M 2 −10 30 20 24 −60 105 45
12 L 17 M 6 −30 45 15 24 −25 105 80
13 R 20 M 4 0 20 20 24 −25 110 85
14 R 18 M 3 −15 30 15 54 −55 125 70
15 L 9 F 1 0 10 10 53 −75 110 35
16 L 19 M 4 0 10 10 47 −60 120 60
17 L 18 M 1 0 10 10 36 −30 140 110
18 R 13 F 6 −30 60 30 32 −45 150 105
19 L 52 M 3 0 15 15 24 −40 140 100
20 R 23 F 60 −20 30 10 24 −70 100 30
21 R 20 M 4 −5 20 15 54 0 135 135
22 R 60 M 1 −10 30 20 38 −10 145 135
23 R 32 M 2 −30 60 30 48 −20 110 90
24 L 33 M 3 −30 60 30 44 −40 110 70

Average 24.6 7.9 −9.6 27.3 17.7 48.3 −39.8 122.1 82.3
SD 15.0 16.1 10.8 18.3 11.5 24.2 22.4 16.2 33.4
MIN 7.0 1.0 0.0 5.0 0.0 24.0 0.0 90.0 30.0
MAX 60.0 60.0 −30.0 60.0 55.0 132.0 −75.0 150.0 135.0

R = right; L = left; F = female; M = male; SD = standard deviation; MIN = minimum; MAX = maximum

surface. Repairing of the collateral ligaments was done if pos-
sible. In delayed cases in which the collateral ligament was
unable to be defined clearly, the retaining soft tissue and the
fibrotic tissue were sutured for the collateral ligament repair.
The tricipital tongue flap was sutured in an inverted V-Y
plasty. The elbow joint was immobilized additionally by a
posterior long-arm slab. The pin was removed and the plaster
slabs were discarded after 2 to 3 weeks to allow active mobili-
zation.
Patients were sent to a physiotherapist for the rehabilitation
program. For range of motion exercise, it emphasis was more on
elbow flexion (between flexion 70–120o ) during the first two
weeks after cast removal to avoid redislocation. Patients then
were allowed to have aggressive rehabilitation in flexion and
extension after that.
The elbow flexion and extension was measured passively
with a handheld goniometer with 1o increments of measurement.
The elbow motion was recorded before and after the operation
by the surgeon who operated on the patients. Only the elbow
motions in flexion and extension were recorded. The elbow sta-
bility after surgery was evaluated mostly by subjective symp-
toms; no specific tests were documented.
Descriptive statistics were computed for age at presentation,
the duration of the dislocation, and preoperative and postopera-
tive arcs of motion. Postoperative arc of motion was correlated
with patient age, preoperative arc of motion, and duration of the
neglected dislocation. We used the Pearson test for correlation
study to analyze our results. Statistical significance was set at
p < 0.05.
RESULTS
The average postoperative followup was 48.3 months,
with a range of 24–132 months (Table 1). The average arc
of elbow flexion was 82o with average maximum flexion
of 122o (range, 90–150o), a gain of 64.6° on average with
Number 431
February 2005 Neglected Dislocation of the Elbow 23

a range of gain of 0 to 115°. Postoperatively the flexion

contractures increased by an average of 30° from 10° pre-
operatively to 40° (range 0–75°) postoperatively (Table 1;
Fig 1). Because the data of forearm rotation were not
recorded completely, we could not evaluate or compare
preoperative and postoperative motion. However, there
were no complaints of limitation of forearm rotation or any
painful motion of the forearm for activities of daily living.
We found a low level of correlation (r ⳱ 0.503, p ⳱
0.012) between the postoperative arcs of elbow flexion
and patient age (Fig. 2). However, there was no correlation
of the postoperative arcs of the elbow flexion to the pre-
operative arc of motion.
There were no cases of myositis ossificans or patients’
complaint of elbow instability at the time of last followup.
One patient had an ulnar nerve neuropraxia postopera-
tively (Patient 3); however, the nerve function gradually
recovered during the 3-month followup.

DISCUSSION
In Thailand, the untreated or neglected posterior elbow
dislocation is not uncommon, especially in provincial hos-
pitals. This usually is a result of a custom done by the
primitive bonesetters. They usually manipulate the dislo-
cated elbow into a straight position without reduction. The
elbow is immobilized in an extended position by the splint
made of multiple longitudinal strips of bamboo stuck to an
underlying sheet of cloth that can be wrapped around the
midarm to midforearm. The splint usually is discarded
after 3–4 weeks after injury at the time that pain and
swelling usually subside. After a brief period of attempting
to regain elbow function, the patient could have poor re-
sults after the treatment from the bonesetter. The patient
Fig 1. This figure shows the result of elbow motion in flexion
and extension 3 years after open reduction of 7-week ne-
glected elbow dislocation in a patient who was 10 years old at
the time of surgery.
Fig 2. The scattergram shows a low level of correlation be-
tween the patient age at the time of open reduction of ne-
glected elbow dislocation and the final arc of elbow motion (r =
0.503, p = 0.012).
later consults an orthopaedic surgeon because of the in-
ability to flex the elbow. This is the reason that in more
than 1⁄2 of the patients in our series, the duration of un-
treated elbow dislocation usually was between 1 and 3
months.
Most of the patients in this series had been operated on
between 1983 and 1993. The cases have been seen less
often in current practice. This may because of a better
health education and healthcare system together with the
decreasing of popularity to receive the treatment from tra-
ditional bonesetters.
The operative technique in most cases in this series was
similar by using Speed’s posterior approach9 with V-Y
muscleplasty and the postoperative program was similar.
The results after open reduction of neglected elbow dislo-
cation with this technique has shown marked improvement
of the arc of elbow flexion and with the functional arc of
motion (30–110° of elbow flexion), as described by Mor-
rey et al.7 Although there may be some flexion contracture
after triceps V-Y muscleplasty, the patient can have func-
tional range of elbow motion without loss of extension
strength. Some patients complained of the aching pain
around the elbow during prolong lifting or carrying heavy
object. Similar findings were reported in our previous
short-term study of patients with considerable flexion con-
tracture of the elbow.6
 Clinical Orthopaedics
24 Mahaisavariya and Laupattarakasem and Related Research

Although our previous study has shown that open re-

duction can be achieved without triceps lengthening, that
approach usually is helpful only for short duration (within
4–8 weeks of injury) of untreated elbow dislocation and
the contracture is minimal.6 This technique was used in
later in our practice when most patients had been followed
only for short periods. There were only two patients (Pa-
tients 23 and 24) who had long-term followup without
triceps lengthening in this study and thus we were unable
to compare the differences with and without triceps length-
ening in this study.
From our experiences, collateral reconstruction may not
be necessary as recommended by Arafiles.1 The ordinary
repair by suturing the collateral ligament after releasing
the contracture was usually sufficient. All cases in the
current study had no complaint of elbow instability at the
final followup after 2 years. It was our observation that the
concentric reduction at the time of surgery may be the key
to prevent later complications including limitation of range
of motion, recurrent dislocation, and the feeling of insta-
bility. To achieve stable and concentric reduction, the
complete clearance of fibro-osseous tissue from the troch-
lear notch, the olecranon fossa, and the coronoid fossa and
complete reduction of the radiohumeral joint are impor-
tant. One report on the use of hinge external fixation has
shown its advantages in enabling the patient to regain
range of motion early with a good functional outcome.4
We have no experience using such external fixation. How-
ever, from our experience, the neglected elbow dislocation
usually occurs in patients in low socioeconomic commu-
nities where there is poor patient compliance even if
braces were available. Further, a hinge external fixator is
generally not affordable or practical on a routine basis in Fig 3A–B. (A) This figure shows good elbow flexion and
developing countries. (B) extension 3 weeks postoperatively in 57-year-old patient
The patient’s age at the time of treatment has been who had a 4-week neglected left elbow dislocation.
questioned regarding its effect on the outcome. Our study
has shown a low level of correlation to the final arc of
elbow flexion. It has been reported6 that some older
patients had very good results even after a short period to intraobserver variation up to 3°.2 Further we had only
of rehabilitation (Fig 3). We found no correlation be- subjective evaluation of elbow stability with no definite
tween the postoperative arc of elbow motion and duration stability test at the time of last followup.
of untreated elbow dislocation preoperative arc of elbow Nonetheless, open reduction of neglected elbow dislo-
flexion. These findings will agree with those reported cation either with or without triceps lengthening can offer
by Naidoo,8 Fowles et al,3 and our own previous short- intermediate-term and long-term postoperative functional
term report.5 However, such kind of injury was uncom- range of elbow motion without compromising elbow sta-
mon in the elderly. Only three patients in this study were bility.
older than 40 years and the oldest patient was 60 years.
Thus, neither age nor length of time since dislo-
cation should influence the decision to perform an open References
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of concurrent controls using other approaches. The mea- GJW: Reliability of range-of-motion measurement in the elbow and
surement method used to measure elbow flexion is subject forearm. J Shoulder Elbow Surg 7:573–580, 1998.
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February 2005
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