Recurrent Traumatic Elbow Dislocation
FRANCISG . Z E I E R ,M.D.
A most infrequent orthopedic problem is
recurrent elbow luxation. Of its etiologies,
congenital and traumatic, the latter prepon-
derates.2 Congenital recurrences from some
inherent defect may be obvious at birth or
appear latently. The classical mechanism of
the acute traumatic form is a fall on an out-
stretched hand with the elbow extended and
the forearm abducted.2 The ginglymus frac-
tion of the elbow is affected.
Traumatic recurrent dislocation is second-
ary to incomplete healing of the initial
trauma, or the ultimate result of a succession
of acute dislocations sustained in the clas-
sical manner.23Unlike those of the shoulder,
80% occur in children younger than 15 years
of age;’9*22
glenohumeral luxations are more
characteristic of early adulthood, and re-
currences approach 90% in persons 20 years
of age.23The rate of recidivism at the elbow
is exceedingly 10w.19.24In a series of 110 el-
bow luxations at one large medical center,
only two recurrent cases were reported.”
Jacobs in 1971,4 reported a solitary case and
reviewed the literature, finding only 41 re-
ported cases. The present article describes
a lone case, accompanied by a review of the
literature of the intervening decade. By Jan-
uary 31, 1981 the count was still only 85
cases recorded.
CASE HISTORY
A 14-year-old boy suffered an initial episode
of elbow luxation in the classical manner when
From the Orthopedic Department, Welborn Clinic,
421 Chestnut Street, Evansville, Indiana 4771 3.
Reprint requests to Francis G . Zeier, M.D.
Received: May 1 1 , 1981.
0009-921 X/82/0900/21 I
21 1
he experienced a hurtling fall. He received con-
ventional treatment from the Emergency Depart-
ment physician of a local hospital. Despite a care-
fully outlined postreduction regimen, he prema-
turely would periodically remove the protective
immobilization to resume personal contact sport
activities. Occasionally abashed, he would request
that his companions pull his elbow into joint.
Ultimately luxations would recur with minor
provocation. He therefore appealed to his physi-
cian for more definitive treatment who provided
a large file of pre- and postreduction roentgeno-
grams. In addition to the usual posterior displace-
ment, progressive lateral displacement was noted,
suggesting that total capsular disruption existed,
especially the ulnar collateral ligament avulsion
in addition to the more frequently affected radial
collateral (Figs. 1A and 1B). An exhaustive re-
view of the relevant literature found that many
techniques have been devised for treatment of re-
current traumatic elbow dislocation. However,
few children have recovered spontaneously, be-
cause their dislocations were based on excessive
capsular elasticity, which improves with maturity.
Therefore, the most recently proposed and fre-
quently performed procedure, that of Osborne and
Cotterill,14was chosen.
MATERIALS AND METHODS
Medial and lateral approaches to the ginglymus
fibrous joint capsule were made. Findings on ex-
posure were frustrating. Disruption was complete,
and the essential collateral ligaments were twisted,
torn, and retracted irreparably. Debridement
yielded a few loose bodies and hyaline flakes. No
evidence of osteochondritis dissecans presented.
The ginglymal articular surface was abraded, and
some scattered areas of osteocartilaginous defects
were skived smooth. Osborne-Cotterill repairs
were not feasible, and the necessary surgical
trauma of the approaches precluded other ac-
cepted method^.^^^^"^'* In view of the author’s suc-
cesses in reconstruction of irreparable ligaments
from trauma to other joints, as well as the isolated
experiences of Rehn,” Knoflach’ and Spring,”
$01.00 0 J. B. Lippincott Co.
 Clinical Orthopaedics
212 Zeier and Related Research

FIGS. 1A AND 1B. (A) Drawing of anteroposterior view

of most recent preoperative roentgenogram of right elbow,
revealing a traumatic dislocation with marked lateral dis-
placement of the proximal radioulnar unit. (B) Lateral view
of latest preoperative roentgenogram of right elbow showing
typical posterior radioulnar displacement depicted by artist.

employing fascia lata, the author devised a new
technique' of substituting tendinous fascia lata
strips in the form of dual slings between the distal
humerus and the proximal ulna for the mutilated
collateral and anterior ligaments.
To ensure positive attachment of soft tissues to
bone, multiple tunnels were bored in the involved
osseous constituents.6 In the distal humerus, a
transverse tunnel was bored at the junction of the
distal shaft and epicondyles, and two vertical tun-
nels were drilled extra-articularly and just subep-
icondylar. The lateral tunnel one was 2 cm deep
and blind, except for two eyelets from the depth
through the cortex; the medial vertical was drilled
through the epicondyle to communicate with the
medial intermuscular septum after the ulnar nerve
was anteriorly translocated for its protection. In
the proximal ulna, two transverse tunnels were
located, one just distal to the radial notch and the
other deep to the distal extent of the coronoid
tuberosity. Two tendinous strips of fascia lata, 1.5
cm wide and of ample length, were procured from
the inferior third of a lateral thigh.
The proximal sling was installed by threading
one end of a strip through the transverse tunnel
of the humerus toward one direction and through
the proximal tunnel of the ulna toward the op-
posite direction and led back to itself to form a
loop to hold the trochlear notch and the radial
head firmly opposed to the distal humeral condyle.
Extraosseously the loop was deep to the brachialis
anticus muscle and crossed the ginglymus ante-
riorly along either side of the anticus tendon. It
was sutured to itself hastily.
The distal sling was installed to suspend the
distal extent of the coronoid tuberosity from the
two epicondyles. One end of the second strip was
prepared by inserting double crisscross Bunnel
pull-out wires, which were introduced into the lat-
eral vertical tunnel and out through the eyelets
to the skin surfa~e.~."This strip was well anchored
in the blind tunnel, and the wires were tied over
a swatch of felt and a button (Fig. 2). The loose
end of the strip was gently drawn distally toward
the compromised radial collateral and, after an
assistant flexed the elbow to a 100" angle (Fig.
2), sutured to the lateral arc of the annular lig-
ament. The angle was maintained until postop-
erative immobilization was assured. The strip was
twisted posterior to the radial neck, crossed the
interosseous space in the quadrilateral ligament-
oblique cord interval and threaded through the
distal tunnel of the ulna. On the medial surface
of the ulna it overlay the remnants of the ulnar
collateral, crossed the medial trochlear joint line,
was threaded through the medial epicondylar tun-
nel, and laced through two transverse slits in the
distal end of the septum to which it was junctured
after Pulvertaft (Fig. 3). Final attention was paid
to the proximal sling. The hasty suture was re-
Number 169
September, 1982 Traumatic Elbow Dislocation 2 13

moved, and the two ends were gently tugged to

overlap them, allowing sufficient slack to provide
complete elbow extension after healing. Finally,
a side-to-side juncture of the ends of the strip was
accomplished with two rows of sutures. Wherever
fascia1 grafts passed over joint lines they were
flattened and tacked to subjacent capsular rem-
nants with interrupted sutures to prevent their
curling and becoming necrotic due to decreased
revascularization (Figs. 2 and 3).
The wounds were irrigated for clot removal,
inspected for hemostasis and relationship of nerves
to the grafts, and then closed. Repair of the ap-
proaches involved resuturing the origins of the
extensores carpi radialis longus and brevis and the
extensor digitorum communis laterally and the
humeral heads of the flexor carpi ulnaris and the
pronator radii teres rnedially to their origins. All FIG.2. Drawing of lateral aspect of right elbow
deep sutures, except the pull-out wires, were joint showing intraosseous lateral implantation of
slowly absorbable. After wounds dressing, a well distal sling anchored by Bunnell pull-out wires.
padded immedially bivalved plaster of Paris cast The sling is sutured distally to lateral quadrant
from the metacarpophalangeal joints to the axilla of the annular ligament, then winds posterior to
was applied. the radial neck.
Physical therapy was initiated as comfort per-
mitted. Clenching the fist and active shoulder use
were rehearsed, and muscle setting beneath the sence of blood clots and infection. They are
cast was taught. Immobilization and protruding easily penetrated by extracellular fluids and
sutures were removed five weeks after operation. by neocapillaries derived from their new am-
Active exercises were pursued. Postoperative fol- bience. Revitalized grafts in loci of specific
low-up was discontinued by mutual agreement
after four years; the subject was relocating to seek function are transformed, within limits, into
employment. The patient was greatly satisfied the specialized tissues by hypertrophy and
with the results, although there was less than 10" metaplasia for which they were substituted.
loss of extension and flexion objectively, which Wolffs Law applies to soft tissues as well
was actually not disabling.

RESULTS
Dual slings of tendinous fascia lata func-
tioned well as substitutes for the subject's
irreparable fibrous ginglymus joint capsule.
Instability was corrected and recurrent gin-
glymal luxations ceased. The mild limitation
of motion was attributable to scar tissue and
traumatic arthritis; the latter was calculated
to progress.

DISCUSSION
Fresh autogenous fascia lata grafts have
been successfully employed to repair certain
somatic defects since the beginning of the
20th century. They are almost always avail-
able, and because their cells and fibers are
relatively undifferentiated, most survive un-
der favorable circumstances, i.e., in the ab-
FIG. 3. Drawing of medial view of right elbow
joint with dual slings. The proximal sling main-
tains the proximal radioulnar unit in close ap-
position to the humeral condyles. The overlapping
ends are sutured making a side to side juncture.
Only the medial portion of the distal sling is vis-
ible. It is implanted in the distal ulnar tunnel and
the medial epicondylar tunnel and fixed to medial
intermuscular septum by Pulvertaft juncture.

214 Zeier
as to bone.” These tissues are altered phys-
ically and functionally, fulfilling Wilhelm
Roux’s Law, “adaptation to useful func-
tion,” quoted by Phemister.”
The pioneers were Kirschner* and Phem-
ister,15 who experimented on varieties and
combinations of connective tissue grafting
into animals, the latter studying the results
histopathologically. The term “creeping sub-
stitution” was coined to describe the slow
process exerted by pluripotential cells, prob-
ably of neocapillary origin, the absorption
of the graft by “clastic” cells, and its si-
multaneous regeneration to host tissue elab-
orated by “blastic cells”.”
More recently, freeze-dried homo- and
heterogenous grafts have been used. These
merely serve as a trellis or framework upon
which the host area can regenerate its tissue
and reconstitute the defect. The latter are
second-rate to autogenous grafts. In related
studies on humans, McArthur” and Lewis
and Davis” were the pioneers. Lewis and
Davis” advocated fascia lata grafts as being
“more resistant, more elastic, and thinner,”
assuring their adequate nutritional support
during the early critical hours.
SUMMARY
Another example of a rare complication
of a common elbow luxation is added to the
recorded cases, coupled with an updated re-
view of the literature. In a 14-year-old boy,
the etiology initially was typical trauma and
subsequently resulted in chronic instability.
The severity of the ligamentous trauma was
not appreciated until the lesion was exam-
ined by medial and lateral exposures of the
elbow. The Osborne and Cotterill repair pro-
cedure was found not feasible. Substitution
of dual slings of tendinous fascia lata by im-
plantation successfully restored ginglymus
joint stability and corrected recurrent elbow
dislocation. No recurrences occurred after
repeated follow-up examinations. This pro-
cedure is recommended when other options
are nonexistent.
Clinical Orthopaedics
and Related Research
REFERENCES
1. Blount, W. P.: Personal communication, 1980.
2. Callander, C. L.: Surgical Anatomy, ed. 2. Phila-
delphia, London, W. B. Saunders Co., 1939.
3. Edmondson, A. S.: Surgical techniques. In Ed-
mondson, A. S., and Crenshaw, A. H., (eds.):
Campbell’s Operative Orthopedics, vol. 1, ed. 6. St.
Louis, C. V. Mosby Co., 1980.
4. Jacobs, R. L.: Recurrent dislocation of the elbow
and review of the literature. Clin. Orthop. 74: 15 I ,
1971.
5. Kepel, A.: Operation for habitual traumatic dislo-
cation of the elbow. J. Bone Joint Surg. 33A:707,
1951.
6. Kernwein, G. A.: A study of tendon implantation
into bone. Surg. Gynecol. Obstet. 75:794, 1942.
7. King, T.: Recurrent dislocation of the elbow. J.
Bone Joint Surg. 35B:50, 1953.
8. Kirschner, M.: Ueber Frei Sehen und Fascien trans-
plantation. Beitr. Z. Klin. Chir. 65:472, 1909.
9. Knoflach, J. B.: Zur Operation des habitueller El-
lenbogen luxation. Zlb. 62:2897, 1935.
10. Lewis, D., and Davis, C. B.: Experimental direct
transplantation of tendon and fascia. JAMA 57:540,
191 1.
1 1 . Lindscheid, R. L., and Wheeler, D. K.: Elbow dis-
location. JAMA 194:171, 1965.
12. McArthur, L. L.: Autoplastic sutures in hernia and
other diseases: Preliminary Report. JAMA 37:1162,
1901.
13. Milch, J. H.: Bilateral posterior dislocation of the
elbow. J. Bone Joint Surg. 18:777, 1937.
14. Osborne, G. V., and Cotterill, P.: Recurrent dislo-
cation of the elbow joint. J. Bone Joint Surg.
48B:340, 1966.
15. Phemister, D. B.: The fate of transplanted bone and
regenerative powers of other constituents. Surg.
Gynecol. Obstet. 19(8):303, 1914.
16. Pulvertaft, R. G.: Tendon grafts for flexor tendon
injuries. J. Bone Joint Surg. 28B:75, 1956.
17. Rehn, E.: Gelenksplastic fur habitueller Ellenbo-
genluxation. Neue Deutche Chir. 26B:522, 1924.
18. Reichenheim, P. P.: Transplantation of biceps ten-
don as treatment for recurrent dislocation of the
elbow. Br. J. Surg. 35:301, 1947.
19. Sorrel, E.: Luxation recidivante due conde. Opk-
ation Gutrison Bull. et Mkm. SOC.Nat. de Chir.
60790, 1935.
20. Textbook of Fractures and Dislocations,
adelphia, Lea & Febiger Co., 1928.
21. Spring, E. W.: Report of a case of recurrent dis-
location of the elbow. J. Bone Joint Surg. 35B:55,
1953.
22. Trias, A., and Comeau, Y.: Recurrent dislocation
of the elbow in children. Clin. Orthop. 100:74, 1974.
23. Turek, S. L.: Orthopedic Principles and Their Ap-
plication, ed. 3. Philadelphia, J. B. Lippincott Co.,
1977.
24. Wright, P. E.: Dislocations. In Edmondson, A. S.,
and Crenshaw, A. H. (eds.): Campbell’s Operative
Orthopedics. vol. I, ed. 6. St. Louis, C. V. Mosby
Co., 1980.