|Year : 2021 | Volume
| Issue : 2 | Page : 50-52
Lateral elbow dislocation with medial epicondyle fracture in a kabaddi player: A case report of rare association
Diwakar Pratap, Naveen Agarwal, Tariq Akhtar Ansari, Ganesh Singh Dharmshaktu
Department of Orthopaedics, Government Medical College, Haldwani, Uttarakhand, India
|Date of Submission||02-Jun-2021|
|Date of Decision||16-Jun-2021|
|Date of Acceptance||18-Jun-2021|
|Date of Web Publication||26-Aug-2021|
Dr. Ganesh Singh Dharmshaktu
Department of Orthopaedics, Government Medical College, Haldwani - 263 139, Uttarakhand
Source of Support: None, Conflict of Interest: None
Lateral elbow dislocation is a rare injury with few reported cases. Most elbow dislocations are posterior and many have associated fractures of either humeral condyles. The medial epicondyle fracture in the setting of lateral elbow dislocation is a rare injury pattern. We report a case of lateral elbow dislocation with medial epicondyle displaced fracture in a 15-year-old male patient following a contact-sports-related injury. The elbow was reduced in the emergency and the medial fracture was fixed later with a pin and screw. There was no ulnar nerve injury associated primarily with the injury and was also not observed after surgery or during follow-up. The functional outcome was good and fracture united uneventfully. The patient had stable elbow with good range of motion and no clinical instability noted in the follow-up of 13 months. There was, however, gradual loosening of the screws noted in the follow-up and implants were removed at 9 months. There was 10° of cubitus valgus noted at last follow-up and the Mayo Elbow Performance Score was 90 depicting excellent outcome. The lateral elbow dislocation requires careful identification and exclusion of any associated nerve injury, soft tissue injury or bony fracture or their incarceration. The standard management and early rehabilitation leads to the optimum outcome.
Keywords: Elbow dislocation, elbow injury, fracture-dislocation, lateral dislocation, medial epicondyle fracture
|How to cite this article:|
Pratap D, Agarwal N, Ansari TA, Dharmshaktu GS. Lateral elbow dislocation with medial epicondyle fracture in a kabaddi player: A case report of rare association. J Orthop Dis Traumatol 2021;4:50-2
|How to cite this URL:|
Pratap D, Agarwal N, Ansari TA, Dharmshaktu GS. Lateral elbow dislocation with medial epicondyle fracture in a kabaddi player: A case report of rare association. J Orthop Dis Traumatol [serial online] 2021 [cited 2022 Aug 9];4:50-2. Available from: https://jodt.org/text.asp?2021/4/2/50/324620
| Introduction|| |
The elbow dislocation is the most common dislocation in children and the second most common in adults following shoulder dislocation with most elbow dislocations being posterior. Elbow dislocation in sagittal plane or in the plane of elbow movement is found to be more common with some element of coronal plane involvement in few cases like those with posterolateral or posteromedial elbow dislocations. Pure and complete medial or lateral dislocation is very rare. There are few reported incomplete lateral elbow dislocations with subtle radiological features that may be missed or neglected in the emergency room in the absence of careful assessment. Pure lateral elbow dislocations require careful identification and may be managed by close reduction under sedation in the emergency settings. Simultaneous presence of an associated humeral condyle or epicondyle fracture, in the majority of cases, makes elbow dislocation a complex dislocation and requires careful management for optimal outcome. The concomitant medial epicondyle fracture with lateral elbow dislocation is by far a rare injury pattern.
| Case Report|| |
A 15-year-old male patient presented to us with a history of injury while playing kabaddi as he was trying to catch an opponent and the opponent fell over his right elbow while falling on the ground at the same time. The exact position of the affected limb was not recalled by the patient. He could not continue the play due to pain and disability and was rushed to the nearest primary health center where pain medicines were given before referral to higher center. There was marked swelling at the elbow along with deformity and the patient was holding the affected elbow in semi-extension by his opposite upper limb. The elbow radiographs revealed dislocation of the ulnohumeral articulation with proximal ulna placed lateral to the humerus and there was no posterior element of dislocation. This corresponded to the diagnosis of lateral elbow dislocation [Figure 1]. Apart from the dislocation, the medial epicondyle was also fractured. There was no other injury and the distal neurovascular status was intact. One quick attempt of gentle reduction was tried but due to pain and apprehension of the patient not continued and the patient was planned for reduction under sedation. The elbow was reduced under sedation and confirmed on post reduction radiographs for concentric reduction [Figure 2]a and [Figure 2]b. The remaining medial epicondyle fracture was planned for elective fixation. Two days later following the preanesthetic fitness, medial epicondyle was fixed by open reduction and fixation with two Kirschner wires (K-wires) one of which was later changed with a cannulated cancellous screw with washer [Figure 2]c. The ulnar nerve was protected throughout the surgery and no transposition was done by us. Wound was closed after thorough saline lavage and a protective plaster slab was applied in 90° of elbow flexion. The postoperative period was uneventful and the stitches and plaster slabs were removed at 2 and 5 weeks later, respectively. The elbow was then underwent supervised physiotherapy to regain full range of motion by the 3rd month [Figure 3]a. There was no complication related to fracture or surgical technique noted in the follow-up of 13 months except gradual loosening of screw that was felt by the patient on medial aspect but without any wound or localized clinical infection [Figure 3]b. All the implants were removed by the 9th month [Figure 4]. Clinically insignificant, 10° of valgus deformity was noted at the elbow in the final follow-up. The Mayo Elbow Performance Score (MEPS) was 90 at the time of final follow-up.
|Figure 1: The elbow radiograph in orthogonal planes showing lateral dislocation of the elbow in anteroposterior view with no posterior element in lateral view suggestive of lateral elbow dislocation. There is an associated displaced medial epicondyle fracture noted lying within ulnohumeral widened space|
Click here to view
|Figure 2: The postreduction radiograph showing reduced elbow joint with displaced medial epicondyle fracture (a and b). The immediate post operative radiograph (c) showing the medial condyle fracture fixed with one screw with washer and a smooth K wire|
Click here to view
|Figure 3: Radiograph at three month (a) before supervised physiotherapy session showing stable reduction but subsequent aseptic loosening of screw noted at subsequent visit at 8th month (b)|
Click here to view
|Figure 4: The radiograph following the radiograph after the removal of implants at 9 month showing good union of fracture with stable elbow|
Click here to view
| Discussion|| |
The lateral dislocation is a rare injury with only handful of cases reported in the literature. ,, The confirmation of injury on imaging and exclusion of any associated injuries should be done in the emergency settings. Many of these cases are reported to have an associated ulnar nerve involvement. However, no nerve-related problem was noted in our case despite the fractured medial epicondyle that is adjacent to the ulnar nerve. However, as we managed medial epicondyle fracture by open reduction, careful identification, and protection was ensured to avoid inadvertent ulnar nerve injury throughout the procedure. The medial epicondyle screws and wires were introduced to avoid ulnar nerve injuries at the time of operation and also in the future. No ulnar nerve transposition, however, was done by us. Some of the lateral dislocations may prove difficult to reduce as swelling, soft tissue incarceration, or associated injuries hinder it. Our case was also tried once with emergent closed reduction that failed following which another attempt was made under sedation. Most of the time elbow is reduced uneventfully following either of various described techniques. Simple gentle traction and counter-traction along with medial push over the elbow region is one of the described methods of treatment. We found it easy and applied this technique on our own discretion.
Adjacent soft-tissue and ligamentous injuries may accompany these dislocations and many times interposition of these tissues may obstruct smooth reduction., Assessment of instability should thus be checked in acute phase and each follow-up period for appropriate management. Early movement, however, has been always beneficial in gaining the early range of motion and good functional outcome. In our case, we surgically fixed medial epicondyle fracture with local soft tissue repair and early physiotherapy was initiated leading to a satisfactory outcome. The elbow dislocation is supposed to follow a pattern or a cycle from lateral to medial elbow structures giving way leading to the posterior dislocation, the commoner injury. This sequence of injuries leading to simple elbow dislocation was termed “Horii circle” by O'Driscoll. In our case, the proposed fixed elbow position and superimposed valgus force concentrating over the elbow joint might have resulted in medial ligamentous damage followed by medial epicondyle avulsion. The continuing force subsequently might have resulted in progressive lateral dislocation of the ulnohumeral articulation. The MEPS is a well-described instrument to ascertain elbow limitation during activities of daily living. The same score was used in our case and the overall outcome was good with a score of 90 (90 to 100 = excellent). On extensive literature search, the authors could not find similar described injury. The lateral dislocation requires careful identification and proper reporting so that more comprehensive insights may be gained by their study. Multi-centric collaborative studies may be planned to increase the case pool of this rare sort of elbow injury in the future work to enrich the medical literature with fruitful takeaways.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form the patient (s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initial s will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Grazette AJ, Aquilina A. The assessment and management of simple elbow dislocations. Open Orthop J 2017;11:1373-9.
de Haan J, Schep NW, Tuinebreijer WE, Patka P, den Hartog D. Simple elbow dislocations: A systematic review of the literature. Arch Orthop Trauma Surg 2010;130:241-9.
Dharmshaktu GS. Incomplete lateral elbow dislocation in children: A report of two cases. Indian J Case Rep 2029;5:126-9.
Watanabe K, Fukuzawa T, Mitsui K. Successful closed reduction of a lateral elbow dislocation. Case Rep Orthop 2016;2016:5934281.
Lu X, Yan G, Lu M, Guo Y. Epidemiologic features and management of elbow dislocation with associated fracture in pediatric population. Medicine (Baltimore) 2017;96:e8595.
Dharmshaktu GS, Singhal A. Lateral dislocation of the elbow: A report of two cases and literature review. Clin Trial Orthop Disord 2016;1:79-82.
Chhaparwal M, Aroojis A, Divekar M, Kulkarni S, Vaidya SV. Irreducible lateral dislocation of the elbow. J Postgrad Med 1997;43:19-20.
] [Full text]
Van Lieshout EM, Iordens GI, Polinder S, Eygendaal D, Verhofstad MH, Schep NW, et al
. Early mobilization versus plaster immobilization of simple elbow dislocations: A cost analysis of the FuncSiE multicenter randomized clinical trial. Arch Orthop Trauma Surg 2020;140:877-86.
O'Driscoll SW. Elbow instability. Acta Orthop Belg 1999;65:404-15.
Cusick MC, Bonnaig NS, Azar FM, Mauck BM, Smith RA, Throckmorton TW. Accuracy and reliability of the Mayo Elbow Performance Score. J Hand Surg Am 2014;39:1146-50.
[Figure 1], [Figure 2], [Figure 3], [Figure 4]