Hayrettin KESMEZACAR, İlker Abdullah SARIKAYA

Konservatif tedavi edilen basit dirsek çıkıklarının sonuçları

Amaç: Basit dirsek çıkıklarında genel olarak kabul edilen tedavi kapalı redüksiyon ve kısa süreli tespittir. Ancak, bu tedavi yöntemi sonuçlarını bildiren çok fazla çalışma bulunmamaktadır. Bu çalışmada konservatif tedavi edilen basit dirsek çıkıklarının klinik ve radyografik sonuçları geriye dönük olarak incelendi. Çalışma planı: Basit dirsek çıkığı nedeniyle kapalı redüksiyon ve immobilizasyon ile tedavi edilen 21 hasta (16 erkek, 5 kadın) değerlendirildi. Kırıksız çıkıklar ve ek cerrahi ya da immobilizasyon gerektirmeyen hafif kopma kırıklarının eşlik ettiği çıkıklar basit çıkık olarak kabul edildi. Çıkık sırasında olguların ortalama yaşı 35 (dağılım 16-59) idi. Çıkıkların tamamı posterior çıkık şeklindeydi. On bir hastada (%52.4) dirsek çıkığına eşlik eden hafif kopma kırığı vardı. Kapalı redüksiyon sonrası dört hastaya (%19.1) atel, 17 hastaya (%81) menteşeli breys uygulandı. Breys uygulanan hastalarda ilk hafta sonunda giderek artan şekilde aktif ve pasif harekete başlandı. Ortalama breys kullanım süresi 27±16 gün idi. Atel uygulanan hastalara ise üç hafta immobilizasyon uygulandı. Hastalar ortalama 34 aylık (dağılım 12-99 ay) takip süresinin sonunda klinik olarak hareket açıklığı, instabilite ve nörolojik bulgular yönünden, fonksiyonel olarak Mayo Dirsek Performans Skoru (MDPS) ve Broberg-Morrey Fonksiyonel Derecelendirme İndeksi (BMFDİ) ile değerlendirildi. Radyografik incelemede standart ön-arka, yan grafilerde konsantrik redüksiyon, dejenerasyon, heterotopik kemikleşme varlığı araştırıldı. Sonuçlar: Sağlam tarafla karşılaştırıldığında, çıkık dirseklerin fleksiyon, ekstansiyon ve pronasyon dereceleri ve fleksiyon arkları anlamlı derecede azalmış bulunurken (p

The results of conservatively treated simple elbow dislocations

Objectives: Closed reduction followed by short-time immobilization is the generally accepted treatment for simple elbow dislocations. However, the number of studies concerning the results of this method is limited. In this study, the clinical and radiographic results of conservatively treated simple elbow dislocations were retrospectively evaluated. Methods: The study included 21 patients (16 males, 5 females) who underwent closed reduction and immobilization for simple elbow dislocations. Simple dislocations were defined as non-fracture dislocations and dislocations accompanied by minor avulsion fractures that did not require additional surgery or immobilization. The mean age of the patients at the time of injury was 35 years (range 16 to 59 years). All the patients had posterior dislocations. Eleven patients (52.4%) had minor avulsion fractures. Following closed reduction, a plaster splint and hinged brace were used in four (19.1%) and 17 (81%) patients, respectively. Incremental active and passive motions were started at the end of the first week in patients in whom a brace was used. The mean duration of brace use was 27±16 days. Patients using a plaster splint were immobilized for three weeks. The patients were assessed clinically with respect to range of motion, instability, and neurologic findings after a mean follow-up period of 34 months (range 12 to 99 months). Functional assessments included the Mayo Elbow Performance Score (MEPS) and the Broberg-Morrey Functional Rating Index (BMFRI). Standard elbow anteroposterior and lateral radiographs were examined for concentric reduction and signs of degeneration and heterotopic ossification. Results: Compared to the normal side, the degrees of flexion, extension, flexion arc, and pronation were significantly decreased in dislocated elbows (p<0.05), while the degrees of supination and rotational arc were similar. There was no muscular atrophy. Four patients (19.1%) had residual instability and six patients (28.6%) had mild to moderate neurological complaints that were primarily related to the ulnar nerve. Three patients complained of mild pain, and one patient complained of moderate pain at rest. Radiographic assessment showed mild degeneration in three patients (14.3%), and mild to moderate heterotopic ossification in 14 patients (66.7%). Patients with and without heterotopic ossification did not differ significantly with respect to the values of joint range of motion. The mean MEPS and BMFRI scores were 96.9 and 97.7, respectively. The scores of both systems were excellent in 20 patients (95.2%) and moderate in one patient (4.8%). The majority of the patients (81%) reported complaints about their elbows including sensation of stiffness in the elbow, pain during strenuous work or sports activities, and limitation of movement. Only four patients (19.1%) reported a feeling of full recovery. Conclusion: Although closed reduction with short-term immobilization is a universally accepted method for simple elbow dislocations with excellent functional scores, it is associated with significant limitations in joint movements and a great majority of patients do not consider themselves fully recovered.

___

1. Linscheid RL, O’Driscoll SW. Elbow dislocations. In: Morrey BF, editor. The elbow and its disorders. 2nd ed. Philadelphia: W. B. Saunders; 1993. p. 441-52.
2. Josefsson PO, Nilsson BE. Incidence of elbow dislocation. Acta Orthop Scand 1986;57:537-8.
3. Duckworth AD, Kulijdian A, McKee MD, Ring D. Residual subluxation of the elbow after dislocation or fracture-dislocation: treatment with active elbow exercises and avoidance of varus stress. J Shoulder Elbow Surg 2008;17:276-80.
4. O’Driscoll SW, Jupiter JB, King GJ, Hotchkiss RN, Morrey BF. The unstable elbow. Instr Course Lect 2001;50:89-102.
5. Mehlhoff TL, Noble PC, Bennett JB, Tullos HS. Simple dislocation of the elbow in the adult. Results after closed treatment. J Bone Joint Surg [Am] 1988;70:244-9.
6. Josefsson PO, Gentz CF, Johnell O, Wendeberg B. Surgical versus non-surgical treatment of ligamentous injuries following dislocation of the elbow joint. A prospective randomized study. J Bone Joint Surg [Am] 1987;69:605-8.
7. Lansinger O, Karlsson J, Körner L, Måre K. Dislocation of the elbow joint. Arch Orthop Trauma Surg 1984;102:183-6.
8. Broberg MA, Morrey BF. Results of delayed excision of the radial head after fracture. J Bone Joint Surg [Am] 1986;68: 669-74.
9. Morrey BF, An KN, Chao EYS. Functional evaluation of the elbow. In: Morrey BF, editor. The elbow and its disorders. 2nd ed. Philadelphia: W. B. Saunders; 1993. p. 86-9.
10. Jeon IH, Kim SY, Kim PT. Primary ligament repair for elbow dislocation. Keio J Med 2008;57:99-104.
11. Dürig M, Müller W, Rüedi TP, Gauer EF. The operative treatment of elbow dislocation in the adult. J Bone Joint Surg [Am] 1979;61:239-44.
12. Cromack PI. The mechanism and nature of the injury in dislocations of the elbow and a method of treatment. Aust N Z J Surg 1961;30:212-6.
13. Osborne G, Cotterill P. Recurrent dislocation of the elbow. J Bone Joint Surg [Br] 1966;48:340-6.
14. Micic I, Kim SY, Park IH, Kim PT, Jeon IH. Surgical management of unstable elbow dislocation without intra-articular fracture. Int Orthop 2009;33:1141-7.
15. Ross G, McDevitt ER, Chronister R, Ove PN. Treatment of simple elbow dislocation using an immediate motion protocol. Am J Sports Med 1999;27:308-11.
16. Habernek H, Ortner F. The influence of anatomic factors in elbow joint dislocation. Clin Orthop Relat Res 1992; (274):226-30.
17. Josefsson PO, Johnell O, Gentz CF. Long-term sequelae of simple dislocation of the elbow. J Bone Joint Surg [Am] 1984;66:927-30.
18. O’Driscoll SW, Morrey BF, Korinek S, An KN. Elbow subluxation and dislocation. A spectrum of instability. Clin Orthop Relat Res 1992;(280):186-97.
19. Morrey BF, An KN. Articular and ligamentous contributions to the stability of the elbow joint. Am J Sports Med 1983;11:315-9.
20. Morrey BF, Tanaka S, An KN. Valgus stability of the elbow. A definition of primary and secondary constraints. Clin Orthop Relat Res 1991;(265):187-95.
21. Jensen SL, Deutch SR, Olsen BS, Søjbjerg JO, Sneppen O. Laxity of the elbow after experimental excision of the radial head and division of the medial collateral ligament. Efficacy of ligament repair and radial head prosthetic replacement: a cadaver study. J Bone Joint Surg [Br] 2003;85:1006-10.
22. Ring D, Jupiter JB. Reconstruction of posttraumatic elbow instability. Clin Orthop Relat Res 2000;(370):44-56.
23. Johansson O. Capsular and ligament injuries of the elbow joint. A clinical and arthrographic study. Acta Chir Scand Suppl 1962;Suppl 287:1-159.
24. King T. Recurrent dislocation of the elbow. J Bone Joint Surg [Br] 1953;35:50-4.
25. McKee MD, Schemitsch EH, Sala MJ, O’driscoll SW. The pathoanatomy of lateral ligamentous disruption in complex elbow instability. J Shoulder Elbow Surg 2003;12:391-6.
26. O’Driscoll SW, Bell DF, Morrey BF. Posterolateral rotatory instability of the elbow. J Bone Joint Surg [Am] 1991; 73:440-6.
27. Schwab GH, Bennett JB, Woods GW, Tullos HS. Biomechanics of elbow instability: the role of the medial collateral ligament. Clin Orthop Relat Res 1980;(146):42-52.
28. Ahmad CS, Park MC, Elattrache NS. Elbow medial ulnar collateral ligament insufficiency alters posteromedial olecranon contact. Am J Sports Med 2004;32:1607-12.
29. Eygendaal D, Verdegaal SH, Obermann WR, van Vugt AB, Pöll RG, Rozing PM. Posterolateral dislocation of the elbow joint. Relationship to medial instability. J Bone Joint Surg [Am] 2000;82:555-60.
30. Royle SG. Posterior dislocation of the elbow. Clin Orthop Relat Res 1991;(269):201-4.
31. Josefsson PO, Gentz CF, Johnell O, Wendeberg B. Dislocations of the elbow and intraarticular fractures. Clin Orthop Relat Res 1989;(246):126-30.
32. Kini MG. Dislocation of the elbow and its complications: a simple technique for excision of the elbow. J Bone Joint Surg [Am] 1940;22:107-17.
33. Linscheid RL, Wheeler DK. Elbow dislocations. JAMA 1965;194:1171-6.
34. Neviaser JS, Wickstrom JK. Dislocation of the elbow: a retrospective study of 115 patients. South Med J 1977;70:172-3.
35. Protzman RR. Dislocation of the elbow joint. J Bone Joint Surg [Am] 1978;60:539-41.
36. Maripuri SN, Debnath UK, Rao P, Mohanty K. Simple elbow dislocation among adults: a comparative study of two different methods of treatment. Injury 2007;38:1254-8.