Acute elbow dislocation with arterial rupture. Analysis of nine cases.

UNLABELLED: Elbow dislocations are the most frequently encountered dislocations after shoulder dislocations. In their vast majority these injuries involve only the joint and carry a good prognosis. Close anatomic proximity to the joint of neurovascular structures put them at risk of concomitant injury but this occurrence remains, actually very rare. The objective of this study is to retrospectively analyze the results of nine cases of elbow dislocations with brachial artery complications and to propose coherent therapeutic guidelines derived from this experience.

MATERIALS AND METHODS: From 1999 to 2004, 357 elbow dislocations were treated by the traumatology team at the Purpan University Hospital and 340 at the Rangueil University Hospital in Toulouse, France. These two teaching institutions combined their series, contributing to seven dislocations associated with a brachial artery partial rupture, resulting in ischemia. Between 2001 and 2006 at the Le Mans Regional Hospital Center, 138 dislocations of the elbow were treated, and included two cases involving rupture of the brachial artery. In all these institutions' emergency departments, elbow dislocations were mainly treated on an outpatient basis: closed reduction under ultra short-acting products general anesthesia, with stability evaluation followed by cast immobilization. In the rare instances of ischemia, the artery was repaired in concert with the vascular surgery team. All the nine cases had a similar treatment protocol and were submitted to an identical outcome evaluation method. The patients were all males with a mean age of 37.3 years (range, 18-58 years). The combined injury occurred at sports in two cases, because of a fall in three cases and as a result of a traffic accident in four cases. Ischemia was complete in three cases (no radial or ulnar pulse and devascularized hand). In the six other cases, the clinical presentation was subacute. An arteriogram was obtained in five cases after reduction of the dislocation, confirming the brachial axis disruption. Median and/or ulnar nerve injury was suspected in six patients. Only five elbows remained stable after reduction allowing plaster cast immobilization. In the other cases, dislocation recurrence or consequential residual varus/valgus laxity required external fixation or a cross-pinning fixation. An autologous vein, brachial artery bypass was performed in eight cases and an end-to-end anastomosis was carried out in one case. Revascularization was reestablished between 4 and 19 h after injury (mean 10.5 h).

RESULTS: All the patients were seen at a minimum of 2 years' follow-up (mean of 4.3 years). On the basis of Mayo Clinic score, the results were considered excellent in three cases, good in four cases, and poor in two cases. No patients complained of elbow instability. The X-rays showed a reduced elbow in all cases and heterotopic ossifications in three cases. No degenerative lesion was observed at the longest follow-up.

DISCUSSION: The incidence of a combined vascular injury with dislocation remains difficult to establish because the literature reports sporadic short series of clinical cases. The prevalence of this association is estimated to be between 0.3 and 1.7% in hospitals. The vascular lesion risk is probably related to the displacement extent and this later as a consequence of the injury intensity. This context calls for a diagnostic warning signal of possibly associated vascular involvement. Assessment of arterial vascularization should be systematic and mandatory with any osteoarticular injury. The slightest vascular status clinical doubt after reducing any dislocation presses for vascular patency work-up: echo-Doppler, angio-scan, arteriography. The multi-parametric nature of these combined injuries explain why their sometimes disappointing outcome remains dependent on the ability to deal with contradictory healing concerns: skin condition, capsular, and ligaments damages, type of revascularization procedure used, joint stability after closed reduction. This last parameter, being a substantial determinant for the period of immobilization, appears crucial to the final functional outcome, particularly in terms of range of motion loss or residual flexion contracture.

LEVEL OF EVIDENCE: Level IV. Therapeutic retrospective study.