COMPLEX INJURY TO THE ELBOW JOINT

High-velocity trauma now often results in complex injuries to the uppe r extremity, and especially the elbow joint. These can lead to both an enormous reduction in the range of motion of the shoulder, elbow and wrist joints, in severe cases with complete loss of upper extremity fu nction. A complex injury is defined as a fracture and/or dislocation o f the elbow in association with(1) a serial injury of the upper extrem ity, (2) a severe soft tissue trauma, or (3) concomitant injury to ves sels or nerves. Serial fractures, in particular, can lead to enormous problems with treatment and are often associated with special complica tions. A standardized operative approach therefore seems essential. An analysis of our patient population was made to compare the frequency of different injury types, develop specific treatment regimens, and do cument the clinical course. We made a retrospective analysis of patien ts admitted to our facility between 1981 and 1992, with particular ref erence to cause of accident, severity of injury (ISS), type of fractur e of the upper extremity (according to the AO classification), extent of soft tissue trauma and whether closed or open, and the concomitant injuries (vascular, compartment and nerve lesions). Type and sequence of therapy and any complications were noted, and the clinical course u p to consolidation was recorded. The functional result (i.e., ROM, neu rology) was observed at primary discharge and 12 weeks, 6 months and 2 years later. In the time period mentioned 224 complex injuries of the elbow region were noted. Often MVAs were the cause of the complex tra uma (39% car/30% motorcycle). The average injury severity was scored a s 32(ISS) in these, mostly polytraumatized, patients (68%). The most f requent fracture combination at the elbow region was combined with C2/ C3 fractures of the distal humerus (57%) and proximal ulna (43%). A ve ry commonly seen complex injury was the Monteggia equivalent, with fra cture dislocation of the proximal ulna. Most (82%) of the injuries at the elbow region were open, and open lesions were similarly frequently seen at the forearm shaft. The most frequent concomitant injuries was were to the nerves (63.5%) and the plexus. A compartment syndrome dev eloped in 23.8%. This complication was frequently seen in multiple tra uma patients after primary resuscitation (extensive volume therapy) an d in serial fractures with more than three associated lesions. In 67% of these complex injuries a definitive operation was performed as prim ary treatment (in the first 24 h after injury). Debridement of open fr actures and fasciotomy in compartment syndrome of the forearm are stan dard techniques in the initial care. In serial fractures all concomita nt (humerus, forearm, wrist, etc.) fractures were operated on primaril y. This primary treatment included ORIF of humeral and forearm fractur es in 76%. In patients with multiple injuries (ISS > 30) primary treat ment was not possible in 37%, and in these cases transfixation of the elbow joint was performed. Other indications for transfixation were se vere comminution of the elbow joint, impossibility of achieving comple te stability after ORIF, extensive soft tissue injuries with healing d ependent on short-term immobilization, and finally status following ex tensive ligamentous reconstruction. The most frequent permanent distur bance was a persisting nerve lesion in our patients. A significantly r educed range of motion (30% deficit flexion/extension) was mostly seen at the elbow (17%); most frequently associated with serial fractures (> 3 associated injuries) and with severe semicircular soft tissue tra uma. The most severe injury in combined trauma of the upper extremity is a serial fracture in the elbow region. Such fractures are often ass ociated with vascular and nerve lesions. Even with primary fracture st abilization and early soft tissue management these often end with sign ificant functional deficits. Planned arthrolysis (6 months posttrauma) and enforced rehabilitation can significantly improve the outcome of these complex injuries.