Autumn isn’t just the season for falling leaves. From October through winter, doctors treat many patients related to accidental falls, including slipping on the ice, falling from a ladder while cleaning a gutter or decorating for the holidays. Whatever the cause, if you fall on an outstretched arm, you stand a chance of dislocating an elbow.
Treatment can involve a few days in a sling, followed quickly by physical therapy to avoid a contracted elbow, which can make it difficult to rotate or extend the arm. Patients are often placed in casts too long, according to Hill Hastings, MD, an orthopedic surgeon at the Indiana Hand to Shoulder Center, now affiliated with Indiana University Health Orthopedics & Sports Medicine.
“If you immobilize for longer than three weeks, results are much less effective than when you start early motion,” he says. “Because dislocation can tear the lining of the elbow and lead to contracture, it’s very important to start movement early,” he says.
Things can get much more complicated if a dislocated elbow is accompanied by fracture, says Hastings, a nationally-known expert in managing fractures of the elbow, clavicle and wrist. Operative repair is usually recommended when there are fractures associated with the dislocation. “The radial head is often fractured with elbow dislocation,” he says. “It may require fracture repair or radial head partial elbow replacement when severely fragmented.”
Even the best orthopedic surgeons can miss fractures in a dislocated elbow—an omission that can have consequences for patients. “If you look at the competency of orthopedic surgeons, the elbow is an area where they often feel the least comfortable and experienced, and an area where we see the most problems,” Hastings says.
That’s due in part to the complexity of the elbow, which is actually three joints in one. It’s also related to the extent of the trauma. “We have an entity called terrible triad, which is a combination of ligament injury, radial head injury and coronoid fracture injury and that can lead to a very challenging problem for physicians to handle unless they deal with complex elbow trauma on a routine basis,” Hastings says.
Patients are often referred to him for reconstruction after they haven’t done well or because an injury is so complicated or unstable that their surgeon doesn’t feel comfortable handling it. “The stability of the elbow depends on ligaments and the bony architecture of the elbow,” he says. “The more lesions you have involved, the more unstable the elbow comes.”
Hastings has worked with a global device manufacturer to develop solutions for fractures. He says the biomechanics of implants have improved significantly in the past five to 10 years. One of the latest advances is a radial head fracture plate based on computer modeling. “It matches the plate to the anatomy of the radial head and allows us to develop a plate that optimizes the size and trajectory of the screws, so we can capture the major components of the fracture in the best way,” he says. “That’s allowed us to repair many radial heads that weren’t previously treatable.”