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An Unusual Case Of Old Unreduced Simultaneous Bilateral Elbow Dislocation Associated With Traumatic Pseudoaneurysm Of Brachial Artery

 Dipak Shrestha*,Md Ruhullah**,Umesh Kumar Sharma***,

* Lecturer
** Orthopaedic Surgeon
***Associate professor
Dept. Of Orthopaedics,Dhulikhel Hospital,Kathmandu University, School of Medical Sciences

Address for Correspondence:

Dipak Shrestha
Dept. Of Orthopaedics
Dhulikhel Hospital
Kathmandu University, School of Medical Sciences

J.Orthopaedics 2007;4(4)e12


Simultaneous bilateral elbow dislocation is rare injury and only 13 cases are reported in literature. 9 cases were purely ligamentous injury and 4 cases were associated with additional osseous injury. Untreated or neglected unilateral dislocation of elbow is not uncommon in developing countries but untreated or neglected simultaneous bilateral elbow dislocation has not been reported in English literature.  

We report an unusual case of simultaneous bilateral elbow dislocation of elbow which was untreated for 9 months making her handicap for daily activities of living.

Material and Methods :

After 9 months of fall injury from tree about 10mts height, a 30 years old female presented in Dhulikhel Hospital complaing of inability to flex both elbow sufficiently to feed herself and to take care of personal hygiene like washing face or combing hair or buttoning clothes and applying “bindis” over forehead. She was dependent to her children for these activities. Otherwise she had to take food or drink like canines by bringing mouth to the plate. Clinical examinations and radiographic investigations revealed bilateral posterior dislocation of elbow with mature myositis mass on right side and ununitted olecranon fracture on left side with intact distal neurovascular structures on both sides. Range of movement of right and left elbow was 4-10˚ and 8-22˚ respectively with restricted pronation on both sides (Fig: 1a)

Figure 1a: Range of movement of elbow before surgery. 
Figure 1b, 1c: Pre operative and post operative radiographs.

Open reduction and radio humeral Kirschner wire fixation was done of both elbow in a week apart as described by Speed JS for old unreduced elbow dislocation.1 Myositis mass was excised on right elbow and tension band wiring for fracture olecranon was done on left elbow (Fig: 1b,c). Ulnar nerve was transposed anteriorly on both sides. On 5th post operative day, oozing of fresh blood was noted from incision site of right elbow and on removal of clots; there was continuous trickling of fresh blood. Distal radial pulsation was intact. Coagulation profiles were within normal range. Colour flow arterial doppler ultrasonography revealed pseudo-aneurysm of brachial artery about 2.5cm proximal to bifurcation into cubital fossa (Fig: 2). Brachial artery was explored; distal and proximal mobilization was done; pseudo-aneurysmal sac was excised and end to end anastomosis was performed (Fig: 3). Post operative events were uneventful. Active movement of left elbow was started on 2nd postoperative week after removal of radio humeral Kirschner wire but delayed incremental range of movement was started on right side.

Figure 2: Doppler ultrasonography showing brachial artery (BA) and aneurysmal sac (AS).

Figure 3: Exploration of brachial artery (BA) and aneurysmal sac (AS): before and after end to end anastomosis

During last follow up period after 1 year of surgery, range of movement of right and left elbows was 15-100˚ and 0-90˚ respectively with full supination and terminally restricted pronation (Fig: 4). Distal neuro- vascular structures were intact and she was no longer dependent over her children for her previous disabilities.







Figure 4: Range of movement of both elbows at 12 months follow up. 


Though the elbow is highly constrained and stable joint, dislocation is common injury especially in 10 -20 yrs of population .2 Posterior elbow dislocation occurs when valgus and external ratatory torque is applied when a person fall with elbow in extension or in flexion .3 

Unreduced posterior dislocation which is primarily seen in developing countries is one of the challenges for restoring stable and functional range of movement in the presence of incipient or established soft tissue contracture. Unilateral untreated dislocation may be compatible with life with difficulties but when it is bilateral as in our case, patient’s routine activities are severely affected because of restriction of bilateral elbow movement. Socio- economic factors are major constraints that prevent patients seeking for medical help despite severe disabilities. English literature search revealed only cases of simultaneous bilateral neglected dislocation of elbow which had been promptly relocated.

Kovrizhnyi VG et al, Maitra AK and Schonbauer HR had reported bilateral simultaneous dislocation of elbow in literature. 4, 5, 6 Syed AA et al. reported a case of simultaneous bilateral elbow dislocation with unilateral radial head fracture in a female gymnast which was promptly reduced followed by immediate mobilization .7 Koslowsky TC et al. had found two cases of simultaneous bilateral elbow dislocation following fall from 5 mts. tall ladder and mountain bike respectively. Three elbows were reduced with closed technique and one with open method. All elbows were actively mobilized with external fixator with motion capacity and resulted into excellent clinical outcomes.8

Injury to brachial artery with closed elbow dislocation without osseous injury is also rare (5-13%).9 Injuries to part of the vessel wall without complete rupture or transsection can give rise to pseudo-aneurysm which is a late sequalae of trauma and may not be detected early because it may not disturb distal pulsation. Pseudo-aneurysm of size less than 2 cm may be silent, asymptomatic and may go unnoticed for long time during long enlarging period unless it compresses surrounding nerves or causes thrombo- embolic phenomena to distal part or produces pulsatile mass.10 In our case pseudo-aneurysm sac probably got injured during surgery and detected when it started leaking post operatively.

When pseudo aneurysm is detected, treatments are surgical reconstruction or color-doppler ultrasonographic guidance ligation, endovascular graft implantation, embolization or ultrasound-guided thrombin injection. A single small aneurysm distal to the brachial bifurcation can be ligated but aneurysm at the brachial truncus or in the distal region, reconstruction is necessary for the viability of the extremity, as in our patient.10

Old unreduced simultaneous bilateral dislocation of elbow with severe disabilities is still found in developing country like Nepal. Open reduction, V-Y plasty of triceps muscle and early mobilization of elbow with can add good range of movement. In cases with neglected dislocation of elbow, traumatic pseudo-aneurysm of distal part of brachial artery should be ruled out before surgery.

Reference :

1.     Speed JS. An operation for unreduced posterior dislocation of the elbow. South Med J; 1925, p18:193.

2.     Hotchkiss RN. Fracture and dislocations of elbow. In: Rockwood CA, Green DP, Bucholz RW, Heckman JD (eds) Fracture in Adult. 4th ed. Vol. 1. Lippincott – Raven, Philadelphia; 1996, p 929-1024.

3.     Kovrizhnyi VG, Savvin EM. A case of simultaneous bilateral luxation in the elbow joint. Klin Khir; 1969, 5: p65.

4.     Sojbjerg JO, Helmig P, Kjaersgaard AP. Dislocation of the elbow: an experimental study of the ligamentous injuries. Orthopedics; 1989, 12(3): p461- 3.

5.     Maitra AK. A rare case of bilateral simultaneous posterior dislocation of the elbow. Br J Clin Pract; 1979, 33(8): p233-5.

6.     Schonbauer HR. Simultaneous, bilateral dislocation of the elbow. Monatsschr Unfallheilkd Versicherungsmed; 1957, 60(4): p119-21.

7.     Syed AA, O'Flanagan J. Simultaneous bilateral elbow dislocation in an international gymnast. Br J Sports Med; 1999, 33(2):p132-3.

8.     Koslowsky TC, Mader K, Siedek M, Pennig D. Treatment of bilateral elbow dislocation using external fixation with motion capacity: a report of 2 cases. J Orthop Trauma; 2006, 20(7): p499-502.

9.     Platz A, Heinzelmann M, Ertel W, Trentz O. Posterior elbow dislocation with associated vascular injury after blunt trauma. J Trauma; 1999, 46(5): p948-50.

10.  Yetkin U, Gurbuz A. Post-Traumatic Pseudoaneurysm of the Brachial Artery and Its Surgical Treatment. Tex Heart Inst J; 2003, 30(4): p 293–297.

This is a peer reviewed paper 

Please cite as : Dipak Shrestha : An Unusual Case Of Old Unreduced Simultaneous Bilateral Elbow Dislocation Associated With Traumatic Pseudoaneurysm Of Brachial Artery

J.Orthopaedics 2007;4(4)e12





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