Integrative Trauma and Emergency

Medicine
Open Access Full Text Article Case Report

Recurrent Dislocation of the Elbow: Report Of Two Cases

This article was published in the following Scient Open Access Journal:
Integrative Trauma and Emergency Medicine
Received February 15, 2018; Accepted February 22, 2018; Published March 02, 2018
Otman Benabdallah*
Abstract
Centres Hospitaliers De Tanger, Morocco
Two cases of recurrent dislocation with posterolateral instability of the elbow are
reported. The dislocation resulted from laxity of the capsuloligamentous complex. Surgical
treatment using Osborne and Cotterill’s procedure was performed for the reconstruction
and reinforcement of the lateral collateral ligament and capsule complex. The follow up
was more than ten years for the first case and five years for the second case .There were
no recurrent dislocations and no limitation of movements. The patients were satisfied with
their surgical treatment.
Keywords: Recurrent Dislocation, Elbow, Capsular-Collateral Ligament Complex

Introduction
Recurrent dislocation of the elbow is infrequent. In 1971, Jacobs [1] found only
forty cases in the literature. More recently, the literature has been enriched with several
studies [2-9]. Several theories of the pathogenesis suggest that bone lesions or failure
of the lateral ligaments and capsule play a role in the recurrence of this condition. Many
surgical procedures have been described for repairing the anatomical lesions: tendon
transfers, bone blocks, ligament reconstruction [1,10]. The treatment should target
the lesions responsible, principally the capsuloligament [9,11-14]. The purpose of this
paper is to present two cases of recurrent dislocation of the elbow and to re-emphasize
the importance of repair of the postelateral ligament and capsular structures in the
treatment of this unusual disorder.

Case Reports
Case I: A sportsman aged twenty two had sustained a postero-lateral elbow
dislocation in a fall during a tennis match approximately fifteen months prior to
admission. This had been reduced by a physician and immobilized by a cast, which
was removed by the patient after a week. In the months following the initial injury,
he sustained repeated episodes of dislocation after moderate injuries, and these were
reduced by friends. Gradually, the patient began to complain of apprehension and pain
and important instability when actively using the involved extremity in tennis matches.
On examination, he had a full range of motion of the elbow, with marked laxity of
the internal lateral ligaments and weakness in the muscles, particularly the biceps.
He was able to dislocate his elbow by extending and contracting his forearm. Initial
roentgenograms did not show anything more than the first dislocation. Dynamic
roentgenograms carried out under anaesthesia showed postero-lateral dislocation of
the elbow by forced manipulation (Figure 1).
The operation, carried out in May 1995, used a lateral approach. It followed the
method of Osborne and Cotterill, which consists of tightening the postero-lateral
ligaments by suturing them with non-absorbable sutures passed through transverse
holes drilled on the lateral surface of the condyle. The arm was immobilized in a plaster
cast for four weeks. This was followed by physical therapy and active mobilization for
muscular reinforcement.
In the last examination, more than ten years later, the patient was found to be
symptom-free, and the dislocation had not recurred.

*Corresponding author: Otman Benabdallah, Centres

Case II: A twenty five-year-old man had a fall while engaged in a martial art one
hospitaliers de Tanger, Morocco, Tel: 00212 (0)61 24 83 year prior to admission. He sustained a left postero-lateral elbow dislocation, which
42, Email: otman.benabdallah@hotmail.com required reduction and immobilization for three weeks. After several weeks, the patient

Volume 1 • Issue 1 • 002 www.scientonline.org Integr Trauma Emerg Med

Citation: Otman Benabdallah (2018). Recurrent Dislocation of the Elbow: Report of Two Cases
Figure 1: Dynamic roentgenograms under anaesthesia showing a postero-
lateral dislocation of the elbow by forced manipulation.
Figure 2A: Examination without anaesthesia shows an important laterality
movement expressing the significant laxity of the elbow.
Figure 2B: Vacuity of the coronoid fossa confirming the dislocated elbow.
sustained a new fall on the same elbow with another dislocation,
which was reduced by a colleague. Then over the next few months
he had multiple recurrent dislocations while practising sport.
On examination, the elbow had an almost full range of motion,
but with apprehension for some movements liable to cause
instability of the elbow (extending the elbow and contracting the
muscle). Laterality movements showed a certain complaisance
even without anaesthesia. Roentgenograms confirmed this
complaisance (abnormal internal laterality, Figure 2A) and
dislocation expressed by vacuity of the coronoid fossa in the
dynamic x-ray (Figure 2B) with no other anomaly in the humero-
radial and humero-ulnar joint.
Exploration was carried out via a postero-lateral incision.
Considerable laxity of the postero-lateral ligament structure
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Page 2 of 3
was evident (avulsion of the postero-lateral capsuloligamentous
complex and the presence of a lateral pocket palpable with
the finger). With the lateral ligament tightened by pulling it
upwards with the finger, dislocation of the elbow was difficult. A
capsuloligamentous repair was carried out by making drill holes
and suturing the ligament in the lateral epicondyle (Osborne and
Cotterill’s method). The elbow was immobilized for four weeks
in a plaster cast.
Follow up more than five years later revealed a stable, pain-
free elbow, and dislocation had not recurred.
Discussion
Hassman, et al. [9] reported that in thirty one surgically
treated recurrent dislocations of the elbow, the instability was
attributed to:
- a bone lesion in ten cases
- a capsuloligamental lesion in seventeen cases
- bone and ligament lesions in two cases
Surgery included
- bone block in ten cases
- dynamic tendon transfer in four cases
- ligament and capsular repair in fifteen cases
However, in some cases, the follow-up periods were too
short to permit assessment of the results. In one case, treatment
by a bone block failed, but there were no failures after capsule
ligament repair.
In the literature, apart from cases of a disorder of connective
tissue like Ehlers-Danlos syndrome[15], where the elbow can
be dislocated on single occasions (the joints are hypermobile),
the pathogenesis of recurrent dislocations of the elbow was
attributed to bone lesions (dysplasia of the coronoid fossa,
anterior fracture of the apophysis during the initial dislocation,
trochlear notch insufficiency, or a defect in the postero-lateral
margin of the capitellum, as well as a shovel-like defect in the head
of the radius), to bone and ligament lesions, or to ligament and
capsular lesions [9,10]. This last condition seems to be the most
probable and now a majority of authors [9,11,13,14] insist on the
importance of the lateral ligament and capsule for stability of the
elbow (seventeen cases cited in Hassman, et al. [9]). We agree with
Osborne and Cotterill and others [9,13] that axial loading of the
extended humero-ulnar joint forces the coronoid process against
the laterally sloping surface of the trochlea, and if the lateral
capsulo-ligament system is lax, the radio-ulnar complex simply
displaces posteriorly and laterally . Repeated dislocations result
in the formation of the lateral pocket. Also according to Osborne
and Cotterill [3], the essential lesion of the elbow is a “failure of
the postero-lateral ligamentous and capsular structures, torn or
stretched at the time of an initial simple traumatic dislocation, to
become reattached”.
Some authors [13] consider that bone defects of the joint are
just a secondary phenomenon in the pathogenesis.
Could inadequate immobilization be one cause of the failure
of the ligament to heal? The literature [1,14] does not define
the best treatment for an initial dislocation. In practice, many
Integr Trauma Emerg Med
Citation: Otman Benabdallah (2018). Recurrent Dislocation of the Elbow: Report of Two Cases
patients remove the immobilization earlier than recommended
and experience no instability or recurrences. This could even
be considered a preventive measure, as it allows the soft tissues
to heal. The primum movens is the lesion of the ligamentous
capsular complex and its healing with sufficient or insufficient
immobilization after a primary traumatism.
In our two cases, significant laxity of the postero-lateral
ligament was found in both patients clinically and operatively.
No bone lesions or intra-articular loose bodies were found in our
patients, perhaps because the traumatism was not very old and
was not accompanied by initial fractures, as was true of cases
cited in some articles [9,12,13]. After ligamentous capsular repair,
the results were encouraging after follow-up of ten and five years
respectively. The patients had no recurrences, and they were pain
free with a good range of motion. Both patients returned to their
normal activities.
We felt that Osborne and Cotterill’s procedure was the
most suitable for our two cases because the anatomical
element responsible was the capsuloligamental complex. The
result of the capsuloligamentous repair is encouraging, based
on follow-up of 10 years for case 1 and 5 years for case 2. This
technique is recommended for its simplicity and for the fact
that it attacks the essential lesion. Until now there have been
no reported failures after capsuloligament repair. Of course,
the number of reported cases remains too small to draw
significant conclusions.
Conclusion
Inadequate immobilization of the elbow following the initial
injury seems not to be the only cause of recurrent dislocation of
the elbow; failure of the lateral capsuloligament complex is the
primum movens of instability of the elbow. Surgical repair using
the procedure of Osborne and Cotterill is the recommended
technique for this disorder because it attacks the essential
lesion.
Copyright: © 2018 Otman Benabdallah. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits
unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.
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Page 3 of 3
Aknowlegement
I want to thank very much Professor Eirlys Davis for her
invaluable help.
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