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PRIMARY EXCISIOK FOR ELBOW-JOINT WOUNDS 265
THE RESULTS OF PRIMARY EXCISION FOR WOUNDS OF
THE ELBOW -JOINT.
BY CAPTAIS A. EISDELL MOORE, R.A.RI.C.
DUI~ING
the last year a considerable number of wounds in the region of the elbow,
with fractures involving the joint, have been treated by a primary excision of the
elbow-joint at the casualty cleariny station. As a result, the stafï's of the orthopædic hospitals are being called upon to treat an increasing number of flail elbowjoints, a disability which causes great impairment of function, and which is difficult
to correct satisfactorily.
The following remarks are based on eleven consecutive cases (as set out in table
form on the following page) recently treated at the Bristol orthopzdic centre, and which
had had primary excision of the elbow-joint
performed at t.he front. It is doiibtful if in
more than two patients (Cases 9 and 10, Fig.
266) the result can undeniably be called good.
One appreeiates that becaiise this is an orthopzdic centre the cases seen probably include the
more unsatisfactory results, still the publishing
of them may be of use t o the surgeon at the
C.C.S.
The Relation between the Amount of Bone
Removed and the Subsequent Functional Result.
-In classifying these cases one realizes a t once
that the final functional result depends mainly
on the amount of bone that has becn renioved.
Colonel Mansell MouIlin' advocates primary excision provided sufficient bone is removed, and
advises a thorough removal of the articular ends
of the humerus, radius, and ulna, whilst Major
Swan2 and Captain Sheppards advocate a less
extensive operation ; the following cases support
fully the latter opinion.
Of the eleven cases given, ten have flail
elbows to a greater or lesser degree, and the
uselessness of the limb is-if
the length of time
from the original wound be taken into accountin almost direct proportion t o the amount of
bone removed. The cases are arranged according
FIG. 259.-Case
1. Pte. B. Esteiisive
t o the extent of the operation, and it will be
primary excision.
noted that as the amount of bone removed
decreases so does the functional result improve. Thus Case 1, Fig. 259, shows a gap
of 4& inches between the cut ends of the humerus, and radius and ulna. Undoubtedly
some of this is due t o the strekhing of the soft parts; still, the original removal of
bone must have been very extensive. Naturally the elbow-joint, as such, is useless.
Case 11, Pig. 267, shows an ankylosis-the
result of removing too little bone-so
from this series of eleven. one would gather that the tendency in this operation is a t
present t o remove too much bone rather than too little.
THE BRITISH JOURNAL O F SURGERY
266
TABLE SHOWING THE RESULTS OF ELEVEN CASES OF
j
90"
90"
210"
50"
70"
Full
1900
GO"
900
Flail
Full
2000
70"
90"
2 niths.
Flail
Full
190"
90"
900
9 inths.
G mtlis.
Flail
Full
160"
in.
5 mths.
3 mt,hs.
Flail
Full
210"
90"
'JO"
Humerus : lower end ;
iniich new bone forniec
Radius : untouched
Vliia : untouched
1 in.
5 mtlis.
li mths.
Flnil
Full
2000
GO"
20"
Pte. B.
Humerus : belov, epicondyle
Radius : artka. s i d a c e
Ulna : olecranon proces'
in.
O inths.
6 n.ths.
Weali
Full
l'?O"
Si1
30"
10
F'ensnr. Il.
N g . 266
Humerus : above epicondyle
Radius : untouched
Ulna : untouched
in.
7 mths.
4 IiithS.
Weak
Fil11
2000
30"
30"
11
Bdr. E.,
Fig. 267
Humerus : artic. surfact
Radius : artic. surface
Ulna : artic. surface
-
8 mtlis.
iaths.
h1,ylosed
??il
Xi1
Nil
Nil
4: in.
6 mtlis.
2 niths.
Flnil
Humerus : lower end
Radius : head
Ulna : olecrnnon
2 in.
3 mths.
2f niths.
Flail
Full
Hiiinerus : lower end
Radius : hend
Ulnn : olecranon
2 in.
8 mths.
1: mths.
Flail
3'igs. 260, 2til
4
Lt. J.,
Eigs. 262, 2G3,
264
FIiunerus : lower end
Radius : head
Ulna : olecrnnon
2 in.
10 mtiis.
1 mth.
5
Pte. A.
Hiimerus : louer end
Radiiis : untouched
Ulna : olecranon
IB in.
5 rnths.
G
Pte. P.,
Fig. 265
Humerus : lower end
Radius : nntoucheù
U l m : untouched
$ in.
7
Rfm. A.
Humerus : lower end
Radius : untouched
Tlns. : untouched
t
8
Pte. R.
9
1
Pte. B.,
Fig. 259
Hiiineriis : lower end
Radiiis : head and tubercle
Ulna : olecrnnon
2
Agt. M.
3
Pte. S.,
1
~
Fi111 2!0"
-~
Case 12, Pte. P. ( F i g s . 268, 269, X O ) , is one in which arthroplasty was performed eleven
PRIMARY EXCISION FOR ELEOW-JOINT WOUNDS
267
~~
Koiie
Good
Forearin inuscles arising froiii huiiieriis formed new attacliiiient t o forearin bones, and flexion
action of supinator ttius lost.
~
Koiic
'
Veryweab
Active to
iU"
Gooù
Supported in plaster i n early treatinent.
Marked orerridiiig of bones in voluntary flexion.
Actit P to
Y 00
Fair
Gap hetii-eeii ends of bones decreased rapidly on wearing support.
2;oiie
Fair
Complicated by ulnar paralysis.
Capsulorrhaphy perforined 5 months after wound.
7 inonths after wound had 30" voluntary flexion, and lateral inobility decreased ta 30' internally
and 30' externally.
Ac1 ive t o
1100
Fair
Complicated by ulnar paralysis.
GapsuZ~,rrhaphvperformed with ulnar suture 9 nionths after woiind.
12 months lafter wound ,active flexion t o GO", lateral mobility decreased t o 10' internally and 20'
externally. Some grating on extension.
Good
pou er
Good
None
lI
After support for 2 rnontlis ( 5 months after uound till 7 inonths after l%ound)voluntary flesion
t a GO0 returned.
Fair
~
1
Good
Supported in plaster in early treatment.
I n voliintary flexion arm siipinated first and theii flexed, inostly by means of supinator longus.
Active t o 1
Good
Markecl tendency for hurnerus ta override outwards.
Good
Treated in a straight Thomas splint after primary excision.
Operation 8 months after mound to repair ulnar nerve. Excess of callus removed and a r m
flexed. No attempt at arthroplasty, this being left till later date.
Cornplete.
biit a i t h
difficulty
GO0
1
~
Nil
l
~
~
~
-
rnonths aftcr the nound, and is included for cornparison with the above priinary excisions.
~
_
_
_
_
268
THE BRITISH JOURNAL O F SURGERY
Method of Limited Excision.-Of
course i t is impossible t o lay down definite rules
for any war siirgery, and the amount of bone removed must depend largely on the
amount of coniminution. Yet 1 would urge that the lines for excision follow Captain
Sheppard’s method as far as possible; that is t o Say, the lower end of the humerus is
rounded off above the epicondyles, and thc radius and ulna are preserved intact. If
comminution extends beyond this line there is a great temptation t o remove more
bone : but it is bettrr t o leave this as far as possible, and t o cover in the ends of
the comminuted bones with a muscle-fascia flap in the same way as is done in
performing an arthroplasty. A comparison between Cases 1 (Fig. 259) and 6 (Fig. 265)
brings out this point ; al1 comminiited bone was removed in Case 1, whilst in Case 6
the lower end of the humrriis, although badly hroken, was left i n situ, and though it
forms no ideal articular surface, the functional result obtained is much better than
with Case 1. Case 4 (Figs. 262, 263, 261), where the z-ray showing the original injury
is available, is also instructive. A piece of ühell is seen lging in the comminuted
FIG.:26û.-Case
3. Pte. S. Rones separateù
in extension.
FIG. ZGL-Canse
3. Pte. S. Rones oierriding
before flexion occur~.
lower end of the humerus. The excision performed included the humerus, the radius,
and ulna, and the result is not good. One feels that had the operation been limited
t o the removal of the lower end of the humerus, the patient woiild have had a much
more serviceable joint.
Relation of the Extensive Operation to Sepsis.-It
has been a g u e d that wide
excision is the best treatment from the point of view of controlling sepsis. I n this
series only one case healed within a month, the others give an average of over three
months. This is iiot rapid healing; but certainly the more bone removed the more
speedy is the first closure of the wound. This, however, by no means compensates
for the resulting loss of function.
Again, one cannot but feel that there is a definite risk in the extensive opening
up of raw bone surfaces in the presence of sepsis, and also that the sepsis may in
itself defeat the real purpose for which primary excision is performed, by stimulating
the osteogenetic power of the bone. A glance at the radiogram of Case 11 (Fig. 267)
PRIMARY EXCISION FOR ELBOW-JOINT WOUNDS 269
shows the large amount of new bone thrown out. It is probable that if an excision of
the same extent as was done in this case primarily, in the presence of sepsis, had been
done later when the sepsis had cleared up, a movable joint would have been obtained.
The Ability to Preserve Muscular Attachments in the Limited Excision.-In
regard to the preservation O€ niuscular attachments, the iniportance of leaving the
4. Lt. J. Heforc
operstioii.
FIC. ?F?.-Cnsc
FIc:. ?UB.-Cnsc
,1. Lt. .T. nuriiiz
treatrneiit nftrr ]'rinidry rxcision.
Drniiiaye tube iii silii.
4. 1,t. J . hfter
treûtmeiit bg sulqiort.
FIG. 264.-Case
triceps has been noted in niany papers ; but less attention has been paid to the
equally important point of leaving the origin of the siipinator longus. Case 9 pro:
rides a good example. The patient in flexing his elbow uses his siipinator longus
considerably niore than his biceps. To preserve the origin of the supinator longus is
of increased importance, of course, if
the radius is badly comminuted at its
upper end. Considering that the origin
of the supinator longus extends high
iip the external supra-condylar ridge,
it is seldom necessary to interfere with
this muscle at al1 in desling with a
woiind limited t o the elbow-joint.
Another case (Case 1 ) where the origin
of the miiscle has been removed shows
also that it is useless as a flexor of
the elbow in its new attachment to
the radius, although the patient has
a strong wrist and hand from the new
attacliment of flexorç and extensors of
the wrist and fingers.
The Resulting Flail Joint.-An
analysis of the ten cases which developed flail-joints after primary excisions
shows tliat :F I ~ .26L-Casc
6. Pte. P. Conimiiiuted lower eiiù of
1 . Passive movenient is usually
Iiumerus has beeri preserred.
possible froni full flexion t o about 20
degrees over full extension, and lateral mobility varies from 20 degrees externally only
to 90 degrees both internally and externally. This excessive lateral movement is a great
disability, the forearm tending to drop downwards when the upper arm is abducted,
and so practically preventing any use being made of the shouider-joint.
2. Active movenient is usually possible, although weak, but in a certain niimber
V O L . VI.-NO.
22.
19
270
THE BRITISH JOURNAL O F SURGERY
Active movement is the st.andard of success, and unless
active movement is good, and lateral mobility slight,
there is no doubt that a n elbow ankylosed in g m d
position gives the patient a great deal more serviceable limb.
The resulting joint is also greatly dependent upon
the immediate post-operative treatment. The forcarm
must be supported efficicntly t o prevent the fibrous
union from becoming stretched, and it is noteworthy
t h a t in Cases 1 and 2, where no active niovement
was possible six mnnths and threc months respectively
after operation, no attention had been paid t o the
support of the forearm, and in some of the other cases
the weight of the forearm had been taken by the
yoiing fibrous tissue far too soon.
This stretching of the fibrous union also accounts
for a condition of overriding of the bones when
voliintary flexion returns. The humerus overrides the
forearm bones on their outer side, and in flexion the
arm is apparently shortened before the movement , of
flexion occurs by contraction of the long flexors of
the forearm. This " taking in of the slack of the
joint" is well seen in Figs. 260 and 061. This patient
Yrc] 268.-Case 10. Pencr. D. Limitecl
had a lucky formation of a periosteal bone spur on
excision. Useiui joint.
the inner side of the humerus, and this acted as a
pivot which gave support to the ulna in flexion. He had a very iisefiil arm.
The Treatment of the Flaïl Joint---This is
t h e problem that most concerns the surgeon a t
the orthopæriic hospital. The joint has become
flail as a result o f : (1) Too wide a removal
of bone ; ( 2 ) Subsequent stretching of the soft
tissues.
The former cnnnot be remedied (those
extensive enough for bone-grafting t o be considered are classed as flail limbs, not flail
joints) : but the result of stretching of' the soft
tissues may be considerably helped by :A. Support.-In
al1 cases the u-eight of
the forearm must be taken from the soft tissues
joining the humerus and forearm. This can be
done by a simple forearm sling bringing the
wrist well up towards the neck, or the arm may
be put up in full flexion in plaster-of-Paris for
a month or six weeks, t o allow contraction of
the strctched soft tissues. The actual improvement possible, even after there has been stretching, is seen in Figs. 263 and 264, where a
Zf-inch p p was reduced to half an inch by
this means alone.
B . Massage, Electriciig, and ilydrotherapy,
t o improve the tone of the stretched tissues.
c. Operatbn-In Cases 5 and 6 in this
series an attempt was made to reef in the
PIO. ?G'l.-Caae
11. Xür. 6. Ankylosis.
excess of new fibrous tissue that was allowing
the excessive play at the elbow. A simple capsulorrhaphy through a posterior incision
of cases is quite absent.
PRIMARY EXCISION FOR ELBOMr-JOINT WOUNDS 271
was performed, and the new ‘capsule’ reefed posteriorly and at both sides. There was
some improvement in the degree of lateral mobility in each case, but one of the patients
(Case 6, Fig. 265) suffered some subsequent inconvenience from a ‘grating’ of the two
bone surfaces thus brought closer together. 1 do not think this would have occurred
had the ends of the bone a t the primary excision been covered by muscle-fascia flaps.
D. Mechunicul Treatment.-The
functional report on the above cases was made
before any mechanical support was provided. The provision of a light aluminium
support consisting of two lateral pieces
hinged a t the elbow-joint and restraining
lateral mobility, whilst allowing flexion
and extension, considerably aids voluntary
movement.
PIC. 2GS.-Casc
12. Pte. 1’. Shoeing aiikylosis
hefore operatioii.
FI<:. 270.-Case
FIG. 269.-Caw 12. Pte. F. Fhowiiip extension
ohtained after limitfd artliropldsty.
1’2. Ftr. P. Showin? flexion ohtained
after limited arthroplasty.
Cornparison of Results of Primary Excision with a Case of Arthroplasty for
Anky1osis.-In
comparison with the above series, 1 would quote- the following case
272
THE BRITISH JOURNAL O F SURGERY
of arthroplasty of the elbow performed for ankylosis after a gunshot wound. Case 12
(Figs. 268, 269, 270). This patient had very little comminution of the bone, but a
septic arthritis, and injury t o both median and iilnar nerves. Nerve repair was
performed six months after the wound, and a partial arthroplasty 9ve months later.
The arthroplasty consisted in removing the external condyle of the humerus piecemeal, and the articular surface of the head of the radius, then dislocating the joint
outwards, and sawing the humerus off just below the epicondyles. This method
allows the bone t o be removed through a small incision, with no injury t o the triceps
tendons, and only a little weakening of the external aspect of the joint. The sigmoid
cavity of the ulna was preserved, and the lower end of the humerus rounded off and
covered by a flap of muscle-fasria from the extensor origin. The joint was kept in
full flexion for three weeks without any attempt at movement. At the end of this
time there were 40 degrees passive niovenient without pain, and six weeks after the
operation there is 7.5 degrees voliintary inovenient, painless, and on1y 5 degrees lateral
mobility internall'; and none externally.
CONCLUSIONS.
1. Extensive primary excision must resnlt in a flail joint.
2. Limited excision is satisfactory.
3. If the bone is comminuted, muscle-fascia fiap should be carried in t o cover
comminuted bone as is done in arthroplasty.
4. Post-operative support of forearrn is essential.
5 . Rest is more important than early movement.
6. Capsulorrhaphy in certain chosen cases of flail elbow does good.
REFEREXCES.
*
COL. MASSELL MOULLIS. Rrit. Med. Jour.. 1917, Kov. 3.
MAJOR JOCELYX
SIVAN, Brit. M e d . Jour., 1918, Jan. 26.
CAPT. MQIR SHEPPARD,
Brit. X e d . Jour., 1918, Feb. 2.
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