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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.