Bilateral posterior elbow dislocation with heterotopic ossification in a child

Abstract

A 13-year-old boy, right hand dominant, presented acutely to the casualty department having injured both elbows following a fall from height. The patient had been climbing a 7 ft fence and had caught his shoelace at the top, falling onto his outstretched hands. There was obvious deformity bilaterally at the elbow with painful restriction of movement. There was no neurovascular deficit at this time. Aside from a minor head injury, with no sequelae, there were no other associated injuries.Radiographs confirmed bilateral posterior dislocation of the elbows (Figs. 1 and 2). Closed reduction under adequate sedation and analgesia was performed. The right elbow was reduced upon the first attempt (Fig. 3). The left elbow required two attempts to obtain reduction. Check radiographs of this elbow revealed a fracture of the coronoid process (Fig. 4).Bilateral above elbow plaster of paris backslabs were applied and the patient was admitted overnight for analgesia, elevation and observations.The patient was discharged the next day and reviewed at fracture clinic 10 days post injury. At this point the backslabs were discarded and the patient was encouraged to mobilise both elbows. As the left elbow was more painful at this point, a collar and cuff was retained on that side.Two weeks later both elbows were markedly stiff with a range of movement from 45 to 1008 bilaterally. Urgent physiotherapy was instituted at this point consisting of a limited session of passive exercise followed immediately by active training.Four weeks later, the right elbow had improved significantly, with a good range of movement and no instability. Examination of the left elbow revealed a firm mass of scar tissue palpable over the medial collateral ligament. There was no instability but the range of movement was limited slightly, the elbow lacking approximately 108 of full extension.At further review, 5 months later, radiographs were taken (Figs. 5 and 6), and showed Grade II heterotopic ossification 2 around the right elbow, and Grade IV heterotopic ossification 2 around the left elbow. Bone biochemistry was normal. Despite this, right and left elbows achieved a range of movement of 40-1008 and 30-1108, respectively, with well preserved pronation and supination in both forearms. This represents a marked deterioration of elbow function compared to previous review. The patient, however, was satisfied with the range of movement and was not keen on operative intervention. He was therefore treated conservatively.

Good functional recovery after bilateral elbow dislocation associated with bilateral distal radius and ulna fractures

“…Bilateral elbow dislocation (BED) is a rare injury with only 20 reported cases to the present moment. That includes 9 isolated BED (7 adult and 2 pediatric) 2 , 3 , 4 , 5 , 6 , 7 , 8 , 9 , 10 and 10 BED associated with a skeletal injury (7 adult and 5 pediatric). 7 , 11 , 12 , 13 , 14 , 15 , 16 , 17 , 18 , 19 , 20 None of the cases sustained a BED associated with bilateral forearm fracture which makes the reported case unique.…”

“…Nevertheless, unilateral elbow dislocations are the second most common major joint dislocation, with a reported incidence of 5.21 dislocations per 100.000 people/year in the US population 1 . Contrarily, bilateral elbow dislocation (BED) is an extremely rare injury with only 20 reported cases 2–20 …”

“… 1 Contrarily, bilateral elbow dislocation (BED) is an extremely rare injury with only 20 reported cases. 2 , 3 , 4 , 5 , 6 , 7 , 8 , 9 , 10 , 11 , 12 , 13 , 14 , 15 , 16 , 17 , 18 , 19 , 20 The above‐mentioned includes 11 bilateral elbow dislocations associated with a skeletal injury, none of which describe associated bilateral fracture of the distal forearm. Complications after unilateral elbow dislocation are common and include residual pain, chronic stiffness, heterotopic ossifications, and functional instability, which can enhance early arthrosis and lead to permanent incapacity to work.…”

A Rare Case of Traumatic Bilateral Elbow Dislocation Without a Fracture in a Seven-Year-Old Female Child

“…There have only been reported 24 cases of simultaneous bilateral elbow dislocations since 1957 in the literature for all age groups (including adults, adolescents, and children). Pediatric bilateral elbow dislocations are even rarer as there have only been reported six other cases regarding patients under 18-years-old, five with concurrent periarticular fractures and one without a fracture [4][5][6][7][8][9]. The latter, which reported a 16-year-old child in 1969, had a similar mechanism of injury (falling with outstretched arms) and resembled the clinical presentation (acute pain and lack of movements due to sharp pain with x-rays featuring bilateral posterior dislocation of the elbows) with the difference of the joint being slightly more edematous and the arms to appear shortened due to the posterior displacement of the forearms [4].…”

“…The long-term outcomes of bilateral elbow dislocation cases are promising, with reports of full recovery and return to recreation and sports activities. From the six pediatric cases, the two reported full range of motion [ 4 , 7 ], three reported some loss of motion range [ 5 , 8 , 9 ] and one did not report any outcome [ 6 ]. The earliest return to sports activities was six weeks [ 9 ], with most patients returning in three to six months after injury.…”