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PROGNOSIS

XIII.—PROGNOSIS IN INJURIES OF THEELBOW-JOINT

INJURIES about the elbow-joint give rise to moreanxiety than those involving any other joint in thebody. Permanent stiffness will result in a certain

proportion of the cases in spite of the utmost skilland care. No joint is quicker in taking advantage ofthe slightest error of judgment on the part of thesurgeon. Complications, some of them rarely seenelsewhere, are not very uncommon, and these may beextremely serious. On the average dislocationsinvolve a greater risk of permanent limitation ofmovement than fractures, though the most serious ofall complications, ischsemic paralysis, usually followsa fracture. Some of the minor fractures-e.g., of theradial head, and of the coronoid process, and -separa-tion of the internal condyle, are produced by whatwe might term attempted dislocation, the wholejoint being severely wrenched. This explains in somecases the unexpectedly poor results, though theexcessive amount of swelling should have warned thesurgeon of the true nature of the damage.

In children the supra-condylar fracture of thehumerus is the commonest lesion. Transcondy-lar fractures and separation of the epiphysisare much less common and demand no separateconsideration. The fracture is very rarely compound,and if it is-the skin wound is usually no more thana puncture-the prognosis is but little affected.It is of paramount importance that in all thesefractures the displacement, often considerable, shouldbe corrected without delay. If the reduction is atleast fair, if not perfect, and as a result flexion isobtained without undue force, and is maintained fora sufficient time, the prognosis in the vast majorityof cases is excellent. It is essential, however, thatafter fixation for four weeks, movement should berestored only by relaxation of the fixation apparatusand by encouraging active use of the arm : all passiveefforts to extend the joint must be avoided. Too

vigorous treatment by an ambitious masseur alonecan be responsible for a disastrous result unless theerror be discovered in time. The worst mistake thatcan be made is to give an anaesthetic and forcibly toextend the joint. Such treatment invariably makesmatters worse and produces the opposite effect to thatanticipated. Supposing the lower fragment is still

displaced behind the upper and yet, in spite of therisk, flexion well above a right angle has been achieved,the final result, although in jeopardy, is by no meanshopeless. Some of these cases in which the " setting "of the fracture has failed, nevertheless give goodresults.

Operative reduction in a difficult case should onlybe considered within the first few days. Late

attempts-i.e., after the first week at the most, tocorrect displacement by open operation are to becondemned ; the prognosis will be worse rather thanbetter after such interference. In a case seen someweeks after the injury with flexion checked by thedisplaced upper fragment, the outlook as regardsfull flexion, though bad, is not hopeless. In somecases, at any rate, as a result of absorption of thebone in front, full flexion may be gradually restoredin the course of several months. Although this happyprogress cannot be relied upon with confidence, thepossibility should always be waited for. A notuncommon error in the setting is a tilt inwards of the

lower fragment, which eventually produces the gun-stock deformity, or cubitus varus. This can berevealed by X rays after setting, and should alwaysbe looked for ; an effort should be made to overcomeit by a second manipulation, though this is difficult.If it is not detected till later, it is better not to

operate, but to wait till extension is restored and thensee whether the degree of deformity warrants osteo-tomy. This deformity sometimes causes considerableinconvenience, besides being unsightly.

Fracture of the elbow-joint may involve injury toone of the main nerve trunks. As a rule completerecovery follows conservative treatment. Very rarelythe median nerve is gravely damaged or even divided.

TWO GRAVE COMPLICATIONS

Besides limitation of movement due to fibrosis ofthe capsule or permanent displacement of thefragments, two grave complications may be metwith : (1) ischaemic paralysis or contracture, and(2) myositis ossificans.

Ischaemic paralysis.-This is usually associatedwith an excessive amount of swelling, and almostwithout exception a considerable degree of unreduceddisplacement. Possible contributing factors are

flexion of the joint beyond the limits of safety underthe circumstances, and tight bandaging. The com-plication can be avoided by adequate reduction ofthe displacement, by not flexing the joint till thisis achieved, and by fixing the forearm at an anglesomewhat lower than it is possible to flex it withoutundue force. Though the ischaemia is now said to bedue to acute venous obstruction, feeling the radialpulse at the wrist when the joint is setting is a usefulguide. If, in spite of every care, signs of ischemiadevelop, considerable improvement may be achievedby freely incising the deep fascia and thus relievingtension : the degree of flexion should be reducedand the arm placed on a pillow. By these means acase with a very black outlook may eventually givean excellent result, at any rate so far as ischaemiccontracture is concerned. If the condition is wellestablished the prognosis is undoubtedly very badThough gangrene, except for a patch of skin, isuncommon, complete recovery from any but themildest degree of this complication is impossible.

In so-called myositis ossificans, calcification andossification occur in the capsule or muscles or both.Here again the early recognition and prompt treat-ment of the condition have a profound influence onthe result. This is true of children to a far greaterextent than of adults, in whom the prognosis is muchless favourable. If the complication is recognisedearly in a child and promptly treated by completeand absolute fixation of the elbow, the opacities seenin the X ray often disappear within a few weeks,and the result may be still be perfect. If, however,abnormal shadows are seen both in front and behind,if the true nature of the trouble has not been recog-nised early, and particularly if it has been aggravatedby injudicious attempts to force a return to mobility,then the outlook as regards mobility is extremelybad. However, even in such cases patience mayeventually be rewarded. In adults the response to

prompt treatment is usually disappointing, and theprognosis is much less promising, though even heremovement may return after many months of fixation.Removal of the new-formed bone in the early monthsis worse than useless. Later, operation offers a

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chance of increasing the range of movement, butanything approaching a perfect result must not beexpected. This complication is also met with afterdislocations. -

DISPLACEMENT OF THE CONDYLES

Separation of the internal epicondyle is probablyproduced by forcible abduction of the forearm, andtherefore the joint may have been severely wrenched ;if treated by simple flexion, as a rule the prognosis isgood. The desire to avoid even the slightest dis-

ability in a lad who has shown an exceptionalaptitude for games may justify operation. Occa-

sionally the separated epicondyle is sucked into thejoint and caught between the humerus and ulna,and this may occur with or without complete dis-location. Open operation is usually necessary and theprognosis is not quite so good as in simple cases.

The ulnar nerve may be bruised, but usually recoversafter the operation. Condylar fractures which involvethe articular surface, are more serious. The external

condyle is more commonly displaced in children, and,as a rule, the loose fragment is rotated on an antero-posterior axis, often through an angle of more than90 degrees. This calls for open operation : the

result, though good, is often imperfect. When thetrue nature of the lesion, particularly as regards therotation of the condyle, has been overlooked, theresult may be surprisingly good in spite of the factthat union has failed to occur. The carrying anglewill be accentuated. By the time middle age isreached osteo-arthritic changes will be giving trouble,while in addition there is always present the possi-bility of neuritis of the ulnar nerve. This complica-tion may commence many years after the fracture.Fragments chipped off the head of the radius anddisplaced should be removed without delay; theoutlook is then good. If their removal is delayed,when superior judgment should have led to theirremoval earlier, the result is much less favourable.

FRACTURE OF THE NECK OF THE RADIUS

The final result in fracture of the neck of the radius

depends on the ability of the surgeon by open opera-tion to restore the head to something very close toits normal position. The younger the patient themore likely is this to be achieved. If it has been found

necessary to remove the head of the radius, per-manent weakness may result : later osteo-arthritic

changes are inevitable. In a child, when the headcannot be restored to perfect position, and yet itsremoval is considered unnecessary and inadvisable,a guarded prognosis should be given. The result

may be good, but is often imperfect.DISLOCATION

Dislocations in children as a rule do well, andeven in adults the results are often surprisinglygood. Each case, however, should be regarded asone of potential myositis ossificans and treated withthe utmost gentleness after reduction. In dislocationof the radius alone, the results depend on the earlycourse of the case. If dealt with promptly, andsuccessfully, the reduction being apparently stableand easily maintained by simple flexion, all shouldbe well. If, on the other hand, delay has occurredbefore reduction is attempted, or, when attempted,difficulties are encountered and, though apparentlyreduced, the head is unstable, and when perhaps asecond anaesthetic is given for further efforts to bemade, permanent impairment of function to a varyingdegree is certain to occur, particularly in adults.Periarticular calcification and ossification can occurwith surprising rapidity in some of these cases.

COMMON FRACTURES IN ADULTS

In adults the common fractures involve theolecranon, the head of the radius, or the coronoidprocess. Olecranon fractures with displacement aretreated as a rule by operation and give excellentresults. The probability of osteo-arthritic changesdepends largely on the operative skill of the surgeon.Even in elderly patients the results without operationand with movements commenced not later than fourweeks after the fracture may be all that they require.Fractures of the head and neck of the radius, whetheroperation is deemed advisable or not, do fairly wellif treated by early active movements and massage-i.e., as soon as the wound has healed if operatedupon and sooner if not. Fractures of the coronoidprobably result from "attempted dislocations " ;the severity of the general damage to the joint andthe degree of the resulting swelling determine thefinal result. The more severe the injury appears tobe the greater the need for initial rest and extracare in restoring mobility. It is unwise in an adultto maintain flexion above a right angle for more thana fortnight.

LESS COMMON FRACTURES

Of the less common fractures, a transverse juxta-articular fracture of the humerus is always difficult totreat, since any attempt to move the elbow beforeunion is firm only results in bending the callus anddelaying the union. T and Y fractures should betreated by operation and, if possible, fixation of thefragments, so that movements may be commencedreasonably early. Much depends on the skill of thesurgeon and the accuracy of the replacement. Theseare grave fractures and, on the whole, the results arefar from perfect. Severe trauma to the elbow, evenin the absence of clear evidence of fracture, may leadto the formation of loose bodies in the joint, withimpairment of function and a varying degree of

disability. This is more commonly seen in adults thanin children. In some cases the capitellum is brokenaway and displaced forwards and upwards. Its

prompt removal-it is rarely possible and wise toreplace and fix it-leads to a fairly good early result,but eventually, as after removal of the radial head,it is certain to be marred by osteo-arthritis. In

assessing the degree of disability likely to occur aftera particular injury of the elbow-joint, the sex,

occupations, and work of the patient should be givenevery consideration.

H. A. T. FAIRBANK, M.S., F.R.C.S.,Senior Orthopædic Surgeon, King’s College Hospital.

. ROYAL SEA-BATHING HOSPITAL, MARGATE.-Thereport of this hospital for 1933 shows that the averagedaily number of occupied beds was 308, the same,within a minute fraction, as in the preceding year. The

average cost per occupied bed was E117 19s. lld., as

against JE122 18s. 10d. in 1932. The medical superin-tendent, Dr. R. W. Armstrong, reports that the proportionof cases discharged as "

quiescent " reached the satis-factory figure of 77 per cent. for those suffering fromsurgical tuberculosis, and 61 per cent. for the non-tuber-culous. The latter group comprised a considerablenumber of cases which were not susceptible of cure.

Last summer there were few days on which heliotherapywas unable to be practised. He adds : " There werelong periods, however, when wind, which is ordinarily socharacteristic of the climate of Thanet, was completelyor almost completely absent, and it was noticeable thatduring these periods many patients tolerated sun-treat-ment relatively ill, and on the whole one rather formedthe impression that less benefit accrued than in the morenormal type of summer."