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A total of 14 women and seven men with a mean age of 43 years (18 to 68) who sustained a Mason type IV fracture of the elbow, without an additional type II or III coronoid fracture, were evaluated after a mean of 21 years (14 to 46). Primary treatment included closed elbow reduction followed by immobilisation in a plaster in all cases, with an additional excision of the radial head in 11, partial resection in two and suturing of the annular ligament in two. Delayed radial head excision was performed in two patients and an ulnar nerve transposition in one. The uninjured elbows served as controls. Nine patients had no symptoms, 11 reported slight impairment, and one severe impairment of the elbow. Elbow flexion was impaired by a mean of 3 degrees (sd 4) and extension by a mean of 9 degrees (sd 4) (p < 0.01). None experienced chronic elbow instability or recurrent dislocation. There were more degenerative changes in the formerly injured elbows, but none had developed a reduction in joint space. We conclude that most patients with a Mason type IV fracture of the elbow report a good long-term outcome.

Sixty-two patients older than 16 years of age at the time of injury were reexamined an average of five years (range, 1 to 12 years) after a dislocation of the elbow without concomitant fracture. Thirty-four were treated nonsurgically with closed reduction and immobilization in a plaster cast. Twenty-eight were treated surgically with primary ligament repair followed by immobilization in plaster. Ligament repair was performed medially in all cases and laterally in 17, on the average two days after injury. At follow-up examination, the most common complaint in both groups was limited range of motion, decreased extension being the most common. In no respect were the surgically treated elbows better than those treated nonsurgically. No evidence was found to recommend primary surgical treatment of ligament injuries associated with dislocation of the elbow.

Totally, 178 elbow dislocations--with and without concomitant fracture--that had occurred in the city of Malmö in the course of 12 years were studied. There was some preponderance of left-sided injury, but no significant sex difference. The dislocations were most frequent in the very young and occurred most often in conjunction with sports activities.

Of 23 patients with an elbow dislocation associated with at least one displaced fracture of the radial head, 19 patients had the radial head extirpated two days range, 0-16 days) after injury. In four elbows, redislocation occurred. All four redislocations were associated with a displaced fracture of the coronoid process. A follow-up examination was performed in 19 patients between three and 34 years after the injury. Severe osteoarthritis with reduced joint space developed in 12 elbows. Reduced range of motion was the most common complaint, and reduced extension was the most common finding. To lower the risk and prevent severe instability, the radial head should be preserved if possible. If the radial head must be resected, suturing of torn ligaments and muscles at the epicondyles is essential.

The opinions concerning presence of instability and ligamentous injuries following dislocation of the elbow differ. Thirty-one patients with an elbow dislocation without concomitant fracture were examined under anesthesia for stability at an average time of two days after the injury. All elbows were unstable to valgus stress in the extended position compared with the healthy side. Eight elbows were unstable to varus stress. Nine elbows were easily redislocated in semiflexed position under anesthesia. Surgical exposure and ligament suture were performed medially in all cases and laterally in 18 cases. All the ligaments were completely ruptured or avulsed in the epicondyle attachment. In most cases the ligamentous ruptures were combined with rupture or avulsion of the muscular origins at the epicondyles. The degree of muscular damage was correlated with the tendency to redislocate under anesthesia.

Arthrography has been suggested as a useful tool for diagnosing ligament ruptures. In 14 consecutive patients with non-fractured elbow dislocations arthrography was performed after reduction of the dislocation. One or two days following arthrography all elbows were examined under general anesthesia with regard to stability and half of them were randomized for surgery with exploration and suture of both the ulnar and the radial collateral ligaments. Arthrography, even if performed within 24 hours after the injury, was found to be unreliable in diagnosing ligament injuries after elbow dislocation. Leakage of the contrast medium was more or less limited to the site of the major injury, which in the dorsal and dorso-radial dislocation was a rupture of the volar aspect of the capsule and the ulnar side of the joint in the radial dislocation.

Fifty-two patients with a radiographically verified dislocation of the elbow were re-examined at an average of twenty-four years after injury. Half of the patients had no residual symptoms or signs whatsoever and more than one-third had a slight or moderate decrease in the range of extension, which was associated with slight degenerative change in the joint or with periarticular calcification. No reduction in joint space was evident. Even when the examination revealed some instability in a few patients they did not register complaints. Among the patients who had sustained the injury when they were less than sixteen years old, there were few with residual symptoms, signs, or radiographic changes.

Thirty consecutive patients who had dislocation of the elbow without concomitant fracture and who were sixteen years old or more were examined under general anesthesia for stability of the joint at an average of four days after the injury. All of the elbows showed medial and sixteen showed both medial and lateral instability. The patients were then randomly assigned to undergo either non-surgical or surgical treatment of the ligamentous injuries. All of the surgically treated elbows showed complete rupture or avulsion of both the medial and lateral collateral ligaments, and in about half of these patients the muscle origins were found to be torn from the humeral epicondyles. At follow-up, both groups showed generally good results; the differences were not statistically significant. There was no evidence that the results of surgical repair of the ligaments were any better than those of non-surgical treatment.