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ORIGINAL ARTICLE  
Year : 2013  |  Volume : 47  |  Issue : 4  |  Page : 382-387
Sideswipe injuries around the elbow: Management and functional evaluation


1 Department of Orthopedics, Indraprastha Apollo Hospital, New Delhi, India
2 Department of Plastic Surgery, Indraprastha Apollo Hospital, New Delhi, India

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Date of Web Publication12-Jul-2013
 

   Abstract 

Introduction: Sideswipe injuries constitute a subgroup of complex elbow trauma. Almost all of these are high energy open injuries. There is no fixed protocol that is followed in the earlier studies. The injury pattern is grotesque and ill managed with poor functional outcome. We report the functional outcome in our series of patients who sustained sideswipe injuries.
Materials and Methods: Thirty four patients presenting with sideswipe injuries around the elbow were managed and functional results evaluated. The patients were followed for 15-94 months (mean 74 months). 32 of these were males and two were females. The injuries were sustained between 8 years and 48 years age group (mean 30 years). The right side was affected in 20 and left side was injured in 14 patients. Road traffic accident was the cause in all patients. Principles of management followed were (1) debridement and stabilization of fractures, (2) vascular repair, (3) redebridement, (4) nerve repair and (5) soft tissue cover. An external fixator was used for fracture stabilization in 20 patients with open fractures. Internal fixation was used as a stabilization modality in 12 patients. Primary nerve repair was carried out in 4 cases. In case of segmental loss, tendon transfers or nerve grafting was carried out at a later date once softtissue healing was complete. Soft tissue coverage was provided within 24-48 h of injury. Results were evaluated using the Mayo elbow performance score.
Results: The average Mayo elbow performance score was 70. Excellent results (score > 90) in accordance with Mayo elbow score were seen in 30% of the patients. Good results (score 75-89) were seen in 33% of the patients.
Conclusion: Sideswipe injuries should be managed timely, aggressively and an algorithmic protocol should be followed to achieve best results. The injury pattern is distinct for which a multispecialty approach is needed and an orthopedic, vascular and plastic surgeon must be involved. Limb salvage is possible in most cases.

Keywords: Elbow, functional outcome, sideswipe injury

How to cite this article:
Kharbanda Y, Sharma M, Singh K, Kumar L. Sideswipe injuries around the elbow: Management and functional evaluation. Indian J Orthop 2013;47:382-7

How to cite this URL:
Kharbanda Y, Sharma M, Singh K, Kumar L. Sideswipe injuries around the elbow: Management and functional evaluation. Indian J Orthop [serial online] 2013 [cited 2019 Dec 9];47:382-7. Available from: http://www.ijoonline.com/text.asp?2013/47/4/382/114923

   Introduction Top


Sideswipe injuries (syn. baby car injuries, traffic elbow injury) are sustained when a patient while travelling in a vehicle with elbow resting on the window is hit by a coming object or a vehicle on the road. [1] These injuries constitute a subgroup of complex elbow trauma. [1],[2],[3] Almost all of these are high energy trauma. [4] Majority of these are open injuries and can be prevented by keeping the limbs inside the vehicles. Patients usually have polytrauma, commonly head and chest injuries. [2],[4],[5],[6] Commonly sustained in countries where open window buses or cars are still used for travelling. [1] Management of these injuries is difficult and involves a multidisciplinary approach using orthopedic, plastic and vascular surgeons. These injuries have a high complication rate and poor outcome. Complications such as stiffness, contractures, nonunion, deformity and loss of function are common. [2],[3],[5] Management of sideswipe injuries requires a specific treatment algorithm which should be followed to maximize functional outcome. A meticulous assessment in the triage followed by careful planning and a staged surgical protocol with initial soft tissue debridement, fracture stabilization followed by the vascular repair should be followed. Wound coverage is given primarily in cases where soft tissue is not much contaminated and approximation is achieved primarily. Secondary coverage such as split skin graft and flaps are used in case of soft tissue loss. The authors have analyzed the results of sideswipe injury cases in this study.


   Materials and Methods Top


Thirty four patients presenting with sideswipe injuries around the elbow between July 2004 and June 2008 were managed and functional results evaluated. This is a prospective case study approved by the Ethics Committee and informed consent was taken from all the patients. We grossly followed an algorithmic protocol to manage sideswipe injuries [Figure 1].
Figure 1: The protocol followed in treating sideswipe injuries

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Twenty two of these were open injuries according to Gustilo and Anderson classification [Figure 2]a. [6] Classification was carried out postdebridement. Twelve of these were closed injuries. All the patients sustained injuries while their elbow were protruding outside their vehicles and were hit by another vehicle on the road. All of them presented within 12 h of the injury. None of the patients died of polytrauma. Associated injuries were Chest-pneumothorax, (n=1), flail chest, (n=2), head injury-skull fracture, (n=4), extradural hematoma, (n=1). Isolated management cannot be described Comorbid conditions such as diabetes and hypertension were seen in two patients. 32 of these were males and two were females. The mean age was 30 years (range 8-48 years). The right side was affected in 20 patients. Right side was the dominant hand in 30 patients. All patients were managed in accordance with the advanced trauma management guidelines. Bony injury pattern commonly encountered in sideswipe injuries include comminuted fractures of the lower end of humerus, fracture of olecranon at coronoid level, anterior dislocation of the radial head, fracture of radius and ulna and fracture shaft of humerus. All these were accompanied by variable degree of bone loss [Figure 2]b. Three patients had a concomitant elbow dislocation. [Table 1] enlists the type of neurovascular insult sustained and the procedure adopted. Radial nerve palsy was the most commonly encountered nerve injury (n = 10) presenting as neuropraxia, division or segmental loss. Four patients had a loss of bony segment in the humerus. The average injury severity score was 24. Principles of management followed were (1) debridement and stabilization of fractures, (2) vascular repair, (3) redebridement, (4) nerve repair and (5) soft tissue cover. Protocol followed in acute management was initial joint assessment by orthopedic, vascular and plastic surgeon in triage and decide salvageability and plan accordingly. All patients were triaged and subjected to limb salvage. All patients were given intravenous antibiotics at their arrival to the emergency. A thorough wound lavage was done using 4-5 L of normal saline in all open fractures, followed by aseptic dressing and splintage. Thorough, primary debridement was followed by redraping and rescrubbing of the same operating team and then followed by stabilization of fractures with the external or internal fixation and reassessment of vascular status after bony fixation. Redebridement was carried out after vascular repair so that bleeding margins are achieved. Postoperative radiographs were carried out to assess the fixation and reduction [Figure 2]c. A relook debridement was carried out after 24-48 h before proceeding for any kind of soft tissue cover. An external fixator was used for fracture stabilization in 20/34 patients [Figure 2] (18/22 patients with open fractures and two closed fractures). In 16 patients (12/34 patients with closed fractures and in 4/22 open cases) internal fixation was used as a stabilization modality. External fixation was used as a temporary stabilization measure and converted to internal fixation after wound coverage. We did not use trans-fixation for stabilization in our patients. Infection was seen in two open fractures and was managed by wound lavage, intravenous antibiotic and vacuum assisted closure [Table 2]. Primary nerve repair was carried out in 4 cases (two radial and two median nerve) [Table 1]. In case of segmental loss, tendon transfers or nerve grafting was left for a later date once softtissue healing was complete. Soft tissue coverage was provided within 24-48 h of injury to prevent tissue necrosis and bone death [Table 3] and [Figure 2]. Secondary procedures carried out were bone grafting (n = 8), tendon transfers (n = 6) and free fibular transfers (n = 4) [Figure 2]d, e extensor mechanism repair (n0 = 1). Rehabilitation in the acute stage was aimed at prevention of deformity and to keep joints supple for secondary procedures. Physiotherapy in the later stages was focused at improving range of motion and to maximize power after tendon transfers.
Figure 2: (a) Clinical photograph showing a typical sideswipe injury around the elbow (b) Anteroposterior view of the arm showing the bone loss in the humerus (c) Postoperative picture showing the external fixator stabilization and latissimus dorsi myocutaneous flap (d) Postoperative radiographs showing the free fibula used as a bone graft to fill the humeral defect (e) clinical photograph showing functional result

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Table 1: Neuro - vascular injury and treatment given


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Table 2: Secondary procedures and soft tissue cover


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Table 3: Complications


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   Results Top


Results were evaluated using the Mayo elbow performance score. [7] The average Mayo elbow performance score

was 70. The average followup was for 74 months (range 15-94 months). Excellent results (score > 90) in accordance with Mayo elbow score were seen in nine patients. Good results (score 75-89) were seen in 10 patients [Figure 3], [Figure 4]. Four patients lost to followup after a period of one year. Limb salvage was possible in 32/34 patients. In two patients attempts at limb salvage had to be abandoned, one in the early stages due to a mangled extremity and one later in the course of treatment due to a resultant non-functional limb. Above elbow amputation was done in these two patients. Six patients had fused elbow, ankylosis of elbow (2 cases) and arthrodesis (4 cases that had a free fibular transfer) and had poor results (score < 60). Bone loss of less than 5 cm in the humerus was managed by docking and defects more than 5 cm were managed by free fibula transfer [Figure 2]b. Fusion (arthrodesis) was carried out in 4 cases with >5 cm bone loss and severe softtissue loss. A free fibular graft was used to fill the gap and fixation was carried out with a plate [Figure 2]d.
Figure 3: (a) Clinical photograph showing typical sideswipe injury in a child. (b) Intraoperative photgraph after debridement showing fixator in situ. (c) Postoperative lateral radiograph showing fixation of humerus, elbow and forearm fractures. (d-f) Clinical photographs showing functional result and a good hand grip

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Figure 4: (a) Clinical photograph showing sideswipe injury with open fractures (b and c) Radiographs showing fractured humerus and forearm bones (d) Intraoperative photograph after debridement showing fixator in situ (e and f) Clinical photographs showing final functional outcome

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Complications of the procedures and their management are listed in [Table 3]. Pin tract infection was the most common early complication and nonunion was the most common late complication encountered. Nonunion was seen in eight patients for whom autogenous corticocancellous bone grafting had to be carried out at a later stage. All nonunions healed. Nonunion was commonly seen in the humerus (n=4), ulna (n=3) and radius shaft (n=1) in our series [Table 3]. It is a common complication and is also reported by other authors. [2],[8] Tendon transfer procedures were done in cases segmental loss of radial nerve (modified Jones transfer in six patients) and Volkman's ischemic contracture (brachioradialis to flexor pollicis longus and extensor carpi radialis to flexor digitorum profundus in two patients) after an average of 6 months. All regained good function of the hand such as the ability to write, hold the glass of water, able to tie shirt buttons [Figure 2]e. Refractures were not seen in our series. Range of motion at the elbow in the functional range (30-130°) average 110° and a good hand function was the end result in 10 patients. Twelve patients had a reasonable range of motion at the elbow (60-110°) average 70°.


   Discussion Top


The term "Sideswipe injuries" is grossly insufficient as it describes only mode of trauma and gives little information about the nature of the injury.

This particular injury around the elbow often involves multiple bone fractures and variable injury patterns. They are defined as complex elbow injuries as standardized concepts usually do not apply. [2],[4],[5],[6] Fracture pattern may be at single or multiple levels in the same bone or may involve multiple bones. There may be variable degree of bone comminution and softtissue and/or bone loss. Stable fixation and pain free motion is the goal of treatment. [3],[9],[10],[11] The most frequent combination fracture pattern was a supracondylar fracture of the humerus associated with intraarticular extension and fracture of radius and ulna. Internal fixation should be the preferred stabilization modality of choice in closed fractures and in clean open grade one and grade two injuries. [3],[5] External fixation should be limited to open fractures, marked comminution, bone loss, extensive softtissue damage and multiple injured patient (in accordance with the principles of damage control orthopaedics). [1],[12],[13],[14],[15] We used internal fixation in 47% patients (n = 16) and external fixation combined with limited internal fixation in 58% patients (n = 20). We have used a tubular external fixator in all our cases, [9] as opposed to the dynamic fixator preferred by some authors. [2],[16],[17] Transfixation of the elbow joint has been used by Morrey et al. in cases of severe comminution, instability and extensive softtissue injuries. [9] Articulated external fixator has been used as an alternative to transfixation in cases of complex elbow trauma. [17]

Wound coverage was needed in 22 cases of open injuries [Table 2]. We resorted to early wound coverage with skin grafts and flaps so as to decrease infection, tissue edema and tissue death and allow early mobilization. [11],[18] Some authors believe that tissue hypoxia in the early postoperative period delays wound healing and increases chances of infection. [19] We have successfully skin grafted open wounds, within 24-48 h after a redebridement and with split skin grafts and flaps within 2-3 weeks of the injury [Table 2]. The authors believe that early split skin graft acts as a biological dressing and prevents tissue death and helps control infection. Muscle transposition was carried out in two patients and six patients needed latissimus dorsi myocutaneous flap. Stevanovic et al.[18] recommend pedicled latissimus dorsi flaps for defects not extending more than 8 cm below the elbow. Free tissue transfer was carried out in four patients.

Radial nerve palsy was the most common nerve deficit found in 29% of our injured patients, as opposed to the ulnar nerve lesions found commonly in some series. [5] Six of these radial nerve injuries had segmental loss and tendon transfers (modified Jones transfer) had to be carried out later. Ulnar nerve lesions were found in 5.8% of patients and median nerve injuries were found in 11.6% of patients. All ulnar nerve lesions recovered after a period of observation of 3-6 months. Median nerve injuries recovered after end to end anastomosis or nerve grafting [Table 1]. Some authors have reported a 50% [19] and 63.5% [5] neural complications. We did not encounter any brachial plexus injuries in our series. Vascular injury was found in 17.6% patients. End to end anastomosis and vein grafts were performed [Table 1] in 5 cases only after primary debridement and stabilization with an external fixation. Compartment syndrome was not seen as a complication in our series, contrary to that reported by other authors. [5] Bone graft was used in case of nonunions. Wild et al. in 1982 [15] achieved primary union with the external fixator in 5/16 patients. The functional results did not correlate with the Injury Severity score of the individual patients. Open fractures, associated nerve injuries, softtissue loss, bone loss, primary method of fracture stabilization (external fixation) and poor rehabilitation, all had poor results and did correlate with poor functional results. All the above factors had a bearing on the end results of the study, individually as well as cumulatively. Seekamp et al. [20] have evaluated prognostic criteria for poor functional results in elbow injuries and found nerve lesions as the most significant factor for poor outcome. They also found the method of primary treatment to be of prognostic implication with external fixator application correlating with a poor functional outcome. Solomon et al. in their study published in 2003 [21] also found nerve injuries to be associated with lower functional outcomes at a minimum of one year followup. Contrary to the observations, Yokoyama et al. in their publication in 1998 [22] found that there was no correlation between injury severity score, open injuries, neurovascular injuries or the timing of surgery and the functional outcome in floating elbow injury in adults.

To conclude limb salvage is possible in most cases if an algorithmic approach is followed and multiple procedures may be needed to achieve functional results with a multidisciplinary approach consisting of an orthopaedic, vascular and plastic surgeons. The authors stress the need for an aggressive, timely and step wise approach for treatment of such injuries.

 
   References Top

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2.Bain GI. A review of complex trauma to the elbow. Aust N Z J Surg 1999;69:578-81.  Back to cited text no. 2
    
3.Simpson NS, Jupiter JB. Complex fracture patterns of the upper extremity. Clin Orthop Relat Res 1995;318:43-53.  Back to cited text no. 3
    
4.Lobenhoffer P, Tscherne H. Definition of complex trauma and general management principles. Orthopade 1997;26:1014-9.  Back to cited text no. 4
    
5.Regel G, Seekamp A, Blauth M, Klemme R, Kuhn K, Tscherne H. Complex injury of the elbow joint. Unfallchirurg 1996;99:92-9.  Back to cited text no. 5
    
6.Gustilo RB, Anderson JT. Prevention of infection in the treatment of one thousand and twenty-five open fractures of long bones: Retrospective and prospective analyses. J Bone Joint Surg Am 1976;58:453-8.  Back to cited text no. 6
    
7.Morrey BF, An KN, Chao EY. Functional evaluation of the elbow. In: Morrey BF, editor. The Elbow and Its Disorders. 2 nd ed. Philadelphia: W. B. Saunders; 1993. p. 86-9.  Back to cited text no. 7
    
8.Pierce RO Jr, Hodurski DF. Fractures of the humerus, radius and ulna in the same extremity. J Trauma 1979;19:182-5.  Back to cited text no. 8
    
9.Kazakos CJ, Galanis VG, Verettas DA, Dimitrakopoulou A, Polychronidis A, Simopoulos C. Unusual patterns of Monteggia fracture-dislocation. J Orthop Surg Res 2006;1:12.  Back to cited text no. 9
    
10.Hastings H 2 nd , Engles DR. Fixation of complex elbow fractures, Part I. General overview and distal humerus fractures. Hand Clin 1997;13:703-19.  Back to cited text no. 10
    
11.Pederson WC, Sanders WE. Bone and softtissue reconstruction. In: Rockwood CA Jr, Green DP, Bucholz RW, Heckman JD, editors. Rockwood and Green's Fractures in Adults. 4. Philadelphia: Lippincott-Raven; 1996. p. 387-8.  Back to cited text no. 11
    
12.Levin LS, Goldner RD, Urbaniak JR, Nunley JA, Hardaker WT Jr. Management of severe musculoskeletal injuries of the upper extremity. J Orthop Trauma 1990;4:432-40.  Back to cited text no. 12
    
13.Putnam MD, Walsh TM 4 th . External fixation for open fractures of the upper extremity. Hand Clin 1993;9:613-23.  Back to cited text no. 13
    
14.Smith DK, Cooney WP. External fixation of high-energy upper extremity injuries. J Orthop Trauma 1990;4:7-18.  Back to cited text no. 14
    
15.Wild JJ Jr, Hanson GW, Bennett JB, Tullos HS. External fixation use in the management of massive upper extremity trauma. Clin Orthop Relat Res 1982;164:172-6.  Back to cited text no. 15
    
16.McKee MD, Bowden SH, King GJ, Patterson SD, Jupiter JB, Bamberger HB, et al. Management of recurrent, complex instability of the elbow with a hinged external fixator. J Bone Joint Surg Br 1998;80:1031-6.  Back to cited text no. 16
    
17.Schmickal T, Wentzensen A. Treatment of complex elbow injuries by joint-spanning articulated fixator. Unfallchirurg 2000;103:191-6.  Back to cited text no. 17
    
18.Stevanovic M, Sharpe F, Itamura JM. Treatment of soft tissue problems about the elbow. Clin Orthop Relat Res 2000;370:127-37.  Back to cited text no. 18
    
19.Tscherne H, Regel G. Care of the polytraumatised patient. European Instructional Course Lectures EFFORT 1995;2:86-97.  Back to cited text no. 19
    
20.Seekamp A, Regel G, Blauth M, Klages U, Klemme R, Tscherne H. Long term results of therapy of open and closed fractures of the elbow joint. Unfallchirurg 1997;100:205-11.  Back to cited text no. 20
    
21.Solomon HB, Zadnik M, Eglseder WA. A review of outcomes in 18 patients with floating elbow. J Orthop Trauma 2003;17:563-70.  Back to cited text no. 21
    
22.Yokoyama K, Itoman M, Kobayashi A, Shindo M, Futami T. Functional outcomes of floating elbow injuries in adult patients. J Orthop Trauma 1998;12:284-90.  Back to cited text no. 22
    

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Correspondence Address:
Mrinal Sharma
Indraprastha Apollo Hospital, Sarita Vihar, New Delhi
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0019-5413.114923

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    Figures

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  [Table 1], [Table 2], [Table 3]

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