The Antiglide Plate for Distal Fibular Fixation

Thirty consecutive patients who had dis-location of the elbow without concomitant fracture andwho were sixteen years old or more were examined undergeneral anesthesia for stability of the joint at an averageof four days after the injury. All of the elbows showedmedial and sixteen showed both medial and lateral in-stabihity The patients were then randomly assigned toundergo either non-surgical or surgical treatment of thehigamentous injuries. All of the surgically treated elbowsshowed complete rupture or avulsion of both the medialand lateral collateral ligaments, and in about half ofthese patients the muscle origins were found to be tornfrom the humeral epicondyles.At follow-up, both groups showed generally goodresults; the differences were not statistically significant.There was no evidence that the results of surgical repairof the ligaments were any better than those of non-sur-gical treatment. In a previous study of acute dislocation of the elbowwithout concomitant fracture5, all of the elbows were foundto have a complete rupture of both the medial and the lateralcollateral ligaments and extensive damage to the anteriorcapsule. Injuries of varying degree were also found in themuscles surrounding the elbow. In the past, although mostauthors27-9’#{176}2 have recommended closed reduction fol-lowed by a short period of immobilization for patients whohave this injury,have recommended primary sur-gical repair of the ligaments.We conducted a randomized prospective study of pa-tients who had dislocation of the elbow that was treatedeither by primary surgical repair of the ligaments and im-mobilization in a cast or by closed reduction and immobi-lization in a cast. The purpose of the study was to attemptto determine if one form of treatment was superior to theother. * No benefits in any form have been received or will be received from a commercial party related directly or indirectly to the subject ofthis article.No funds were received in support of this study.1 Department of Orthopaedics. Malm#{246}General Hospital, 5-214 01Malmri, Sweden. Please address requests for reprints to Dr. Josefsson.Materials and Methods Thirty consecutive patients who had acute dislocationofthe elbow were included in this study. Only those patientswho were sixteen years old or older and whose injured elbowhad been free from symptoms before the injury were in-cluded. Patients who had a dislocation with a concomitantfracture, except for those with a small avulsed fragment.were excluded. The largest avulsed fragment that was ac-ceptable was two by three millimeters in size and was theonly one from the coronoid process.There were ten male and twenty female patients. Theaverage age at the time of injury in the surgical group was35 ± 13 years (range, sixteen to sixty-three years) and in the non-surgical group. 34 ± 18 years (range. sixteen toseventy years). Eighteen dislocations were of the left andtwelve, of the right elbow.Twenty-eight patients had a posterior or posterolateraldislocation and two, a lateral dislocation. Most of the pa-tients had fallen on a level surface and only three had fallenfrom an elevation. The circumstances of the accidents var-ied, but the largest group (nine patients) had been injuredwhile playing a sport.All of the dislocations were initially reduced in theemergency room, without anesthesia for most patients. andthe limb was then immobilized in a plaster cast. A roent-genographic examination was performed to confirm the re-duction in all patients. The patients were then examinedunder general anesthesia at an average of four days (range.one to seven days) after reduction in order to compare thestability of the reduced joint with that of the contralateralelbow. When the patients were tested with the elbow in fullbut unforced extension, all ofthe reduced elbows had medialligamentous instability and sixteen elbows, lateral ligamen-tous instability also. The lateral instability was generallyless severe but one of the elbows with lateral instabilityredislocated when lateral stress was applied. Eleven elbowscould be redislocated easily with the patient under generalanesthesia; this occurred most often when the elbow was inapproximately 45 degrees of flexion.For most patients roentgenograms of the injured elbowwere made after the examination under general anesthesia In the patients who had a dislocation that was treated /\Examined Not examined 14(living abroad)606P. 0. JOSEFSSON ET AL. THE JOURNAL OF BONE AND JOINT SURGERYFIG. 1-AFIG. 1-B Figs. I -A and I -B: Roentgenograms of the left elbow of an eighteen-year-old woman who had a posterior dislocation that was treated non-operattvel .Fig. 1-A: An increased joint space was seen on the roentgenogram that was made with the patient under anesthesia.Fig. I-B: At nine days postoperatively. the joint space had returned to normal. in order to confirm that the joint had remained reduced. Inthe non-surgically treated patients an increased width in thejoint space of the reduced elbow was often seen on the firstroentgenograrn (Fig. 1-A) that was made under anesthesia,but a roentgenograrn that was made a few days after theexamination under general anesthesia with the patient awakeand with tonus in the muscles invariably showed that thewidth of the joint space had returned to normal (Fig. 1-B).Surgical or non-surgical treatment of the elbow wasdetermined by random selection from a pool of thirty sealedenvelopes. Fifteen of the envelopes indicated surgical andfifteen indicated non-surgical treatment. In this manner, anequal number of patients were assigned to each treatmentgroup.surgically, both the medial and the lateral side of the jointwere explored by two separate lengthwise incisions. Themuscles originating from the epicondyles were found to beeither completely or partially avulsed, medially in twelvepatients and laterally in six patients. Both the medial andlateral collateral ligaments were found to be totally ruptured,although only eight elbows showed lateral instability. Themajor part ofthe ruptured ligament in each patient was foundto be localized to the humeral attachments. Six of the elevenelbows that were easily redislocated were treated surgically.Of these the muscles were found to be torn on the medialside in all and on the lateral side in four. The anterior capsuleand the brachialis muscle could only be partially inspectedthrough the lateral incisions, but extensive damage wasseen. Ligamentous and muscular injuries were sutured in