Effectiveness of the lateral unilateral dynamic external fixator after elbow ligament injury

Background: The optimum management of ligamentous injuries of the elbow is not known. Use of dynamic external fixators has been advocated to stabilize the joint while maintaining motion, but there are no published data to corroborate their efficacy. The purpose of this study was to test the hypothesis that a laterally applied unilateral dynamic external fixator is capable of stabilizing and restoring normal kinematics to elbows with varying degrees of soft-tissue injury. Methods: Six fresh-frozen cadaveric upper extremities, from donors who were an average of seventy-six years of age at the time of death, were tested in a custom apparatus with an electromagnetic tracking device to analyze the kinematic behavior. Testing began with an injury of either the lateral or the medial collateral ligament, which was followed by a second test with an injury to the ligament on the contralateral side of the joint. In each test, the varus-valgus displacement and the forearm rotatory displacement were measured through the arc of elbow flexion under three loading conditions (hand weight alone, hand weight plus 3.5 N, and hand weight plus 7 N). After each test (with each injury), a unilateral external fixator was applied from the lateral aspect of the elbow, and the same measurements were conducted under the three loading conditions across the elbow joint. Results: With varus stress testing, both after injury of the medial collateral ligament alone and after injury of the lateral collateral ligament and extensor mass alone, the laterally applied unilateral dynamic external fixator was capable of maintaining the displacements within the laxity envelope of an uninjured elbow. With valgus stress testing, after either lateral or medial ligamentous injury, the fixator was unable to maintain displacements within the normal laxity envelope when a 7-N load was applied to the elbow. When both medial and lateral injuries were present, the lateral fixator maintained varus displacement within normal limits, but valgus displacement was consistently maintained within normal limits only when no additional load was applied to the forearm. Conclusions: A lateral dynamic elbow external fixator is capable of maintaining varus displacements within normal limits in the presence of medial and lateral collateral ligament injuries and with a 7-N load added to the limb. However, valgus displacement is only consistently maintained within normal limits if no additional displacement force is added to the weight of the hand and forearm. The maintenance of valgus displacement is more sensitive to additional load and specifically to the extent of medial soft-tissue injury. Clinical Relevance: The use of external fixation of the elbow is growing in popularity. Yet, there is virtually no information with regard to the adequacy of various constructs in the context of specific pathological conditions. We demonstrated that a limited spectrum of soft-tissue injuries about the elbow can be adequately managed with a laterally applied half-pin fixator.