Simple Elbow Dislocations Research Articles

Unstable elbow dislocations: a case report of a new surgical technique.

This case report describes our first clinical experience of a previously described new surgical technique for the treatment of unstable simple elbow dislocations. The technique utilises a central strip of the distal triceps tendon which is harvested proximally at the musculotendonous junction and left attached at its insertion on the olecranon. The strip is the passed through the olecranon fossa and attached to the coronoid process to stabilise the joint. We encountered an early postoperative complication that led to a modification of our technique and ultimately an excellent recovery of a stable pain free joint with a full range of movement.

Initial joint stability affects the outcome after conservative treatment of simple elbow dislocations: a retrospective study.

BackgroundConservative treatment of simple elbow dislocations can lead to complications such as persisting pain and restricted joint mobility. The current aim was to identify patients with deteriorated outcome after conservative treatment and to investigate a possible association with initial joint (in)stability.MethodsSixty-eight patients (mean age 37.1 ± 17.2 years) with simple elbow dislocations received conservative treatment. After closed reduction, joint stability was tested by varus and valgus stress under fluoroscopy. According to the findings under fluoroscopy, three different groups of instability could be identified: (1) slight instability (joint angulation <10°; n = 49), (2) moderate instability (angulation ≥10°; n = 19) and (3) gross instability. Patients with gross instability (re-dislocation under stability testing) were treated with primary surgical ligament repair and therefore excluded from this study. Additionally, MRIs and radiographs were analysed regarding warning signs of instability such as the drop sign and joint incongruence. Main outcome parameters were the Mayo Elbow Performance Score (MEPS), range of motion (ROM), complications and revision rates.ResultsAfter 40.7 ± 20.4 months, the overall MEPS was excellent (94.2 ± 11.3) with a trend of slightly worse clinical results in group 2 (95.8 ± 9.0 vs. 90.0 ± 15.2 points; p = 0.154). In group 1, significantly more patients achieved an excellent result regarding the MEPS scoring system (77.6 vs. 52.6 %; p = 0.043) and elbow extension was significantly worse in group 2 (5.3 ± 9.9° vs. 1.4 ± 3.0°; p = 0.015). Seven treatment complications occurred in group 2 (36.8 %) compared with two in group 1 (4.1 %, p < 0.0001). Six patients (8.8 %) needed secondary surgery with an 8.4-fold higher risk for revision surgery in group 2 (p = 0.007). The presence of a positive drop sign or joint incongruence led to higher odds ratio (OR) for complications (OR = 15.9) and revision surgery (OR = 10.3).ConclusionsThis study demonstrates that patients with moderate joint instability after simple elbow dislocation have a significantly worse clinical outcome, more complications and a higher need for secondary revision surgery following conservative treatment compared to patients with slight elbow instability.

Early mobilisation versus plaster immobilisation of simple elbow dislocations: results of the FuncSiE multicentre randomised clinical trial

Background/aimTo compare outcome of early mobilisation and plaster immobilisation in patients with a simple elbow dislocation. We hypothesised that early mobilisation would result in earlier functional recovery.MethodsFrom August 2009 to...

Old Unreduced Elbow Fracture and Fracture Dislocation: Treatment With Open Reduction and Hinge External Fixation

Background: Old unreduced elbow dislocation and fracture-dislocation, although rare, are one of the challenges in orthopedic surgery. The application of the hinged elbow external fixator can confer early range of motion after open reduction and reconstruction in spite of severe soft tissue and bony injury. Objectives: This study presents our results of open reduction and reconstruction in old simple elbow dislocation and old elbow fracturedislocation. Patients and Methods: In 12 patients with old elbow dislocation, open reduction and bone and soft tissue reconstruction was done and early postoperative range of motion was begun with the aid of hinged elbow external fixators. Results: The mean elbow range of motion at the final follow-up was 98 degrees (SD = 10). According to the Mayo Elbow Performance Index score, 6 patients achieved excellent results and 2 other had good results with a mean value of 92 (SD = 8). Conclusions: We recommend hinged elbow external fixation in old elbow dislocation for early range of motion and maintenance of concentric reduction with acceptable results.

The treatment of simple elbow dislocation in adults.

Simple elbow dislocation is a complex soft-tissue injury that can cause permanent symptoms. Its incidence is 5 to 6 cases per 100 000 persons per year. Its proper treatment is debated; options range from immobilization in a cast to surgical intervention. We systematically reviewed the literature on the treatment of simple elbow dislocation and performed a meta-analysis, primarily on the basis of clinical scores and secondarily with respect to pain, range of motion, and return to work. A randomized controlled trial (RCT) showed that clinical results at short-term follow-up were superior for early functional treatment compared to immobilization in a cast. Brief immobilization, however, reduced pain initially, and the long-term results of early mobilization and immobilization in a cast were the same. Our meta-analysis showed that early mobilization enables patients to return to work earlier (difference of mean values -2.91, 95% confidence interval [CI] -3.18 to -2.64), and that the extent of soft-tissue injury is correlated with the clinical outcome (inverse relationship; difference of mean values -12.07, 95% CI -23.88 to -0.26). Surgical and conservative treatment were compared in a single RCT, which revealed no significant difference in outcomes. A meta-analysis of two retrospective comparative studies showed no advantage of immediate ligament repair over delayed surgery. Early functional treatment is the evidence-based therapeutic standard for simple elbow dislocation. The past few years have seen further developments in surgery for simple elbow dislocation. Further study is needed to determine whether surgery for elbow dislocation with high-grade instability can prevent persistent pain, limitation of motion, and chronic instability.

The frequency and risk factors for subsequent surgery after a simple elbow dislocation

IntroductionSimple elbow dislocations treated by closed reduction are thought to result in a satisfactory return of function in most patients. Little, however, is known about how many patients ultimately proceed to subsequent surgical treatment due to the low patient numbers and significant loss to follow-up in the current literature. The purpose of this study was to establish the rate of and risk factors for subsequent surgical treatment after closed reduction of a simple elbow dislocation at a population level. Patients and methodsAll patients aged 16 years or older who underwent closed reduction of a simple elbow dislocation between 1994 and 2010 were identified using a population database. Subsequent procedures performed for joint contractures, instability or arthritis were recorded. Outcomes were modelled as a function of age, sex, income quintile, co-morbidity, urban/rural status, physician speciality performing the initial reduction and whether orthopaedic consultation and/or post-reduction radiograph was performed within 28 days of the injury, in a time-to-event analysis. ResultsWe identified 4878 elbow dislocations with a minimum 2-year follow-up: stabilisation surgery was performed in 112 (2.3%) at a median time of 1 month, contracture release in 59 (1.2%) at median 9 months and arthroplasty in seven (0.1%) at median 25 months. Admission to hospital for the initial reduction was associated with an increased risk of undergoing stabilisation (hazard ratio (HR), 2.50; 95% confidence interval (CI), 1.67–3.74) and contracture release (HR, 1.93; CI, 1.08–3.44). Multiple reduction attempts increased the risk of requiring contracture release (HR, 3.71; CI, 1.22–11.29). Survival analysis demonstrated that all subsequent procedures had taken place by 4–5 years. ConclusionFew patients with simple elbow dislocations develop complications requiring surgery, but those that do most commonly undergo soft-tissue stabilisation or contracture release within 4 years of the injury. Contrary to current thinking, surgery for instability is performed more often than joint contracture release, albeit with slightly different time patterns.

Conservative Management of Elbow Dislocations With an Overhead Motion Protocol

To report the results of using an overhead motion protocol in 27 patients and to assess final range of motion and incidence of persistent instability in this cohort. A total of 27 patients were included who sustained a simple elbow dislocation and were treated nonsurgically with an overhead motion protocol designed to convert gravity from a distracting to a stabilizing force. Motion was initiated within 1 week of injury and average follow-up was 29 months. Final arc of motion and prevalence of instability were the primary outcomes measures. Final mean arc of extension to flexion was from 6° to 137°, and of pronation to supination was from 87° to 86°. No recurrent instability was observed in this cohort and all patients were fully functional and without limitations at latest follow-up. The overhead motion protocol was a reliable rehabilitation program after elbow dislocation that allowed for controlled early motion by placing the elbow in an inherently stable position. Prompt initiation of motion in a protected position can optimize final motion and satisfaction outcomes, and when done in a mechanically advantageous position it can potentially limit the risk of recurrent instability. Therapeutic IV.

Cost analysis and outcomes of simple elbow dislocations.

To evaluate the management, clinical outcome and cost implications of three different treatment regimes for simple elbow dislocations. Following institutional board approval, we performed a retrospective review of all consecutive patients treated for simple elbow dislocations in a Level I trauma centre between January 2008 and December 2010. Based on the length of elbow immobilisation (LOI), patients were divided in three groups (Group I, < 2 wk; Group II, 2-3 wk; and Group III, > 3 wk). Outcome was considered satisfactory when a patient could achieve a pain-free range of motion ≥ 100° (from 30° to 130°). The associated direct medical costs for the treatment of each patient were then calculated and analysed. We identified 80 patients who met the inclusion criteria. Due to loss to follow up, 13 patients were excluded from further analysis, leaving 67 patients for the final analysis. The mean LOI was 14 d (median 15 d; range 3-43 d) with a mean duration of hospital engagement of 67 d (median 57 d; range 10-351 d). Group III (prolonged immobilisation) had a statistically significant worse outcome in comparison to Group I and II (P = 0.04 and P = 0.01 respectively); however, there was no significant difference in the outcome between groups I and II (P = 0.30). No statistically significant difference in the direct medical costs between the groups was identified. The length of elbow immobilization doesn't influence the medical cost; however immobilisation longer than three weeks is associated with persistent stiffness and a less satisfactory clinical outcome.

Unstable elbow dislocations: the description and cadaveric feasibility study of a new surgical technique.

Introduction: A small proportion of simple elbow dislocations are grossly unstable and joint congruence is not maintained after reduction. In this rare situation operative treatment is indicated. We describe a new intra articular reconstruction that utilises a slip of triceps tendon to provide immediate stability to the elbow. Methods: We assessed 20 cadaveric elbows, measuring the length of triceps tendon available and required to complete the reconstruction. We then sequentially sectioned the ligamentous stabilisers of an elbow before performing the new technique. We measured the displacement and angulation possible at the elbow before and after the reconstruction. Results: All 20 elbows had sufficient triceps tendon length to complete the new technique. Prior to the reconstruction greater than 30 mm of joint distraction and 90 degrees varus or valgus angulation was possible. Following the reconstruction it was not possible to re-dislocate the elbow. Only 2 mm of joint distraction and 10 degrees of varus or valgus angulation were possible with the triceps graft fixed in position. Discussion: This novel technique elegantly avoids many of the problems associated with current methods. We have demonstrated that it is technically feasible and easy to perform with minimal equipment requirements or costs.

FuncSiE Trial: EM of Elbow Dislocation Brings Faster Functional Recovery

The Functional Treatment Versus Plaster for Simple Elbow Dislocations trial [FuncSiE; NTR2025] found that early mobilization vs plaster immobilization resulted in earlier recovery of function and return to work, without any redislocations or persistent instability, as discussed in this article.

The epidemiology of closed reduction for simple elbow dislocations and the incidence of early subsequent open reduction

Simple elbow dislocations are often treated with closed reduction (CR); however, the rate of CR failure and factors that may predict failure have been largely underinvestigated. The objectives of this study were (1) to determine the incidence of elbow dislocations treated by CR in a universal health care system and (2) to identify patient characteristics associated with failed CR, defined as the subsequent need for open reduction. Patients ≥16 years old who underwent elbow CR by a physician between 1994 and 2010 were identified from administrative databases. Concurrent elbow fractures were excluded. The incidence density rate (IDR) of CR per 100,000 eligible person-years among the general population was calculated. Failed CR was defined as subsequent open reduction with or without ligament repair or reconstruction within 90days. Patient and provider characteristics were modeled in a multivariate logistic regression for failure. The cohort consisted of 4878 patients (median age, 41years) who underwent CR (IDR, 2.65 per 100,000 person-years), and 75 (1.5%) underwent subsequent open reduction with or without ligament repair or reconstruction (median time, 15days). Young men (≤20years) had the highest IDR (7.45 per 100,000 person-years), twice that of young women (P=.005). Patient characteristics associated with failed CR included older age (P=.001), admission to the hospital (P<.0001), >1 attempted CR (P=.001), and new orthopedic consultation in the 4 weeks after the CR (P=.02). Young men are at highest risk for CR for simple elbow dislocations; however, older patients are more likely to require open intervention, as are those with markers of a difficult reduction signifying potentially greater soft tissue damage. A comprehensive understanding of the epidemiology of simple elbow dislocation will aid management decisions.

Arthroscopic and open management of posterolateral rotatory instability of the elbow.

Posterolateral rotatory instability (PLRI) is the most common cause of residual instability following a simple elbow dislocation. PLRI may result from trauma or iatrogenic injury to the radial ulnohumeral ligament during treatment for other conditions, such as lateral epicondylitis. PLRI can be identified through a combination of history and physical examination, and confirmed with magnetic resonance imaging arthrography. Once diagnosed, surgery is necessary to correct persistent instability. Instability can be confirmed arthroscopically through several findings, including subluxation of the radial head on the capitellum and the arthroscopic "drive through sign of the elbow." Acute repairs, both open and arthroscopic, heal with excellent patient outcomes. In the chronic setting, graft reconstruction may be required. This report describes arthroscopic repair of the radial ulnohumeral ligament and open reconstruction with associated outcomes. A high index of suspicion is necessary to correctly diagnosis this condition in patients with lateral elbow pain and feelings of instability.

Children’s Orthopaedics

The August 2014 Children’s orthopaedics Roundup360 looks at: Conservative treatment still OK in paediatric clavicular fractures; Femoral anteversion not the usual suspect in patellar inversion; Shoulder dislocation best treated with an operation; Perthes’ disease results in poorer quality of adult life; Physiotherapy little benefit in supracondylar fractures; Congenital vertical talus addressed at the midtarsal joint; Single-sitting DDH surgery worth the effort; and cubitus valgus associated with simple elbow dislocation

A Preliminary Report of Acute and Subacute Arthroscopic Repair of the Radial Ulnohumeral Ligament After Elbow Dislocation in the High-Demand Patient

The purpose of this study was to evaluate functional outcomes, range of motion (ROM), elbow stability, and time to return to full activities after acute and subacute arthroscopic repair of a simple elbow dislocation in high-demand patients. "High-demand patients" were defined as in-season athletes and individuals who required use of both hands for their profession and believed that they could not miss the 6 weeks of work that may be required with conservative treatment in an elbow brace. We retrospectively reviewed 14 consecutive patients with a simple elbow dislocation who underwent arthroscopic repair of the radial ulnohumeral ligament from 2008-2012. Outcomes measures included the Mayo Elbow Performance Score (MEPS), elbow ROM, elbow stability, and time to return to full activities. Each patient was contacted once by telephone to determine the current activity level and presence of any pain or functional limitations. The mean patient age was 25 years, with telephone follow-up at a mean of 30 months and clinical examination after a minimum of 6 months. The postoperative MEPS was excellent (mean, 99.6; range, 95 to 100) for all 14 patients, and all returned to their preinjury level of function with no restrictions or instability. Final ROM averaged -3° of full extension to greater than 130° of flexion. The mean time to return to full activities in and out of a brace was 2.7 weeks and 6.6 weeks, respectively, in the acute group and 4.6 weeks and 8.9 weeks, respectively, in the subacute group. All patients were satisfied with their outcome. Conservative management remains the gold standard for most simple elbow dislocations. We believe that certain high-demand patients may be candidates for acute arthroscopic ligamentous repair. Our preliminary data show that acute arthroscopic repair of the radial ulnohumeral ligament is a safe, effective procedure that restores stability to the elbow and allows patients to quickly return to full activities. Level IV, therapeutic case series.

Complications of Hinged External Fixation Compared With Cross-pinning of the Elbow for Acute and Subacute Instability

Elbows that are unstable after injury or reconstructive surgery often are stabilized using external fixation or cross-pinning of the joint supplemented by cast immobilization. The superiority of one approach or the other remains a matter of debate. We compared patients treated with external fixation or cross-pinning in terms of (1) adverse events, (2) Broberg and Morrey scores, and (3) ROM. Between 1998 and 2010, 19 patients (19 elbows) had hinged external fixation and 10 patients (11 elbows) cross-pinning and casting for subacute or acute posttraumatic elbow instability. Our general indications for both techniques were persistent elbow instability after usual treatment. Initially, we used external fixation for delayed treatment of fracture-dislocations and cross-pinning for simple elbow dislocations in patients who could not tolerate surgery, but more recently we have used cross-pinning for both indications. Adverse events, elbow scores, and ROM were retrospectively evaluated by chart review, with the latter two end points being calculated at a mean of 31 months (range, 5-83 months) and 10 months (range, 5-21 months) after index procedure for the patients treated with external fixation and cross-pinning, respectively. Seven of 19 patients treated with external fixation experienced nine device-related adverse events: three pin tract infections, two nerve problems, one broken pin, one residual subluxation, one suture abscess, and one pin tract fracture of the ulna resulting in a nonunion. Of the 10 patients (11 elbows) treated with cross-pinning, one patient had pin tract inflammation that resolved with pin removal. Mean Broberg and Morrey score was 90 (95% CI, 84-95) after external fixation and 90 (95% CI, 84-96) after cross-pinning (p = 0.88). There were no differences between the external fixation and cross-pinning groups in mean flexion (123° versus 128°, p = 0.49), extension (29° versus 29°, p = 0.97), forearm pronation (68° versus 74°, p = 0.56), and forearm supination (47° versus 68°, p = 0.15). When the elbow remains unstable after reduction and usual treatment for fractures and dislocations or has been out of place for more than 2 weeks, both cross-pinning and external fixation can help maintain elbow alignment while structures heal. Hinged external fixation is associated with more adverse events related to the device, but Broberg and Morrey score and ROM are similar between techniques. Level III, therapeutic study. See Instructions for Authors for a complete description of levels of evidence.

Comparative Study of Simple and Complex Open Elbow Dislocations

Open elbow dislocations are rare injuries. Most of the evidence related to these dislocations is found in case reports or in series with closed injuries. We reviewed the experiences of three centers in the treatment of open elbow dislocations. We compared the results after operative treatment of simple and complex open dislocations in terms of (1) ROM, (2) functional score, and (3) complications. Eighteen patients were retrospectively included in this study: 11 with simple open elbow dislocations and seven with complex open elbow dislocations. Mean age was 40 years. Thirteen were men. Eight patients presented neurovascular injuries. Evaluation included ROM of the elbow and forearm as measured by hand-held goniometer. We then classified the results using the 100-point Broberg and Morrey functional rating index based on ROM, grip strength, elbow stability, and pain. Scores of 95 to 100 were considered excellent, 80 to 94 good, 60 to 79 fair, and less than 60 poor. Complications were recorded. Minimum followup was 6 months (mean, 25 months; range, 6-72 months). We found no differences between simple and complex open elbow dislocations related to ROM (median flexion/extension: 117° versus 110°, p = 0.12; forearm rotation: 160° versus 170°, p = 0.67). According to the Broberg and Morrey score, four patients had excellent results, five good, and one fair in the simple dislocation group, whereas in the complex dislocation group, four patients had excellent results, two good, and one fair (p = 0.8). No difference in complication rate was found between groups (p = 0.63). All complications in the simple dislocation group were neurovascular. In the complex dislocation group, there was one case of brachial artery occlusion, two cases of heterotopic ossification, one case of infection and nonunion, and one case of infection. No patients had recurrent elbow instability. No differences between simple and complex open elbow dislocations were found in terms of ROM, functional results, and rate of complications. Complications in the simple dislocation group were related to neurovascular injuries in contrast to the complex dislocation group where complications were associated with the bony injury. Level IV, prognostic study. See Instructions for Authors for a complete description of levels of evidence.

The role of simple elbow dislocations in cubitus valgus development in children

We investigated the functional and radiological outcomes of conservatively treated simple traumatic elbow dislocations and subsequent incidence of cubitus valgus development in children. Eleven patients (one female, ten male; mean age 9.8 years, range seven to 12 years) who presented to our hospital with simple elbow dislocations and were conservatively treated between July 2008 and September 2010 were included in the study. All were posterolateral closed dislocations. None of the patients had accompanying elbow fractures. All patients had pre- and postoperative radiographic examinations. The carrying angle of the involved elbow was measured and compared to the contralateral non-injured elbow during follow-up. The incidence and severity of cubitus valgus development was assessed. The functional and clinical outcomes were evaluated using the Mayo Elbow Performance Scale. The mean monitoring period was 24.3 months (range 19-30 months). All patients had satisfactory good and excellent results (85-100 points; mean 96.8 points) according to the Mayo Elbow Performance Scale. The final average elbow flexion was 137° (range, 130-145°) and average extension was 8.6° (range 0-20°) with full supination and pronation in traumatic elbow. Four patients (36.4%) had an average increase (cubitus valgus) of 14.5° (10-20°) in carrying angle compared to the other elbow. While isolated traumatic dislocation of the elbow is uncommon among children, it can be successfully treated by urgent closed reduction, proper fixation of the elbow and appropriate timely rehabilitation. However, it should be considered that some patients may develop cubitus valgus deformity in a later period. Therefore, each patient with a simple traumatic elbow dislocation should be followed, and the parents should be informed of the potential for any deformity development.

Simple Medial Elbow Dislocations: A Rare Injury at Risk for Early Instability

To report the presentation, treatment, and outcomes of a series of simple medial elbow dislocations and to identify features distinguishing this injury from the more common dislocation patterns. From 2000 to 2011, 4 cases of simple medial elbow dislocations were treated at a single referral center. Retrospective review was conducted to evaluate presentation, treatment, and outcomes. The mean patient age was 56 years (range, 49-61 y). All dislocations were in the nondominant arm of women after a fall from standing height. Two elbows had immediate closed reduction, and 2 elbows could not be reduced acutely. All elbows presented within 2.5 weeks of injury with recurrent instability or dislocation. Two patients also had acute symptoms of ulnar neuropathy. All patients had surgical repair of the lateral collateral ligament complex and extensor tendon origin. Three patients had ulnar nerve decompressions. All elbows were stable to valgus, varus, and rotatory stress testing, with no subjective instability at a minimum follow-up of 8 months (range, 8-144 mo). Three patients reported no pain. Symptoms of ulnar neuropathy resolved in all patients. Mean elbow range of motion was from 13° to 135° of extension/flexion, with full pronation and supination. Simple medial elbow dislocations may be at risk for early instability and may represent a more noteworthy soft tissue injury than typical dislocation patterns. Surgical treatment of early instability in these injuries led to acceptable patient outcomes.

Ellenbogenluxationsverletzungen beim Trendsport Bouldern

Bouldering is a new trend sport which has become popular in recent years. From April 2011 to June 2012 a total of 5 patients with elbow dislocations from bouldering were admitted to our level 1 trauma center. The injuries varied from simple elbow dislocations to complex fracture dislocations. Elbow dislocations occurred during falling backwards when patients tried to protect themselves by retroversion of both arms. In all cases the falling height was less than 4 meters. The bouldering injury pattern, the diagnostic and therapeutic management as well as the rehabilitation program are described in detail in this article. To the best of our knowledge this is the first report on the special danger of bouldering for complex elbow injuries.

Elbow Dislocations: A Review Ranging from Soft Tissue Injuries to Complex Elbow Fracture Dislocations

This review on elbow dislocations describes ligament and bone injuries as well as the typical injury mechanisms and the main classifications of elbow dislocations. Current treatment concepts of simple, that is, stable, or complex unstable elbow dislocations are outlined by means of case reports. Special emphasis is put on injuries to the medial ulnar collateral ligament (MUCL) and on posttraumatic elbow stiffness.