Interventions for treating acute elbow dislocations in adults

Patient satisfaction, joint stability and return to sports following simple elbow dislocations: surgical versus non-surgical treatment

PURPOSE

While conservative management is commonly promoted for simple elbow dislocations, the importance of primary surgical treatment in these injuries is still undetermined. The objective of this study was to report patient-reported outcome measures (PROMs), return to sports (RTS) and joint stability using ultrasound in patients following conservative or surgical treatment after simple elbow dislocation.

METHODS

Patients with a minimum follow-up of 24 months after conservative (CT) or surgical treatment (ST) following simple elbow dislocation were included in this retrospective study. To evaluate patients' postoperative outcome and satisfaction, the Elbow Self-Assessment Score (ESAS) was used, and validated scores such as the Mayo elbow performance score (MEPS), the Quick Disability of Arm and Shoulder Score (Quick-DASH) and RTS were assessed. For objective assessment of residual joint instability, a standardized clinical examination as well as a dynamic ultrasound evaluation of the affected and the contralateral elbow was performed.

RESULTS

Forty-four patients (26 women, 18 men) with an average age of 41.5 ± 15.3 years were available for follow-up survey (65.5 ± 30.4 months; range 26-123). 21 patients were treated conservatively and twenty-three patients received surgical treatment. CT and ST resulted in similar outcome with regard to ROM, ESAS (CT: 99.4 ± 1.5; ST: 99.8 ± 0.3), MEPS (CT: 97.3 ± 6.8 points; ST: 98.7 ± 3.3) and Quick-DASH (CT: 7.8 ± 10.4; ST: 6.3 ± 7.9) (n.s.). There was no difference in elbow stability and laxity measured by ultrasound between the study groups and compared to the healthy elbow (n.s.). Two patients of the CT group (10%) complained about persistent subjective elbow instability. RTS was faster after surgical compared to conservative treatment (p = 0.036).

CONCLUSION

Both, conservative and surgical treatment results in high patient satisfaction and good-to-excellent functional outcome after simple elbow dislocation. Even though ultrasound evaluation showed no significant differences in joint gapping between groups, 10% of conservatively treated patients complained about severe subjective instability. Surgically treated patients returned faster to their preoperatively performed sports. Thus, primary surgical treatment may be beneficial for high demanding patients.

LEVEL OF EVIDENCE

Therapeutic study, Level III.

Distal Radius Fracture with Ipsilateral Elbow Dislocation: A Rare but Challenging Injury

Distal radius fractures are common and account for approximately 14% to 18% of all adult extremity injuries. On rare occasions, ipsilateral elbow dislocation can be observed additionally. However, this can be missed without careful examination, especially in patients experiencing altered mental status. The aim of this study was to analyze the mechanism, level of injury, demographics, and associated injuries in distal radius fracture with ipsilateral elbow dislocation. Between 2012 and 2019, we searched our trauma database for distal radius fracture with ipsilateral elbow dislocation. All patients older than 18 years old were included. Data on demographics, mechanism of injury, level of energy, and subsequent treatment were collected. A total of seven patients were identified. The mean age in this cohort was 68.7 ± 13.3 years old, and the left side was involved in 71.4% of the patients. Females were affected in 85.7% (n = 6/7) of cases, all of whom suffered from low-energy monotrauma at a mean age of 71.5 ± 12.3 years old. One male patient suffered from high-energy trauma (52 years old). Mainly, posterior elbow dislocations were observed (66.7%; n = 4/6). Distal radius fracture patterns, in accordance with the AO classification, included two C2-, two C3-, one C1-, and one B1-type fractures. In the patient suffering from high-energy trauma, the closed distal radius fracture was classified as type C3. Associated injures included open elbow dislocation, ulnar artery rupture, and damage to the flexor digitorum superficialis. Although distal radius fracture with ipsilateral elbow dislocation is thought to be from high-energy trauma, this study shows that most patients were elderly females suffering from low-energy mechanisms. It is important for clinicians to maintain a high level of suspicion for any concomitant injury in this population.

Investigating the Effects of Physical Therapy Timing, Intensity and Duration on Post-Traumatic Joint Contracture in a Rat Elbow Model

BACKGROUND

Post-traumatic joint contracture (PTJC), characterized by loss of motion and permanent stiffness, affects up to 50% of patients following elbow joint dislocation or fracture. Mechanisms governing successful conservative treatment methods aimed at preventing elbow PTJC and avoiding operative treatments (e.g., physical therapy) are poorly understood. Using a previously established rat model of elbow PTJC, the purpose of this study was to explore the effect of varying timing, intensity and duration of active, functional exercise on joint motion outcomes.

METHODS

Following a surgically-induced unilateral elbow dislocation in rats, injured limbs were immobilized in bandages for 42 days followed by free mobilization for 42 additional days producing long-term PTJC. This work summarizes several studies (Phases I-III) that investigated the effects of early versus delayed therapy (timing), free mobilization versus forced treadmill walking (intensity), and limited-time versus unlimited use (duration) on elbow PTJC.

RESULTS

Joint motion outcomes in therapy groups showed no improvements compared to non-treated injured animals when therapy began day 14 post-injury or later regardless of timing, intensity or duration. Improved joint range-of-motion was only achieved when bandages were permanently removed at day 3 post-injury, regardless of whether added treadmill walking was performed.

CONCLUSION

Early motion is essential to preserving range-of-motion following traumatic elbow injury in a rat model.

Injury of the brachial artery accompanying simple closed elbow dislocation: a case report

Background:

Elbow dislocation is the second common dislocation in adults, after the shoulder. The anatomical proximity to the joint of the brachial artery could lead to concomitant vascular injuries, even if their occurrence remains very rare.

Method:

It is reported the case of a right-hand-dominant 42-year-old man who sustained a simple closed posterior elbow dislocation of his left elbow, associated to a complete brachial artery rupture. He urgently underwent the reduction of the joint dislocation and an artery-repairing surgical procedure using a graft from ipsilateral saphenous vein.

Results:

The full functional capacity of the elbow was obtained.

Conclusions:

The abundance of the brachial artery collateral network may hide the presence of a vascular injury, potentially associated to a closed elbow dislocation. Therefore, a high index of suspicious should be maintained. The Emergency Team plays a crucial role in its early diagnosis, which is essential to avoid irreversible ischemia related damages. A prompt reduction of the joint dislocation and the vascular injury surgical repair are required. Regarding the treatment of the concomitant collateral ligaments and capsular injuries, the indication to proceed to the simultaneous ligaments reconstruction is still controversial in literature.

Risk Factors for the Occurrence and Progression of Posttraumatic Elbow Stiffness: A Case-Control Study of 688 Cases

Background: Elbow stiffness is a severe complication after trauma. Surgical or conservative treatments may be ineffective for restoring functional elbow motion. We aim to evaluate intrinsic and extrinsic factors for the occurrence and severity of elbow stiffness.

Methods: This retrospective case–control study included mild/moderate stiffness, severe stiffness, and non-stiffness groups between January 2011 and December 2017 at a single orthopedic center. Multivariable logistic regression analysis and subgroup analysis were used to evaluate age, gender, body mass index, muscle strength, fracture type and site, injury mechanism, immobilization time, elbow dysfunction time, multiple surgeries, nerve symptoms, physical therapy, smoking and alcohol abuse, and dominant hand of stiff elbow as potential risk factors for the occurrence and severity of elbow stiffness.

Results: There were 461 patients in the stiffness group and 227 patients in the non-stiffness group. The odds ratios (ORs) of the age, muscle strength, and injury mechanism were 0.960, 0.333, and 0.216 for the occurrence of elbow stiffness. In subgroup evaluation, increased cast immobilization time might be a risk factor for patients receiving conservative therapies (OR = 2.02; p = 0.014). In the evaluation on factors for progression of elbow stiffness, “multiple surgeries” might be a risk factor in surgical treatment by subgroup analysis (OR = 1.943; p = 0.026). Nevertheless, alcohol abuse might increase severity of elbow stiffness in conservatively treated patients (OR = 3.082; p = 0.025).

Conclusion: Increased cast immobilization time in the conservative therapy might be a risk factor for stiffness occurrence. Multiple surgeries might be risk factors for stiffness progression. Alcohol abuse potentially increased stiffness severity after conservative treatment.

Epidemiology and treatment of acute elbow dislocations: current concept based on primary surgical ligament repair of unstable simple elbow dislocations

Purpose

Acute elbow dislocations are complex injuries that predispose to chronic instability and pain. The ideal treatment strategy is part of controversial discussion and evidence-based recommendations for the treatment could not be concluded from the literature. The purpose of the present study was to assess current epidemiological data, injury pattern, and the changing trend for treatment.

Methods

This study presents a retrospective review of 72 patients ≥ 18 years of age who were treated in our level I trauma centre with acute elbow dislocations from 2014 to 2018. The data were acquired by analysis of the institution’s database, and radiological examinations.

Results

The average age of the patients was 48.5 years (range 18–86). The ratio of male to female patients was 1.9:1. A fall onto the outstretched arm (42%) was the most common injury mechanism. By classification, 42% of the elbow dislocations were simple, and 58% complex. A total of 85% of patients underwent surgery including 73% of the simple elbow dislocations due to remaining instability or non-congruency of the reduced elbow. The indication for surgical treatment correlated merely with the grade of instability and displacement, but not with age.

Conclusion

Acute elbow dislocations need identification of the precise injury pattern and instability after reduction of the elbow joint. To achieve a congruent and stable joint, we recommend primary surgical repair as first-line treatment for patients with unstable simple and complex elbow dislocation independent of age.

Ipsilateral simultaneous inferior shoulder dislocation and posterior elbow dislocation: A case report

This case report presents a 21-year-old male construction worker with ipsilateral inferior shoulder and posterior elbow dislocations, accompanied with other injuries. Such a combination of injury undoubtedly occurs; however, to the best of our knowledge, this is the first reported case. The prompt closed reductions without waiting for anesthesia were accomplished without the help of an assistant using a novel technique. The patient returned to his job with considerable recovery of motion and strength despite his permanent paralysis of the deltoid muscle and he was still employed as a worker after four years. He was abducting his arm by using his accessory muscles, which contribute to abduction when arm is externally rotated. The maneuver described in the report can be used to reduce all inferior shoulder dislocations and it is worth to know that working at a job requiring high level of activity is still possible despite a permanent loss of axillary nerve function.

Reattachment of the flexor and extensor tendons at the epicondyle in elbow instability: a biomechanical comparison of techniques

Background

Elbow dislocation represents a common injury, especially in the younger population. If treated surgically, the reattached tendons require a high amount of primary stability to allow for an early rehabilitation to avoid postoperative stiffness. The purpose of this study was to assess the biomechanical properties of a single and a double row technique for reattachment of the common extensor and common flexor muscles origin. We hypothesized that the double row technique would provide greater stability in terms of pullout forces than the single row technique.

Methods

Twelve cadaveric specimens were randomized into two groups of fixation methods for the common extensor tendon or the common flexor tendon at the elbow (1): a single row technique using two knotted 3.0 mm suture anchors, and (2) a double row technique using an additional knotless 3.5 mm anchor. The repairs were cyclically loaded over 500 cycles at 1 Hz from 10 N to a maximum of 100 N (extensors) or 150 N (flexors), and then pulled to failure. Stiffness and maximum load at failure and mode of failure were recorded and calculated.

Results

No significant differences in stiffness were observed between the two techniques for both the extensor and flexor reattachment (P = 0.701 and P = 0.306, respectively). The mean maximum load at failure indicated that the double row construct was significantly stronger than the single row construct. This was found to be true for both the extensor and flexor reattachment (213.6; SD 78.7 N versus 384.1; SD 105.6 N, P = 0.010 and 203.7; SD 65.8 N versus 318.0; SD 64.6 N, P = 0.013, respectively).

Conclusions

The double row technique provides significant greater stability to the reattached common flexor or extensor origin to the medial or lateral epicondyle. Thus, it should be considered in the development of improved repair techniques for stabilizers of the elbow.

Study design

Controlled laboratory study.

The Assessment and Management of Simple Elbow Dislocations

Background:

Simple elbow dislocations are a commonly seen joint dislocation involving a sequential disruption of the soft tissue stabilisers without a significant associated fracture.

Methods:

A selective literature search was performed and personal surgical experiences are reported.

Results:

The majority of these injuries can be treated with expedient closed reduction, with the intact bony congruency of the elbow joint conferring early stability. Early mobilisation after reduction results in a faster recovery with good functional outcomes. Surgical intervention for persistent instability or stiffness is uncommonly required. Although, early surgical ligamentous repair has been considered, the current evidence does not demonstrate any long-term benefits compared to non-operative treatment.

Conclusion:

The majority of simple elbow dislocations can be successfully managed non-operatively with good reliable outcomes. Careful follow up is essential, however, to identify patients that may occasionally develop persistent instability or stiffness and require intervention.

Extensive soft tissue lesions in redislocated after simple elbow dislocations

BACKGROUND

The majority of simple elbow dislocations (no associated fractures) can be treated nonoperatively with a short period of immobilization followed by guided aftercare. This case series describes the soft tissue injuries in a rare subset of patients in whom the elbow redislocated despite adequate immobilization.

METHODS

During a 6-year period, 8 patients were identified. They were all treated with reduction and casting in 90° of flexion or more. At 1 week of follow-up, redislocation had occurred in all patients and open soft tissue repair was performed. The injuries were documented and the patients were followed up clinically and with radiographs.

RESULTS

Extensive soft tissue injuries, including both collateral ligament injuries and muscle origin avulsions from either or both sides, were found in all patients. The functional result at follow-up was satisfactory in all patients.

CONCLUSION

Vast soft tissue injuries including both collateral ligaments and muscle origins should be expected in the event of early severe instability of a dislocated elbow joint.

Cost analysis and outcomes of simple elbow dislocations

AIM: To evaluate the management, clinical outcome and cost implications of three different treatment regimes for simple elbow dislocations.

METHODS: 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.

RESULTS: 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.

CONCLUSION: 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.

The treatment of simple elbow dislocation in adults

BACKGROUND

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.

METHODS

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.

RESULTS

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.

CONCLUSION

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.

Elbow rehabilitation in traumatic pathology

The elbow, intermediate joint of the upper limb, frequently undergoes to pathological events and is especially prone to stiffness. Rehabilitation plays an important role in recovering functional activities. For the rehabilitation team, this goal always represents a challenge, as the treatment has to be continuously modeled and calibrated on the needs of the individual patient, even many times during the same rehabilitation cycle. Containing the effects of immobilization, avoiding to excessively stress the healing tissues, satisfying specific clinical criteria before moving to the next rehabilitation stage, basing the rehabilitation plan on up-to-date clinical and scientific data that can be adapted to each patient and to his/her needs are the basic principles of the rehabilitation plan, which can be chronologically grouped into four rehabilitation stages. After summarizing the general principles of elbow treatment, the specific principles of rehabilitation after elbow fractures and elbow instability are presented, and then the rehabilitative approach to the most frequent and feared pathological conditions of the elbow, namely stiffness, is described.