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Breulmann FL, Lappen S, Ehmann Y, Bischofreiter M, Lacheta L, Siebenlist S. Treatment strategies for simple elbow dislocation - a systematic review. BMC Musculoskelet Disord 2024; 25:148. [PMID: 38365699 PMCID: PMC10874000 DOI: 10.1186/s12891-024-07260-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/22/2023] [Accepted: 02/04/2024] [Indexed: 02/18/2024] Open
Abstract
BACKGROUND Current treatment concepts for simple elbow dislocation involve conservative and surgical approaches. The aim of this systematic review was to identify the superiority of one treatment strategy over the other by a qualitative analysis in adult patients who suffered simple elbow luxation. STUDY DESIGN A systematic review in accordance with the PRISMA guidelines and following the suggestions for reporting on qualitative summaries was performed. A literature search was conducted using PubMed and Scopus, including variations and combinations of the following keywords: elbow, radiohumeral, ulnohumeral, radioulnar, luxation, and therapy. Seventeen studies that performed a randomized controlled trial to compare treatment strategies as conservative or surgical procedures were included. Reviews are not selected for further qualitative analysis. The following outcome parameters were compared: range of motion (ROM), Mayo Elbow Performance Score (MEPS), Disabilities of the Arm, Shoulder and Hand outcome measure (Quick-DASH), recurrent instability, pain measured by visual analog scale (VAS) and time to return to work (RW). RESULTS Early mobilization after conservative treatment strategies showed improved ROM compared to immobilization for up to 3 weeks after surgery with less extension deficit in the early mobilization group (16° ± 13°. vs. 19.5° ± 3°, p < 0.05), as well as excellent clinical outcome scores. Surgical approaches showed similar results compared to conservative treatment, leading to improved ROM (115 vs. 118 ± 2.8) and MEPS: 95 ± 7 vs. 92 ± 4. CONCLUSION Conservative treatment with early functional training of the elbow remains the first-line therapy for simple elbow dislocation. The surgical procedure provides similar outcomes compared to conservative treatment regarding MEPS and ROM for patients with slight initial instability in physical examination and radiographs. People with red flags for persistent instability, such as severe bilateral ligament injuries and moderate to severe instability during initial physical examination, should be considered for a primary surgical approach to prevent recurrent posterolateral and valgus instability. Postoperative early mobilization and early mobilization for conservatively treated patients is beneficial to improve patient outcome and ROM.
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Affiliation(s)
- Franziska Lioba Breulmann
- Department of Sports Orthopedics, Klinikum Rechts Der Isar, Technical University of Munich, Ismaningerstraße 22, Munich, 81675, Germany
| | - Sebastian Lappen
- Department of Sports Orthopedics, Klinikum Rechts Der Isar, Technical University of Munich, Ismaningerstraße 22, Munich, 81675, Germany
| | - Yannick Ehmann
- Department of Sports Orthopedics, Klinikum Rechts Der Isar, Technical University of Munich, Ismaningerstraße 22, Munich, 81675, Germany
| | - Martin Bischofreiter
- Department of Orthopedic Surgery, Ordensklinikum Barmherzige Schwestern Linz, Linz, 4010, Austria
- Department of Orthopedics and Traumatology, Klinik Diakonissen Schladming, Schladming, 8970, Austria
| | - Lucca Lacheta
- Department of Sports Orthopedics, Klinikum Rechts Der Isar, Technical University of Munich, Ismaningerstraße 22, Munich, 81675, Germany
| | - Sebastian Siebenlist
- Department of Sports Orthopedics, Klinikum Rechts Der Isar, Technical University of Munich, Ismaningerstraße 22, Munich, 81675, Germany.
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Albayrak M. Simple lateral elbow dislocation: A case report. World J Surg Proced 2023; 13:7-13. [DOI: 10.5412/wjsp.v13.i2.7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/25/2023] [Revised: 07/19/2023] [Accepted: 08/08/2023] [Indexed: 09/27/2023] Open
Abstract
BACKGROUND Simple lateral elbow dislocation (SLED) is a rare type of elbow dislocation; however, its treatment may be complicated by accompanying soft tissue or neurovascular damage. Herein, we report a rare case of SLED managed secon-darily with open reduction and soft tissue repair following failure of closed reduction.
CASE SUMMARY A 67-year-old woman suffered SLED after falling on her outstretched left hand with her elbow extended. She developed pain, swelling, and movement restriction in the elbow; there were no neurovascular symptoms, except for numbness in the 4th and 5th digits. Radiologic investigation confirmed the SLED, and a closed reduction under anesthesia was performed. The follow-up radiographs at 1-wk revealed failure of reduction; accordingly, open reduction with lateral collateral ligament and common extensor origin repair were carried out. The patient regained full elbow range of motion by six weeks.
CONCLUSION Adequate concentric reduction for SLED, conservatively or surgically, reduces complications and provides a more functional joint.
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Affiliation(s)
- Mehmet Albayrak
- Department of Orthopaedics and Traumatology, Ozel Tekirdag Yasam Hospital, Tekirdag 59020, Turkey
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3
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Klute L, Henssler L, Alt V, Kerschbaum M. [Elbow joint dislocation : Frequent concomitant injuries and current treatment concepts]. UNFALLCHIRURGIE (HEIDELBERG, GERMANY) 2023; 126:405-418. [PMID: 37081090 PMCID: PMC10160183 DOI: 10.1007/s00113-023-01318-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 03/14/2023] [Indexed: 04/22/2023]
Abstract
Dislocations of the elbow joint are among the most prevalent dislocation injuries in the human body after shoulder joint dislocations and represent a challenge in the clinical routine because of the concomitant injuries and complications. They predominantly affect young adults who become injured during athletic or daily activities. A distinction is generally made between a simple elbow dislocation and a dislocation fracture of the elbow; however, a uniform classification or treatment algorithm has not yet been established, especially for simple elbow dislocations with associated ligamentous, muscular and capsular concomitant injuries. Due to this and the complexity of this injury, a standardized approach is needed to initiate the optimal treatment at an early stage and to correctly select the narrow treatment pathway between impending chronic instability and elbow stiffness.
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Affiliation(s)
- Lisa Klute
- Klinik und Poliklinik für Unfallchirurgie, Universitätsklinikum Regensburg (UKR), Franz-Josef-Strauss-Allee 11, 93053, Regensburg, Deutschland.
| | - Leopold Henssler
- Klinik und Poliklinik für Unfallchirurgie, Universitätsklinikum Regensburg (UKR), Franz-Josef-Strauss-Allee 11, 93053, Regensburg, Deutschland
| | - Volker Alt
- Klinik und Poliklinik für Unfallchirurgie, Universitätsklinikum Regensburg (UKR), Franz-Josef-Strauss-Allee 11, 93053, Regensburg, Deutschland
| | - Maximilian Kerschbaum
- Klinik und Poliklinik für Unfallchirurgie, Universitätsklinikum Regensburg (UKR), Franz-Josef-Strauss-Allee 11, 93053, Regensburg, Deutschland.
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Corbet C, Boudissa M, Dao Lena S, Ruatti S, Corcella D, Tonetti J. Surgical treatment of terrible triad of the elbow: Retrospective continuous 50-patient series at 2 years' follow-up. Orthop Traumatol Surg Res 2023; 109:103057. [PMID: 34536597 DOI: 10.1016/j.otsr.2021.103057] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/26/2019] [Revised: 10/02/2020] [Accepted: 12/31/2020] [Indexed: 02/03/2023]
Abstract
INTRODUCTION Terrible triad (TT) of the elbow is an association at high risk of instability. Treatment aims to restore joint stability. Lateral collateral ligament (LCL) repair is systematic, whereas medial collateral ligament (MCL) repair is only exceptionally necessary. The main aim of the present study was to assess clinical results in TT surgery. The secondary objective was to compare clinical progression with versus without MCL repair. MATERIAL AND METHODS A retrospective study included 50 TTs operated on via an isolated lateral or combined medial-lateral approach. Clinical assessment comprised MEPS, QuickDASH, VAS, flexion-extension and pronation-supination, and return to work and sport. Subgroup analysis was made according to associated MCL repair. RESULTS Fifty patients (19 female, 31 male) were operated on between January 2006 and January 2017. Mean follow-up was 24 months. At last follow-up, mean MEPS was 89.1, VAS 0.7, QuickDASH 16, flexion-extension 114°, and pronation-supination 137°. Only MEPS was significantly improved by MCL repair (p=0.02), with no significant difference in complications. DISCUSSION TT surgery with immediate mobilization gave good long-term functional results, not significantly improved by MCL repair. The lateral approach should be adopted in first line, with the medial approach in second line in case of persistent instability after lateral osteo-ligamentous repair. LEVEL OF EVIDENCE IV; retrospective study.
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Affiliation(s)
- Clémentine Corbet
- Service Orthopédie et Traumatologie, CHU Grenoble Alpes, Boulevard de la Chantourne, 38700 La Tronche, France.
| | - Mehdi Boudissa
- Service Orthopédie et Traumatologie, CHU Grenoble Alpes, Boulevard de la Chantourne, 38700 La Tronche, France
| | | | - Sébastien Ruatti
- Service Orthopédie et Traumatologie, CHU Grenoble Alpes, Boulevard de la Chantourne, 38700 La Tronche, France
| | - Denis Corcella
- Service de Chirurgie de la Main et des Brûlés, CHU Grenoble Alpes, Boulevard de la Chantourne, 38700 La Tronche, France
| | - Jérôme Tonetti
- Service Orthopédie et Traumatologie, CHU Grenoble Alpes, Boulevard de la Chantourne, 38700 La Tronche, France
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Almigdad A, AlRousan F, Alomari B, Altani E, Al Adaileh G, Arabiat M. Posteromedial elbow dislocation with irreducible medial condyle fracture in adult, a case report. Trauma Case Rep 2023; 44:100781. [PMID: 36785782 PMCID: PMC9920247 DOI: 10.1016/j.tcr.2023.100781] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/04/2023] [Indexed: 02/08/2023] Open
Abstract
Elbow dislocation is a common elbow injury classified into simple or complex depending on the associated bony injuries. Posterolateral dislocation is the most common, while posteromedial elbow dislocation is rare. Elbow fracture-dislocation in adults usually has a typical pattern of associated fractures. However, medial condyle fracture is an uncommon pattern in the context of elbow dislocation in adults. The following report describes a thirty-two-year-old male who developed posteromedial elbow dislocation with an irreducible medial condyle fracture.
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Lytle J, Meyers A, Ballard E, Fallahi AK, Nelson R. Global elbow instability: a case report. JSES REVIEWS, REPORTS, AND TECHNIQUES 2023; 3:120-124. [PMID: 37588066 PMCID: PMC10426550 DOI: 10.1016/j.xrrt.2022.08.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 08/18/2023]
Affiliation(s)
- Jacob Lytle
- Orthopedic Surgery Department, Ascension Genesys Hospital, Grand Blanc, MI, USA
- Michigan State University, Statewide Campus System, East Lansing, MI, USA
| | - Amy Meyers
- Orthopedic Surgery Department, Ascension Genesys Hospital, Grand Blanc, MI, USA
- Michigan State University, Statewide Campus System, East Lansing, MI, USA
| | - Eric Ballard
- Orthopedic Surgery Department, Ascension Genesys Hospital, Grand Blanc, MI, USA
- Michigan State University, Statewide Campus System, East Lansing, MI, USA
| | | | - Ryan Nelson
- Greater Michigan Orthopedics, Grand Blanc, MI, USA
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Olasinde AA, Iryivuze O, Sikakluya FK. Open postero-lateral dislocation of the left elbow secondary to assault: A case report. Int J Surg Case Rep 2022; 101:107798. [PMID: 36434868 PMCID: PMC9691437 DOI: 10.1016/j.ijscr.2022.107798] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2022] [Revised: 11/21/2022] [Accepted: 11/21/2022] [Indexed: 11/24/2022] Open
Abstract
INTRODUCTION AND IMPORTANCE Simple closed lateral elbow dislocation is rare, often associated with neurovascular injury and closed reduction may be difficult. Open complex postero-lateral dislocation has not been previously reported. CASE PRESENTATION We present a case of open left posterior lateral elbow dislocation secondary to assault with a cutlass causing an avulsion fracture of the lateral epicondyle and common extensor origin tendon which prevented congruent reduction until the avulsed fragment was fixed with a bone screw. CLINICAL DISCUSSION The patient had hemorrhagic shock from excessive uncontrolled bleeding from the machete cut for which he was resuscitated with a blood transfusion. There was a longitudinal laceration on the lateral aspect of the elbow extending onto the proximal forearm with open posterolateral dislocation of the left elbow, avulsion of the common extensor origin with lateral epicondyle fracture and an open left wrist fracture dislocation with level VII laceration of the extensor tendon. The wound was explored under general anesthesia with generous saline irrigation, reduction of the dislocated left elbow and screw fixation of the lateral epicondyle fracture and primary wound closure plus primary repair of extensor tendons. A post-operative full arm Plaster of Paris cast was applied. Supervised active and passive range of motion exercise was commenced two weeks post-operatively. CONCLUSION The patient had uneventful recovery with left elbow range of motion of 30 to 100 degrees two months post discharge.
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Affiliation(s)
- Anthony Ayotunde Olasinde
- Faculty of Clinical Medicine and Dentistry, Department of Surgery, Kampala International University Western Campus, Ishaka-Bushenyi, Uganda,Corresponding author at: Faculty of Clinical Medicine and Dentistry, Department of Surgery, Kampala International University Western Campus, P.O.Box 70, Ishaka-Bushenyi, Uganda.
| | - Olivier Iryivuze
- Faculty of Clinical Medicine and Dentistry, Department of Surgery, Kampala International University Western Campus, Ishaka-Bushenyi, Uganda
| | - Franck Katembo Sikakluya
- Faculty of Clinical Medicine and Dentistry, Department of Surgery, Kampala International University Western Campus, Ishaka-Bushenyi, Uganda,Faculty of Medicine, Université Catholique du Graben, Butembo, Democratic Republic of the Congo
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Abstract
BACKGROUND The elbow is one of the most commonly dislocated joints, and dislocation is usually accompanied with an assortment of soft tissue injuries. The purpose of this study was to retrospectively analyze and describe the patterns of ligamentous, tendinous, and muscular injuries in patients with an acute elbow dislocation and subsequent magnetic resonance image (MRI) evaluation. METHODS From 2008 to 2020, 235 patients clinically diagnosed with an elbow dislocation were seen in the department, of which only 19 underwent an MRI of the affected elbow. Twelve patients met inclusion criteria, and MRIs were evaluated by both a radiologist and an upper extremity orthopedic surgeon. Magnetic resonance images were assessed for injury to the ulnar collateral ligament (UCL); radial collateral ligament (RCL); lateral ulnar collateral ligament (LUCL); common flexor and extensor tendons; biceps, brachialis, and triceps tendons; fracture; and joint effusion. RESULTS Magnetic resonance imaging findings included the following: UCL was injured in 11 of 12 patients; RCL was injured in 9 of 12 patients; LUCL was injured in 9 of 12 patients; common flexor tendon was injured in 11 of 12 patients; and common extensor tendon was injured in 9 of 12 elbows. The biceps, brachialis, and triceps tendons showed injury in 1 of 12, 2 of 12, and 2 of 12 elbows, respectively. Four elbows had at least 1 fracture present, whereas 8 demonstrated an effusion. CONCLUSIONS In this series, injuries to the UCL and common flexor tendon were most common. Although ligamentous injuries are exceedingly common in elbow dislocations, large studies of MRI findings prove difficult due to MRI costs.
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Affiliation(s)
- Cory Demino
- University of Pittsburgh, PA, USA,Cory Demino, School of Medicine, University of Pittsburgh, 3550 Terrace Street, Pittsburgh, PA 15213, USA.
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Catapano M, Pupic N, Multani I, Wasserstein D, Henry P. Early functional mobilization for non-operative treatment of simple elbow dislocations: a systematic review. Shoulder Elbow 2022; 14:211-221. [PMID: 35265188 PMCID: PMC8899322 DOI: 10.1177/1758573220957631] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/16/2020] [Accepted: 08/18/2020] [Indexed: 11/17/2022]
Abstract
PURPOSE This systematic review aims to elucidate a non-operative rehabilitation program that optimizes recovery based on published approaches and outcomes. METHODS Searches of four databases from inception to 1 January 2020 were performed to identify clinical studies addressing the non-operative management of simple elbow dislocations. RESULTS Of 2435 studies that were eligible for title screen, 15 studies satisfied inclusion criteria. Three randomized control studies demonstrated that early mobilization expedited the return of range of motion, function and return to work or activities, however, resulted in increased pain within the six-week rehabilitation period compared to Plaster of Paris casting for 21 days. Patients returned to work sooner after early mobilization (10 vs. 18 days; p = 0.02) compared to Plaster of Paris casting. In all studies, early mobilization resulted in similar re-dislocation rates of 1.3% (3/237) versus 2.2% (12/549) in those with Plaster of Paris casting as well as lower incidence of heterotopic ossification (36% vs. 54%). No significant differences between rehabilitation protocols were determined; however, the large majority of recent papers utilized rehabilitation protocols. CONCLUSION Early mobilization of simple elbow dislocations results in early return of Range-of-Motion, function and return to work with no increase in complication rates; however, increased pain during the rehabilitation period.
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Affiliation(s)
- Michael Catapano
- Division of Physical Medicine and Rehabilitation, Department of Medicine, University of Toronto, Toronto, ON, Canada,Michael Catapano, Toronto Rehabilitation Institute, 550 University Avenue, Toronto, ON, Canada M5G 2A2.
| | - Nikola Pupic
- Division of Orthopedic Surgery, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, ON, Canada,Institute of Bio-Materials and Biomedical Engineering, University of Toronto, Toronto, ON, Canada,Toronto Rehabilitation Institute, Toronto, ON, Canada
| | | | - David Wasserstein
- Division of Orthopedic Surgery, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, ON, Canada,Orthopaedic Rehabilitation Institute, Toronto, ON, Canada
| | - Patrick Henry
- Division of Orthopedic Surgery, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, ON, Canada,Orthopaedic Rehabilitation Institute, Toronto, ON, Canada
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Schubert I, Strohm PC, Maier D, Zwingmann J. Simple traumatic elbow dislocations; benefit from early functional rehabilitation: A systematic review with meta-analysis including PRISMA criteria. Medicine (Baltimore) 2021; 100:e27168. [PMID: 34871203 PMCID: PMC8568443 DOI: 10.1097/md.0000000000027168] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/31/2019] [Accepted: 08/16/2021] [Indexed: 01/05/2023] Open
Abstract
INTRODUCTION Elbow dislocation is the second most frequent joint dislocation after shoulder dislocation. They have a high relevance because they can result in subsequent damage and limitations in range of motion. The treatment options are controversially discussed.The purpose of this systematic review and meta-analysis was to review the literature and analyze the evidence of early functional rehabilitation. METHODS A systematic literature search was performed via Ovid Medline, whereby 1645 publications were identified and evaluated in a stepwise approach. Of these publications 29 met the inclusion criteria of the authors and described simple elbow dislocations in 5765 patients.Data from the studies and subgroups included were initially categorized descriptively in conservative and surgical primary therapies, in immobilizing (immobilization lasting 2 weeks or longer) and free-functional follow-up treatments, and those data were then extracted from each subgroup in absolutes. We then pooled these numbers into descriptive statistics to ensure their comparability. We determined the success rates from the numbers of excellent and good results of the specific used outcome scores. RESULTS The effect estimate of the conservative therapy's success rate was 84% and for surgical treatment 80% (P < .0001). The difference between the immobilizing treatment (78% success rate) and early-function therapy (83% success rate) was significant (P = .002).In a subgroup analysis the success rate of conservative and immobilizing therapy was 79%, of conservative and early-functional therapy 91%, of surgical and immobilizing groups' was 77% and of the surgical and early-functional therapies was 93%. The difference among the 4 treatment options was significant (P < .0001), as were differences between the 2 conservative groups (P < .0001) and between the 2 surgical groups (P = .044). DISCUSSION Conservative therapy is the dominant therapy. Regardless of the primary therapy chosen in simple elbow dislocations: early functional follow-up care seems to be superior to immobilizing therapy with a duration more than 2 weeks.
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Affiliation(s)
- Ilona Schubert
- Clinic for Orthopedics and Trauma Surgery, Klinikum Bamberg, Germany
| | - Peter C. Strohm
- Clinic for Orthopedics and Trauma Surgery, Klinikum Bamberg, Germany
| | - Dirk Maier
- Department of Orthopedic and Trauma Surgery, University of Freiburg Medical Center, Germany
| | - Jörn Zwingmann
- Clinic of Orthopedic and Trauma Surgery, Oberschwabenklinik Ravensburg, Germany
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11
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Alidina S, Alidina J, Souza F, Kalandiak S, Subhawong TK. Radiographic Evaluation of Elbow Fractures. Semin Musculoskelet Radiol 2021; 25:529-537. [PMID: 34706382 DOI: 10.1055/s-0041-1731083] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
Fractures and dislocations of the elbow are a common cause of emergency department visits each year. Radiography remains the bedrock of an initial injury assessment, and recognition of distinctive injury patterns based on fracture location, morphology, and severity, guides optimal clinical decision-making. This article reviews basic elbow anatomy, frequently seen fractures and injury patterns, and highlights how these findings influence surgical planning and patient management.
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Affiliation(s)
- Sameer Alidina
- University of Vermont Larner College of Medicine, Burlington, Vermont
| | - Jasim Alidina
- Department of Radiology, University of Miami Miller School of Medicine/Jackson Memorial Hospital, Miami, Florida
| | - Felipe Souza
- Department of Radiology, University of Miami Miller School of Medicine/Jackson Memorial Hospital, Miami, Florida
| | - Steven Kalandiak
- Department of Orthopaedic Surgery, University of Miami Miller School of Medicine, Miami, Florida
| | - Ty K Subhawong
- Department of Radiology, University of Miami Miller School of Medicine/Jackson Memorial Hospital, Miami, Florida
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Abstract
Approximately 4.1% of all fractures in the elderly involve the elbow. Most elbow injuries in geriatric patients occur as the result of low-energy mechanisms such as falls from standing height. Elbow injuries in elderly patients present complex challenges because of insufficient bone quality, comminution, articular fragmentation, and preexisting conditions, such as arthritis. Medical comorbidities and baseline level of function must be heavily considered in surgical decision making.
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Affiliation(s)
- Naoko Onizuka
- Department of Orthopaedic Surgery, University of Minnesota, 2512 South 7th Street, Suite R200, Minneapolis, MN 55455, USA; Department of Orthopaedic Surgery, Methodist Hospital, 6500 Excelsior Boulevard, Saint Louis Park, MN 55426, USA
| | - Julie Switzer
- Department of Orthopaedic Surgery, University of Minnesota, 2512 South 7th Street, Suite R200, Minneapolis, MN 55455, USA; Department of Orthopaedic Surgery, Methodist Hospital, 6500 Excelsior Boulevard, Saint Louis Park, MN 55426, USA
| | - Chad Myeroff
- TRIA Orthopedic Center, 155 Radio Drive, Woodbury, MN 55125, USA.
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Dwyer T, Burns D, Nauth A, Kawam K, Brull R. Regional anesthesia and acute compartment syndrome: principles for practice. Reg Anesth Pain Med 2021; 46:1091-1099. [PMID: 34187911 DOI: 10.1136/rapm-2021-102735] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2021] [Accepted: 05/10/2021] [Indexed: 11/04/2022]
Abstract
Acute compartment syndrome (ACS) is a potentially reversible orthopedic surgical emergency leading to tissue ischemia and ultimately cell death. Diagnosis of ACS can be challenging, as neither clinical symptoms nor signs are sufficiently sensitive. The cardinal symptom associated with ACS is pain reported in excess of what would otherwise be expected for the underlying injury, and not reasonably managed by opioid-based analgesia. Regional anesthesia (RA) techniques are traditionally discouraged in clinical settings where the development of ACS is a concern as sensory and motor nerve blockade may mask symptoms and signs of ACS. This Education article addresses the most common trauma and elective orthopedic surgical procedures in adults with a view towards assessing their respective risk of ACS and offering suggestions regarding the suitability of RA for each type of surgery.
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Affiliation(s)
- Tim Dwyer
- Department of Surgery, University of Toronto Division of Orthopaedics, Toronto, Ontario, Canada .,Department of Surgery, Women's College Hospital, Toronto, Ontario, Canada.,Department of Surgery, Mt Sinai Hospital, Toronto, Ontario, Canada
| | - David Burns
- University of Toronto Division of Orthopaedics, Toronto, Ontario, Canada
| | - Aaron Nauth
- Department of Surgery, University of Toronto Division of Orthopaedics, Toronto, Ontario, Canada.,Department of Surgery, St Michael's Hospital, Toronto, Ontario, Canada
| | - Kaitlin Kawam
- University of Toronto Division of Orthopaedics, Toronto, Ontario, Canada
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Ellwein A, Füßler L, Ferle M, Smith T, Lill H, Pastor MF. Suture tape augmentation of the lateral ulnar collateral ligament increases load to failure in simulated posterolateral rotatory instability. Knee Surg Sports Traumatol Arthrosc 2021; 29:284-291. [PMID: 32162045 DOI: 10.1007/s00167-020-05918-5] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/07/2019] [Accepted: 02/24/2020] [Indexed: 11/24/2022]
Abstract
PURPOSE Simple elbow dislocations are accompanied with lateral ulnar collateral ligament ruptures. For persisting instability, surgery is indicated to prevent chronic posterolateral rotatory instability. After lateral collateral ligament (LCL) complex repair the repair is protected by temporary immobilization, limited range of motion and hinged bracing. Internal bracing is an operative alternative augmenting the LCL repair using non-absorbable suture tapes. However, the stability of LCL repair with and without additional augmentation remains unclear. The hypothesis was that LCL repair with additional suture tape augmentation would improve load to failure. Secondary goal of this study was to evaluate different humeral fixation techniques. A humeral fixation using separate anchors for the LCL repair and the augmentation was not expected to provide superior stability compared to using only one single anchor. METHODS Twenty-one elbows were tested. A cyclic varus rotational torque of 0.5-3.5 Nm was applied in 90°, 60°, 30°, and 120° elbow flexion to the intact, torn, and repaired LCLs. The specimens were randomized into three groups: repair alone (group I), repair with additional internal bracing using two anchors (group II), repair using one humeral anchor (group III). A load-to-failure protocol was conducted. RESULTS Load to failure was significantly higher in groups II (26.6 Nm; P = 0.017) and III (23.18 Nm; P = 0.038) than in group I (12.13 Nm). No significant difference was observed between group II and III. All specimens lost reduction after LCL dissection by a mean of 4.48° ± 4.99° (range 0.66-15.82). The mean reduction gain after repair was 7.21° ± 4.97° (2.70-21.23; mean over reduction, 2.73°). The laxity was comparable between the intact and repaired LCLs (n.s.), except for varus movements at 30° in group II (P = 0.035) and 30° (P = 0.001) and 120° in group III (P = 0.008) with significantly less laxity. Inserting the ulnar suture anchor showed failure in the thread in 10 cases. CONCLUSION LCL repair with additional internal bracing yielded higher load to failure than repair alone. Repair with additional internal bracing for the humeral side using one anchor was sufficient. A higher primary stability would facilitate postoperative management and allow immediate functional treatment. Reducing the number of humeral anchors would save costs.
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Affiliation(s)
- Alexander Ellwein
- Department of Orthopedic Surgery, Medical School Hannover, DIAKOVERE Annastift, Anna-von-Borries-Straße 1-7, 30625, Hannover, Germany. .,Department of Orthopedic Surgery and Traumatology, DIAKOVERE Friederikenstift, Humboldtstr. 5, 30169, Hannover, Germany.
| | - Luca Füßler
- Department of Orthopedic Surgery, Medical School Hannover, DIAKOVERE Annastift, Anna-von-Borries-Straße 1-7, 30625, Hannover, Germany
| | - Manuel Ferle
- Laboratory of Biomechanics and Biomaterials, Medical School Hannover, 30625, Hannover, Germany
| | - Tomas Smith
- Department of Orthopedic Surgery, Medical School Hannover, DIAKOVERE Annastift, Anna-von-Borries-Straße 1-7, 30625, Hannover, Germany
| | - Helmut Lill
- Department of Orthopedic Surgery and Traumatology, DIAKOVERE Friederikenstift, Humboldtstr. 5, 30169, Hannover, Germany
| | - Marc-Frederic Pastor
- Department of Orthopedic Surgery, Medical School Hannover, DIAKOVERE Annastift, Anna-von-Borries-Straße 1-7, 30625, Hannover, Germany
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Acute elbow dislocation: comparison between magnetic resonance imaging and intra-operative finding of ligament injury. INTERNATIONAL ORTHOPAEDICS 2020; 45:265-273. [PMID: 33200244 DOI: 10.1007/s00264-020-04875-5] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/09/2020] [Accepted: 11/09/2020] [Indexed: 10/23/2022]
Abstract
PURPOSE The aim of this current study was to assess elbow ligament tears after dislocation using magnetic resonance imaging (MRI) and to correlate any pre-operative imaging with intra-operative findings of elbow ligament tears. METHODS We prospectively included 32 patients with acute elbow dislocation investigated by MRI at a means of five days from dislocation. A simple elbow dislocation was diagnosed in 14 patients (44%); associated bone injuries were identified in 18 elbows (56%). Surgical repair of elbow ligaments was carried out in 23 patients, and nine cases were treated non-operatively. A blinded MRI evaluation of all 32 elbows was performed by an orthopaedic surgeon (rater 1) and a musculoskeletal radiologist (rater 2). RESULTS Inter-rater agreement for MRI evaluation of 32 was poor for lateral ulnar collateral ligament (LUCL) tears, fair for radial collateral ligament (RCL), moderate for annular ligament (AL), and fair for ulnar collateral ligament (UCL). All tears were reported as complete by rater 1; 13/32 partial tears were identified by rater 2 (LUCL = 2, RCL = 2, UCL = 9). Correlation between surgical and MRI findings showed good inter-rater agreement for LUCL and AL tears in both raters. Agreement for RCL tear was poor for rater 1 and fair for rater 2; agreement for UCL tear was fair for rater 1 and poor for rater 2. Intra-operative findings showed ten radial head fractures (RHFs) and ten coronoid fractures (CFs). LUCL tears were found in the four cases of type II RHFs and in 3/4 cases of CFs. Bone injuries and ligament tears were not significantly associated. CONCLUSION MRI scan supported surgeons to identify soft tissue injuries and to address the most suitable surgical approach after acute elbow dislocation. Inter-observer agreement for intra-operative findings was high for LCL complex injuries and poor for UCL.
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Common Extensor Complex Is a Predictor to Determine the Stability in Simple Posterolateral Elbow Dislocation: Analysis of MR Images of Stable vs. Unstable Dislocation. J Clin Med 2020; 9:jcm9103094. [PMID: 32992826 PMCID: PMC7601526 DOI: 10.3390/jcm9103094] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2020] [Revised: 09/18/2020] [Accepted: 09/23/2020] [Indexed: 11/17/2022] Open
Abstract
Simple posterolateral elbow dislocations (SPLED) may be treated nonoperatively using closed reduction, followed by controlled mobilization. However, the extent of soft tissue injuries might affect the choice of treatment, rehabilitation approach, and prognosis. The purpose of this study is to compare the characteristics of soft tissue injuries between patients with unstable and stable SPLED using MRI findings. Thirty MRIs of elbows with SPLED (unstable group (n = 15); stable group (n = 15)) were randomly reviewed by two experienced musculoskeletal radiologists. Soft tissue injuries were characterized as an intact, partial tear or complete tear for the: medial collateral ligament (MCL) complex, common flexor complex, lateral collateral ligament (LCL) complex, common extensor complex, anterior capsule, and posterior capsule. Moderate to substantial interobserver reliability and substantial to perfect intraobserver reliability were observed for medial and lateral complexes in SPLED. The proportion of soft-tissue injuries of the common extensor complex were significantly different between the unstable (four partial tears and 11 complete tears) and stable groups (11 partial tears and four complete tears). In conclusion, based on MRI findings, the degree of common extensor complex injuries may be a predictor of stability and help inform treatment decisions for SPLED.
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Abstract
This article is a brief overview of the elbow dislocations focusing on updates in treatment and rehabilitation protocols. The fight between obtaining elbow stability without leading to long-term elbow stiffness has been a continued focus in field of sports medicine. This article highlights advances made to help treat the injuries appropriately and obtain optimal patient outcomes.
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Early mobilization versus plaster immobilization of simple elbow dislocations: a cost analysis of the FuncSiE multicenter randomized clinical trial. Arch Orthop Trauma Surg 2020; 140:877-886. [PMID: 31760487 PMCID: PMC7295826 DOI: 10.1007/s00402-019-03309-1] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/29/2019] [Indexed: 01/12/2023]
Abstract
INTRODUCTION The primary aim was to assess and compare the total costs (direct health care costs and indirect costs due to loss of production) after early mobilization versus plaster immobilization in patients with a simple elbow dislocation. It was hypothesized that early mobilization would not lead to higher direct and indirect costs. MATERIALS AND METHODS This study used data of a multicenter randomized clinical trial (FuncSiE trial). From August 25, 2009 until September 18, 2012, 100 adult patients with a simple elbow dislocation were recruited and randomized to early mobilization (immediate motion exercises; n = 48) or 3 weeks plaster immobilization (n = 52). Patients completed questionnaires on health-related quality of life [EuroQoL-5D (EQ-5D) and Short Form-36 (SF-36 PCS and SF-36 MCS)], health care use, and work absence. Follow-up was 1 year. Primary outcome were the total costs at 1 year. Analysis was by intention to treat. RESULTS There were no significant differences in EQ-5D, SF-36 PCS, and SF-36 MCS between the two groups. Mean total costs per patient were €3624 in the early mobilization group versus €7072 in the plaster group (p = 0.094). Shorter work absenteeism in the early mobilization group (10 versus 18 days; p = 0.027) did not lead to significantly lower costs for loss of productivity (€1719 in the early mobilization group versus €4589; p = 0.120). CONCLUSION From a clinical and a socio-economic point of view, early mobilization should be the treatment of choice for a simple elbow dislocation. Plaster immobilization has inferior results at almost double the cost.
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Lee JH, Lee JH, Kim KC, Ahn KB, Rhyou IH. Treatment of posteromedial and posterolateral dislocation of the acute unstable elbow joint: a strategic approach. J Shoulder Elbow Surg 2019; 28:2007-2016. [PMID: 31540726 DOI: 10.1016/j.jse.2019.05.029] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/11/2018] [Revised: 05/23/2019] [Accepted: 05/28/2019] [Indexed: 02/01/2023]
Abstract
BACKGROUND The purpose of this study was to evaluate the different treatment strategies for posterolateral and posteromedial elbow dislocation. METHODS The study enrolled 21 patients with unstable simple elbow dislocation including 16 cases of posterolateral dislocation (PLDL) and 5 cases of posteromedial dislocation (PMDL). In patients with PLDL, the medial side was evaluated and repaired first, followed by the lateral side. In patients with PMDL, the lateral side was repaired first, followed by the medial side according to residual instability. RESULTS Among the 16 cases of unstable PLDL, 7 of 9 presenting with complex combined tear of the ulnar collateral ligament (UCL) and flexor muscle on magnetic resonance imaging showed abnormality on valgus stress testing and UCL repair. Three of 7 cases required additional lateral collateral ligament complex (LCLC) repair. Two of 9 cases showing medial complex dual lesions had normal findings on valgus stress testing and were treated only with LCLC repair. Seven of 16 cases without medial complex dual lesion had normal findings on valgus stress testing, and only LCLC repair was performed. All 5 cases of unstable PMDL showed distraction-type LCLC injury on magnetic resonance imaging and required no additional UCL repair after LCLC repair. There were no cases of recurrent instability following this treatment algorithm. CONCLUSIONS In unstable elbow dislocation, PLDL and PMDL are caused by different mechanisms following damage to different structures. Therefore, different strategies are needed to ameliorate the dislocation and instability.
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Affiliation(s)
- Jung Hyun Lee
- Department of Orthopaedic Surgery, Upper Extremity and Microsurgery Center, Pohang Semyeong Christianity Hospital, Gyeongsangbuk-do, Republic of Korea
| | - Ji-Ho Lee
- Department of Orthopaedic Surgery, Upper Extremity and Microsurgery Center, Pohang Semyeong Christianity Hospital, Gyeongsangbuk-do, Republic of Korea
| | - Kyung Chul Kim
- Department of Orthopaedic Surgery, Upper Extremity and Microsurgery Center, Pohang Semyeong Christianity Hospital, Gyeongsangbuk-do, Republic of Korea
| | - Kee Baek Ahn
- Department of Orthopaedic Surgery, Upper Extremity and Microsurgery Center, Pohang Semyeong Christianity Hospital, Gyeongsangbuk-do, Republic of Korea
| | - In Hyeok Rhyou
- Department of Orthopaedic Surgery, Upper Extremity and Microsurgery Center, Pohang Semyeong Christianity Hospital, Gyeongsangbuk-do, Republic of Korea.
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Ando A, Hagiwara Y, Koide M, Yamashiro M, Matsuda M, Itoi E. Lateral dislocation of the elbow with concomitant lateral epicondyle fracture: A case report and review of the literature. J Orthop Sci 2019; 24:563-567. [PMID: 28162856 DOI: 10.1016/j.jos.2016.12.028] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/09/2016] [Revised: 12/24/2016] [Accepted: 12/28/2016] [Indexed: 10/20/2022]
Affiliation(s)
- Akira Ando
- Department of Orthopaedic Surgery, Matsuda Hospital, 17-1 Sanezawa Aza Tatsutayashiki, Izumiku, Sendai, Japan.
| | - Yoshihiro Hagiwara
- Department of Orthopaedic Surgery, Tohoku University School of Medicine, 1-1 Seiryomachi, Aobaku, Sendai, Japan
| | - Masashi Koide
- Department of Orthopaedic Surgery, Tohoku University School of Medicine, 1-1 Seiryomachi, Aobaku, Sendai, Japan
| | - Masahiro Yamashiro
- Department of Orthopaedic Surgery, Matsuda Hospital, 17-1 Sanezawa Aza Tatsutayashiki, Izumiku, Sendai, Japan
| | - Michimasa Matsuda
- Department of Orthopaedic Surgery, Matsuda Hospital, 17-1 Sanezawa Aza Tatsutayashiki, Izumiku, Sendai, Japan
| | - Eiji Itoi
- Department of Orthopaedic Surgery, Tohoku University School of Medicine, 1-1 Seiryomachi, Aobaku, Sendai, Japan
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Cho CH, Kim BS, Rhyou IH, Park SG, Choi S, Yoon JP, Choi CH, Dan J. Posteromedial Elbow Dislocations without Relevant Osseous Lesions: Clinical Characteristics, Soft-Tissue Injury Patterns, Treatments, and Outcomes. J Bone Joint Surg Am 2018; 100:2066-2072. [PMID: 30516630 DOI: 10.2106/jbjs.18.00051] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND Although simple posterolateral or posterior elbow dislocations are relatively common and usually stable after closed reduction, simple posteromedial dislocations are extremely rare and poorly characterized. We investigated the clinical characteristics, soft-tissue injury patterns, treatments, and outcomes of a series of posteromedial elbow dislocations without relevant osseous lesions. METHODS We retrospectively reviewed 20 cases of simple posteromedial elbow dislocations without relevant osseous lesions that were treated at 7 fellowship training hospitals during a 10-year period. Soft-tissue injury patterns in 15 cases were investigated with use of magnetic resonance imaging. Clinical outcomes were evaluated after an average of 56.1 months (range, 24 to 93 months) with use of the Mayo Elbow Performance Score (MEPS) and the Quick-DASH (an abbreviated version of the Disabilities of the Arm, Shoulder and Hand [DASH]) score. Complications were also evaluated. RESULTS On magnetic resonance imaging, significant tears of the lateral collateral ligament complex and common extensor group were observed in all cases. Seventeen cases (85%) required surgical treatment for acute instability. Fourteen cases underwent only lateral complex repair and 3 underwent repair of both the medial and lateral complexes. At the time of the latest follow-up, the mean MEPS and Quick-DASH scores were 85.8 ± 15.0 and 10.5 ± 16.3, respectively. Seventeen patients (85%) had a satisfactory clinical outcome. Complications following treatment included 4 patients with heterotopic ossification; 2 of these patients also experienced posttraumatic elbow stiffness, which was treated with arthrolysis at 8 and 18 months after the initial operation. CONCLUSIONS Posteromedial elbow dislocations without relevant osseous lesions are associated with a more severe soft-tissue injury, especially to the lateral complex, resulting in a high rate of surgical treatment. With careful post-reduction evaluation, either operative or nonoperative treatment provided satisfactory clinical outcomes. LEVEL OF EVIDENCE Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.
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Affiliation(s)
- Chul-Hyun Cho
- Department of Orthopedic Surgery, Dongsan Medical Center, School of Medicine, Keimyung University, Daegu, South Korea
| | - Beom-Soo Kim
- Department of Orthopedic Surgery, Dongsan Medical Center, School of Medicine, Keimyung University, Daegu, South Korea
| | - In Hyeok Rhyou
- Department of Orthopedic Surgery, Upper Extremity and Microsurgery Center, Semyeong Christianity Hospital, Pohang, South Korea
| | - Sam-Guk Park
- Department of Orthopedic Surgery, Yeungnam University Hospital, Daegu, South Korea
| | - Sung Choi
- Department of Orthopedic Surgery, Daegu Fatima Hospital, Daegu, South Korea
| | - Jong Pil Yoon
- Department of Orthopedic Surgery, Kyungpook National University School of Medicine, Daegu, South Korea
| | - Chang-Hyuk Choi
- Department of Orthopedic Surgery, Daegu Catholic University Medical Center, Daegu, South Korea
| | - Jinmyoung Dan
- Department of Orthopedic Surgery, Gumi CHA University Hospital, Gumi, South Korea
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Gottlieb M, Schiebout J. Elbow Dislocations in the Emergency Department: A Review of Reduction Techniques. J Emerg Med 2018; 54:849-854. [DOI: 10.1016/j.jemermed.2018.02.011] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2017] [Revised: 02/04/2018] [Accepted: 02/07/2018] [Indexed: 01/13/2023]
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Grazette AJ, Aquilina A. The Assessment and Management of Simple Elbow Dislocations. Open Orthop J 2017; 11:1373-1379. [PMID: 29290877 PMCID: PMC5721315 DOI: 10.2174/1874325001711011373] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/21/2017] [Revised: 07/18/2017] [Accepted: 07/18/2017] [Indexed: 11/22/2022] Open
Abstract
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.
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Affiliation(s)
- Andrew J Grazette
- University Hospitals Coventry and Warwickshire, Clifford Bridge Road, CV2 2DX, Coventry, UK
| | - Alex Aquilina
- University Hospitals Coventry and Warwickshire, Clifford Bridge Road, CV2 2DX, Coventry, UK
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Schnetzke M, Aytac S, Keil H, Deuss M, Studier-Fischer S, Grützner PA, Guehring T. Unstable simple elbow dislocations: medium-term results after non-surgical and surgical treatment. Knee Surg Sports Traumatol Arthrosc 2017; 25:2271-2279. [PMID: 27043345 DOI: 10.1007/s00167-016-4100-7] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/08/2015] [Accepted: 03/22/2016] [Indexed: 10/22/2022]
Abstract
PURPOSE Determination of the appropriate treatment of unstable simple elbow dislocations is difficult and a topic of ongoing discussion. The aim of this study was to analyse the outcome and complications after surgery and conservative treatment, with special focus on post-traumatic joint laxity. METHODS In this retrospective study, 118 consecutive patients with simple elbow dislocations underwent stability testing by fluoroscopy after joint reduction and were assigned to groups 1 (slight), 2 (moderate) or 3 (gross) depending on post-traumatic joint laxity. All patients of group 1 underwent conservative treatment, and of group 3 primary ligament repair. In patients with moderate elbow laxity, the treatment was decided individually. All patients underwent a similar functional rehabilitation programme during treatment. Clinical outcome was determined after an average of 3.4 ± 1.5 years using the Mayo Elbow Performance Score (MEPS), and treatment-associated complications and revisions were recorded. RESULTS Forty-nine patients (41.5 %) were assigned to group 1, 41 patients (34.7 %) to group 2 and 28 patients (23.7 %) to group 3. In group 2, 22 patients underwent ligament repair, while 19 patients were treated conservatively. On average, an excellent MEPS was achieved in group 1 after conservative treatment (MEPS 95.8 ± 9.0), similar to results after ligament repair of grossly unstable elbows in group 3 (91.6 ± 11.7). Interestingly, in group 2 conservative treatment was associated with a slightly lower MEPS (90.0 vs. 95.7), and significantly fewer patients achieved an excellent MEPS (81.8 vs. 52.6 %, p = 0.045). Similarly, conservative treatment in group 2 was associated with a fivefold to sixfold risk of complications (p = 0.032) and revision surgery (p = 0.023). CONCLUSIONS This study supports the notion that patients with slight elbow laxity can be treated non-operatively, while primary surgical treatment should be performed in patients with moderate and gross laxity to avoid post-traumatic sequelae and decrease revision rates. LEVEL OF EVIDENCE Retrospective Cohort Study, Level III.
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Affiliation(s)
- Marc Schnetzke
- Department of Trauma and Orthopedic Surgery, BG Trauma Center Ludwigshafen at the University of Heidelberg, Ludwig-Guttmann-Strasse 13, 67071, Ludwigshafen on the Rhine, Germany
| | - Sara Aytac
- Department of Trauma and Orthopedic Surgery, BG Trauma Center Ludwigshafen at the University of Heidelberg, Ludwig-Guttmann-Strasse 13, 67071, Ludwigshafen on the Rhine, Germany
| | - Holger Keil
- Department of Trauma and Orthopedic Surgery, BG Trauma Center Ludwigshafen at the University of Heidelberg, Ludwig-Guttmann-Strasse 13, 67071, Ludwigshafen on the Rhine, Germany
| | - Moritz Deuss
- Department of Trauma and Orthopedic Surgery, BG Trauma Center Ludwigshafen at the University of Heidelberg, Ludwig-Guttmann-Strasse 13, 67071, Ludwigshafen on the Rhine, Germany
| | - Stefan Studier-Fischer
- Department of Trauma and Orthopedic Surgery, BG Trauma Center Ludwigshafen at the University of Heidelberg, Ludwig-Guttmann-Strasse 13, 67071, Ludwigshafen on the Rhine, Germany
| | - Paul-Alfred Grützner
- Department of Trauma and Orthopedic Surgery, BG Trauma Center Ludwigshafen at the University of Heidelberg, Ludwig-Guttmann-Strasse 13, 67071, Ludwigshafen on the Rhine, Germany
| | - Thorsten Guehring
- Department of Trauma and Orthopedic Surgery, BG Trauma Center Ludwigshafen at the University of Heidelberg, Ludwig-Guttmann-Strasse 13, 67071, Ludwigshafen on the Rhine, Germany.
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Adolfsson LE, Nestorson JO, Scheer JH. Extensive soft tissue lesions in redislocated after simple elbow dislocations. J Shoulder Elbow Surg 2017; 26:1294-1297. [PMID: 28478899 DOI: 10.1016/j.jse.2017.02.019] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/29/2016] [Revised: 02/04/2017] [Accepted: 02/07/2017] [Indexed: 02/01/2023]
Abstract
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.
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Affiliation(s)
- Lars E Adolfsson
- Department of Orthopedic Surgery, Linköping University, Linköping, Sweden; Department of Medical and Health Sciences, Linköping University, Linköping, Sweden
| | - Jens O Nestorson
- Department of Orthopedic Surgery, Linköping University, Linköping, Sweden; Department of Medical and Health Sciences, Linköping University, Linköping, Sweden
| | - Johan H Scheer
- Department of Orthopedic Surgery, Linköping University, Linköping, Sweden; Department of Medical and Health Sciences, Linköping University, Linköping, Sweden.
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Schnetzke M, Schüler S, Hoffend J, Simon R, Keil H, Porschke F, Studier-Fischer S, Grützner PA, Guehring T. Interobserver and intraobserver agreement of ligamentous injuries on conventional MRI after simple elbow dislocation. BMC Musculoskelet Disord 2017; 18:85. [PMID: 28219360 PMCID: PMC5319117 DOI: 10.1186/s12891-017-1451-2] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/01/2016] [Accepted: 02/13/2017] [Indexed: 11/10/2022] Open
Abstract
Background The primary objective of this study was to assess the interobserver and intraobserver agreement on ligamentous injuries on conventional magnetic resonance imaging (MRI) in acute simple elbow dislocation. The secondary objectives were to determine the interobserver agreement on the assessment of joint congruity, joint effusion, loose bodies and chondral lesions on conventional MRI. Methods Conventional MRIs (1.5 Tesla, elbow specific surface coil) of 30 patients (40.7 years; range 14–72) with simple elbow dislocations were evaluated by four blinded examiners. An analysis of the interobserver agreement of all raters and for several subgroups (radiologists, orthopaedics, experienced, non-experienced) was performed. The examiners assessed the integrity (intact, partial tear, complete tear) of the lateral collateral ligament (LCL), medial collateral ligament (MCL), extensor and flexor tendons, as well as the presence of joint congruity, joint effusion, loose bodies and chondral lesions. Agreement strength, correlation and proportion of exact agreement were determined for interobserver agreement, and intraobserver agreement analyses. Results Interobserver agreement of all examiners was fair to moderate for collateral ligaments (LCL: 0.441, MCL: 0.275). Exact agreement of all raters was found in 33.3% for the LCL and in 26.7% for the MCL. The both experienced examiners showed highest agreement strength for the LCL (0.619) and the radiologists showed highest agreement strength for the MCL (0.627), the proportion of exact agreement was 60.0% in both categories. A high proportion of exact agreement regarding joint congruity (90%), joint effusion (100%), loose bodies (96.7%) and chondral lesion (80%) was found among the radiologists. The evaluation of the intraobserver agreement revealed slight to substantial agreement (0.227 to 0.718) for the collateral ligaments. Conclusions This study shows difficulties in the evaluation of ligaments by conventional MRI technique as demonstrated by a weak inter- and intraobserver agreement. This should be the basis to develop new MRI quality standards with special focus on coronal oblique reconstructions to improve the evaluation of ligament injuries after simple elbow dislocations.
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Affiliation(s)
- Marc Schnetzke
- Clinic for Trauma and Orthopaedic Surgery, BG Trauma Center Ludwigshafen at Heidelberg University Hospital, Ludwig-Guttmann-Strasse 13, Ludwigshafen on the Rhine, 67071, Germany
| | - Svenja Schüler
- Institute of Medical Biometry and Informatics, University of Heidelberg, Heidelberg, Germany
| | - Johannes Hoffend
- Department for Radiology, Klinikum der Stadt Ludwigshafen gGmbH, Ludwigshafen on the Rhine, Germany
| | - Rainer Simon
- Clinic for Trauma and Orthopaedic Surgery, BG Trauma Center Ludwigshafen at Heidelberg University Hospital, Ludwig-Guttmann-Strasse 13, Ludwigshafen on the Rhine, 67071, Germany
| | - Holger Keil
- Clinic for Trauma and Orthopaedic Surgery, BG Trauma Center Ludwigshafen at Heidelberg University Hospital, Ludwig-Guttmann-Strasse 13, Ludwigshafen on the Rhine, 67071, Germany
| | - Felix Porschke
- Clinic for Trauma and Orthopaedic Surgery, BG Trauma Center Ludwigshafen at Heidelberg University Hospital, Ludwig-Guttmann-Strasse 13, Ludwigshafen on the Rhine, 67071, Germany
| | - Stefan Studier-Fischer
- Clinic for Trauma and Orthopaedic Surgery, BG Trauma Center Ludwigshafen at Heidelberg University Hospital, Ludwig-Guttmann-Strasse 13, Ludwigshafen on the Rhine, 67071, Germany
| | - Paul-Alfred Grützner
- Clinic for Trauma and Orthopaedic Surgery, BG Trauma Center Ludwigshafen at Heidelberg University Hospital, Ludwig-Guttmann-Strasse 13, Ludwigshafen on the Rhine, 67071, Germany
| | - Thorsten Guehring
- Clinic for Trauma and Orthopaedic Surgery, BG Trauma Center Ludwigshafen at Heidelberg University Hospital, Ludwig-Guttmann-Strasse 13, Ludwigshafen on the Rhine, 67071, Germany.
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Watanabe K, Fukuzawa T, Mitsui K. Successful Closed Reduction of a Lateral Elbow Dislocation. Case Rep Orthop 2016; 2016:5934281. [PMID: 28097029 PMCID: PMC5209600 DOI: 10.1155/2016/5934281] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2016] [Revised: 11/23/2016] [Accepted: 12/04/2016] [Indexed: 11/17/2022] Open
Abstract
In this report, we present a case of lateral elbow dislocation treated with closed reduction. Lateral elbow dislocation is rare, and a closed reduction is reported with even less frequency. The reduction can be hindered by swelling and soft tissue interposition, and we describe the use of a nonoperative reduction technique performed under mild sedation with early physiotherapy to avoid joint stiffness. No additional complication was observed, and the normal range of elbow movement and function was obtained by early physiotherapy.
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Affiliation(s)
- Kenya Watanabe
- Department of Orthopedics, Nagano Prefectural Suzaka Hospital, Suzaka, Nagano, Japan
| | - Takuma Fukuzawa
- Department of Orthopedics, Nagano Prefectural Suzaka Hospital, Suzaka, Nagano, Japan
| | - Katsuhiro Mitsui
- Department of Orthopedics, Nagano Prefectural Suzaka Hospital, Suzaka, Nagano, Japan
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Abstract
Elbow stiffness is a common consequence following trauma with the management of this condition posing a challenge to therapists and surgeons alike. This paper discusses the role of conservative treatment, such as exercise and splinting, in the prevention and management of the stiff elbow, along with a review of available evidence, to justify their usage.
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Affiliation(s)
- Val Jones
- Val Jones, Sheffield Shoulder & Elbow Unit, Northern General Hospital, Herries Road, Sheffield S5 7AU, UK. Tel: +44 01142 714857.
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29
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Schnetzke M, Aytac S, Studier-Fischer S, Grützner PA, Guehring T. Initial joint stability affects the outcome after conservative treatment of simple elbow dislocations: a retrospective study. J Orthop Surg Res 2015; 10:128. [PMID: 26289111 PMCID: PMC4545864 DOI: 10.1186/s13018-015-0273-x] [Citation(s) in RCA: 36] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/14/2015] [Accepted: 08/09/2015] [Indexed: 01/28/2023] Open
Abstract
BACKGROUND Conservative 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. METHODS Sixty-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. RESULTS After 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). CONCLUSIONS This 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.
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Affiliation(s)
- Marc Schnetzke
- Berufsgenossenschaftliche Unfallklinik Ludwigshafen, Abteilung für Unfallchirurgie und Orthopädie, Ludwig Guttmann Straße 13, 67071, Ludwigshafen am Rhein, Germany.
| | - Sara Aytac
- Berufsgenossenschaftliche Unfallklinik Ludwigshafen, Abteilung für Unfallchirurgie und Orthopädie, Ludwig Guttmann Straße 13, 67071, Ludwigshafen am Rhein, Germany.
| | - Stefan Studier-Fischer
- Berufsgenossenschaftliche Unfallklinik Ludwigshafen, Abteilung für Unfallchirurgie und Orthopädie, Ludwig Guttmann Straße 13, 67071, Ludwigshafen am Rhein, Germany.
| | - Paul-Alfred Grützner
- Berufsgenossenschaftliche Unfallklinik Ludwigshafen, Abteilung für Unfallchirurgie und Orthopädie, Ludwig Guttmann Straße 13, 67071, Ludwigshafen am Rhein, Germany.
| | - Thorsten Guehring
- Berufsgenossenschaftliche Unfallklinik Ludwigshafen, Abteilung für Unfallchirurgie und Orthopädie, Ludwig Guttmann Straße 13, 67071, Ludwigshafen am Rhein, Germany.
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Panteli M, Pountos I, Kanakaris NK, Tosounidis TH, Giannoudis PV. Cost analysis and outcomes of simple elbow dislocations. World J Orthop 2015; 6:513-520. [PMID: 26301180 PMCID: PMC4539474 DOI: 10.5312/wjo.v6.i7.513] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/02/2015] [Revised: 04/28/2015] [Accepted: 06/02/2015] [Indexed: 02/06/2023] Open
Abstract
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.
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Harris M, Bishop T, Bernard J. Unstable elbow dislocations: the description and cadaveric feasibility study of a new surgical technique. SICOT J 2015; 1:23. [PMID: 27163079 PMCID: PMC4849263 DOI: 10.1051/sicotj/2015023] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/12/2023] Open
Abstract
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.
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Affiliation(s)
- Mark Harris
- Department of Orthopaedic surgery, St Georges NHS Foundation Trust Blackshaw Road Tooting, London SW17 0QT UK
| | - Timothy Bishop
- Department of Orthopaedic surgery, St Georges NHS Foundation Trust Blackshaw Road Tooting, London SW17 0QT UK
| | - Jason Bernard
- Department of Orthopaedic surgery, St Georges NHS Foundation Trust Blackshaw Road Tooting, London SW17 0QT UK
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Iordens GIT, Van Lieshout EMM, Schep NWL, De Haan J, Tuinebreijer WE, Eygendaal D, Van Beeck E, Patka P, Verhofstad MHJ, Den Hartog D. Early mobilisation versus plaster immobilisation of simple elbow dislocations: results of the FuncSiE multicentre randomised clinical trial. Br J Sports Med 2015; 51:531-538. [PMID: 26175020 DOI: 10.1136/bjsports-2015-094704] [Citation(s) in RCA: 44] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/17/2015] [Indexed: 11/04/2022]
Abstract
BACKGROUND/AIM To 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. METHODS From August 2009 to September 2012, 100 adult patients with a simple elbow dislocation were enrolled in this multicentre randomised controlled trial. Patients were randomised to early mobilisation (n=48) or 3 weeks plaster immobilisation (n=52). Primary outcome measure was the Quick Disabilities of the Arm, Shoulder, and Hand (Quick-DASH) score. Secondary outcomes were the Oxford Elbow Score, Mayo Elbow Performance Index, pain, range of motion, complications and activity resumption. Patients were followed for 1 year. RESULTS Quick-DASH scores at 1 year were 4.0 (95% CI 0.9 to 7.1) points in the early mobilisation group versus 4.2 (95% CI 1.2 to 7.2) in the plaster immobilisation group. At 6 weeks, early mobilised patients reported less disability (Quick-DASH 12 (95% CI 9 to 15) points vs 19 (95% CI 16 to 22); p<0.05) and had a larger arc of flexion and extension (121° (95% CI 115° to 127°) vs 102° (95% CI 96° to 108°); p<0.05). Patients returned to work sooner after early mobilisation (10 vs 18 days; p=0.020). Complications occurred in 12 patients; this was unrelated to treatment. No recurrent dislocations occurred. CONCLUSIONS Early active mobilisation is a safe and effective treatment for simple elbow dislocations. Patients recovered faster and returned to work earlier without increasing the complication rate. No evidence was found supporting treatment benefit at 1 year. TRIAL REGISTRATION NUMBER NTR 2025.
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Affiliation(s)
- Gijs I T Iordens
- Trauma Research Unit, Department of Surgery, Erasmus MC, University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Esther M M Van Lieshout
- Trauma Research Unit, Department of Surgery, Erasmus MC, University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Niels W L Schep
- Trauma Unit, Department of Surgery, Academic Medical Center, Amsterdam, The Netherlands
| | - Jeroen De Haan
- Department of Surgery, Westfriesgasthuis, Hoorn, The Netherlands
| | - Wim E Tuinebreijer
- Trauma Research Unit, Department of Surgery, Erasmus MC, University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Denise Eygendaal
- Department of Orthopaedic Surgery, Upper Limb Unit, Amphia Hospital, Breda, The Netherlands
| | - Ed Van Beeck
- Department of Public Health, Erasmus MC, University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Peter Patka
- Department of Emergency Medicine, Erasmus MC, University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Michael H J Verhofstad
- Trauma Research Unit, Department of Surgery, Erasmus MC, University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Dennis Den Hartog
- Trauma Research Unit, Department of Surgery, Erasmus MC, University Medical Center Rotterdam, Rotterdam, The Netherlands
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Hackl M, Beyer F, Wegmann K, Leschinger T, Burkhart KJ, Müller LP. The treatment of simple elbow dislocation in adults. DEUTSCHES ARZTEBLATT INTERNATIONAL 2015; 112:311-9. [PMID: 26037467 PMCID: PMC4455254 DOI: 10.3238/arztebl.2015.0311] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/27/2014] [Revised: 01/29/2015] [Accepted: 01/29/2015] [Indexed: 01/29/2023]
Abstract
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.
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Affiliation(s)
- Michael Hackl
- Department of Trauma-, Hand- and Elbow Surgery, University Hospital of Cologne
| | - Frank Beyer
- Department of Trauma-, Hand- and Elbow Surgery, University Hospital of Cologne
| | - Kilian Wegmann
- Department of Trauma-, Hand- and Elbow Surgery, University Hospital of Cologne
| | - Tim Leschinger
- Department of Trauma-, Hand- and Elbow Surgery, University Hospital of Cologne
| | | | - Lars Peter Müller
- Department of Trauma-, Hand- and Elbow Surgery, University Hospital of Cologne
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The frequency and risk factors for subsequent surgery after a simple elbow dislocation. Injury 2015; 46:1156-60. [PMID: 25796345 DOI: 10.1016/j.injury.2015.02.009] [Citation(s) in RCA: 37] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/02/2014] [Revised: 02/07/2015] [Accepted: 02/08/2015] [Indexed: 02/02/2023]
Abstract
INTRODUCTION Simple 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 METHODS All 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. RESULTS We 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. CONCLUSION Few 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.
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Giannakos A, Drenck T, Frosch KH. Akute und chronische Instabilitäten des Ellenbogengelenks. ACTA ACUST UNITED AC 2014. [DOI: 10.1007/s10039-014-2114-2] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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Hollinger B, Dehlinger F, Franke S. Diagnostik und Therapie der ligamentären Ellenbogeninstabilitäten. ACTA ACUST UNITED AC 2014. [DOI: 10.1007/s11678-014-0280-2] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
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The role of simple elbow dislocations in cubitus valgus development in children. INTERNATIONAL ORTHOPAEDICS 2013; 38:797-802. [PMID: 24337926 DOI: 10.1007/s00264-013-2199-4] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/05/2013] [Accepted: 11/11/2013] [Indexed: 12/28/2022]
Abstract
PURPOSE We investigated the functional and radiological outcomes of conservatively treated simple traumatic elbow dislocations and subsequent incidence of cubitus valgus development in children. METHODS 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). RESULTS 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. CONCLUSIONS 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.
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Gokcen B, Ozyurek S, Atik A, Sivrioglu AK, Kaya E, Keklikci K. Successful Closed Manipulation of Simple Lateral Dislocation of the Elbow Joint: A Case Report. Oman Med J 2013; 28:e062. [PMID: 31011404 DOI: 10.5001/omj.2013.131] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
The elbow is the second most commonly dislocated joint in adults. Simple lateral dislocation of the elbow joint is a rare traumatic injury, and successful closed reduction is difficult and even rarer. Our proposition is to report this rare case of traumatic simple lateral dislocation treated with closed reduction under sedation emphasizing the use of this simple technique initially in order to avoid possible complications with general anesthesia and surgery.
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Affiliation(s)
- Bahadir Gokcen
- Bingol State Hospital, Department of Orthopedics and Traumatology, Bingol, Turkey
| | - Selahattin Ozyurek
- Aksaz Military Hospital, Department of Orthopedics and Traumatology, Aksaz Military Hospital, 48150 Marmaris, Mugla, Turkey
| | - Aziz Atik
- Izmir Military Hospital, Department of Orthopedics and Traumatology, Izmir, Turkey
| | | | - Erkan Kaya
- Bursa Military Hospital, Department of Physical Medicine and Rehabilitation, Bursa, Turkey
| | - Kenan Keklikci
- Assistant Professor, GATA Haydarpasa Training Hospital, Department of Orthopedics and Traumatology, Istanbul, Turkey
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Jockel CR, Katolik LI, Zelouf DS. Simple medial elbow dislocations: a rare injury at risk for early instability. J Hand Surg Am 2013; 38:1768-73. [PMID: 23845588 DOI: 10.1016/j.jhsa.2013.05.014] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/05/2012] [Revised: 05/11/2013] [Accepted: 05/13/2013] [Indexed: 02/02/2023]
Abstract
PURPOSE 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. METHODS 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. RESULTS 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. CONCLUSIONS 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.
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Affiliation(s)
- Christopher R Jockel
- Thomas Jefferson University Hospital, Philadelphia Hand Center, Philadelphia, PA, USA
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Dehlinger F, Franke S, Hollinger B. Therapeutic options for acute and chronic elbow instability. Eur J Trauma Emerg Surg 2012; 38:585-92. [PMID: 26814543 DOI: 10.1007/s00068-012-0205-y] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2012] [Accepted: 06/16/2012] [Indexed: 10/28/2022]
Abstract
INTRODUCTION Acute elbow instability usually develops after injuries involving the bony or ligamentous stabilizers of the joint. It occurs frequently after dislocation and/or fracture-dislocation, but isolated valgus or varus overloading can also lead to ligament ruptures with subsequent instability. Chronic instability can result from incompletely healed acute injuries or from recurring microtrauma, for example after repetitive strain from participating in certain sports. CONCLUSION Stable conditions of the joint are essential for early functional post-traumatic or postoperative treatment of the elbow, as permanent mobility deficits may result otherwise. The following article gives an overview of the current understanding of these injuries and concepts in treatment.
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Affiliation(s)
- F Dehlinger
- ARCUS-Sportklinik, Rastatter Str. 17-19, 75179, Pforzheim, Germany.
| | - S Franke
- ARCUS-Sportklinik, Rastatter Str. 17-19, 75179, Pforzheim, Germany
| | - B Hollinger
- ARCUS-Sportklinik, Rastatter Str. 17-19, 75179, Pforzheim, Germany.
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42
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Thomas LG, Williams DT. Simple posterior elbow dislocation and brachial artery transection. J ROY ARMY MED CORPS 2012; 158:50-2. [PMID: 22545375 DOI: 10.1136/jramc-158-01-13] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
We report the uncommon occurrence of a complete brachial artery transection following simple posterior dislocation of the elbow, successfully managed by cephalic vein interposition grafting. This case together with a review of the literature was conducted with the aim of highlighting important issues regarding the diagnosis, management and prognosis of this rare complication.
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Affiliation(s)
- L G Thomas
- RAMC, Department of Vascular Surgery, Ysbyty Gwynedd, Bangor, UK
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Abstract
BACKGROUND Dislocation of the elbow joint is a relatively uncommon injury. OBJECTIVES To assess the effects of various forms of treatment for acute simple elbow dislocations in adults. SEARCH METHODS We searched the Cochrane Bone, Joint and Muscle Trauma Group Specialised Register (April 2011), the Cochrane Central Register of Controlled Trials (The Cochrane Library, 2011 Issue 1), MEDLINE (1948 to March Week 5 2011), EMBASE (1980 to 2011 Week 14), PEDro (April 2011), CINAHL (April 2011), various trial registers, various conference proceedings and bibliographies of relevant articles. SELECTION CRITERIA Randomised or quasi-randomised controlled trials of conservative and surgical treatment of dislocations of the elbow in adults. Excluded were trials involving dislocations with associated fractures, except for avulsion fractures. DATA COLLECTION AND ANALYSIS Data extraction and assessment of risk of bias were independently performed by two review authors. There was no pooling of data. MAIN RESULTS Two small randomised controlled trials, involving a total of 80 participants with simple elbow dislocations, were included. Both trials were methodologically flawed and potentially biased.One trial, involving 50 participants, compared early mobilisation at three days post reduction versus cast immobilisation. At one year follow-up, the recovery of range of motion appeared better in the early mobilisation group (e.g. participants with incomplete recovery of extension: 1/24 versus 5/26; risk ratio 0.22, 95% confidence interval 0.03 to 1.72). However, the results were not statistically significant. There were no reports of instability or recurrence. One person in each group had residual pain at one year.The other trial, involving 30 participants, compared surgical repair of the torn ligaments versus conservative treatment (cast immobilisation for two weeks). At final follow-up (mean 27.5 months), there were no statistically significant differences between the two groups in the numbers of patients who considered their injured elbow to be inferior to their non-injured elbow (10/14 versus 7/14; RR 1.43, 95% CI 0.77 to 2.66) or in other patient complaints about their elbow such as weakness, pain or weather-related discomfort. There were no reports of instability or recurrence. There were no statistically significant differences between the two groups in range of motion of the elbow (extension, flexion, pronation, and supination) or grip strength at follow-up. No participants had neurological disturbances of the hand but two surgical group participants had recurrent dislocation of the ulnar nerve (no other details provided). One person in each group had radiologically detected myositis ossificans (bone formation within muscles following injury). AUTHORS' CONCLUSIONS There is insufficient evidence from randomised controlled trials to determine which method of treatment is the most appropriate for simple dislocations of the elbow in adults. Although weak and inconclusive, the available evidence from a trial comparing surgery versus conservative treatment does not suggest that the surgical repair of elbow ligaments for simple elbow dislocation improves long-term function. Future research should focus on questions relating to non-surgical treatment, such as the duration of immobilisation.
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Affiliation(s)
- Fraser Taylor
- Department of Orthopaedics, Dunedin Hospital, Private Bag 1921, Dunedin, Otago, New Zealand.
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Abstract
Elbow dislocations are common athletic injuries and occur during a fall onto an outstretched hand as a combination of axial-compressive and rotational-shear forces are conducted across the elbow joint. Simple dislocations are those that involve purely ligamentous injury, while complex dislocations include periarticular fractures. The initial assessment, radiographic evaluation, and on-field treatment of these injuries is discussed. Multiple reduction techniques are described with the patient positioned both supine and prone. Definitive management involves primarily nonoperative treatment with limited immobilization and early active range of motion to minimize joint contracture and hasten return to pre-injury activities. For unstable elbows, surgical treatment is usually appropriate. Operative management may involve exploration, lateral ligament repair or reconstruction, and assessment of the need for medial ligament repair or reconstruction. The role of arthroscopic and arthroscopically assisted surgery for elbow dislocation is evolving. Clinical series have shown that extended periods of immobilization (> 3 weeks) are associated with poor outcomes. Early active range of motion should be initiated as early as possible because late or recurrent instability is uncommon. Contracture is the most common adverse sequela of elbow dislocation. The literature indicates an average of 3° to 8° of extension loss with standard management of simple elbow dislocations.
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Affiliation(s)
- Michael P McCabe
- Mississippi Sports Medicine and Orthopaedic Center, Jackson, MS, USA
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de Haan J, Schep NWL, Eygendaal D, Kleinrensink GJ, Tuinebreijer WE, den Hartog D. Stability of the elbow joint: relevant anatomy and clinical implications of in vitro biomechanical studies. Open Orthop J 2011; 5:168-76. [PMID: 21633722 PMCID: PMC3104563 DOI: 10.2174/1874325001105010168] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/13/2011] [Revised: 03/26/2011] [Accepted: 04/01/2011] [Indexed: 11/27/2022] Open
Abstract
The aim of this literature review is to describe the clinical anatomy of the elbow joint based on information from in vitro biomechanical studies. The clinical consequences of this literature review are described and recommendations are given for the treatment of elbow joint dislocation. The PubMed and EMBASE electronic databases and the Cochrane Central Register of Controlled Trials were searched. Studies were eligible for inclusion if they included observations of the anatomy and biomechanics of the elbow joint in human anatomic specimens. Numerous studies of the kinematics, kinesiology and anatomy of the elbow joint in human anatomic specimens yielded important and interesting implications for trauma and orthopaedic surgeons.
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Affiliation(s)
- J de Haan
- Department of Surgery-Traumatology, Westfriesgasthuis, P.O. Box 600, 1620 AR Hoorn, The Netherlands
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de Haan J, den Hartog D, Tuinebreijer WE, Iordens GIT, Breederveld RS, Bronkhorst MWGA, Bruijninckx MMM, De Vries MR, Dwars BJ, Eygendaal D, Haverlag R, Meylaerts SAG, Mulder JWR, Ponsen KJ, Roerdink WH, Roukema GR, Schipper IB, Schouten MA, Sintenie JB, Sivro S, Van den Brand JGH, Van der Meulen HGWM, Van Thiel TPH, Van Vugt AB, Verleisdonk EJMM, Vroemen JPAM, Waleboer M, Willems WJ, Polinder S, Patka P, van Lieshout EMM, Schep NWL. Functional treatment versus plaster for simple elbow dislocations (FuncSiE): a randomized trial. BMC Musculoskelet Disord 2010; 11:263. [PMID: 21073734 PMCID: PMC2994812 DOI: 10.1186/1471-2474-11-263] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/18/2010] [Accepted: 11/12/2010] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Elbow dislocations can be classified as simple or complex. Simple dislocations are characterized by the absence of fractures, while complex dislocations are associated with fractures. After reduction of a simple dislocation, treatment options include immobilization in a static plaster for different periods of time or so-called functional treatment. Functional treatment is characterized by early active motion within the limits of pain with or without the use of a sling or hinged brace. Theoretically, functional treatment should prevent stiffness without introducing increased joint instability. The primary aim of this randomized controlled trial is to compare early functional treatment versus plaster immobilization following simple dislocations of the elbow. METHODS/DESIGN The design of the study will be a multicenter randomized controlled trial of 100 patients who have sustained a simple elbow dislocation. After reduction of the dislocation, patients are randomized between a pressure bandage for 5-7 days and early functional treatment or a plaster in 90 degrees flexion, neutral position for pro-supination for a period of three weeks. In the functional group, treatment is started with early active motion within the limits of pain. Function, pain, and radiographic recovery will be evaluated at regular intervals over the subsequent 12 months. The primary outcome measure is the Quick Disabilities of the Arm, Shoulder, and Hand score. The secondary outcome measures are the Mayo Elbow Performance Index, Oxford elbow score, pain level at both sides, range of motion of the elbow joint at both sides, rate of secondary interventions and complication rates in both groups (secondary dislocation, instability, relaxation), health-related quality of life (Short-Form 36 and EuroQol-5D), radiographic appearance of the elbow joint (degenerative changes and heterotopic ossifications), costs, and cost-effectiveness. DISCUSSION The successful completion of this trial will provide evidence on the effectiveness of a functional treatment for the management of simple elbow dislocations. TRIAL REGISTRATION The trial is registered at the Netherlands Trial Register (NTR2025).
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Affiliation(s)
- Jeroen de Haan
- Department of Surgery-Traumatology, AR Hoorn, The Netherlands
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Abstract
The objective of this retrospective multicentre cohort study was to prospectively assess the long-term functional outcomes of simple and complex elbow dislocations.
We analysed the hospital and outpatient records of 86 patients between 01.03.1999 and 25.02.2009 with an elbow dislocation. After a mean follow-up of 3.3 years, all patients were re-examined at the outpatient clinic for measurement of different outcomes.
The mean range of motion was ROM 135.5°. The Mayo elbow performance index (MEPI) scored an average of 91.9 (87.5% of the patients were rated excellent or good). The average Quick disabilities of the arm, shoulder and hand (Quick- DASH) score was 9.7, the sports/music score 11.5 and work score 6.1. The Oxford function score was 75.7, Oxford pain score 75.2 and Oxford social-psychological score 73.9.
Elbow dislocation is a mild disease and generally, the outcome is excellent. Functional results might improve with early active movements.
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de Haan J, Schep NWL, Zengerink I, van Buijtenen J, Tuinebreijer WE, den Hartog D. Dislocation of the elbow: a retrospective multicentre study of 86 patients. Open Orthop J 2010; 4:76-9. [PMID: 20352027 PMCID: PMC2845787 DOI: 10.2174/1874325001004020076] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/17/2009] [Revised: 12/12/2009] [Accepted: 12/30/2009] [Indexed: 11/22/2022] Open
Abstract
The objective of this retrospective multicentre cohort study was to prospectively assess the long-term functional outcomes of simple and complex elbow dislocations. We analysed the hospital and outpatient records of 86 patients between 01.03.1999 and 25.02.2009 with an elbow dislocation. After a mean follow-up of 3.3 years, all patients were re-examined at the outpatient clinic for measurement of different outcomes. The mean range of motion was ROM 135.5°. The Mayo elbow performance index (MEPI) scored an average of 91.9 (87.5% of the patients were rated excellent or good). The average Quick disabilities of the arm, shoulder and hand (Quick- DASH) score was 9.7, the sports/music score 11.5 and work score 6.1. The Oxford function score was 75.7, Oxford pain score 75.2 and Oxford social-psychological score 73.9. Elbow dislocation is a mild disease and generally, the outcome is excellent. Functional results might improve with early active movements.
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Affiliation(s)
- Jeroen de Haan
- Department of Surgery and Traumatology, Westfriesgasthuis, Maelsonstraat 3, 1624 NP Hoorn, The Netherlands
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