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

Stabilizing effect of an elbow orthosis with an adjustable hinge axis after lateral collateral ligament injury: A biomechanical study

Background

Current commercial elbow braces have a straight hinge that does not account for the native carrying angle of the elbow. The objective of this study was to determine the effectiveness of a custom-designed hinged elbow orthosis (HEO) with variable valgus angulations in stabilizing a lateral collateral ligament (LCL) deficient elbow.

Methods

Eight cadaveric upper extremities were mounted in an elbow motion simulator in the abducted varus gravity-loaded position. The specimens were examined before and after simulated LCL injury and then with the addition of the custom-designed HEO with 0°, 10°, and 20° of valgus angulation. Kinematic data were recorded using an electromagnetic tracking system.

Results

The LCL injured state with or without the brace resulted in significant increases in varus angulation of the elbow compared to the intact state in both pronation and supination (P < 0.05). There were no significant differences in varus-valgus angulation or ulnohumeral rotation between any of the brace angles and the LCL injured state with the forearm pronated and supinated.

Discussion

The custom-designed HEO did not provide any additional stability to the LCL injured elbow. The varus arm position should be avoided during the rehabilitation of an LCL injured elbow even when an HEO is used.

Treatment strategies for simple elbow dislocation - a systematic review

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.

[Ligamentous elbow injuries-When is surgical treatment still indicated?]

The elbow joint is a hinge-type synovial joint and is the second most frequently dislocated joint in adults and the most frequently dislocated joint in children. To find the right treatment options a precise understanding of the injury pattern, anatomy, biomechanics and pathology (simple vs. complex dislocation) is essential for a good reconstruction of the function and to prevent chronic instability and pain. The differentiation between acute and chronic instability gives another variation in the treatment plan. According to the latest literature there are clear indications for surgery of a complex elbow dislocation, whereas for simple dislocations conservative treatment is preferentially recommended; however, when is the surgical treatment of a ligamentous elbow dislocation (still) indicated?

[Augmented primary sutures "internal bracing" following ligamentous elbow dislocation]

OBJECTIVE

Aim of surgical treatment is the primary stabilization of the unstable elbow following a ligamentous elbow dislocation.

INDICATIONS

Ligamentous elbow dislocations are typically accompanied by injuries to the surrounding musculature and collateral ligaments of the elbow joint. Surgical treatment is indicated in case of failure of nonoperative therapy, i.e., when a dislocation can only be prevented in immobilization > 90° and pronation of the elbow or an active muscular centering of the elbow fails after 5-7 days.

CONTRAINDICATIONS

Contraindications for a solely "internal bracing" augmented primary suture are generally in the case of accompanying bony injuries in elbow dislocations, extensive soft-tissue injuries, and septic arthritis of the elbow.

SURGICAL TECHNIQUE

The augmented primary suture of the elbow is performed using both a lateral (Kocher or Kaplan) and medial (FCU split) approach to the elbow. After reduction of the elbow, the collateral ligaments are first augmented with high-strength polyethylene suture and fixed in the distal humerus together with another high-strength polyethylene augmentation suture. The extensors and flexors are then fixed to the medial and lateral epicondyle, respectively, using suture anchors.

POSTOPERATIVE MANAGEMENT

The aim of the postoperative management is early functional exercise of the elbow. The elbow is placed in an elbow brace to avoid varus and valgus load.

RESULTS

Between August 2018 and January 2020, a total of 12 patients were treated with an augmented primary suture following unstable ligamentous elbow dislocation. After a mean follow-up of 14 ± 12.7 months, the mean Mayo Elbow Performance Score was 98.5 points with a mean functional arc of 115°. None of the patients reported a recurrent dislocation or persistent instability of the elbow.

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

PURPOSE

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

METHODS

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

RESULTS

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

CONCLUSION

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

LEVEL OF EVIDENCE

Therapeutic study, Level III.

Magnetic Resonance Imaging Findings After Elbow Dislocation: A Descriptive Study

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.

Early functional mobilization for non-operative treatment of simple elbow dislocations: a systematic review

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.

The inter-individual anatomical variation of the trochlear notch as a predisposition for simple elbow dislocation

PURPOSE

Besides the multi-layered capsule-ligamentous complex of the elbow joint the high bony congruence in the ulnohumeral joint contributes to elbow stability. Therefore, we assume that specific anatomical configurations of the trochlear notch predispose to dislocation. In case of ligamentous elbow dislocation both conservative and surgical treatment is possible without a clear treatment algorithm. Findings of constitutional bony configurations could help deciding for the best treatment option.

METHODS

In this retrospective matched-pair analysis we compared MRI imaging from patients sustaining a primary traumatic elbow dislocation (instability group) with patients suffering from chronic lateral epicondylitis (control group), treated between 2009 and 2019. Two independent observers measured different anatomical landmarks of the trochlear notch in a multiplanar reconstructed standardized sagittal trochlear plane (SSTP). Primarily, opening angle and relative depth of the trochlear notch were determined. After adjustment to the proximal ulnar rim in the SSTP, coronoid and olecranon angle, the articular angle as well as the ratio of the tip heights of the trochlear notch were measured.

RESULTS

We compared 34 patients in the instability group (age 48 ± 14 years, f/m 19/15) with 34 patients in the control group (age 47 ± 16 years, f/m 19/15). Instability group showed a significantly larger opening angle (94.1° ± 6.9° vs. 88.5° ± 6.9°, p = 0.0002), olecranon angle (60.9° ± 5.3° vs. 56.1° ± 5.1°, p < 0.0001) and articular angle (24.7° ± 6.4° vs. 22.3° ± 5.8°, p = 0.02) compared to the control group. Measuring the height from the coronoid (ch) and olecranon (oh) tip also revealed a significantly larger tip ratio (tr = ch/oh) in the instability group (2.7 ± 0.8 vs. 2.2 ± 0.5, p < 0.0001). The relative depth (61.0% ± 8.3% vs. 62.7% ± 6.0%, p = 0.21) of the trochlear notch as well as the coronoid angle (32.8° ± 4.5° vs. 31.7° ± 5.2°, p = 0.30) showed no significant difference in the instability group compared to the control group. The interrater reliability of all measurements was between 0.83 and 0.94.

CONCLUSION

MRI of patients with elbow dislocation show that there seems to be a bony anatomical predisposition. According to the results, it seems reasonable to include predisposing bony factors in the decision-making process when surgical stabilization and conservative treatment is possible. Further biomechanical studies should prove these assumptions to generate critical bony values helping surgeons with decision making.

LEVEL OF EVIDENCE

III.

Elbow Dislocations in the National Football League: Epidemiology and Management

Background Currently, it is not known how the combined osseous and ligamentous injury of a traumatic elbow dislocation in a National Football League (NFL) athlete affects management and return to play. In this study, we aimed to describe the epidemiology, management, and return to play for elbow dislocations in NFL athletes. Methodology This is a descriptive observational study. A retrospective review of all elbow dislocations between 2000 and 2014 (15 seasons) was performed using the NFL Injury Surveillance System (NFLISS). Results Over 15 NFL seasons, 82 elbow dislocations were recorded in the NFLISS. Among players who reported surgery (n = 5), players missed an average of 73.8 days of play. Among those who did not report surgery, players missed an average of 36.1 days. The overall incidence was 0.26 dislocation events per 10,000 athlete exposures. The majority of these injuries occurred during regular-season games, in defensive linebackers and linemen, during tackling contact with another player, and most commonly on a running play. Conclusions This study demonstrates that an elbow dislocation is not a career-ending or season-ending injury in an NFL cohort. Information regarding incidence, positions affected, whether surgical management is utilized, and return to play will help players who sustain and physicians who treat these injuries in elite football athletes understand the impact of their injuries.

Simple traumatic elbow dislocations; benefit from early functional rehabilitation: A systematic review with meta-analysis including PRISMA criteria

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.

Hidden instability in posttraumatic stiff elbows

BACKGROUND

Hidden instability could be one of the reasons for reoccurring stiffness after arthrolysis in posttraumatic elbows. Associated instability in stiff posttraumatic elbows is clinically hard to detect. Surgical treatment for instability and stiffness in the same surgical setting is challenging and has not been evaluated as of yet.

HYPOTHESIS

The primary hypothesis assumes (1) the existence of a posttraumatic "stiff and unstable elbow" and (2) that coexisting instability can be detected by arthroscopic instability testing. The secondary objective was to report the midterm results after arthrolysis and ligament stabilization in the stiff and unstable elbow.

METHODS

From 2005 to 2015, 55 patients received arthroscopic arthrolysis of the elbow due to posttraumatic elbow stiffness at our institution. The arthroscopic instability was categorized into three grades with a switching stick: grade I (= stable), grade II (mild instability) and grade III (grossly instable). In cases of persisting instability (grade II-III), a ligament stabilization procedure was performed and all patients were followed up clinically at a minimum of 12 months. Besides ROM and clinical joint stability, PROs (patient reported outcomes) were assessed with the PREE-score (patient-rated elbow evaluation) and the Oxford-Elbow-score (OES). Furthermore, the MEPS (Mayo-elbow-performance-score) was assessed.

RESULTS

Out of 55 cases presenting for arthrolysis, coexisting elbow instability was detected during arthroscopic instability testing in 22 cases (40%). All 22 patients received additional ligament stabilization. At final follow-up 62.7 ± 35.7 months postoperatively, 20 patients (12 men; 8 women) with a mean age of 42 ± 16.8 were available. PREE, OES and MEPS were 19.8 ± 25.3, 37.5 ± 9.8 and 80 ± 14.5, respectively. ROM improved significantly from 95° ± 29° to 110° ± 24° postoperatively (p = 0.045). Five patients required revision arthrolysis within the follow-up period (20%). One patient demonstrated persisting instability (5%).

CONCLUSION

Intraoperative instability diagnostics during arthroscopic arthrolysis helps detect persisting posttraumatic instability and may provide a solid indication for a concurrent ligament stabilization procedure. This study is the first to present the postoperative results after arthrolysis with stabilization of the posttraumatic, stiff and unstable elbow. However, the results are heterogenic with 25% requiring revision arthrolysis. Therefore, the stiff but unstable elbow remains a complex clinical presentation in need of further investigations.

LEVEL OF EVIDENCE

IV.

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

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

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

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

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

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

Purpose

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

Methods

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

Results

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

Conclusion

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

Posterolateral Rotary Instability of the Elbow in Adolescents: A Report of 2 Cases and Review of the Literature

CASES

The authors present 2 cases of chronic posterolateral rotatory instability (PLRI) of pediatric elbows successfully treated with lateral collateral ligament (LCL) reconstruction using semitendinosus tendon allograft, including the first documented case of LCL reconstruction in the setting of an Osborne-Cotterill lesion in a pediatric patient. Full resolution of PLRI was achieved, and the patients returned to preinjury full-contact sports at 5 months postoperatively.

CONCLUSIONS

Few studies have reported LCL reconstruction in the setting of chronic PLRI in pediatric patients. The purpose of this report is to aid in the diagnosis and treatment of elbow PLRI and to describe a surgical option for recurrent PLRI in pediatric patients.

The Acutely Injured Elbow

The acutely injured elbow can present as a diagnostic challenge, encompassing a spectrum of conditions that involve the various osseous and soft tissue structures of this complex joint. Imaging plays a vital role in the management of these patients by providing an accurate interpretation of the underlying trauma sustained, which can have important implications on the preservation of joint function and stability. This article examines the mechanisms, patterns, classifications, and imaging findings of acute elbow injuries, providing key concepts for the radiologist in the interpretation of these injuries.

Current Approach to the Management of Forearm and Elbow Dislocations in Children

Pediatric orthopedic injuries are a common reason for presentation to the emergency department. This article sequentially discusses 2 important upper extremity injuries that require prompt management in the emergency department. Radial head subluxations are discussed with a focus on current evidence for imaging, reduction techniques, and follow-up. Elbow dislocations, although less common than radial head subluxations, are also addressed, highlighting imaging, reduction, immobilization, and follow-up recommendations.

Analysis of magnetic resonance imaging-confirmed soft tissue injury pattern in simple elbow dislocations

BACKGROUND

The elbow is the second most commonly dislocated joint. Stability depends on the degree of soft tissue injury, with 2 proposed patterns, one starting laterally and the other medially. The purpose of this study was to describe the injured structures observed in magnetic resonance images (MRIs) in a prospective cohort of simple elbow dislocations.

METHODS

We evaluated 17 consecutive cases of simple elbow dislocations. Two musculoskeletal radiologists assessed the initial x-ray images and MRIs performed for all elbows. Radiologists evaluated the following soft tissue structures: medial collateral ligament complex (MCL), flexor-pronator muscle mass origin, anterior capsule (AC), posterior capsule, lateral collateral ligament complex (LCL), and extensor muscle mass origin. The radiologists were blinded to the study hypothesis.

RESULTS

The initial radiographs in 16 patients showed the dislocation was posterolateral in 12, posterior in 3, and posteromedial in 1. We observed complete AC tear in 12 patients, MCL in 10, and LCL in 9. The inter-rater reliability for the radiologists was 0.70 (substantial) for MRI.

CONCLUSIONS

In our series after simple elbow dislocation, complete AC tears were most common, followed by MCL and LCL tears. No single mechanism-related soft tissue injury pattern of simple elbow dislocation was observed, and different grades of soft tissue injury exist.

Determination of Elbow Laxity in a Sequential Soft-Tissue Injury Model: A Cadaveric Study

BACKGROUND

The objective of our study was to analyze, under fluoroscopy, joint angulation of uninjured elbows and elbows with distinct induced collateral ligament injury.

METHODS

Twelve elbow specimens were tested for varus and valgus joint angulation using 4 different examination methods (application of both varus and valgus stress by each of 2 examiners [Examiner 1 and Examiner 2] and application of 1 and 2 Nm of torque using a calibrated electric force scale) in 4 elbow positions (in full extension with 90° of supination and 90° of pronation, and in 30° of flexion with 90° of supination and 90° of pronation). Six elbow specimens were examined under varus stress at each of 5 sequential stages: (1) intact, (2) transection of the lateral ulnar collateral ligament (LUCL), (3) complete transection of the lateral collateral ligament complex (LCLC), (4) transection of the anterior aspect of the capsule (AC), and (5) transection of the medial collateral ligament (MCL). An additional 6 elbow specimens were examined under valgus stress at 5 sequential stages: (1) intact, (2) transection of the anteromedial collateral ligament (AML), (3) complete transection of the MCL, (4) transection of the AC, and (5) transection of the LCLC. Examinations under fluoroscopy were made to measure the joint angulation. Intraclass correlation coefficients (ICCs) were calculated.

RESULTS

Testing of the intact elbow specimen by both examiners showed a joint angulation of <5°. Transection of the LUCL led to a varus joint angulation of 4.3° to 7.0°, and transection of the AML resulted in a valgus joint angulation of 4.9° to 8.8°. Complete dissection of the respective collateral ligament complex resulted in a joint angulation of 7.9° to 13.4° (LCLC) and 9.1° to 12.3° (MCL), and additional transection of the AC led to a joint angulation of >20° in some positions in both the medial and the lateral series. Under varus stress, elbow dislocations occurred only after dissection of the LCLC+AC (26% of the examinations) and additional dissection of the MCL (59%). Under valgus stress, elbow dislocations occurred only after dissection of the MCL+AC (30%) and additional dissection of the LCLC (47%). Very good to excellent ICCs were found among Examiners 1 and 2 and the tests done with the standardized torques at stages 1 through 4.

CONCLUSIONS

Dynamic fluoroscopy makes it possible to distinguish among different stages of collateral ligament injury of the elbow and therefore might be helpful for guiding treatment of simple elbow dislocations.

CLINICAL RELEVANCE

Assessment of collateral ligament injury with varus and valgus stress testing under fluoroscopy is an easily available method and is often used as the imaging modality of choice to determine the degree of elbow laxity. The technique and results described in this study should form the basis for additional clinical studies.

The Assessment and Management of Simple Elbow Dislocations

Background:

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

Methods:

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

Results:

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

Conclusion:

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

Simple elbow dislocation

The elbow is the second most commonly dislocated major joint in adults. Good long-term outcomes have been reported after non-operative management; however, a small proportion (<10%) of patients have a poor outcome and some do require surgical intervention. A review of the anatomy, pathoanatomy, management and outcomes of simple elbow dislocations is presented. Emphasis is placed on emerging concepts regarding the soft tissue injury, the stabilising structures that are injured, the sequence and mechanism of injury and the relationship to elbow stability. The benefits of nonsurgical and surgical management are discussed and a treatment algorithm based on the pathoanatomy is proposed.

Outcomes of After-Hours Hip Fracture Surgery

BACKGROUND

Given single-institution studies showing trends between after-hours hip fracture surgical procedures and adverse outcomes, as well as fixation time targets that may increasingly compel after-hours operations, we investigated the relationship between after-hours hip fracture surgical procedures and adverse outcomes in a large, population-based cohort.

METHODS

All Ontarians who were ≥60 years of age and underwent a hip fracture surgical procedure between April 2002 and March 2014 were eligible for study inclusion. Data were obtained from linked health administrative databases. The primary exposure was after-hours provision of surgical procedures, occurring weekday evenings between the hours of 5 P.M. and 12 A.M. or over the weekend, but not overnight (after 12 A.M. to 7 A.M.). Surgical complications up to 6 months following a hip fracture surgical procedure comprised the primary outcome. Medical complications, including mortality, up to 90 days postoperatively were also assessed. Odds ratios (ORs) were calculated using a logistic regression model that accounted for clustering at the hospital level and adjusted for patient, provider, and fracture characteristics previously shown to explain the majority of variance in hip fracture outcomes.

RESULTS

During the study period, 87,647 patients underwent an isolated hip fracture surgical procedure; 51.2% of these patients had femoral neck fractures, 44.1% had intertrochanteric fractures, and 4.7% had subtrochanteric fractures. The surgical procedure occurred after hours in 59,562 patients (68.0%), and 27,240 patients (31.1%) underwent a surgical procedure during normal hours (7 A.M. to 5 P.M.). Only 845 patients (1%) underwent a surgical procedure overnight. We observed no significant relationships between timing of the surgical procedure and adverse outcomes, except for patients who had undergone an after-hours surgical procedure and had fewer inpatient surgical complications (OR, 0.90 [95% confidence interval, 0.83 to 0.99]; p = 0.01).

CONCLUSIONS

Adverse outcomes following a hip fracture surgical procedure were similar whether a surgical procedure occurred during normal hours or after hours. Concerns regarding the quality of after-hours surgical procedures should not influence hip fracture prioritization policy. However, given that the great majority of hip fracture surgical procedures occurred after hours, future research should examine other potential consequences of this practice, such as financial impact and surgeon burnout.

LEVEL OF EVIDENCE

Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Elbow Dislocations in Contact Sports

Elbow dislocations are more common in athletes than in the general population. Simple elbow dislocations should be managed with early range of motion and early return to sport, even with high-level contact athletes. Patients with instability on examination or with complex elbow dislocations may require surgical intervention. Overall, the outcomes after simple elbow dislocations are excellent and athletes should be able to return to play without significant limitations.