Treatment of posteromedial and posterolateral dislocation of the acute unstable elbow joint: a strategic approach

Simple acute postero-lateral elbow dislocation: A historical perspective

PURPOSE

The aims of this study were to summarize (1) the historical knowledge of the posterolateral elbow dislocation (PLED) pattern and the biomechanical, radiographic, and clinical data that engendered its evolution; and (2) to help clinicians better understand the management of PLED.

METHODS

A literature search was performed using Ovid, Scopus and Cochrane Library, and the Medical Subject Headings vocabulary. Results are discussed as a chronologic review of the relevant literature between 1920-2022.

RESULTS

In 1966 Osborn and Cotterill were the first to describe posterolateral rotatory instability (PLRI) causing the PLED. Several theories on PLED were then published by others surgeons as our understanding of elbow biomechanics continued to improve. Multiple treatment protocols have been designed based on the aforementioned theories. Conservative and surgical treatment for PLED provides excellent functional outcomes. However, high rates of persistent pain stiffness and instability have been reported long-term, and no single approach to treatment has been widely accepted.

CONCLUSION

Despite a growing body of biomechanical evidence, there is no consensus surgical indication for the treatment of PLED. Both conservative and surgical management result in satisfactory functional outcomes after PLED. However, elevated rates of residual pain, and instability have also been described and may limit heavy labor and sports participation. The next challenge for elbow surgeons will be to identify those patients who would benefit from surgical stabilization following PLED.

Treatment Outcomes of Simple Elbow Dislocations: A Systematic Review of 1,081 Cases

BACKGROUND

The treatment of simple elbow dislocations (SEDs) has become more functional last decade with a tendency to shorter immobilization of the elbow, whereas simultaneously, surgical stabilization has been promoted by some authors. The primary aim of this study was to systematically review the literature and analyze the outcomes and complications of different treatment options for acute and persistent SEDs, including operative and nonoperative treatments with varying immobilization periods.

METHODS

A literature search was performed based on the online medical databases MEDLINE, Embase, and the Cochrane databases. Articles presenting patients with a SED were eligible for inclusion. When an SED persists for >3 weeks, it is categorized as persistent. Various outcome measures were assessed, including the range of motion (ROM), patient-reported outcome measures, and complication rates. To get insight into the severity of complications, all complications were categorized as minor or major. The Methodological Index for Nonrandomized Studies was used to assess the methodological quality of nonrandomized studies. The risk of bias in the randomized studies was assessed with the Cochrane risk-of-bias tool.

RESULTS

A total of 37 articles were included with 1,081 dislocated elbows (1,078 patients). A fair quality of evidence was seen for the nonrandomized studies and a low risk of bias for the randomized study. Nonoperative treatment was administered to 710 elbows, with 244 elbows treated with early mobilization, 239 with 1- to 3-week immobilization, and 163 with ≥3-week immobilization. These groups showed a ROM flexion-extension arc (ROM F/E) of 137, 129, and 131°, respectively. Surgical treatment as open reduction and ligament repair or reconstruction was performed in 228 elbows and showed a ROM F/E of 128°. All persistent SEDs were treated surgically and showed a ROM F/E of 90°.

CONCLUSION

The early mobilization treatment showed the most consistent satisfactory outcomes in the literature compared with the other treatment options. Nevertheless, there remains ambiguity regarding which patients would benefit more from surgery than nonoperative treatment.

LEVEL OF EVIDENCE

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

Acute Ligament Injuries of the Elbow

Ulnar collateral, radial collateral, lateral ulnar collateral, and annular ligaments can be injured in an acute trauma, such as valgus stress in athletes and elbow dislocation. Recognizing normal anatomy in magnetic resonance imaging and ultrasonography studies is important to identify ligamentous abnormalities in these imaging modalities.

Feasibility and technique of ultrasound traumatic elbow lesion assessment

INTRODUCTION

The present study aimed to describe the technique of ultrasound traumatic elbow lesion assessment performed by an orthopedic surgeon.

METHODS

Nine patients were included in a single-center study. Clinical examination assessed pain, ranges of elbow motion, neurovascular status and elbow ligament testing. Ultrasound was associated to radiography between days 7 and 15, screening for lesions of the bone, medial ligament (in 30-90° flexion), lateral ligament (elbow at 90° in cobra position) and epitrochlear and epicondylar muscle insertions. Ultrasound scanning time and echogenicity were assessed.

RESULTS

Four radial head osteochondral fractures were detected on ultrasound in addition to the 4 fractures seen on radiography, without significant difference (p=0.071). Clinical examination found 2 cases of valgus laxity and 5 of varus laxity. Ultrasound, performed blind to radiography, found 1 medial collateral ligament anterior bundle lesion (in 1 of the 2 patients with valgus laxity) and 4 lateral collateral ligament ulnar bundle lesions (in 4 of the 5 patients with varus laxity). There were no epicondylar or epitrochlear tendon lesions. Scanning time decreased significantly over the study period, from a mean 30minutes in the first 5 cases to a mean 24.8minutes in the last 5 (p=0.046). Three patients could not be put in the cobra position, and 3 showed poor echogenicity.

DISCUSSION

Ultrasound assessment of traumatic elbow lesions could be performed by an orthopedic surgeon on a well-defined protocol. Lesions on ultrasound matched clinical symptomatology. Inter- and intra-observer reproducibility remain to be assessed.

LEVEL OF EVIDENCE

IV.

Acute elbow dislocation: comparison between magnetic resonance imaging and intra-operative finding of ligament injury

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.

Elbow Dislocation

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.