Posteromedial Elbow Dislocations without Relevant Osseous Lesions: Clinical Characteristics, Soft-Tissue Injury Patterns, Treatments, and Outcomes

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.

Sensitivity and specificity of the posterolateral rotatory drawer test in the diagnosis of lateral collateral ligament insufficiency of the elbow

BACKGROUND

Numerous clinical tests are described for the diagnosis of chronic lateral collateral ligament (LCL) insufficiency of the elbow; however, none of these tests have been adequately assessed for sensitivity, with at most 8 patients included in previous studies. Furthermore, no test has had specificity assessed. The posterolateral rotatory drawer (PLRD) test is thought to have improved diagnostic accuracy over other tests in the awake patient. The aim of this study is to formally assess this test using reference standards in a large cohort of patients.

METHODS

A total of 106 eligible patients were identified for inclusion from a single-surgeon database of operative procedures. Examination under anesthetic (EUA) and arthroscopy were chosen as the reference standards to compare the PLRD test against. Only patients with a clearly documented PLRD test finding performed preoperatively in the clinic, and a clearly documented EUA and/or arthroscopic findings from surgery were included. A total of 102 patients underwent EUA, 74 of whom also underwent arthroscopy. Twenty-eight patients had EUA, and then an open procedure without arthroscopy. Four patients had arthroscopy without a clearly documented EUA. Sensitivity, specificity, and positive (PPV) and negative predictive values (NPV) were calculated with 95% confidence intervals.

RESULTS

Thirty-seven patients had a positive PLRD test, and 69 had a negative test. Compared to the reference standard of EUA (n = 102), the PLRD test had a sensitivity of 97.3% (85.8%-99.9%) and a specificity of 98.5% (91.7%-100%) (PPV = 0.973, NPV = 0.985). Compared to the reference standard of arthroscopy (n = 78), the PLRD test had a sensitivity of 87.5% (61.7%-98.5%) and a specificity of 98.4% (91.3%-100%) (PPV = 0.933, NPV = 0.968). Compared to either reference standard (n = 106), the PLRD test has a sensitivity of 94.7% (82.3%-99.4%) and a specificity of 98.5% (92.1%-100%) (PPV = 0.973, NPV = 0.971).

CONCLUSION

The PLRD test demonstrated an overall sensitivity of 94.7% and specificity of 98.5% with high positive and negative predictive values. This test is recommended as the primary diagnostic tool for LCL insufficiency in the awake patient and should be widely incorporated into surgical training.

Acute elbow dislocation: a critical appraisal of the literature

Background

The purpose of this study was to perform a narrative review of acute elbow dislocation (AED). There are certain aspects of the management of AED that are controversial, including type and length of immobilization, indications for surgery, type of surgery, and new evidence available.

Material and methods

A literature search was performed using MEDLINE and Embase databases for studies regarding AED. Preference was given to studies according to their level of evidence. Studies regarding the outcome of conservative and surgical treatment, including patient-reported outcomes, complications, and conversion to stabilization or revision surgery were included.

Results

We found only 1 level I study and 3 level II randomized clinical trials. The rest consisted of level III-V evidence. Conservative care continues to be the standard of care for stable AEDs. Shorter immobilization periods are favored when possible. A consensus definition of an unstable elbow still needs to be improved. Unstable simple elbow dislocation may benefit from surgical intervention with different techniques showing similar outcomes. Advances in surgical procedures and suture designs, including tapes, and ligament augmentation, need to prove their role in managing acute elbow instability.

Conclusion

There is a need for higher quality studies after the reduction of an AED, including discerning the outcome of specific patterns of injury and particular groups of patients like high-level athletes or people with preoperative laxity. Comparison between different surgical techniques is warranted, including arthroscopic techniques and types of ligament augmentation to promote early motion and reduce postoperative stiffness.

Long-Term Follow-up (14 to 25 Years) Following Closed Reduction and Early Movement for Simple Dislocation of the Elbow

BACKGROUND

We have previously reported on the midterm outcomes after a nonoperative protocol to treat simple dislocations of the elbow that included a short period of splinting followed by early movement. We have now performed extended follow-up of the original patient group from the prior study to determine whether the excellent results that previously had been reported were maintained in the long term and also to determine the rate of and need for any late surgical intervention.

METHODS

We attempted to contact all of the patients from the original study group. We requested that they complete the Oxford Elbow Score (OES) survey, the Disabilities of the Arm, Shoulder and Hand (DASH) questionnaire, and a validated patient satisfaction questionnaire. Patients also were requested to attend a face-to-face assessment to have a clinical examination that included neurovascular, range-of-motion, and ligamentous stability assessments.

RESULTS

Seventy-one patients from the original patient group agreed to participate in the new study. The mean duration of follow-up was 19.3 years. At the time of the final follow-up, patients reported excellent functional outcome scores and a preserved functional range of movement in the injured elbow. The mean OES was 91.6 points, the mean DASH score was 5.22 points, and the mean satisfaction score was 90.9 points. None of the patients had undergone delayed or secondary surgery for instability during the interval period.

CONCLUSIONS

This study demonstrated that the original excellent outcomes following treatment with a protocol of a short period of splinting and early movement remained excellent and were maintained into the very long term.

LEVEL OF EVIDENCE

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

Posteromedial elbow dislocation with irreducible medial condyle fracture in adult, a case report

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.

The radiological findings in complex elbow fracture-dislocation injuries

Elbow fracture-dislocation is a complex injury which can lead to significant bony and soft tissue damage. Surgical intervention is guided towards restoring joint stability, allowing early mobilization and preventing long-term joint stiffness. The most common types are posterolateral, posteromedial, Monteggia type (and variants), and anterior trans-olecranon fracture-dislocations. Posterolateral fracture-dislocation is characterized by a radial head fracture (± anterolateral coronoid fracture) and typically capsuloligamentous disruption (lateral collateral ligaments injury is the most common). A posterolateral fracture-dislocation with radial head and coronoid anterolateral facet fractures is termed a terrible triad injury. In posteromedial fracture-dislocation, there is a fracture of the anteromedial facet of the coronoid, typically with proximal avulsion of the lateral collateral ligaments (± injury to the posterior bundle of the ulnar collateral ligament). Monteggia fracture-dislocation injuries demonstrate proximal ulnar fracture (with possible involvement of the olecranon and the coronoid) and radial head dislocation. These can be divided into apex anterior or apex posterior variants. The latter are commonly associated with radial head fractures and lateral ligamentous injury, and have a worse prognosis. In trans-olecranon fracture-dislocation, there is significant disruption of the greater sigmoid notch and the olecranon, with various involvement of the coronoid and the proximal ulna. The article describes the radiological findings and outlines the management principles in complex elbow fracture-dislocation injuries.

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.

The three-column concept of elbow joint stability and the Wrightington elbow fracture-dislocation classification, emphasizing the role of cross-sectional imaging

Elbow fracture-dislocation is a complex injury with a combination of osseous and soft tissue disruption. Different classification systems have been used to describe the injury pattern and help guide the management. The article describes the important cross-sectional findings in complex elbow fracture-dislocation injuries based on the relatively new Wrightington classification. This includes the various elements and patterns seen in elbow fracture-dislocations providing a simple and comprehensive system to classify these injuries and help guide the surgical management. The article also describes the three-column concept of elbow joint stability, dividing the elbow joint osseous structures into lateral, middle and medial columns. Detailed radiological assessment of the fractures pattern is vital to understand the mechanism of injury, allowing clinicians to predict the associated capsuloligamentous injury and help guide the management decisions. The Wrightington elbow fracture-dislocation classification categorizes the injuries according to the ulnar coronoid process and radial head fractures. Type A is an anteromedial coronoid fracture. Type B is a bifacet or basal coronoid fracture, with B + indicating associated radial head fracture. Type C is a combined anterolateral facet and radial head or comminuted radial head fractures. Type D is a diaphyseal ulnar fracture, with D + indicating associated radial head fracture.

Posteromedial rotatory instability of the elbow: What the radiologist needs to know

Varus posteromedial rotatory instability of the elbow joint is a relatively new subject described for the first time in 2003. It occurs secondary to axial loading of the elbow with varus force and internal rotation of the forearm. There is usually a specific pattern of osseous and soft tissue injuries that can be recognized on imaging. This includes an anteromedial coronoid fracture and avulsion of the lateral collateral ligament complex from its humeral attachment. Ulnar collateral ligament complex injury is also reported, particularly its posterior bundle which plays an important role in posteromedial elbow joint stability. There is high incidence of early osteoarthritis secondary to the resultant varus instability and increased contact pressure at the ulnohumeral joint. Surgical fixation of the coronoid fracture and ligamentous reconstruction maybe indicated to prevent this recurrent instability. The article reviews the key radiological features of posteromedial rotatory instability with multiple examples from different imaging modalities. The relevant anatomy of the elbow joint stabilising structures will be illustrated, in particular the coronoid process anatomy and the O'Driscoll classification for coronoid process fractures. Radiologists should be familiar with the imaging findings of posteromedial rotatory instability.

Characteristics of Elbow Dislocation in Patients with Preexisting Cubitus Varus

BACKGROUND

The aim of this study was to investigate the clinical presentations, patterns of soft-tissue injuries, and outcomes of treatment of elbow dislocations in patients with preexisting cubitus varus.

METHODS

Four cases of elbow dislocation in patients with preexisting cubitus varus, which were treated at 3 residency training hospitals, were retrospectively reviewed. Soft-tissue injury patterns were investigated using magnetic resonance imaging (MRI). Clinical outcomes were assessed at an average of 50.8 months (range, 34-82 months) after treatment using the Mayo Elbow Performance Score (MEPS) and the Quick Disabilities of the Arm, Shoulder and Hand (QuickDASH) score.

RESULTS

The mean patient age was 49.5 years (range, 33-57 years). All patients had a posteromedial elbow dislocation, which was an indirect injury caused by a fall onto an outstretched hand. One patient had failed closed reduction; 3 others had redislocation or gross instability after closed reduction. Significant tears of the lateral collateral ligament complex and common extensor group were shown in MRI. All patients had surgical treatment including lateral complex repair only (n = 2), repair of both sides' complexes (n = 1), and corrective osteotomy with lateral complex repair (n = 1). At the final follow-up, the mean MEPS was 92.5 ± 8.7 and the mean QuickDASH score was 4.5 ± 6.4.

CONCLUSIONS

Elbow dislocation in patients with preexisting cubitus varus may present as posteromedial dislocation with acute instability. Surgical treatment of this injury led to acceptable clinical outcomes.

Treatment of elbow instability: state of the art

The elbow is a congruent joint with a high degree of inherent stability, provided by osseous and soft-tissue constraints; however, when substantial lesions of these stabilising structures happen, instability of the elbow occurs. Significant improvements in surgical elbow instability diagnosis and treatment have been recently introduced both for acute and chronic cases. Specific stress tests, recently introduced in the clinical practice, and different imaging techniques, both static and dynamic, allow assessment of the elbow stabilisers and detection of the instability direction and mechanism even in subtle forms. Many surgical techniques have been standardised and surgical instruments and devices, specifically dedicated to elbow instability treatment, have been developed. Specific rehabilitation protocols have been designed to protect the healing of the elbow stabilisers while minimising elbow stiffness. However, despite the progress, surgical treatments can be challenging even for expert surgeons and the rate of persistent instability, post-traumatic arthritis, stiffness and pain can be still high especially in most demanding cases. The biology of the soft-tissue healing remains one of the most important aspects for future investigation. If future research will help to understand, correct or modulate the biological response of soft-tissue healing, our confidence in elbow instability management and the reproducibility of our treatment will tremendously improve. In this paper, the state of the art of the current knowledge of elbow instability is presented, specifically focusing on modern surgical techniques used to solve instability, with repair or reconstruction of the damaged elbow stabilisers.

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.

Distribution of Osteochondral Lesions in Patients With Simple Elbow Dislocations Based on MRI Analysis

Background:

The clinical relationship between osteochondral lesions and long-term outcomes and patterns in the elbow joint has not yet been established. A sole evaluation from plain standard radiography may underestimate the severity of bony lesions in patients with simple dislocations. It has been suggested that the mechanism of a posterior elbow dislocation could be inferred from the pattern of bony contusions and osteochondral lesions visible on magnetic resonance imaging (MRI) in patients with simple elbow dislocations.

Purpose/Hypothesis:

The purpose of this study was to describe the incidence and distribution of osteochondral lesions based on MRI findings in patients with simple elbow dislocations. We hypothesized that (1) osteochondral lesions are consistently found in patients with simple elbow dislocations and (2) the distribution and severity of osteochondral lesions may explain the mechanism of the simple elbow dislocation.

Study Design:

Cohort study; Level of evidence, 3.

Methods:

A retrospective review of 43 patients with simple elbow dislocations was performed in tertiary-level hospitals from January 2010 to August 2019. Two orthopaedic surgeons separately assessed the initial plain radiographs and MRI scans. Osteochondral lesions were evaluated and categorized based on whether they were located (1) on the lateral side (posterolateral capitellum and radial head; type 1) or (2) on the medial side (posterior trochlea and anteromedial facet of the coronoid; type 2). The severity of the osteochondral lesions was assessed according to the Anderson classification.

Results:

Of the 43 patients, 21 (48.8%) presented with osteochondral lesions on MRI. The type 1 pattern of osteochondral lesions was the most frequently observed on MRI in patients with simple elbow dislocations (69.8% of cases), and these were confirmed by simple radiography. Posterolateral capitellum osteochondral lesions were found in 13 patients. Among them, 10 (76.9%) were advanced-stage lesions (stages III and IV according to the Anderson classification).

Conclusion:

Osteochondral lesions were found on MRI after simple elbow dislocations at a rate of 48.8%. Osteochondral lesions in the posterolateral capitellum were associated with an advanced stage. Clinically, these findings may help surgeons in the diagnosis of osteochondral lesions and in determining how to manage patients with the progression of arthritic changes.

Soft tissue injury patterns in posteromedial rotatory instability with dislocation compared with posteromedial dislocation of the elbow joint

BACKGROUND

We sought to determine injury mechanisms and soft tissue injury patterns of dislocation caused by posteromedial rotatory instability (PMRI) and simple posteromedial (PM) dislocation of the elbow joint that appear similar on simple radiographs.

METHODS

In this retrospective case-series study, we reviewed 13 patients with PMRI dislocation and 10 patients with simple PM dislocation. Three-dimensional computed tomography and magnetic resonance imaging were performed in both groups. The ulnar collateral ligament, lateral collateral ligament complex (LCLC), overlying extensor muscle, and locus of bone contusion were identified. The direction of dislocation was categorized into the pure-posterior or PM type by simple radiographs.

RESULTS

The LCLC was completely ruptured in both groups. A completely torn ulnar collateral ligament was observed in 3 patients (23%) in the PMRI dislocation group and 9 patients (90%) in the simple PM dislocation group (P = .005). Regarding injury patterns of the LCLC and overlying extensor muscle, the distraction type was found in 10 patients (77%) and the stripping type was found in 3 patients (23%) in the PMRI dislocation group, whereas all patients (100%) in the simple PM dislocation group had the distraction type (P = .103). Bone contusion was observed at the posterolateral olecranon in 2 patients (15%) in the PMRI dislocation group and at the PM olecranon in 4 patients (40%), posterolateral olecranon in 1 (10%), posterior olecranon in 1 (10%), and PM-posterolateral olecranon in 1 (10%) in the simple PM dislocation group (P = .008). In the PMRI dislocation group, 7 patients (54%) had the PM type and 6 (46%) had the pure-posterior type.

CONCLUSIONS

Simple PM and PMRI dislocations of the elbow joint might have different soft tissue injury characteristics because of different injury mechanisms.

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

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.