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Nunez A, Winicki N, Chung P, Vong V, Do N. Anterior dislocation of elbow in an adult female: A rare case report. J Am Coll Emerg Physicians Open 2024; 5:e13269. [PMID: 39131825 PMCID: PMC11315643 DOI: 10.1002/emp2.13269] [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: 05/24/2024] [Revised: 07/04/2024] [Accepted: 07/29/2024] [Indexed: 08/13/2024] Open
Abstract
Elbow dislocations are among one of the most frequently dislocated joints, with an incidence of five to six cases annually per 100,000 persons in the United States. The vast majority of elbow dislocations occur posteriorly, secondary to a disruption in the anterior elbow- and posterior elbow-stabilizing structures. Anterior elbow dislocations are rare injuries in both children and adults, occurring as the proximal ulna is forced anterior to the distal humerus with or without the proximal radius. As of 2019, only 21 anterior elbow dislocations without fractures have been reported between 1922 and 2018. Here, we report the rare case of a patient that sustained a complex anterior elbow dislocation after being involved in a motor vehicle collision.
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Affiliation(s)
- Alberto Nunez
- University of California, Riverside School of MedicineRiversideCaliforniaUSA
| | - Nolan Winicki
- University of California, Riverside School of MedicineRiversideCaliforniaUSA
| | - Phillip Chung
- Keck School of Medicine of USCLos AngelesCaliforniaUSA
| | - Vinson Vong
- Department of Emergency MedicineHCA HealthcareRiverside Community HospitalRiversideCaliforniaUSA
| | - Nhan Do
- Department of Emergency MedicineHCA HealthcareRiverside Community HospitalRiversideCaliforniaUSA
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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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Zumbansen N, Lenich A. [Ligamentous elbow injuries-When is surgical treatment still indicated?]. UNFALLCHIRURGIE (HEIDELBERG, GERMANY) 2023; 126:671-678. [PMID: 37344575 DOI: 10.1007/s00113-023-01333-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 04/20/2023] [Indexed: 06/23/2023]
Abstract
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?
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Affiliation(s)
- Nikolaus Zumbansen
- Orthopädie am Stiglmaierplatz, ZEST - Zentrum für Ellenbogen und Schulter-Therapie, Nymphenburgerstr 1, 80335, München, Deutschland
| | - Andreas Lenich
- Orthopädie am Stiglmaierplatz, ZEST - Zentrum für Ellenbogen und Schulter-Therapie, Nymphenburgerstr 1, 80335, München, Deutschland.
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Wegmann S, Ott N, Leschinger T, Hackl M, Müller LP. [Follow-up treatment concepts for elbow injuries]. UNFALLCHIRURGIE (HEIDELBERG, GERMANY) 2023; 126:694-699. [PMID: 37278730 DOI: 10.1007/s00113-023-01327-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 04/06/2023] [Indexed: 06/07/2023]
Abstract
So far there are no clear recommendations for postoperative follow-up treatment of elbow injuries and individual concepts are often chosen. Due to the susceptibility for posttraumatic or postoperative impaired movement up to stiffness of the elbow joint, early mobilization plays a crucial role. Therefore, mid-term to long-term immobilization should be avoided. In addition to the necessary cryotherapy and compression therapy for swelling and pain control in the initial period, early actively assisted mobilization now has an important role. Additionally, active flexion and extension in an overhead position, so-called overhead motion, was recently established. After a short initial immobilization in a cast, mostly 3-5 days, the cast is changed to a dynamic movement orthosis, which when possible enables a free range of motion. Care is taken that varus and valgus loading is avoided. In general loading is avoided for the first 6 weeks, followed by a stepwise increase of loading up to maximum loading. In most cases return to sport is possible after 3 months. After implantation of an elbow prosthesis a maximum loading of 5 kg for single loading and 1 kg for repetitive loading are recommended.
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Affiliation(s)
- Sebastian Wegmann
- Klinik und Poliklinik für Orthopädie, Unfallchirurgie und Plastisch-Ästhetische Chirurgie, Uniklinik Köln, Kerpener Straße 62, 50937, Köln, Deutschland.
| | - Nadine Ott
- Klinik und Poliklinik für Orthopädie, Unfallchirurgie und Plastisch-Ästhetische Chirurgie, Uniklinik Köln, Kerpener Straße 62, 50937, Köln, Deutschland
| | - Tim Leschinger
- Klinik und Poliklinik für Orthopädie, Unfallchirurgie und Plastisch-Ästhetische Chirurgie, Uniklinik Köln, Kerpener Straße 62, 50937, Köln, Deutschland
| | - Michael Hackl
- Klinik und Poliklinik für Orthopädie, Unfallchirurgie und Plastisch-Ästhetische Chirurgie, Uniklinik Köln, Kerpener Straße 62, 50937, Köln, Deutschland
| | - Lars Peter Müller
- Klinik und Poliklinik für Orthopädie, Unfallchirurgie und Plastisch-Ästhetische Chirurgie, Uniklinik Köln, Kerpener Straße 62, 50937, Köln, Deutschland
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Carroll TJ, Dondapati A, Minto J, Hoffman S, Hammert WC, Mahmood B. An Analysis of Patient-Reported Outcomes Measurement Information System (PROMIS) in Non-operative Posterolateral Elbow Dislocations. Cureus 2023; 15:e43297. [PMID: 37692662 PMCID: PMC10492646 DOI: 10.7759/cureus.43297] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/10/2023] [Indexed: 09/12/2023] Open
Abstract
INTRODUCTION The purpose of our study is to analyze the outcomes of traumatic posterolateral elbow dislocations using patient-reported outcomes measurement information system (PROMIS). We hypothesized that physical function (PF) and upper extremity (UE) scores in PROMIS will significantly improve over six months of follow-up and correlate with a positive change in the patient-acceptable symptom state (PASS). METHODS This is a seven-year retrospective study of 165 consecutive adult patients with traumatic posterolateral elbow dislocations. Demographic information, PROMIS PF, PROMIS UE, PROMIS pain interference (PI), PROMIS depression, and PASS were recorded over six months of follow-up. RESULTS At the time of injury, mean PROMIS scores were PF 41.24 (SD 11.16), UE 34.27 (SD 11.87), PI 60.44 (SD 8.07), and depression 49.82 (SD 10.42). At six months, the mean PROMIS scores were PF 39.71 (SD 9.71), UE 33.95 (SD 9.09), PI 57.35 (SD 8.59), and depression 51.43 (SD 10.62). The overall six-month changes in PROMIS scores were PF -1.53, UE -0.32, PI -3.09, and depression +1.61. At the 6-month follow-up, 41.7% responded positively on the PASS, which correlated only with PROMIS PI. CONCLUSIONS Among patients who improved from negative to positive response on PASS, the PROMIS PF, UE, and depression scores did not significantly improve. Only PROMIS PI correlated with PASS at the six-month follow-up; PROMIS PI significantly improved among simple posterolateral elbow dislocation patients at both short-term and long-term follow-up points. PROMIS PF, UE, and depression did not significantly differ between time of injury and short-term and long-term follow-up points.
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Affiliation(s)
- Thomas J Carroll
- Department of Orthopaedic Surgery, University of Rochester, Rochester, USA
| | - Akhil Dondapati
- Department of Orthopaedic Surgery, University of Rochester, Rochester, USA
| | - Jonathan Minto
- Department of Orthopaedic Surgery, University of Rochester, Rochester, USA
| | - Samantha Hoffman
- Department of Orthopaedic Surgery, University of Rochester, Rochester, USA
| | - Warren C Hammert
- Department of Orthopaedic Surgery, Division of Hand Surgery, Duke University Medical Center, Durham, USA
| | - Bilal Mahmood
- Department of Orthopaedic Surgery, University of Rochester, Rochester, USA
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[Augmented primary sutures "internal bracing" following ligamentous elbow dislocation]. OPERATIVE ORTHOPADIE UND TRAUMATOLOGIE 2023; 35:43-55. [PMID: 36469104 PMCID: PMC9895014 DOI: 10.1007/s00064-022-00788-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 01/10/2021] [Revised: 06/23/2021] [Accepted: 09/25/2021] [Indexed: 12/12/2022]
Abstract
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.
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Van Tunen B, Van Lieshout EMM, Mader K, Den Hartog D. Complications and range of motion of patients with an elbow dislocation treated with a hinged external fixator: a retrospective cohort study. Eur J Trauma Emerg Surg 2022; 48:4889-4896. [PMID: 35750865 DOI: 10.1007/s00068-022-02013-x] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2022] [Accepted: 05/23/2022] [Indexed: 12/01/2022]
Abstract
PURPOSE Elbow dislocations are at risk for persistent instability and stiffness of the joint. Treatment with a hinged external fixation provides elbow joint stability, and allows early mobilization to prevent stiffness. Mounting a hinged elbow fixator correctly, however, is technically challenging. The low incidence rate of elbow dislocations with persistent instability suggests that centralization would result in higher surgeon exposure and consequently in less complications. This study aimed to investigate the results of treatment of elbow dislocations with a hinged elbow fixator on the rate of complications, range of motion, level of pain and restrictions in activities of daily living. METHODS A retrospective observational cohort study in a level I trauma center, in which the majority of patients was treated by a dedicated elbow surgeon, was performed. All patients of 16 years or older treated with a hinged external elbow fixator between January 1, 2006 and December 31, 2017 were included. The fixator could be used (1) for the treatment of persistent instability in acute/residual simple and complex dislocations or (2) as revision surgery to treat joint incongruency or a stiff elbow. Patient and injury characteristics, details on treatment, complications, secondary interventions, and range of motion were extracted from the patients' medical files. RESULTS The results of treatment of 34 patients were analyzed with a median follow-up of 13 months. The fixator was removed after a median period of 48 days. Fixator-related complications encountered were six pintract infections, one redisclocation, one joint incongruency, one muscle hernia, and one hardware failure. The median range of motion at the end of follow-up was 140° flexion, 15° constraint in extension, 90° pronation, and 80° supination. CONCLUSION A hinged elbow fixator applied by a dedicated elbow surgeon in cases of elbow instability after elbow dislocations can result in excellent joint function. Fixator-related complications are mostly mild and only temporary.
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Affiliation(s)
- Bart Van Tunen
- Trauma Research Unit, Department of Surgery, Erasmus MC, University Medical Center Rotterdam, P.O. Box 2040, 3000 CA, Rotterdam, The Netherlands
| | - Esther M M Van Lieshout
- Trauma Research Unit, Department of Surgery, Erasmus MC, University Medical Center Rotterdam, P.O. Box 2040, 3000 CA, Rotterdam, The Netherlands
| | - Konrad Mader
- Division Hand, Forearm and Elbow Surgery, Department of Trauma and Orthopaedic Surgery, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Dennis Den Hartog
- Trauma Research Unit, Department of Surgery, Erasmus MC, University Medical Center Rotterdam, P.O. Box 2040, 3000 CA, Rotterdam, The Netherlands.
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Reiter AJ, Castile RM, Schott HR, Kivitz GJ, Chamberlain AM, Lake SP. Investigating the Effects of Physical Therapy Timing, Intensity and Duration on Post-Traumatic Joint Contracture in a Rat Elbow Model. Muscles Ligaments Tendons J 2021; 11:547-553. [PMID: 35265538 PMCID: PMC8902630 DOI: 10.32098/mltj.03.2021.20] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
BACKGROUND Post-traumatic joint contracture (PTJC), characterized by loss of motion and permanent stiffness, affects up to 50% of patients following elbow joint dislocation or fracture. Mechanisms governing successful conservative treatment methods aimed at preventing elbow PTJC and avoiding operative treatments (e.g., physical therapy) are poorly understood. Using a previously established rat model of elbow PTJC, the purpose of this study was to explore the effect of varying timing, intensity and duration of active, functional exercise on joint motion outcomes. METHODS Following a surgically-induced unilateral elbow dislocation in rats, injured limbs were immobilized in bandages for 42 days followed by free mobilization for 42 additional days producing long-term PTJC. This work summarizes several studies (Phases I-III) that investigated the effects of early versus delayed therapy (timing), free mobilization versus forced treadmill walking (intensity), and limited-time versus unlimited use (duration) on elbow PTJC. RESULTS Joint motion outcomes in therapy groups showed no improvements compared to non-treated injured animals when therapy began day 14 post-injury or later regardless of timing, intensity or duration. Improved joint range-of-motion was only achieved when bandages were permanently removed at day 3 post-injury, regardless of whether added treadmill walking was performed. CONCLUSION Early motion is essential to preserving range-of-motion following traumatic elbow injury in a rat model.
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Affiliation(s)
- Alex J. Reiter
- Department of Mechanical Engineering & Materials
Science, Washington University in St. Louis, St. Louis, MO
| | - Ryan M. Castile
- Department of Mechanical Engineering & Materials
Science, Washington University in St. Louis, St. Louis, MO
| | - Hayden R. Schott
- Department of Biomedical Engineering, Washington University
in St. Louis, St. Louis, MO
| | - Griffin J. Kivitz
- Department of Mechanical Engineering & Materials
Science, Washington University in St. Louis, St. Louis, MO
| | - Aaron M. Chamberlain
- Department of Orthopaedic Surgery, Washington University in
St. Louis, St. Louis, MO
| | - Spencer P. Lake
- Department of Mechanical Engineering & Materials
Science, Washington University in St. Louis, St. Louis, MO
- Department of Biomedical Engineering, Washington University
in St. Louis, St. Louis, MO
- Department of Orthopaedic Surgery, Washington University in
St. Louis, St. Louis, MO
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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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Schnetzke M, Ellwein A, Maier D, Wagner FC, Grützner PA, Guehring T. Injury patterns following simple elbow dislocation: radiological analysis implies existence of a pure valgus dislocation mechanism. Arch Orthop Trauma Surg 2021; 141:1649-1657. [PMID: 32780199 PMCID: PMC8437923 DOI: 10.1007/s00402-020-03541-0] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/16/2019] [Accepted: 07/15/2020] [Indexed: 11/25/2022]
Abstract
INTRODUCTION The aim of the present study was to analyze the injury pattern and thus the dislocation mechanism after simple elbow dislocation using radiographs and magnetic resonance imaging (MRI) data sets. MATERIALS AND METHODS The MRI data sets of 64 patients with a mean age of 44 years (18-77 years) were analyzed retrospectively. The inclusion criteria for the study were (1) radiograph with confirmed simple elbow dislocation, (2) low-energy trauma, (3) MRI of the affected elbow ≤ 3 weeks after trauma. The dislocation direction was determined using radiographs. The integrity of the lateral collateral ligament complex (LCLC), common extensor origin (CEO), anterior capsule (AC), medial collateral ligament (MCL), and common flexor origin (CFO) as well as the joint congruity were assessed based on MRI. RESULTS 34 patients (53%) had a posterolateral, 26 patients (41%) a posterior, and 4 patients (6%) a posteromedial dislocation. LCLC and AC were affected in 64 out of 64 patients (100%). MCL was affected in 58 patients (91%). CEO were affected in 25 patients (39%) and the CFO in 20 patients (31%). In 11 patients (17%) the injury pattern was more pronounced medially than laterally (MCL, CFO, LCLC), with 2 of these patients exhibiting only a partial LCLC tear. All cases with joint incongruency (n = 12, 19%) showed CEO and/or CFO involvement. CONCLUSIONS Simple elbow dislocation leads to a very heterogeneous spectrum of soft tissue injury pattern. A small proportion of patients showed medially pronounced injury patterns. These findings strongly indicate existence of a "reversed Horii circle" with an underlying valgus mechanism (medial force induction) originating and continuing from medial to anterior.
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Affiliation(s)
- Marc Schnetzke
- BG Trauma Center Ludwigshafen at the University of Heidelberg, Clinic for Trauma and Orthopaedic Surgery, Ludwigshafen on the Rhine, Germany.
- ATOS Clinic Heidelberg, German Joint Center Heidelberg, Heidelberg, Germany.
| | - Alexander Ellwein
- Department for Orthopaedic Surgery, Medical School Hannover, DIAKOVERE Annastift, Anna-von-Borries-Straße 1-7, 30625, Hannover, Germany
| | - Dirk Maier
- Faculty of Medicine Medical Center, Albert-Ludwigs-University of Freiburg, Hugstetter Strasse 55, 79106, Freiburg, Germany
| | - Ferdinand Christian Wagner
- Faculty of Medicine Medical Center, Albert-Ludwigs-University of Freiburg, Hugstetter Strasse 55, 79106, Freiburg, Germany
| | - Paul-Alfred Grützner
- BG Trauma Center Ludwigshafen at the University of Heidelberg, Clinic for Trauma and Orthopaedic Surgery, Ludwigshafen on the Rhine, Germany
| | - Thorsten Guehring
- Shoulder and Elbow Surgery, Arcus Sportklinik ARCUS Kliniken, Rastatter Str. 17-19, 75179, Pforzheim, Germany
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Goretti C, Pari C, Puzzo A, Rizqallah Y, Bonanno MG, Belluati A. Injury of the brachial artery accompanying simple closed elbow dislocation: a case report. ACTA BIO-MEDICA : ATENEI PARMENSIS 2020; 91:e2020030. [PMID: 33559638 PMCID: PMC7944710 DOI: 10.23750/abm.v91i14-s.8507] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/20/2019] [Accepted: 03/01/2020] [Indexed: 11/30/2022]
Abstract
Background: Elbow dislocation is the second common dislocation in adults, after the shoulder. The anatomical proximity to the joint of the brachial artery could lead to concomitant vascular injuries, even if their occurrence remains very rare. Method: It is reported the case of a right-hand-dominant 42-year-old man who sustained a simple closed posterior elbow dislocation of his left elbow, associated to a complete brachial artery rupture. He urgently underwent the reduction of the joint dislocation and an artery-repairing surgical procedure using a graft from ipsilateral saphenous vein. Results: The full functional capacity of the elbow was obtained. Conclusions: The abundance of the brachial artery collateral network may hide the presence of a vascular injury, potentially associated to a closed elbow dislocation. Therefore, a high index of suspicious should be maintained. The Emergency Team plays a crucial role in its early diagnosis, which is essential to avoid irreversible ischemia related damages. A prompt reduction of the joint dislocation and the vascular injury surgical repair are required. Regarding the treatment of the concomitant collateral ligaments and capsular injuries, the indication to proceed to the simultaneous ligaments reconstruction is still controversial in literature.
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Mühlenfeld N, Frank J, Lustenberger T, Marzi I, Sander AL. Epidemiology and treatment of acute elbow dislocations: current concept based on primary surgical ligament repair of unstable simple elbow dislocations. Eur J Trauma Emerg Surg 2020; 48:629-636. [PMID: 33034663 PMCID: PMC8825363 DOI: 10.1007/s00068-020-01512-z] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2020] [Accepted: 09/25/2020] [Indexed: 10/27/2022]
Abstract
Abstract
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.
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Masionis P, Bobina R, Uvarovas V, Porvaneckas N, Šatkauskas I. Thrombosis of the brachial artery - a rare and devastating complication after a simple closed posterolateral elbow dislocation. Acta Med Litu 2019; 26:167-172. [PMID: 32015671 PMCID: PMC6992364 DOI: 10.6001/actamedica.v26i3.4146] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2019] [Accepted: 10/29/2019] [Indexed: 11/27/2022] Open
Abstract
Dislocation of the elbow joint is the second most common dislocation after the shoulder joint. Although this pathology is relatively common, concomitant vascular injuries are rare. We present a case of a patient who sustained a fall on his arm with an outstretched elbow that resulted in a closed simple posterolateral elbow dislocation and delayed thrombosis of the brachial artery followed by two revascularisation surgeries. The physician must always maintain a high index of suspicion for a concomitant vascular injury before and after closed reduction of the elbow joint and have in mind that complete ischemia without any pulsations could be absent because the elbow is surrounded by rich collateral anastomoses. Suspicion should be even stronger in the presence of bony lesions or open injuries. A team of trauma and vascular surgeons has to work hand in hand as surgical treatment with a saphenous graft or direct suture is the first method of choice with the prior requirement of a stable elbow joint.
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Affiliation(s)
- Povilas Masionis
- Centre of Orthopaedics and Traumatology, Vilnius University Hospital Santaros Klinikos, Faculty of Medicine, Vilnius University, Clinic of Rheumatology, Orthopaedics-Traumatology, and Reconstructive Surgery, Vilnius, Lithuania
| | - Rokas Bobina
- Centre of Orthopaedics and Traumatology, Vilnius University Hospital Santaros Klinikos, Faculty of Medicine, Vilnius University, Clinic of Rheumatology, Orthopaedics-Traumatology, and Reconstructive Surgery, Vilnius, Lithuania
| | - Valentinas Uvarovas
- Centre of Orthopaedics and Traumatology, Vilnius University Hospital Santaros Klinikos, Faculty of Medicine, Vilnius University, Clinic of Rheumatology, Orthopaedics-Traumatology, and Reconstructive Surgery, Vilnius, Lithuania
| | - Narūnas Porvaneckas
- Centre of Orthopedics and Traumatology, Republican Vilnius University Hospital, Faculty of Medicine, Vilnius University, Clinic of Rheumatology, Orthopaedics-Traumatology, and Reconstructive Surgery, Vilnius, Lithuania
| | - Igoris Šatkauskas
- Centre of Orthopaedics and Traumatology, Vilnius University Hospital Santaros Klinikos, Faculty of Medicine, Vilnius University, Clinic of Rheumatology, Orthopaedics-Traumatology, and Reconstructive Surgery, Vilnius, Lithuania
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Schmidt-Horlohé K, Klug A, Weißenberger M, Wincheringer DN, Hoffmann R. [Acute and chronic instability of the elbow joint]. DER ORTHOPADE 2018; 47:695-708. [PMID: 30022303 DOI: 10.1007/s00132-018-3597-5] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
Elbow dislocations are frequent and present with a broad spectrum of subsequent ligamentous and soft tissue injuries. Beside clinical examination, fluoroscopy, ultrasound and magnetic resonance imaging (MRI) can specify the extent of the injuries and provide a foundation for decision-making between conservative and operative treatment. This article highlights the basic underlying biomechanics and anatomy, discusses the trauma mechanisms and presents clinical and imaging diagnostic procedures. Treatment algorithms for conservative and surgical treatment are presented in detail. In addition to acute instability, chronic instability of the elbow has recently been recognized as the cause of a large variety of symptoms, often resulting in significant functional impairment. The most commonly used techniques for reconstruction of the medial and lateral collateral ligaments and the rehabilitation protocols are described in detail.
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Affiliation(s)
- Kay Schmidt-Horlohé
- Zentrum für Ellenbogenchirurgie, Orthopaedicum Wiesbaden - Praxis für Orthopädie, Unfallchirurgie und Sportmedizin, Friedrichstr. 29, 65185, Wiesbaden, Deutschland.
| | - Alexander Klug
- Zentrum für Unfallchirurgie und orthopädische Chirurgie, Berufsgenossenschaftliche Unfallklinik Frankfurt am Main, Friedberger Landstr. 430, 60389, Frankfurt am Main, Deutschland
| | - Manuel Weißenberger
- Orthopädische Klinik König-Ludwig-Haus, Lehrstuhl für Orthopädie, Julius-Maximilians-Universität Würzburg, Brettreichstr. 11, 97074, Würzburg, Deutschland
| | - Den Nis Wincheringer
- Zentrum für Unfallchirurgie und orthopädische Chirurgie, Berufsgenossenschaftliche Unfallklinik Frankfurt am Main, Friedberger Landstr. 430, 60389, Frankfurt am Main, Deutschland
| | - Reinhard Hoffmann
- Zentrum für Unfallchirurgie und orthopädische Chirurgie, Berufsgenossenschaftliche Unfallklinik Frankfurt am Main, Friedberger Landstr. 430, 60389, Frankfurt am Main, Deutschland
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Krticka M, Ira D, Flek M, Svancara J, Pikula R. A Comparative Study of Conservative Functional Treatment versus Acute Ligamentous Repair in Simple Dislocation of the Elbow in Adults. Indian J Orthop 2018; 52:584-589. [PMID: 30532297 PMCID: PMC6241047 DOI: 10.4103/ortho.ijortho_578_16] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
BACKGROUND Elbow dislocation is the second most frequent type of large joint dislocations in adults. Standard treatment of simple elbow dislocation (SED) without manifestation of instability includes closed reduction, short-term immobilization of the elbow followed by functional aftercare. This study evaluates SED treatment, comparing outcomes of conservative functional treatment and surgical therapy. MATERIALS AND METHODS 54 adult patients with SED without manifest instability treated in tertiary hospital between January 2008 and June 2015 were analyzed in this retrospective study. 28 patients were treated conservatively. Closed elbow reduction was followed by short-term plaster splint and active rehabilitation. Twenty six patients underwent closed elbow reduction and subsequent reconstruction of torn collateral ligaments. Postoperatively, plaster splint was applied followed by rehabilitation. RESULTS Patients who were treated conservatively reached statistically significant better scores in Quick Disability Arm Shoulder Hand, Oxford Elbow Score, and Mayo Elbow Performance Score. Functional conservative treatment resulted in a higher range of motion. The complication rate was higher in the group of surgically treated patients. CONCLUSIONS Careful examination of elbow stability after closed reduction of SED is crucial for further therapy. Patients with stable SED should be treated with functional conservative therapy. Surgical collateral ligaments revision and reconstruction are indicated only for patients with manifestation of elbow instability.
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Affiliation(s)
- Milan Krticka
- Department of Trauma Surgery, University Hospital Brno, Brno, Czech Republic,Address for correspondence: Dr. Milan Krticka, Department of Trauma Surgery, University Hospital Brno, Jihlavska 20, 60200 Brno, Czech Republic. E-mail:
| | - Daniel Ira
- Department of Trauma Surgery, University Hospital Brno, Brno, Czech Republic
| | - Martin Flek
- Department of Trauma Surgery, University Hospital Brno, Brno, Czech Republic
| | - Jan Svancara
- Institute of Biostatistics and Analysis, Masaryk University, Brno, Czech Republic
| | - Radek Pikula
- Department of Trauma Surgery, University Hospital Brno, Brno, Czech Republic
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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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Abstract
BACKGROUND Chronic ligamentous instability of the elbow is an important pathology as it is accompanied with pronounced dysfunction. Moreover, it represents an established risk factor for the development of osteoarthritis. Posterolateral rotatory instability (PLRI) caused by insufficiency of the lateral collateral ligament (LCL) is the most common type of chronic elbow instability and is usually a sequel of traumatic elbow dislocation. Chronic overload can lead to insufficiency of the ulnar collateral ligament (UCL) with subsequent valgus instability, especially in overhead athletes. DIAGNOSTICS Subjective instability and recurrent elbow dislocations are not always the main symptoms but elbow instability is instead often characterized by pain and secondary joint stiffness. Many clinical tests are available yet eliciting them can be difficult and inconclusive. A "drop sign" on lateral radiographs as well as the detection of collateral ligament injuries and joint incongruity on MRI scans can support the suspected diagnosis. In some cases, instability can only be verified by diagnostic arthroscopy. TREATMENT Reconstruction of the lateral ulnar collateral ligament (LUCL) for treatment of PLRI generally leads to good clinical results, yet recurrent instability remains an issue and has been reported in 8 % of cases. UCL reconstruction for chronic valgus instability leads to a return-to-sports rate of about 86 % in the overhead athlete. Ulnar neuropathy, which is seen in approximately 6 % of patients, represents the most common complication. On the rare occasion of multidirectional instability, the box-loop technique can be used for simultaneous reconstruction of the LUCL and UCL with a circumferential graft. 15 cases with promising results have been reported in literature thus far.
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Hackl M, Müller LP, Wegmann K. The Circumferential Graft Technique for Treatment of Chronic Multidirectional Ligamentous Elbow Instability. JBJS Essent Surg Tech 2017; 7:e6. [PMID: 30233941 DOI: 10.2106/jbjs.st.16.00078] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
Introduction The circumferential graft technique1,2 represents a potential option for the treatment of multidirectional ligamentous elbow instability using a single tendon graft (Video 1). Indications & Contraindications Step 1 Perform a Medial and Lateral Approach Approach the elbow joint through either a single posterior skin incision or separate lateral and medial incisions. Step 2 Drill the Bone Tunnels Create humeral and ulnar bone tunnels for circumferential graft placement. Step 3 Place the Graft Use a plantaris allograft, which we recommend; however, a semitendinosus autograft may also be used. Step 4 Close the Wound Ensure that meticulous wound closure is achieved as it is key to preventing postoperative complications such as superficial or deep infection and persistent seroma. Results As multidirectional instability represents a rather rare complication following ligamentous elbow dislocation, clinical data regarding the circumferential graft technique are scarce1,2. Pitfalls & Challenges
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Affiliation(s)
- Michael Hackl
- Center for Orthopedic and Trauma Surgery, University Medical Center of Cologne, Cologne, Germany
| | - Lars Peter Müller
- Center for Orthopedic and Trauma Surgery, University Medical Center of Cologne, Cologne, Germany
| | - Kilian Wegmann
- Center for Orthopedic and Trauma Surgery, University Medical Center of Cologne, Cologne, Germany
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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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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: 25] [Impact Index Per Article: 2.8] [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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