The use of hinged elbow orthosis following surgical management of terrible triad injuries of the elbow

PURPOSE

To determine outcomes following surgical management of terrible triad injuries in patients treated with and without a hinged elbow orthosis (HEO) in the post-operative setting.

METHODS

This study was a retrospective review of 41 patients who underwent surgical treatment of terrible triad injuries including radial head fracture, coronoid fracture, and ulnohumeral dislocation between 2008 and 2023 with at least 10-week follow-up.

RESULTS

Nineteen patients were treated post-operatively without HEO, and 22 patients were treated with HEO. There were no differences in range of motion (ROM) between patients treated with and without HEO in final flexion-extension arc (118.4° no HEO, 114.6° HEO, p = 0.59) or pronation-supination arc (147.8° no HEO, 141.4° HEO, p = 0.27). Five patients treated without HEO and one patient treated with HEO returned to the operating room for stiffness (26%, 5%, p = 0.08). QuickDASH scores were similar between groups (p = 0.69).

CONCLUSIONS

This study found no difference in post-operative ROM, complications, or QuickDASH scores in patients treated post-operatively with or without HEO. Based on these results, we cannot determine whether the use of HEO adds additional stability to the elbow while initiating ROM exercises post-operatively.

The Internal Joint Stabilizer of the Elbow: A Systematic Review of the Clinical and Biomechanical Evidence

Purpose

The goal of surgical management for unstable elbow injuries is the restoration of joint concentricity and stability. After internal fixation, concerns may exist regarding instability or durability of the fixation construct. Historically, these scenarios were treated with options such as transarticular pinning or external fixation. Recently, an internal joint stabilizer (IJS) that allows postoperative mobilization was introduced. Our objective was to systematically review the literature to aggregate the clinical and biomechanical evidence for the IJS of the elbow.

Methods

A systematic review of the PubMed and Google Scholar databases was performed, following the PRISMA guidelines. The search results were narrowed from 2015 through 2023 to coincide with the inception of the device being reviewed.

Results

A total of nine retrospective reports on the IJS (N = 171) cases at a mean follow-up of 10.8 months were included. The pooled rate of implant failure was 4.4%, and recurrent instability was 4.1%. Additionally, the we included seven case reports and two biomechanical reports.

Conclusions

The aggregate literature describes satisfactory clinical outcomes with low rates of recurrent instability and device failure for the IJS of the elbow. The limited biomechanical investigations conclude efficacy for stability profiles.

Clinical relevance

Across a spectrum of unstable elbow cases, the IJS prevented recurrent instability during the early postoperative period. Notably, the device requires an additional procedure for removal, and the long-term impact of the retained devices is currently unclear.

Elbow dislocation approach for complex elbow fractures: a cadaveric study

BACKGROUND

Approach need to be considered when surgeons dealt with complex elbow injuries and the choice of the approach is a challenge for surgeons due to the complex anatomy. On the basis of releasing the lateral collateral ligament, we modified the dislocation technique to pursue the superior exposure including not only the distal humeral surface but also the anterior facet of the coronoid process.

METHODS

A total of 4 cadaver specimens and 8 elbows were included in the study. Each cadaver provided one elbow for either the elbow dislocation approach or the posterior olecranon approach. The exposed distal articular surface of humerus, humeral capitulum, humeral trochlea, anterior trochlea of distal humerus, posterior trochlea of distal humerus and the ulnar coronoid process surface were marked by image J software and calculated for a comparison for each surgical approach.

RESULTS

The total distal humeral surface was exposed as a median of 98.2 (97.6, 99.6)% and 62.0 (58.3, 64.5)% for the elbow dislocation approach and the olecranon osteotomy approach (P < 0.001), the capitulum 100% and 32.4 (28.0, 39.2)% (P < 0.001), the trochlea 93.2(90.1, 96.9)% and 72.5 (65.2, 78.8)% (P < 0.001), the anterior trochlear articular surface 96.0(93.0, 97.4)% and 50.3 (43.6, 59.1)% (P < 0.001), the posterior trochlear articular surface 95.4 (93, 100)% and 100% (P = 0.76) and the articular surface of the coronoid process of ulna 71.3 (66.0, 74.2)% and 0% (P < 0.001).

CONCLUSION

For complex elbow fractures, the technique of elbow dislocation provides complete exposure of the distal humerus surface and a significant portion of the coronoid process surface, facilitating direct visualization for reduction and fixation. Level of evidence Anatomy Study; Cadaver Dissection.

High correlation of the subjective elbow value with Mayo Elbow Performance Score and Oxford Elbow Score in patients with elbow dislocation

Background

The purpose of this study was to analyze the correlation of the Subjective Elbow Value (SEV) with 2 widely used elbow scoring systems: Mayo Elbow Performance Score (MEPS) and Oxford Elbow Score (OES) in patients following elbow dislocation.

Methods

In this retrospective single-center study, patients who sustained an elbow dislocation between January 2008 and December 2019 and were at least 2 years out from injury were included. SEV, OES and MEPS were assessed and statistical correlation was calculated using Pearson's correlation coefficient.

Results

A total of 114 patients (61 male, 53 female) with a mean age of 47.1 years (range, 16-70) were analyzed following elbow dislocation. The mean SEV was 87.4% (95% confidence interval (CI) 84.2-90.7), mean MEPS was 88.1 (95% CI 85.1-91.0) points and mean OES was 40.0 (95% CI 38.4-41.7) points. Both MEPS (r = 0.710, P < .001), and OES (r = 0.764, P < .001) demonstrated high correlation with the SEV.

Conclusion

This study demonstrates that the SEV is a valid tool to assess overall status of the elbow in patients following elbow dislocations and presents an expressive but easy to perform addition to more complex scoring systems.

Comparison of Surgical Treatment Outcomes of Pediatric Medial Epicondyle Fractures With and Without Elbow Dislocation

PURPOSE

The aim of this study was to compare surgical treatment outcomes of pediatric medial epicondyle fractures with and without elbow dislocation.

METHODS

A total of 139 patients (75 boys and 64 girls; mean ± SD age, 9.6 ± 3.3 years) who received surgical treatment for medial epicondyle fractures at the Children's Hospital of Nanjing Medical University from January 2012 to December 2018 were included in our study. There were 99 cases that had a medial epicondyle fracture alone (group A) and 40 cases had a concomitant elbow dislocation (group B). Pain, ulnar nerve palsy, and stability of the elbow joint were recorded. Robert's criteria was used to assess elbow function.

RESULTS

The prevalence of ulnar nerve palsy was lower in group A compared to group B, both before and after surgery. More patients underwent ulnar nerve transposition in group B than in group A. The incidence of elbow valgus instability was higher in group B than in group A. At the final follow-up, all patients had achieved good radiographic restoration of the elbow joint. Clinical outcomes in group A, according to Robert's criteria, were better than those in group B.

CONCLUSIONS

Elbow dislocation was associated with poorer functional outcomes following surgical treatment of medial epicondyle fractures in children.

TYPE OF STUDY/LEVEL OF EVIDENCE

Therapeutic IV.

Monteggia fractures and Monteggia-like-lesions: a systematic review

Monteggia injuries are rare, but severe injuries of the elbow including various injury patterns. Treatment of these injuries is still topic of debate and strategies differ widely. In this systematic review on Monteggia injuries in adults, we aimed to clarify the incidence of different injury patterns within Monteggia injuries, investigate the main reasons leading to revision surgery and explore which surgical treatments should be favored to achieve satisfactory clinical results.We initially identified 182 publications and ultimately included 17 retrospective studies comprising 651 cases. All patients were classified using the Bado classification, leading to 30.5% Bado type I fractures, 60.4% type II fractures, 5.1% type III and 3.1% type IV fractures. Mean revision rate was 23%. Ulna non-union (28%) and limited range-of-motion (22%) are the main reasons for revision surgery. Meta-analysis shows a trend toward the use of locking plates for ulna fixation which may lead to less revision surgery and fewer ulna non-unions. Further biomechanical and clinical research is necessary to clarify the role of radial head surgery.

Radial Head Arthroplasty for Fracture: Implant Survivorship and Outcomes at Mean Follow-up of 8 Years

PURPOSE

The purpose of this study was to evaluate implant survivorship and clinical outcomes following radial head arthroplasty for fracture at long-term follow-ups.

METHODS

A retrospective analysis was conducted on adult patients who underwent primary uncemented radial head arthroplasty for radial head or neck fractures between 2012 and 2015. Medical records were reviewed to collect information regarding demographics, injury characteristics, reoperations, and revisions requiring implant removal. A bivariate analysis was conducted to identify potential risk factors for reoperation. A Kaplan-Meier curve was created to determine implant survival rates. Eligible patients were contacted to confirm any reoperations and obtain Quick Disability of the Arm, Shoulder, and Hand scores at long-term follow-ups.

RESULTS

A total of 89 patients were eligible for analysis and assessed at a mean of 97 months after surgery (range, 81-128). Reoperation rate was 16% (14 of 89 patients), including 5% of patients requiring implant removal or revision. However, 93% of reoperations occurred within the first 12 months of the index surgery. Fracture dislocations of the elbow had a higher rate of reoperation. A Kaplan-Meier curve demonstrated an implant survival rate of 96% at 10-year follow-up. Of the patients who responded, the mean Quick Disability of the Arm, Shoulder, and Hand score was 8.7 ± 10.3, with none requiring additional reoperations or revisions. There were otherwise similar outcome scores among patients requiring reoperation versus those who did not.

CONCLUSIONS

Although radial head arthroplasty for fractures has a high potential for reoperation within the first year, survival rates with uncemented implants remain high at 10 years, and patients report excellent Quick Disability of the Arm, Shoulder, and Hand scores at long-term follow-ups, despite any need for reoperation. Fractures with associated elbow dislocation may be at a higher risk for reoperation, and it is important to provide this prognostic information to patients who are likely to require arthroplasty for more extensive injuries.

TYPE OF STUDY/LEVEL OF EVIDENCE

Therapeutic IV.

Divergent Elbow Dislocation Associated with Ipsilateral Fractures of Ulnar Diaphysis and Radial Styloid Process in Adult: A Case Report

Introduction

The divergent elbow dislocation represents a rare lesion where the proximal radioulnar joint is torn and the distal part of the humerus goes between the radius and the ulna, the forearm dislocates posteriorly.

Case Report

We report the case of a 37-year-old male patient who had a traumatic divergent dislocation of the left elbow, associated with ipsilateral fractures of the ulnar diaphysis and the radial styloid process. The elbow joint was reduced under general anesthesia with internal fixation of the ulnar diaphysis fracture and a pinning of the radial styloid fracture. At 3 years of follow-up, the fractures were consolidated and the elbow was stable with a satisfying mobility.

Conclusion

The aim of our case report is to underline the diagnostic and therapeutic challenges of this complex lesion.

[Radial head arthropolasty in unreconstructable comminuted fractures of the radial head: Long-term results and factors influencing the outcome]

BACKGROUND

Radial head arthroplasty is recognized as the gold standard in the treatment of patients with unreconstructable radial head fractures.

OBJECTIVE

The aim of this retrospective study was to investigate the long-term results after prosthetic replacement of the radial head and in a subgroup analysis to identify factors which influence the outcome.

MATERIAL AND METHODS

A total of 48 patients with unreconstructable fractures of the radial head and neck were treated by cementless radial head arthroplasty between 05/2008 and 10/2018 (30 bipolar prosthesis type rHead Recon, 18 monopolar prosthesis type MoPyc). After a mean follow-up of 4.6 years 39 patients were assessed clinically and radiologically.

RESULTS

The median MEP score was 95 points. Compared to the uninjured side the median range of motion was reduced by 10° for extension/flexion as well as for pronation/supination. In 36 of 39 cases an osseous integration of the prosthesis could be documented. One prosthesis had to be removed after 23 months because of painful loosening. Overlengthening was present in 11 cases (28%), 25 patients (64%) had subcollar bone resorption with a stable osteointegrated stem. Nonbridging heterotopic ossification was observed in 15 patients (38%), 16 patients (41%) showed posttraumatic arthrosis. Patients with sustained elbow dislocation had a significantly worse function in the MEP score and tended to develop an arthrosis more frequently. Ulnohumeral joint degeneration was significantly increased when overlengthening was present.

CONCLUSION

Radial head arthroplasty is an effective treatment option for unreconstructable fractures of the radial head and can provide good to excellent mid-term to long-term results. Sustained elbow dislocation as well as overlengthening of the prosthesis had a negative impact on the clinical outcome.

Lateral Ulnar Collateral Ligament Repair With Suture-Tape Augmentation for Traumatic Elbow Instability

PURPOSE

Ligament repair with suture-tape augmentation has been used in the operative treatment of joint instability and may have advantages with respect to early motion and stability. The purpose of this investigation was to describe the clinical results of traumatic elbow instability treated with lateral ulnar collateral ligament repair with suture-tape augmentation.

METHODS

All cases of acute and chronic elbow instability treated surgically between 2018 and 2020 were included if they underwent ligament repair with suture-tape augmentation of the lateral ulnar collateral ligament as part of the procedure. Cases with <6 months of follow-up were excluded. A manual chart review was performed to record patient demographics as well as injury and surgery characteristics. Radiographic outcomes, range of motion, and patient-reported outcome measures, including the visual analog pain scale and Disabilities of the Arm, Shoulder, and Hand, were recorded. Range of motion measurements were recorded at the end of the clinical follow-up, as were surgical complications.

RESULTS

Eighteen cases were included with a mean follow-up of 20 months. Five (28%) cases involved a high-energy mechanism, and 11 (62%) cases involved terrible triad fracture dislocations. The mean Disabilities of the Arm, Shoulder, and Hand questionnaire and visual analog pain scale scores were 17 and 2, respectively. The mean flexion-extension arc was 124°, and 2 (11%) cases had <100° flexion-extension arc. There were 2 (11%) postoperative complications, and both cases had postoperative instability requiring reoperation. We observed no cases of capitellar erosion from the suture-tape material.

CONCLUSIONS

For complex elbow instability, ligament repair with suture-tape augmentation of the lateral ulnar collateral ligament results in acceptable functional outcomes and a reoperation rate comparable with other joint stabilization procedures.

TYPE OF STUDY/LEVEL OF EVIDENCE

Therapeutic IV.

[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.

Prospective clinical results of an additive ligament bracing for stabilizing simple and complex elbow instabilities

INTRODUCTION

Ligament bracing augments ligament repair using a non-absorbable suture tape. Although biomechanically an increase in primary stability has been proven, there is a lack of clinical evidence. Purpose of this study was to evaluate clinical results of patients treated with ligament bracing due to primary elbow instability, including an analysis of complications. Furthermore, clinical results for patients treated with and without early functional mobilization were compared.

MATERIALS AND METHODS

This prospective case-series evaluated clinical and functional results from patients treated with ligament bracing due to primary elbow instability. Clinical outcome measures were range of motion (ROM) as well as objective and subjective elbow scores [Mayo Elbow Performance Score (MEPS); Disabilities of Arm, Shoulder and Hand Score (DASH score)]. Stability was evaluated sonographically by humero-radial gapping under varus stress.

RESULTS

This study involved 34 patients treated with ligament bracing. After a mean follow-up of 12.9 months ROM was 112° ± 29, MEPS 88 ± 13 points, DASH 91 ± 11 points, and 84% were satisfied with their result. Lateral joint gapping was 2.4 mm. No significant difference was observed regarding a postoperative mobilization with and without limitations. Most common complication after ligament bracing was elbow stiffness including heterotopic ossifications in four patients (12%).

CONCLUSION

Operatively treated elbow instability with additional ligament bracing results in good clinical outcomes with high patient satisfaction and recovery of elbow stability. The high primary stability of the ligament bracing allows early functional mobilization without bracing, which facilitates postoperative rehabilitation. Elbow stiffness with heterotopic ossification seems to be a potential complication. Furthermore, the optimal tensioning of the ligament bracing remains challenging, including the risk of an over tensioning.

LEVEL OF EVIDENCE

III.

Open postero-lateral dislocation of the left elbow secondary to assault: A case report

INTRODUCTION AND IMPORTANCE

Simple closed lateral elbow dislocation is rare, often associated with neurovascular injury and closed reduction may be difficult. Open complex postero-lateral dislocation has not been previously reported.

CASE PRESENTATION

We present a case of open left posterior lateral elbow dislocation secondary to assault with a cutlass causing an avulsion fracture of the lateral epicondyle and common extensor origin tendon which prevented congruent reduction until the avulsed fragment was fixed with a bone screw.

CLINICAL DISCUSSION

The patient had hemorrhagic shock from excessive uncontrolled bleeding from the machete cut for which he was resuscitated with a blood transfusion. There was a longitudinal laceration on the lateral aspect of the elbow extending onto the proximal forearm with open posterolateral dislocation of the left elbow, avulsion of the common extensor origin with lateral epicondyle fracture and an open left wrist fracture dislocation with level VII laceration of the extensor tendon. The wound was explored under general anesthesia with generous saline irrigation, reduction of the dislocated left elbow and screw fixation of the lateral epicondyle fracture and primary wound closure plus primary repair of extensor tendons. A post-operative full arm Plaster of Paris cast was applied. Supervised active and passive range of motion exercise was commenced two weeks post-operatively.

CONCLUSION

The patient had uneventful recovery with left elbow range of motion of 30 to 100 degrees two months post discharge.

Anteroposterior Cannulated Screw Fixation of Coronoid Fractures in Terrible Triad Injuries: A Simple Syringe-guided Technique

OBJECTIVE

The fixation of the coronoid fractures in terrible triad injuries is quite challenging. In this study, we introduce a minimally invasive technique using a syringe as a guide for insertion of the cannulated screw in an anterior to posterior fashion to fix the coronoid fracture in patients with terrible triad injuries.

METHODS

In this retrospective study, clinical data of patients suffering from terrible triad injuries between 2012 and 2019 were analyzed. Fifteen patients with an average age of 38.2 years old (21-56 years) were enrolled in this study, of which 12 were males and three were females. The Regan-Morrey type II and type III coronoid fractures in these patients were treated with cannulated screws, inserted anteriorly using a 1 mL syringe as a guide. Outcome measures included pain, range of motion, stability and daily function using Mayo Elbow Performance scores (MEPs). The anteroposterior and lateral radiographs were used for evaluating a healing fracture.

RESULTS

After a mean follow up of 44.2 months (range 13-80), the mean elbow flexion was 128.2°, extension was 12.3°, forearm pronation was 74.6° and supination was 73.6°. A concentric reduction was maintained without severe pain, stiffness, and radiographic evidence of instability in all patients during the follow-up period. The mean MEPs was 89.7 points.

CONCLUSION

The anteroposterior cannulated screw fixation via simple syringe guide is a minimally invasive and safe option for surgical treatment of coronoid fractures in terrible triad injuries.

Overhead arm positioning in the rehabilitation of elbow dislocations: An in vitro biomechanical study

STUDY DESIGN

In vitro biomechanical study.

INTRODUCTION

Elbow stiffness is a common complication following elbow dislocation. Overhead exercises have been proposed to initiate early motion to reduce stiffness through employing gravity to stabilize the elbow. The implications of this position with regard to elbow kinematics after dislocation have not been reported.

PURPOSE OF THE STUDY

To determine the influence of the overhead position on elbow stability following combined medial and lateral collateral ligament (MCL and LCL) injuries.

METHODS

Passive and simulated active extension were performed on 11 cadaveric elbows with the arm in the overhead, dependent, and horizontal positions and with the forearm in pronation, neutral, and supination. Internal-external rotation (IER) and varus-valgus angulation (VVA) of the ulnohumeral joint were assessed for the intact elbow and after simulated MCL-LCL injury. Repeated-measures analyses of variance were conducted to analyze the effects of elbow state, arm position, forearm rotation, and extension angle.

RESULTS

During passive extension with the arm overhead, the pronated position resulted in more internal rotation than supination (-2.6 ± 0.7°, P = .03). There was no effect of forearm rotation on VVA. The overhead position increased internal rotation relative to the dependent position when the forearm was neutral (-8.5 ± 2.5°, P = .04) and relative to the horizontal position when the forearm was supinated (-12.7 ± 2.2°, P= .02). During active extension, pronation increased valgus angle compared to the neutral (+1.2 ± 0.3°, P= .04) and supinated (+1.5 ± 0.4°, P= .03) positions, but did not affect IER. There was no difference between active and passive motion with the arm overhead (P > .05).

DISCUSSION

Movement of the injured elbow in the overhead position most closely replicated kinematics of the intact elbow compared to the other arm positions.

CONCLUSIONS

Overhead elbow extension results in similar kinematics between an intact elbow and an elbow with MCL and LCL tears. As such, therapists might consider early motion in this position to reduce the risk of elbow stiffness after dislocation.

Complications and range of motion of patients with an elbow dislocation treated with a hinged external fixator: a retrospective cohort study

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.

Posteriorly Displaced Radial Head Fractures May Represent the Footprint of an Elbow Dislocation or Subluxation as a Variant of Modified Mason Type 4

BACKGROUND

The purpose of this case series is to describe surgical decision making and clinical outcomes in posteriorly displaced radial head fractures with a major fragment (more than 50% of the head) located behind the humeral condyle. We also document the outcome of open reduction and internal fixation of completely displaced radial head fractures.

METHODS

A retrospective review of the ICUC® (Integrated Comprehensive Unchanged Complete) database was performed between 2012 and 2020. Patients were included if preoperative radiographs demonstrated a major radial head fracture fragment located posterior to the humeral condyle and a minimum of 2-year follow-up data was available.

RESULTS

Ten patients met inclusion criteria. Two patients had an associated elbow dislocation whereas 8 patients did not. All patients were found to have disruption of the lateral collateral ligament complex intraoperatively. Nine radial head fractures were successfully fixed with interfragmentary screws. One multi-fragmented radial head fracture could not be successfully stabilized with interfragmentary screw fixation and was resected. The average time to final follow-up was 4.8 years (range 2.2-8.1). At final follow-up, 6 patients demonstrated radiographic evidence of a healed radial head, 1 patient had avascular necrosis, and 2 had post-traumatic arthritis. None demonstrated radiographic instability. The average functional score was 0.64 (SD 0.81) and pain score was 0.45 (SD 0.93). The average elbow extension was 8 degrees (SD 11), elbow flexion was 139 degrees (SD 6), forearm supination was 60 degrees (SD 27), and forearm pronation was 69 degrees (SD 3).

CONCLUSION

Recognition of a posteriorly displaced radial head fracture is essential, as it may be an indirect sign of elbow instability. This instability should be addressed during surgical intervention.

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.

肱骨小头背侧撕脱性骨折合并肘关节内侧或后内侧脱位的临床治疗

OBJECTIVE

To analyze the possible injury mechanisms in patients with dorsal avulsion fracture of the capitellum combined with medial or posterior medial dislocation of the elbow joint, and to discuss their treatment and prognosis.

METHODS

Retrospective analysis was made on the clinical data of 4 patients with dorsal avulsion fracture of the capitellum combined with medial or posterior medial dislocation of the elbow joint admitted between September 2014 and September 2020, including 3 males and 1 female with an average age of 20.7 years (range, 13-32 years). There were 2 cases of dorsal avulsion fracture of the capitellum combined with medial dislocation of the elbow joint and 2 cases of dorsal avulsion fracture of the capitellum and anterior medial fracture of the coronoid process combined with posterior medial subluxation of the elbow joint. Closed reduction was performed in 3 patients with fresh fracture combined with dislocation, then 2 cases were fixed with tension band and 1 case was fixed with tension band combined with Acumed coronoid anatomic plate. And in patient with old fracture nonunion, the coronoid process was fixed with 1 screw, then the humeral sclerotic bone mass was removed, and finally the lateral collateral ligament was repaired and a hinged external fixator was added.

RESULTS

All the incisions healed by first intention without early complications such as infection or peripheral nerve injury. The 4 patients were followed up 13-30 months (mean, 20.8 months). The fractures all healed with a healing time of 70-90 days (mean, 79.5 days). At 6 months after operation, heterotopic ossification was seen in the posterior aspect of the right elbow joint in 1 case, and the alkaline phosphatase level was normal (67 U/L); the tension band was removed to clear the heterotopic ossification and the elbow joint was released. The rest of the patients had no heterotopic ossification. At last follow-up, all patients had good functional recovery of the elbow joint, with a Mayo score of 85-100 (mean, 92.5), and the excellent and good rate was 100%. The elbow flexion range of motion was 120°-135°, the extension range of motion was 10°-20°, and the pronation and supination range of motion were all 75°-85°.

CONCLUSION

Dorsal avulsion fractures of the capitellum combined with medial or posterior medial dislocation of the elbow may be due to simple varus stress. If an anteromedial coronoid facet fracture also occurs, it may be for the varus posteromedial rotatory instability, which is the opposite mechanism to that of an Osborne-Cotterill lesion. For fresh dorsal avulsion fractures of the capitellum, tension band fixation can be used with good results.

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.

Prognostic Factors Affecting Long-Term Outcomes After Elbow Dislocation: A Longitudinal Cohort Study

Purpose

To describe patient-reported outcomes following simple elbow dislocation and to identify the baseline factors that predict outcomes.

Methods

Adult patients treated with a closed reduction for a simple elbow dislocation with or without minor fracture (coronoid avulsion, radial head fracture, or epicondyle avulsion) from 2000 to 2018 completed outcome instruments including Disabilities of the Arm, Shoulder and Hand (QuickDASH) via Research Electronic Data Capture. Descriptive statistics were calculated. Univariate followed by multivariate Tobit regression models were used to determine factors associated with clinical outcomes on QuickDASH. Social deprivation was measured using the Area Deprivation Index. Patients with additional upper-extremity injuries or associated major fractures (Monteggia or terrible triad injuries, distal humerus fractures, etc) were excluded.

Results

At a mean follow-up of 67.5 months, 95% (38/40) of patients reported satisfaction with treatment, and clinical outcomes were good (QuickDASH 9.0 ± 14.8). Univariate analysis showed that higher Area Deprivation Index, older age, female sex, high-energy mechanism of injury, and worker’s compensation (WC) or Medicare insurance status (vs commercial) was associated with significantly worse QuickDASH scores at follow-up. Early therapy, dominant elbow involvement, presence of minor fractures (minimally displaced radial head, coronoid tip, or epicondylar avulsion fractures), race, and treating service did not influence outcomes in univariate analyses. Multivariate analysis demonstrated a significant association between increased social deprivation, WC insurance, and Medicare insurance and worse QuickDASH scores while controlling for new upper-extremity injury, age, sex, and mechanism of injury.

Conclusions

Outcomes and treatment satisfaction following simple elbow dislocation are generally good but are significantly worse for the patients with greater levels of social deprivation and WC or Medicare insurance. Although surgeons should be aware of the possibility that specific subsets of patients may benefit from early therapy, this factor did not appear to influence long-term outcomes in this small cohort.

Type of study/level of evidence

Prognostic III.

Management of Geriatric Elbow Injury

Approximately 4.1% of all fractures in the elderly involve the elbow. Most elbow injuries in geriatric patients occur as the result of low-energy mechanisms such as falls from standing height. Elbow injuries in elderly patients present complex challenges because of insufficient bone quality, comminution, articular fragmentation, and preexisting conditions, such as arthritis. Medical comorbidities and baseline level of function must be heavily considered in surgical decision making.

Imaging of Elbow Injuries

Familiarity with throwing mechanics during elbow range of motion allows accurate diagnosis of sports-related elbow injuries, which occur in predictable patterns. In addition, repetitive stress-related injuries are often clinically apparent; however, imaging plays an important role in determining severity as well as associated injuries that may affect clinical management. A detailed understanding of elbow imaging regarding anatomy and mechanism of injury results in prompt and precise treatment.

The changing epidemiology of radial head replacement over a 22-year period in Scotland

BACKGROUND

Radial head replacement is used to confer joint stability in the management of acute unstable elbow fractures and dislocations associated with instability. We determined the annual incidence of radial head replacement over a 22-year period in a defined population.

MATERIALS AND METHODS

Hospital episode statistics were collected prospectively at a national level. This database was retrospectively examined to determine the annual incidence of radial head replacement over the study period in adults over 16 years of age.

RESULTS

A total of 615 radial head replacements were performed over the 22 years studied. The overall incidence was 0.65/100,000/year (95% confidence interval, CI, 0.50-0.71). The average adult population during the period was 4,270,593. There was a steady and statistically significant increase in the incidence of radial head replacement over the study period (r ² = 0.816; p < 0.0001). This incidence was significantly greater in women than men (odds ratio 1.46, 95% CI 1.25-1.72; p < 0.001). The peak incidence in men was 0.87/100,000 population/year in the fifth decade of life while in women the peak incidence was in the seventh decade of life (1.38/100,000 population/year).

CONCLUSION

The incidence of radial head replacement has increased steadily over 22 years. We hypothesise that this represents an evolving understanding of the role of radial head replacement in acute trauma in the context of emerging literature during the study period.

Lateral Elbow Dislocation of a Patient with Elbow Flexion Contracture and a Traumatic Brain Lesion

Most of the lateral dislocations reported in previous literatures occurred to healthy patients by accident. However, our patient had limping gait, flexion contracture of the elbow, and spasticity in an affected arm due to a traumatic brain lesion 20 years ago. He fell down while taking a walk and presented with a lateral elbow dislocation accompanying tingling sense in ulnar nerve territory of his hand. Open reduction was performed. The torn MCL was reattached and the ulnar nerve was released. In postoperative six months, the range of motion was regained and the neurologic symptoms were resolved. This case shows that flexion contracture of elbow joint and a brain lesion causing motor disturbance of upper extremity could be the specific condition causing lateral elbow dislocation. Open reduction including repair of MCL and decompression of ulnar nerve, seems quite reasonable for the treatment of the lateral elbow dislocation.

Surgical management of medial and lateral elbow instability secondary to acute atypical complex elbow dislocation: Case report and literature review

•

The patient presented with an atypical complex elbow dislocation with fracture.

•

The patient underwent lateral collateral ligament repair.

•

The patient also underwent medial collateral ligament reconstruction.

•

Elbow stability improved and the patient experienced improved functionality.

•

Care is needed to identify and manage the underlying injury in this type of case.

Introduction and importance

Elbow dislocation is common in adults, and complex elbow dislocations are generally associated with bone fractures. Anteromedial coronoid fracture, in association with lateral collateral ligament (LCL) disruption, often results from varus posteromedial forces. “Terrible triad” injuries are more likely to result from valgus posterolateral forces. However, our case presentation has combined medial and lateral elbow instability in addition to “terrible triad” injury of the elbow with no radial head injury.

Case presentation

The patient was a 38-year-old man with an atypical complex elbow dislocation. He was successfully treated by stabilizing the medial epicondyle and coronoid anterolateral facet fractures, in addition to LCL repair and medial collateral ligament (MCL) reconstruction. A radial head fracture was unnoted. The procedure yielded satisfactory functional outcome, with a stable and painless full elbow range of motion.

Clinical discussion

Multi-ligament injuries with coronoid fractures result in highly unstable elbow joints, forming a variant of the “terrible triad” injury. Surgical options vary according to the surgeon’s experience and equipment availability. In this case, direct LCL repair and MCL reconstruction were performed and were well tolerated. Elbow stability improved and the patient experienced improved functionality with minimal pain. However, it may be premature to report a definite outcome in this case because of short follow-up time postoperatively.

Conclusion

The injury described in this case has a unique presentation as a multi-ligamentous injury will make the elbow very unstable. Thus, careful clinical judgment, knowledge, and experience are needed to identify the underlying injury and for optimal management.

Histopathology of recurrent Steel syndrome in fetuses caused by novel variants of COL27A1 gene

Steel syndrome (STLS) encompasses characteristic facies, dwarfness, irreducible bilateral hip and radial head dislocation, and carpal bone coalition due to COL27A1 mutations. Two consecutive pregnancies in a non-consanguineous couple were terminated because of severe fetal anomalies. Complete autopsies with microscopic exam were performed on both fetuses. Next-generation-based clinical exome sequencing was applied to the first fetus. Exome sequencing results, parental segregation, and affection of the second fetus were confirmed by Sanger sequencing. Both fetuses had signs consistent with STLS. Bilateral capitulum humeri absence explained radial head dislocation in STLS. Metaphyseal cartilage showed severe disorganization. Resting cartilage was hypercellular, organized in irregular nests limited by acellular matrix. Two variants in COL27A1 (c.2548G>A -p.Gly850Arg- and c.3249+1G> T) were found in both fetuses in compound heterozygosity with parental Mendelian segregation. This is the first report to include histology of STLS. The COL27A1 variants here described increase the number of mutations associated with STLS.

Biomechanical comparison of lateral collateral ligament reconstruction with and without additional internal bracing using a three-dimensional elbow simulator

BACKGROUND

Although an additional internal bracing significantly increases stability in a repair of the lateral ulnar collateral ligament, it remains unclear whether it also does in reconstruction. Aim of this study was to implement a three-dimensional elbow simulator for testing posterolateral rotatory instability. We hypothesized that (1) reconstruction with and without internal bracing is comparable in biomechanical properties, and (2) there would be higher load-to-failure with internal bracing.

METHODS

Posterolateral rotatory instability was tested by imitating the lateral pivot shift test in 16 elbows. Valgus and supination torques were simultaneously increased stepwise up to 1.2 Nm. Specimens were tested at 30°, 60°, 90°, and 120° elbow flexion with an intact lateral collateral ligament complex, dissected complex, and after reconstruction with or without internal bracing. Outcome measures included joint gapping, laxity, and load to failure.

FINDINGS

With the implemented elbow simulator no significant difference was observed for gapping or laxity between both treatment groups. Comparing treatment and native ligament, gapping was reduced, especially with increased elbow flexion. Laxity was also reduced at some flexion angles. The mean load-to-failure was 8.1 ± 2.7 Nm without and 9.6 ± 3.6 Nm with internal bracing (P = 0.645).

INTERPRETATION

Both treatments were comparable in biomechanical properties but did not fully restore the native state. Although the additional augmentation of the LUCL reconstruction tends to increase the maximum load to failure, this difference was not statistically significant. Still, reconstruction with internal bracing seems to be a reasonable option in selected primary reconstructions. It could also be useful in revision reconstruction.

Suture tape augmentation of the lateral ulnar collateral ligament increases load to failure in simulated posterolateral rotatory instability

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.

Elbow Instability: Evaluation and Treatment

Acute elbow dislocations are commonly seen in clinical practice, and attention to management principles and strategies can help facilitate improved outcomes. Patients may present with simple elbow dislocation, in which nonoperative treatment is highly successful. Alternatively, fracture dislocations can be sometimes easily managed but frequently are associated with the need for surgical intervention and operative and postoperative challenges.

Management of Monteggia Injuries in the Adult

Monteggia fracture-dislocation of the elbow is a fracture of the proximal ulna with associated dislocation of the radial head or radial neck fracture. In adults, this injury is managed with open reduction and internal fixation of the ulna fracture. Care should be taken to ensure anatomic reduction of the proximal ulna. If radial head dislocation or subluxation persists, reduction of the ulna should be reassessed. Rarely, interposed soft tissue may block radial head reduction, and requires removal. Complications include hardware prominence, stiffness, infection, heterotopic ossification, nerve injury, malunion or nonunion of the ulna, radioulnar synostosis, and persistent radial head instability.

Elbow Fractures

The elbow joint consists of the humeroulnar, humeroradial, and proximal radioulnar joints. Elbow stability is maintained by a combination of static and dynamic constraints. Elbow fractures are challenging to treat because the articular surfaces must be restored perfectly and associated soft tissue injuries must be recognized and appropriately managed. Most elbow fractures are best treated operatively with restoration of normal bony anatomy and rigid internal fixation and repair and/or reconstruction of the collateral ligaments. Advanced imaging, improved understanding of the complex anatomy of the elbow joint, and improved fixation techniques have contributed to improved elbow fracture outcomes.

Terrible triad of the elbow with an ipsilateral Essex-Lopresti injury: case report

Terrible triad of the elbow and the Essex-Lopresti injury are both rare lesions with a historically poor clinical outcome. We present the case of a unique association of the two injuries with an elbow dislocation, radial and coronoid process fractures and a distal radioulnar joint dislocation due to an interosseous membrane rupture. The case was managed with closed reduction of the elbow dislocation and distal radioulnar joint followed by open reduction and repair of the damaged structures in the elbow and an unloading of the interosseous membrane. A high index of suspicion with a detailed examination of the elbow, forearm and wrist associated to a comprehensive imaging were mandatory for a complete diagnosis and an adequate treatment. Six months after the accident, the patient made a good recovery.

Comparison of bipolar and monopolar radial head prostheses in elbow fracture-dislocation

INTRODUCTION

The role of bipolar radial head prostheses (RHP) in elbow fracture-dislocation is controversial, with some reports of poorer stabilization than with monopolar designs. The aim of the present study was to compare mono- versus bi-polar RHPs in elbow fracture-dislocation. The study hypothesis was that mono- and bi-polar RHPs do not differ in clinical and radiological results, complications or revision rates.

MATERIAL AND METHODS

A single-center retrospective study included 58 patients, with a mean age of 55 years (range, 21-84 years). All received RHP for elbow dislocation with association: terrible triad, Monteggia fracture-dislocation, transolecranal dislocation or divergent dislocation. Two groups were compared: Mono-RHP, with monopolar prosthesis (n=40), and Bi-RHP, with bipolar prosthesis (n=18). All patients underwent clinical and radiological examination at last follow-up.

RESULTS

Mean follow-up was 42.7 months (range, 12-131 months). There were no significant (p>0.05) inter-group differences in range of motion or Mayo Elbow Performance Score. Mono- versus bi-polar design did not correlate with onset of complications (p=0.89), surgical revision (p=0.71), persistent or recurrent instability (p=0.59), or ulnohumeral (p=0.62) or capitulum (p=0.159) osteoarthritis at last follow-up.

DISCUSSION AND CONCLUSION

No differences were found between mono- and bi-polar RHPs in the treatment of elbow fracture-dislocation. Clinical and radiographic results were similar, as were complications and revision rates. The literature is inconclusive, reporting contradictory conclusions. We see no contraindications to bipolar RHPs in elbow dislocation with association, notably terrible triad injury.

LEVEL OF EVIDENCE

III, Retrospective case-control study.

Osborne-Cotterill Lesion a Forgotten Injury: Review Article and Case Report

Osborne-Cotterill lesion is an osteochondral fracture located in the posterolateral margin of the humeral capitellum, which may be associated with a defect of the radial head after an elbow dislocation. This lesion causes instability by affecting the lateral ulnar collateral ligament over its capitellar insertion, which is associated with a residual capsular laxity, thereby leading to poor coverage of the radial head, and hence resulting in frequent dislocations. We present a 54-year-old patient, a physician who underwent trauma of the left elbow after falling from a bike and suffered a posterior dislocation fracture of the elbow. The patient subsequently presented episodes of instability, and additional work-up studies diagnosed the occurrence of Osborne-Cotterill lesion. An open reduction and internal fixation of the bony lesion was performed, with reinsertion of the lateral ligamentous complex. Three months after surgery, the patient was asymptomatic, having a flexion of 130º and extension of 0º, and resumed his daily activities without any limitation. Currently, the patient remains asymptomatic 2 years after the procedure. Elbow instability includes a large spectrum of pathological conditions that affect the biomechanics of the joint. The Osborne-Cotterill lesion is one among these conditions. It is a pathology that is often forgotten and easily overlooked. Undoubtedly, this lesion requires surgical intervention.

The lateral ligament is injured preferentially in posterolateral dislocation of the elbow joint

AIMS

The purpose of this study was to evaluate the relationships between the degree of injury to the medial and lateral collateral ligaments (MCL and LCL) and associated fractures in patients with a posterolateral dislocation of the elbow, using CT and MRI.

METHODS

We retrospectively reviewed 64 patients who presented between March 2009 and March 2018 with a posterolateral dislocation of the elbow and who underwent CT and MRI. CT revealed fractures of the radial head, coronoid process, and medial and lateral humeral epicondyles. MRI was used to identify contusion of the bone and collateral ligament injuries by tear, partial or complete tear.

RESULTS

A total of 54 patients had a fracture; some had more than one. Radial head fractures were found in 25 patients and coronoid fractures in 42. Lateral and medial humeral epicondylar fractures were found in eight and six patients, respectively. Contusion of the capitellum was found in 43 patients and rupture of the LCL was seen in all patients (partial in eight and complete in 56), there was complete rupture of the MCL in 37 patients, partial rupture in 19 and eight had no evidence of rupture. The LCL tear did not significantly correlate with the presence of fracture, but the MCL rupture was complete in patients with a radial head fracture (p = 0.047) and there was significantly increased association in those without a coronoid fracture (p = 0.015).

CONCLUSION

In posterolateral dislocation of the elbow, LCL ruptures are mostly complete, while the MCL exhibits various degrees of injury, which are significantly associated with the associated fractures. Cite this article: Bone Joint J 2020;102-B(2):227-231.

Early mobilization versus plaster immobilization of simple elbow dislocations: a cost analysis of the FuncSiE multicenter randomized clinical trial

INTRODUCTION

The primary aim was to assess and compare the total costs (direct health care costs and indirect costs due to loss of production) after early mobilization versus plaster immobilization in patients with a simple elbow dislocation. It was hypothesized that early mobilization would not lead to higher direct and indirect costs.

MATERIALS AND METHODS

This study used data of a multicenter randomized clinical trial (FuncSiE trial). From August 25, 2009 until September 18, 2012, 100 adult patients with a simple elbow dislocation were recruited and randomized to early mobilization (immediate motion exercises; n = 48) or 3 weeks plaster immobilization (n = 52). Patients completed questionnaires on health-related quality of life [EuroQoL-5D (EQ-5D) and Short Form-36 (SF-36 PCS and SF-36 MCS)], health care use, and work absence. Follow-up was 1 year. Primary outcome were the total costs at 1 year. Analysis was by intention to treat.

RESULTS

There were no significant differences in EQ-5D, SF-36 PCS, and SF-36 MCS between the two groups. Mean total costs per patient were €3624 in the early mobilization group versus €7072 in the plaster group (p = 0.094). Shorter work absenteeism in the early mobilization group (10 versus 18 days; p = 0.027) did not lead to significantly lower costs for loss of productivity (€1719 in the early mobilization group versus €4589; p = 0.120).

CONCLUSION

From a clinical and a socio-economic point of view, early mobilization should be the treatment of choice for a simple elbow dislocation. Plaster immobilization has inferior results at almost double the cost.

Conservative Versus Surgical Management of Elbow Medial Ulnar Collateral Ligament Injury: A Systematic Review

Objective

Several studies have been published regarding the treatment of medial ulnar collateral ligament (MUCL) injuries for professional overhead athletes. However, there is a paucity of data regarding non‐professional athletes. The aim of this systematic review was to compare the rate of outcome scores and complications of conservative versus operative treatments both in non‐professional athletes and in non‐sport‐related trauma patients with MUCL lesions.

Methods

A systematic review of the published literature was performed by applying the PRISMA guidelines. A search was conducted using three databases: Medline, Science Direct, and Web of Science. The keywords used were “ulnar collateral ligament injury,” “elbow,” “surgery,” and “conservative treatment”. Patients were divided into three groups: patients who underwent conservative treatment (C‐group), surgical treatment (S‐group), and surgery after a failed conservative treatment (C&S‐group). Clinical outcomes were analyzed: Disability of Arm, Shoulder and Hand (DASH), Conway scale, Carson score, and Kerlan–Jobe Orthopaedic Clinic score (KJOC).

Results

A total of 15 studies were included, evaluating 513 patients. Although good and excellent outcomes were found for most patients during daily and/or sport activities, independently of the type of treatment, the C‐group had better results. Excellent results were found in 98.8% of the C‐group, in 88.1% of the S‐group, and in 87.7% of the C&S‐group. The complication rate in the C‐group was statistically higher compared to the S and C&S groups (P < 0.001). However, its complication rate was higher with lower patient satisfaction.

Conclusions

There is insufficient evidence to establish statistically significant differences in the effects of conservative versus surgical treatments on the functional outcomes of patients with MUCL lesions. However, a period of rehabilitation therapy and the functional request of the single injured subject are useful to discern which patients genuinely require MUCL surgical repair.

The Emergent Evaluation and Treatment of Elbow and Forearm Injuries

This article provides an updated review of the emergent evalution and treatment of elbow and forearm injuries in the emergency department. Clinically necessary imaging is discussed. Common and uncommon injuries of the elbow and forearm are reviewed with an emphasis on early recognition, efficient management, and avoidance of complications. The astute emergency physician will rely on a focused history and precise examination, applied anatomic knowledge, and strong radiographic interpretative skills to avoid missed injuries and complications.

Chronically unreduced elbow dislocation treated with box-loop ligament reconstruction: The first case series

OBJECTIVES

Describing our initial experience of performing box-loop ligament reconstruction in patients with chronically unreduced elbow dislocation.

DESIGN

Retrospective review.

SETTING

One tertiary referral centre.

PATIENTS/PARTICIPANTS

Six patients treated with box-loop ligament reconstruction from 2015 to 2018 were included in this study.

INTERVENTION

Box-loop ligament reconstruction.

MAIN OUTCOME MEASUREMENT

Quick disabilities of the arm, shoulder and hand (Q-DASH) and Mayo elbow performance index (MEPI) score.

RESULTS

All subjects exhibited substantial increase of range of flexion-extension motion of the affected elbow, from a mean of 24.2° initially to 119.2° postoperatively during the follow-up period (median = 14 months, range 12-31 months). The subjects recorded an average MEPI score of 82.5 points, and average Q-DASH score of 16.2 points. There were no complications that occurred.

CONCLUSIONS

This is the first case series of patients with chronically unreduced elbow dislocation treated with box-loop ligament reconstruction. Using this technique, all subjects had excellent outcome without any complication. Further studies with larger samples and better methodology are required to investigate the safety and efficacy of such technique.

Repair and augmentation of the lateral collateral ligament complex using internal bracing in dislocations and fracture dislocations of the elbow restores stability and allows early rehabilitation

PURPOSE

Most elbow dislocations can be treated conservatively, with surgery indicated in special circumstances. Surgical options, apart from fracture fixation, range from repair or reconstruction of the damaged ligaments to static external fixation, usually entailing either a long period of immobilization followed by carefully monitored initiation of movement or dynamic external fixation. In general, no consensus regarding surgical treatment has been reached. A new method of open ligament repair and augmentation of the lateral ulnar collateral ligament using a non-absorbable suture tape in cases of acute and subacute elbow instability following dislocations has been described here, which allows an early, brace-free initiation of the full range of motion. This is the first description of the technique of internal bracing of the lateral elbow with preliminary patient outcome parameters for acute treatment of posterolateral rotatory instability.

METHODS

Seventeen patients (14 males and 3 females) with acute or subacute posterolateral elbow instability as a result of dislocation or fracture dislocation were treated in our centre (Sporthopaedicum, Straubing, Regensburg, Germany) from 2014 to 2015 with open LUCL re-fixation and non-absorbable suture tape augmentation. The elbows were actively mobilized immediately after the operation and a maximum bracing period of 3 days.

RESULTS

At 10 month median follow-up, none of the patients showed clinically apparent signs of instability or suffered subluxation or re-dislocation. One patient required re-operation for heterotopic ossification. The median range of motion was from 10° (0-40) to 130° (90-50) and median Oxford, Mayo Elbow Performance score, Simple Elbow Value, and DASH Scores were 41(29-48), 100 (70-100), 83% (60-95), and 18.5 (1.6-66), respectively. All patients reported a complete return to pre-injury level of activity.

CONCLUSION

Augmentation with a non-absorbable suture tape acting as an 'Internal Brace' following an elbow dislocation is a safe adjunct to primary ligament repair and may allow the early mobilization and recovery of elbow stability and range of motion.

LEVEL OF EVIDENCE

IV.

The value of elbow arthroscopy in diagnosing and treatment of radial head fractures

Background

Surgical treatment of radial head fractures is increasingly performed arthroscopically. These fractures often feature concomitant injuries to the elbow joint, which may be under-diagnosed in the radiological examinations. Little is known about the diagnostic value of arthroscopy, the treatment options that arise from arthroscopically assisted fracture fixation and clinical results. We hypothesized that arthroscopy can detect additional concomitant injuries and simultaneously expands the therapeutic options. Therefore aim of this study was to compare arthroscopic and radiologic findings, to assess the distinct arthroscopic procedures and to follow up on the clinical outcomes.

Methods

Twenty patients with radial head fractures were retrospectively included in two study centers. All patients underwent elbow arthroscopy due to at least one of the following suspected concomitant injuries: osteochondral lesions of the humeral capitellum, injuries of the collateral ligaments or loose joint bodies. Preoperative radiological findings were compared to arthroscopic findings. Afterwards, arthroscopic treatment options and clinical outcomes were assessed.

Results

Arthroscopic findings led to revision of the classified fracture type in 70% (p = 0.001) when compared to preoperative conventional radiographs (CR) and in 9% (p = 0.598) when compared to computed tomography (CT) or magnetic resonance imaging (MRI). Diagnosis of loose bodies was missed in 60% (p < 0.001) of the CR and in 18% (p = 0.269) of the CT/MRI scans. Osteochondral lesions were not identified in 94% (p < 0.001) of the CR and in 27% (p = 0.17) of the CT/MRI scans. Percutaneous screw fixation was performed in 65% and partial radial head resection in 10%. Arthroscopy revealed elbow instability in 35%, leading to lateral collateral ligament reconstruction. After a mean follow up of 41.4 ± 3.4 months functional outcome was excellent in all cases (DASH-Score 0.6 ± 0.8; MEPI-Score 98.5 ± 2.4; OES-Score 47.3 ± 1.1).

Conclusions

Elbow arthroscopy has a significant diagnostic value in radial head fractures when compared to standard radiological imaging. Although statistically not significant, arthroscopy also revealed concomitant injuries in patients that presented with an uneventful MRI/CT. Furthermore, all intraarticular findings could be treated arthroscopically allowing for excellent functional outcomes.

Trial registration

Institutional Review Board University of Munich (LMU), Trial Number 507–14.

Recent trends in children's elbow dislocation with or without a concomitant fracture

BACKGROUND

The elbow is the joint that most usually dislocates in children. In contrast to the widely known recent increase in the incidence of upper-extremity fractures and their operative treatment in children, potential trends in elbow dislocation are not clear. In this study we aimed to clarify the recent epidemiology of childhood elbow dislocation, in particular the potential change in incidence and treatment.

METHODS

A population-based study was performed to evaluate the annual incidence and the characteristics of injury, patients and treatment. All children < 16 years of age with an elbow dislocation in 1996-2014 in the Oulu University Hospital District, Finland, were included. Elbow dislocations with and without an associated fracture were included. The mean number of children in the population at risk was 85,600, according Statistics Finland.

RESULTS

There were 104 patients with a mean age of 11.3 years (SD 2.6). The annual incidence was 6.4 (mean) per 100,000 children in 1996-2014 and no changing trend in incidence during the study period was found. Trampoline jumping was the most usual reason for the dislocations (N = 15, 14.4%). The majority (N = 73/104, 70.2%) were treated non-operatively by reduction and casting. There was no change in surgical treatment during the study time.

CONCLUSION

In contrast to increasing incidence of upper-extremity fractures in children, there has not been a change in the incidence of elbow dislocation in children. There was no change in surgical treatment in 1996-2014.

On-field Management of Shoulder and Elbow Injuries in Baseball Athletes

PURPOSE OF REVIEW

The goal of this review article is to help medical personnel of all levels and backgrounds identify and appropriately manage on-field acute shoulder and elbow injuries in the baseball athlete. This article discusses the most common acute shoulder and elbow injuries in baseball players along with recommendations for appropriate on-field management.

RECENT FINDINGS

Shoulder and elbow injuries are very common in baseball players and can be problematic because of the unique demands placed on the shoulder and elbow during the throwing and swinging motions. While many shoulder and elbow injuries in baseball players are chronic, some acute injuries, including dislocations and fractures, require urgent on-field management. Evaluation should begin with a broad assessment to rule out life-threatening emergencies prior to performing a neurovascular evaluation of the affected extremity. Red-flag signs during examination, such as difficulty breathing, asymmetric pulses, weakness, and limb discoloration, require emergent treatment. In the absence of an emergency, the evaluating medical team should complete a basic neurovascular exam before performing any further on-field care. Contusions, dislocations, and fractures are the most commonly seen acute shoulder and elbow injuries in baseball athletes. Athletic trainers and physicians caring for these athletes should be familiar with these injuries and their appropriate on-field management.

Treatment of Chronic Simple Elbow Dislocation by Two Separate Incisions - A Case Report

INTRODUCTION

Chronic elbow dislocation is a highly disabling condition to be treated and to provide a successful functional outcome. Surgical treatment of such conditions might result in persisting instability or stiffness of the elbow joint due to associated shortening and contracture of the soft tissues and articular incongruity. Most of the described open reduction techniques are through an extensile posterior approach which might result in increased post-operative stiffness. We report the treatment of such a case with separate medial and lateral incisions with the excellent functional outcome at 1-year follow-up.

CASE REPORT

A 45-year-old lady with 2-month-old elbow dislocation was planned for open reduction of the joint through two separate incisions, medial and lateral. Surgical details and difficulties faced will be analyzed in this paper. The patient currently has 30-140°flexion with complete pronation-supination movements at 1-year follow-up.

CONCLUSION

Chronic dislocation of the elbow is a highly disabling condition and has a very unpredictable outcome. By combining an understanding in the anatomy and biomechanics of the elbow with a proper surgical technique tailored to the individual patient, it is possible to achieve a functional and painless elbow in the majority of cases. By accessing medial and lateral elbow separately, the morbidity and wound complications of an extensile posterior approach can be reduced and also it has similar, if not better, functional results.