Simple medial elbow dislocations: a rare injury at risk for early instability

Acute elbow dislocation: a critical appraisal of the literature

Background

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

Material and methods

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

Results

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

Conclusion

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

Ulnar nerve neuropathy caused by pathologic ossification: a case report

PURPOSE

Cubital tunnel syndrome is a well-described entity with many reported etiologies and anatomical compression sites. Accessory ossicles of either traumatic or congenital origin might occur around the elbow joint. Only one case reporting such ossicles compressing the ulnar nerve exists in previous literature. We aim to present this entity with a detailed description of the patient history and treatment.

CASE REPORT

We report a case of 30-year-old female presenting with classical signs of cubital tunnel syndrome-positive Wartenberg's and Froment's signs, hypoesthesia in the fourth and fifth finger with decreased finger duction strength but without gross hypotrophy of interosseous and hypothenar muscles. Tinel's sign was positive over the ulnar sulcus and an accessory ossicle was found on the elbow radiograph within the ulnar sulcus. The first signs of calcification in this patient were reported 6 years prior in a follow-up after the dislocation of her elbow joint following a bike accident. The EMG confirmed ulnar nerve neuropathy in the elbow area. The ossicle was extirpated, the ulnar nerve was decompressed in the ulnar sulcus in a standard manner and the symptoms quickly resolved. The patient has been regularly visiting our outpatient clinic for the next 12 years without any complaints considering her elbow and the ulnar nerve.

CONCLUSION

This is a rare case of cubital tunnel syndrome caused by an accessory ossicle of traumatic origin. Simple bone extirpation with ulnar nerve release followed by anterior subcutaneous transposition is the recommended method of treatment. No report of congenital accessory bones causing ulnar nerve compression in the elbow exists in the literature.

[Clinical treatment of dorsal avulsion fracture of the capitellum combined with medial or posterior medial dislocation of the elbow joint]

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.

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

INTRODUCTION

Elbow dislocation is the second most frequent joint dislocation after shoulder dislocation. They have a high relevance because they can result in subsequent damage and limitations in range of motion. The treatment options are controversially discussed.The purpose of this systematic review and meta-analysis was to review the literature and analyze the evidence of early functional rehabilitation.

METHODS

A systematic literature search was performed via Ovid Medline, whereby 1645 publications were identified and evaluated in a stepwise approach. Of these publications 29 met the inclusion criteria of the authors and described simple elbow dislocations in 5765 patients.Data from the studies and subgroups included were initially categorized descriptively in conservative and surgical primary therapies, in immobilizing (immobilization lasting 2 weeks or longer) and free-functional follow-up treatments, and those data were then extracted from each subgroup in absolutes. We then pooled these numbers into descriptive statistics to ensure their comparability. We determined the success rates from the numbers of excellent and good results of the specific used outcome scores.

RESULTS

The effect estimate of the conservative therapy's success rate was 84% and for surgical treatment 80% (P < .0001). The difference between the immobilizing treatment (78% success rate) and early-function therapy (83% success rate) was significant (P = .002).In a subgroup analysis the success rate of conservative and immobilizing therapy was 79%, of conservative and early-functional therapy 91%, of surgical and immobilizing groups' was 77% and of the surgical and early-functional therapies was 93%. The difference among the 4 treatment options was significant (P < .0001), as were differences between the 2 conservative groups (P < .0001) and between the 2 surgical groups (P = .044).

DISCUSSION

Conservative therapy is the dominant therapy. Regardless of the primary therapy chosen in simple elbow dislocations: early functional follow-up care seems to be superior to immobilizing therapy with a duration more than 2 weeks.

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

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

Common Extensor Complex Is a Predictor to Determine the Stability in Simple Posterolateral Elbow Dislocation: Analysis of MR Images of Stable vs. Unstable Dislocation

Simple posterolateral elbow dislocations (SPLED) may be treated nonoperatively using closed reduction, followed by controlled mobilization. However, the extent of soft tissue injuries might affect the choice of treatment, rehabilitation approach, and prognosis. The purpose of this study is to compare the characteristics of soft tissue injuries between patients with unstable and stable SPLED using MRI findings. Thirty MRIs of elbows with SPLED (unstable group (n = 15); stable group (n = 15)) were randomly reviewed by two experienced musculoskeletal radiologists. Soft tissue injuries were characterized as an intact, partial tear or complete tear for the: medial collateral ligament (MCL) complex, common flexor complex, lateral collateral ligament (LCL) complex, common extensor complex, anterior capsule, and posterior capsule. Moderate to substantial interobserver reliability and substantial to perfect intraobserver reliability were observed for medial and lateral complexes in SPLED. The proportion of soft-tissue injuries of the common extensor complex were significantly different between the unstable (four partial tears and 11 complete tears) and stable groups (11 partial tears and four complete tears). In conclusion, based on MRI findings, the degree of common extensor complex injuries may be a predictor of stability and help inform treatment decisions for SPLED.

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.

Most coronoid fractures and fracture-dislocations with no radial head involvement can be treated nonsurgically with elbow immobilization

HYPOTHESIS

Conservative treatment of isolated coronoid fractures and fracture-dislocations focused on soft-tissue healing can provide good clinical results in the majority of patients. Our aims were (1) to evaluate the outcome of a conservative treatment protocol designed for isolated coronoid fractures with or without associated elbow dislocations (ICFs) and (2) to characterize the fractures with a dedicated image analysis protocol.

METHODS

Of 38 consecutive patients sustaining acute ICFs, 28 were treated nonsurgically after meeting specific inclusion criteria, prospectively followed up, and clinically evaluated at least 1 year after sustaining their injuries. All cases underwent elbow computed tomography scans with tri-plane and 3-dimensional reconstructions according to a specific protocol referenced to the proximal ulna.

RESULTS

The study included 15 male and 13 female patients, with a mean follow-up period of 32 ± 14 months (range, 12-61 months). An associated dislocation was presented in 8 (29%). Mean extension and flexion were 2° ± 8° (range, -10° to 30°) and 139° ± 11° (range, 110°-155°), respectively. Mean pronation and supination were 74° ± 3° (range, 60°-75°) and 83° ± 9° (range, 40°-85°), respectively. Of the patients, 78% rated their elbow as being normal or nearly normal. The mean Mayo Elbow Performance Score was 95 ± 9 (range, 70-100). The mean Disabilities of the Arm, Shoulder and Hand score was 7 ± 13 (range, 0-57). The mean coronoid fracture height was 5.7 ± 1.2 mm (range, 3.7-7.9 mm). The mean percentage of coronoid height fractured was 33% ± 6% (range, 23%-43%). Mean fracture displacement was 2.7 ± 2 mm (range, 1-9 mm). Of the fractures, 23 (82%) were located at the anteromedial coronoid.

CONCLUSION

An ICF with a perfectly reduced ulnohumeral joint, a competent sublime tubercle, and a fractured coronoid height up to 50% can be treated without surgery with excellent or good results in more than 90% of cases regardless of the location of the fracture in the coronoid or the type of soft tissue-associated disruptions.

Unusual combination of elbow dislocation with a retained intraarticular fragment and trochlear fracture and ipsilateral distal radius fracture in an amateur snowboarder: A case report and review of literatures

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Most common damage caused by snowboarding is wrist injury.

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Mechnism of elbow dislocation resulting from falls on the outstretched hand.

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Elbow dislocation with ipsilateral distal radius fracture is not a common injury.

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Such combined injury caused by fall on outstretched hand on the snow surface during snowboarding.

Introduction: The most common damage caused by snowboarding is wrist injury. However, Elbow injuries are relatively rare. In general, elbow dislocation with ipsilateral distal radius fracture is also very rare.

Presentation of case: We present an 18-year-old right hand dominant male with distal radius extra-articular fracture and elbow fracture dislocation. Computed tomographic scan and Magnetic resonance image of elbow joint showed retained intra-articular fragment, trochlear fracture, and the humeral attachment site of lateral collateral ligament (LCL) with rupture. The ruptured LCL was repaired, and then, the distal radius fracture was fixed with a volar distal radius locking plate. At one year after surgery, the patient did not complain of any subjective symptoms or functional deficit.

Discussion: The injury mechanism would fall into the outstretched arm state, leading first to hyperextension of the wrist, resulting in fracture of the distal radius. The remaining force is then applied to the elbow joint by an external rotation and valgus moment arm, resulting in the rupture of the LCL of the elbow joint. In this state, the remaining force is transmitted through the olecranon to the trochlea as a shear force, resulting in osteochondral fracture and subsequent dislocation of the elbow joint.

Conclusion: Combined injury of extremity from snowboarding is relatively rare, but we experienced a case of elbow dislocation combined with distal radius fracture caused by fall on outstretched hand on the snow surface during snowboarding in a young adult.

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

BACKGROUND

Although simple posterolateral or posterior elbow dislocations are relatively common and usually stable after closed reduction, simple posteromedial dislocations are extremely rare and poorly characterized. We investigated the clinical characteristics, soft-tissue injury patterns, treatments, and outcomes of a series of posteromedial elbow dislocations without relevant osseous lesions.

METHODS

We retrospectively reviewed 20 cases of simple posteromedial elbow dislocations without relevant osseous lesions that were treated at 7 fellowship training hospitals during a 10-year period. Soft-tissue injury patterns in 15 cases were investigated with use of magnetic resonance imaging. Clinical outcomes were evaluated after an average of 56.1 months (range, 24 to 93 months) with use of the Mayo Elbow Performance Score (MEPS) and the Quick-DASH (an abbreviated version of the Disabilities of the Arm, Shoulder and Hand [DASH]) score. Complications were also evaluated.

RESULTS

On magnetic resonance imaging, significant tears of the lateral collateral ligament complex and common extensor group were observed in all cases. Seventeen cases (85%) required surgical treatment for acute instability. Fourteen cases underwent only lateral complex repair and 3 underwent repair of both the medial and lateral complexes. At the time of the latest follow-up, the mean MEPS and Quick-DASH scores were 85.8 ± 15.0 and 10.5 ± 16.3, respectively. Seventeen patients (85%) had a satisfactory clinical outcome. Complications following treatment included 4 patients with heterotopic ossification; 2 of these patients also experienced posttraumatic elbow stiffness, which was treated with arthrolysis at 8 and 18 months after the initial operation.

CONCLUSIONS

Posteromedial elbow dislocations without relevant osseous lesions are associated with a more severe soft-tissue injury, especially to the lateral complex, resulting in a high rate of surgical treatment. With careful post-reduction evaluation, either operative or nonoperative treatment provided satisfactory clinical outcomes.

LEVEL OF EVIDENCE

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

Pure Medial Elbow Dislocation without Concomitant Fracture in a 10-Year-Old Child

Pediatric elbow dislocations are rare injuries and are often accompanied by concomitant fractures. We report a rare case of medial dislocation of the right elbow without accompanying fracture in a 10.5-year-old boy after fall from a bicycle. After radiographic and magnetic resonance imaging evaluation, closed reduction under general anesthesia was performed and the elbow was immobilized in a posterior above-elbow slab. Elbow mobilization was started after 2 weeks and the posterior slab was discontinued after 4 weeks. At 3 months, the patient had a full range of active elbow flexion extension and pronation supination. At 4-year followup, radiographs show a normal alignment of the elbow with mild changes of heterotopic ossification. We believe that this is the first such case ever reported in literature. Early recognition and prompt diagnosis is the key to achieve a good result.

Extensive soft tissue lesions in redislocated after simple elbow dislocations

BACKGROUND

The majority of simple elbow dislocations (no associated fractures) can be treated nonoperatively with a short period of immobilization followed by guided aftercare. This case series describes the soft tissue injuries in a rare subset of patients in whom the elbow redislocated despite adequate immobilization.

METHODS

During a 6-year period, 8 patients were identified. They were all treated with reduction and casting in 90° of flexion or more. At 1 week of follow-up, redislocation had occurred in all patients and open soft tissue repair was performed. The injuries were documented and the patients were followed up clinically and with radiographs.

RESULTS

Extensive soft tissue injuries, including both collateral ligament injuries and muscle origin avulsions from either or both sides, were found in all patients. The functional result at follow-up was satisfactory in all patients.

CONCLUSION

Vast soft tissue injuries including both collateral ligaments and muscle origins should be expected in the event of early severe instability of a dislocated elbow joint.

Optimizing the rehabilitation of elbow lateral collateral ligament injuries: a biomechanical study

BACKGROUND

Elbow lateral collateral ligament (LCL) injury may arise after trauma or lateral surgical approaches. The optimal method of rehabilitating the LCL-insufficient elbow is unclear. Therapists often prescribe active motion exercises with the forearm pronated. Recently, overhead exercises have become popular as they may enable gravity to compress the elbow joint, improving stability, although this has not been proved biomechanically. This investigation aimed to quantify the effects of several variables used in LCL injury rehabilitation on elbow stability.

METHODS

Seven cadaveric specimens were tested in a custom elbow motion simulator in 3 arm positions (overhead, dependent, and varus) and 2 forearm positions (pronation and supination) during passive and simulated active elbow extension. Three injury patterns were studied (intact, LCL injury, and LCL with common extensor origin injury). An electromagnetic tracking device measured ulnohumeral kinematics.

RESULTS

Following combined LCL and common extensor origin injury, overhead positioning enhanced elbow stability relative to the other arm positions (P < .01 in pronation; P = .04 in supination). Active motion stabilized the LCL-deficient elbow in the dependent (P = .02) and varus (P < .01) positions. Pronation improved stability in the overhead (P = .05), dependent (P = .06), and varus (P < .01) positions.

CONCLUSIONS

Rehabilitation with the arm overhead improves elbow stability after LCL injury. Initiating earlier range of motion in this "safe position" might decrease elbow stiffness and allow optimal ligament healing. If exercises are done in the dependent position, active motion with forearm pronation should be encouraged. Varus arm positioning should be avoided.

Simple Elbow Dislocation

Simple elbow dislocation refers to those elbow dislocations that do not involve an osseous injury. A complex elbow dislocation refers to an elbow that has dislocated with an osseous injury. Most simple elbow dislocations are treated nonoperatively. Understanding the importance of the soft tissue injury following a simple elbow dislocation is a key to being successful with treatment.

MDCT findings after elbow dislocation: a retrospective study of 140 patients

OBJECTIVE

To assess the number and anatomical location of fractures associated with elbow dislocation, to study the correlation between the direction of dislocation and the trauma energy, and to assess radiographs' diagnostic performance characteristics for fractures using MDCT as a reference standard.

MATERIALS AND METHODS

A retrospective study was performed at a level 1 trauma center, finding a total of 140 patients who had sustained an elbow dislocation and who had undergone a subsequent MDCT examination. The CT and radiographs of the patient were reviewed by two musculoskeletal radiologists. CT images were analyzed for the site and size of the fracture fragments. In addition, the primary direction of the dislocation, patients' age, and gender were recorded. Trauma energy was also assessed.

RESULTS

One hundred and thirty-four out of 140 patients (96%) had a fracture that was seen on the correlative CT examination. The most common anatomical fracture locations were the coronoid process of the ulna 84 out of 140 (60%), the radial head 75 out of 140 (54%), and the humeral capitellum 57 out of 140 (41%). Multiple fractures were seen in 71 out of 134 (53%) patients with fractures. The left elbow was more commonly dislocated than the right one. The overall sensitivity of the radiographs was 62% and the specificity 96%.

CONCLUSION

Small fractures and impaction fractures are almost invariably present in elbow dislocations, and half of the patients have more than one fracture. Radiographs have a sensitivity of only 62%. MDCT is an invaluable method for determining the extent of bony injury and revealing occult fractures.

The role of simple elbow dislocations in cubitus valgus development in children

PURPOSE

We investigated the functional and radiological outcomes of conservatively treated simple traumatic elbow dislocations and subsequent incidence of cubitus valgus development in children.

METHODS

Eleven patients (one female, ten male; mean age 9.8 years, range seven to 12 years) who presented to our hospital with simple elbow dislocations and were conservatively treated between July 2008 and September 2010 were included in the study. All were posterolateral closed dislocations. None of the patients had accompanying elbow fractures. All patients had pre- and postoperative radiographic examinations. The carrying angle of the involved elbow was measured and compared to the contralateral non-injured elbow during follow-up. The incidence and severity of cubitus valgus development was assessed. The functional and clinical outcomes were evaluated using the Mayo Elbow Performance Scale. The mean monitoring period was 24.3 months (range 19-30 months).

RESULTS

All patients had satisfactory good and excellent results (85-100 points; mean 96.8 points) according to the Mayo Elbow Performance Scale. The final average elbow flexion was 137° (range, 130-145°) and average extension was 8.6° (range 0-20°) with full supination and pronation in traumatic elbow. Four patients (36.4%) had an average increase (cubitus valgus) of 14.5° (10-20°) in carrying angle compared to the other elbow.

CONCLUSIONS

While isolated traumatic dislocation of the elbow is uncommon among children, it can be successfully treated by urgent closed reduction, proper fixation of the elbow and appropriate timely rehabilitation. However, it should be considered that some patients may develop cubitus valgus deformity in a later period. Therefore, each patient with a simple traumatic elbow dislocation should be followed, and the parents should be informed of the potential for any deformity development.