Primary Ligament Repair for Acute Elbow Dislocation

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

LEVEL OF EVIDENCE

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

Surgical Treatment of Adams Type IV Anterolateral Fracture of the Ulna Coronoid Process

OBJECTIVE

Anterolateral coronal fractures are so rare that the mechanism of injury, the type of combined fracture and ligament injury, and the optimal treatment are unknown. To study the outcome of surgical treatments for anterolateral (AL) fracture of the ulna coronoid process (Adams Type IV) and summarize the characteristics of this type of fracture and to guide clinical applications.

METHODS

From February 2015 to April 2021, 32 patients were included in the study. All patients had standard radiography with anteroposterior and lateral views, computed tomography, and intraoperative fluoroscopy. All patients were treated surgically. Surgery-related information, including surgical approach, operation duration, blood loss, and repairing the lateral collateral ligament and the medial collateral ligament integrity, were recorded. The patient's clinical details, such as the final range of motion (ROM), the Broberg-Morrey scores and the visual analogue scale (VAS) at the last follow-up, were described. The chi-square test or Fisher's exact test was used for statistical analysis.

RESULTS

We divided patients into two groups according to the anterolateral coronoid fracture morphology. In the intact group, 20 patients with an intact anterolateral coronoid fracture fragment. In the comminuted group, 12 patients with comminuted anterolateral coronoid fracture fragments extended the less sigmoid notch of the ulna. There was no difference in age, sex, total incision length, follow-up duration, and recovery with rehabilitation among the two groups (all Ps >0.05). The other follow-up outcomes, such as elbow ROM (Flexion, Extension, Posterior rotation, Anterior rotation), VAS score, or Broberg-Morrey scores, were not different between the two groups (all Ps >0.05). Both groups achieved relatively satisfactory clinical outcomes, and the Broberg-Morrey score and index excellence rate reached 84.38%. There is a statistical difference in the history of elbow dislocation (P = 0.017), radial head fracture type (P = 0.041), operation duration (P = 0.014) and blood loss at operation (P = 0.029) between the two groups. Cannulated screws, anchors, and sutures were used as point fixation in the coronoid process of the ulna. There was a statistical difference between the two groups in the choice of internal fixation (P = 0.020).

CONCLUSIONS

For anterolateral ulnar coronoid fractures with different degrees of comminution, effective and reliable surgical treatment can achieve better results and fewer complications.

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.

Acute Ligament Injuries of the Elbow

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

Elbow Dislocation

This article is a brief overview of the elbow dislocations focusing on updates in treatment and rehabilitation protocols. The fight between obtaining elbow stability without leading to long-term elbow stiffness has been a continued focus in field of sports medicine. This article highlights advances made to help treat the injuries appropriately and obtain optimal patient outcomes.