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Kemler BR, Willier DP, D'Amore T, Cohen SB, Dodson CC, Ciccotti MG. Return to play after UCL injury in gymnasts. PHYSICIAN SPORTSMED 2025; 53:112-118. [PMID: 39375830 DOI: 10.1080/00913847.2024.2414462] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/13/2024] [Revised: 09/09/2024] [Accepted: 10/06/2024] [Indexed: 10/09/2024]
Abstract
BACKGROUND Injuries to the ulnar collateral ligament (UCL) are commonly reported in traditional overhead sports. Conversely, there is a lack of evidence outlining management and return to play (RTP) outcomes for gymnasts. This study aimed to evaluate RTP and patient reported outcomes (PROs) in gymnasts after operative and non-operative treatment of UCL injuries. METHODS Gymnasts who presented with UCL injury and underwent operative and non-operative treatment were evaluated. Patient reported outcomes were collected via telephone: Conway-Jobe Scale, Kerlan-Jobe Orthopaedic Clinic Shoulder and Elbow (KJOC) Score, Mayo Elbow Performance (MEP) Score, and quick DASH (qDASH) and Timmerman-Andrews (TA) Elbow Score. RESULTS Nine patients met inclusion criteria and were available for follow-up. Five were initially treated operatively and four were initially treated non-operatively. The operative group initially consisted of three ulnar collateral ligament reconstructions (UCLR) and two UCL repairs with internal bracing. One patient crossed over to the operative group after failing non-operative treatment and underwent UCLR four months post injury. Overall, 66.7% and 100% of operatively and non-operatively treated gymnasts were able to return to play, respectively. At final follow-up, the operative groups' mean KJOC, MEP, TA, and qDASH scores were: 68.4 ± 7.7, 97.5 ± 2.7, 90.8 ± 10.7, and 1.9 ± 3.0, respectively. For the non-operative group, the mean scores were 67.4 ± 9.0, 71.7 ± 5.8, 71.7 ± 14.4, and 11.4 ± 9.9, respectively. Treatment satisfaction for the operative group was 81.7 ± 27.5 compared to 80.6 ± 34.5 in the non-operative group. Odds ratios indicated no differences between groups. CONCLUSION Both operative and non-operative interventions for UCL injuries in gymnasts can provide favorable outcomes with respect to return to play and subjective patient-reported outcomes. Further research is warranted to determine optimal treatment, especially regarding indications for operative vs. nonoperative treatment, of UCL injury based on injury severity and location in gymnasts. LEVEL OF EVIDENCE Case series; Level III Evidence.
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Almeida GG, Afonso PD. Shoulder, arm, and elbow injuries in soccer players. Skeletal Radiol 2025; 54:731-741. [PMID: 38441615 DOI: 10.1007/s00256-024-04630-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/08/2023] [Revised: 02/14/2024] [Accepted: 02/16/2024] [Indexed: 02/22/2025]
Abstract
Soccer is a global widespread sport with a high injury rate, mostly to the lower limbs. Even though upper limb injuries are much less common among soccer players, their prevalence has increased in recent years. This is due to several reasons/factors, including new and more aggressive tactics, a rise in the number of younger players with different levels of skeletal maturation, and due to the growth of women's participation in sports, which is in line with the fast progression in the degree of professionalism in women's soccer. This review paper aims to (a) describe the most common injuries in the shoulder, arm, and elbow in soccer players and (b) to show the role of different imaging modalities in diagnosing upper extremity injuries that can occur in this sport. Familiarity with these injuries and their mechanisms will lead to a quicker diagnosis and correct reporting of imaging of soccer players.
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Affiliation(s)
- Gonçalo G Almeida
- Radiology and Nuclear Medicine, Kantonsspital St. Gallen, Rorschacherstrasse 95, 9007, St. Gallen, Switzerland
| | - P Diana Afonso
- Musculoskeletal Imaging Unit, Radiology Department, Hospital da Luz, Grupo Luz Saúde, Lisbon, Portugal.
- Radiology Department, Hospital Particular da Madeira, Grupo HPA, Funchal, Madeira Island, Portugal.
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Auberger G, Leclerc P, Marmor S. Elbow dislocation associated with bifocal radial fracture: A case report. Trauma Case Rep 2024; 54:101121. [PMID: 39679201 PMCID: PMC11638643 DOI: 10.1016/j.tcr.2024.101121] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/23/2024] [Indexed: 12/17/2024] Open
Abstract
Introduction Radial diaphyseal fractures are relatively common in daily trauma practice. We present a unique case of a bifocal radial fracture associated with a posterolateral elbow dislocation. Case report A 36-year-old obese female patient was admitted to our service after a low-energy fall in stairs. She presented with a radial diaphyseal fracture, a radial neck fracture with approximately 15° angulation, and a posterolateral elbow dislocation. The first procedure involved an urgent reduction of the elbow dislocation, followed by surgical fixation of the bifocal radial fractures and reattachment of the external and posterolateral elbow structures. Conclusion A bifocal radial fracture associated with an elbow dislocation is, to our knowledge, a previously unreported injury. The clinical outcome after osteosynthesis and elbow stabilization was favorable.
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Affiliation(s)
- Guillaume Auberger
- Department of Orthopedic Surgery and Traumatology, La Croix Saint Simon Hospital, Paris, France
| | - Philippe Leclerc
- Department of Orthopedic Surgery and Traumatology, La Croix Saint Simon Hospital, Paris, France
| | - Simon Marmor
- Department of Orthopedic Surgery and Traumatology, La Croix Saint Simon Hospital, Paris, France
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Baltassat A, Baldairon F, Berthe S, Bellier A, Bahlouli N, Clavert P. Creation of a replicable anatomic model of terrible triad of the elbow. J Orthop Surg Res 2024; 19:638. [PMID: 39380019 PMCID: PMC11463038 DOI: 10.1186/s13018-024-05069-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/26/2024] [Accepted: 09/07/2024] [Indexed: 10/10/2024] Open
Abstract
BACKGROUND Terrible triad of the elbow (TTE) is a complex dislocation associating radial head (RH) and coronoid process (CP) fractures. There is at present no reproducible anatomic model for TTE, and pathophysiology is unclear. The main aim of the present study was to create and validate an anatomic model of TTE. Secondary objectives were to assess breaking forces and relative forearm rotation with respect to the humerus before dislocation. METHODS An experimental comparative study was conducted on 5 fresh human specimens aged 87.4 ± 8.6 years, testing 10 upper limbs. After dissection conserving the medial and lateral ligaments, interosseous membrane and joint capsule, elbows were reproducibly positioned in maximal pronation and 15° flexion, for axial compression on a rapid (100 mm/min) or slow (10 mm/min) protocol, applied by randomization between the two elbows of a given cadaver, measuring breaking forces and relative forearm rotation with respect to the humerus before dislocation. RESULTS The rapid protocol reproduced 4 posterolateral and 1 divergent anteroposterior TTE, and the slow protocol 5 posterolateral TTE. Mean breaking forces were 3,126 ± 1,066 N for the lateral collateral ligament (LCL), 3,026 ± 1,308 N for the RH and 2,613 ± 1,120 N for the CP. Comparing mean breaking forces for all injured structures in a given elbow on the rapid protocol found a p-value of 0.033. Comparison of difference in breaking forces in the three structures (LCL, RH and CP) between the slow and rapid protocols found a mean difference of -4%. Mean relative forearm rotation with respect to the humerus before dislocation was 1.6 ± 1.2° in external rotation. CONCLUSIONS We create and validate an anatomic model of TTE by exerting axial compression on an elbow in 15° flexion and maximal pronation at speeds of 100 and 10 mm/min.
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Affiliation(s)
- Antoine Baltassat
- Service de Chirurgie du Membre Supérieur, Hôpital de Hautepierre 2 - CHU Strasbourg, Avenue Molière, Strasbourg, 67000, France.
| | - Florent Baldairon
- Service de Chirurgie du Membre Supérieur, Hôpital de Hautepierre 2 - CHU Strasbourg, Avenue Molière, Strasbourg, 67000, France
| | - Samuel Berthe
- ICube laboratory, University of Strasbourg/CNRS, 2 rue Boussingault, Strasbourg, 67000, France
| | - Alexandre Bellier
- Univ. Grenoble Alpes, LADAF, CIC INSERM 1406, AGEIS, Grenoble, France
| | - Nadia Bahlouli
- ICube laboratory, University of Strasbourg/CNRS, 2 rue Boussingault, Strasbourg, 67000, France
| | - Philippe Clavert
- Service de Chirurgie du Membre Supérieur, Hôpital de Hautepierre 2 - CHU Strasbourg, Avenue Molière, Strasbourg, 67000, France
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Jauffrit D, Heraudet P, Tibbo M, Erbland A, Carlier Y, Mansat P, Laumonerie P. Simple acute postero-lateral elbow dislocation: A historical perspective. Injury 2024; 55:111353. [PMID: 38266328 DOI: 10.1016/j.injury.2024.111353] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/12/2023] [Revised: 12/31/2023] [Accepted: 01/14/2024] [Indexed: 01/26/2024]
Abstract
PURPOSE The aims of this study were to summarize (1) the historical knowledge of the posterolateral elbow dislocation (PLED) pattern and the biomechanical, radiographic, and clinical data that engendered its evolution; and (2) to help clinicians better understand the management of PLED. METHODS A literature search was performed using Ovid, Scopus and Cochrane Library, and the Medical Subject Headings vocabulary. Results are discussed as a chronologic review of the relevant literature between 1920-2022. RESULTS In 1966 Osborn and Cotterill were the first to describe posterolateral rotatory instability (PLRI) causing the PLED. Several theories on PLED were then published by others surgeons as our understanding of elbow biomechanics continued to improve. Multiple treatment protocols have been designed based on the aforementioned theories. Conservative and surgical treatment for PLED provides excellent functional outcomes. However, high rates of persistent pain stiffness and instability have been reported long-term, and no single approach to treatment has been widely accepted. CONCLUSION Despite a growing body of biomechanical evidence, there is no consensus surgical indication for the treatment of PLED. Both conservative and surgical management result in satisfactory functional outcomes after PLED. However, elevated rates of residual pain, and instability have also been described and may limit heavy labor and sports participation. The next challenge for elbow surgeons will be to identify those patients who would benefit from surgical stabilization following PLED.
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Affiliation(s)
- Daphné Jauffrit
- Department of orthopedic surgery, Hôpital Pellegrin, Bordeaux 31600 France
| | - Paul Heraudet
- Department of orthopedic surgery, Hôpital Pellegrin, Bordeaux 31600 France
| | - Meagan Tibbo
- Department of Orthopedic Surgery, Mayo Clinic, Phoenix, AZ, US
| | - Alexandra Erbland
- Department of orthopedic surgery, Hôpital Pellegrin, Bordeaux 31600 France
| | - Yacine Carlier
- Centre de l'Arthrose, Clinique du Sport, Mérignac 33700, France
| | - Pierre Mansat
- Department of orthopedic surgery, Hôpital Pierre Paul Riquet, Toulouse 31300 France
| | - Pierre Laumonerie
- Department of orthopedic surgery, Hôpital Pellegrin, Bordeaux 31600 France.
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Laumonerie P, Mansat P. Terrible triad injury of the elbow: a spectrum of theories. JSES Int 2023; 7:2565-2568. [PMID: 37969512 PMCID: PMC10638559 DOI: 10.1016/j.jseint.2023.03.018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2023] Open
Abstract
For more than one century, understanding the injury mechanism leading to the terrible triad of the elbow (TTE) was a significant challenge for surgeons. We aimed to summarize: (1) the history of the treatment of TTE and (2) the increasing scientific knowledge that supported its evolution. Five electronic databases were searched between 1920 and 2022. Results were reported as a comprehensive review of the relevant literature. Between 1940 and 1980, surgical exploration allowed observation of complex elbow instability involving both radial head, coronoid process, and ligament(s) injuries. In 1966, Osborne introduced the concept of posterolateral rotatory instability as the first mechanism injury to explain the complex elbow instability. From 1980 to 1995, a biomechanical revolution by American pioneers critically improved our understanding of elbow instability. After 1992, a few unifying theories and surgical protocols were provided, but those have divided the surgeons' population. The formalization of the TTE treatment allowed avoiding of terrible short-term outcomes. However, post-traumatic osteoarthritis (PTOA) at long-term follow-up is still an issue. No consensual surgical protocol for the treatment of TTE has been widely accepted. While the outcomes of the TTE have been improved, the rate of PTOA at long-term follow-up is still high regardless of the treatments. The terrible triad has given way to the subtle triad with persistent microinstability of the elbow. The next challenge for elbow surgeons is to diagnose and fix this persistent subclinical instability after surgery in order to prevent the onset of PTOA.
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Affiliation(s)
- Pierre Laumonerie
- Department of Orthopedics and Traumatology, Hôpital Pellegrin, Bordeaux, France
| | - Pierre Mansat
- Department of Orthopedic Surgery, Hôpital Pierre-Paul Riquet, Toulouse, France
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Barco R, Gonzalez-Escobar S, Acerboni-Flores F, Vaquero-Picado A. Acute elbow dislocation: a critical appraisal of the literature. JSES Int 2023; 7:2560-2564. [PMID: 37969505 PMCID: PMC10638560 DOI: 10.1016/j.jseint.2023.03.019] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2023] Open
Abstract
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.
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Affiliation(s)
- Raul Barco
- Upper Limb Unit, Hospital Universitario La Paz, Fundación Instituto de Investigación IDIPaz, Madrid, Spain
| | | | - Francesc Acerboni-Flores
- Parc Taulí Hospital Universitari, Institut d’Investigació i Innovació Parc Taulí I3PT, Universitat Atónoma de Barcelona, Sabadell, Spain
| | - Alfonso Vaquero-Picado
- Upper Limb Unit, Hospital Universitario La Paz, Fundación Instituto de Investigación IDIPaz, Madrid, Spain
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8
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Klug A, Sauter M, Hoffmann R. [Terrible triad injuries]. UNFALLCHIRURGIE (HEIDELBERG, GERMANY) 2023; 126:679-686. [PMID: 37115205 DOI: 10.1007/s00113-023-01321-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 03/17/2023] [Indexed: 04/29/2023]
Abstract
The complex injury pattern of a posterior elbow dislocation with concomitant radial head and coronoid fractures is usually referred to as a terrible triad injury. Due to the concomitant compromise of several osteoligamentous structures of the elbow joint relevant for stability, these injuries pose a particularly major challenge to the treating trauma surgeons. For this reason, a careful preoperative analysis of all relevant injury components is mandatory in order to make an adequate treatment decision. In most cases, surgical treatment addressing all elements relevant for stability is necessary to achieve a stable and congruent elbow joint. Only this enables early functional follow-up treatment and minimizes the complication rate. Delayed or even insufficient treatment with persistent (sub)dislocation must be avoided at all costs, otherwise there is a high risk of serious posttraumatic functional disorders of the elbow with rapid progression of osteoarthritis.
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Affiliation(s)
- Alexander Klug
- BG Unfallklinik Frankfurt am Main, Friedberger Landstr. 430, 60389, Frankfurt, Deutschland.
| | - Matthias Sauter
- BG Unfallklinik Frankfurt am Main, Friedberger Landstr. 430, 60389, Frankfurt, Deutschland
| | - Reinhard Hoffmann
- BG Unfallklinik Frankfurt am Main, Friedberger Landstr. 430, 60389, Frankfurt, Deutschland
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Lanzerath F, Knifka J, Leschinger T, Ott N, Kahmann S, Hackl M, Müller LP, Wegmann K. The simulation of terrible triad injuries in fresh-frozen human cadaveric specimens with intact soft tissue envelope. Arch Orthop Trauma Surg 2023; 143:4229-4237. [PMID: 36512058 PMCID: PMC10293332 DOI: 10.1007/s00402-022-04677-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/16/2022] [Accepted: 10/23/2022] [Indexed: 12/15/2022]
Abstract
INTRODUCTION The aim of the present study was to develop a technical process to reproducibly generate terrible triad injuries (TTI) in fresh-frozen human cadaveric specimens, while leaving the skin intact. Such "pre-fractured" specimens, used for scientific analysis and for surgical education, might help to improve current treatment, which is complex and prone to complications. MATERIALS AND METHODS To induce the desired fractures, a custom-made fracturing unit was used to apply an axial force on the extended cadaveric elbow specimens, with the forearm pronated and under valgus load. To simulate the valgus load, a pneumatic cylinder was developed to apply valgus stress to the joint by an additional force vector from the lateral side of the joint. RESULTS The success rate of TTI induction was 92.3% (12/13). Of the 12 radial head fractures, 3 (25%) were classified Mason type II and 9 (75%) Mason type III. The coronoid fractures were grouped in tip subtype 2 (5 fractures, 41.7%), anteromedial facet (AMF) subtype 2 (4 fractures, 33.3%), AMF subtype 3 (1 fracture, 8.3%) and basal subtype 1 (2 fractures, 16.7%). CONCLUSIONS The present study provides an instrument for successful and reproducible production of dislocation fracture patterns with their typical accompanying soft tissue lesions. The methodology might be applied on a broad basis to be able to perform biomechanical studies regarding primary stability of fixation concepts for TTI and to educate surgeons in a fairly realistic scenario with the surgical treatment of TTI.
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Affiliation(s)
- Fabian Lanzerath
- Department of Orthopedic and Trauma Surgery, University Hospital Cologne, Kerpener Street 62, 50937, Cologne, Germany.
- Department of Anatomy I, Medical Faculty, University of Cologne, Cologne, Germany.
| | - Jutta Knifka
- Department of Orthopedic and Trauma Surgery, University Hospital Cologne, Kerpener Street 62, 50937, Cologne, Germany
- Department of Anatomy I, Medical Faculty, University of Cologne, Cologne, Germany
| | - Tim Leschinger
- Department of Orthopedic and Trauma Surgery, University Hospital Cologne, Kerpener Street 62, 50937, Cologne, Germany
| | - Nadine Ott
- Department of Orthopedic and Trauma Surgery, University Hospital Cologne, Kerpener Street 62, 50937, Cologne, Germany
| | - Stephanie Kahmann
- Department of Orthopedic and Trauma Surgery, University Hospital Cologne, Kerpener Street 62, 50937, Cologne, Germany
| | - Michael Hackl
- Department of Orthopedic and Trauma Surgery, University Hospital Cologne, Kerpener Street 62, 50937, Cologne, Germany
| | - Lars P Müller
- Department of Orthopedic and Trauma Surgery, University Hospital Cologne, Kerpener Street 62, 50937, Cologne, Germany
| | - Kilian Wegmann
- OCM (Orthopädische Chirurgie München) Clinic, Munich, Germany
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Bozon O, Chrosciany S, Loisel M, Dellestable A, Gubbiotti L, Dumartinet-Gibaud R, Obrecht E, Tibbo M, Sos C, Laumonerie P. Terrible triad injury of the elbow: a historical perspective. INTERNATIONAL ORTHOPAEDICS 2022; 46:2265-2272. [PMID: 35725951 DOI: 10.1007/s00264-022-05472-4] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/19/2022] [Accepted: 06/03/2022] [Indexed: 10/18/2022]
Abstract
PURPOSE The aims of this study are to summarize (1) the history of terrible triad injury (TTi) treatment and (2) the clinical and biomechanical data that engendered its evolution. METHODS A literature search was performed using five electronic databases. Results were discussed as a chronologic review of the relevant literature between 1920 and 2022. RESULTS In 1962, Osborne was the first to describe a link between elbow dislocation, radial head fracture, and lateral collateral ligament complex injury via a novel mechanism: posterolateral rotatory instability (PLRI). Given that untreated elbow instability leads to post-traumatic osteoarthritis (PTOA), there has been increasing interest in elbow biomechanics since the 1980s. Data from studies in that period revolutionized the approach to elbow instability. The authors demonstrated that TTi could occur via a PLRI mechanism with a disruption of the lateral collateral ulnar ligament and a functionally competent anterior medial collateral ligament (aMCL). Since the 1990s, due to the difficulty in identifying its pathoanatomic features, some began to speculate about a sequence of injuries and mechanisms leading to TTi. However, the clinical literature has largely been unable to reproduce in vitro findings describing the pathomechanics of TTi. Some aspects of treatment remain controversial including systematic coronoid and aMCL repair. CONCLUSION Despite a growing body of biomechanics data, there is no widely accepted surgical protocol for the treatment of TTi. Functional outcomes among patients have greatly improved. Better diagnosis and treatment of infra-clinical instability after a TTi may be an important stepping stone to prevent the onset of moderate/severe PTOA.
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Affiliation(s)
- Olivier Bozon
- Department of Orthopedics and Traumatology, Hôpital Lapeyronie, Montpelier, France
| | - Sacha Chrosciany
- Department of Orthopedics and Traumatology, Hôpital Dupuytren, Limoges, France
| | - Marie Loisel
- Department of Orthopedics and Traumatology, Hôpital Pontchaillou, Rennes, France
| | - Arthur Dellestable
- Department of Orthopedics and Traumatology, Hôpital Cavale Blanche, Brest, France
| | - Laura Gubbiotti
- Department of Orthopedics and Traumatology, Hôpital Côte de Nacre, Caen, France
| | | | - Elise Obrecht
- Department of Orthopedics and Traumatology, Hôpital Charles Nicolle, Rouen, France
| | - Meagan Tibbo
- Department of Orthopedics, Mayo Clinic, Rochester, MN, USA
| | - Clara Sos
- Department of Orthopedics and Traumatology, Hôpital Trousseau, Tours, France
| | - Pierre Laumonerie
- Department of Orthopedics and Traumatology, Hôpital Pellegrin, Place Amélie Raba-Léon, 33000, Bordeaux, France.
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11
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Medial elbow dislocations: a case report on the complex simple dislocation. CURRENT ORTHOPAEDIC PRACTICE 2022. [DOI: 10.1097/bco.0000000000001122] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
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Al-Ani Z, Tham JL, Ooi MWX, Wright A, Ricks M, Watts AC. The radiological findings in complex elbow fracture-dislocation injuries. Skeletal Radiol 2022; 51:891-904. [PMID: 34480618 DOI: 10.1007/s00256-021-03900-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/24/2021] [Revised: 08/17/2021] [Accepted: 08/28/2021] [Indexed: 02/02/2023]
Abstract
Elbow fracture-dislocation is a complex injury which can lead to significant bony and soft tissue damage. Surgical intervention is guided towards restoring joint stability, allowing early mobilization and preventing long-term joint stiffness. The most common types are posterolateral, posteromedial, Monteggia type (and variants), and anterior trans-olecranon fracture-dislocations. Posterolateral fracture-dislocation is characterized by a radial head fracture (± anterolateral coronoid fracture) and typically capsuloligamentous disruption (lateral collateral ligaments injury is the most common). A posterolateral fracture-dislocation with radial head and coronoid anterolateral facet fractures is termed a terrible triad injury. In posteromedial fracture-dislocation, there is a fracture of the anteromedial facet of the coronoid, typically with proximal avulsion of the lateral collateral ligaments (± injury to the posterior bundle of the ulnar collateral ligament). Monteggia fracture-dislocation injuries demonstrate proximal ulnar fracture (with possible involvement of the olecranon and the coronoid) and radial head dislocation. These can be divided into apex anterior or apex posterior variants. The latter are commonly associated with radial head fractures and lateral ligamentous injury, and have a worse prognosis. In trans-olecranon fracture-dislocation, there is significant disruption of the greater sigmoid notch and the olecranon, with various involvement of the coronoid and the proximal ulna. The article describes the radiological findings and outlines the management principles in complex elbow fracture-dislocation injuries.
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Affiliation(s)
- Zeid Al-Ani
- Radiology Department, Wrightington, Wigan and Leigh NHS Foundation Trust, Royal Albert Edward Infirmary, Wigan Lane, Wigan, WN1 2NN, UK.
| | - Jun-Li Tham
- Radiology Department, Wrightington, Wigan and Leigh NHS Foundation Trust, Royal Albert Edward Infirmary, Wigan Lane, Wigan, WN1 2NN, UK
| | - Michelle Wei Xin Ooi
- Radiology Department, Wrightington, Wigan and Leigh NHS Foundation Trust, Royal Albert Edward Infirmary, Wigan Lane, Wigan, WN1 2NN, UK
| | - Andrew Wright
- Upper Limb Unit, Wrightington Hospital, Wrightington, Wigan and Leigh NHS Foundation Trust, Wigan, UK
| | - Matthew Ricks
- Upper Limb Unit, Wrightington Hospital, Wrightington, Wigan and Leigh NHS Foundation Trust, Wigan, UK
| | - Adam C Watts
- Upper Limb Unit, Wrightington Hospital, Wrightington, Wigan and Leigh NHS Foundation Trust, Wigan, UK
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Danilov MA, Ershov DS, Liadova MV, Badriev DA, Ershov NS. TREATMENT OF SIMPLE CHRONIC INSTABILITY OF THE ELBOW JOINT. SURGICAL PRACTICE 2022. [DOI: 10.38181/2223-2427-2022-1-14-21] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
Simple chronic instability of the elbow joint is one of the urgent problems in modern traumatology due to the fact that the standard tactics of managing patients with traumatic injuries of the elbow joint due to dislocation, which amounts to its elimination, immobilization of the upper limb and subsequent development of movements in the joint, most often does not take into account damage to specific soft tissue structures. With untimely treatment for qualified help, with late or unsuccessful attempts to eliminate dislocation of the bones of the forearm, less often with chronic traumatization of the ligamentous apparatus of the elbow joint during some types of occupation, one of the most unpleasant complications may form, namely, chronic instability. This article discusses the main types of chronic instability of the elbow joint, analyzes approaches to the management of patients with simple chronic instability. Despite the not very high occurrence of this pathology, the effectiveness of modern surgical treatment options aimed at reconstruction of the ligamentous apparatus of the elbow joint, the percentage of unsatisfactory results of treatment of simple chronic recurrent and persistent instability of the elbow joint remains high.
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Affiliation(s)
- M. A. Danilov
- Pirogov Russian National Research Medical University
| | - D. S. Ershov
- Pirogov Russian National Research Medical University
| | - M. V. Liadova
- Pirogov Russian National Research Medical University
| | - D. A. Badriev
- Pirogov Russian National Research Medical University
| | - N. S. Ershov
- Pirogov Russian National Research Medical University
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[Clinical treatment of dorsal avulsion fracture of the capitellum combined with medial or posterior medial dislocation of the elbow joint]. ZHONGGUO XIU FU CHONG JIAN WAI KE ZA ZHI = ZHONGGUO XIUFU CHONGJIAN WAIKE ZAZHI = CHINESE JOURNAL OF REPARATIVE AND RECONSTRUCTIVE SURGERY 2022; 36:149-154. [PMID: 35172398 PMCID: PMC8863534 DOI: 10.7507/1002-1892.202108029] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Indexed: 01/24/2023]
Abstract
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.
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Rhyou IH, Lee JH, Cho CH, Park SG, Lee JH, Kim KC. Patterns of injury mechanism observed in terrible triad. J Shoulder Elbow Surg 2021; 30:e583-e593. [PMID: 33545337 DOI: 10.1016/j.jse.2020.12.015] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/17/2020] [Revised: 12/16/2020] [Accepted: 12/17/2020] [Indexed: 02/01/2023]
Abstract
INTRODUCTION The purpose of this study was to classify the injury mechanism of terrible triad (TT) and suggest a treatment method according to the mechanism. MATERIALS AND METHODS Forty TTs with magnetic resonance imaging (MRI) scans and 3-dimensional computed tomography (3D CT) were enrolled. 3D CT scans of coronoid fractures were used for classifying into O'Driscoll type representing injury mechanisms and measuring sizes. In MRI scans, lateral collateral ligament complex (LCLC) injuries were classified into distraction (D) type caused by varus force and stripping (S) type caused by forearm external rotation force. Using these findings, possible injury mechanisms were speculated and classified into groups. Characteristic soft tissue injury patterns of collateral ligaments and overlying muscles, direction of dislocation in simple radiographs, and the amount of involvement of radial head fracture were investigated. Ulnar- and radial-side instabilities of soft tissues were newly defined and investigated. RESULTS There were 29 (73%) cases by posterolateral external rotation (PLER), 5 (13%) cases by posteromedial external rotation (PMER), and 6 (14%) cases by posteromedial internal rotation (PMIR). Simple radiographs showed all posterolateral dislocations in PLER TT compared to posteromedial or pure posterior dislocations in PMER or PMIR TT. Regarding LCLC and overlying extensor muscle, they were all completely torn with D type in all PLER compared to D type in PMER or PMIR. The ulnar collateral ligament was spared in 5 (17%) cases among 29 PLER in contrast to complete rupture in all PMER and PMIR. In PLER, PMER, and PMIR, involvement ratios of radial head fracture were 82% (range, 27%-100%), 61% (range, 25%-100%), and 61% (range, 25%-100%), respectively, and sizes of coronoid fractures were 7 mm (range, 1-14 mm), 6 mm (range, 2-11 mm), and 10 mm (range, 2-16 mm), respectively. In PLER, PMER, and PMIR, percentages of ulnar-side instabilities were 17%, 20%, and 17%, respectively, and those of radial-side instabilities were 59%, 60%, and 83%, respectively. CONCLUSIONS TT is caused by at least 3 mechanisms (PLER, PMER, and PMIR) with characteristic soft tissue injuries and fracture patterns. PLER is the main mechanism of injury. It is always observed in the form of posterolateral dislocation on simple radiographs compared with pure posterior or posteromedial dislocation of PMER or PMIR. It should be managed individually based on injury mechanisms presenting different instability patterns.
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Affiliation(s)
- In Hyeok Rhyou
- Department of Orthopaedic Surgery, Upper Extremity and Microsurgery Center, Pohang Semyeong Christianity Hospital, Pohang, Republic of Korea.
| | - Jung Hyun Lee
- Department of Orthopaedic Surgery, Upper Extremity and Microsurgery Center, Pohang Semyeong Christianity Hospital, Pohang, Republic of Korea
| | - Chul-Hyun Cho
- Department of Orthopedic Surgery, Keimyung University Dongsan Hospital, Keimyung University School of Medicine, Daegu, Republic of Korea
| | - Sam-Guk Park
- Department of Orthopedic Surgery, College of Medicine, Yeungnam University, Daegu, Republic of Korea
| | - Ji-Ho Lee
- Department of Orthopaedic Surgery, Upper Extremity and Microsurgery Center, Pohang Semyeong Christianity Hospital, Pohang, Republic of Korea
| | - Kyung Chul Kim
- Department of Orthopaedic Surgery, Upper Extremity and Microsurgery Center, Pohang Semyeong Christianity Hospital, Pohang, Republic of Korea
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Al-Ani Z, Wright A, Ricks M, Watts AC. The three-column concept of elbow joint stability and the Wrightington elbow fracture-dislocation classification, emphasizing the role of cross-sectional imaging. Emerg Radiol 2021; 29:133-145. [PMID: 34403038 DOI: 10.1007/s10140-021-01978-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2021] [Accepted: 08/08/2021] [Indexed: 11/28/2022]
Abstract
Elbow fracture-dislocation is a complex injury with a combination of osseous and soft tissue disruption. Different classification systems have been used to describe the injury pattern and help guide the management. The article describes the important cross-sectional findings in complex elbow fracture-dislocation injuries based on the relatively new Wrightington classification. This includes the various elements and patterns seen in elbow fracture-dislocations providing a simple and comprehensive system to classify these injuries and help guide the surgical management. The article also describes the three-column concept of elbow joint stability, dividing the elbow joint osseous structures into lateral, middle and medial columns. Detailed radiological assessment of the fractures pattern is vital to understand the mechanism of injury, allowing clinicians to predict the associated capsuloligamentous injury and help guide the management decisions. The Wrightington elbow fracture-dislocation classification categorizes the injuries according to the ulnar coronoid process and radial head fractures. Type A is an anteromedial coronoid fracture. Type B is a bifacet or basal coronoid fracture, with B + indicating associated radial head fracture. Type C is a combined anterolateral facet and radial head or comminuted radial head fractures. Type D is a diaphyseal ulnar fracture, with D + indicating associated radial head fracture.
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Affiliation(s)
- Zeid Al-Ani
- Radiology Department, Wrightington, Wigan and Leigh NHS Foundation Trust, Royal Albert Edward Infirmary, Wigan Lane, Wigan, WN1 2NN, UK.
| | - Andrew Wright
- Upper Limb Unit, Wrightington Hospital, Wrightington, Wigan and Leigh NHS Foundation Trust, Wigan, UK
| | - Matthew Ricks
- Upper Limb Unit, Wrightington Hospital, Wrightington, Wigan and Leigh NHS Foundation Trust, Wigan, UK
| | - Adam C Watts
- Upper Limb Unit, Wrightington Hospital, Wrightington, Wigan and Leigh NHS Foundation Trust, Wigan, UK
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Jung HS, Lee JS, Kim JY, Baek SH, Lee GY, Choi JH. Analysis of Fracture Characteristic and Medial Collateral Ligament Injury Relationships in Terrible Triad Elbow Injuries. J Hand Surg Am 2021; 46:713.e1-713.e9. [PMID: 33795153 DOI: 10.1016/j.jhsa.2021.01.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/09/2020] [Revised: 11/09/2020] [Accepted: 01/20/2021] [Indexed: 02/02/2023]
Abstract
PURPOSE The objectives of this study were to identify the relationship between fracture characteristics and medial collateral ligament (MCL) injuries in terrible triad injuries of the elbow. METHODS Between 2010 and 2018, 60 patients who underwent surgery for terrible triad elbow injuries were retrospectively reviewed. Using magnetic resonance imaging (MRI) assessments, patients were stratified into those who had intact or low-grade partial MCL tears (low-grade MRI-MCL group) and those who had high-grade partial or full-thickness MCL tears (high-grade MRI-MCL group). We also analyzed patients according to whether they underwent MCL repair surgery. Fractures of the radial head were assessed according to Mason's classification system and measurements of fracture fragment arc on axial cuts. Fractures of the coronoid processes were assessed according to the system of Regan and Morrey and measurements of coronoid process volumes. RESULTS Patients in the high-grade MRI-MCL group (28 patients) had a more comminuted and higher fragment arc of radial head fractures than those in the low-grade MRI-MCL group (32 patients) (143º ± 45º vs 119º ± 31º). However, the volume of coronoid fracture fragments was smaller in the high-grade MRI-MCL than in the low-grade MRI-MCL group (359 ± 325 mm3 vs 722 ± 448 mm3). The MCL repair group (22 patients) also had a more comminuted and higher fragment arc in radial head fractures (153º ± 44º vs 117º ± 31º) and a smaller coronoid process fracture volume (236 ± 224 mm3 vs 735 ± 419 mm3) than the non-MCL repair group (38 patients). CONCLUSIONS Our results demonstrated that high-grade MCL injuries are associated with comminuted and larger-sized radial head fractures, as well as smaller-sized coronoid process fractures in terrible triad injuries. In making a decision regarding surgical treatment, these fracture characteristics could help to predict the severity for MCL injury in terrible triad injuries. TYPE OF STUDY/LEVEL OF EVIDENCE Prognostic IV.
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Affiliation(s)
| | - Jae Sung Lee
- Department of Orthopaedic Surgery, Seoul, Korea.
| | | | - Suk Ho Baek
- Department of Orthopaedic Surgery, Seoul, Korea
| | | | - Jin Hwa Choi
- Department of Radiation Oncology, Medical Center of Chung-Ang University School of Medicine, Seoul, Korea
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Pal CP, Mittal V, Dinkar KS, Kapoor R, Gupta M. Neglected posterior dislocation of elbow: A review. J Clin Orthop Trauma 2021; 18:100-104. [PMID: 33996454 PMCID: PMC8102760 DOI: 10.1016/j.jcot.2021.04.016] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/07/2021] [Revised: 04/08/2021] [Accepted: 04/13/2021] [Indexed: 10/21/2022] Open
Abstract
Untreated traumatic posterior dislocation of the elbow joint, 3 weeks or older, is defined as "neglected posterior dislocation of the elbow". Around 90% of these are of posterolateral type. These are much more common in the developing and underdeveloped countries. Patients presents with a deformed, stiff and painful elbow with difficulty to perform activities of daily living. The clinical picture looks quite similar to malunited supracondylar fracture of the elbow. Diagnosis is usually confirmed radiographically. CT and MRI scan give additional information and are recommended before embarking on surgery. Treatment is quite challenging due to the significant soft tissue contractures, ligamentous insufficiencies and fibrosis, with possible associated nerve injuries, myositis ossificans, non-compliant patients and the need for long-term postoperative physiotherapy. Goal of surgical treatment is to achieve a painless, stable and mobile elbow with a congruent joint space. We have reviewed the literature and present our view on the prognosis and recommended surgical technique to treat this condition.
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Affiliation(s)
- Chandra Prakash Pal
- Department of Orthopaedics, 5 th Floor, New Surgery Building, Sarojini Naidu Medical College, Agra, 282001, Uttar Pradesh, India
| | - Vivek Mittal
- Department of Orthopaedics, 5 th Floor, New Surgery Building, Sarojini Naidu Medical College, Agra, 282001, Uttar Pradesh, India
| | - Karuna Shankar Dinkar
- Department of Orthopaedics, 5 th Floor, New Surgery Building, Sarojini Naidu Medical College, Agra, 282001, Uttar Pradesh, India
| | - Rajat Kapoor
- Department of Orthopaedics, 5 th Floor, New Surgery Building, Sarojini Naidu Medical College, Agra, 282001, Uttar Pradesh, India
| | - Mayur Gupta
- Department of Orthopaedics, 5 th Floor, New Surgery Building, Sarojini Naidu Medical College, Agra, 282001, Uttar Pradesh, India
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Lee JH, Ahn KB, Kwon KR, Kim KC, Rhyou IH. Differences in Rupture Patterns and Associated Lesions Related to Traumatic Distal Triceps Tendon Rupture Between Outstretched Hand and Direct Injuries. Clin Orthop Relat Res 2021; 479:781-789. [PMID: 33181575 PMCID: PMC8083823 DOI: 10.1097/corr.0000000000001550] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/10/2020] [Accepted: 10/07/2020] [Indexed: 01/31/2023]
Abstract
BACKGROUND Traumatic distal triceps tendon rupture results in substantial disability in the absence of an appropriate diagnosis and treatment. To the best of our knowledge, differences in the degree of injury according to the injury mechanisms and associated lesions are not well known. QUESTIONS/PURPOSES In this study, we asked: (1) What differences are seen in triceps tear patterns between indirect injuries (fall on an outstretched hand) and direct injuries? (2) What are the associated elbow and soft tissue injuries seen in indirect and direct triceps ruptures? METHODS Between 2006 and 2017, one center treated 73 elbows of 72 patients for distal triceps tendon rupture. Of those, 70% (51 of 73 elbows) was excluded from this study; 8% (6 of 73) were related to systemic diseases, 59% (43 of 73) sustained open injuries, and 3% (2 of 73) were related to local steroid injections. We retrospectively collected data on traumatic distal triceps tendon rupture in 30% (22 of 73) of elbows at a single trauma center during a 10-year period. A fall on an outstretched hand was the cause of injury in 15 patients and direct blow by object or contusion were the cause in seven. MRI and surgery were performed in all patients. Traumatic distal triceps tendon rupture was classified by the Giannicola method, which is classified according to the depth and degree of the lesion based on MRI and surgical findings. Associated fractures and bone contusions on MRI were characterized. Ligament injuries on MRI was divided into partial and complete rupture. Agreement between the MRI and intraoperative findings for the presence of a traumatic distal triceps tendon rupture was perfect, and the Giannicola classification of traumatic distal triceps tendon rupture was good (kappa = 0.713). RESULTS In the indirect injury group (fall on an outstretched hand), 15 of 15 patients had injuries that involved only the tendinous portion of the distal triceps, but these injuries were not full-thickness tears, whereas in the direct injury group, three of seven patients had a full-thickness rupture (odds ratio [OR] 1.75 [95% CI 0.92 to 3.32]; p = 0.02). The direct injury group had no associated ligamentous injuries while 14 of 15 patients with indirect injuries had ligamentous injuries (OR 0.13 [95% CI 0.02 to 0.78]; p < 0.001; associated injuries in the indirect group: anterior medial collateral ligament [14 of 15], posterior medial collateral ligament [7 of 15], and lateral collateral ligament complex [2 of 15]). Similarly, one of seven patients in the direct injury group had a bone injury (capitellar contusion), whereas 15 of 15 patients with indirect ruptures had associated fractures or bone contusions (OR 16.0 [95% CI 2.4 to 106.7]; p < 0.001). CONCLUSION A fall on an outstretched hand may result in an injury mostly to the lateral and long head of distal triceps tendon and an intact medial head tendon; however, direct injuries can involve full-thickness ruptures. Although a traumatic distal triceps tendon rupture occurs after a fall on an outstretched hand, radial neck, capitellar, and medial collateral ligament injury can occur because of valgus load and remnant extensor mechanisms. Based on our finding, the clinician encountering a distal triceps tendon rupture due to a fall on an outstretched hand should be aware of the possibility of remaining elbow extensor mechanism by intact medial head tendon portion, and associated injuries, which may induce latent complications. LEVEL OF EVIDENCE Level III, prognostic study.
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Affiliation(s)
- Ji Ho Lee
- J. H. Lee, K. B. Ahn, K. C. Kim, I. H. Rhyou, Department of Orthopedic Surgery, Upper Extremity and Microsurgery Center, SM Christianity Hospital, Pohang, South Korea
- K. R. Kwon, Department of Radiology Semyeong Christianity Hospital, Pohang, South Korea
| | - Kee Baek Ahn
- J. H. Lee, K. B. Ahn, K. C. Kim, I. H. Rhyou, Department of Orthopedic Surgery, Upper Extremity and Microsurgery Center, SM Christianity Hospital, Pohang, South Korea
- K. R. Kwon, Department of Radiology Semyeong Christianity Hospital, Pohang, South Korea
| | - Kwi Ryun Kwon
- J. H. Lee, K. B. Ahn, K. C. Kim, I. H. Rhyou, Department of Orthopedic Surgery, Upper Extremity and Microsurgery Center, SM Christianity Hospital, Pohang, South Korea
- K. R. Kwon, Department of Radiology Semyeong Christianity Hospital, Pohang, South Korea
| | - Kyung Chul Kim
- J. H. Lee, K. B. Ahn, K. C. Kim, I. H. Rhyou, Department of Orthopedic Surgery, Upper Extremity and Microsurgery Center, SM Christianity Hospital, Pohang, South Korea
- K. R. Kwon, Department of Radiology Semyeong Christianity Hospital, Pohang, South Korea
| | - In Hyeok Rhyou
- J. H. Lee, K. B. Ahn, K. C. Kim, I. H. Rhyou, Department of Orthopedic Surgery, Upper Extremity and Microsurgery Center, SM Christianity Hospital, Pohang, South Korea
- K. R. Kwon, Department of Radiology Semyeong Christianity Hospital, Pohang, South Korea
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Feasibility and technique of ultrasound traumatic elbow lesion assessment. Orthop Traumatol Surg Res 2021; 107:102836. [PMID: 33524629 DOI: 10.1016/j.otsr.2021.102836] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/17/2020] [Revised: 08/04/2020] [Accepted: 08/18/2020] [Indexed: 02/03/2023]
Abstract
INTRODUCTION The present study aimed to describe the technique of ultrasound traumatic elbow lesion assessment performed by an orthopedic surgeon. METHODS Nine patients were included in a single-center study. Clinical examination assessed pain, ranges of elbow motion, neurovascular status and elbow ligament testing. Ultrasound was associated to radiography between days 7 and 15, screening for lesions of the bone, medial ligament (in 30-90° flexion), lateral ligament (elbow at 90° in cobra position) and epitrochlear and epicondylar muscle insertions. Ultrasound scanning time and echogenicity were assessed. RESULTS Four radial head osteochondral fractures were detected on ultrasound in addition to the 4 fractures seen on radiography, without significant difference (p=0.071). Clinical examination found 2 cases of valgus laxity and 5 of varus laxity. Ultrasound, performed blind to radiography, found 1 medial collateral ligament anterior bundle lesion (in 1 of the 2 patients with valgus laxity) and 4 lateral collateral ligament ulnar bundle lesions (in 4 of the 5 patients with varus laxity). There were no epicondylar or epitrochlear tendon lesions. Scanning time decreased significantly over the study period, from a mean 30minutes in the first 5 cases to a mean 24.8minutes in the last 5 (p=0.046). Three patients could not be put in the cobra position, and 3 showed poor echogenicity. DISCUSSION Ultrasound assessment of traumatic elbow lesions could be performed by an orthopedic surgeon on a well-defined protocol. Lesions on ultrasound matched clinical symptomatology. Inter- and intra-observer reproducibility remain to be assessed. LEVEL OF EVIDENCE IV.
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Bellato E, Castoldi F, Marmotti A, Greco V, Pautasso A, Blonna D. Relationship Between the Lateral Collateral Ligament of the Elbow and the Kocher Approach: A Cadaver Study. J Hand Surg Am 2021; 46:245.e1-245.e7. [PMID: 33308903 DOI: 10.1016/j.jhsa.2020.09.013] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/08/2019] [Revised: 07/16/2020] [Accepted: 09/28/2020] [Indexed: 02/02/2023]
Abstract
PURPOSE The lateral ulnar collateral ligament (LUCL) is considered to be the portion of the lateral collateral ligament playing the most important stabilizing role. Iatrogenic forms of posterolateral rotatory instability have been described. The Kocher approach is a popular approach to the lateral side of the elbow. The aim of this study was to describe the relationship between the LUCL and the Kocher interval. METHODS The Kocher interval was identified and marked in 20 cadavers. The LUCL was identified and the distance between the LUCL insertion on the tubercle of the cresta supinatoris and the Kocher interval was calculated (TK distance). This distance was considered 0 if the Kocher interval was directly above the tubercle, as a positive value if it was anterior to the tubercle, and as a negative value if it was posterior. Finally, the Kocher interval was sharply opened, and elbow stability was tested using the posterolateral rotatory drawer test. RESULTS A discrete LUCL was identified in 16 specimens. The mean TK distance was -2.3 ± 4.4 mm (range, -11 to +10). The median TK distance was -3 mm. The posterolateral rotatory drawer test was positive for subluxation after the sharp incision of the Kocher interval in 15 specimens. The median TK distance was significantly higher in the stable group (+2 mm) than in the unstable group (-3 mm). CONCLUSIONS The LUCL often lies beneath the Kocher interval and is at risk during the Kocher approach. CLINICAL RELEVANCE Iatrogenic forms of posterolateral rotatory instability could result from this approach.
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Affiliation(s)
| | | | - Antonio Marmotti
- San Luigi Gonzaga Hospital, Orthopedics and Traumatology Department, University of Turin - Medical School, Turin, Italy
| | | | | | - Davide Blonna
- Mauriziano-Umberto I Hospital, Orthopedics and Traumatology Department, University of Turin - Medical School, Turin, Italy
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Cho CH, Kim DH, Park SG, Shin D, Kim BS. Characteristics of Elbow Dislocation in Patients with Preexisting Cubitus Varus. Clin Orthop Surg 2021; 13:83-87. [PMID: 33747383 PMCID: PMC7948041 DOI: 10.4055/cios20040] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/02/2020] [Accepted: 05/17/2020] [Indexed: 11/28/2022] Open
Abstract
BACKGROUND The aim of this study was to investigate the clinical presentations, patterns of soft-tissue injuries, and outcomes of treatment of elbow dislocations in patients with preexisting cubitus varus. METHODS Four cases of elbow dislocation in patients with preexisting cubitus varus, which were treated at 3 residency training hospitals, were retrospectively reviewed. Soft-tissue injury patterns were investigated using magnetic resonance imaging (MRI). Clinical outcomes were assessed at an average of 50.8 months (range, 34-82 months) after treatment using the Mayo Elbow Performance Score (MEPS) and the Quick Disabilities of the Arm, Shoulder and Hand (QuickDASH) score. RESULTS The mean patient age was 49.5 years (range, 33-57 years). All patients had a posteromedial elbow dislocation, which was an indirect injury caused by a fall onto an outstretched hand. One patient had failed closed reduction; 3 others had redislocation or gross instability after closed reduction. Significant tears of the lateral collateral ligament complex and common extensor group were shown in MRI. All patients had surgical treatment including lateral complex repair only (n = 2), repair of both sides' complexes (n = 1), and corrective osteotomy with lateral complex repair (n = 1). At the final follow-up, the mean MEPS was 92.5 ± 8.7 and the mean QuickDASH score was 4.5 ± 6.4. CONCLUSIONS Elbow dislocation in patients with preexisting cubitus varus may present as posteromedial dislocation with acute instability. Surgical treatment of this injury led to acceptable clinical outcomes.
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Affiliation(s)
- Chul-Hyun Cho
- Department of Orthopedic Surgery, Keimyung University Dongsan Hospital, Keimyung University School of Medicine, Daegu, Korea
| | - Du-Han Kim
- Department of Orthopedic Surgery, Keimyung University Dongsan Hospital, Keimyung University School of Medicine, Daegu, Korea
| | - Sam-Guk Park
- Department of Orthopedic Surgery, Yeungnam University Hospital, Daegu, Korea
| | - Dongju Shin
- Department of Orthopedic Surgery, Daegu Fatima Hospital, Daegu, Korea
| | - Beom-Soo Kim
- Department of Orthopedic Surgery, Keimyung University Dongsan Hospital, Keimyung University School of Medicine, Daegu, Korea
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Schnetzke M, Ellwein A, Maier D, Wagner FC, Grützner PA, Guehring T. Injury patterns following simple elbow dislocation: radiological analysis implies existence of a pure valgus dislocation mechanism. Arch Orthop Trauma Surg 2021; 141:1649-1657. [PMID: 32780199 PMCID: PMC8437923 DOI: 10.1007/s00402-020-03541-0] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/16/2019] [Accepted: 07/15/2020] [Indexed: 11/25/2022]
Abstract
INTRODUCTION The aim of the present study was to analyze the injury pattern and thus the dislocation mechanism after simple elbow dislocation using radiographs and magnetic resonance imaging (MRI) data sets. MATERIALS AND METHODS The MRI data sets of 64 patients with a mean age of 44 years (18-77 years) were analyzed retrospectively. The inclusion criteria for the study were (1) radiograph with confirmed simple elbow dislocation, (2) low-energy trauma, (3) MRI of the affected elbow ≤ 3 weeks after trauma. The dislocation direction was determined using radiographs. The integrity of the lateral collateral ligament complex (LCLC), common extensor origin (CEO), anterior capsule (AC), medial collateral ligament (MCL), and common flexor origin (CFO) as well as the joint congruity were assessed based on MRI. RESULTS 34 patients (53%) had a posterolateral, 26 patients (41%) a posterior, and 4 patients (6%) a posteromedial dislocation. LCLC and AC were affected in 64 out of 64 patients (100%). MCL was affected in 58 patients (91%). CEO were affected in 25 patients (39%) and the CFO in 20 patients (31%). In 11 patients (17%) the injury pattern was more pronounced medially than laterally (MCL, CFO, LCLC), with 2 of these patients exhibiting only a partial LCLC tear. All cases with joint incongruency (n = 12, 19%) showed CEO and/or CFO involvement. CONCLUSIONS Simple elbow dislocation leads to a very heterogeneous spectrum of soft tissue injury pattern. A small proportion of patients showed medially pronounced injury patterns. These findings strongly indicate existence of a "reversed Horii circle" with an underlying valgus mechanism (medial force induction) originating and continuing from medial to anterior.
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Affiliation(s)
- Marc Schnetzke
- BG Trauma Center Ludwigshafen at the University of Heidelberg, Clinic for Trauma and Orthopaedic Surgery, Ludwigshafen on the Rhine, Germany.
- ATOS Clinic Heidelberg, German Joint Center Heidelberg, Heidelberg, Germany.
| | - Alexander Ellwein
- Department for Orthopaedic Surgery, Medical School Hannover, DIAKOVERE Annastift, Anna-von-Borries-Straße 1-7, 30625, Hannover, Germany
| | - Dirk Maier
- Faculty of Medicine Medical Center, Albert-Ludwigs-University of Freiburg, Hugstetter Strasse 55, 79106, Freiburg, Germany
| | - Ferdinand Christian Wagner
- Faculty of Medicine Medical Center, Albert-Ludwigs-University of Freiburg, Hugstetter Strasse 55, 79106, Freiburg, Germany
| | - Paul-Alfred Grützner
- BG Trauma Center Ludwigshafen at the University of Heidelberg, Clinic for Trauma and Orthopaedic Surgery, Ludwigshafen on the Rhine, Germany
| | - Thorsten Guehring
- Shoulder and Elbow Surgery, Arcus Sportklinik ARCUS Kliniken, Rastatter Str. 17-19, 75179, Pforzheim, Germany
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Acute elbow dislocation: comparison between magnetic resonance imaging and intra-operative finding of ligament injury. INTERNATIONAL ORTHOPAEDICS 2020; 45:265-273. [PMID: 33200244 DOI: 10.1007/s00264-020-04875-5] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/09/2020] [Accepted: 11/09/2020] [Indexed: 10/23/2022]
Abstract
PURPOSE The aim of this current study was to assess elbow ligament tears after dislocation using magnetic resonance imaging (MRI) and to correlate any pre-operative imaging with intra-operative findings of elbow ligament tears. METHODS We prospectively included 32 patients with acute elbow dislocation investigated by MRI at a means of five days from dislocation. A simple elbow dislocation was diagnosed in 14 patients (44%); associated bone injuries were identified in 18 elbows (56%). Surgical repair of elbow ligaments was carried out in 23 patients, and nine cases were treated non-operatively. A blinded MRI evaluation of all 32 elbows was performed by an orthopaedic surgeon (rater 1) and a musculoskeletal radiologist (rater 2). RESULTS Inter-rater agreement for MRI evaluation of 32 was poor for lateral ulnar collateral ligament (LUCL) tears, fair for radial collateral ligament (RCL), moderate for annular ligament (AL), and fair for ulnar collateral ligament (UCL). All tears were reported as complete by rater 1; 13/32 partial tears were identified by rater 2 (LUCL = 2, RCL = 2, UCL = 9). Correlation between surgical and MRI findings showed good inter-rater agreement for LUCL and AL tears in both raters. Agreement for RCL tear was poor for rater 1 and fair for rater 2; agreement for UCL tear was fair for rater 1 and poor for rater 2. Intra-operative findings showed ten radial head fractures (RHFs) and ten coronoid fractures (CFs). LUCL tears were found in the four cases of type II RHFs and in 3/4 cases of CFs. Bone injuries and ligament tears were not significantly associated. CONCLUSION MRI scan supported surgeons to identify soft tissue injuries and to address the most suitable surgical approach after acute elbow dislocation. Inter-observer agreement for intra-operative findings was high for LCL complex injuries and poor for UCL.
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Common Extensor Complex Is a Predictor to Determine the Stability in Simple Posterolateral Elbow Dislocation: Analysis of MR Images of Stable vs. Unstable Dislocation. J Clin Med 2020; 9:jcm9103094. [PMID: 32992826 PMCID: PMC7601526 DOI: 10.3390/jcm9103094] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2020] [Revised: 09/18/2020] [Accepted: 09/23/2020] [Indexed: 11/17/2022] Open
Abstract
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.
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Kim H, Kholinne E, Kwak JM, Park D, Shin MJ, Kim DM, Lim TK, Koh KH, Jeon IH. Distribution of Osteochondral Lesions in Patients With Simple Elbow Dislocations Based on MRI Analysis. Orthop J Sports Med 2020; 8:2325967120946269. [PMID: 32923505 PMCID: PMC7457416 DOI: 10.1177/2325967120946269] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/15/2020] [Accepted: 03/30/2020] [Indexed: 01/14/2023] Open
Abstract
Background: The clinical relationship between osteochondral lesions and long-term
outcomes and patterns in the elbow joint has not yet been established. A
sole evaluation from plain standard radiography may underestimate the
severity of bony lesions in patients with simple dislocations. It has been
suggested that the mechanism of a posterior elbow dislocation could be
inferred from the pattern of bony contusions and osteochondral lesions
visible on magnetic resonance imaging (MRI) in patients with simple elbow
dislocations. Purpose/Hypothesis: The purpose of this study was to describe the incidence and distribution of
osteochondral lesions based on MRI findings in patients with simple elbow
dislocations. We hypothesized that (1) osteochondral lesions are
consistently found in patients with simple elbow dislocations and (2) the
distribution and severity of osteochondral lesions may explain the mechanism
of the simple elbow dislocation. Study Design: Cohort study; Level of evidence, 3. Methods: A retrospective review of 43 patients with simple elbow dislocations was
performed in tertiary-level hospitals from January 2010 to August 2019. Two
orthopaedic surgeons separately assessed the initial plain radiographs and
MRI scans. Osteochondral lesions were evaluated and categorized based on
whether they were located (1) on the lateral side (posterolateral capitellum
and radial head; type 1) or (2) on the medial side (posterior trochlea and
anteromedial facet of the coronoid; type 2). The severity of the
osteochondral lesions was assessed according to the Anderson
classification. Results: Of the 43 patients, 21 (48.8%) presented with osteochondral lesions on MRI.
The type 1 pattern of osteochondral lesions was the most frequently observed
on MRI in patients with simple elbow dislocations (69.8% of cases), and
these were confirmed by simple radiography. Posterolateral capitellum
osteochondral lesions were found in 13 patients. Among them, 10 (76.9%) were
advanced-stage lesions (stages III and IV according to the Anderson
classification). Conclusion: Osteochondral lesions were found on MRI after simple elbow dislocations at a
rate of 48.8%. Osteochondral lesions in the posterolateral capitellum were
associated with an advanced stage. Clinically, these findings may help
surgeons in the diagnosis of osteochondral lesions and in determining how to
manage patients with the progression of arthritic changes.
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Affiliation(s)
- Hyojune Kim
- Department of Orthopedic Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Erica Kholinne
- Department of Orthopedic Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea.,Department of Orthopedic Surgery, St Carolus Hospital, Jakarta, Indonesia
| | - Jae-Man Kwak
- Department of Orthopedic Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Dongjun Park
- Department of Orthopedic Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Myung-Jin Shin
- Department of Orthopedic Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Dong-Min Kim
- Department of Orthopedic Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Tae Kang Lim
- Department of Orthopedic Surgery, Eulji Hospital, Eulji University School of Medicine, Daejeon, Republic of Korea
| | - Kyoung-Hwan Koh
- Department of Orthopedic Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - In-Ho Jeon
- Department of Orthopedic Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
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Abstract
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.
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Affiliation(s)
- Kaare S Midtgaard
- The Steadman Clinic, Steadman Philippon Research Institute, 181 West Meadow Drive, Suite 400, Vail, CO 81657, USA; Oslo University Hospital, Division of Orthopaedic Surgery, Kirkeveien 166, Oslo 0450, Norway; Norwegian Armed Forces Joint Medical Services, Forsvarsvegen 75, Sessvollmoen 2058, Norway
| | - Joseph J Ruzbarsky
- The Steadman Clinic, Steadman Philippon Research Institute, 181 West Meadow Drive, Suite 400, Vail, CO 81657, USA
| | - Thomas R Hackett
- The Steadman Clinic, Steadman Philippon Research Institute, 181 West Meadow Drive, Suite 400, Vail, CO 81657, USA
| | - Randall W Viola
- The Steadman Clinic, Steadman Philippon Research Institute, 181 West Meadow Drive, Suite 400, Vail, CO 81657, USA.
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Soft tissue injury patterns in posteromedial rotatory instability with dislocation compared with posteromedial dislocation of the elbow joint. J Shoulder Elbow Surg 2020; 29:1259-1266. [PMID: 32061512 DOI: 10.1016/j.jse.2019.11.002] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/17/2019] [Revised: 10/30/2019] [Accepted: 11/07/2019] [Indexed: 02/01/2023]
Abstract
BACKGROUND We sought to determine injury mechanisms and soft tissue injury patterns of dislocation caused by posteromedial rotatory instability (PMRI) and simple posteromedial (PM) dislocation of the elbow joint that appear similar on simple radiographs. METHODS In this retrospective case-series study, we reviewed 13 patients with PMRI dislocation and 10 patients with simple PM dislocation. Three-dimensional computed tomography and magnetic resonance imaging were performed in both groups. The ulnar collateral ligament, lateral collateral ligament complex (LCLC), overlying extensor muscle, and locus of bone contusion were identified. The direction of dislocation was categorized into the pure-posterior or PM type by simple radiographs. RESULTS The LCLC was completely ruptured in both groups. A completely torn ulnar collateral ligament was observed in 3 patients (23%) in the PMRI dislocation group and 9 patients (90%) in the simple PM dislocation group (P = .005). Regarding injury patterns of the LCLC and overlying extensor muscle, the distraction type was found in 10 patients (77%) and the stripping type was found in 3 patients (23%) in the PMRI dislocation group, whereas all patients (100%) in the simple PM dislocation group had the distraction type (P = .103). Bone contusion was observed at the posterolateral olecranon in 2 patients (15%) in the PMRI dislocation group and at the PM olecranon in 4 patients (40%), posterolateral olecranon in 1 (10%), posterior olecranon in 1 (10%), and PM-posterolateral olecranon in 1 (10%) in the simple PM dislocation group (P = .008). In the PMRI dislocation group, 7 patients (54%) had the PM type and 6 (46%) had the pure-posterior type. CONCLUSIONS Simple PM and PMRI dislocations of the elbow joint might have different soft tissue injury characteristics because of different injury mechanisms.
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Abstract
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.
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Lee SH, Nam DJ, Yu HK, Kim JW. The lateral ligament is injured preferentially in posterolateral dislocation of the elbow joint. Bone Joint J 2020; 102-B:227-231. [PMID: 32009431 DOI: 10.1302/0301-620x.102b2.bjj-2019-0966.r1] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
Abstract
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.
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Affiliation(s)
- Sung H Lee
- Department of Orthopaedic Surgery, School of Medicine, Wonkwang University Hospital, Iksan, South Korea
| | - Dae J Nam
- Department of Orthopaedic Surgery, School of Medicine, Wonkwang University Hospital, Iksan, South Korea
| | - Hyun K Yu
- Department of Orthopaedic Surgery, School of Medicine, Wonkwang University Hospital, Iksan, South Korea
| | - Jeong W Kim
- Department of Orthopaedic Surgery, School of Medicine, Wonkwang University Hospital, Iksan, South Korea
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Lee JH, Lee JH, Kim KC, Ahn KB, Rhyou IH. Treatment of posteromedial and posterolateral dislocation of the acute unstable elbow joint: a strategic approach. J Shoulder Elbow Surg 2019; 28:2007-2016. [PMID: 31540726 DOI: 10.1016/j.jse.2019.05.029] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/11/2018] [Revised: 05/23/2019] [Accepted: 05/28/2019] [Indexed: 02/01/2023]
Abstract
BACKGROUND The purpose of this study was to evaluate the different treatment strategies for posterolateral and posteromedial elbow dislocation. METHODS The study enrolled 21 patients with unstable simple elbow dislocation including 16 cases of posterolateral dislocation (PLDL) and 5 cases of posteromedial dislocation (PMDL). In patients with PLDL, the medial side was evaluated and repaired first, followed by the lateral side. In patients with PMDL, the lateral side was repaired first, followed by the medial side according to residual instability. RESULTS Among the 16 cases of unstable PLDL, 7 of 9 presenting with complex combined tear of the ulnar collateral ligament (UCL) and flexor muscle on magnetic resonance imaging showed abnormality on valgus stress testing and UCL repair. Three of 7 cases required additional lateral collateral ligament complex (LCLC) repair. Two of 9 cases showing medial complex dual lesions had normal findings on valgus stress testing and were treated only with LCLC repair. Seven of 16 cases without medial complex dual lesion had normal findings on valgus stress testing, and only LCLC repair was performed. All 5 cases of unstable PMDL showed distraction-type LCLC injury on magnetic resonance imaging and required no additional UCL repair after LCLC repair. There were no cases of recurrent instability following this treatment algorithm. CONCLUSIONS In unstable elbow dislocation, PLDL and PMDL are caused by different mechanisms following damage to different structures. Therefore, different strategies are needed to ameliorate the dislocation and instability.
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Affiliation(s)
- Jung Hyun Lee
- Department of Orthopaedic Surgery, Upper Extremity and Microsurgery Center, Pohang Semyeong Christianity Hospital, Gyeongsangbuk-do, Republic of Korea
| | - Ji-Ho Lee
- Department of Orthopaedic Surgery, Upper Extremity and Microsurgery Center, Pohang Semyeong Christianity Hospital, Gyeongsangbuk-do, Republic of Korea
| | - Kyung Chul Kim
- Department of Orthopaedic Surgery, Upper Extremity and Microsurgery Center, Pohang Semyeong Christianity Hospital, Gyeongsangbuk-do, Republic of Korea
| | - Kee Baek Ahn
- Department of Orthopaedic Surgery, Upper Extremity and Microsurgery Center, Pohang Semyeong Christianity Hospital, Gyeongsangbuk-do, Republic of Korea
| | - In Hyeok Rhyou
- Department of Orthopaedic Surgery, Upper Extremity and Microsurgery Center, Pohang Semyeong Christianity Hospital, Gyeongsangbuk-do, Republic of Korea.
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Foruria AM, Gutiérrez B, Cobos J, Haeni DL, Valencia M, Calvo E. Most coronoid fractures and fracture-dislocations with no radial head involvement can be treated nonsurgically with elbow immobilization. J Shoulder Elbow Surg 2019; 28:1395-1405. [PMID: 30956143 DOI: 10.1016/j.jse.2019.01.005] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/29/2018] [Revised: 12/19/2018] [Accepted: 01/06/2019] [Indexed: 02/01/2023]
Abstract
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.
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Affiliation(s)
- Antonio M Foruria
- Shoulder and Elbow Reconstructive Surgery Unit, Orthopedic Surgery and Trauma Department, Fundación Jiménez Díaz University Hospital, Madrid, Spain.
| | - Begoña Gutiérrez
- Muscle-Skeletal Radiology Unit, Radiology Department, Fundación Jiménez Díaz University Hospital, Madrid, Spain
| | - Jesús Cobos
- Shoulder and Elbow Reconstructive Surgery Unit, Orthopedic Surgery and Trauma Department, Fundación Jiménez Díaz University Hospital, Madrid, Spain
| | - David L Haeni
- Shoulder and Elbow Reconstructive Surgery Unit, Orthopedic Surgery and Trauma Department, Fundación Jiménez Díaz University Hospital, Madrid, Spain
| | - Maria Valencia
- Shoulder and Elbow Reconstructive Surgery Unit, Orthopedic Surgery and Trauma Department, Fundación Jiménez Díaz University Hospital, Madrid, Spain
| | - Emilio Calvo
- Shoulder and Elbow Reconstructive Surgery Unit, Orthopedic Surgery and Trauma Department, Fundación Jiménez Díaz University Hospital, Madrid, Spain
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Abstract
The acutely injured elbow can present as a diagnostic challenge, encompassing a spectrum of conditions that involve the various osseous and soft tissue structures of this complex joint. Imaging plays a vital role in the management of these patients by providing an accurate interpretation of the underlying trauma sustained, which can have important implications on the preservation of joint function and stability. This article examines the mechanisms, patterns, classifications, and imaging findings of acute elbow injuries, providing key concepts for the radiologist in the interpretation of these injuries.
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Affiliation(s)
- Teck Yew Chin
- Department of Diagnostic Radiology, Khoo Teck Puat Hospital, 90 Yishun Central, Singapore 768828, Republic of Singapore.
| | - Hong Chou
- Department of Diagnostic Radiology, Khoo Teck Puat Hospital, 90 Yishun Central, Singapore 768828, Republic of Singapore
| | - Wilfred C G Peh
- Department of Diagnostic Radiology, Khoo Teck Puat Hospital, 90 Yishun Central, Singapore 768828, Republic of Singapore
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Abstract
Pediatric orthopedic injuries are a common reason for presentation to the emergency department. This article sequentially discusses 2 important upper extremity injuries that require prompt management in the emergency department. Radial head subluxations are discussed with a focus on current evidence for imaging, reduction techniques, and follow-up. Elbow dislocations, although less common than radial head subluxations, are also addressed, highlighting imaging, reduction, immobilization, and follow-up recommendations.
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Luokkala T, Temperley D, Basu S, Karjalainen TV, Watts AC. Analysis of magnetic resonance imaging-confirmed soft tissue injury pattern in simple elbow dislocations. J Shoulder Elbow Surg 2019; 28:341-348. [PMID: 30414825 DOI: 10.1016/j.jse.2018.08.010] [Citation(s) in RCA: 25] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/14/2018] [Revised: 08/03/2018] [Accepted: 08/11/2018] [Indexed: 02/01/2023]
Abstract
BACKGROUND The elbow is the second most commonly dislocated joint. Stability depends on the degree of soft tissue injury, with 2 proposed patterns, one starting laterally and the other medially. The purpose of this study was to describe the injured structures observed in magnetic resonance images (MRIs) in a prospective cohort of simple elbow dislocations. METHODS We evaluated 17 consecutive cases of simple elbow dislocations. Two musculoskeletal radiologists assessed the initial x-ray images and MRIs performed for all elbows. Radiologists evaluated the following soft tissue structures: medial collateral ligament complex (MCL), flexor-pronator muscle mass origin, anterior capsule (AC), posterior capsule, lateral collateral ligament complex (LCL), and extensor muscle mass origin. The radiologists were blinded to the study hypothesis. RESULTS The initial radiographs in 16 patients showed the dislocation was posterolateral in 12, posterior in 3, and posteromedial in 1. We observed complete AC tear in 12 patients, MCL in 10, and LCL in 9. The inter-rater reliability for the radiologists was 0.70 (substantial) for MRI. CONCLUSIONS In our series after simple elbow dislocation, complete AC tears were most common, followed by MCL and LCL tears. No single mechanism-related soft tissue injury pattern of simple elbow dislocation was observed, and different grades of soft tissue injury exist.
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Affiliation(s)
- Toni Luokkala
- Wrightington Hospital Upper Limb Unit, Wrightington Hospital, Wrightington, Wigan and Leigh National Health Service Foundation Trust, Wigan, UK; Department of Surgery, Central Finland Central Hospital, Jyväskylä, Finland.
| | - David Temperley
- Wrightington Hospital Upper Limb Unit, Wrightington Hospital, Wrightington, Wigan and Leigh National Health Service Foundation Trust, Wigan, UK
| | - Subhasis Basu
- Wrightington Hospital Upper Limb Unit, Wrightington Hospital, Wrightington, Wigan and Leigh National Health Service Foundation Trust, Wigan, UK
| | | | - Adam C Watts
- Wrightington Hospital Upper Limb Unit, Wrightington Hospital, Wrightington, Wigan and Leigh National Health Service Foundation Trust, Wigan, UK
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Abehsera E, Guerre E, Duriez P, El Rafei M, Fontaine C, Chantelot C. Ligaments injuries check-up and assessment of their healing potential in simple posterolateral elbow dislocation: about 25 cases. EUROPEAN JOURNAL OF ORTHOPAEDIC SURGERY AND TRAUMATOLOGY 2019; 29:785-792. [PMID: 30649622 DOI: 10.1007/s00590-019-02374-x] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/09/2018] [Accepted: 01/04/2019] [Indexed: 12/17/2022]
Abstract
INTRODUCTION Elbow dislocation can lead to instability and stiffness of the elbow. The main goal of this study was to list the initial elbow ligaments injuries caused by simple posterolateral elbow dislocations. The secondary goals were to assess ligament healing 2 months after the initial dislocation, to research a correlation between ligaments injuries and clinical course, and to search for predictive factors of instability. PATIENTS AND METHODS Patients who had simple posterolateral elbow dislocation for the first time between January 2015 and May 2016 were included. Each patient had an MRI scan of their traumatised elbow on the day of the dislocation and then again 2 months later. The assessment was performed thanks to a clinical examination and calculation of functional recovery scores. The Mann-Whitney U test was used to research a correlation between the healing of ligaments injuries and clinical course. RESULTS Twenty-five patients were included in the study. The initial MRI scans showed 70% and 54% ligament rupture, respectively, for the anterior band (ant MCL) and the posterior band (post MCL) of the medial collateral ligament (MCL), as well as 79% for the ulnar (ULCL) and 50% for the radial (RLCL) lateral collateral ligaments. The healing rate 2 months after dislocation was fairly low from 18% for the ULCL up to 41% for the anterior band of the MCL. No correlation was found between the ligament healing noticeable on MRI scans and clinical course. No elbow instability was diagnosed during the 4-month follow-up. CONCLUSION Elbow dislocation is particularly damaging for ligaments. There is no predominance on medial or lateral ligament for rupture. The low healing rate 2 months after the initial dislocation could be explained by performing a follow-up MRI scan too early.
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Affiliation(s)
- Eric Abehsera
- Service de Chirurgie Orthopédique et Traumatologique, CHRU de Lille, Avenue du Professeur Emile Laine, Lille, France.
- Service d'Orthopédie B, Chirurgie de la Main et Membre Supérieur, CHRU de Lille, Avenue du Professeur Emile Laine, Lille, France.
| | - Elvire Guerre
- Service d'Orthopédie B, Chirurgie de la Main et Membre Supérieur, CHRU de Lille, Avenue du Professeur Emile Laine, Lille, France
| | - Pauline Duriez
- Service de Chirurgie Orthopédique et Traumatologique, CHRU de Lille, Avenue du Professeur Emile Laine, Lille, France
| | - Mazen El Rafei
- Service d'Imagerie de l'Appareil Locomoteur, CHRU de Lille, Avenue du Professeur Emile Laine, Lille, France
| | - Christian Fontaine
- Service d'Orthopédie B, Chirurgie de la Main et Membre Supérieur, CHRU de Lille, Avenue du Professeur Emile Laine, Lille, France
| | - Christophe Chantelot
- Service de Chirurgie Orthopédique et Traumatologique, CHRU de Lille, Avenue du Professeur Emile Laine, Lille, France
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Cho CH, Kim BS, Rhyou IH, Park SG, Choi S, Yoon JP, Choi CH, Dan J. Posteromedial Elbow Dislocations without Relevant Osseous Lesions: Clinical Characteristics, Soft-Tissue Injury Patterns, Treatments, and Outcomes. J Bone Joint Surg Am 2018; 100:2066-2072. [PMID: 30516630 DOI: 10.2106/jbjs.18.00051] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
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.
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Affiliation(s)
- Chul-Hyun Cho
- Department of Orthopedic Surgery, Dongsan Medical Center, School of Medicine, Keimyung University, Daegu, South Korea
| | - Beom-Soo Kim
- Department of Orthopedic Surgery, Dongsan Medical Center, School of Medicine, Keimyung University, Daegu, South Korea
| | - In Hyeok Rhyou
- Department of Orthopedic Surgery, Upper Extremity and Microsurgery Center, Semyeong Christianity Hospital, Pohang, South Korea
| | - Sam-Guk Park
- Department of Orthopedic Surgery, Yeungnam University Hospital, Daegu, South Korea
| | - Sung Choi
- Department of Orthopedic Surgery, Daegu Fatima Hospital, Daegu, South Korea
| | - Jong Pil Yoon
- Department of Orthopedic Surgery, Kyungpook National University School of Medicine, Daegu, South Korea
| | - Chang-Hyuk Choi
- Department of Orthopedic Surgery, Daegu Catholic University Medical Center, Daegu, South Korea
| | - Jinmyoung Dan
- Department of Orthopedic Surgery, Gumi CHA University Hospital, Gumi, South Korea
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Shukla DR, Golan E, Weiser MC, Nasser P, Choueka J, Hausman M. The Posterior Bundle's Effect on Posteromedial Elbow Instability After a Transverse Coronoid Fracture: A Biomechanical Study. J Hand Surg Am 2018; 43:381.e1-381.e8. [PMID: 29103848 DOI: 10.1016/j.jhsa.2017.09.018] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/11/2016] [Revised: 08/21/2017] [Accepted: 09/25/2017] [Indexed: 02/02/2023]
Abstract
PURPOSE There has been increased interest in the role of the posterior bundle of the medial collateral ligament (pMUCL) in the elbow, particularly its effects on posteromedial rotatory stability. The ligament's effect in the context of an unfixable coronoid fracture has not been the focus of any study. The purposes of this biomechanical study were to evaluate the stabilizing effect of the pMUCL with a transverse coronoid fracture and to assess the effect of graft reconstruction of the ligament. METHODS We simulated a varus and internal rotatory subluxation in 7 cadaveric elbows at 30°, 60°, and 90° elbow flexion. The amount of ulnar rotation and medial ulnohumeral joint gapping were assessed in the intact elbow after we created a transverse coronoid injury, after we divided the pMUCL, and finally, after we performed a graft reconstruction of the pMUCL. RESULTS At all angles tested, some stability was lost after cutting the pMUCL once the coronoid had been injured, because mean proximal ulnohumeral joint gapping increased afterward by 2.1, 2.2, and 1.3 mm at 90°, 60°, and 30°, respectively. Ulnar internal rotation significantly increased after pMUCL transection at 90°. At 60° and 30° elbow flexion, ulnar rotation increased after resection of the coronoid but not after pMUCL resection. CONCLUSIONS An uninjured pMUCL stabilizes against varus internal rotatory instability in the setting of a transverse coronoid fracture at higher flexion angles. Further research is needed to optimize graft reconstruction of the pMUCL. CLINICAL RELEVANCE The pMUCL is an important secondary stabilizer against posteromedial instability in the coronoid-deficient elbow. In the setting of an unfixable coronoid fracture, the surgeon should examine for posteromedial instability and consider addressing the pMUCL surgically.
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Affiliation(s)
- Dave R Shukla
- Leni and Peter May Department of Orthopaedic Surgery, Icahn School of Medicine at Mount Sinai, New York, NY.
| | - Elan Golan
- Maimonides Department of Orthopaedic Surgery, Maimonides Medical Center, Brooklyn, NY
| | - Mitch C Weiser
- Leni and Peter May Department of Orthopaedic Surgery, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Philip Nasser
- Leni and Peter May Department of Orthopaedic Surgery, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Jack Choueka
- Maimonides Department of Orthopaedic Surgery, Maimonides Medical Center, Brooklyn, NY
| | - Michael Hausman
- Leni and Peter May Department of Orthopaedic Surgery, Icahn School of Medicine at Mount Sinai, New York, NY
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Beck M, Wichelhaus A, Mittlmeier T. [Ulnar collateral ligament reconstruction of the elbow in posttraumatic and chronic ligament instability]. OPERATIVE ORTHOPADIE UND TRAUMATOLOGIE 2017; 30:64-70. [PMID: 29159462 DOI: 10.1007/s00064-017-0523-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/01/2016] [Revised: 04/25/2017] [Accepted: 07/08/2017] [Indexed: 10/18/2022]
Abstract
OBJECTIVE Restoration of ulnar elbow stability in cases of posttraumatic and chronic ulnar ligament instability. INDICATIONS Symptomatic therapy-resistant ulnar ligament instability of the elbow. CONTRAINDICATIONS Arthrofibrosis and high-grade elbow arthrosis. SURGICAL TECHNIQUE Anatomical reconstruction of the ulnar collateral ligament (UCL) with autologous tendon graft (tendons of the palmaris longus muscle and gracilis muscle) in implant-free docking technique. POSTOPERATIVE MANAGEMENT A cast for 1 week, then 5 weeks orthesis with limitation of complete extension and flexion; full weight bearing after 3 months. RESULTS After 2 years 90% of the patients are able to return at an equal level of activity. The overall complication rate is 10.4%. The most common complication is ulnar nerve neurapraxia in 7.8% of the patients.
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Affiliation(s)
- M Beck
- Klinik für Orthopädie und Unfallchirurgie, St. Bernwardkrankenhaus Hildesheim, Treibestrassse 9, 31134, Hildesheim, Deutschland.
| | - A Wichelhaus
- Abteilung für Unfall‑, Hand- und Wiederherstellungschirurgie, Universitätsmedizin Rostock, Rostock, Deutschland
| | - T Mittlmeier
- Abteilung für Unfall‑, Hand- und Wiederherstellungschirurgie, Universitätsmedizin Rostock, Rostock, Deutschland
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40
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Rhyou IH, Lee JH, Kim KC, Ahn KB, Moon SC, Kim HJ, Lee JH. What Injury Mechanism and Patterns of Ligament Status Are Associated With Isolated Coronoid, Isolated Radial Head, and Combined Fractures? Clin Orthop Relat Res 2017; 475:2308-2315. [PMID: 28405856 PMCID: PMC5539024 DOI: 10.1007/s11999-017-5348-z] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/13/2016] [Accepted: 04/05/2017] [Indexed: 01/31/2023]
Abstract
BACKGROUND Isolated coronoid, isolated radial head, and combined coronoid and radial head fractures are common elbow fractures, and specific ligamentous injury of each fracture configuration has been reported. However, the osseous injury mechanism related to ligament status remains unclear. QUESTIONS/PURPOSES The objectives of this study were: (1) to determine what ligamentous injury patterns (medial or lateral collateral) and bone contusion patterns (medial or lateral) are associated with isolated coronoid, isolated radial head, and combined coronoid and radial head fractures; (2) to correlate the osseous injury mechanism based on these findings with isolated coronoid, isolated radial head, and combined coronoid and radial head fractures; and (3) to determine whether isolated and combined coronoid fractures have different fracture lines through the coronoid (tip or anteromedial facet), speculated to be caused by different injury mechanisms. METHODS Between June 2007 and June 2012, 100 patients with elbow fractures were included in the cohort, with 46 of these patients being excluded owing to incongruity for our surgical indication. Finally, 54 patients with surgically treated elbow fractures who had MRI preoperatively were assessed retrospectively. There were 17 elbows with isolated coronoid fractures, 22 with isolated radial head fractures, and 15 with combined coronoid and radial head fractures. Collateral ligament injury pattern and existence of distal humerus bone contusion were reviewed on MR images. RESULTS Patients with isolated radial head fractures were at greater risk of medial collateral ligament rupture compared with patients with isolated coronoid fractures (radial head only: 15 of 22 [68%]; coronoid only: three of 17 [18%]; odds ratio [OR], 10.0; 95% CI, 2.2-46.5; p = 0.002). Patients with isolated coronoid fractures had greater risk of lateral ulnar collateral ligament ruptures (coronoid: 16 of 17 [94%]; radial head: seven of 22 [32%]; OR, 3.5; 95% CI, 3.8-333.3; p < 0.001). The presence of radial head fractures was associated with the risk of lateral bone bruising (isolated radial head fracture: 32 of 37 [86%], isolated coronoid fracture: four of 17 [24%]; OR, 29.6; 95% CI, 5.2-168.9; p < 0.001). Medial bone bruising was only detected in isolated coronoid fractures (isolated coronoid fracture: 12 of 17 [71%], others: zero of 37 [0%]). All isolated coronoid fractures involved the anteromedial facet of the coronoid (17 of 17; 100%). However, combined coronoid and radial head fractures often involved the tip (13 of 15; 87%). CONCLUSIONS Isolated coronoid fractures mostly involved the anteromedial facet of the coronoid process associated with lateral ulnar collateral ligament rupture and medial bone bruising. However, isolated radial head fractures were associated with medial collateral ligament rupture and lateral bone bruising. Combined coronoid and radial head fractures mostly involved a tip fracture of the coronoid with lateral ulnar collateral ligament rupture and lateral bone bruising. Thus surgeons may predict which ligament they should be aware of in the surgical field. LEVEL OF EVIDENCE Level III, prognostic study.
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Affiliation(s)
- In Hyeok Rhyou
- Department of Orthopedic Surgery, Upper Extremity and Microsurgery Center, Pohang SM Christianity Hospital, Daedo Dong 94-5, Nam Gu, Pohang, Kyeongbuk, South Korea
| | - Ji-Ho Lee
- Department of Orthopedic Surgery, Upper Extremity and Microsurgery Center, Pohang SM Christianity Hospital, Daedo Dong 94-5, Nam Gu, Pohang, Kyeongbuk, South Korea.
| | - Kyung Chul Kim
- Department of Orthopedic Surgery, Upper Extremity and Microsurgery Center, Pohang SM Christianity Hospital, Daedo Dong 94-5, Nam Gu, Pohang, Kyeongbuk, South Korea
| | - Kee Baek Ahn
- Department of Orthopedic Surgery, Upper Extremity and Microsurgery Center, Pohang SM Christianity Hospital, Daedo Dong 94-5, Nam Gu, Pohang, Kyeongbuk, South Korea
| | - Seong Cheol Moon
- Department of Orthopedic Surgery, Upper Extremity and Microsurgery Center, Pohang SM Christianity Hospital, Daedo Dong 94-5, Nam Gu, Pohang, Kyeongbuk, South Korea
| | - Hyeong Jin Kim
- Department of Orthopedic Surgery, Upper Extremity and Microsurgery Center, Pohang SM Christianity Hospital, Daedo Dong 94-5, Nam Gu, Pohang, Kyeongbuk, South Korea
| | - Jung Hyun Lee
- Department of Orthopedic Surgery, Upper Extremity and Microsurgery Center, Pohang SM Christianity Hospital, Daedo Dong 94-5, Nam Gu, Pohang, Kyeongbuk, South Korea
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Abstract
BACKGROUND Chronic ligamentous instability of the elbow is an important pathology as it is accompanied with pronounced dysfunction. Moreover, it represents an established risk factor for the development of osteoarthritis. Posterolateral rotatory instability (PLRI) caused by insufficiency of the lateral collateral ligament (LCL) is the most common type of chronic elbow instability and is usually a sequel of traumatic elbow dislocation. Chronic overload can lead to insufficiency of the ulnar collateral ligament (UCL) with subsequent valgus instability, especially in overhead athletes. DIAGNOSTICS Subjective instability and recurrent elbow dislocations are not always the main symptoms but elbow instability is instead often characterized by pain and secondary joint stiffness. Many clinical tests are available yet eliciting them can be difficult and inconclusive. A "drop sign" on lateral radiographs as well as the detection of collateral ligament injuries and joint incongruity on MRI scans can support the suspected diagnosis. In some cases, instability can only be verified by diagnostic arthroscopy. TREATMENT Reconstruction of the lateral ulnar collateral ligament (LUCL) for treatment of PLRI generally leads to good clinical results, yet recurrent instability remains an issue and has been reported in 8 % of cases. UCL reconstruction for chronic valgus instability leads to a return-to-sports rate of about 86 % in the overhead athlete. Ulnar neuropathy, which is seen in approximately 6 % of patients, represents the most common complication. On the rare occasion of multidirectional instability, the box-loop technique can be used for simultaneous reconstruction of the LUCL and UCL with a circumferential graft. 15 cases with promising results have been reported in literature thus far.
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Hackl M, Leschinger T, Uschok S, Müller LP, Wegmann K. Rehabilitation of elbow fractures and dislocations. ACTA ACUST UNITED AC 2017. [DOI: 10.1007/s11678-017-0425-1] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
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Abstract
The treatment of complex elbow dislocation fractures is a challenge to both the treating surgeon as well as to the patient due to the complex bony and soft tissue anatomy of the joint. In order to establish an expedient treatment algorithm, all osseous and ligamentous injuries need to be thoroughly assessed. Furthermore, a detailed knowledge of the joint-stabilizing structures, practicable surgical approaches as well as the possible techniques for fracture fixation and/or arthroplasty are essential to facilitate early rehabilitation of the elbow and avoid injury-related complications. Any unnecessary delay in treatment of this complex injury can result in posttraumatic functional disorders, recurrent instability and secondary arthrosis. In conclusion, the goals of surgical treatment must be the correct restoration of the joint anatomy and stability as the prerequisites for any successful treatment of elbow fracture dislocations in order to enable early motion of the joint.
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Affiliation(s)
- S Siebenlist
- Abteilung und Poliklinik für Sportorthopädie, Klinikum rechts der Isar, Technische Universität München, Ismaninger Str. 22, 81675, München, Deutschland.
| | - K F Braun
- Klinik und Poliklinik für Unfallchirurgie, Klinikum rechts der Isar, Technische Universität München, München, Deutschland
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44
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Robinson PM, Griffiths E, Watts AC. Simple elbow dislocation. Shoulder Elbow 2017; 9:195-204. [PMID: 28588660 PMCID: PMC5444606 DOI: 10.1177/1758573217694163] [Citation(s) in RCA: 43] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/06/2016] [Revised: 12/23/2016] [Accepted: 01/24/2017] [Indexed: 01/02/2023]
Abstract
The elbow is the second most commonly dislocated major joint in adults. Good long-term outcomes have been reported after non-operative management; however, a small proportion (<10%) of patients have a poor outcome and some do require surgical intervention. A review of the anatomy, pathoanatomy, management and outcomes of simple elbow dislocations is presented. Emphasis is placed on emerging concepts regarding the soft tissue injury, the stabilising structures that are injured, the sequence and mechanism of injury and the relationship to elbow stability. The benefits of nonsurgical and surgical management are discussed and a treatment algorithm based on the pathoanatomy is proposed.
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Affiliation(s)
- Paul M. Robinson
- Paul M. Robinson, Peterborough and Stamford Hospitals NHS Foundation Trust, Peterborough City Hospital, Bretton Gate, Peterborough, Cambridgeshire PE3 9GZ, UK.
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Adolfsson LE, Nestorson JO, Scheer JH. Extensive soft tissue lesions in redislocated after simple elbow dislocations. J Shoulder Elbow Surg 2017; 26:1294-1297. [PMID: 28478899 DOI: 10.1016/j.jse.2017.02.019] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/29/2016] [Revised: 02/04/2017] [Accepted: 02/07/2017] [Indexed: 02/01/2023]
Abstract
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.
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Affiliation(s)
- Lars E Adolfsson
- Department of Orthopedic Surgery, Linköping University, Linköping, Sweden; Department of Medical and Health Sciences, Linköping University, Linköping, Sweden
| | - Jens O Nestorson
- Department of Orthopedic Surgery, Linköping University, Linköping, Sweden; Department of Medical and Health Sciences, Linköping University, Linköping, Sweden
| | - Johan H Scheer
- Department of Orthopedic Surgery, Linköping University, Linköping, Sweden; Department of Medical and Health Sciences, Linköping University, Linköping, Sweden.
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Operative Therapie der Terrible-Triad-Verletzung des Ellenbogens. OPERATIVE ORTHOPADIE UND TRAUMATOLOGIE 2017; 29:125-137. [DOI: 10.1007/s00064-017-0489-5] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/01/2016] [Revised: 10/13/2016] [Accepted: 10/14/2016] [Indexed: 10/19/2022]
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Abstract
Elbow dislocations are more common in athletes than in the general population. Simple elbow dislocations should be managed with early range of motion and early return to sport, even with high-level contact athletes. Patients with instability on examination or with complex elbow dislocations may require surgical intervention. Overall, the outcomes after simple elbow dislocations are excellent and athletes should be able to return to play without significant limitations.
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Affiliation(s)
- Mark S Morris
- Department of Orthopaedic Surgery, University of Michigan, 1500 East Medical Center Drive TC2912, Ann Arbor, MI 48109-5328, USA
| | - Kagan Ozer
- Department of Orthopaedic Surgery, University of Michigan, 2098 South Main Street, Ann Arbor, MI 48103, USA.
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48
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Marinelli A, Guerra E, Rotini R. Elbow instability: Are we able to classify it? Review of the literature and proposal of an all-inclusive classification system. Musculoskelet Surg 2016; 100:61-71. [PMID: 27900701 DOI: 10.1007/s12306-016-0424-1] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2016] [Accepted: 08/30/2016] [Indexed: 11/25/2022]
Abstract
BACKGROUND In the recent years, considerable improvements have come in biomechanical knowledge about the role of elbow stabilizers. In particular, the complex interactions among the different stabilizers when injured at the same time have been better understood. Anyway, uncertainties about both nomenclature and classification still exist in the definition of the different patterns of instability. MATERIAL AND METHODS The authors examine the literature of the last 130 years about elbow instability classification, analyzing the intuitions and the value of each of them. However, because of the lack of a satisfactory classification, in 2015 a working group has been created inside SICSeG (Italian Society of Shoulder and Elbow Surgery) with the aim of defining an exhaustive classification as simple, complete and reproducible as possible. RESULTS A new all-inclusive elbow instability classification is proposed. This classification considers two main parameters: timing (acute and chronic forms) and involved stabilizers (simple and complex forms), and four secondary parameters: etiology (traumatic, rheumatic, congenital…), the involved joint (radius and ulna as a single unit articulating with the humerus or the proximal radio-ulnar joint), the degree of displacement (dislocation or subluxation) and the mechanism of instability or dislocation (PLRI, PMRI, direct axial loading, pure varus or valgus stress). CONCLUSIONS This classification is at the same time complete enough to include all the instability patterns and practical enough to be effectively used in the clinical practice. This classification can help in defining a shared language, can improve our understanding of the disorder, reduce misunderstanding of diagnosis and improve comparison among different case series.
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Affiliation(s)
- A Marinelli
- Shoulder and Elbow Unit, Istituto Ortopedico Rizzoli, Bologna, Italy.
| | - E Guerra
- Shoulder and Elbow Unit, Istituto Ortopedico Rizzoli, Bologna, Italy
| | - R Rotini
- Shoulder and Elbow Unit, Istituto Ortopedico Rizzoli, Bologna, Italy
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Shukla DR, Golan E, Nasser P, Culbertson M, Hausman M. Importance of the posterior bundle of the medial ulnar collateral ligament. J Shoulder Elbow Surg 2016; 25:1868-1873. [PMID: 27282737 DOI: 10.1016/j.jse.2016.04.008] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/27/2015] [Revised: 04/01/2016] [Accepted: 04/05/2016] [Indexed: 02/01/2023]
Abstract
BACKGROUND There has been a renewed interest in the pathomechanics of elbow dislocation, with recent literature having suggested that the medial ulnar collateral ligament is more often disrupted in dislocations than the lateral ligamentous complex. The purpose of this serial sectioning study was to determine the influence of the posterior bundle of the medial ulnar collateral ligament (pMUCL) as a stabilizer against elbow dislocation. METHODS An elbow dislocation was simulated in 5 cadaveric elbows by mechanically applying an external rotation moment and valgus force. Medial ulnohumeral joint gapping was measured at 30°, 60°, and 90° of flexion in an intact elbow after sectioning of the medial collateral ligament's anterior bundle (aMUCL) and then after sectioning of the pMUCL as well. RESULTS After sectioning of the aMUCL, the pMUCL was able to stabilize the joint against dislocation. After aMUCL sectioning, the proximal joint space significantly increased by 4.2 ± 0.6 mm at 30° of flexion and 2.6 ± 0.3 mm at 60° of flexion, although it did not dislocate. The gapping increase of 0.9 ± 0.6 at 90° of flexion did not reach significance. After sectioning of the pMUCL (after having already sectioned the aMUCL), all of the specimens frankly dislocated at all flexion angles. CONCLUSIONS An intact pMUCL can prevent elbow dislocation and limited joint subluxation to within 6.6 mm. Our findings indicate that repair or reconstruction may be warranted in certain circumstances (ie, residual instability after operative management of a terrible triad injury or after aMUCL reconstruction).
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Affiliation(s)
- Dave R Shukla
- Leni & Peter May Department of Orthopaedic Surgery, Icahn School of Medicine at Mount Sinai, New York, NY, USA.
| | - Elan Golan
- Maimonides Department of Orthopaedic Surgery, Maimonides Medical Center, Brooklyn, NY, USA
| | - Philip Nasser
- Leni & Peter May Department of Orthopaedic Surgery, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Maya Culbertson
- Maimonides Department of Orthopaedic Surgery, Maimonides Medical Center, Brooklyn, NY, USA
| | - Michael Hausman
- Leni & Peter May Department of Orthopaedic Surgery, Icahn School of Medicine at Mount Sinai, New York, NY, USA
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Hackl M, Leschinger T, Ries C, Neiss WF, Müller LP, Wegmann K. Laterale ulnare Kollateralbandplastik. DER ORTHOPADE 2016; 45:895-900. [DOI: 10.1007/s00132-016-3321-2] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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