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Le GAT, To K, Dang NT, Nguyen VT, Phan TN, Nguyen VT, Ton TTT, Vo TT. The anconeus-triceps lateral flap approach in terrible triad of the elbow: good outcome in a series of ten cases. Ann Med Surg (Lond) 2024; 86:4352-4357. [PMID: 39118682 PMCID: PMC11305737 DOI: 10.1097/ms9.0000000000002211] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2024] [Accepted: 05/14/2024] [Indexed: 08/10/2024] Open
Abstract
Introduction Standard surgical management for the terrible triad of the elbow (TTE) has been established since 2004, yet postoperative complications are common and consensus on optimal management is absent. Different surgical algorithms for treating TTE and their efficacy have been reported worldwide, yet evidence from Vietnam remains limited. Methods Ten cases diagnosed with TTE admitted to the Hospital of Traumatology and Orthopedics, a tertiary orthopedic center in Ho Chi Minh City, were presented to demonstrate the effectiveness and rate of postoperative complications following our stepwise surgical procedures using the anconeus-triceps lateral flap approach. The intraoperative "drop sign", quantitative assessment of pain and level of upper arm disability (via VAS and QuickDASH score) was mentioned to assess the algorithm's benefit. All patients' information was retrieved from medical records from August 2022 to January 2024. Results All 10 cases required repair of the lateral ligament complex and underwent surgery within 2 days of hospitalization. Immediate postoperative imaging revealed no drop sign, and none of the patients experienced elbow dislocation nor the need for repeated surgery, and a full range of elbow motion was demonstrated at 3-6 months follow-up. Conclusion TTE is a challenging injury that almost always obligates surgical correction. The anconeus-triceps lateral flap approach, with its advantages of better visualization and preservation of certain essential stabilizing muscles of the elbow, was demonstrated to yield a high success rate and low postoperative complication rate.
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Affiliation(s)
- Gia Anh Thy Le
- Department of Upper Limbs, Hospital for Traumatology and Orthopaedics, Ho Chi Minh City
| | - Kha To
- School of Medicine, Vietnam National University Ho Chi Minh City
- Trauma and Orthopedics Department, Thong Nhat Hospital
- Division of Surgery and Interventional Science
- Institute of Sport, Exercise and Health, University College London, London, UK
| | - Nghia Thanh Dang
- School of Medicine, Vietnam National University Ho Chi Minh City
| | - Viet Tan Nguyen
- Department of Upper Limbs, Hospital for Traumatology and Orthopaedics, Ho Chi Minh City
| | - Tri Nguyen Phan
- Department of Upper Limbs, Hospital for Traumatology and Orthopaedics, Ho Chi Minh City
| | - Van Thai Nguyen
- Department of Upper Limbs, Hospital for Traumatology and Orthopaedics, Ho Chi Minh City
- Department of Orthopaedics and Trauma, Pham Ngoc Thach Medical University, Ho Chi Minh City, Vietnam
| | - Thi Thanh Thao Ton
- Department of Upper Limbs, Hospital for Traumatology and Orthopaedics, Ho Chi Minh City
| | - Thanh Toan Vo
- Trauma and Orthopedics Department, Thong Nhat Hospital
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Breulmann FL, Lappen S, Ehmann Y, Bischofreiter M, Lacheta L, Siebenlist S. Treatment strategies for simple elbow dislocation - a systematic review. BMC Musculoskelet Disord 2024; 25:148. [PMID: 38365699 PMCID: PMC10874000 DOI: 10.1186/s12891-024-07260-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/22/2023] [Accepted: 02/04/2024] [Indexed: 02/18/2024] Open
Abstract
BACKGROUND Current treatment concepts for simple elbow dislocation involve conservative and surgical approaches. The aim of this systematic review was to identify the superiority of one treatment strategy over the other by a qualitative analysis in adult patients who suffered simple elbow luxation. STUDY DESIGN A systematic review in accordance with the PRISMA guidelines and following the suggestions for reporting on qualitative summaries was performed. A literature search was conducted using PubMed and Scopus, including variations and combinations of the following keywords: elbow, radiohumeral, ulnohumeral, radioulnar, luxation, and therapy. Seventeen studies that performed a randomized controlled trial to compare treatment strategies as conservative or surgical procedures were included. Reviews are not selected for further qualitative analysis. The following outcome parameters were compared: range of motion (ROM), Mayo Elbow Performance Score (MEPS), Disabilities of the Arm, Shoulder and Hand outcome measure (Quick-DASH), recurrent instability, pain measured by visual analog scale (VAS) and time to return to work (RW). RESULTS Early mobilization after conservative treatment strategies showed improved ROM compared to immobilization for up to 3 weeks after surgery with less extension deficit in the early mobilization group (16° ± 13°. vs. 19.5° ± 3°, p < 0.05), as well as excellent clinical outcome scores. Surgical approaches showed similar results compared to conservative treatment, leading to improved ROM (115 vs. 118 ± 2.8) and MEPS: 95 ± 7 vs. 92 ± 4. CONCLUSION Conservative treatment with early functional training of the elbow remains the first-line therapy for simple elbow dislocation. The surgical procedure provides similar outcomes compared to conservative treatment regarding MEPS and ROM for patients with slight initial instability in physical examination and radiographs. People with red flags for persistent instability, such as severe bilateral ligament injuries and moderate to severe instability during initial physical examination, should be considered for a primary surgical approach to prevent recurrent posterolateral and valgus instability. Postoperative early mobilization and early mobilization for conservatively treated patients is beneficial to improve patient outcome and ROM.
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Affiliation(s)
- Franziska Lioba Breulmann
- Department of Sports Orthopedics, Klinikum Rechts Der Isar, Technical University of Munich, Ismaningerstraße 22, Munich, 81675, Germany
| | - Sebastian Lappen
- Department of Sports Orthopedics, Klinikum Rechts Der Isar, Technical University of Munich, Ismaningerstraße 22, Munich, 81675, Germany
| | - Yannick Ehmann
- Department of Sports Orthopedics, Klinikum Rechts Der Isar, Technical University of Munich, Ismaningerstraße 22, Munich, 81675, Germany
| | - Martin Bischofreiter
- Department of Orthopedic Surgery, Ordensklinikum Barmherzige Schwestern Linz, Linz, 4010, Austria
- Department of Orthopedics and Traumatology, Klinik Diakonissen Schladming, Schladming, 8970, Austria
| | - Lucca Lacheta
- Department of Sports Orthopedics, Klinikum Rechts Der Isar, Technical University of Munich, Ismaningerstraße 22, Munich, 81675, Germany
| | - Sebastian Siebenlist
- Department of Sports Orthopedics, Klinikum Rechts Der Isar, Technical University of Munich, Ismaningerstraße 22, Munich, 81675, Germany.
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Pierreux P, Caekebeke P, van Riet R. The role of arthroscopy in instability of the elbow. JSES Int 2023; 7:2594-2599. [PMID: 37969538 PMCID: PMC10638551 DOI: 10.1016/j.jseint.2022.12.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022] Open
Affiliation(s)
- Pieter Pierreux
- Department of Orthopaedics and Traumatology, Orthoclinic Brugge, AZ Sint-Jan AV, Brugge, Belgium
| | - Pieter Caekebeke
- Department of Orthopedic Surgery and Traumatology, Genk, Belgium
| | - Roger van Riet
- Department of Orthopedic Surgery, AZ Monica and University of Antwerp, Antwerp, Belgium
- Orthopedic Specialists, Harley Street Specialist Hospital, London, United Kingdom
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Baek S, Lee GH, Shin MH, Kim TM, Oh KS, Chung SW. Transient postoperative inferior subluxation of the shoulder after surgical stabilization of recurrent anterior dislocation in a patient with myasthenia gravis: a case report. Clin Shoulder Elb 2023; 26:302-305. [PMID: 35545243 PMCID: PMC10497917 DOI: 10.5397/cise.2022.00794] [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: 01/19/2022] [Revised: 03/10/2022] [Accepted: 03/18/2022] [Indexed: 11/25/2022] Open
Abstract
The authors present a case of transient postoperative inferior subluxation of the shoulder after arthroscopic surgical stabilization for recurrent anterior dislocation. The patient was a 61-year-old woman with myasthenia gravis (MG). The first anterior shoulder dislocation occurred because of a fall to the ground. Despite a successful closed reduction, two more dislocations occurred in 3 weeks. Magnetic resonance imaging revealed an anterior labroligamentous periosteal sleeve avulsion (ALPSA) lesion, an engaging Hill-Sachs lesion, and large tears of the supraspinatus and infraspinatus tendons. The patient underwent arthroscopic rotator cuff repair and ALPSA repair with a remplissage procedure. Intraoperatively, no tendency for instability was found; however, a widened glenohumeral joint space and inferior subluxation of the humeral head without functional compromise was observed on the day after surgery and disappeared spontaneously on radiographs 2 weeks later. To the authors' knowledge, this is the first report documenting the occurrence of transient postoperative inferior subluxation of the shoulder in a patient with MG.
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Affiliation(s)
- Samuel Baek
- Department of Orthopaedic Surgery, Seoul Red Cross Hospital, Seoul, Korea
| | - Geum-Ho Lee
- Department of Orthopaedic Surgery, Seoul Red Cross Hospital, Seoul, Korea
| | - Myung Ho Shin
- Department of Orthopaedic Surgery, CM Hospital, Seoul, Korea
| | - Tae Min Kim
- Department of Orthopaedic Surgery, Seoul Prime Hospital, Seoul, Korea
| | - Kyung-Soo Oh
- Department of Orthopaedic Surgery, Konkuk University School of Medicine, Seoul, Korea
| | - Seok Won Chung
- Department of Orthopaedic Surgery, Konkuk University School of Medicine, Seoul, Korea
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Lone AH, Hamid MA, Geelani ZA, Naseer Y. Coronoid fixation and lateral collateral ligament repair in varus posteromedial rotatory instability of the elbow. J Clin Orthop Trauma 2023; 37:102107. [PMID: 36879988 PMCID: PMC9984882 DOI: 10.1016/j.jcot.2023.102107] [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: 05/29/2022] [Revised: 12/10/2022] [Accepted: 01/10/2023] [Indexed: 01/13/2023] Open
Abstract
Background Varus posteromedial rotatory instability is a relatively rare elbow injury, that has been infrequently reported in published literature. We intended to evaluate the outcomes of surgical management of this rare injury with anteromedial coronoid fixation, and, in selected patients, lateral ulnar collateral ligament (LUCL) repair. Methods Between 2017 and 2020, we identified 12 patients with anteromedial coronoid fractures, and a varus posteromedial rotatory instability, who underwent surgery for fixation of the coronoid fracture, with or without LCL repair. All the included patients were either O'Driscoll subtype 2-2, or subtype 2-3. All the 12 patients were followed up for a minimum of 24 months, and their functional outcomes assessed using the Mayo Elbow Performance Score (MEPS). Results The mean MEPS recorded in our study was 92.08, and the mean range of elbow flexion achieved was 124.2°. The mean flexion contracture in our patients was 5.83°. Three of our twelve patients (25%) suffered from elbow stiffness even at final follow-up. The results were graded as Excellent in eight, Good in three, and Fair in one patient. Conclusion Coronoid fractures and LUCL disruptions associated with varus posteromedial rotatory instability can be reliably managed by employing a protocol that combines radiographic parameters, as well as intra-operative assessments of stability. While surgical intervention successfully restored stability, there is a learning curve to the management of these injuries and complications are not uncommon, particularly elbow stiffness. Hence, in addition to surgical fixation, emphasis should also be placed on intensive post-operative rehabilitation to improve outcomes.
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Affiliation(s)
- Ansarul Haq Lone
- Orthopaedic Surgery, Government Hospital for Bone & Joint Surgery, Srinagar, Jammu & Kashmir, India
| | - Muhammad A. Hamid
- Orthopaedic Surgery, Government Hospital for Bone & Joint Surgery, Srinagar, Jammu & Kashmir, India
| | - Zubair A. Geelani
- Orthopaedic Surgery, Government Hospital for Bone & Joint Surgery, Srinagar, Jammu & Kashmir, India
| | - Yawar Naseer
- Orthopaedic Surgery, Government Hospital for Bone & Joint Surgery, Srinagar, Jammu & Kashmir, India
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Grieser T. Posttreatment Changes of the Elbow. Semin Musculoskelet Radiol 2022; 26:271-294. [PMID: 35654095 DOI: 10.1055/s-0042-1743402] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
Radiologists should be familiar with the typical surgical procedures applied at the elbow and aware of the spectrum of normal and pathologic appearances of posttreatment situations throughout all radiologic modalities. Most important in the case of posttraumatic surgical elbow procedures is correct postoperative elbow joint alignment, appropriate fixation of joint-forming fragments, and proper insertion of screws, plates, and anchor devices that do not conflict with intra-articular or bony structures. To report soft tissue repair procedures correctly, radiologists need to know the broad spectrum of different techniques applied and their appearance on magnetic resonance imaging.
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Affiliation(s)
- Thomas Grieser
- Department of Diagnostic and Interventional Radiology, University Hospital Augsburg, Augsburg, Germany
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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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8
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De Giorgi S, Vicenti G, Bizzoca D, Carrozzo M, Baglioni M, Virgilio A, Moretti L, Moretti B. Lateral collateral ulnar ligament reconstruction techniques in posterolateral rotatory instability of the elbow: A systematic review. Injury 2022; 53 Suppl 1:S8-S12. [PMID: 33187675 DOI: 10.1016/j.injury.2020.11.010] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/13/2020] [Revised: 10/28/2020] [Accepted: 11/05/2020] [Indexed: 02/02/2023]
Abstract
BACKGROUND Elbow chronic instability is a disable complication, presenting as recurrent joint subluxations or dislocations. This systematic review aims to assess (1) the clinical outcome and (2) the complication rates of the surgical techniques currently used in the management of posterolateral rotatory elbow instability. METHODS OVID-MEDLINE®, SCOPUS, and PubMed were searched from January 2009 to February 2019 to identify relevant studies. The search terms used were "LUCL", "Posterolateral dislocation", "Elbow Docking technique", "Elbow Jobe technique" and "Elbow single strand technique". The methodological qualities of the studies were evaluated, relevant data were extracted. RESULTS Three studies, published between 2012 and 2015, were included in this review. No studies concerning the single strand technique met the inclusion criteria. The included studies had a level of evidence IV and recruited 33 patients undergoing a Jobe technique reconstruction and 8 patients undergoing a Docking technique. Jobe procedure registered better clinical and functional outcome, assessed using the Mayo Clinic Elbow Performance Scale (MEPS), compared with patients managed with Docking technique. Nonetheless, this difference is not significant. There was not a significantly different complication rate (p = 0.57) between patients treated with these two different techniques. CONCLUSION This systematic review showed that both Jobe and Docking techniques are safe and effective in the treatment of posterolateral elbow instability. However, future studies with larger sample size and a longer follow-up interval are needed to draw stronger conclusions on the efficacy of the different LUCL surgical reconstruction techniques.
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Affiliation(s)
- Silvana De Giorgi
- Orthopaedic & Trauma Unit, Department of Basic Medical Sciences, Neuroscience and Sense Organs, School of Medicine, University of Bari "Aldo Moro"-AOU Consorziale "Policlinico", Bari, Italy
| | - Giovanni Vicenti
- Orthopaedic & Trauma Unit, Department of Basic Medical Sciences, Neuroscience and Sense Organs, School of Medicine, University of Bari "Aldo Moro"-AOU Consorziale "Policlinico", Bari, Italy.
| | - Davide Bizzoca
- Orthopaedic & Trauma Unit, Department of Basic Medical Sciences, Neuroscience and Sense Organs, School of Medicine, University of Bari "Aldo Moro"-AOU Consorziale "Policlinico", Bari, Italy
| | - Massimiliano Carrozzo
- Orthopaedic & Trauma Unit, Department of Basic Medical Sciences, Neuroscience and Sense Organs, School of Medicine, University of Bari "Aldo Moro"-AOU Consorziale "Policlinico", Bari, Italy
| | - Marco Baglioni
- Orthopaedic & Trauma Unit, Department of Basic Medical Sciences, Neuroscience and Sense Organs, School of Medicine, University of Bari "Aldo Moro"-AOU Consorziale "Policlinico", Bari, Italy
| | - Antonio Virgilio
- Orthopaedic & Trauma Unit, Department of Basic Medical Sciences, Neuroscience and Sense Organs, School of Medicine, University of Bari "Aldo Moro"-AOU Consorziale "Policlinico", Bari, Italy
| | - Lorenzo Moretti
- Orthopaedic & Trauma Unit, Department of Basic Medical Sciences, Neuroscience and Sense Organs, School of Medicine, University of Bari "Aldo Moro"-AOU Consorziale "Policlinico", Bari, Italy
| | - Biagio Moretti
- Orthopaedic & Trauma Unit, Department of Basic Medical Sciences, Neuroscience and Sense Organs, School of Medicine, University of Bari "Aldo Moro"-AOU Consorziale "Policlinico", Bari, Italy
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9
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Kilgus S, Eder C, Siegert P, Moroder P, Zimmermann E, Thiele K. The inter-individual anatomical variation of the trochlear notch as a predisposition for simple elbow dislocation. Arch Orthop Trauma Surg 2022; 142:3405-3413. [PMID: 34953138 PMCID: PMC9522744 DOI: 10.1007/s00402-021-04284-2] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/08/2021] [Accepted: 11/27/2021] [Indexed: 11/25/2022]
Abstract
PURPOSE Besides the multi-layered capsule-ligamentous complex of the elbow joint the high bony congruence in the ulnohumeral joint contributes to elbow stability. Therefore, we assume that specific anatomical configurations of the trochlear notch predispose to dislocation. In case of ligamentous elbow dislocation both conservative and surgical treatment is possible without a clear treatment algorithm. Findings of constitutional bony configurations could help deciding for the best treatment option. METHODS In this retrospective matched-pair analysis we compared MRI imaging from patients sustaining a primary traumatic elbow dislocation (instability group) with patients suffering from chronic lateral epicondylitis (control group), treated between 2009 and 2019. Two independent observers measured different anatomical landmarks of the trochlear notch in a multiplanar reconstructed standardized sagittal trochlear plane (SSTP). Primarily, opening angle and relative depth of the trochlear notch were determined. After adjustment to the proximal ulnar rim in the SSTP, coronoid and olecranon angle, the articular angle as well as the ratio of the tip heights of the trochlear notch were measured. RESULTS We compared 34 patients in the instability group (age 48 ± 14 years, f/m 19/15) with 34 patients in the control group (age 47 ± 16 years, f/m 19/15). Instability group showed a significantly larger opening angle (94.1° ± 6.9° vs. 88.5° ± 6.9°, p = 0.0002), olecranon angle (60.9° ± 5.3° vs. 56.1° ± 5.1°, p < 0.0001) and articular angle (24.7° ± 6.4° vs. 22.3° ± 5.8°, p = 0.02) compared to the control group. Measuring the height from the coronoid (ch) and olecranon (oh) tip also revealed a significantly larger tip ratio (tr = ch/oh) in the instability group (2.7 ± 0.8 vs. 2.2 ± 0.5, p < 0.0001). The relative depth (61.0% ± 8.3% vs. 62.7% ± 6.0%, p = 0.21) of the trochlear notch as well as the coronoid angle (32.8° ± 4.5° vs. 31.7° ± 5.2°, p = 0.30) showed no significant difference in the instability group compared to the control group. The interrater reliability of all measurements was between 0.83 and 0.94. CONCLUSION MRI of patients with elbow dislocation show that there seems to be a bony anatomical predisposition. According to the results, it seems reasonable to include predisposing bony factors in the decision-making process when surgical stabilization and conservative treatment is possible. Further biomechanical studies should prove these assumptions to generate critical bony values helping surgeons with decision making. LEVEL OF EVIDENCE III.
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Affiliation(s)
- Sofia Kilgus
- Center for Musculoskeletal Surgery, Charité-University Medicine Berlin, Augustenburger Platz 1, Berlin, 13353 Germany
| | - Christian Eder
- Center for Musculoskeletal Surgery, Charité-University Medicine Berlin, Augustenburger Platz 1, Berlin, 13353 Germany
| | - Paul Siegert
- Center for Musculoskeletal Surgery, Charité-University Medicine Berlin, Augustenburger Platz 1, Berlin, 13353 Germany ,Orthopedic Hospital Speising, Speisinger Street 109, 1130 Vienna, Austria
| | - Philipp Moroder
- Center for Musculoskeletal Surgery, Charité-University Medicine Berlin, Augustenburger Platz 1, Berlin, 13353 Germany
| | - Elke Zimmermann
- Department of Radiology, Charité-University Medicine Berlin, Chariteplatz 1, Berlin, 10117 Germany
| | - Kathi Thiele
- Center for Musculoskeletal Surgery, Charité-University Medicine Berlin, Augustenburger Platz 1, Berlin, 13353 Germany
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10
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Carroll PJ, Morrissey DI. Posterior (Boyd) approach to terrible triad injuries. JSES Int 2021; 6:315-320. [PMID: 35252933 PMCID: PMC8888163 DOI: 10.1016/j.jseint.2021.11.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Background A ‘terrible triad injury of the elbow’ (TTIE) refers to an injury pattern involving posterior dislocation of the ulnohumeral joint, fracture of the radial head, and fracture of the coronoid process of the ulna. It is a complex injury to the elbow joint and can result in long-term elbow instability, pain, stiffness, and arthritis. In specific cases, it may be treated conservatively, but in most circumstances, surgical stabilization is advised. The ‘drop sign’ is an objective static radiographically measured ulnohumeral distance of ≥4 mm seen intraoperatively and postoperatively. Although controversial, it may portend postoperative instability and arthritis. The senior author repairs these injuries in a standardized fashion through a modified Boyd rather than a lateral approach. Our aim was to assess the number of cases demonstrating an intraoperative drop sign after surgical treatment of a TTIE with this approach. Methods We retrospectively analyzed 22 consecutive patients with 23 acute TTIEs. These injuries were treated by a single surgeon using a modified Boyd (posterior) approach to the elbow. Intraoperative image intensifier x-rays were analyzed by the two authors to assess for a ‘drop sign’. Results None of the 23 cases had ‘drop signs’ on intraoperative imaging after stabilization. No patient has redislocated, underwent reoperation, or had symptoms of instability at follow-up. Conclusion None of our patient cohort had an intraoperative ‘drop sign’ after standardized stabilization for a TTIE injury using a modified Boyd approach.
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11
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Reichert ILH, Ganeshamoorthy S, Aggarwal S, Arya A, Sinha J. Dislocations of the elbow - An instructional review. J Clin Orthop Trauma 2021; 21:101484. [PMID: 34367909 PMCID: PMC8321949 DOI: 10.1016/j.jcot.2021.101484] [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: 05/23/2021] [Accepted: 06/20/2021] [Indexed: 11/27/2022] Open
Abstract
Dislocations of the elbow require recognition of the injury pattern followed by adequate treatment to allow early mobilisation. Not every injury requires surgery but if surgery is undertaken all structures providing stability should be addressed, including fractures, medial and lateral ligament insertion and the radial head. The current concepts of biomechanical modelling are addressed and surgical implications discussed.
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Affiliation(s)
- Ines LH. Reichert
- King's College Hospital, Denmark Hill, King's College Hospital NHS Foundation Trust, London, UK
| | | | - Saurabh Aggarwal
- Princess Royal University Hospital, King's College Hospital NHS Foundation Trust, London, UK
| | - Anand Arya
- King's College Hospital, Denmark Hill, King's College Hospital NHS Foundation Trust, London, UK
| | - Joydeep Sinha
- King's College Hospital, Denmark Hill, King's College Hospital NHS Foundation Trust, London, UK
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12
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Stratchko L, Rosas H. Imaging of Elbow Injuries. Clin Sports Med 2021; 40:601-623. [PMID: 34509201 DOI: 10.1016/j.csm.2021.05.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Familiarity with throwing mechanics during elbow range of motion allows accurate diagnosis of sports-related elbow injuries, which occur in predictable patterns. In addition, repetitive stress-related injuries are often clinically apparent; however, imaging plays an important role in determining severity as well as associated injuries that may affect clinical management. A detailed understanding of elbow imaging regarding anatomy and mechanism of injury results in prompt and precise treatment.
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Affiliation(s)
- Lindsay Stratchko
- University of Wisconsin School of Medicine and Public Health, 600 Highland Avenue, Madison, WI 53792, USA.
| | - Humberto Rosas
- University of Wisconsin School of Medicine and Public Health, 600 Highland Avenue, Madison, WI 53792, USA
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Schoch C, Dittrich M, Seilern Und Aspang J, Geyer M, Geyer S. Autologous triceps tendon graft for LUCL reconstruction of the elbow: clinical outcome after 7.5 years. EUROPEAN JOURNAL OF ORTHOPAEDIC SURGERY AND TRAUMATOLOGY 2021; 32:1111-1118. [PMID: 34363106 DOI: 10.1007/s00590-021-03081-2] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/01/2021] [Accepted: 07/26/2021] [Indexed: 10/20/2022]
Abstract
PURPOSE The objective of this study was to assess mid- to long-term functional outcomes in patients treated for symptomatic posterolateral instability of the elbow (PLRI) using an autologous ipsilateral triceps tendon as graft. METHODS A total of 196 patients were treated with autologous triceps tendon graft for symptomatic PLRI at single orthopedic institution from 2006 to 2013. The surgical treatment contained arthroscopic instability testing, reconstruction of the lateral ulnar collateral ligament (LUCL) and harvesting autologous ipsilateral triceps tendon as graft. The follow-up outcomes included range of motion (ROM), pain measured on a visual analogue scale (VAS), Mayo Elbow Performance Score (MEPS), Oxford Elbow Score (OES) and ultrasound to evaluate the integrity of the refixation of the common extensor. RESULTS A total of 178 patients (female: 73; male: 105) were available for follow-up at a mean of 91 months (range 48-144). No patient reported pain at rest; VAS during activity was 1.8 (range 0-5). The ROM decreased slightly compared to preoperative measurements. Flexion decreased significantly from 135.4 to 131.1, though still within the functional arc of motion. All but 13 patients (8.5%) were clinically stable. However, only two patients received a revision of the LUCL reconstruction due to subjective instability. The mean MEPS in the final follow-up was 91.3 (range 73-100). The mean OES was 46.5 (range 39-48). Three patients reported a pain-free clicking of the elbow. No patient complained about donor site morbidity of the ipsilateral triceps tendon. Ultrasound evaluation showed integrity of the common extensors in all patients. CONCLUSIONS LUCL reconstruction using the ipsilateral triceps tendon as graft shows good to excellent mid- to long-term results in the treatment of symptomatic posterolateral elbow joint instability with a low re-instability and complication rate.
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Affiliation(s)
- Christian Schoch
- St. Vinzenz Klinik Pfronten GmbH, Kirchweg 15, 87459, Pfronten, Germany.
| | - Michael Dittrich
- St. Vinzenz Klinik Pfronten GmbH, Kirchweg 15, 87459, Pfronten, Germany
| | | | - Michael Geyer
- St. Vinzenz Klinik Pfronten GmbH, Kirchweg 15, 87459, Pfronten, Germany
| | - Stephanie Geyer
- Department for Orthopaedic Sports Medicine, Technical University Munich, Klinikum Rechts Der Isar, Munich, Germany
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Geyer S, Seilern Und Aspang J, Geyer M, Schoch C. Hidden instability in posttraumatic stiff elbows. EUROPEAN JOURNAL OF ORTHOPAEDIC SURGERY AND TRAUMATOLOGY 2021; 31:1135-1141. [PMID: 33417047 DOI: 10.1007/s00590-020-02846-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/30/2020] [Accepted: 12/03/2020] [Indexed: 02/07/2023]
Abstract
BACKGROUND Hidden instability could be one of the reasons for reoccurring stiffness after arthrolysis in posttraumatic elbows. Associated instability in stiff posttraumatic elbows is clinically hard to detect. Surgical treatment for instability and stiffness in the same surgical setting is challenging and has not been evaluated as of yet. HYPOTHESIS The primary hypothesis assumes (1) the existence of a posttraumatic "stiff and unstable elbow" and (2) that coexisting instability can be detected by arthroscopic instability testing. The secondary objective was to report the midterm results after arthrolysis and ligament stabilization in the stiff and unstable elbow. METHODS From 2005 to 2015, 55 patients received arthroscopic arthrolysis of the elbow due to posttraumatic elbow stiffness at our institution. The arthroscopic instability was categorized into three grades with a switching stick: grade I (= stable), grade II (mild instability) and grade III (grossly instable). In cases of persisting instability (grade II-III), a ligament stabilization procedure was performed and all patients were followed up clinically at a minimum of 12 months. Besides ROM and clinical joint stability, PROs (patient reported outcomes) were assessed with the PREE-score (patient-rated elbow evaluation) and the Oxford-Elbow-score (OES). Furthermore, the MEPS (Mayo-elbow-performance-score) was assessed. RESULTS Out of 55 cases presenting for arthrolysis, coexisting elbow instability was detected during arthroscopic instability testing in 22 cases (40%). All 22 patients received additional ligament stabilization. At final follow-up 62.7 ± 35.7 months postoperatively, 20 patients (12 men; 8 women) with a mean age of 42 ± 16.8 were available. PREE, OES and MEPS were 19.8 ± 25.3, 37.5 ± 9.8 and 80 ± 14.5, respectively. ROM improved significantly from 95° ± 29° to 110° ± 24° postoperatively (p = 0.045). Five patients required revision arthrolysis within the follow-up period (20%). One patient demonstrated persisting instability (5%). CONCLUSION Intraoperative instability diagnostics during arthroscopic arthrolysis helps detect persisting posttraumatic instability and may provide a solid indication for a concurrent ligament stabilization procedure. This study is the first to present the postoperative results after arthrolysis with stabilization of the posttraumatic, stiff and unstable elbow. However, the results are heterogenic with 25% requiring revision arthrolysis. Therefore, the stiff but unstable elbow remains a complex clinical presentation in need of further investigations. LEVEL OF EVIDENCE IV.
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Affiliation(s)
- Stephanie Geyer
- Department for Orthopedic Sports Medicine, Klinikum rechts der Isar, Technical University Munich, Ismaningerstr. 22, 81675, Munich, Germany.
| | - Jesse Seilern Und Aspang
- Department for Orthopedic Sports Medicine, Klinikum rechts der Isar, Technical University Munich, Ismaningerstr. 22, 81675, Munich, Germany
| | - Michael Geyer
- Department for Orthopedics, St. Vinzenz Klinik, Kirchenweg 15, 87459, Pfronten, Germany
| | - Christian Schoch
- Department for Orthopedics, St. Vinzenz Klinik, Kirchenweg 15, 87459, Pfronten, Germany
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15
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Abstract
The elbow is the second most commonly dislocated major joint in adults with estimated incidence of 5 dislocations per 100,000 persons per year. A comprehensive understanding of elbow anatomy and biomechanics is essential to optimize rehabilitation of elbow injuries. This allows for implementation of a systematic therapy program that encourages early mobilization within a safe arc of motion while maintaining joint stability. To optimize outcomes, close communication between surgeon and therapist is necessary to allow for implementation of an individualized rehabilitation program. This article reviews key concepts that enable the clinician to apply an evidence-informed approach when managing elbow instability.
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Affiliation(s)
- Joey G Pipicelli
- Roth
- McFarlane Hand & Upper Limb Centre, 268 Grosvenor Street, London, Ontario N6A 4V2, Canada; Division of Hand Therapy, St. Joseph's Health Care, London, Ontario, Canada
| | - Graham J W King
- Roth
- McFarlane Hand & Upper Limb Centre, 268 Grosvenor Street, London, Ontario N6A 4V2, Canada; Division of Orthopaedics, Western University, St. Joseph's Health Care, London, Ontario, Canada.
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A Practical Method for Obtaining True Lateral Elbow X-rays in a Paediatric Age Group: Lateral Elbow X-ray in the Standing Salute Position. Indian J Orthop 2020; 55:125-129. [PMID: 33569106 PMCID: PMC7851228 DOI: 10.1007/s43465-020-00238-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/20/2020] [Accepted: 08/14/2020] [Indexed: 02/04/2023]
Abstract
INTRODUCTION Paediatric elbow fractures constitute 10% of all paediatric fractures. Radiological interpretation of the immature elbow is difficult due to its cartilaginous structure. We aimed to describe an X-ray technique in paediatric patients to obtain true lateral elbow X-rays and to prevent the repeat X-ray shots. MATERIALS AND METHODS Radiographs of 39 children, with a mean age of 48.17 months (range; 7-84 months), with elbow trauma were included. All elbow lateral radiographs were taken in the 90º flexion position. In the first group, radiographs were taken using the standard technique(lateral radiographs in shoulder internal rotation). In the second group, lateral radiographs of the elbow were taken while the patient was standing and the forearm was elevated passively with 90° shoulder abduction and 90° elbow flexion (standing salute position). Three criteria were examined from the graphs to determine the true lateral elbow graphy. RESULTS In group 1 (n = 20) and group 2 (n = 19), lateral elbow radiographs were evaluated. No statistically significant differences were found between the groups, in terms of mean age and distal humeral fractures. In group 2; the presence of humeroulnar joint space, partial coronoid superposition of the radius head and presence of the hourglass formation were significantly higher. DISCUSSION It is clear that radiographs taken in appropriate positions decreases diagnostic errors. In our study, the ratio of correct lateral radiographs was significantly higher in the radiograph group in the standing salute position, suggesting this method was safe for accurate lateral radiographs, in accordance with our hypothesis.
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Moon JG, Kim JH, Jung YJ, Lim MJ, Lee HD. Relationship between the tilt angle of bipolar radial head prostheses and radiological radiocapitellar instability. ACTA ORTHOPAEDICA ET TRAUMATOLOGICA TURCICA 2020; 54:372-377. [PMID: 32812873 DOI: 10.5152/j.aott.2020.19138] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
OBJECTIVE This study aimed to radiologically assess the relationship between the tilt angle of the bipolar radial head prostheses and radiocapitellar instability. METHODS In this radiological study, 28 consecutive patients (13 females and 15 males: mean age=47 years and age range=23-77 years) who underwent cemented bipolar radial head arthroplasty (Judet CRF II) because of comminuted radial head fracture with elbow instability were retrospectively reviewed. RESULTS There was excellent intra- and interobserver reliability for the measurements of the tilt angle and the radiocapitellar distance. ICC for interobserver reliability of the tilt angle was 0.93, and ICC for intraobserver reliability for the 2 observers was 0.96 and 0.97, respectively. ICC for interobserver reliability of the radiocapitellar distance was 0.87, and ICC for intraobserver reliability for the 2 observers was 0.91 and 0.93, respectively. The mean tilt angle was 17.6° (range=1°-35°), and the mean radiocapitellar distance was 8 mm (range=1-17 mm). Pearson's correlation revealed a strong significant positive correlation between the tilt angle and the radiocapitellar distance (r=0.77 and p<0.001). CONCLUSION Evidence from this study has demonstrated a strong positive correlation between the tilt angle of bipolar radial head prostheses and radiocapitellar instability. The tilt angle can be used as an indicator of radiocapitellar joint instability following bipolar radial head prostheses. LEVEL OF EVIDENCE Level IV, Diagnostic study.
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Affiliation(s)
- Jun-Gyu Moon
- Department of Orthopedic Surgery, Korea University Guro Hospital, Seoul, Korea
| | - Jung-Hoon Kim
- Department of Orthopedic Surgery, Korea University Guro Hospital, Seoul, Korea
| | - Young-Jin Jung
- Department of Orthopedic Surgery, Korea University Guro Hospital, Seoul, Korea
| | - Moo-Joon Lim
- Department of Orthopedic Surgery, Korea University Guro Hospital, Seoul, Korea
| | - Hee-Dong Lee
- Department of Orthopedic Surgery, Korea University Guro Hospital, Seoul, Korea
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18
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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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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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20
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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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21
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Badre A, Axford DT, Banayan S, Johnson JA, King GJW. Role of the anconeus in the stability of a lateral ligament and common extensor origin-deficient elbow: an in vitro biomechanical study. J Shoulder Elbow Surg 2019; 28:974-981. [PMID: 30723030 DOI: 10.1016/j.jse.2018.11.040] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/23/2018] [Revised: 10/31/2018] [Accepted: 11/09/2018] [Indexed: 02/01/2023]
Abstract
BACKGROUND The role of the anconeus in elbow stability has been a long-standing debate. Anatomic and electromyographic studies have suggested a potential role as a stabilizer. However, to our knowledge, no clinical or biomechanical studies have investigated its role in improving the stability of a combined lateral collateral ligament and common extensor origin (LCL + CEO)-deficient elbow. METHODS Seven cadaveric upper extremities were mounted in an elbow motion simulator in the varus position. An injured model was created by sectioning of the CEO and the LCL. The anconeus tendon and its aponeurosis were sutured in a Krackow fashion and tensioned to 10 N and 20 N using a transosseous tunnel. Varus-valgus angles and ulnohumeral rotations were recorded using an electromagnetic tracking system during simulated active elbow flexion with the forearm pronated and supinated. RESULTS During active motion, the injured model resulted in a significant increase in varus angulation (P = .0001 for pronation; P = .001 for supination) and external rotation (P = .001 for pronation; P = .003 for supination) of the ulnohumeral articulation compared with the intact state. Tensioning of the anconeus significantly decreased the varus angulation (P = .006 for 10 N pronation; P = .0001 for 20 N pronation; P = .0001 for 10 N supination; P = .0001 for 20 N supination) and external rotation angle (P = .008 for 10 N pronation; P = .0001 for 20 N pronation; P = .0001 for 10 N supination; P = .0001 for 20 N supination) of the injured elbow. CONCLUSIONS In the highly unstable varus elbow orientation, anconeus tensioning restores the in vitro stability of a combined LCL + CEO-deficient elbow during simulated active motion with the forearm in both pronation and supination. These results may have several clinical implications in managing symptomatic lateral elbow instability.
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Affiliation(s)
- Armin Badre
- Roth-McFarlane Hand & Upper Limb Centre, St. Joseph's Health Care, London, ON, Canada; Division of Orthopaedic Surgery, Department of Surgery, Western University, London, ON, Canada.
| | - David T Axford
- Roth-McFarlane Hand & Upper Limb Centre, St. Joseph's Health Care, London, ON, Canada; Department of Mechanical and Materials Engineering, Western University, London, ON, Canada
| | - Sara Banayan
- Roth-McFarlane Hand & Upper Limb Centre, St. Joseph's Health Care, London, ON, Canada; Department of Mechanical and Materials Engineering, Western University, London, ON, Canada
| | - James A Johnson
- Roth-McFarlane Hand & Upper Limb Centre, St. Joseph's Health Care, London, ON, Canada; Department of Mechanical and Materials Engineering, Western University, London, ON, Canada
| | - Graham J W King
- Roth-McFarlane Hand & Upper Limb Centre, St. Joseph's Health Care, London, ON, Canada; Division of Orthopaedic Surgery, Department of Surgery, Western University, London, ON, Canada
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22
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Kani KK, Chew FS. Terrible triad injuries of the elbow. Emerg Radiol 2019; 26:341-347. [PMID: 30690677 DOI: 10.1007/s10140-019-01676-1] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2018] [Accepted: 01/18/2019] [Indexed: 12/14/2022]
Abstract
Terrible triad injury of the elbow is a complex injury that is classically defined as elbow dislocation along with fractures of the coronoid process of the ulna and the radial head. The injury is usually associated with typical soft-tissue disruptions (with common involvement of the lateral collateral ligament complex, elbow joint capsule, as well as the common extensor and flexor-pronator tendons) that are best understood in the context of injury mechanism as well as the role and relevance of the various elbow stabilizers. The goals of this article are to review the pertinent anatomy, mechanism of injury, classification and imaging of terrible triad injuries of the elbow with brief descriptions of treatment, and complications of this complex injury.
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Affiliation(s)
- Kimia Khalatbari Kani
- Department of Diagnostic Radiology and Nuclear Medicine, University of Maryland School of Medicine, Baltimore, MD, USA.
| | - Felix S Chew
- Department of Radiology, University of Washington, 4245 Roosevelt Way NE, Box 354755, Seattle, WA, 98105, USA
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Schmidt-Horlohé K, Klug A, Weißenberger M, Wincheringer DN, Hoffmann R. [Acute and chronic instability of the elbow joint]. DER ORTHOPADE 2018; 47:695-708. [PMID: 30022303 DOI: 10.1007/s00132-018-3597-5] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
Elbow dislocations are frequent and present with a broad spectrum of subsequent ligamentous and soft tissue injuries. Beside clinical examination, fluoroscopy, ultrasound and magnetic resonance imaging (MRI) can specify the extent of the injuries and provide a foundation for decision-making between conservative and operative treatment. This article highlights the basic underlying biomechanics and anatomy, discusses the trauma mechanisms and presents clinical and imaging diagnostic procedures. Treatment algorithms for conservative and surgical treatment are presented in detail. In addition to acute instability, chronic instability of the elbow has recently been recognized as the cause of a large variety of symptoms, often resulting in significant functional impairment. The most commonly used techniques for reconstruction of the medial and lateral collateral ligaments and the rehabilitation protocols are described in detail.
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Affiliation(s)
- Kay Schmidt-Horlohé
- Zentrum für Ellenbogenchirurgie, Orthopaedicum Wiesbaden - Praxis für Orthopädie, Unfallchirurgie und Sportmedizin, Friedrichstr. 29, 65185, Wiesbaden, Deutschland.
| | - Alexander Klug
- Zentrum für Unfallchirurgie und orthopädische Chirurgie, Berufsgenossenschaftliche Unfallklinik Frankfurt am Main, Friedberger Landstr. 430, 60389, Frankfurt am Main, Deutschland
| | - Manuel Weißenberger
- Orthopädische Klinik König-Ludwig-Haus, Lehrstuhl für Orthopädie, Julius-Maximilians-Universität Würzburg, Brettreichstr. 11, 97074, Würzburg, Deutschland
| | - Den Nis Wincheringer
- Zentrum für Unfallchirurgie und orthopädische Chirurgie, Berufsgenossenschaftliche Unfallklinik Frankfurt am Main, Friedberger Landstr. 430, 60389, Frankfurt am Main, Deutschland
| | - Reinhard Hoffmann
- Zentrum für Unfallchirurgie und orthopädische Chirurgie, Berufsgenossenschaftliche Unfallklinik Frankfurt am Main, Friedberger Landstr. 430, 60389, Frankfurt am Main, Deutschland
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25
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Gottlieb M, Schiebout J. Elbow Dislocations in the Emergency Department: A Review of Reduction Techniques. J Emerg Med 2018; 54:849-854. [DOI: 10.1016/j.jemermed.2018.02.011] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2017] [Revised: 02/04/2018] [Accepted: 02/07/2018] [Indexed: 01/13/2023]
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Instabilität nach operativer und konservativer Versorgung von isolierten Mason-II-Frakturen. Unfallchirurg 2018; 122:219-224. [DOI: 10.1007/s00113-018-0504-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/17/2022]
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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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28
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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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Schnetzke M, Aytac S, Keil H, Deuss M, Studier-Fischer S, Grützner PA, Guehring T. Unstable simple elbow dislocations: medium-term results after non-surgical and surgical treatment. Knee Surg Sports Traumatol Arthrosc 2017; 25:2271-2279. [PMID: 27043345 DOI: 10.1007/s00167-016-4100-7] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/08/2015] [Accepted: 03/22/2016] [Indexed: 10/22/2022]
Abstract
PURPOSE Determination of the appropriate treatment of unstable simple elbow dislocations is difficult and a topic of ongoing discussion. The aim of this study was to analyse the outcome and complications after surgery and conservative treatment, with special focus on post-traumatic joint laxity. METHODS In this retrospective study, 118 consecutive patients with simple elbow dislocations underwent stability testing by fluoroscopy after joint reduction and were assigned to groups 1 (slight), 2 (moderate) or 3 (gross) depending on post-traumatic joint laxity. All patients of group 1 underwent conservative treatment, and of group 3 primary ligament repair. In patients with moderate elbow laxity, the treatment was decided individually. All patients underwent a similar functional rehabilitation programme during treatment. Clinical outcome was determined after an average of 3.4 ± 1.5 years using the Mayo Elbow Performance Score (MEPS), and treatment-associated complications and revisions were recorded. RESULTS Forty-nine patients (41.5 %) were assigned to group 1, 41 patients (34.7 %) to group 2 and 28 patients (23.7 %) to group 3. In group 2, 22 patients underwent ligament repair, while 19 patients were treated conservatively. On average, an excellent MEPS was achieved in group 1 after conservative treatment (MEPS 95.8 ± 9.0), similar to results after ligament repair of grossly unstable elbows in group 3 (91.6 ± 11.7). Interestingly, in group 2 conservative treatment was associated with a slightly lower MEPS (90.0 vs. 95.7), and significantly fewer patients achieved an excellent MEPS (81.8 vs. 52.6 %, p = 0.045). Similarly, conservative treatment in group 2 was associated with a fivefold to sixfold risk of complications (p = 0.032) and revision surgery (p = 0.023). CONCLUSIONS This study supports the notion that patients with slight elbow laxity can be treated non-operatively, while primary surgical treatment should be performed in patients with moderate and gross laxity to avoid post-traumatic sequelae and decrease revision rates. LEVEL OF EVIDENCE Retrospective Cohort Study, Level III.
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Affiliation(s)
- Marc Schnetzke
- Department of Trauma and Orthopedic Surgery, BG Trauma Center Ludwigshafen at the University of Heidelberg, Ludwig-Guttmann-Strasse 13, 67071, Ludwigshafen on the Rhine, Germany
| | - Sara Aytac
- Department of Trauma and Orthopedic Surgery, BG Trauma Center Ludwigshafen at the University of Heidelberg, Ludwig-Guttmann-Strasse 13, 67071, Ludwigshafen on the Rhine, Germany
| | - Holger Keil
- Department of Trauma and Orthopedic Surgery, BG Trauma Center Ludwigshafen at the University of Heidelberg, Ludwig-Guttmann-Strasse 13, 67071, Ludwigshafen on the Rhine, Germany
| | - Moritz Deuss
- Department of Trauma and Orthopedic Surgery, BG Trauma Center Ludwigshafen at the University of Heidelberg, Ludwig-Guttmann-Strasse 13, 67071, Ludwigshafen on the Rhine, Germany
| | - Stefan Studier-Fischer
- Department of Trauma and Orthopedic Surgery, BG Trauma Center Ludwigshafen at the University of Heidelberg, Ludwig-Guttmann-Strasse 13, 67071, Ludwigshafen on the Rhine, Germany
| | - Paul-Alfred Grützner
- Department of Trauma and Orthopedic Surgery, BG Trauma Center Ludwigshafen at the University of Heidelberg, Ludwig-Guttmann-Strasse 13, 67071, Ludwigshafen on the Rhine, Germany
| | - Thorsten Guehring
- Department of Trauma and Orthopedic Surgery, BG Trauma Center Ludwigshafen at the University of Heidelberg, Ludwig-Guttmann-Strasse 13, 67071, Ludwigshafen on the Rhine, Germany.
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van Riet RP. Assessment and decision making in the unstable elbow: management of simple dislocations. Shoulder Elbow 2017; 9:136-143. [PMID: 28405226 PMCID: PMC5384540 DOI: 10.1177/1758573216686533] [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: 10/30/2016] [Accepted: 11/30/2016] [Indexed: 11/16/2022]
Abstract
Simple elbow dislocations are usually treated conservatively. Radiographs are negative in simple dislocations. Results are generally good, although a small percentage of patients may develop chronic instability. Ligamentous repair can be indicated in high demand patients or if the elbow remains unstable following a closed reduction. Chronic instability is classified per their direction. Surgery is often indicated in the chronically unstable elbow.
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Affiliation(s)
- Roger P. van Riet
- Monica Hospital, Deurne, Antwerp, Belgium,University of Antwerp, Belgium,Roger P. van Riet, Monica Hospital, Stevenslei 20, Deurne, Antwerp, 2100 Belgium.
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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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Kim JW, Lee SH, Kim SJ, Park JS. Surgical Technique for Arthroscopic Lateral Collateral Ligament Repair. JBJS Essent Surg Tech 2016; 6:e33. [PMID: 30233926 DOI: 10.2106/jbjs.st.16.00030] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
Introduction Arthroscopic repair of the lateral collateral ligament (LCL) complex in patients who have posterolateral rotatory instability after an unstable elbow dislocation, with or without an intra-articular fracture, is an alternative treatment for restoring stability of the elbow and obtaining successful clinical and radiographic results. Indications & Contraindications Step 1 Computed Tomography CT Magnetic Resonance Imaging MRI and Preoperative Planning Obtain radiographs and CT and MRI scans to make an accurate analysis of the fracture patterns and develop an understanding of soft-tissue comorbidities. Step 2 Position the Patient and Place the Portals Place the patient in the lateral decubitus position and create proximal anteromedial, proximal anterolateral, anterolateral, and radial head portals as working portals and a posterior soft-spot portal as a viewing portal for the repair of the LCL complex. Step 3 Diagnostic Arthroscopy Identify concomitant radial head and coronoid fractures, and confirm the LCL-complex tear intraoperatively. Step 4 Management of Concomitant Injuries Treat intra-articular fractures arthroscopically before the LCL-complex repair. Step 5 Arthroscopic LCL-Complex Repair Video 1 After soft-tissue debridement using the soft-spot portal as a viewing portal and the proximal anterolateral portal as a working portal, decorticate the footprint of the humeral attachment of the LCL complex with use of a shaver or burr and then make a modified Mason-Allen stitch using a needle, fixing the suture with a knotless anchor, to achieve a stable elbow joint. Step 6 Postoperative Management After postoperative immobilization of the elbow for 2 to 3 days, instruct the patient to perform passive exercises, returning to a full range of motion at 4 to 6 weeks after surgery, and typically returning to full activity at 3 months after the operation. Results To date, arthroscopic LCL-complex repair has produced excellent results, with all 13 patients in our original study reporting complete resolution of the elbow instability and demonstrating a negative result on the lateral pivot-shift test15. Pitfalls & Challenges
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Affiliation(s)
- Jeong Woo Kim
- Department of Orthopedic Surgery, Wonkwang University Hospital, Iksan, South Korea
| | - Sung Hyun Lee
- Department of Orthopedic Surgery, Wonkwang University Hospital, Iksan, South Korea
| | - Se Jin Kim
- Department of Orthopedic Surgery, Wonkwang University Hospital, Iksan, South Korea
| | - Jin Sung Park
- Department of Orthopedic Surgery, Wonkwang University Hospital, Iksan, South Korea.,Department of Orthopedic Surgery, Presbyterian Medical Center, Jeonju, South Korea
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Kim JW, Yi Y, Kim TK, Kang HJ, Kim JY, Lee JM, Bae KH, Joo MS. Arthroscopic Lateral Collateral Ligament Repair. J Bone Joint Surg Am 2016; 98:1268-76. [PMID: 27489317 DOI: 10.2106/jbjs.15.00811] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND Lateral ulnar collateral ligament injury following unstable elbow dislocation can induce posterolateral rotatory instability that requires surgery. The aim of this study was to determine the effectiveness of arthroscopic repair of the lateral collateral ligament (LCL) complex in an unstable elbow joint. METHODS The study group consisted of 13 patients who experienced posterolateral rotatory instability after an unstable elbow dislocation with an injury to the lateral ulnar collateral ligament. The diagnosis was confirmed with computed tomography (CT), magnetic resonance imaging (MRI), and physical examination. The patients underwent arthroscopically assisted surgery between May 2011 and January 2013 and were followed for a minimum of 18 months postoperatively. Coronoid and/or radial head fractures combined with the ligament injury were treated through an arthroscopic technique. Range of motion, pain, outcomes according to the Mayo Elbow Performance Score (MEPS) and Nestor grading system, and surgical complications were evaluated. CT and MRI were performed at 3 months postoperatively, and isometric muscle strength was measured at the time of final follow-up. RESULTS At the time of final follow-up, at a minimum of 18 months, all 13 patients reported complete resolution of the instability and average (and standard deviation) extension of 3° ± 1°, flexion of 138° ± 6°, supination of 88° ± 5°, and pronation of 87° ± 6. The mean MEPS was 92 points and, according to this validated outcome score, the results were rated as excellent in 12 patients and good in 1 patient. According to the Nestor grading system, the results were rated as excellent in 11 patients and good in 2. Complete healing was seen on the 3-month follow-up MRI in 12 patients; however, 1 patient had mild widening of the radiocapitellar joint space with incomplete healing but no instability symptoms. All patients demonstrated normal strength on elbow flexion, extension, pronation, and supination at the final follow-up visit. CONCLUSIONS Arthroscopic repair of the LCL complex in patients with posterolateral rotatory instability after an unstable elbow dislocation, with or without an intra-articular fracture, is an alternative treatment option for restoring elbow stability and achieving satisfactory clinical and radiographic results. LEVEL OF EVIDENCE Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.
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Affiliation(s)
- Jeong Woo Kim
- Department of Orthopedic Surgery, Wonkwang University Hospital, Iksan, South Korea
| | - Young Yi
- Department of Orthopaedic Surgery, Seoul Paik Hospital, Seoul, South Korea
| | - Tae Kyun Kim
- Department of Orthopedic Surgery, Wonkwang University Hospital, Iksan, South Korea
| | - Hong Je Kang
- Department of Orthopedic Surgery, Wonkwang University Hospital, Iksan, South Korea
| | - Jong Yun Kim
- Department of Orthopedic Surgery, Presbyterian Medical Center, Jeonju, South Korea
| | - Jong Myoung Lee
- Department of Orthopedic Surgery, Presbyterian Medical Center, Jeonju, South Korea
| | - Kyu Hwan Bae
- Department of Orthopedic Surgery, Wonkwang University Hospital, Iksan, South Korea
| | - Min Su Joo
- Department of Orthopedic Surgery, Wonkwang University Hospital, Iksan, South Korea
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Abutalib RA, Khoshhal KI. Multiple Concomitant Injuries in One Upper Extremity: A Case Report. AMERICAN JOURNAL OF CASE REPORTS 2016; 17:6-11. [PMID: 26732673 PMCID: PMC4708097 DOI: 10.12659/ajcr.894984] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
Patient: Male, 36 Final Diagnosis: Multiple concomitant right upper limb fractures Symptoms: — Medication: — Clinical Procedure: Open reduction and internal fixation of right upper limb fractures Specialty: Orthopedics and Traumatology
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Affiliation(s)
- Raid A Abutalib
- Department of Orthopedic Surgery, King Fahad Hospital, Almadinah Almunawwarah, Saudi Arabia
| | - Khalid I Khoshhal
- Department of Orthopedic Surgery, College of Medicine, Taibah University, Almadinah Almunawwarah, Saudi Arabia
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Abstract
Simple elbow dislocation refers to those elbow dislocations that do not involve an osseous injury. A complex elbow dislocation refers to an elbow that has dislocated with an osseous injury. Most simple elbow dislocations are treated nonoperatively. Understanding the importance of the soft tissue injury following a simple elbow dislocation is a key to being successful with treatment.
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Affiliation(s)
- April Armstrong
- Department of Orthopedics, Bone and Joint Institute, Penn State Hershey Medical Center, 30 Hope Drive, Hershey, PA 17033, USA.
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Schnetzke M, Aytac S, Studier-Fischer S, Grützner PA, Guehring T. Initial joint stability affects the outcome after conservative treatment of simple elbow dislocations: a retrospective study. J Orthop Surg Res 2015; 10:128. [PMID: 26289111 PMCID: PMC4545864 DOI: 10.1186/s13018-015-0273-x] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/14/2015] [Accepted: 08/09/2015] [Indexed: 01/28/2023] Open
Abstract
BACKGROUND Conservative treatment of simple elbow dislocations can lead to complications such as persisting pain and restricted joint mobility. The current aim was to identify patients with deteriorated outcome after conservative treatment and to investigate a possible association with initial joint (in)stability. METHODS Sixty-eight patients (mean age 37.1 ± 17.2 years) with simple elbow dislocations received conservative treatment. After closed reduction, joint stability was tested by varus and valgus stress under fluoroscopy. According to the findings under fluoroscopy, three different groups of instability could be identified: (1) slight instability (joint angulation <10°; n = 49), (2) moderate instability (angulation ≥10°; n = 19) and (3) gross instability. Patients with gross instability (re-dislocation under stability testing) were treated with primary surgical ligament repair and therefore excluded from this study. Additionally, MRIs and radiographs were analysed regarding warning signs of instability such as the drop sign and joint incongruence. Main outcome parameters were the Mayo Elbow Performance Score (MEPS), range of motion (ROM), complications and revision rates. RESULTS After 40.7 ± 20.4 months, the overall MEPS was excellent (94.2 ± 11.3) with a trend of slightly worse clinical results in group 2 (95.8 ± 9.0 vs. 90.0 ± 15.2 points; p = 0.154). In group 1, significantly more patients achieved an excellent result regarding the MEPS scoring system (77.6 vs. 52.6 %; p = 0.043) and elbow extension was significantly worse in group 2 (5.3 ± 9.9° vs. 1.4 ± 3.0°; p = 0.015). Seven treatment complications occurred in group 2 (36.8 %) compared with two in group 1 (4.1 %, p < 0.0001). Six patients (8.8 %) needed secondary surgery with an 8.4-fold higher risk for revision surgery in group 2 (p = 0.007). The presence of a positive drop sign or joint incongruence led to higher odds ratio (OR) for complications (OR = 15.9) and revision surgery (OR = 10.3). CONCLUSIONS This study demonstrates that patients with moderate joint instability after simple elbow dislocation have a significantly worse clinical outcome, more complications and a higher need for secondary revision surgery following conservative treatment compared to patients with slight elbow instability.
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Affiliation(s)
- Marc Schnetzke
- Berufsgenossenschaftliche Unfallklinik Ludwigshafen, Abteilung für Unfallchirurgie und Orthopädie, Ludwig Guttmann Straße 13, 67071, Ludwigshafen am Rhein, Germany.
| | - Sara Aytac
- Berufsgenossenschaftliche Unfallklinik Ludwigshafen, Abteilung für Unfallchirurgie und Orthopädie, Ludwig Guttmann Straße 13, 67071, Ludwigshafen am Rhein, Germany.
| | - Stefan Studier-Fischer
- Berufsgenossenschaftliche Unfallklinik Ludwigshafen, Abteilung für Unfallchirurgie und Orthopädie, Ludwig Guttmann Straße 13, 67071, Ludwigshafen am Rhein, Germany.
| | - Paul-Alfred Grützner
- Berufsgenossenschaftliche Unfallklinik Ludwigshafen, Abteilung für Unfallchirurgie und Orthopädie, Ludwig Guttmann Straße 13, 67071, Ludwigshafen am Rhein, Germany.
| | - Thorsten Guehring
- Berufsgenossenschaftliche Unfallklinik Ludwigshafen, Abteilung für Unfallchirurgie und Orthopädie, Ludwig Guttmann Straße 13, 67071, Ludwigshafen am Rhein, Germany.
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Panteli M, Pountos I, Kanakaris NK, Tosounidis TH, Giannoudis PV. Cost analysis and outcomes of simple elbow dislocations. World J Orthop 2015; 6:513-520. [PMID: 26301180 PMCID: PMC4539474 DOI: 10.5312/wjo.v6.i7.513] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/02/2015] [Revised: 04/28/2015] [Accepted: 06/02/2015] [Indexed: 02/06/2023] Open
Abstract
AIM: To evaluate the management, clinical outcome and cost implications of three different treatment regimes for simple elbow dislocations.
METHODS: Following institutional board approval, we performed a retrospective review of all consecutive patients treated for simple elbow dislocations in a Level I trauma centre between January 2008 and December 2010. Based on the length of elbow immobilisation (LOI), patients were divided in three groups (Group I, < 2 wk; Group II, 2-3 wk; and Group III, > 3 wk). Outcome was considered satisfactory when a patient could achieve a pain-free range of motion ≥ 100° (from 30° to 130°). The associated direct medical costs for the treatment of each patient were then calculated and analysed.
RESULTS: We identified 80 patients who met the inclusion criteria. Due to loss to follow up, 13 patients were excluded from further analysis, leaving 67 patients for the final analysis. The mean LOI was 14 d (median 15 d; range 3-43 d) with a mean duration of hospital engagement of 67 d (median 57 d; range 10-351 d). Group III (prolonged immobilisation) had a statistically significant worse outcome in comparison to Group I and II (P = 0.04 and P = 0.01 respectively); however, there was no significant difference in the outcome between groups I and II (P = 0.30). No statistically significant difference in the direct medical costs between the groups was identified.
CONCLUSION: The length of elbow immobilization doesn’t influence the medical cost; however immobilisation longer than three weeks is associated with persistent stiffness and a less satisfactory clinical outcome.
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Iordens GIT, Van Lieshout EMM, Schep NWL, De Haan J, Tuinebreijer WE, Eygendaal D, Van Beeck E, Patka P, Verhofstad MHJ, Den Hartog D. Early mobilisation versus plaster immobilisation of simple elbow dislocations: results of the FuncSiE multicentre randomised clinical trial. Br J Sports Med 2015; 51:531-538. [PMID: 26175020 DOI: 10.1136/bjsports-2015-094704] [Citation(s) in RCA: 51] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/17/2015] [Indexed: 11/04/2022]
Abstract
BACKGROUND/AIM To compare outcome of early mobilisation and plaster immobilisation in patients with a simple elbow dislocation. We hypothesised that early mobilisation would result in earlier functional recovery. METHODS From August 2009 to September 2012, 100 adult patients with a simple elbow dislocation were enrolled in this multicentre randomised controlled trial. Patients were randomised to early mobilisation (n=48) or 3 weeks plaster immobilisation (n=52). Primary outcome measure was the Quick Disabilities of the Arm, Shoulder, and Hand (Quick-DASH) score. Secondary outcomes were the Oxford Elbow Score, Mayo Elbow Performance Index, pain, range of motion, complications and activity resumption. Patients were followed for 1 year. RESULTS Quick-DASH scores at 1 year were 4.0 (95% CI 0.9 to 7.1) points in the early mobilisation group versus 4.2 (95% CI 1.2 to 7.2) in the plaster immobilisation group. At 6 weeks, early mobilised patients reported less disability (Quick-DASH 12 (95% CI 9 to 15) points vs 19 (95% CI 16 to 22); p<0.05) and had a larger arc of flexion and extension (121° (95% CI 115° to 127°) vs 102° (95% CI 96° to 108°); p<0.05). Patients returned to work sooner after early mobilisation (10 vs 18 days; p=0.020). Complications occurred in 12 patients; this was unrelated to treatment. No recurrent dislocations occurred. CONCLUSIONS Early active mobilisation is a safe and effective treatment for simple elbow dislocations. Patients recovered faster and returned to work earlier without increasing the complication rate. No evidence was found supporting treatment benefit at 1 year. TRIAL REGISTRATION NUMBER NTR 2025.
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Affiliation(s)
- Gijs I T Iordens
- Trauma Research Unit, Department of Surgery, Erasmus MC, University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Esther M M Van Lieshout
- Trauma Research Unit, Department of Surgery, Erasmus MC, University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Niels W L Schep
- Trauma Unit, Department of Surgery, Academic Medical Center, Amsterdam, The Netherlands
| | - Jeroen De Haan
- Department of Surgery, Westfriesgasthuis, Hoorn, The Netherlands
| | - Wim E Tuinebreijer
- Trauma Research Unit, Department of Surgery, Erasmus MC, University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Denise Eygendaal
- Department of Orthopaedic Surgery, Upper Limb Unit, Amphia Hospital, Breda, The Netherlands
| | - Ed Van Beeck
- Department of Public Health, Erasmus MC, University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Peter Patka
- Department of Emergency Medicine, Erasmus MC, University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Michael H J Verhofstad
- Trauma Research Unit, Department of Surgery, Erasmus MC, University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Dennis Den Hartog
- Trauma Research Unit, Department of Surgery, Erasmus MC, University Medical Center Rotterdam, Rotterdam, The Netherlands
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Rhyou IH, Lim KS, Kim KC, Lee JH, Ahn KB, Moon SC. Drop sign of the elbow joint after surgical stabilization of an unstable simple posterolateral dislocation: natural course and contributing factors. J Shoulder Elbow Surg 2015; 24:1081-9. [PMID: 25825136 DOI: 10.1016/j.jse.2015.01.018] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/31/2014] [Revised: 01/22/2015] [Accepted: 01/31/2015] [Indexed: 02/01/2023]
Abstract
BACKGROUND We performed this study to investigate the natural course and factors affecting the incidence of drop sign immediately after stabilization of an unstable posterolateral (PL) dislocation of the elbow. METHODS Twenty-three patients who underwent a stabilization procedure for persistent instability after closed reduction of PL dislocation of the elbow were enrolled. The natural course was evaluated with simple radiographs taken at regular intervals after the operation. Primary repair of medial or lateral ligaments and overlying muscles, degree of adjacent muscle injury, and type of anesthesia were analyzed to determine their relationship to postoperative drop sign. Functional outcomes were evaluated by the Disabilities of the Arm, Shoulder, and Hand score and Mayo Elbow Performance Score. RESULTS A postoperative drop sign was observed in 4 cases (17%) and resolved within 1 week after the operation. There was no significant relationship between preoperative factors and drop sign except method of anesthesia. All drop signs were found in patients who had received a regional block (P = .006). There were no statistically significant differences in functional outcome between the drop sign group and the non-drop sign group. CONCLUSIONS A postoperative drop sign was observed in 17% of patients who underwent a surgical stabilization procedure for an unstable PL elbow dislocation; this sign spontaneously disappeared in all 4 patients within 1 week of the operation. The drop sign was possibly caused by delayed return of muscle tone. A postoperative drop sign did not indicate the need to perform an additional stabilization procedure, nor did it affect postoperative functional outcome.
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Affiliation(s)
- In Hyeok Rhyou
- Upper Extremity and Microsurgery Center, Semyeong Christianity Hospital, Pohang, South Korea.
| | - Kyung Sup Lim
- Upper Extremity and Microsurgery Center, Semyeong Christianity Hospital, Pohang, South Korea
| | - Kyung Chul Kim
- Upper Extremity and Microsurgery Center, Semyeong Christianity Hospital, Pohang, South Korea
| | - Ji-Ho Lee
- Upper Extremity and Microsurgery Center, Semyeong Christianity Hospital, Pohang, South Korea
| | - Ki-Baek Ahn
- Upper Extremity and Microsurgery Center, Semyeong Christianity Hospital, Pohang, South Korea
| | - Seong Cheol Moon
- Upper Extremity and Microsurgery Center, Semyeong Christianity Hospital, Pohang, South Korea
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Watters TS, Garrigues GE, Ring D, Ruch DS. Fixation versus replacement of radial head in terrible triad: is there a difference in elbow stability and prognosis? Clin Orthop Relat Res 2014; 472:2128-35. [PMID: 24136807 PMCID: PMC4048405 DOI: 10.1007/s11999-013-3331-x] [Citation(s) in RCA: 80] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND Surgical treatment for terrible triad injuries of the elbow (defined as elbow dislocations with concomitant fractures of the radial head and coronoid) remains a challenging clinical problem. Specifically, the question of whether to repair or replace the radial head remains controversial. QUESTIONS/PURPOSES We compared patients with terrible triad injuries of the elbow whose radial head fracture was treated with either internal fixation and internal fixation (ORIF) or radial head arthroplasty in terms of (1) clinical outcome measures (DASH and Broberg-Morrey scores, ROM), (2) elbow stability and radiographic signs of arthrosis, and (3) complications and reoperation rates. METHODS Retrospective review identified 39 patients with terrible triad injuries and minimum 18-month complete clinical and radiographic followup (mean, 24 months; range, 18-53 months). Patients were managed with a standard algorithm consisting of (1) repair (n = 9) or replacement (n = 30) of the radial head, (2) repair of the lateral ulnar collateral ligament, and (3) repair of the coronoid fracture. During the study period, the radial head generally was internally fixed when there were fewer than four articular fragments; otherwise, it was replaced. Evaluation included the DASH score, the Broberg-Morrey index, measurements of elbow stability and motion, and radiographic assessment for signs of arthrosis; chart review was performed for complications and reoperations. Complete followup was available on 87% (39 of 45 patients). RESULTS There were no differences between groups in terms of ROM or elbow scores. All patients who underwent radial head arthroplasty at the index procedure had a stable elbow at final followup whereas three of nine patients who underwent ORIF were unstable (p = 0.009). However, 11 patients who underwent arthroplasty demonstrated radiographic signs of arthrosis compared to none in the ORIF group (p = 0.04). Eleven patients (28%) underwent reoperation (seven arthroplasty, four ORIF) for various reasons. With the numbers available, there was no difference in reoperation rate between groups (p = 0.45). CONCLUSIONS For terrible triad injuries, radial head arthroplasty afforded the ability to obtain elbow stability with comparable overall outcomes when compared to ORIF. As these injuries commonly occur in younger patients, longer-term studies will be required to ascertain whether the apparent benefits of radial head arthroplasty are offset by late complications of arthroplasty, such as loosening. LEVEL OF EVIDENCE Level III, therapeutic study. See the Instructions for Authors for a complete description of levels of evidence.
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Affiliation(s)
- Tyler Steven Watters
- />Department of Orthopaedic Surgery, Duke University Medical Center, DUMC 3000, Durham, NC 27710 USA
| | - Grant E. Garrigues
- />Department of Orthopaedic Surgery, Duke University Medical Center, DUMC 3000, Durham, NC 27710 USA
| | - David Ring
- />Department of Orthopaedic Surgery, Massachusetts General Hospital, Boston, MA USA
| | - David S. Ruch
- />Department of Orthopaedic Surgery, Duke University Medical Center, DUMC 3000, Durham, NC 27710 USA
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Alolabi B, Gray A, Ferreira LM, Johnson JA, Athwal GS, King GJW. Rehabilitation of the medial- and lateral collateral ligament-deficient elbow: an in vitro biomechanical study. J Hand Ther 2013; 25:363-72; quiz 373. [PMID: 22959533 DOI: 10.1016/j.jht.2012.06.001] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/02/2011] [Revised: 05/23/2012] [Accepted: 06/03/2012] [Indexed: 02/03/2023]
Abstract
DESIGN In vitro biomechanical research using an elbow motion simulator. INTRODUCTION The optimal rehabilitation of elbow dislocations with medial collateral ligament (MCL) and lateral collateral ligament (LCL) injuries has not been defined. PURPOSE To determine a safe rehabilitation protocol for elbow dislocations with MCL and LCL injuries. METHODS Eight cadaveric elbows underwent simulated active and passive motions with the arm in multiple orientations. Varus-valgus angulation and internal-external rotation of the ulna relative to the humerus were quantified for the intact joint and with injured MCL and LCL. RESULTS Active motion with injured MCL and LCL in the horizontal and vertical orientations resulted in kinematics similar to the intact elbow, whereas passive motion resulted in significant kinematic alterations. Marked elbow instability was noted in the varus and valgus orientations using both active and passive motion. CONCLUSIONS Elbows with MCL and LCL injuries should be rehabilitated using active motion in the horizontal or vertical orientations. LEVEL OF EVIDENCE Basic science research.
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Affiliation(s)
- Bashar Alolabi
- Hand and Upper Limb Center, St. Joseph's Health Centre, London, Ontario, Canada.
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Schaeffeler C, Waldt S, Woertler K. Traumatic instability of the elbow - anatomy, pathomechanisms and presentation on imaging. Eur Radiol 2013; 23:2582-93. [DOI: 10.1007/s00330-013-2855-5] [Citation(s) in RCA: 38] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2013] [Revised: 02/27/2013] [Accepted: 03/10/2013] [Indexed: 11/28/2022]
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Sheehan SE, Dyer GS, Sodickson AD, Patel KI, Khurana B. Traumatic Elbow Injuries: What the Orthopedic Surgeon Wants to Know. Radiographics 2013; 33:869-88. [DOI: 10.1148/rg.333125176] [Citation(s) in RCA: 68] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
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Pipicelli JG, Chinchalkar SJ, Grewal R, King GJW. Therapeutic implications of the radiographic "drop sign" following elbow dislocation. J Hand Ther 2013; 25:346-53; quiz 354. [PMID: 22704479 DOI: 10.1016/j.jht.2012.03.003] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/01/2012] [Accepted: 03/10/2012] [Indexed: 02/03/2023]
Affiliation(s)
- Joey G Pipicelli
- Division of Hand Therapy, Hand and Upper Limb Centre, St. Joseph's Health Care, London, Ontario, Canada.
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Lee AT, Schrumpf MA, Choi D, Meyers KN, Patel R, Wright TM, Hotchkiss RN, Daluiski A. The influence of gravity on the unstable elbow. J Shoulder Elbow Surg 2013; 22:81-7. [PMID: 23237692 DOI: 10.1016/j.jse.2012.08.012] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/02/2012] [Revised: 07/06/2012] [Accepted: 08/16/2012] [Indexed: 02/01/2023]
Abstract
BACKGROUND Safely permitting early range of motion after a destabilizing injury to the elbow is believed to optimize return of function. However, the range-of-motion exercises must be balanced against the risk of re-dislocation or subluxation. The goal of this study was to describe the position of the upper limb that permitted the greatest motion while minimizing the risk of re-dislocation or subluxation. METHODS Seven cadaveric elbows were affixed with a 3-dimensional motion capture system. Ulnohumeral distraction was recorded at flexion angles from 10° to 90° for intact, approach only (sham procedure), and LCL-sectioned. Ulnohumeral separation was recorded in 3 distinct positions of the upper limb that are frequently used in a clinical setting: 1) trunk seated upright with arm at the side; 2) trunk seated upright with elbow in hinged-brace; and 3) trunk supine with shoulder flexed and internally rotated - "gravity-assisted overhead motion" protocol. RESULTS A significant ulnohumeral distraction difference was found between the supine and the upright protocols. Upon direct comparison, 104% more displacement occurred across the ulnohumeral joint in the upright LCL-sectioned condition compared to the supine LCL-sectioned condition (P = .001). The greatest ulnohumeral distraction occurred in the seated upright range of motion with a hinged elbow brace (range, 2.5-5.6 mm). CONCLUSION The overhead motion protocol is a safe protocol for unstable elbows. The supine position results in the least amount of ulnohumeral distraction across flexion angles from 10° to 90°. The upright protocols, especially with the hinged elbow brace, exhibited ulnohumeral distraction that may result in dislocation.
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Affiliation(s)
- Arthur T Lee
- Hand and Upper Extremity Surgery Department, Hospital for Special Surgery, New York, NY 10021, USA
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Yoon A, Athwal GS, Faber KJ, King GJW. Radial head fractures. J Hand Surg Am 2012; 37:2626-34. [PMID: 23174078 DOI: 10.1016/j.jhsa.2012.10.001] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/04/2012] [Accepted: 10/03/2012] [Indexed: 02/02/2023]
Abstract
Fractures of the radial head are the most common fractures in the elbow, and they frequently have associated ligamentous, cartilaginous, or other bony injuries. Clinical assessment and radiological investigation allow for accurate diagnosis and the formulation of a management plan. Undisplaced or minimally displaced fractures with no rotational block to motion can be treated nonoperatively with excellent results expected. The minimum amount of displacement in a partial articular radial head fracture required for open reduction and internal fixation to provide a superior outcome to nonoperative management is still unknown. Medium-term data suggest that patients with comminuted radial head fractures do well with radial head replacement.
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Affiliation(s)
- Albert Yoon
- Hand and Upper Limb Centre, St. Joseph's Health Centre, London, Ontario, Canada
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Radial head translation measurement in healthy individuals: the radiocapitellar ratio. J Shoulder Elbow Surg 2012; 21:574-9. [PMID: 21724422 DOI: 10.1016/j.jse.2011.03.017] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/19/2010] [Revised: 03/14/2011] [Accepted: 03/27/2011] [Indexed: 02/07/2023]
Abstract
HYPOTHESIS We hypothesized that the radiocapitellar ratio (RCR) is a valid and reproducible method to assess radial head translation in healthy individuals and that the normal RCR of healthy individuals is 0%. MATERIALS AND METHODS Lateral radiographs of the elbow were examined in 40 healthy patients. The measurement method of the RCR was the displacement of the radial head (minimal distance between the right bisector of the radial head and the center of the capitellum) divided by the diameter of the capitellum. Intraobserver and interobserver reliability was evaluated using intraclass correlation (ICC). RESULTS The RCR was 4% ± 4% (range, -7% to 19%). The mean RCR of 4% measured in this cohort represents an anterior displacement of 1 mm in a capitellum of 25 mm. Intraobserver reliability was good (ICC, 0.72) and interobserver reliability was fair (ICC, 0.52). A significant side-to-side correlation was observed (r = 0.4, P = .009). No difference was identified between men and women, and no correlation was identified between age and the RCR. The standard deviation of the centered RCR measurements was 3%, which represented the variability of RCR measurements. CONCLUSIONS The results of this study confirm the traditional belief that in the normal elbow, the radial head is generally aligned towards the capitellum on lateral radiographs. Accordingly, a RCR observed outside the ranges of 1 mm posterior (-5%) to 3 mm anterior (13%) in a 25 mm capitellum suggests a misalignment at the RC joint of the elbow. The RCR method to assess RC joint translations has demonstrated a normal distribution in healthy individuals and good reliability.
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Pipicelli JG, Chinchalkar SJ, Grewal R, Athwal GS. Rehabilitation considerations in the management of terrible triad injury to the elbow. Tech Hand Up Extrem Surg 2011; 15:198-208. [PMID: 22105630 DOI: 10.1097/bth.0b013e31822911fd] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/31/2023]
Abstract
An elbow dislocation associated with a radial head and coronoid fractures is termed a terrible triad. This injury almost always renders the elbow unstable requiring surgical intervention. The primary goal of surgery is to stabilize the elbow to permit early motion to prevent stiffness. Recent literature has improved our understanding of elbow anatomy and biomechanics as well as the pathoanatomy of this injury. This article reviews key concepts that will allow the surgeon and therapist to apply an systematic rehabilitation approach when managing such injuries.
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Affiliation(s)
- Joey G Pipicelli
- Division of Hand Therapy, Hand and Upper Limb Centre, St. Joseph's Health Care, 268 Grosvenor Street, London, Ontario, Canada.
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