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Elbow Dislocations: A Review Ranging from Soft Tissue Injuries to Complex Elbow Fracture Dislocations

DOI: 10.1155/2013/951397

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This review on elbow dislocations describes ligament and bone injuries as well as the typical injury mechanisms and the main classifications of elbow dislocations. Current treatment concepts of simple, that is, stable, or complex unstable elbow dislocations are outlined by means of case reports. Special emphasis is put on injuries to the medial ulnar collateral ligament (MUCL) and on posttraumatic elbow stiffness. 1. Introduction Even simple elbow dislocations do not necessarily represent benign injuries. Anakwe showed in a retrospective trial with almost 180 patients that simple elbow dislocations caused considerable residual pain and stiffness in 62% and 56% of the patients, respectively [1]. According to Anakwe, elbow dislocations can be defined as simple if an elbow is stable when put through full range of motion after repositioning. Typically, simple elbow dislocations occur when a person falls onto an outstretched hand. Axial compression on the elbow in combination with supination and valgus stress primarily result in the rupture of the lateral ulnar collateral ligament (LUCL), which may cause posterolateral subluxation (Figure 1(a)). Extended elbow dislocations often involve severe ruptures with anterior and posterior capsule distractions followed by muscle injuries and, finally, by total elbow dislocation with rupture of the anterior MUCL (Figure 1(b)). This ligament tends to rupture in two stages; that is, the rupture of the posterior MUCL (Figure 1(a)) is followed by the rupture of the anteromedial bundle of the ligament complex [2, 3] (Figure 1(b)). This trauma mechanism has been described by O’Driscoll, who has also classified posttraumatic elbow instability according to the following five criteria: the articulations involved, the direction of the displacement, the degree of the displacement, the timing, and the presence or absence of associated fractures [3]. Fractures of a bony structure with a buttress function immediately result in elbow instability. The function of the medial ulnar collateral ligament complex and particularly its role in complex elbow dislocations has been investigated intensively. However, single injuries to the MUCL seem to be rare. Figure 1: (a) Dorsal view to an anatomic elbow preparation. The posterior lateral ulnar collateral ligament (LUCL) and the posterior medial ulnar collateral ligament (MUCL) are visible. The posterior part of the ligamentum annulare with its insertion to the ulnar and the above lying distal part of the LCL can be seen. (b) Ventral view to an anatomic elbow preparation with demonstration of


[1]  R. E. Anakwe, S. D. Middleton, P. J. Jenkins, M. M. McQueen, and C. M. Court-Brown, “Patient-reported outcomes after simple dislocation of the elbow,” Journal of Bone and Joint Surgery A, vol. 93, no. 13, pp. 1220–1226, 2011.
[2]  S. W. O'Driscoll, B. F. Morrey, S. Korinek, and K. N. An, “Elbow subluxation and dislocation: a spectrum of instability,” Clinical Orthopaedics and Related Research, no. 280, pp. 186–197, 1992.
[3]  S. W. O'Driscoll, J. B. Jupiter, G. J. King, R. N. Hotchkiss, and B. F. Morrey, “The unstable elbow,” Instructional Course Lectures, vol. 50, pp. 89–102, 2001.
[4]  P. Harding, T. Rasekaba, L. Smirneos, and A. E. Holland, “Early mobilisation for elbow fractures in adults,” Cochrane Database of Systematic Reviews, no. 6, Article ID CD008130, 2011.
[5]  B. F. Morrey and K.-N. An, “Stability of the elbow: osseous constraints,” Journal of Shoulder and Elbow Surgery, vol. 14, no. 1, supplement, pp. S174–S178, 2005.
[6]  G. H. Callaway, L. D. Field, X. H. Deng et al., “Biomechanical evaluation of the medial collateral ligament of the elbow,” Journal of Bone and Joint Surgery A, vol. 79, no. 8, pp. 1223–1231, 1997.
[7]  I. H. Jeon, J. Sanchez-Sotelo, K. Zhao, K. N. An, and B. M. Morrey, “The contribution of the coronoid and radial head to the stability of the elbow,” Journal of Bone and Joint Surgery B, vol. 94, no. 1, pp. 86–92, 2012.
[8]  J. G. Alcid, C. S. Ahmad, and T. Q. Lee, “Elbow anatomy and structural biomechanics,” Clinics in Sports Medicine, vol. 23, no. 4, pp. 503–517, 2004.
[9]  R. N. Hotchkiss and A. J. Weiland, “Valgus stability of the elbow,” Journal of Orthopaedic Research, vol. 5, no. 3, pp. 372–377, 1987.
[10]  C. R. Pribyl, D. K. Hurley, D. C. Wascher, T. P. McNally, K. Firoozbakhsh, and M. W. Weiser, “Elbow ligament strain under valgus load: a biomechanical study,” Orthopedics, vol. 22, no. 6, pp. 607–612, 1999.
[11]  J. W. Pollock, J. Brownhill, L. Ferreira, C. P. McDonald, J. Johnson, and G. King, “The effect of anteromedial facet fractures of the coronoid and lateral collateral ligament injury on elbow stability and kinematics,” Journal of Bone and Joint Surgery A, vol. 91, no. 6, pp. 1448–1458, 2009.
[12]  A. G. Schneeberger, M. M. Sadowski, and H. A. C. Jacob, “Coronoid process and radial head as posterolateral rotatory stabilizers of the elbow,” Journal of Bone and Joint Surgery A, vol. 86, no. 5, pp. 975–982, 2004.
[13]  J. T. Rohrbough, D. W. Altchek, J. Hyman, R. J. Williams III, and J. D. Botts, “Medial collateral ligament reconstruction of the elbow using the docking technique,” American Journal of Sports Medicine, vol. 30, no. 4, pp. 541–548, 2002.
[14]  J. P. Duggan Jr., U. C. Osadebe, J. W. Alexander, P. C. Noble, and D. M. Lintner, “The impact of ulnar collateral ligament tear and reconstruction on contact pressures in the lateral compartment of the elbow,” Journal of Shoulder and Elbow Surgery, vol. 20, no. 2, pp. 226–233, 2011.
[15]  N. Takigawa, J. Ryu, V. L. Kish, M. Kinoshita, and M. Abe, “Functional anatomy of the lateral collateral ligament complex of the elbow: morphology and strain,” Journal of Hand Surgery, vol. 30, no. 2, pp. 143–147, 2005.
[16]  M. S. Cohen and H. Hastings II, “Rotatory instability of the elbow: the anatomy and role of the lateral stabilizers,” Journal of Bone and Joint Surgery A, vol. 79, no. 2, pp. 225–233, 1997.
[17]  D. Ring and J. B. Jupiter, “Current concepts review: fracture-dislocation of the elbow,” Journal of Bone and Joint Surgery A, vol. 80, no. 4, pp. 566–580, 1998.
[18]  N. P. Iannuzzi and S. S. Leopold, “In brief: the Mason classification of radial head fractures,” Clinical Orthopaedics and Related Research, vol. 470, no. 6, pp. 1799–1802, 2012.
[19]  W. Regan and B. Morrey, “Fractures of the coronoid process of the ulna,” Journal of Bone and Joint Surgery A, vol. 71, no. 9, pp. 1348–1354, 1989.
[20]  R. N. Hotchkiss, “Fracture and dislocation of the elbow,” in Rockwood and Green'S Fractures in Adults, C. A. Rockwood, R. W. Bucholz, C. S. M. Court-Brown, J. D. Heckman, and P. Tornetta, Eds., vol. 1, pp. 929–1024, Lippincott-Raven, Philadelphia, Pa, USA, 1996.
[21]  J. Quintero and T. Varecka, “Complex elbow injuries,” in AO Principles of Fracture Management, T. P. Ruedi, R. Buckley, and C. Moran, Eds., pp. 626–642, Thieme Medical, Stuttgart, Germany, 1st edition, 2008.
[22]  S. Siebenlist, K. Schmidt-Horlohé, R. Hoffmann et al., “Proximal ulna fractures,” Zeitschrift Für Orthop?die Und Unfallchirurgie, vol. 149, no. 3, pp. e1–e19, 2011.
[23]  D. Ring and J. N. Doornberg, “Fracture of the anteromedial facet of the coronoid process: surgical technique,” Journal of Bone and Joint Surgery A, vol. 89, supplement 2, no. 2, pp. 267–283, 2007.
[24]  D. Ring, R. N. Hotchkiss, D. Guss, and J. B. Jupiter, “Hinged elbow external fixation for severe elbow contracture,” Journal of Bone and Joint Surgery A, vol. 87, no. 6, pp. 1293–1296, 2005.
[25]  N. W. L. Schep, J. De Haan, G. I. T. Iordens et al., “A hinged external fixator for complex elbow dislocations: a multicenter prospective cohort study,” BMC Musculoskeletal Disorders, vol. 12, article 130, 2011.
[26]  A. K. B. S?rensen and J. O. S?jbjerg, “Treatment of persistent instability after posterior fracture-dislocation of the elbow: restoring stability and mobility by internal fixation and hinged external fixation,” Journal of Shoulder and Elbow Surgery, vol. 20, no. 8, pp. 1300–1309, 2011.
[27]  S. Heck, S. Gick, J. Dargel, and D. Pennig, “External fixation with motion capacity in acute dislocations and fracture dislocations of the elbow: fixation with motion capacity,” Unfallchirurg, vol. 114, no. 2, pp. 114–122, 2011.
[28]  A. Chamseddine, H. Zein, B. Obeid, F. Khodari, and A. Saleh, “Posterolateral rotatory instability of the elbow secondary to sprain,” Chirurgie de la Main, vol. 30, no. 1, pp. 52–55, 2011.
[29]  S. W. O'Driscoll, “Classification and spectrum of elbow instability: recurrent instability,” in The Elbow and Its Disorders, B. F. Morrey, Ed., pp. 453–4563, Philadelphia, Pa, USA, 2nd edition, 1993.
[30]  S. Bell, “(iii) Elbow instability, mechanism and management,” Current Orthopaedics, vol. 22, no. 2, pp. 90–103, 2008.
[31]  A. D. Duckworth, D. Ring, A. Kulijdian, and M. D. McKee, “Unstable elbow dislocations,” Journal of Shoulder and Elbow Surgery, vol. 17, no. 2, pp. 281–286, 2008.
[32]  A. A. Awmf, “AWMF-003-001, S3-leitlinie prophylaxe der ven?osen thromboembolie (VTE),”
[33]  T. Mittlmeier and M. Beck, “Luxation des ellenbogengelenks des erwachsenen,” Der Unfallchirurg, vol. 112, no. 5, pp. 487–505, 2009.
[34]  T. C. Koslowsky, K. Mader, M. Siedek, and D. Pennig, “Treatment of bilateral elbow dislocation using external fixation with motion capacity: a report of 2 cases,” Journal of Orthopaedic Trauma, vol. 20, no. 7, pp. 499–502, 2006.
[35]  L. Kaas, P. A. A. Struijs, D. Ring, C. N. van Dijk, and D. Eygendaal, “Treatment of Mason type II radial head fractures without associated fractures or elbow dislocation: a systematic review,” The Journal of Hand Surgery, vol. 37, no. 7, pp. 1416–1421, 2012.
[36]  A. D. Duckworth, B. S. Watson, E. M. Will et al., “Radial head and neck fractures: functional results and predictors of outcome,” Journal of Trauma, Injury, Infection and Critical Care, vol. 71, no. 3, pp. 643–648, 2011.
[37]  S. R. Deutch, S. L. Jensen, S. Tyrdal, B. S. Olsen, and O. Sneppen, “Elbow joint stability following experimental osteoligamentous injury and reconstruction,” Journal of Shoulder and Elbow Surgery, vol. 12, no. 5, pp. 466–471, 2003.
[38]  G. Giannicola, F. M. Sacchetti, A. Greco, G. Cinotti, and F. Postacchini, “Management of complex elbow instability,” Musculoskeletal Surgery, vol. 94, supplement 1, pp. S25–S36, 2010.
[39]  T. G. Guitton and D. Ring, “Nonsurgically treated terrible triad injuries of the elbow: report of four cases,” Journal of Hand Surgery, vol. 35, no. 3, pp. 464–467, 2010.
[40]  U. Heim, “Combined fractures of the radius and the ulna at the elbow level in the adult. analysis of 120 cases after more than 1 year,” Revue de Chirurgie Orthopédique et Réparatrice de L'appareil Moteur, vol. 84, no. 2, pp. 142–153, 1998.
[41]  J. D. O'Holleran and D. W. Altchek, “The Thrower's elbow: arthroscopic treatment of valgus extension overload syndrome,” HSS Journal, vol. 2, no. 1, pp. 83–93, 2006.
[42]  K. J. Jones, D. C. Osbahr, M. A. Schrumpf, J. S. Dines, and D. W. Altchek, “Ulnar collateral ligament reconstruction in throwing athletes: a review of current concepts. AAOS exhibit selection,” The Journal of Bone and Joint Surgery, vol. 94, no. 8, p. e49, 2012.
[43]  M. Geyer and H. St?hr, “Arthroskopische abkl?rung und therapie des humeroradialen impingements,” Arthroskopie, vol. 14, no. 3, pp. 171–176, 2001.
[44]  M. Geyer, “Ligament reconstruction with a single strand trizeps tendon graft in posterolateral rotational instability of the elbow,” The Bone & Joint Journal, vol. 92, Orthopaedic Proceedings, supplement 4, p. 571, 2010.
[45]  D. Eygendaal, S. H. M. Verdegaal, W. R. Obermann, A. B. van Vugt, R. G. P?ll, and P. M. Rozing, “Posterolateral dislocation of the elbow joint: relationship to medial instability,” Journal of Bone and Joint Surgery A, vol. 82, no. 4, pp. 555–560, 2000.
[46]  G. Osborne and P. Cotterill, “Recurrent dislocation of the elbow,” Journal of Bone and Joint Surgery B, vol. 48, no. 2, pp. 340–346, 1966.
[47]  J. A. Baumfeld, R. P. van Riet, M. E. Zobitz, D. Eygendaal, K.-N. An, and S. P. Steinmann, “Triceps tendon properties and its potential as an autograft,” Journal of Shoulder and Elbow Surgery, vol. 19, no. 5, pp. 697–699, 2010.
[48]  A. M. Murthi, J. D. Keener, A. D. Armstrong, and C. L. Getz, “The recurrent unstable elbow: diagnosis and treatment,” The Journal of Bone and Joint Surgery A, vol. 92, no. 8, pp. 1794–1804, 2010.
[49]  M. H. Ebrahimzadeh, H. Amadzadeh-Chabock, and D. Ring, “Traumatic elbow instability,” The Journal of Hand Surgery, vol. 35, no. 7, pp. 1220–1225, 2010.
[50]  M. Damiani and G. J. W. King, “Coronoid and radial head reconstruction in chronic posttraumatic elbow subluxation,” Instructional Course Lectures, vol. 58, pp. 481–493, 2009.
[51]  R. C. McKee and M. D. McKee, “Complex fractures of the proximal ulna: the critical importance of the coronoid fragment,” Instructional Course Lectures, vol. 61, pp. 227–233, 2012.
[52]  R. P. van Riet, B. F. Morrey, and S. W. O'Driscoll, “Use of osteochondral bone graft in coronoid fractures,” Journal of Shoulder and Elbow Surgery, vol. 14, no. 5, pp. 519–523, 2005.
[53]  H. Hastings II and T. J. Graham, “The classification and treatment of heterotopic ossification about the elbow and forearm,” Hand Clinics, vol. 10, no. 3, pp. 417–437, 1994.
[54]  R. R. Protzman, “Dislocation of the elbow joint,” Journal of Bone and Joint Surgery A, vol. 60, no. 4, pp. 539–541, 1978.
[55]  H. C. Thompson III and A. Garcia, “Myositis ossificans: aftermath of elbow injuries,” Clinical Orthopaedics and Related Research, vol. 50, pp. 129–134, 1967.
[56]  G. S. Athwal, M. L. Ramsey, S. P. Steinmann, and J. M. Wolf, “Fractures and dislocations of the elbow: a return to the basics,” Instructional Course Lectures, vol. 60, pp. 199–214, 2011.
[57]  J. B. Jupiter, S. W. O'Driscoll, and M. S. Cohen, “The assessment and management of the stiff elbow,” Instructional Course Lectures, vol. 52, pp. 93–111, 2003.
[58]  D. E. Garland and R. M. O'Hollaren, “Fractures and dislocations about the elbow in the head-injured adult,” Clinical Orthopaedics and Related Research, vol. 168, pp. 38–41, 1982.
[59]  M. Duerig, W. Mueller, T. P. Ruedi, and E. F. Gauer, “The operative treatment of elbow dislocation in the adult,” Journal of Bone and Joint Surgery A, vol. 61, no. 2, pp. 239–244, 1979.
[60]  T. L. Mehlhoff, P. C. Noble, J. B. Bennett, and H. S. Tullos, “Simple dislocation of the elbow in the adult. Results after closed treatment,” Journal of Bone and Joint Surgery A, vol. 70, no. 2, pp. 244–249, 1988.
[61]  P. K. Mathew, G. S. Athwal, and G. J. W. King, “Terrible triad injury of the elbow: current concepts,” Journal of the American Academy of Orthopaedic Surgeons, vol. 17, no. 3, pp. 137–151, 2009.
[62]  N. M. Germscheid and K. A. Hildebrand, “Regional variation is present in elbow capsules after injury,” Clinical Orthopaedics and Related Research, no. 450, pp. 219–224, 2006.
[63]  H. Li, W. Xie, J. A. Strong, and J.-M. Zhang, “Systemic antiinflammatory corticosteroid reduces mechanical pain behavior, sympathetic sprouting, and elevation of proinflammatory cytokines in a rat model of neuropathic pain,” Anesthesiology, vol. 107, no. 3, pp. 469–477, 2007.
[64]  K. C. Gilbert and N. J. Brown, “Aldosterone and inflammation,” Current Opinion in Endocrinology, Diabetes and Obesity, vol. 17, no. 3, pp. 199–204, 2010.
[65]  C. J. Brandt, D. Kammer, A. Fiebeler, and U. Klinge, “Beneficial effects of hydrocortisone or spironolactone coating on foreign body response to mesh biomaterial in a mouse model,” Journal of Biomedical Materials Research A, vol. 99, no. 3, pp. 335–343, 2011.
[66]  A. Ehsan, J. I. Huang, M. Lyons, and D. P. Hanel, “Surgical management of posttraumatic elbow arthrofibrosis,” Journal of Trauma, Injury, Infection, and Critical Care, vol. 72, no. 5, pp. 1399–1403, 2012.
[67]  D. Blonna, G.-C. Lee, and S. W. O'Driscoll, “Arthroscopic restoration of terminal elbow extension in high-level athletes,” The American Journal of Sports Medicine, vol. 38, no. 12, pp. 2509–2515, 2010.
[68]  S. A. Tucker, F. H. Savoie III., and M. J. O'Brien, “Arthroscopic management of the post-traumatic stiff elbow,” Journal of Shoulder and Elbow Surgery, vol. 20, no. 2, supplement, pp. S83–S89, 2011.
[69]  M. T. Keschner and N. Paksima, “The stiff elbow,” Bulletin of the NYU Hospital for Joint Diseases, vol. 65, no. 1, pp. 24–28, 2007.
[70]  A. S. Bauer, B. K. Lawson, R. L. Bliss, and G. S. M. Dyer, “Risk factors for posttraumatic heterotopic ossification of the elbow: case-control study,” Journal of Hand Surgery, vol. 37, no. 7, pp. 1422.e6–1429.e6, 2012.


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