New Injury Mechanism and Treatment Algorithm of Posterior Elbow Dislocation

In Hyeok Rhyou

doi:10.12671/jkfs.2019.32.1.61

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Rhyou: New Injury Mechanism and Treatment Algorithm of Posterior Elbow Dislocation

Review Article

Journal of the Korean Fracture Society 2019; 32(1): 61-71.

Published online: 25 January 2019

DOI: https://doi.org/10.12671/jkfs.2019.32.1.61

New Injury Mechanism and Treatment Algorithm of Posterior Elbow Dislocation

In Hyeok Rhyou, M.D.

Department of Orthopedic Surgery, Upper Extremity and Microsurgery Center, Semyeong Christianity Hospital, Pohang, Korea.

Correspondence to: In Hyeok Rhyou, M.D. Department of Orthopedic Surgery, Upper Extremity and Microsurgery Center, Semyeong Christianity Hospital, 351 Posco-daero, Nam-gu, Pohang 37816, Korea. Tel: +82-54-289-1765, Fax: +82-54-289-1766, osdrrih@gmail.com

Received 28 November 2018 Revised 25 December 2018 Accepted 25 December 2018

The Korean Fracture Society

(open-access):

This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/4.0) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.

Abstract

Although the concept of a single elbow dislocation mechanism, in which all dislocations start from the lateral side of the elbow joint and progress to the medial side, has never been able to explain the various conflicting experimental and clinical observations thus far, new studies and proposals for a valid mechanism have not been reported. The new proposal for posteromedial and posterolateral dislocation of the elbow joint according to the authors' study and the new treatment algorithm based on this new study can explain the various clinical and experimental results that have been difficult to explain, and provide a reasonable approach to the treatment of elbow dislocations.

Keywords: Elbow dislocation, Posteromedial and posterolateral dislocation, Treatment algorithm

Figures and Tables

Fig. 1

(A, B) Simple anteroposterior and lateral radiographs of posterolateral dislocation of the elbow joint. (C) On the fat-suppressed T2-weighted coronal view of the magnetic resonance imaging scan, there are distractive injury patterns of the ulnar collateral ligament and flexor-pronator teres muscles caused by the valgus force applied medially (solid arrow) and stripping injury pattern of the lateral collateral ligament complex caused by the forearm external rotational force (dotted arrow) appearing ‘peeled-off’ from the lateral epicondyle and located near the original attachment site. (D) Lateral bony contusion seen on the posterior capitellum and radial head (solid arrows) on the fat-suppressed T2-weighted sagittal view.

Fig. 2

(A, B) Simple anteroposterior and lateral radiographs of posteromedial dislocation of the elbow joint. (C) On the T1-weighted coronal view of magnetic resonance imaging (MRI) scan, there is a distractive injury pattern of the lateral collateral ligament complex caused by the varus force and migrated distally from the original attachment site of the lateral epicondyle (solid arrow). (D) On the T2-weighted fat suppressed axial view of the MRI scan, there is medial bony contusion on the posterior trochlea (dotted arrow) and proximal ulna (solid arrow).

Fig. 3

Sequential scenario of the most common posterolateral dislocation of the elbow joint. (A) The axial force applied along the forearm during the initial injury converts to a valgus force at the medial side due to the cubitus valgus and causes distractive injury of the ulnar collateral ligament and flexor-pronator teres muscles. By the ongoing valgus force, the coronoid process is disengaged from the trochlear notch and the forearm displaces laterally at the first step. (B) Accompanying forearm external rotation displaces the radial head posterior to the posterior capitellum and causes abutment between the radial ahead and the posterior capitellum, which leads to a lateral bony contusion. (C) Finally, the posterolateral dislocation of the elbow joint develops by the continuously applied axial force.

Fig. 4

Sequential scenario of the rare posteromedial dislocation of the elbow joint. (A) The axial force applied along the forearm during the initial injury converts to a varus force at the lateral side, which is rare due to the common cubitus valgus characteristics and more commonly seen in less valgus carrying angle, and causes the distractive injury of the lateral collateral ligament complex and extensor muscles. By the ongoing varus force, the coronoid process is disengaged from the trochlear notch and the forearm displaces medially at the first step. (B) Accompanying forearm external rotation displaces the radial head posterior to the posterior capitellum without impaction and causes abutment between the proximal ulna and the posteromedial capitellum, leading to the medial bony contusion. (C) Finally the posteromedial dislocation of the elbow joint develops by the continuously applied axial force.

Fig. 5

Treatment algorithm for the unstable posterolateral (PL) dislocation of the elbow joint. MRI: magnetic resonance imaging, UCL: ulnar collateral ligament, F-PT: flexor-pronator teres, LCLC: lateral collateral ligament complex, ROM: range of motion.

Fig. 6

Treatment algorithm for the posteromedial (PM) dislocation of the elbow joint. LCLC: lateral collateral ligament complex, ROM: range of motion, UCL: ulnar collateral ligament.

Notes

^{Financial support} None.

^{Conflict of interests} None.

References

1. O'Driscoll SW, Morrey BF, Korinek S, An KN. Elbow subluxation and dislocation. A spectrum of instability. Clin Orthop Relat Res. 1992; (280):186–197.

2. Josefsson PO, Johnell O, Wendeberg B. Ligamentous injuries in dislocations of the elbow joint. Clin Orthop Relat Res. 1987; (221):221–225.

3. Josefsson PO, Gentz CF, Johnell O, Wendeberg B. Surgical versus nonsurgical treatment of ligamentous injuries following dislocations of the elbow joint. Clin Orthop Relat Res. 1987; (214):165–169.

4. Josefsson PO, Gentz CF, Johnell O, Wendeberg B. Surgical versus non-surgical treatment of ligamentous injuries following dislocation of the elbow joint. A prospective randomized study. J Bone Joint Surg Am. 1987; 69:605–608.

5. Søjbjerg JO, Helmig P, Kjaersgaard-Andersen P. Dislocation of the elbow: an experimental study of the ligamentous injuries. Orthopedics. 1989; 12:461–463.

6. Hobgood ER, Khan SO, Field LD. Acute dislocations of the adult elbow. Hand Clin. 2008; 24:1–7.

7. Schreiber JJ, Warren RF, Hotchkiss RN, Daluiski A. An online video investigation into the mechanism of elbow dislocation. J Hand Surg Am. 2013; 38:488–494.

8. Fritz RC, Breidahl WH. Radiographic and special studies: recent advances in imaging of the elbow. Clin Sports Med. 2004; 23:567–580. ix

9. Lowden C, Garvin G, King GJ. Imaging of the elbow following trauma. Hand Clin. 2004; 20:353–361.

10. Rosenberg ZS, Blutreich SI, Schweitzer ME, Zember JS, Fillmore K. MRI features of posterior capitellar impaction injuries. AJR Am J Roentgenol. 2008; 190:435–441.

11. Rhyou IH, Kim YS. New mechanism of the posterior elbow dislocation. Knee Surg Sports Traumatol Arthrosc. 2012; 20:2535–2541.

12. Mayne IP, Wasserstein D, Modi CS, Henry PD, Mahomed N, Veillette C. The epidemiology of closed reduction for simple elbow dislocations and the incidence of early subsequent open reduction. J Shoulder Elbow Surg. 2015; 24:83–90.

13. Kuhn MA, Ross G. Acute elbow dislocations. Orthop Clin North Am. 2008; 39:155–161. v

14. Morrey BF, Tanaka S, An KN. Valgus stability of the elbow. A definition of primary and secondary constraints. Clin Orthop Relat Res. 1991; (265):187–195.

15. Funk DA, An KN, Morrey BF, Daube JR. Electromyographic analysis of muscles across the elbow joint. J Orthop Res. 1987; 5:529–538.

16. Hotchkiss RN, Weiland AJ. Valgus stability of the elbow. J Orthop Res. 1987; 5:372–377.

17. Søjbjerg JO, Ovesen J, Nielsen S. Experimental elbow instability after transection of the medial collateral ligament. Clin Orthop Relat Res. 1987; (218):186–190.

18. Morrey BF, An KN. Articular and ligamentous contributions to the stability of the elbow joint. Am J Sports Med. 1983; 11:315–319.

19. Morrey BF, An KN. Functional anatomy of the ligaments of the elbow. Clin Orthop Relat Res. 1985; (201):84–90.

20. Martin BF. The annular ligament of the superior radio-ulnar joint. J Anat. 1958; 92:473–482.

21. Modi CS, Lawrence E, Lawrence TM. Elbow instability. Orthop Trauma. 2012; 26:316–327.

22. Deutch SR, Jensen SL, Olsen BS, Sneppen O. Elbow joint stability in relation to forced external rotation: an experimental study of the osseous constraint. J Shoulder Elbow Surg. 2003; 12:287–292.

23. Schreiber JJ, Potter HG, Warren RF, Hotchkiss RN, Daluiski A. Magnetic resonance imaging findings in acute elbow dislocation: insight into mechanism. J Hand Surg Am. 2014; 39:199–205.

24. Cohen MS, Hastings H 2nd. Acute elbow dislocation: evaluation and management. J Am Acad Orthop Surg. 1998; 6:15–23.

25. Sheps DM, Hildebrand KA, Boorman RS. Simple dislocations of the elbow: evaluation and treatment. Hand Clin. 2004; 20:389–404.

26. Shukla DR, Pillai G, McAnany S, Hausman M, Parsons BO. Heterotopic ossification formation after fracture-dislocations of the elbow. J Shoulder Elbow Surg. 2015; 24:333–338.

27. Rhyou IH, Kim KC, Lee JH, Kim SY. Strategic approach to O'Driscoll type 2 anteromedial coronoid facet fracture. J Shoulder Elbow Surg. 2014; 23:924–932.

28. O'Driscoll SW, Jupiter JB, King GJ, Hotchkiss RN, Morrey BF. The unstable elbow. Instr Course Lect. 2001; 50:89–102.

29. Mehlhoff TL, Noble PC, Bennett JB, Tullos HS. Simple dislocation of the elbow in the adult. Results after closed treatment. J Bone Joint Surg Am. 1988; 70:244–249.

30. Hildebrand KA, Patterson SD, King GJ. Acute elbow dislocations: simple and complex. Orthop Clin North Am. 1999; 30:63–79.

31. Dowdy PA, Bain GI, King GJ, Patterson SD. The midline posterior elbow incision. An anatomical appraisal. J Bone Joint Surg Br. 1995; 77:696–699.

32. Rhyou IH, Kim KC, Kim KW, Lee JH, Kim SY. Collateral ligament injury in the displaced radial head and neck fracture: correlation with fracture morphology and management strategy to the torn ulnar collateral ligament. J Shoulder Elbow Surg. 2013; 22:261–267.

33. 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; 24:1081–1089.

34. van der Ley J, van Niekerk JL, Binnendijk B. Conservative treatment of elbow dislocations in adults. Neth J Surg. 1987; 39:167–169.

35. Dürig M, Müller W, Rüedi TP, Gauer EF. The operative treatment of elbow dislocation in the adult. J Bone Joint Surg Am. 1979; 61:239–244.

36. Eygendaal D, Verdegaal SH, Obermann WR, van Vugt AB, Pöll RG, Rozing PM. Posterolateral dislocation of the elbow joint. Relationship to medial instability. J Bone Joint Surg Am. 2000; 82:555–560.

37. Anakwe RE, Middleton SD, Jenkins PJ, McQueen MM, Court-Brown CM. Patient-reported outcomes after simple dislocation of the elbow. J Bone Joint Surg Am. 2011; 93:1220–1226.

38. Micic I, Kim SY, Park IH, Kim PT, Jeon IH. Surgical management of unstable elbow dislocation without intra-articular fracture. Int Orthop. 2009; 33:1141–1147.

39. Ross G, McDevitt ER, Chronister R, Ove PN. Treatment of simple elbow dislocation using an immediate motion protocol. Am J Sports Med. 1999; 27:308–311.

40. O'Driscoll SW, Bell DF, Morrey BF. Posterolateral rotatory instability of the elbow. J Bone Joint Surg Am. 1991; 73:440–446.

41. Linscheid RL, Wheeler DK. Elbow dislocations. JAMA. 1965; 194:1171–1176.

42. Akansel G, Dalbayrak S, Yilmaz M, Bekler H, Arslan A. MRI demonstration of intra-articular median nerve entrapment after elbow dislocation. Skeletal Radiol. 2003; 32:537–541.

43. Matev I. A radiological sign of entrapment of the median nerve in the elbow joint after posterior dislocation. A report of two cases. J Bone Joint Surg Br. 1976; 58:353–355.

44. Squires NA, Tomaino MM. Brachial artery rupture without median nerve dysfunction after closed elbow dislocation. Am J Orthop (Belle Mead NJ). 2003; 32:298–300.

45. Abrams GD, Bellino MJ, Cheung EV. Risk factors for development of heterotopic ossification of the elbow after fracture fixation. J Shoulder Elbow Surg. 2012; 21:1550–1554.

46. Viola RW, Hastings H 2nd. Treatment of ectopic ossification about the elbow. Clin Orthop Relat Res. 2000; (370):65–86.

47. Ahmed I, Mistry J. The management of acute and chronic elbow instability. Orthop Clin North Am. 2015; 46:271–280.

48. Josefsson PO, Johnell O, Gentz CF. Long-term sequelae of simple dislocation of the elbow. J Bone Joint Surg Am. 1984; 66:927–930.

49. Schmidt SA, Kjaersgaard-Andersen P, Pedersen NW, Kristensen SS, Pedersen P, Nielsen JB. The use of indomethacin to prevent the formation of heterotopic bone after total hip replacement. A randomized, double-blind clinical trial. J Bone Joint Surg Am. 1988; 70:834–838.

50. Ring D, Jupiter JB. Excision of heterotopic bone around the elbow. Tech Hand Up Extrem Surg. 2004; 8:25–33.

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ORCID iDs: In Hyeok Rhyou
https://orcid.org/0000-0001-9312-2952
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