American Shoulder and Elbow Surgeons
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Average 3.8 of 65 Ratings
Technique guide are not considered high yield topics for orthopaedic standardized exams including the ABOS, EBOT and RC.
A 30-year-old woman falls onto an outstretched arm while rollerblading. She presents to the emergency room with the elbow deformity shown in Figure A. On physical examination she is unable to range her elbow. She is distally neurovascularly intact. Her radiograph is shown in Figure B. What is the next step in management of this patient?
Closed reduction, hinged external fixator
Closed reduction, acute surgical repair of the lateral collateral ligament complex
Open reduction and surgical repair of the lateral collateral ligament complex
Closed reduction, splinting & early passive ROM
Closed reduction, splinting & early active ROM
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The clinical presentation is consistent with a simple elbow dislocation. Initial management should include closed reduction, splinting or sling placement for comfort and early active ROM exercises.
Simple elbow dislocations should be reduced and treatment guided by the relative stability of the joint during the arc of motion. The elbow should be splinted where it is most stable. After 5-7 days the splint can be discontinued and active ROM started to apply compressive stability to the joint. A hinged brace with an appropriate extension block can facilitate motion through the stable arc.
Armstrong discusses pathomechanics and basis for treatment in simple elbow dislocations. She emphasizes delineating the arc through which the elbow is stable and using this to guide initial management. Early surgical management may be warranted when the elbow is unstable with 60 degrees or more of flexion.
Josefsson et al. studied 30 patients who had sustained simple elbow dislocations and prospectively randomized the patients into non-operative and operative study arms. Operative intervention included reattachment of avulsed ligaments/muscles from the distal humerus. They found no statistical difference in clinical outcomes between the groups regardless of the severity of the instability.
Figure A demonstrates a clinical photo of a patient having sustained an elbow dislocation. Figure B is a radiograph demonstrating a posterolateral elbow dislocation, which is named based on the direction that the ulna/radius move relative to the humerus. Illustration A is a video that reviews the pathomechanics of elbow dislocations.
Answer 1, 2: While use of a hinged external fixator may be appropriate when instability persists after repair/reconstruction of the LCL complex, it is not the first step in the initial management of a simple elbow dislocation.
Answer 3: Open reduction may be warranted if closed reduction is unsuccessful, however an initial attempt at conservative measures should be made.
Answer 4: Closed reduction needs to be followed by splinting to give the tissues a chance to recover from the initial injury; use of ACTIVE range of motion exercises early, will help to provide dynamic compressive stability to the joint.
Josefsson PO, Gentz CF, Johnell O, Wendeberg B.
J Bone Joint Surg Am. 1987 Apr;69(4):605-8. PMID: 3571318 (Link to Abstract)
Josefsson, JBJS 1987
Please rate question.
Average 4.0 of 15 Ratings
A 26-year-old male wrestler suffers the elbow injury shown in Figure A. On physical exam he is neurologically intact and has a palpable radial pulse. He is treated with closed reduction in the emergency room. In order to optimize his clinical outcomes, which of the following treatment and rehabilitation protocols should be avoided?
Immediate active and active-assist range of motion through a stable arc
Initial splinting and immobilization for 4 weeks followed by physical therapy
Initial splinting in 90 degrees of flexion with neutral forearm rotation
A range of motion protocol that limits full extension in the early phases of rehab
Light duty use of the affected arm immediately following immobilization
Prolonged splinting following simple elbow dislocations of greater than 2 weeks after reduction can lead to chronic stiffness and poor outcomes and should be avoided. All of the remaining answers are appropriate in the rehabilitation of these injuries.
Simple elbow dislocations are second only to the shoulder in rates of joint dislocation. Closed reduction with early rehabilitation has proven the most effective treatment for these injuries when the elbow is stable. Rehabilitation for a simple elbow dislocations should include initial splinting in 90 degrees of flexion with neutral forearm rotation and immediate active and active-assist range of motion through a stable arc. Full extension should be avoided initially in rehab. The patient should be encouraged to use the affected arm for light duty immediately following immobilization.
Mehloff et al. determined that elbows splinted longer than 2 weeks had decreased ROM at 1 year. They further describe the benefits of using the affected arm for light duty after 2 weeks of rest.
Smith et al. describe the effectiveness of immediate active and active-assist ROM exercises after reduction.
O'Driscoll et al. describe how to test an elbow for posterolateral instability, which can occur after an elbow dislocation. They emphasize the elbow is most unstable in extension immediately after injury. Therefore, the elbow should be splinted in 90 degrees of flexion with neutral forearm rotation until therapy begins.
Figure A is a lateral radiograph of the elbow which shows a simple posterior elbow dislocation. The anatomic description is based on the anatomic location of olecranon relative to humerus.
O'Driscoll SW, Bell DF, Morrey BF.
J Bone Joint Surg Am. 1991 Mar;73(3):440-6. PMID: 2002081 (Link to Abstract)
O'Driscoll, JBJS 1991
Mehlhoff TL, Noble PC, Bennett JB, Tullos HS.
J Bone Joint Surg Am. 1988 Feb;70(2):244-9. PMID: 3343270 (Link to Abstract)
Mehlhoff, JBJS 1988
Average 3.0 of 60 Ratings
A 34-year-old male falls from a roof and sustains a right elbow dislocation that is closed reduced in the emergency room. An AP radiograph is shown in Figure A. This injury pattern is at highest risk for which of the following?
Anterior interosseous nerve palsy
Varus posteromedial rotatory instability
Posterior interosseous nerve palsy
Valgus posterolateral rotatory instability
Elbow instability when pushing oneself up from a seated position in a chair
Anteromedial coronoid facet fracture and LCL injury following an elbow dislocation is commonly associated with varus posteromedial rotatory instability. Varus and posteromedial rotation force on the forearm results in rupture of the LCL from its humeral origin. As the LCL ruptures, the medial coronoid process is fractured as it impacts against and under the medial trochlea. Fracture involvement of the sublime tubercle, where the MCL attaches, can lead to more instability. The lateral pivot shift test is similar to pushing oneself up from a seated position in a chair is an indication of valgus posterolateral rotatory instability. Ulnar neuropathy can be seen following this injury pattern but AIN and PIN nerve palsy do not commonly characterize this injury pattern.
The review article by O'Driscoll highlights key points in diagnosis and management of capitellum, distal humerus, coronoid, and terrible triad injuries.
The article by Doornberg and Ring is a Level 4 study of 18 patients that sustained varus posteromedial rotational injuries resulting in anteromedial facet coronoid fractures. They found that lack of fixation at injury or malunion of the anteromedial facet were significant predictors of suboptimal functional outcome and development of arthrosis.
The anteromedial facet is highlighted in yellow as displayed in Illustration A. Illustration B depicts the lateral collateral ligament injury evident during varus stress fluroscopic examination.
O'Driscoll SW, Jupiter JB, Cohen MS, Ring D, McKee MD.
Instr Course Lect. 2003;52:113-34. PMID: 12690844 (Link to Abstract)
Doornberg JN, Ring DC
J Bone Joint Surg Am. 2006 Oct;88(10):2216-24. PMID: 17015599 (Link to Abstract)
Doornberg, JBJS 2006
Average 3.0 of 37 Ratings
What is the most common mode of failure of the lateral ulnar collateral ligament associated with an elbow dislocation?
ligament avulsion off the humeral origin
ligament avulsion off the ulnar insertion
bony avulsion of the humeral origin
combined proximal and distal ligament avulsions
The lateral ulnar collateral ligament (LUCL) is often injured with elbow dislocations, and is most commonly injured at the proximal origin.
McKee noted that in 62 consecutive operative elbow dislocations and fracture/dislocations, the LUCL was ruptured in all of the patients, proximally in 32, bony avulsion proximally in 5, midsubstance rupture in 18, ulnar detachment in 3, ulnar bony avulsion in only 1, and combined patterns in 3.
Pugh et al established a standard protocol to treat elbow fracture dislocations (terrible triad) which includes coronoid repair, radial head repair/replacement, LUCL repair, and MCL and/or external fixation as needed.
McKee MD, Schemitsch EH, Sala MJ, O'driscoll SW
J Shoulder Elbow Surg. 12(4):391-6. PMID: 12934037 (Link to Abstract)
McKee, JSES 2003
Pugh DM, Wild LM, Schemitsch EH, King GJ, McKee MD
J Bone Joint Surg Am. 2004 Jun;86-A(6):1122-30. PMID: 15173283 (Link to Abstract)
Pugh, JBJS 2004
Average 4.0 of 21 Ratings
You are planning open reduction and internal fixation for a comminuted radial head fracture. To avoid impingement with the proximal ulna, you need to carefully place your fixation. What percent of the proximal radial head articulates with the proximal ulna?
Only 75% of the radial head articulates with the ulna. The remaining 25% (approximately 90 degree arc) which does not articulate is considered the "safe zone" and is important for placement of fixation.
Caputo et al looked at 24 cadevaric arms and found the average arc of the nonarticulating radial head was 113 degrees (range, 106 degrees to 120 degrees; standard deviation, 4 degrees). They found the nonarticulating portion of the radial head (or safe zone for prominent fixation) consistently encompassed a 90 degree angle localized by palpation of the radial styloid and Lister's tubercle.
Smith et al in a similar cadaveric study identified a 110 degree safe zone based on cross-sectional dissections and landmarks. In this regard they were able to show this 110 degree arc of safe articulation in the proximal radius.
A "safe zone" of approximately 110 degrees of radial head surface was first identified by cross-sectional anatomic dissections.
Cohen et al reviewed the classification, diagnosis, and management of acute elbow dislocations and specifically discuss treatment of associated proximal radial fracture where fixation needs to be applied in the "safe zone."
Illustration A depicts the radial head safe zone during forearm pronation, supination, and neutral positions.
Caputo AE, Mazzocca AD, Santoro VM.
J Hand Surg Am. 1998 Nov;23(6):1082-90. PMID: 9848563 (Link to Abstract)
Caputo, JHS 1998
Smith GR, Hotchkiss RN.
J Shoulder Elbow Surg. 1996 Mar-Apr;5(2 Pt 1):113-7. PMID: 8742874 (Link to Abstract)
Smith, JSES 1996
Cohen MS, Hastings H 2nd.
J Am Acad Orthop Surg. 1998 Jan-Feb;6(1):15-23. PMID: 9692937 (Link to Abstract)
Cohen, JAAOS 1998
Average 4.0 of 34 Ratings
Which of the following is most commonly associated with both simple and complex elbow dislocations?
radial head fracture
radial neck fracture
loss of terminal extension
coronoid base fracture
Elbow dislocations are classified as either simple (no associated fracture) or complex (associated fracture). The goal of treatment is a stable joint that tolerates early motion. The initial range of motion is the stable arc found on postreduction examination. Studies have demonstrated a better outcome when simple elbow dislocations are treated non-surgically rather than with surgical repair. Simple elbow dislocations usually have an excellent outcome (return of functional range of motion with normal strength). A loss of terminal extension is the most common sequelae.
Ross et al. reported on 20 patients with simple closed posterior elbow dislocations who were treated with immediate active ROM under close supervision. They found a final arc of motion of -4 to 139 degrees, with final motion reached a mean of 19 days after dislocation. Only 1 patient had recurrent instability.
Ross G, McDevitt ER, Chronister R, Ove PN.
Am J Sports Med. 1999 May-Jun;27(3):308-11. PMID: 10352765 (Link to Abstract)
Ross, AJSM 1999
Average 3.0 of 42 Ratings
Title: Recurrent Elbow Instability Presenter: Melvin P. Rosenwasser, MDColumbia...
Elbow Fractures and DislocationsCore Currriculum WebinarsBrought to you in by Am...
HPI - Patient sustained a fall on an outstretched hand in July of 2016 (approximately 6 months ago), injuring his left elbow.
The patient had primary care in another hospital, with routine XRays of the elbow ruling out a fracture. He was treated with an above-elbow splint for 5 weeks, followed by rehabilitation.
He now presents to our clinic with left elbow deformity, pain, loss of motion and function, and a feeling of instability.
Would you order additional diagnostic studies in this patient?
HPI - Right hand dominant farmer who fell from a stillage (ca. 1.5 m height) 12m ago. He sustained a right transolecranon fracture dislocation and a L1 burst fracture. Underwent ORIF olecranon and coronoid process with LCP olecranon plate and radial head replacement, L1 fracture being managed conservatively.
C/o painful limited ROM right elbow making it difficult to continue with his hard labour farm work. Pain whilst loading both in flexion and extension with pm over radial joint line. Recent Xrays suggstive for possttraumatic OA, possibly overstuffing of the radial head replacement.
How would you treat this patient's post traumatic OA
HPI - Fall from motor bike 4 mths ago. Patient refused surgery and got it treated by a bone setter who put him in a cast for a month.Minimal to no motion at the elbow.
How would you treat this patient?
HPI - h/o fall 5 days ago treated in another hospital for medial elbow dislocation and radial head fracture. The elbow was not able to be completely reduced secondary to an intra articular fragment. The patient was reffered for further management
How would you treat this injury?
HPI - fall from bike, immediate reduction and cast temporary
How would you treat this?
HPI - Dislocated his elbow 8 years ago in the Honduras after a fall from a tree. No other injuries prior/since. Now unable to do lawnwork and labor (his profession in the US). Chronic pain with use. This is his dominant side.
What would you do with this injury?