Loss of flexion associated with reduced satisfaction and a greater likeliness of reporting functional impairment

Issue: August 2012

While most orthopedic surgeons have treated and occasionally see a dislocated elbow, it is an infrequent injury for most of us to treat. Raymond E. Anakwe, FRCS Ed (Tr&Ortho), recently reported a review of 110 patients treated at the Edinburgh Orthopaedic Trauma Unit, Royal Infirmary of Edinburgh in the United Kingdom. I found his team’s findings informative, and I think Orthopedics Today readers will as well.

— Douglas W. Jackson, MD
Chief Medical Editor

Douglas W. Jackson, MD: How did your recent study define a “simple” elbow dislocation? What population did you review?

Raymond E. Anakwe, FRCS Ed (Tr&Orth): We defined a simple dislocation of the elbow as one without associated fracture or persistent instability requiring early surgery. Our trauma center is the only trauma unit serving a well-defined and stable population, and so we are able to undertake reliable epidemiological studies. By examining our trauma database, we were able to identify all patients treated for a simple elbow dislocation at our center during a 10-year period.

We identified 140 patients and were able to review 110 patients (79%) in the clinic. The incidence of simple elbow dislocation was 2.9 (95% CI, 1.8 to 3.5) per 100,000 per year. Fifty-nine patients (54%) were men and the mean patient age was 38.8 years, although the mean age of the men was younger than that of the women (33.2 years compared to 45.3 years).

Jackson: What were the long-term outcomes of the patients included in your study?

Anakwe: Patients were followed up for a mean of 88 months and reported long-term residual deficits in both the range of motion and grip strength. In summary, residual pain and stiffness were common but functional outcomes were good at long-term follow-up.

Raymond E. Anakwe

The mean DASH score was 6.7 points (95% CI, 4 to 9 points), and the mean Oxford elbow score was 90.3 points (95% CI, 87.8 to 92.9 points). Satisfaction scores were excellent, and the mean satisfaction score was 85.6 points out of 100. These functional scores and outcomes were worse for women, however.

Sixty-two patients (56%) reported residual subjective stiffness of the elbow. Nine patients (8%) reported subjective instability, and 68 patients (62%) reported residual pain. Of the nine patients who reported subjective instability, one patient had objective evidence of valgus instability on clinical assessment and one other had clinically detectable posterolateral instability. The other seven patients had no clinically detectable signs of instability. In total, nine patients (8%) demonstrated objective signs of elbow instability on stress testing or pivot-shift testing but seven of these patients were entirely asymptomatic. The patients who reported subjective stiffness were objectively shown to have reduced elbow flexion-extension range of movement.

The DASH, Oxford elbow, and satisfaction scores all correlated with the absolute range of motion in the injured elbow. Overall satisfaction correlated with both the Oxford elbow score and the DASH score.

Jackson: What is your group’s recommended treatment for a simple elbow dislocation?

Anakwe: In our unit, a patient presenting with a simple elbow dislocation is seen in the emergency department where, after an examination and neurovascular assessment, the diagnosis is confirmed with radiographs. The elbow is then reduced under conscious sedation before it is taken through a range of motion to assess stability. The aim of this examination is not to provoke persistent instability, but rather to confirm that a congruent reduction has been achieved and can be maintained through an arc of movement and to unmask any gross instability that may require early surgery. Joint reduction is confirmed with further radiographs.

The elbow is immobilized in a posterior splint, and the patient is reviewed in the trauma clinic within the next week where the splint is removed, the elbow is examined and further radiographs are taken. The patient is encouraged to use the arm for normal activities of daily living, but to avoid both heavy lifting and activities involving full supination combined with extension for 6 weeks. Physical therapy is not routinely prescribed, but left to the discretion of the treating surgeon.

If a congruent reduction cannot be confidently achieved under conscious sedation or if there is evidence of marked instability, then the patient is taken to the operating theater where an examination under general anesthesia is performed, joint reduction can be confirmed or complex instability can be addressed with surgery.

Jackson: How significant was the residual pain and loss of motion in your reported patient population? Were any secondary procedures performed on this population to address the long-term findings?

Anakwe: Many patients in our study experienced a loss of terminal elbow extension, as has been reported in previous studies. However, this loss appeared to have little impact on patient-reported function. Loss of flexion, however, was associated with reduced satisfaction and a greater likeliness of reporting functional impairment.

While two patients underwent late arthrolysis surgery for stiffness, there were no cases of late surgery for instability. Fifty-four patients reported regular sporting activity before their injury, and 10 patients of these had given up their primary sport or had to modify their technique to accommodate residual elbow symptoms. In particular, six patients had given up or modified weightlifting or other weighted upper body activities.

With modern treatment involving a shortened period of immobilization and early movement, rates of instability are low. Instability does occur, and we identified a prevalence of 8% for both functional and objective instability. If we do not look for it, we are unlikely to find it. Nevertheless, most orthopedic surgeons will treat stiffness as a complication of these injuries. Instability is less common, and functional or clinically important instability probably relates to the demands we place on the elbow.

Reference:

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; 6;93(13):1220-1226.

For more information:

Raymond E. Anakwe, FRCS Ed (Tr&Orth), is a hand and upper limb surgery fellow at the Edinburgh Orthopaedic Trauma Unit, Royal Infirmary of Edinburgh in the United Kingdom. He can be reached at raymundus@doctors.org.uk.
Disclosure: Anakwe has no relevant financial disclosures.