Patients report high levels of satisfaction 10 years after simple elbow dislocation

In a long-term study, patients reported satisfactory functional outcomes after simple dislocations of the elbow, although they also reported high rates of residual pain and stiffness based on results at 10 postoperative years.

“Simple dislocations of the elbow are not necessarily benign injuries,” Scott D. Middleton, MB, ChB, a trainee in the Orthopaedic Trauma Unit at the Royal Infirmary, Edinburgh, Scotland, said at the 12th EFORT Congress 2011.

“With nonoperative treatment and early movement, there are still high rates of residual pain and stiffness several years after injury, but the functional outcomes and satisfaction are good,” he said.

To address a number of questions concerning patient-reported outcomes after simple elbow dislocation, Middleton and colleagues reviewed data from all adult patients treated at their trauma center for simple elbow dislocation over a 10-year period, identifying 163 patients. After applying exclusion criteria and eliminating patients who did not complete the evaluation, the researchers reviewed 110 patients at 88 mean months after injury.

Scott D. Middleton

At this particular Scottish center, methods for simple elbow dislocation involve reducing the elbow and then immobilization in a posterior splint, according to Middleton.

“Following reduction, the patient is reviewed in the trauma clinic within the week,” he said. “Patients routinely have their splint removed in the fracture clinic at 1 week and patients are encouraged to resume everyday normal activities of daily living while avoiding heavy lifting and any activities involving full supination combined with extension for at least 6 weeks.”

Researchers asked patients to complete the Disabilities of the Arm, Shoulder and Hand (DASH) questionnaire, the Oxford Elbow Score (OES), and a patient satisfaction questionnaire rating their level of satisfaction on a visual analogue scale ranging from 0 to 100.

Middleton and colleagues calculated the incidence of simple elbow dislocation at 2.9 per 100,000 per year.

“We observed that residual stiffness after elbow dislocation was not at the rate previously thought: 62 patients, or 56%, reported subjective stiffness, and 68 patients, or 62%, complained of pain in their elbow, which was unsurprising given the magnitude of soft-tissue injury involved,” Middleton said.

He explained that 9 patients (8%) reported subjective instability, and instability did not usually limit activities.

Results revealed mean DASH scores of 6.5, a mean OES of 90.6, and mean patient satisfaction ratings of 85.6.

“As in previous work, many patients experienced loss of terminal elbow extension, although this had little impact on patient-reported outcomes,” Middleton said. “With the results of flexion, however, patients were likely to be less satisfied and more likely to report functional impairments. In particular, greater movement predicted improved pain and function … in keeping with the rationale of early active movement as a treatment strategy to avoid joint stiffness and contracture.”

The researchers observed a correlation between the DASH, OES and satisfaction scores, and absolute range of movement, Middleton said. Overall satisfaction was also related to the OES and DASH score, and the OES and DASH scores correlated with each other. Controlling for age, Middleton and colleagues found women, as well as patients with reduced absolute range of elbow flexion, were more likely to report worse DASH scores. Women also had poorer scores on the psychosocial component of the OES. Reduced elbow flexion–extension arc of movement predicted poorer scores in the overall OES, the pain component and overall satisfaction, based on the results. – by Tina DiMarcantonio

Reference:

• Middleton S, Anakwe R, Jenkins P, et al. Long-term patient-reported outcomes after simple dislocation of the elbow. Paper #1167. Presented at the 12th EFORT Congress 2011. June 1-4. Copenhagen.

• Scott D. Middleton, MB, ChB, can be reached at the Orthopaedic Trauma Unit, Royal Infirmary of Edinburgh, 51 Little France Crescent, Edinburgh, EH16 4SA, Scotland, United Kingdom; +44 131 536 1000; email: scottmiddleton@doctors.org.uk.
• Disclosure: Middleton has no relevant financial disclosure.

Middleton and colleagues have reported on the long-term results of nonoperative management of “simple” elbow dislocations and have shown that the condition is not as benign as the term “simple” would imply. While instability is a rare long-term complication of this condition, residual stiffness, pain and functional limitations were commonplace. I have long felt that the term “simple elbow dislocation” should be eliminated and replaced with “ligamentous dislocation” and “fracture-dislocation” to differentiate those that are primarily soft tissue injuries from those that are combination ligamentous and bony injuries.

The amount of energy necessary to dislocate the elbow is tremendous, and the soft tissue injury is typically extensive; so as the authors indicate, it is not surprising to have long-term sequelae. On the other hand, when bony injuries are not present and recurrent instability is less of a concern, there is the potential to “over-treat” these injuries with extended splinting. The authors clearly show that loss of elbow flexion (not extension, which is common) can lead to poorer functional outcomes, patient satisfaction and residual pain. This article should serve to remind treating physicians that meticulous attention to rehabilitation following these injuries is critical to improve long-term outcomes.

— William N. Levine, MD
Orthopedics Today Editorial Board member
Vice Chairman and Professor, Department of Orthopaedic Surgery
Co-Director, Center for Shoulder, Elbow, and Sports Medicine
Columbia University Medical Center, New York
Disclosure: He has no relevant financial disclosures.