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Simple elbow dislocation among adults: A comparative study of two different methods of treatment
Injury, Int. J. Care Injured (2007) 38, 1254—1258
www.elsevier.com/locate/injury
Simple elbow dislocation among adults: A comparative study of two different methods of treatment Subramanyam Naidu Maripuri, Ujjwal Kanti Debnath *, Prabhakar Rao, Khitish Mohanty Department of Trauma and Orthopaedics, University Hospital of Wales, Heath Park, Cardiff, CF14 4XW, UK Accepted 12 February 2007
KEYWORDS Simple elbow dislocation; Plaster immobilisation; Early mobilisation
Summary Post-manipulation treatment of elbow dislocation includes plaster of Paris immobilisation for a mean of 2 weeks followed by physiotherapy, or sling support followed by early mobilisation. This study retrospectively reviewed 42 simple elbow dislocations. The management of 20 patients by the plaster of Paris method and 22 by the sling method was assessed after a minimum follow-up of 2 years using Mayo Elbow Performance Index (MEPI) scores, the Quick Disabilities of the Arm, Shoulder and Hand (DASH) questionnaire and time off work. The final functional outcome in the plaster of Paris group showed 10 excellent, 2 good, 5 fair and 3 poor results, compared with 19 excellent, 1 good and 2 fair results in the sling group. The mean times to return to work in plaster of Paris group and sling group were 6.6 and 3.2 weeks, respectively ( p < 0.001). Early mobilisation did not result in redislocation or late instability of the elbow. Thus the final functional outcome of the sling and early mobilisation group was significantly better than in the plaster of Paris immobilisation group. # 2007 Elsevier Ltd. All rights reserved.
Introduction The elbow is the second most common site for nonprosthetic joint dislocation.3,15 Elbow stiffness has been the most common complication following * Corresponding author. Present address: 23, Barons Court Road, Cardiff, CF23 9DF, UK. Tel.: +44 7811165794; fax: +44 2920453745. E-mail address: [email protected] (U.K. Debnath).
dislocation.3,5,8 Except in the case of dislocations with associated osseous lesions, conservative treatment is the mainstay of management.4 There is evidence that larger flexion contracture is associated with longer immobilisation after simple dislocation.8 Traditionally, the elbow is placed in a plaster of Paris (POP) cast for a few weeks after closed reduction, followed by physiotherapy. Better understanding of the pathomechanics of elbow dislocation in recent years has led to a change in
0020–1383/$ — see front matter # 2007 Elsevier Ltd. All rights reserved. doi:10.1016/j.injury.2007.02.040
Simple elbow dislocation in adults
1255
treatment trends.3,11,14 The current trend is to treat simple dislocations with early, aggressive physiotherapy following closed reduction, without any form of immobilisation.3,11,14 From the literature, it is evident that immobilisation for more than 2 weeks is not advisable in view of likely complications,8 but it is not clear whether immobilisation for less than 2 weeks is justified for simple elbow dislocations. There are no comparative studies of these two different treatment trends in English literature. In this retrospective study, we compared the outcome of the two methods, i.e. POP immobilisation for a mean duration of 2 weeks, and early mobilisation with sling support only.
Methods We retrospectively analysed the cases of 47 patients with a mean age 42.5 years (range 16—64 years), who were treated at our institution for simple dislocation of elbow between 2000 and 2004. After a minimum follow-up of 2 years (range 2—5 years), the cases of 42 people (19 males and 23 females) were reviewed; 5 individuals were lost to follow-up. The criteria for inclusion were defined as: age 16 years or older; dislocation simple and treated with closed reduction; concentric relocation confirmed by radiography; and minimum follow-up of 2 years. A simple dislocation is defined as a closed dislocation without any associated fractures or neurovascular deficit. The two groups were comparable in variables such as age, gender, mechanism of injury, hand dominance, absence of previous elbow injury or stiffness and absence of associated ipsilateral arm fractures (Table 1). All cases were initially treated by attempted manipulation under sedation (MUS) in the emergency department. Where this was unsuccessful, manipulation under anaesthesia (MUA) in theatre was performed. The method of relocation of elbow was uniform in all cases, i.e. the push—pull technique. The allocation of treatment method was entirely dependent upon the treating doctor, and there were no other factors affecting the allocation. The treatment decision was not influenced by the
swelling or severity of injury, since all the dislocations in this series resulted from low-energy impact following falls. Cases were divided into two groups depending on the management after closed reduction. POP immobilisation was the treatment selected in 20 cases, for a mean of 14 days (range 12—20 days), followed by physiotherapy. Sling application and early mobilisation was selected in 22 cases; the sling group were allowed early active movements within the limits of pain. No passive stretching was used in the rehabilitation in either group. The criterion for discharge from physiotherapy was a 1008 arc of motion of the affected elbow. At the final follow-up examination, all the patients were assessed using the Mayo Elbow Performance Index (MEPI) and the Quick Disabilities of the Arm, Shoulder and Hand (DASH) questionnaire. The follow-up was performed by SNM and UKD, who were not the treating surgeons. We recorded age, gender, dominance of hand, laterality (i.e. right or left side), mechanism of injury, initial method of reduction, post-reduction treatment method, initiation of physiotherapy, duration of physiotherapy and time taken to return to work. Radiographs were reviewed carefully to exclude fractures and loose bodies, and to determine the direction of dislocation. The components of MEPI score include pain, arc of movement, stability and daily function with a maximum possible total score of 100. All the patients were questioned carefully about pain, its severity and response to analgesics, and rest pain. Arc of movement was measured by standard goniometric assessment. Stability of joint was evaluated by varus and valgus stress tests. The outcome was graded as excellent (90—100 points), good (75—89 points), fair (60—74 points) or poor (<60 points). The Quick DASH is scored in two components: the disability/symptom section (11 items, scored 1—5) and the optional high-performance sport/music or work modules (4 items, scored 1—5). The assigned values for all completed responses are simply summed and averaged, producing a score out of 5; this value is then transformed to a score out of 100 by subtracting 1 and multiplying by 25. The transformation makes the score easier to compare
Table 1 Demographic data for the two groups Group
Number in group
Mean agea (range)
M:F
Injury on dominant: non-dominant side
Previous elbow injury or stiffness
Ipsilateral arm fractures
Mechanism of injury
Sling POP
22 20
41 (19—60) 44 (16—64)
10:12 9:11
11:11 9:11
Nil Nil
Nil Nil
Simple fall Simple fall
POP, plaster of Paris; M, male; F, female. a In years.
1256
S.N. Maripuri et al.
Figure 1 Showing initiation of physiotherapy in two different groups.
with other measures scaled 0—100. A higher score indicates greater disability. Statistical analysis was carried out with SPSS (version 14, Chicago, IL, USA). Student’s t-test was performed for comparing outcome scores between the two groups.
Results Elbow dislocation was more prevalent among females, with a male:female ratio of 1:1.33. Prevalence of elbow dislocation on the left side was slightly higher than on the right side (23:19). There were 22 non-dominant and 20 dominant elbow dislocations. Posterolateral dislocation was the most common (60%), followed by direct posterior (30%) and posteromedial (10%) dislocations. There were no anterior dislocations. Initiation of physiotherapy was comparatively delayed in the POP group; all the patients in
Figure 2 Showing the total duration of physiotherapy in two groups.
the sling group started physiotherapy within 2 weeks, whereas only 50% in POP group undertook physiotherapy at 2 weeks (Fig. 1). The duration of physiotherapy was longer in POP group (Fig. 2). The mean MEPI scores in the POP and sling groups were 83.8 and 96.5, respectively ( p < 0.05). The mean Quick DASH scores in the POP and sling groups were 12.8 and 2.7, respectively ( p < 0.05). The POP group regained function of the elbow significantly later, after a mean of 6.6 weeks, compared with the sling group, who regained function after a mean of 3.2 weeks ( p < 0.001). There was one recurrent dislocation in the POP group, which was stabilised surgically later on. The final functional outcomes (Tables 2 and 3) in the POP group were 10 excellent, 2 good, 5 fair, 3 poor; and in the sling group were 19 excellent, 1 good, 2 fair ( p < 0.05).
Table 2 Final outcome (Mayo Elbow Performance Index score) of the two groups Group
Number in group
Excellent
Good
Fair
Poor
Sling POP
22 20
19 10
1 2
2 5
0 3
POP, plaster of Paris; excellent, 90—100; good, 75—89; fair, 60—74; poor, <60.
Table 3 Differences in functional scores between the two groups Measure
Sling group (S.E.M.)
POP group (S.E.M.)
p-Value a
MEPI (mean score) DASH (mean score) Weeks off work (mean)
96.5 (1.9) 2.7 (1.5) 3.2 (0.29)
83.8 (4.2) 12.8 (3.5) 6.6 (0.64)
<0.05 <0.05 <0.001
MEPI, Mayo Elbow Performance Index; S.E.M., standard error of mean; DASH, Disabilities of the Arm, Shoulder and Hand. a Student’s t-test.
Simple elbow dislocation in adults
Discussion Rest and motion are the two most common methods of treatment of injured musculoskeletal tissues.16,17 The post-manipulation management of elbow dislocations ranges from aggressive immediate motion to traditional POP immobilisation. In the past, several authors suggested a period of immobilisation lasting up to 2 weeks.1,7,13 Mehlhoff et al. suggested that gentle active flexion should be started as soon as pain allows and unprotected flexion-extension should be initiated before 2 weeks.8 The disadvantages of immobilisation have been widely recognised (e.g. pain, persistent stiffness, late degenerative changes, etc.).4,16,17 Longer immobilisation resulted in larger flexion contracture and unsatisfactory results.8 Early mobilisation, on the other hand, does not contribute to a higher incidence of instability and redislocation.2,8 Ross et al. used an immediate motion protocol after closed reduction without any immobilisation and achieved 95% excellent results in their study.14 The natural stability of the elbow joint against dislocation results primarily from its bony architecture, reinforced by the medial and lateral thickening of the capsule.10 With flexion, posterior dislocation is prevented by abutment of the radial head against the capitellum and of the coronoid process against the trochlea. With full extension, the coronoid process impacts against the trochlea and the olecranon process locks itself into the olecranon fossa, which affords stability.10 Osseous articulation alone contributes to a third of joint stability in both flexion and extension.9 This inherent stability should be enough to allow early mobilisation in most simple dislocations, with a caution to avoid valgus stress.8 Most authors reported favourable results after conservative management. Children have a better final functional outcome than adults.1,5 The success of non-operative management is thus explained by the stabilising effect of joint surfaces, particularly during ligamentous healing.6 Protzman suggested immediate reduction, followed by 1—5 days of immobilisation, for uncomplicated dislocations.13 Salter’s clinical observation and research on the deleterious effects of immobilisation on joints led him to the biological concept of continuous passive motion.16,17 However, the elbow joint is an exception to this principle since it has a natural tendency to develop myositis ossificans following passive movements. Forceful passive manipulation in the rehabilitation period should be avoided, to prevent this complication.18 Although evidence is growing in favour of early active mobilisation, there are no studies compar-
1257 ing the outcome of different treatment methods for simple elbow dislocation.12 Royle compared the outcome of plaster immobilisation versus sling and early mobilisation, but most of their study group had associated fractures.15 In the present study, we compared the outcome of the two different treatment methods with the emphasis on return to function, initiation of physiotherapy and duration of physiotherapy. The results were excellent in 86% (19/22) of the sling group and 50% (10/20) of the POP group. The immediate motion protocol used by Ross et al. was quite intense and the study group were young (aged 18—24 years) and highly motivated.14 This protocol may not be practicable in all centres. The sling and early mobilisation method in the present study was a middle path between POP immobilisation and the immediate motion protocol. O’Driscoll et al. studied cadaveric elbow specimens and found no significant increase in valgus laxity after reduction, compared with the intact elbows during simulated active flexion. If valgus stability is demonstrated with the forearm in pronation, they recommend immediate mobilisation in a hinged cast brace.11 One case of redislocation in our series despite POP immobilisation, and the absence of redislocations in the sling group, suggest that early mobilisation does not contribute to instability. Josefsson provided favourable support to this conclusion.5,6 There are limitations to this study, i.e. it is a retrospective review with an entirely doctor-dependent selection of post-reduction treatment method. Since valgus instability was tested only in individuals who underwent MUA (one-third of the total), it was difficult to correlate the initial instability in either of the groups. We conclude that early active mobilisation is a safe and cost-effective method of treatment in simple elbow dislocations. A sling may be applied for comfort while not exercising. Early mobilisation did not result in redislocation or late instability of elbow. The duration of physiotherapy and time taken to return to work were significantly shorter in the sling and early mobilisation group. The final functional outcomes of the sling and early mobilisation group were significantly better than in the POP immobilisation group.
Acknowledgement We thank Katie Jenkins for assistance with collection of case notes and organising clinic appointments.
1258
References 1. Borris LC, Lassen MR, Christensen CS. Elbow dislocations in children and adults. A long-term follow-up of conservatively treated patients. Acta Orthop Scand 1987;58: 649—51. 2. Conn Jr J, Wade P. Injuries of the elbow: a ten year review. J Trauma 1961;1:248—68. 3. Coonrad RW, Roush TF, Major NM, et al. The drop sign, a radiographic warning of elbow instability. J Shoulder Elbow Surg 2005;14:312—7. 4. Habernek H, Ortner F. The influence of anatomic factors in elbow joint dislocation. Clin Orthop 1982;274:226—30. 5. Josefsson PO, Johnell O, Gentz CF. Long term sequelae of simple dislocation of the elbow. J Bone Joint Surg 1984;66: 927—30. 6. Josefsson PO, Johnell O, Wendeberg B. Ligamentous injuries in dislocations of the elbow joint. Clin Orthop 1987;221: 221—5. 7. Lansinger O, Karlsson J, Korner L, et al. Dislocation of the elbow joint. Arch Orthop Trauma Surg 1984;102:183—6. 8. Mehlhoff TL, Noble PC, Bennet JB, et al. Simple dislocation of the elbow in adult. J Bone Joint Surg Am 1988;70: 244—9.
S.N. Maripuri et al. 9. Morrey BF, An KN. Articular and ligamentous contributions to the stability of the elbow joint. Am J Sports Med 1983;11: 315—9. 10. Neviaser JS, Wickstrom JK. Dislocation of the elbow: a retrospective study of 115 patients. Southern Med J 1977;70:172—3. 11. O’Driscoll SW, Morrey BF, Korinek S, et al. Elbow subluxation and dislocation. A spectrum of instability. Clin Orthop 1992;280:186—97. 12. Potier KCS. Best evidence topic reports. Plaster or collar and cuff after reducing dislocated elbow. Emerg Med J 2004;21: 337—8. 13. Protzman R. Dislocation of the elbow joint. J Bone Joint Surg Am 1978;60:539—41. 14. Ross G, McDevitt ER, Chronister R, et al. Treatment of simple elbow dislocation using an immediate motion protocol. Am J Sports Med 1999;27:308—11. 15. Royle SG. Posterior dislocation of elbow. Clin Orthop 1991;269:201—4. 16. Salter RB. The biologic concept of continuous passive motion of synovial joints. Clin Orthop 1989;242:12—25. 17. Salter RB. The physiologic basis of continuous passive motion for articular cartilage healing and regeneration. Hand Clin 1994;10:211—9. 18. Watson-Jones R. 6th ed., Fractures and joint injuries, vol. 2, 6th ed. London: Churchill Livingstone; 1982. p. 632.
www.elsevier.com/locate/injury
Simple elbow dislocation among adults: A comparative study of two different methods of treatment Subramanyam Naidu Maripuri, Ujjwal Kanti Debnath *, Prabhakar Rao, Khitish Mohanty Department of Trauma and Orthopaedics, University Hospital of Wales, Heath Park, Cardiff, CF14 4XW, UK Accepted 12 February 2007
KEYWORDS Simple elbow dislocation; Plaster immobilisation; Early mobilisation
Summary Post-manipulation treatment of elbow dislocation includes plaster of Paris immobilisation for a mean of 2 weeks followed by physiotherapy, or sling support followed by early mobilisation. This study retrospectively reviewed 42 simple elbow dislocations. The management of 20 patients by the plaster of Paris method and 22 by the sling method was assessed after a minimum follow-up of 2 years using Mayo Elbow Performance Index (MEPI) scores, the Quick Disabilities of the Arm, Shoulder and Hand (DASH) questionnaire and time off work. The final functional outcome in the plaster of Paris group showed 10 excellent, 2 good, 5 fair and 3 poor results, compared with 19 excellent, 1 good and 2 fair results in the sling group. The mean times to return to work in plaster of Paris group and sling group were 6.6 and 3.2 weeks, respectively ( p < 0.001). Early mobilisation did not result in redislocation or late instability of the elbow. Thus the final functional outcome of the sling and early mobilisation group was significantly better than in the plaster of Paris immobilisation group. # 2007 Elsevier Ltd. All rights reserved.
Introduction The elbow is the second most common site for nonprosthetic joint dislocation.3,15 Elbow stiffness has been the most common complication following * Corresponding author. Present address: 23, Barons Court Road, Cardiff, CF23 9DF, UK. Tel.: +44 7811165794; fax: +44 2920453745. E-mail address: [email protected] (U.K. Debnath).
dislocation.3,5,8 Except in the case of dislocations with associated osseous lesions, conservative treatment is the mainstay of management.4 There is evidence that larger flexion contracture is associated with longer immobilisation after simple dislocation.8 Traditionally, the elbow is placed in a plaster of Paris (POP) cast for a few weeks after closed reduction, followed by physiotherapy. Better understanding of the pathomechanics of elbow dislocation in recent years has led to a change in
0020–1383/$ — see front matter # 2007 Elsevier Ltd. All rights reserved. doi:10.1016/j.injury.2007.02.040
Simple elbow dislocation in adults
1255
treatment trends.3,11,14 The current trend is to treat simple dislocations with early, aggressive physiotherapy following closed reduction, without any form of immobilisation.3,11,14 From the literature, it is evident that immobilisation for more than 2 weeks is not advisable in view of likely complications,8 but it is not clear whether immobilisation for less than 2 weeks is justified for simple elbow dislocations. There are no comparative studies of these two different treatment trends in English literature. In this retrospective study, we compared the outcome of the two methods, i.e. POP immobilisation for a mean duration of 2 weeks, and early mobilisation with sling support only.
Methods We retrospectively analysed the cases of 47 patients with a mean age 42.5 years (range 16—64 years), who were treated at our institution for simple dislocation of elbow between 2000 and 2004. After a minimum follow-up of 2 years (range 2—5 years), the cases of 42 people (19 males and 23 females) were reviewed; 5 individuals were lost to follow-up. The criteria for inclusion were defined as: age 16 years or older; dislocation simple and treated with closed reduction; concentric relocation confirmed by radiography; and minimum follow-up of 2 years. A simple dislocation is defined as a closed dislocation without any associated fractures or neurovascular deficit. The two groups were comparable in variables such as age, gender, mechanism of injury, hand dominance, absence of previous elbow injury or stiffness and absence of associated ipsilateral arm fractures (Table 1). All cases were initially treated by attempted manipulation under sedation (MUS) in the emergency department. Where this was unsuccessful, manipulation under anaesthesia (MUA) in theatre was performed. The method of relocation of elbow was uniform in all cases, i.e. the push—pull technique. The allocation of treatment method was entirely dependent upon the treating doctor, and there were no other factors affecting the allocation. The treatment decision was not influenced by the
swelling or severity of injury, since all the dislocations in this series resulted from low-energy impact following falls. Cases were divided into two groups depending on the management after closed reduction. POP immobilisation was the treatment selected in 20 cases, for a mean of 14 days (range 12—20 days), followed by physiotherapy. Sling application and early mobilisation was selected in 22 cases; the sling group were allowed early active movements within the limits of pain. No passive stretching was used in the rehabilitation in either group. The criterion for discharge from physiotherapy was a 1008 arc of motion of the affected elbow. At the final follow-up examination, all the patients were assessed using the Mayo Elbow Performance Index (MEPI) and the Quick Disabilities of the Arm, Shoulder and Hand (DASH) questionnaire. The follow-up was performed by SNM and UKD, who were not the treating surgeons. We recorded age, gender, dominance of hand, laterality (i.e. right or left side), mechanism of injury, initial method of reduction, post-reduction treatment method, initiation of physiotherapy, duration of physiotherapy and time taken to return to work. Radiographs were reviewed carefully to exclude fractures and loose bodies, and to determine the direction of dislocation. The components of MEPI score include pain, arc of movement, stability and daily function with a maximum possible total score of 100. All the patients were questioned carefully about pain, its severity and response to analgesics, and rest pain. Arc of movement was measured by standard goniometric assessment. Stability of joint was evaluated by varus and valgus stress tests. The outcome was graded as excellent (90—100 points), good (75—89 points), fair (60—74 points) or poor (<60 points). The Quick DASH is scored in two components: the disability/symptom section (11 items, scored 1—5) and the optional high-performance sport/music or work modules (4 items, scored 1—5). The assigned values for all completed responses are simply summed and averaged, producing a score out of 5; this value is then transformed to a score out of 100 by subtracting 1 and multiplying by 25. The transformation makes the score easier to compare
Table 1 Demographic data for the two groups Group
Number in group
Mean agea (range)
M:F
Injury on dominant: non-dominant side
Previous elbow injury or stiffness
Ipsilateral arm fractures
Mechanism of injury
Sling POP
22 20
41 (19—60) 44 (16—64)
10:12 9:11
11:11 9:11
Nil Nil
Nil Nil
Simple fall Simple fall
POP, plaster of Paris; M, male; F, female. a In years.
1256
S.N. Maripuri et al.
Figure 1 Showing initiation of physiotherapy in two different groups.
with other measures scaled 0—100. A higher score indicates greater disability. Statistical analysis was carried out with SPSS (version 14, Chicago, IL, USA). Student’s t-test was performed for comparing outcome scores between the two groups.
Results Elbow dislocation was more prevalent among females, with a male:female ratio of 1:1.33. Prevalence of elbow dislocation on the left side was slightly higher than on the right side (23:19). There were 22 non-dominant and 20 dominant elbow dislocations. Posterolateral dislocation was the most common (60%), followed by direct posterior (30%) and posteromedial (10%) dislocations. There were no anterior dislocations. Initiation of physiotherapy was comparatively delayed in the POP group; all the patients in
Figure 2 Showing the total duration of physiotherapy in two groups.
the sling group started physiotherapy within 2 weeks, whereas only 50% in POP group undertook physiotherapy at 2 weeks (Fig. 1). The duration of physiotherapy was longer in POP group (Fig. 2). The mean MEPI scores in the POP and sling groups were 83.8 and 96.5, respectively ( p < 0.05). The mean Quick DASH scores in the POP and sling groups were 12.8 and 2.7, respectively ( p < 0.05). The POP group regained function of the elbow significantly later, after a mean of 6.6 weeks, compared with the sling group, who regained function after a mean of 3.2 weeks ( p < 0.001). There was one recurrent dislocation in the POP group, which was stabilised surgically later on. The final functional outcomes (Tables 2 and 3) in the POP group were 10 excellent, 2 good, 5 fair, 3 poor; and in the sling group were 19 excellent, 1 good, 2 fair ( p < 0.05).
Table 2 Final outcome (Mayo Elbow Performance Index score) of the two groups Group
Number in group
Excellent
Good
Fair
Poor
Sling POP
22 20
19 10
1 2
2 5
0 3
POP, plaster of Paris; excellent, 90—100; good, 75—89; fair, 60—74; poor, <60.
Table 3 Differences in functional scores between the two groups Measure
Sling group (S.E.M.)
POP group (S.E.M.)
p-Value a
MEPI (mean score) DASH (mean score) Weeks off work (mean)
96.5 (1.9) 2.7 (1.5) 3.2 (0.29)
83.8 (4.2) 12.8 (3.5) 6.6 (0.64)
<0.05 <0.05 <0.001
MEPI, Mayo Elbow Performance Index; S.E.M., standard error of mean; DASH, Disabilities of the Arm, Shoulder and Hand. a Student’s t-test.
Simple elbow dislocation in adults
Discussion Rest and motion are the two most common methods of treatment of injured musculoskeletal tissues.16,17 The post-manipulation management of elbow dislocations ranges from aggressive immediate motion to traditional POP immobilisation. In the past, several authors suggested a period of immobilisation lasting up to 2 weeks.1,7,13 Mehlhoff et al. suggested that gentle active flexion should be started as soon as pain allows and unprotected flexion-extension should be initiated before 2 weeks.8 The disadvantages of immobilisation have been widely recognised (e.g. pain, persistent stiffness, late degenerative changes, etc.).4,16,17 Longer immobilisation resulted in larger flexion contracture and unsatisfactory results.8 Early mobilisation, on the other hand, does not contribute to a higher incidence of instability and redislocation.2,8 Ross et al. used an immediate motion protocol after closed reduction without any immobilisation and achieved 95% excellent results in their study.14 The natural stability of the elbow joint against dislocation results primarily from its bony architecture, reinforced by the medial and lateral thickening of the capsule.10 With flexion, posterior dislocation is prevented by abutment of the radial head against the capitellum and of the coronoid process against the trochlea. With full extension, the coronoid process impacts against the trochlea and the olecranon process locks itself into the olecranon fossa, which affords stability.10 Osseous articulation alone contributes to a third of joint stability in both flexion and extension.9 This inherent stability should be enough to allow early mobilisation in most simple dislocations, with a caution to avoid valgus stress.8 Most authors reported favourable results after conservative management. Children have a better final functional outcome than adults.1,5 The success of non-operative management is thus explained by the stabilising effect of joint surfaces, particularly during ligamentous healing.6 Protzman suggested immediate reduction, followed by 1—5 days of immobilisation, for uncomplicated dislocations.13 Salter’s clinical observation and research on the deleterious effects of immobilisation on joints led him to the biological concept of continuous passive motion.16,17 However, the elbow joint is an exception to this principle since it has a natural tendency to develop myositis ossificans following passive movements. Forceful passive manipulation in the rehabilitation period should be avoided, to prevent this complication.18 Although evidence is growing in favour of early active mobilisation, there are no studies compar-
1257 ing the outcome of different treatment methods for simple elbow dislocation.12 Royle compared the outcome of plaster immobilisation versus sling and early mobilisation, but most of their study group had associated fractures.15 In the present study, we compared the outcome of the two different treatment methods with the emphasis on return to function, initiation of physiotherapy and duration of physiotherapy. The results were excellent in 86% (19/22) of the sling group and 50% (10/20) of the POP group. The immediate motion protocol used by Ross et al. was quite intense and the study group were young (aged 18—24 years) and highly motivated.14 This protocol may not be practicable in all centres. The sling and early mobilisation method in the present study was a middle path between POP immobilisation and the immediate motion protocol. O’Driscoll et al. studied cadaveric elbow specimens and found no significant increase in valgus laxity after reduction, compared with the intact elbows during simulated active flexion. If valgus stability is demonstrated with the forearm in pronation, they recommend immediate mobilisation in a hinged cast brace.11 One case of redislocation in our series despite POP immobilisation, and the absence of redislocations in the sling group, suggest that early mobilisation does not contribute to instability. Josefsson provided favourable support to this conclusion.5,6 There are limitations to this study, i.e. it is a retrospective review with an entirely doctor-dependent selection of post-reduction treatment method. Since valgus instability was tested only in individuals who underwent MUA (one-third of the total), it was difficult to correlate the initial instability in either of the groups. We conclude that early active mobilisation is a safe and cost-effective method of treatment in simple elbow dislocations. A sling may be applied for comfort while not exercising. Early mobilisation did not result in redislocation or late instability of elbow. The duration of physiotherapy and time taken to return to work were significantly shorter in the sling and early mobilisation group. The final functional outcomes of the sling and early mobilisation group were significantly better than in the POP immobilisation group.
Acknowledgement We thank Katie Jenkins for assistance with collection of case notes and organising clinic appointments.
1258
References 1. Borris LC, Lassen MR, Christensen CS. Elbow dislocations in children and adults. A long-term follow-up of conservatively treated patients. Acta Orthop Scand 1987;58: 649—51. 2. Conn Jr J, Wade P. Injuries of the elbow: a ten year review. J Trauma 1961;1:248—68. 3. Coonrad RW, Roush TF, Major NM, et al. The drop sign, a radiographic warning of elbow instability. J Shoulder Elbow Surg 2005;14:312—7. 4. Habernek H, Ortner F. The influence of anatomic factors in elbow joint dislocation. Clin Orthop 1982;274:226—30. 5. Josefsson PO, Johnell O, Gentz CF. Long term sequelae of simple dislocation of the elbow. J Bone Joint Surg 1984;66: 927—30. 6. Josefsson PO, Johnell O, Wendeberg B. Ligamentous injuries in dislocations of the elbow joint. Clin Orthop 1987;221: 221—5. 7. Lansinger O, Karlsson J, Korner L, et al. Dislocation of the elbow joint. Arch Orthop Trauma Surg 1984;102:183—6. 8. Mehlhoff TL, Noble PC, Bennet JB, et al. Simple dislocation of the elbow in adult. J Bone Joint Surg Am 1988;70: 244—9.
S.N. Maripuri et al. 9. Morrey BF, An KN. Articular and ligamentous contributions to the stability of the elbow joint. Am J Sports Med 1983;11: 315—9. 10. Neviaser JS, Wickstrom JK. Dislocation of the elbow: a retrospective study of 115 patients. Southern Med J 1977;70:172—3. 11. O’Driscoll SW, Morrey BF, Korinek S, et al. Elbow subluxation and dislocation. A spectrum of instability. Clin Orthop 1992;280:186—97. 12. Potier KCS. Best evidence topic reports. Plaster or collar and cuff after reducing dislocated elbow. Emerg Med J 2004;21: 337—8. 13. Protzman R. Dislocation of the elbow joint. J Bone Joint Surg Am 1978;60:539—41. 14. Ross G, McDevitt ER, Chronister R, et al. Treatment of simple elbow dislocation using an immediate motion protocol. Am J Sports Med 1999;27:308—11. 15. Royle SG. Posterior dislocation of elbow. Clin Orthop 1991;269:201—4. 16. Salter RB. The biologic concept of continuous passive motion of synovial joints. Clin Orthop 1989;242:12—25. 17. Salter RB. The physiologic basis of continuous passive motion for articular cartilage healing and regeneration. Hand Clin 1994;10:211—9. 18. Watson-Jones R. 6th ed., Fractures and joint injuries, vol. 2, 6th ed. London: Churchill Livingstone; 1982. p. 632.