Hindawi Publishing Corporation

Advances in Orthopedics
Volume 2013, Article ID 951397, 11 pages
http://dx.doi.org/10.1155/2013/951397

Review Article
Elbow Dislocations: A Review Ranging from Soft Tissue Injuries
to Complex Elbow Fracture Dislocations

Carsten Englert,1 Johannes Zellner,1 Michael Koller,2

Michael Nerlich,1 and Andreas Lenich3
1
Department of Trauma Surgery, University Hospital Regensburg, Franz-Josef-Strauss-Allee 11,
93053 Regensburg, Germany
2
Centre for Clinical Studies, University Hospital Regensburg, Franz-Josef-Strauss-Allee 11,
93053 Regensburg, Germany
3
Department of Orthopedic Surgery, Ismaninger Strasse 22, 81675 Muenchen, Germany

Correspondence should be addressed to Carsten Englert; [email protected]

Received 30 June 2013; Accepted 21 August 2013

Academic Editor: Masato Takao

Copyright © 2013 Carsten Englert et al. This is an open access article distributed under the Creative Commons Attribution License,
which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

This review on elbow dislocations describes ligament and bone injuries as well as the typical injury mechanisms and the main
classifications of elbow dislocations. Current treatment concepts of simple, that is, stable, or complex unstable elbow dislocations
are outlined by means of case reports. Special emphasis is put on injuries to the medial ulnar collateral ligament (MUCL) and on
posttraumatic elbow stiffness.

1. Introduction O’Driscoll, who has also classified posttraumatic elbow insta-

bility according to the following five criteria: the articulations
Even simple elbow dislocations do not necessarily represent involved, the direction of the displacement, the degree of
benign injuries. Anakwe showed in a retrospective trial with the displacement, the timing, and the presence or absence of
almost 180 patients that simple elbow dislocations caused associated fractures [3]. Fractures of a bony structure with
considerable residual pain and stiffness in 62% and 56% of the a buttress function immediately result in elbow instability.
patients, respectively [1]. According to Anakwe, elbow dislo- The function of the medial ulnar collateral ligament complex
cations can be defined as simple if an elbow is stable when put and particularly its role in complex elbow dislocations has
through full range of motion after repositioning. Typically, been investigated intensively. However, single injuries to the
simple elbow dislocations occur when a person falls onto an MUCL seem to be rare.
outstretched hand. Axial compression on the elbow in com- Overall, injury classification helps to understand the
bination with supination and valgus stress primarily result in pathology of a trauma and aids in making decisions on the
the rupture of the lateral ulnar collateral ligament (LUCL), best form of treatment. However, not all of the wide range
which may cause posterolateral subluxation (Figure 1(a)). of treatment options available correspond to the criteria
Extended elbow dislocations often involve severe ruptures of evidence-based medicine [4]. Therefore, we present a
with anterior and posterior capsule distractions followed by treatment algorithm that is based on our clinical evidence
muscle injuries and, finally, by total elbow dislocation with with our preferred classification of elbow dislocations.
rupture of the anterior MUCL (Figure 1(b)). This ligament Drawbacks and complications during the treatment of elbow
tends to rupture in two stages; that is, the rupture of the dislocations are of particular interest, and special emphasis is
posterior MUCL (Figure 1(a)) is followed by the rupture placed on elbow stiffness. We also discuss new basic scientific
of the anteromedial bundle of the ligament complex [2, 3] aspects of the treatment of this complication and present
(Figure 1(b)). This trauma mechanism has been described by first clinical results.
2 Advances in Orthopedics

(a) (b) (c)

Figure 1: (a) Dorsal view to an anatomic elbow preparation. The posterior lateral ulnar collateral ligament (LUCL) and the posterior medial
ulnar collateral ligament (MUCL) are visible. The posterior part of the ligamentum annulare with its insertion to the ulnar and the above
lying distal part of the LCL can be seen. (b) Ventral view to an anatomic elbow preparation with demonstration of the anterior medial ulnar
collateral ligament (aMUCL). The plane joint surface of the anteromedial facet of the olecranon can be seen, which has a buttress function
in varus and valgus stress. (c) Lateral view to an anatomical elbow preparation with an illustration of the lateral collateral ligament complex
(LCL) which is formed by the annular ring running to the radial epicondyle humeri.

2. The Anatomy and Biomechanics of is given by capsular and ligamentous structures [5]. Valgus
Ligaments and Bony Structures elbow stability depends on ligaments as well as on bony struc-
tures [6]. Experiments imitating coronoid fractures without
The elbow represents one of the most stable joints in the any injuries to the ligaments as classified by Morrey have
human body. The close connection of the ulnohumeral and shown that resection of the radial head mainly influences
the capitulo-radial joints results in a high range of motion of valgus and external rotation, whereas coronoid deficiency
the elbow with regard to extension and flexion as well as the results in varus laxity and posterior translation (Figure 2(a)).
pronation and supination of the forearm. Bony structures, the Overall, the radial head comprises approximately 40% of the
joint capsule, as well as the lateral and medial ulnar collateral stabilizing surface.
ligaments allow direct motion control and high stability. Neither medial-oblique, lateral-oblique, nor even type II
The capitulo-radial joint compartment also contains ligament coronoid fractures caused any significant changes in elbow
structures. The radial head is surrounded by the annular liga- stability if the capsuloligamentous structures remained intact,
ment that holds the radial head in place and makes rotational even if the radial head had been removed. Type III fractures
movements possible. The annular ligament encloses the radial showed sudden angular and translational changes between
head and inserts the ulna in dorsal and palmar directions 30∘ and 60∘ of elbow flexion, both in the presence or
(Figure 1(c)). The part of the annular ligament that lies above absence of the radial head (Figure 2(b)). The radial head is
the LUCL runs into the lateral humeral epicondyle and forms an important stabilizer during valgus and external rotation
the lateral collateral ligament (LCL). Bones and ligaments are (Figure 2(a)), especially in type II or III coronoid fractures,
considered static and primary stabilizing factors. Secondary whereas valgus and external rotational stability depend on the
stabilizing factors are joint-crossing muscles that additionally remaining total articular surface of the radial head. Posterior
contribute to elbow stability [3]. and proximal translations are influenced by the isolated
The bony structures of the humeral trochlea sulcus and articular surface involvement of the coronoid [7].
the connecting sigmoid notch of the olecranon have a buttress The MUCL is composed of three branches, the anterior,
function and are the main stabilizing factor in varus and the posterior, and the oblique bundle, which is also com-
valgus stress and during rotational movements (Figure 1(b)). monly termed “transverse ligament.” Gross anatomical trials
Caused by the semilunar surface of the capitulum humeri and have shown that the anterior bundle is easily distinguished
the olecranon, the range of motion is limited in extension and from the underlying joint capsule. The anterior bundle
flexion. Biomechanical trials have shown bony structures to consists of two separate histological layers: the deeper layer is
be the main stabilizers of the elbow. 55% of varus stress is composed of collagen bundles contained within the capsule,
absorbed by bone compartments in full extension and even and the shallower layer is a distinct ligamentous structure
75% at 90∘ of flexion. During varus stress, only minor support above the capsule. The anterior bundle originates from the
Advances in Orthopedics 3

(a) (b)

Figure 2: (a) The combined mechanical function of MUCL, anteromedial facet of the olecranon and radial head in valgus, and external
rotational stability are demonstrated. (b) The yellow spot on the anatomical preparation illustrates types I and II coronoid fractures. Type III
fractures of the olecranon (green spot) involve the anterior MUCL, which result in sudden angular and translational instability of the elbow
between 30∘ and 60∘ .

anteroinferior edge of the medial humeral epicondyle and complex [3, 12]. During pronation and extension of the elbow,
inserts on the sublime tubercle of the ulna. The posterior the maximal load is transmitted through the radial column
bundle originates from the posteroinferior aspect of the with up to 60% of the load. Even a single radial head fracture
medial humeral epicondyle and has a broad insertion on with an intact medial collateral ligament complex results
the medial edge of the olecranon. The posterior bundle is in up to 30% loss of resistance [13–15]. The posterolateral
not easily recognizable because it consists of a single layer rotational stability depends on the lateral ulnohumeral liga-
of collagen bundles within the posteromedial aspect of the ment, the ligamentum annulare, as well as on the muscular
capsule. The transverse ligament varies in both size and structures [16].
gross appearance because it extends from the inferomedial
margin of the coronoid process to the medial edge of the 3. Classification
olecranon [6]. Biomechanical trials have shown that the
MUCL predominantly contributes to the valgus stability of 3.1. Simple Elbow Dislocation from LUCL to MUCL.
the elbow. The tension of the anterior and posterior bundles O’Driscoll postulated that elbows dislocate in 3 stages
varies according to the degree of elbow flexion. In contrast to from the lateral to the medial side [3]. In simple posterior
the anterior and posterior bundles, the transverse ligament dislocations, the mechanism of injury can be thought of as a
is not important for elbow stability because it does not circle of soft tissue disruption that starts from the lateral side
span the ulnohumeral joint [8]. The anterior bundle of the and progresses to the medial side.
MUCL serves as the primary static stabilizer to valgus stress Stage 1 is characterized by the total disruption of the
from 20∘ to 120∘ of elbow flexion [9]. The anterior bundle lateral ulnar collateral ligament and the partial or total dis-
of the MUCL is more susceptible to valgus overload than ruption of the remaining lateral collateral ligament complex,
the posterior bundle in extension or at a low flexion angle. resulting in posterolateral rotatory subluxation of an elbow
The posterior bundle is more susceptible at higher flexion that may reduce spontaneously. Patients suffer from pain
angles of the elbow. However, other authors have reported when varus stress is applied to the elbow.
that the posterior bundle serves as a secondary stabilizer Stage 2 includes the disruption of the anterior capsule that
at high degrees of flexion [10]. Pollock et al. demonstrated results in incomplete elbow dislocation in a posterolateral
that posterior bundle sectioning resulted in a 30% increase direction. X-rays may show a coronoid process perched
in maximum varus and valgus laxity and a 29% increase in on the humeral trochlea. Reduction is very easy and often
maximum internal rotation during pronated active flexion. unknowingly instigated by patients when bending the elbow.
These findings suggest that the posterior bundle may be Stage 3 is divided into two subgroups:
important in the late cocking phase of throwing [11]. (a) Describing the disruption of all soft tissues sur-
The radial head is essential for the stability of the rounding and including the posterior part of the
radial column of the elbow, particularly in elbow dislocation medial collateral ligament except for the anterior
fractures involving injuries to the medial collateral ligament bundle. This bundle forms the pivot around which the
 4 Advances in Orthopedics

elbow dislocates in a posterior direction by way of a 3.5. Fracture Dislocations of the Elbow. Elbow dislocations are
posterolateral rotatory mechanism; not only characterized according to the morphological crite-
ria of the radial head and the coronoid, but mainly according
(b) Being the complete disruption of the medial collateral
to the direction of dislocation, namely, anterior, posterior,
ligament complex of the elbow [3].
and divergent. The position of the forearm is described to the
upper arm. Posterior dislocations are the most frequent, and
Another model described by Ring and Jupiter [17] divides
anterior dislocations are the least common form. Anterior
the stabilizing factors into anterior, posterior, medial, and
elbow dislocations always involve fractures of the olecranon.
lateral columns. The risk of chronic instability increases with
Divergent elbow dislocations separating the radius and the
the amount of columns injured. In this model, single MUCL
ulna occur in high-impact trauma and include rupture of
rupture is viewed as a minor injury. No different grading
the membrana interossea, ligamentum annulare, and often
exists for injuries to the MUCL in comparison to injuries to
rupture of the distal radioulnar joint.
the LUCL as classified by O’Driscoll.

3.2. Radial Head Fractures. Mason has classified radial head 3.6. Anterior or Transolecranon Fracture Dislocations. This
fractures into three types according to morph metric criteria complex injury occurs after a direct high-energy blow to
[18]. This classification was extended by Johanson, who the posterior aspect of the forearm with the elbow in 90∘ of
additionally described elbow dislocation: flexion [21]. The forearm dislocates in anterior direction in
relation to the incisura trochlearis in contrast to the anterior
Type I: 2-part radial head fractures without any or less than Monteggia dislocation. Distal of the ulna fracture line, the
2 mm of fragment dislocation, membrana interossea, and the distal radio-ulnar joint remain
intact. Anterior Monteggia dislocations involve additional
Type II: 2-part radial head fractures with more than 2 mm
injuries to the membrana interossea and the distal radio-
fragment dislocation,
ulnar joint [22].
Type III: multiple fragment radial head fractures that are sur-
gically reconstructable,
3.7. Posterior Monteggia Fracture Dislocations. This injury
Type IV: Radial head fractures with additional ligamentous occurs after high-energy traumas and involves a multifrag-
injury and dislocation. mentary fracture of the proximal ulna. Triangular or quad-
rangular fragments are frequent and typically involve the
3.3. Coronoid Process Fractures. Coronoid process fractures coronoid process. Usually, the radial head becomes fractured
have been classified by Regan und Morrey [19] as well as by and dislocated dorsally to the distal ulna fragment. The lateral
O’Driscoll et al. [2]. Regan and Morrey simplified matters ligament complex may be torn, but the medial ligament
by dividing coronoid fractures in the sagittal plane into two remains intact.
groups, above 50% or below 50% of the height measured In elbow dislocation fractures, it is most important to
from the tip to the baseline. O’Driscoll’s classification takes reconstruct the ulnohumeral joint, particularly fragments of
into account that coronoid process injuries are shear stress the coronoid base. The anteromedial bundle of the medial
fractures that involve the ligamentous insertion of the medial collateral ligament inserts on the coronoid base, stabilizing
ulnar collateral ligament complex (Figure 2(b)). Ulna stress the joint during valgus stress, which represents an important
leads to an avulsion fracture of the coronoid process by the part of the stabilizing medial column. Loss of the medial ulnar
anteromedial bundle of the medial ulnar collateral ligament collateral ligament in the context of a fractured coronoid be
(MUCL). treated surgically, for example, by splitting the flexor muscles
[23]. Complex fractures involving instability after internal
osteosynthesis and ligament reconstruction can be treated
3.4. Terrible Triad Injury. Injury mechanisms with com- with the additional application of a hinged fixator that can be
pressive force to the radial head and a fracture line in applied with a limited range of motion in very difficult cases
the radial neck should draw attention to the lateral ulnar [24–27].
collateral ligaments (LUCL). The combination of coronoid
and radial head fractures with rupture of the (LUCL) was first
described by Hotchkiss [20] and has been termed “terrible 4. Diagnostics
triad injury.” According to the stability criteria and column
theory established by Ring and Jupiter [17], at least two Patient questionnaires on elbow dislocations should include
stabilizing columns (anterior and lateral) are lost in such topics, such as trauma mechanism, impact, and posttrau-
injuries. Because of the coronoid fracture, the medial column matic neurological sensations. Clinical examinations should
may also be involved. If the fracture line crosses the coronoid start distally from the injured joint and include the check-
base, in which the anteromedial bundle of the (MUCL) ing of vascular, sensory, and muscular functions. Two-
inserts, the medial column is also lost. Resection of the dimensional X-ray images should be taken before and after
fractured radial head is likely to destabilize the elbow, which repositioning maneuvers and should include the radial head
increases the risk of further dislocation and posttraumatic and the olecranon. CT scans may be indicated in case of
instability. inconclusive X-ray results or if surgery is required.
Advances in Orthopedics 5

Table 1: Classification of elbow instability and labeling of injured categorized three stages of instability between athletes and
ligaments. nonathletes. Because of the lack of sufficient evidence-based
data, we developed our own posttrauma concept for simple
Direction of instability
elbow dislocations that was based on biomechanical findings
Varus Valgus and our own experience. Choice of therapy, that is, surgical or
LCL + LUCL 0∘ aMUCL conservative treatment, depends on the individual instability
LCL > LUCL 30∘ aMUCL > pMUCL criteria present. Severe joint and ligament reconstructions
LCL ≥ LUCL 60∘ aMUCL < MUCL (pMUCL) with persisting instability require elbow bridging with a
LUCL 90∘ MUCL (PMCL) hinged fixator with or without limited extension of the elbow
Overextension Ventral capsule + aMUCL + LCL to retain stability and joint movement [27], which will be
explained in the following.

5.1. Single Capsular and Ligamentous Injuries. In elbow dis-

locations, single ligamentous or capsular injuries are rare
[31]. Patients with stages 1 and 2 of elbow dislocations may
be treated by distraction and flexion, whereas patients with
severely dislocated elbows at stage 3 should only be treated
under anesthesia. For all patients, stability tests should be
carried out immediately. Patients suffering from pain should
also be treated under anesthesia and with technical support
by fluoroscopic guidance (Figure 3).
Once an elbow is stabile after reduction, a plaster
cast is applied for 3 to 5 days to maintain the forearm
in supination and the elbow flexed at 90∘ . Lymphatic
Ext/flex 0–30–60–90 ∘
drainage and a muscle pump should be applied. Accord-
Figure 3: Examination of the elbow joint under intensifier during ing to the guidelines developed by the German Associa-
0-30-60-90∘ of varus and valgus stresses. tion for Evidence-Based Medicine (Arbeitsgemeinschaft der
Wissenschaftlichen Medizinischen Fachgesellschaften e.V.,
AWMF), thrombosis prophylaxis is not necessary [32]. It is
Ligament elbow injuries are difficult to detect on X-ray mandatory, however, that patients are clinically reevaluated
images. For example, initial subluxation of the elbow with within 7 days after the trauma. To relieve the injured ligament
rupture of the (LUCL) may lead to persistent posteroradial complex (partially or completely torn LUCL and MUCL), a
instability [28]. Therefore, an MRI should be conducted in splinted brace with limited extension or flexion is applied for
inconclusive cases or in patients with clinical symptoms 6 weeks. The range of motion needs to be adjusted according
persisting for more than 10 days. to the injured ligament. For example, the torn LUCL could be
We recommend the following procedure for testing for set at 0-30-110∘ for extension and flexion in weeks 1 and 2, at
elbow ligamentous instability. The patient’s arm should be 0-20-120∘ in weeks 3 and 4, and at 0-10-130∘ in weeks 5 and
positioned under the radiograph intensifier as shown in 6. After the 6th week, free range of motion with lightweight
Figure 3. Humero-ulnar joints should be examined during should be possible. The range of motion is then expanded
valgus and varus stress tests at the flexion angles of 0∘ -30∘ - by 10∘ per week according to a patient’s pain symptoms.
60∘ -90∘ under the radiograph intensifier (Figure 3). Insta- Physiotherapists can monitor the healing process with its
bilities become visible by a widened joint gap that can be inflammatory reaction. However, elbow injuries may result
documented by a printout. A standardized documentation in stiffness as well as in instability. Both conditions have to be
may allow the specification of the injured ligaments (Table 1). identified during both surgical and conservative treatments,
and therapeutic strategies have to be adjusted according to
possible complications during the healing process.
5. Therapeutic Strategies for Elbow If an elbow is unstable in extension, it can rarely be
Dislocations Depend on the Injury stabilized by a plaster cast at 90∘ of flexion. In such cases, the
Classification cast has to be applied at 110∘ of flexion because such an angle
will reduce even most complex elbow dislocations (stage 3).
The main goal in the treatment of elbow injuries is mobi- The tension of the triceps tendon and the bony formation of
lization within the first three weeks after trauma. Unfor- the humeral groove to the proximal ulnar will reduce and
tunately, hardly any evidence-based data are available in stabilize the elbow in an anatomical position. Sometimes,
this respect [4]. Most of the relevant literature reports state interposition of in the capsule, ligaments, or muscles or
that clinical outcomes decrease with increasing time until even chondral fragments may block the repositioning of the
the immobilization of the elbow after trauma. Based on elbow; such patients require immediate surgery within 24
the classification established by O’Driscoll [29], Bell [30] hours. Unstable elbows due to a torn capsule and ligament
presented an algorithm for simple elbow dislocations, which structures need to be stabilized by the open reconstruction of
6 Advances in Orthopedics

always result in elbow instability and thus always necessitate

surgery in our opinion.

5.3.1. Radial Column in Terrible Triad Injuries. 50% of terrible

triad elbow injuries are marked by a complete rupture of the
radial capsuloligament complex combined with injuries to
the osseous and articular lignment [21]. Because of the high
risk of redislocation, chronic instability, and posttraumatic
arthritis, surgery is justified. Fractured radial heads and
the torn ligaments should be restored to rebuild the radial
column. The elbow prefers to bend into the valgus position.
Without any tension on the ulnar complex, the radial head
Figure 4: Isolated rupture of the lateral ulnar collateral ligament is more loaded by the deviation of the elbow. Therefore,
(LUCL) resulting in persistent posterolateral rotational instability reconstruction of the radial head is necessary, which can be
(PLRI) in a patient who works as an anesthesiologist. She was not very difficult in some cases. Even the option of reconstructing
able to retract the speculum after trauma. The picture illustrates the the radial head on a table followed by reinsertion in situ has
intraoperative reconstruction of the proximal torn LUCL. been suggested to avoid a radial head prosthesis. However,
if there is no alternative, a radial head prosthesis is an
adequate method for restoring the radial bony column. To
address posterolateral instability due to the rupture of the
the ligament structures and/or by applying a hinged fixator. radial humero-ulnar ligament, the ligament complex should
There are a lot of discussions about which intervention is best, be reattached by suture or with a suture anchor. Ligaments
ligament reconstruction alone or a hinged fixator without or are mainly ruptured in the proximal third and can easily be
with ligament augmentation. Some authors prefer ligament reattached by transosseous sutures.
reconstruction [3, 33], others ligament reconstruction with a
hinged fixator [31], and still others a hinged fixator alone [34].
5.3.2. Coronoid Process Fractures and the Ulnar Ligament
5.2. Elbow Dislocation Starting from the Radial Column. Complex. The classification of fractured coronoids by Mor-
Radial head injuries should be handled with care, and rey and Regan can be expanded by the O’Driscoll classifi-
possible injuries to the lateral ligament complex should be cation, which provides information about the involvement
excluded. Some authors have suggested that the choice of of the medial column and ligament complex (Figure 2(b)).
treatment of singular radial head injuries should depend on In fractures of the coronoid facet of the ulnohumeral joint
the extent of fragment dislocation [35, 36]. In simple elbow (type III), the bony stabilizing column on the medial side
dislocations, the radial column is often combined with a is lost and has to be restored. Such restoration can be
radial head injury type Mason II and rupture of the lateral done by an anteromedial approach, that is, by splitting the
ulnar collateral ligament (LUCL). This common complication flexor muscles [40]. Small coronoid shear fractures (types I-
often results in persistent posteroradial instability and should II) with a ruptured anterior capsule and muscle brachialis
be addressed by reconstructing the radial head and by can be reattached by suturing the anterior capsule to the
augmenting the ruptured ligament complex [12] (Figure 4). proximal ulna through drill holes from a radial approach.
Biomechanical investigations have shown that absence of By this approach, ruptured lateral ligament complex can be
the radial head induce rotatory laxity of 145% compared easily stabilized by transosseous suture. The coronoid can
to intact elbow joints. Absence of the radial head and the also be addressed by a posterior approach by releasing the
coronoid process results in the deviation and dislocation flexor muscle group or by an anteromedial approach by
of the joint, regardless of its collateral ligament status [37]. splitting the flexor muscle group with readaptation of the
Biomechanical trials have shown that the lateral collateral anteromedial capsula and medial ulnar collateral ligament
ligament is the primary stabilizer to external rotation and complex (anterior ulnohumeral bundle of MUCL) [3]. If the
posterolateral stabilization (Figure 2(a)). Reconstruction of lateral ulnar collateral ligament (LUCL) has to be addressed,
the LUCL alone, even without the radial head, is beneficial. the coronoid tip can be fixed by a lateral approach (Kochers
Because of the shear forces caused by a dislocation, approach).
the capitulum humeri should be checked for osteochondral Readapting the medial ulnar collateral ligament (MUCL)
defects, even if none were detected on MRI. without the coronoid process is rarely necessary. The buttress
function of the lateral column is restored after rebuilding the
radial column by osteosynthesis of the radial head and suture
5.3. Terrible Triad Injury. The insufficiency of the available of the LUCL. Only if the restoration of the radial column is
data and the manifold posttraumatic complications in elbow fragile or instable with persistent valgus stress to the elbow
injuries have resulted in a wide range of suggestions on how should the ulna ligament complex be restored or a hinged
to treat terrible triad injuries [38, 39]. Although some authors external fixator be applied with a limited range of motion to
have suggested conservative treatment, terrible triad injuries 0–40–140∘ for 3 weeks [27].
Advances in Orthopedics 7

5.4. Elbow Dislocations Affecting the Medial Column. Most Table 2: Oral cortisone drug medication in stiff shoulder or stiff
of the knowledge on single MUCL lesions has been gained elbow therapy.
from examining athletes such as javelin throwers or handball
Period of therapy Dosage of oral cortisone therapy
players [41]. Chronic instability requires surgery includ-
ing ligament augmentation [42]. In our experience, acute 1–5 40 mg per day
trauma patients with a valgus stress injury and a consecutive 6–10 30 mg per day
single MUCL lesion suffer from limited range of motion 11–15 20 mg per day
(Figure 5(a)). Two-dimensional X-ray images of the elbow 16–20 10 mg per day
often show no fractures with regular alignment. MRI illus-
trates in such cases single MUCL injury (Figures 5(b)-5(c)).
However, patients unable to bend their elbow are usually in
reported an incidence of posttraumatic heterotopic ossifica-
pain if they try to do so. Patients tend to extend their elbow
tion between 1.6% and 56%. In elbow fracture dislocations,
and reject any flexion above 80∘ , which is a strong clinical
elbow stiffness and heterotopic ossification affect up to 20%
marker for MUCL distortion or rupture. Bracing the elbow
of the patients [55, 56]. Concurrent elbow and radial head
with a limited range of motion in flexion will lead to a pain-
injuries raise this incidence rate to almost 90%, and even
free stable elbow within 2 to 4 weeks or, in severe cases, up to
patients with an isolated injury to the radial head suffer elbow
8 weeks.
stiffness in 5 to 10% [57, 58]. Duerig reported that elbow
dislocations are rarely unstable in the absence of an associated
6. Complications in Elbow Dislocations and articular fracture. Most posterior elbow dislocations are
Dislocation Fractures stable and would, thus, benefit from active exercises and
functional use of the arm within 2 weeks after the injury [59].
6.1. Chronic Instability. Pain and persistent instability have to Mehlhoff et al. suggested that early mobilization is paramount
be observed and, in individual cases, stabilized by ligament for avoiding arthrofibrosis in elbow dislocations and is, thus,
complex augmentation [43, 44]. Sometimes, elbow disloca- the key factor in posttraumatic care. However, in a followup
tions categorized as stage 1 and stage 2 are underestimated. of 52 patients, the same authors reported 24 patients suffering
Insufficient clinical and radiological examinations may clas- from persistent pain and 34 patients with a limited range of
sify an injury as a distortion, and the patient is discharged motion, which is a rather questionable result [60]. Yet, early
without any further treatment. Ruptured collateral ligaments mobilization has been suggested by the AAOS for simple
result in hyper-mobility of the elbow joint; this condition and complex elbow dislocations [61]. This elbow mobilization
leads to the very painful overcompensation of the extensor program allows controlled movements without putting strain
muscle group [45]. Elongation of the scar tissue of the on injured structures. However, little data is available on early
ruptured LUCL complex requires a ligament plastic. Several motion therapy.
methods have been described for this procedure, such as From a basic research view, inflammatory reactions of the
the transplantation of a biceps tendon through the coronoid healing process are responsible for capsulitis and shrinkage
process or reinforcement of the collateral ligaments [46] of the capsula by SMA myofibroblasts [62]. A torn capsula
or the reconstruction of the collateral ligament complex by will inflame and develop a kind of capsular adhesive during
autograft transplantation of triceps tendon [44, 47] or by a the healing process. Scar tissue formed by fibrocytes and
gracilis graft [48]. myocytes may impede the desired healing process, particu-
In elbow fracture dislocations, surgeons aim at achieving larly if an elbow is immobilized for 3 weeks after the trauma.
anatomical reduction and stabilization of the elbow joint [49]. According to our experience, elbows will also get stiff when
The medial facet of the coronoid to the humeral trochlear immobilized for more than 3 weeks after the trauma. How-
is identified as a key factor for the medial stability of the ever, capsular fibrosis can be stopped and even reduced again
elbow, and intensive reconstruction maneuvers are indicated by the oral administration of cortisol and spironolactone [63–
to regain stability of the elbow joint if the medial facet of the 65] (Table 2, Figures 6(a)–6(c)). Temporary elbow stiffness
coronoid is lost [50, 51]. Milch’s and Wainwright’s presented is a normal occurrence and should be treated with pain-
a bone block procedure, which has a mechanical effect on free long-lasting flexion and extension exercises over a long
the coronoid process to prevent its disengagement under period of time. In severe cases, cortisol and spironolactone
the trochlear by an anterior approach [46]. Furthermore, may be administered additionally.
osteochondral autografts have been tried for rebuilding the
lost medial coronoid facet, but only with minor success [52].
6.3. Heterotopic Ossification in Elbow Dislocations. Hetero-
topic ossification (HO) of the elbow is a common posttrau-
6.2. Elbow Stiffness and Physiotherapy. In posttraumatic care, matic occurrence resulting in limited range of motion [66].
elbow arthrofibrosis and heterotopic ossification are common The role of HO in elbow stiffness has to be analyzed by
complications that depend on the severity of an injury [1, CT scans with three-dimensional volume rendering, which
53]. Arthrofibrosis frequently occurs after elbow dislocation helps to analyze bony impingement areas. Arthroscopy is
leading to a median extension loss of 8∘ after one year [54]. In a common approach for releasing HO and regaining better
a trial by Protzman et al., almost 50% of patients developed range of motion [67–69]. Risk factors for HO are the time
heterotopic ossifications of the torn ligaments. Other authors elapsed between trauma and surgery as well as the number of
8 Advances in Orthopedics

(a)

(b) (c)

Figure 5: (a) Isolated rupture of the anterior medial ulnar collateral ligament (aMUCL) by valgus stress trauma. The patient was typically
suffering from a limited range of motion in flexion. Full range of motion with a stable elbow was restored with conservative treatment 10
weeks after trauma. (b) MRI proofed isolated aMUCL rupture of the photographed patient. The sagittal plane illustrated an inflammatory
reaction. (c) The frontal plane demonstrated the rupture of the MUCL complex from its proximal insertion on the medial epicondyle humeri.

days of immobilization after surgery [70]. Anti-inflammatory 2. Patients with severe elbow instability require an MRI
drugs, such as indometacin and radiation therapy, have been or a CT scan.
suggested as part of the operative treatment of HO [69].
3. In case of instability after repositioning, a plaster cast
should be applied at 110∘ of flexion, and secondary
surgical stabilization needs to be achieved within 5
7. Conclusion days.

1. Elbow dislocation is a severe injury leading to disabil- 4. Elbows that have been fluoroscopically proven to be
ity. Initial diagnostics should include instability tests laterally instable or medially stable have to be fur-
under fluoroscopic guidance. ther investigated for posterolateral instability, which
Advances in Orthopedics 9

(a) (b)

(c)

Figure 6: (a) X-rays illustrating radial head multifragmentary fracture. One slice of the CT scan proves the bony tendon tear of the triceps by
a young sports student, who was suffering from an elbow dislocation. (b) Postoperative X-rays demonstrating radial head reconstruction and
stabilization. The bony tear of the triceps tendon was sutured to the olecranon tip. (c) Forty-eight weeks after trauma, the young athlete was
not able to straighten the left elbow. Full range of motion was restored within 6 weeks by applying oral cortisone therapy with Prednisolon
5 mg tablets in decreasing dosage as described in Table 2.

requires surgical reconstruction of the LUCL com- [2] S. W. O’Driscoll, B. F. Morrey, S. Korinek, and K. N. An, “Elbow
plex. subluxation and dislocation: a spectrum of instability,” Clinical
Orthopaedics and Related Research, no. 280, pp. 186–197, 1992.
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ally stable band complex can be treated conservatively F. Morrey, “The unstable elbow,” Instructional Course Lectures,
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tion of the forearm. [4] P. Harding, T. Rasekaba, L. Smirneos, and A. E. Holland, “Early
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dislocation are common occurrences and should be evaluation of the medial collateral ligament of the elbow,”
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limited range of motion and, in severe cases, by oral 1997.
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Morrey, “The contribution of the coronoid and radial head to
the stability of the elbow,” Journal of Bone and Joint Surgery B,
Conflict of Interests vol. 94, no. 1, pp. 86–92, 2012.
The authors declare that there is no conflict of interests [8] J. G. Alcid, C. S. Ahmad, and T. Q. Lee, “Elbow anatomy and
structural biomechanics,” Clinics in Sports Medicine, vol. 23, no.
regarding the publication of this paper. No benefits in any
4, pp. 503–517, 2004.
form have been received or will be received from a commer-
[9] R. N. Hotchkiss and A. J. Weiland, “Valgus stability of the
cial party related directly or indirectly to the subject of this elbow,” Journal of Orthopaedic Research, vol. 5, no. 3, pp. 372–
paper. 377, 1987.
[10] C. R. Pribyl, D. K. Hurley, D. C. Wascher, T. P. McNally, K.
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