The Journal of Bone & Joint Surgery

The Journal of Bone & Joint Surgery, Volume 93, Issue 13

Scientific Articles | July 06, 2011

Patient-Reported Outcomes After Simple Dislocation of the Elbow

Raymond E. Anakwe, MBChB, MRCSEd¹; Scott D. Middleton, MBChB¹; Paul J. Jenkins, MBChB, MRCSEd¹; Margaret M. McQueen, MD, FRCSEd(Tr&Orth)¹; Charles M. Court-Brown, MD, FRCSEd(Tr&Orth)¹

¹ Orthopaedic Trauma Unit, Royal Infirmary of Edinburgh, 51 Little France Crescent, Edinburgh EH16 4SA, United Kingdom. E-mail address for R.E. Anakwe: raymundus@doctors.org.uk

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Disclosure: None of the authors received payments or services, either directly or indirectly (i.e., via his or her institution), from a third party in support of any aspect of this work. None of the authors, or their institution(s), have had any financial relationship, in the thirty-six months prior to submission of this work, with any entity in the biomedical arena that could be perceived to influence or have the potential to influence what is written in this work. Also, no author has had any other relationships, or has engaged in any other activities, that could be perceived to influence or have the potential to influence what is written in this work. The complete Disclosures of Potential Conflicts of Interest submitted by authors are always provided with the online version of the article.

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Investigation performed at the Orthopaedic Trauma Unit, Royal Infirmary of Edinburgh, Edinburgh, United Kingdom

J Bone Joint Surg Am, 2011 Jul 06;93(13):1220-1226. doi: 10.2106/JBJS.J.00860

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Abstract

Background:

The current study was designed to investigate the epidemiology and long-term clinical and patient-reported outcomes following simple dislocation of the elbow in adults.

Methods:

We identified all adult patients treated at our trauma center for a simple dislocation of the elbow during a ten-year period. One hundred and forty patients were eligible for review, and 110 (79%) were reviewed at a mean of eighty-eight months (range, sixteen to 171 months) after the injury. This review included clinical examination, the Disabilities of the Arm, Shoulder and Hand (DASH) questionnaire, the Oxford elbow questionnaire, and a patient satisfaction questionnaire.

Results:

Patients reported long-term residual deficits in the range of elbow motion. The mean DASH score was 6.7 points (95% confidence interval, 4 to 9 points). The mean Oxford elbow score was 90.3 points (95% confidence interval, 87.8 to 92.9 points). The mean satisfaction score was 85.6 points (95% confidence interval, 82.2 to 89 points). Sixty-two patients (56%) reported residual subjective stiffness of the elbow. Nine patients (8%) reported subjective instability, and sixty-eight (62%) reported residual pain. The satisfaction and DASH scores showed good correlation with absolute range of motion in the injured elbow, as did the overall Oxford elbow score and the pain and function components of that score. Multivariate analysis demonstrated that loss of elbow flexion (p = 0.001) and female sex (p = 0.002) were both independent predictors of a poorer DASH score. Reduced elbow flexion also predicted a poorer score on the function component of the Oxford elbow score (p = 0.02). A reduced flexion-extension arc of motion predicted a poorer overall Oxford elbow score (p = 0.02), a poorer score on the pain component of the Oxford elbow score (p = 0.02), and poorer overall satisfaction (p = 0.005). Female sex predicted a poorer score on the psychosocial component of the Oxford elbow score (p < 0.05).

Conclusions:

Although patients generally report a favorable long-term functional outcome after simple dislocation of the elbow, these injuries are not entirely benign. The rate of residual pain and elbow stiffness is high. Functional instability is less common and does not often limit activities.

Level of Evidence:

Prognostic Level III. See Instructions to Authors for a complete description of levels of evidence.

Figures in this Article

Introduction

Dislocation of the elbow without associated fracture or persistent instability requiring surgery is considered to be a simple dislocation^1,2. This injury is commonly treated with closed reduction and early motion, and subsequent patient-reported outcomes have been reported to be favorable^1-4, although a prolonged period of immobilization has been associated with a poorer outcome. These studies traditionally reported outcome using surgeon-rated measures rather than patient-reported outcome measures. However, despite the fact that elbow dislocation is termed a "simple" injury, it may be associated with major soft-tissue injury around the elbow. Careful radiographic and clinical examination to detect a fracture or instability is an important part of the assessment following reduction of the elbow and minimizes that possibility that a more complex injury remains undetected.

Since elbow motion and arm strength only partially account for the patient's perception of function and disability following elbow injury⁵, these two objective measures may not accurately reflect the patient's functional result. Patient-reported outcome measures provide a reliable means to assess function and compare outcomes over time and between different patient groups⁶. Patient satisfaction, level of function, and disability related to activities of daily living following single dislocation of the elbow have not been well described, although they are widely believed to be favorable^2-4.

Early motion is the standard for modern rehabilitation following closed reduction of the dislocated elbow^1,7. During the past decade, our unit and many units elsewhere have reduced the duration of elbow immobilization to three weeks or less. The current study was designed to address the lack of research formally assessing the results of this rehabilitation approach as well as recent reports indicating the potential underestimation of subtle instability following this injury^8,9. The aims of the study were to describe the epidemiology and long-term clinical and patient-reported functional outcome following simple dislocation of the elbow treated with an early motion program.

Materials and Methods

The study was approved by our institutional review board. We consulted our trauma database and performed a manual review of patient records in order to identify all adult patients treated at our trauma center for a simple dislocation of the elbow between 1998 and 2007. Our center is the only provider of trauma care in an urban setting and has a well-defined patient population. A patient presenting with elbow dislocation would be seen in the emergency department, where the diagnosis was confirmed by radiography before reduction was performed under conscious sedation. The reduced elbow was examined through a range of motion to assess stability, and the reduction was confirmed with further radiographs. If a congruent reduction could not be achieved or if there was evidence of marked instability, an examination was performed under general anesthesia in the operating room. Any associated deep wound was covered with a sterile dressing and examined under anesthesia in the operating room; debridement was performed as necessary, and the wound was closed either primarily or with secondary delayed suturing, depending on the extent of wound contamination.

The elbow was usually immobilized in a posterior splint, and the patient was reviewed in the trauma clinic within the following week. Once the splint was removed, the patient was 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 until six weeks after the injury. Physical therapy was prescribed, at the discretion of the treating surgeon, if a residual deficit in elbow motion was evident or if the patient reported stiffness.

The initial and subsequent radiographs for each patient in the study were reviewed to confirm the nature of the dislocation and the absence of an associated fracture. Patients were eligible for inclusion if they had an acute dislocation of the elbow without an associated fracture (including avulsion of an osseous flake at the attachment point of a ligament or the capsule) and without evidence of major ligamentous instability. The dislocation was described on the basis of the direction of translation of the radius and ulna relative to the distal aspect of the humerus. Patient demographic information as well as data on the injury and the treatment were collated from patient charts and records. Patients were contacted by mail and asked to complete the Disabilities of the Arm, Shoulder and Hand (DASH) questionnaire, the Oxford elbow questionnaire, and a patient satisfaction questionnaire. Both the DASH and the Oxford elbow questionnaire are patient-reported outcome measures validated for use following elbow injury or surgery^10,11. The satisfaction questionnaire was modified from one previously described and validated in our unit to measure patient satisfaction following elective surgery¹². The patient was asked to rate his or her level of overall satisfaction with the result of the treatment for the elbow injury on an anchored visual analog scale measuring 100 mm; the response was converted to a score between 0 and 100. The patient was also asked whether or not subjective pain, stiffness, and instability persisted; the answer to each of these three questions was recorded in the form of a dichotomous yes or no response.

The patient was also asked to attend a review appointment in the outpatient clinic, during which a comprehensive clinical examination was performed by one of the authors (R.E.A. and S.D.M.). Both elbows were examined and directly compared. The neurovascular status was assessed. The range of elbow flexion and extension was measured with use of a long goniometer, and the range of pronation and supination was measured with the elbow held in 90° of flexion. Grip strength was measured with use of a calibrated Jamar hydraulic hand dynamometer (Jamar Labs, Irvington, New York), employing a standard protocol and the second handle setting¹³. The stability of each elbow was examined with use of varus and valgus stress testing performed at 30° of flexion, and a pivot-shift test was also performed to reveal any posterolateral instability¹⁴.

We identified 163 patients treated at our institution for a simple dislocation of the elbow during the study period. Twenty-three of these patients were excluded: six had died since the injury, three had moved abroad, five had sustained associated injuries of the ipsilateral upper limb at the time of the dislocation, seven had been diagnosed with a systemic soft-tissue condition or a neurological disease that might be expected to adversely affect the reported outcome or that would prevent meaningful assessment (spinocerebellar ataxia, cerebrovascular accident with persisting weakness, "hypermobility syndrome," Ehlers-Danlos syndrome, or paraplegia), and two patients had undergone acute ligament repair and/or external fixation for the treatment of elbow instability. One hundred and fifteen (82%) of the remaining 140 patients eligible for review returned completed questionnaires. Five of these patients returned the questionnaires by mail but declined to attend the clinic. These five patients and the twenty-five patients who did not return the questionnaires were considered to be nonresponders for the purpose of the statistical analysis. Thus, the study group consisted of 110 patients (79% of the cohort). The case notes and radiographs for the patients in the study group were compared with those of the nonresponders, and the groups were found to be similar with regard to patient age and sex and the mechanism and pattern of injury. The incidence of simple elbow dislocation in our population was calculated on the basis of data from the General Register Office for Scotland, which indicated that the adult population served by our trauma unit comprised 558,710 individuals¹⁵.

Statistical Analysis

Histograms were used to confirm the normality of continuous variables. Range of motion was compared between injured and uninjured elbows with use of paired t tests, and is reported as the mean and the associated 95% confidence interval (CI). The absolute difference in range of motion between the injured and the uninjured elbow was also calculated for each patient. The DASH, Oxford elbow, and satisfaction scores are reported as the mean and 95% confidence interval. The pain, function, and psychosocial components of the Oxford elbow score are also reported individually. The Oxford elbow score and each of its components were scaled on a range of 0 to 100. A chi-square test was used to compare dichotomous variables. One-way analysis of variance was used to compare data among more than two groups (i.e., mechanism of injury, direction of dislocation, and duration of splinting). A Bonferroni correction was used to set the alpha error at which a difference among multiple groups was considered significant (i.e., the required p value equaled 0.05 divided by the number of tests performed in that group of comparisons). The variables (sex, age, and range of elbow motion) that were independently predictive of each patient-reported outcome (DASH score, Oxford elbow score, and satisfaction score) were determined by generating a separate multivariate linear regression model for that measure. A variable was included in the multivariate model if its p value on univariate testing was <0.1, and a forward stepwise technique was used to derive the final model, in which a value of p < 0.05 was considered significant. The result for each variable is reported as the regression coefficient (B) and its associated 95% confidence interval and p value. In addition, the overall F statistic and adjusted r² value of each final model is reported in order to allow quantification of the accuracy of the model.

Source of Funding

There was no external funding for this study.

Results

The incidence of simple elbow dislocation in this population was 2.9 (95% CI, 1.8 to 3.5) per 100,000 per year. Fifty-nine (54%) of the 110 patients with clinical and functional follow-up were men. The mean patient age was 38.8 years (range, fifteen to eighty-eight years; standard deviation, 17.6 years), although the mean age of the men was younger than that of the women (33.2 compared with 45.3 years; p < 0.001). The mean duration of follow-up was eighty-eight months (range, sixteen to 171 months). The mechanism of injury involved a fall from a standing height in sixty-three patients (57%), sports in seventeen (15%), a fall from a greater height in fourteen (13%), an assault in ten (9%), and a pedestrian-motor vehicle accident in six patients (6%). The mechanism of injury differed with respect to sex. Men were more likely to sustain the dislocation as a result of an assault (p = 0.016) or sports (p = 0.01), and women were more likely to sustain the injury in a fall from a standing height (p = 0.009). The rate of dislocation resulting from a vehicular accident (p = 0.854) or a fall from a height (p = 0.387) did not differ significantly between the sexes (Table I). An association between patient age and the mechanism of injury was clearly evident (F = 4.6, p = 0.002 [one-way analysis of variance]). For instance, the mean age of patients injured during sports (26.1 years) was 17.9 years (95% CI, 5.0 to 30.8 years) younger than the mean age of patients injured in a fall from a standing height (44.1 years) (p = 0.001). The mechanism of injury was not an important predictor of any of the outcome measures.

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TABLE I Patient Demographics, Mechanism of Injury, and Patient-Reported Functional Scores

	Men	Women	P Value
No. of patients	59	51
Mean age (yr)	33.2	45.3	<0.001
Mechanism of injury (no. [%])
Fall from standing height	27 (46%)	36 (71%)	0.009
Fall from a greater height	6 (10%)	8 (16)	0.387
Assault	9 (15%)	1 (2%)	0.016
Pedestrian-motor vehicle accident	3 (5%)	3 (6%)	0.854
Sport	14 (24%)	3 (6%)	0.010
Mean patient-reported outcome measures
DASH*	3.9	9.9	0.014
Oxford elbow score
Overall, on scale of 0 to 100	93.5	86.7	0.009
Pain component, on scale of 0 to 100	95.2	90.9	0.022
Function component, on scale of 0 to 100	96.2	89.0	0.039
Psychosocial component, on scale of 0 to 100	89.3	80.1	0.004
Satisfaction, on scale of 0 to 100	86.8	84.0	0.395

*DASH = Disabilities of the Arm, Shoulder and Hand.

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TABLE I Patient Demographics, Mechanism of Injury, and Patient-Reported Functional Scores

	Men	Women	P Value
No. of patients	59	51
Mean age (yr)	33.2	45.3	<0.001
Mechanism of injury (no. [%])
Fall from standing height	27 (46%)	36 (71%)	0.009
Fall from a greater height	6 (10%)	8 (16)	0.387
Assault	9 (15%)	1 (2%)	0.016
Pedestrian-motor vehicle accident	3 (5%)	3 (6%)	0.854
Sport	14 (24%)	3 (6%)	0.010
Mean patient-reported outcome measures
DASH*	3.9	9.9	0.014
Oxford elbow score
Overall, on scale of 0 to 100	93.5	86.7	0.009
Pain component, on scale of 0 to 100	95.2	90.9	0.022
Function component, on scale of 0 to 100	96.2	89.0	0.039
Psychosocial component, on scale of 0 to 100	89.3	80.1	0.004
Satisfaction, on scale of 0 to 100	86.8	84.0	0.395

*DASH = Disabilities of the Arm, Shoulder and Hand.

Closed treatment in the emergency department was not possible in seven cases (6%); these patients underwent treatment under general anesthesia in the operating room. Two of these seven patients (2% of the study group) had sustained open injuries requiring irrigation and debridement. A third patient had sustained a closed anterior dislocation of the elbow with a concomitant injury of the brachial artery requiring surgical repair. (This patient was the only patient in the study group who had sustained an anterior rather than a posterior dislocation.) The remaining four patients (4% of the study group) required treatment in the operating room because either a congruent reduction or a subsequent examination for stability could not be performed under conscious sedation in the emergency department. All four of these patients had a stable and congruently reduced elbow after assessment and/or reduction in the operating room and were treated with use of a posterior splint and a subsequent program of early elbow motion. Two of these four patients subsequently developed subjective instability, and varus instability was clinically detectable at the time of follow-up in one of these two patients. Five patients (5%) sustained a concomitant peripheral nerve injury, which affected the ulnar nerve in two patients (2%) and the median nerve in three (3%). Both patients who exhibited ulnar nerve dysfunction at presentation had persistent altered sensation in the distribution of the ulnar nerve at the time of the clinical review (157 and 162 months after the injury). Two patients (2%) underwent late surgery for elbow stiffness thirteen months after a closed posterior dislocation. No patients underwent late surgery for instability.

Eleven patients (10%) were not treated with any form of immobilization following reduction of the dislocated elbow. Ninety-three patients (85%) were treated with use of a posterior splint for between one and three weeks. Only six patients (5%) were immobilized for a longer period of four weeks (four patients, 4%) or six weeks (two patients, 2%). These longer periods of splinting were usually used at the request of the patient to manage pain, and the mean age of these patients (47.3 years) was older than that of the study group as a whole.

Patients reported long-term residual deficits in both the range of motion (flexion-extension arc and pronation-supination arc) and grip strength (Table II). 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). The mean satisfaction score was 85.6 points (95% CI, 82.2 to 89 points). Univariate testing demonstrated that the mean values of these functional scores and outcomes were worse among the women than among the men (Table I). Nine patients (8%) demonstrated objective signs of elbow instability on stress testing or pivot-shift testing: two patients demonstrated instability to varus stress, one demonstrated instability to valgus stress, one demonstrated evidence of both varus and valgus instability, and five patients (4%) demonstrated posterolateral instability. Sixty-two patients (56%) reported residual subjective stiffness of the elbow. Nine patients (8%) reported subjective instability, and sixty-eight patients (62%) reported residual pain. Only one of the nine patients who reported subjective instability had clinically detectable valgus instability and only one other had clinically detectable posterolateral instability. The patients who reported subjective stiffness were objectively shown to have reduced mean elbow flexion (p = 0.026) and a reduced mean flexion-extension arc of motion (p = 0.033) (Table II). The DASH, Oxford elbow, and satisfaction scores were all correlated with the absolute range of motion in the injured elbow (Table III). Overall satisfaction was correlated with both the Oxford elbow score (r = 0.787, p < 0.001) and the DASH score (r = −0.723, p < 0.001). The Oxford elbow and DASH scores were also correlated with each other (r = 0.911, p < 0.001).

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TABLE II Clinical Range of Motion and Grip Strength According to Sex, Injured Versus Uninjured Side, Dominant Side, and Reported Presence of Subjective Stiffness

	Extension (deg)	Flexion (deg)	Flexion-Extension Arc (deg)	Pronation (deg)	Supination (deg)	Grip Strength (Nm)
Side-to-side difference
Injured side*	8.1 (6.6 to 9.7)	135 (134 to 137)	128 (125 to 130)	83 (81 to 84)	83 (82 to 85)	33 (31 to 35)
Uninjured side*	0.4 (—0.3 to 1.1)	137 (136 to 138)	137 (135 to 138)	84 (83 to 85)	84 (83 to 86)	34.1 (32.4 to 35.8)
Difference between injured and uninjured side*	7.7 (6.5 to 9.4)	—1 (—1.6 to —0.4)	—8.9 (—10.5 to —7.0)	—1.5 (—2.2 to 0.7)	—1 (—1.8 to —0.2)	—1.1 (—0.5 to —1.8)
P value†	<0.001	0.002	<0.001	<0.001	0.011	0.001
Sex
Difference between males and females*	—2.3 (—5.1 to 0.6)	—0.7 (—1.9 to 0.6)	1.6 (—1.6 to 4.8)	0.9 (—0.7 to 2.5)	0.8 (—1.2 to 1.9)	—0.4 (—1.8 to 1.0)
P value†	0.127	0.305	0.321	0.287	0.673	0.566
Involved side
Difference between dominant and nondominant involved side*	—1.3 (—4.4 to 1.7)	0 (—1.3 to 1.3)	1.3 (—1.9 to 4.6)	0.9 (—0.7 to 2.5)	0.1 (—1.5 to 1.7)	2.5 (1.12 to 3.9)
P value†	0.377	1	0.416	0.285	0.923	<0.001
Subjective stiffness reported
Difference between yes and no response*	1.7 (—1.3 to 4.7)	—3.2 (—5.9 to —0.4)	—4.6 (—9.4 to —0.4)	—2.7 (—5.6 to 0.1)	—1.9 (—4.7 to 0.9)	—2.8 (—6.1 to 0.5)
P value†	0.253	0.026	0.033	0.06	0.18	0.093

*The values are given as the mean, with the 95% confidence interval in parentheses.
†Determined with use of an independent-samples Student t test.

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TABLE II Clinical Range of Motion and Grip Strength According to Sex, Injured Versus Uninjured Side, Dominant Side, and Reported Presence of Subjective Stiffness

	Extension (deg)	Flexion (deg)	Flexion-Extension Arc (deg)	Pronation (deg)	Supination (deg)	Grip Strength (Nm)
Side-to-side difference
Injured side*	8.1 (6.6 to 9.7)	135 (134 to 137)	128 (125 to 130)	83 (81 to 84)	83 (82 to 85)	33 (31 to 35)
Uninjured side*	0.4 (—0.3 to 1.1)	137 (136 to 138)	137 (135 to 138)	84 (83 to 85)	84 (83 to 86)	34.1 (32.4 to 35.8)
Difference between injured and uninjured side*	7.7 (6.5 to 9.4)	—1 (—1.6 to —0.4)	—8.9 (—10.5 to —7.0)	—1.5 (—2.2 to 0.7)	—1 (—1.8 to —0.2)	—1.1 (—0.5 to —1.8)
P value†	<0.001	0.002	<0.001	<0.001	0.011	0.001
Sex
Difference between males and females*	—2.3 (—5.1 to 0.6)	—0.7 (—1.9 to 0.6)	1.6 (—1.6 to 4.8)	0.9 (—0.7 to 2.5)	0.8 (—1.2 to 1.9)	—0.4 (—1.8 to 1.0)
P value†	0.127	0.305	0.321	0.287	0.673	0.566
Involved side
Difference between dominant and nondominant involved side*	—1.3 (—4.4 to 1.7)	0 (—1.3 to 1.3)	1.3 (—1.9 to 4.6)	0.9 (—0.7 to 2.5)	0.1 (—1.5 to 1.7)	2.5 (1.12 to 3.9)
P value†	0.377	1	0.416	0.285	0.923	<0.001
Subjective stiffness reported
Difference between yes and no response*	1.7 (—1.3 to 4.7)	—3.2 (—5.9 to —0.4)	—4.6 (—9.4 to —0.4)	—2.7 (—5.6 to 0.1)	—1.9 (—4.7 to 0.9)	—2.8 (—6.1 to 0.5)
P value†	0.253	0.026	0.033	0.06	0.18	0.093

*The values are given as the mean, with the 95% confidence interval in parentheses.
†Determined with use of an independent-samples Student t test.

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TABLE III Correlation of Satisfaction and Patient-Reported Functional Outcome Measures with Clinical Range of Motion and Grip Strength*

	DASH Score	Oxford Elbow Score	Satisfaction Score
Absolute range of motion
Flexion	—0.224, 0.021	0.302, 0.001	0.329, 0.001
Extension	0.198, 0.041	—0.279, 0.03	—0.293, 0.002
Flexion-extension arc	—0.279, 0.004	0.372, <0.001	0.380, <0.001
Pronation	—0.240, 0.013	0.313, 0.001	0.306, 0.001
Supination	—0.155, 0.110	0.240, 0.012	0.291, 0.002
Grip strength	—0.421, <0.001	0.348, <0.001	0.231, 0.016
Difference between injured and uninjured side
Flexion deficit	—0.109, 0.263	0.091, 0.347	0.129, 0.189
Extension deficit	0.203, 0.036	—0.258, 0.007	—0.232, 0.016
Flexion-extension arc deficit	—0.243, 0.012	0.271, 0.004	0.259, 0.007
Pronation deficit	—0.138, 0.155	0.084, 0.384	0.015, 0.879
Supination deficit	—0.006, 0.948	0.017, 0.862	0.033, 0.737
Grip strength deficit	—0.114, 0.243	0.156, 0.105	0.056, 0.566

*Calculated with use of the Spearman rank test. The values are given as the Spearman rho and the p value for the bivariate correlation. *DASH = Disabilities of the Arm, Shoulder and Hand.

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TABLE III Correlation of Satisfaction and Patient-Reported Functional Outcome Measures with Clinical Range of Motion and Grip Strength*

	DASH Score	Oxford Elbow Score	Satisfaction Score
Absolute range of motion
Flexion	—0.224, 0.021	0.302, 0.001	0.329, 0.001
Extension	0.198, 0.041	—0.279, 0.03	—0.293, 0.002
Flexion-extension arc	—0.279, 0.004	0.372, <0.001	0.380, <0.001
Pronation	—0.240, 0.013	0.313, 0.001	0.306, 0.001
Supination	—0.155, 0.110	0.240, 0.012	0.291, 0.002
Grip strength	—0.421, <0.001	0.348, <0.001	0.231, 0.016
Difference between injured and uninjured side
Flexion deficit	—0.109, 0.263	0.091, 0.347	0.129, 0.189
Extension deficit	0.203, 0.036	—0.258, 0.007	—0.232, 0.016
Flexion-extension arc deficit	—0.243, 0.012	0.271, 0.004	0.259, 0.007
Pronation deficit	—0.138, 0.155	0.084, 0.384	0.015, 0.879
Supination deficit	—0.006, 0.948	0.017, 0.862	0.033, 0.737
Grip strength deficit	—0.114, 0.243	0.156, 0.105	0.056, 0.566

*Calculated with use of the Spearman rank test. The values are given as the Spearman rho and the p value for the bivariate correlation. *DASH = Disabilities of the Arm, Shoulder and Hand.

Fifty-four patients (48%) reported that they had participated in sports activities prior to the injury, and ten of these patients (19% of the fifty-four) had either given up their primary sport or had to modify their technique to accommodate residual elbow symptoms. In particular, six of these patients had given up or modified weightlifting or other weighted upper-body activities.

Multivariate linear regression analysis indicated that, after controlling for age, a reduced absolute range of elbow flexion (p = 0.001) and female sex (p = 0.002) were both independent predictors of a poorer DASH score. Female sex predicted a poorer psychosocial component of the Oxford elbow score (p = 0.011). Reduced elbow flexion predicted a poorer overall Oxford elbow score (p = 0.005) and a poorer function component of the Oxford elbow score (p = 0.0021). A reduced flexion-extension arc of motion predicted a poorer value for the pain component of the Oxford elbow score (p = 0.02) and for the satisfaction score (p = 0.005) (see Appendix).

Discussion

Our study demonstrated that the range of elbow motion was an important predictor of patient-reported outcome following elbow dislocation. Impaired motion in the flexion-extension plane was clearly an important predictor of poorer function and satisfaction. In addition, a greater deficit in the total flexion-extension arc was a predictor of poorer DASH, Oxford elbow, and patient satisfaction scores (Table III).

Motion in the flexion-extension plane, whether measured as absolute flexion or as the flexion-extension arc, influenced a patient's perception of the outcome following an elbow injury. In particular, greater motion predicted better pain and function components of the Oxford elbow score as well as better overall Oxford elbow, DASH, and satisfaction scores. These associations appear intuitive and are consistent with the rationale for the use of early active motion to avoid joint stiffness and contracture. Many of the patients in our study experienced a loss of terminal elbow extension, as has been reported in previous studies², although 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.

The influence of sex (which has not been previously examined, to our knowledge) was found to be important. Our data suggest that the epidemiology of simple elbow dislocation is different in men than in women, particularly with respect to the mechanism of injury. In addition, the mechanism of injury correlated with patient age, and the women in our series were typically older than the men. High-energy injuries were generally sustained by young men, whereas lower-energy injuries were sustained by older women. Women reported a poorer functional outcome than men, after controlling for patient age, although the reasons for this difference are not clear. The specific outcome measures found to be poorer for women than for men were the DASH score and the psychosocial component of the Oxford elbow score. The distinction between impairment and disability following elbow trauma has been previously highlighted⁵, and it is clear that patient-reported outcome measures are more complex than simple measures of ability. Patient-reported measures probably incorporate a reporting of patient satisfaction, and they may also reflect the general physical and mental health of the patient as well as the success of the informed consent process in managing the patient's expectations^5,16. Previous investigations have shown that one particular advantage of the DASH score is that it reflects less easily defined psychosocial factors and is therefore a more complete representation of subjective outcome^5,17. While these psychosocial factors cannot be directly addressed by surgery, they can potentially be targeted by the broader treatment strategy, and it is interesting to note that the women in the study were no less satisfied than the men despite their poorer reported outcome.

No recurrent dislocations occurred in the patients in our series, and treatment with early motion was not associated with a high rate of subsequent elbow instability. Although instability requiring surgery occurred in two patients, this instability was evident during the initial clinical assessment and did not represent a complication of early motion. Both of these patients were treated with primary ligament reconstruction and/or external fixation.

The importance of early motion to the final outcome of treatment for simple elbow dislocation was demonstrated by Mehlhoff et al¹. This observation has guided modern treatment, and a patient in our unit is rarely immobilized for longer than three weeks. A shorter period of immobilization could potentially expose patients to a greater risk of subsequent instability. However, our data suggest that both objective and subjective elbow instability are rare at the time of long-term follow-up, and that any symptoms that do occur are often of little functional consequence. Although there is a high rate of residual pain and stiffness, patients generally have a high level of satisfaction and excellent functional outcome scores following conservative management and an early motion program. Patients who engaged in regular sports activity prior to the injury were typically still able to do so subsequently, although they reported greater difficulty with weight training and other weighted upper-limb activities that place greater demands on the elbow.

Defining instability can be difficult. The two patients who required surgery for instability were identified at presentation; however, nine other patients reported subjective instability at the time of the follow-up. Only two of these patients had objective signs of instability, and an additional seven patients had clinically demonstrable signs of elbow instability but were otherwise asymptomatic. It would be logical to expect the symptoms to be related to the functional demands placed on the elbow, such that weighted upper-limb activities and sports might reveal symptoms that could otherwise be subtle or undetected. Consequently, it is possible that functionally demonstrated instability is uncommon but that the true overall rate of instability is greater. The importance of the true rate of instability can be debated, but the existence of true instability may influence the treatment offered to athletes, manual laborers, or other patients with high functional demands. The protocol used at our institution to carefully evaluate the elbow for instability at presentation, combined with early active motion, was successful in avoiding the need for subsequent surgery for the treatment of elbow instability in any patient in the study group.

Reduced elbow function correlated with poorer outcomes as measured by the DASH and Oxford elbow scores. A reduced flexion-extension arc of elbow motion correlated with a poorer pain component of the Oxford elbow score and lower reported patient satisfaction. We were unable to demonstrate that the duration of elbow immobilization had any effect on outcome. Only six of our patients were splinted for longer than three weeks, and it is possible that the outcome does not depend as strongly on the duration of immobilization when that duration is short as when the immobilization is prolonged.

Patient-reported outcome measures are particularly useful because the scores are easily communicated by the patient, they remove surgeon bias, and they represent the functional outcome. A previous study by Josefsson et al. established that the long-term outcome following conservative treatment of a simple elbow dislocation is generally favorable², and our data support this conclusion. The extent of soft-tissue injury associated with a simple dislocation of the elbow can be extensive, despite the description of the injury as a simple one^18,19, and such an injury may not be entirely benign even though the functional outcome is generally favorable.

The current study presents long-term follow-up data for a large group of patients. To our knowledge, this series is unique in reporting long-term functional outcomes, patient-reported outcome measures, and information regarding patient satisfaction, range of motion, and elbow stability. Great care was taken to include only patients with a simple elbow dislocation, the study was undertaken at a center that is the sole provider of trauma care for a well-defined urban population, and follow-up data were obtained for 79% of the patients, which may increase the reliability and validity of our data. In addition, the mean duration of follow-up of eighty-eight months was longer than that in previous studies (although it ranged from sixteen to 171 months for individual patients). Since previous research suggests that patients complete their recovery and return to normal activity by six months after such an injury³, we believe that the duration of follow-up in our study allowed us to assess the final outcome. Future studies could productively examine whether the outcome differs among specific patient groups. In particular, athletes, manual laborers, and other patients who impose higher demands on the elbow might be less satisfied or report higher levels of subjective pain and instability.

A simple dislocation of the elbow is not necessarily a benign injury. Although conservative treatment and early elbow motion result in a favorable functional outcome and satisfaction several years after the injury, the rates of residual pain (62%) and stiffness (56%) are high. Functional instability is less common (8%) and does not often limit activities.

Appendix

A table showing the results of the multivariate regression analyses is available with the electronic version of this article at jbjs.org.

References

Mehlhoff TL; Noble PC; Bennett JB; Tullos HS. Simple dislocation of the elbow in the adult. Results after closed treatment. J Bone Joint Surg Am. 1988;70:244-9.[PubMed]

Josefsson PO; Johnell O; Gentz CF. Long-term sequelae of simple dislocation of the elbow. J Bone Joint Surg Am. 1984;66:927-30.[PubMed]

Protzman RR. Dislocation of the elbow joint. J Bone Joint Surg Am. 1978;60:539-41.[PubMed]

Cohen MS; Hastings H 2nd. Acute elbow dislocation: evaluation and management. J Am Acad Orthop Surg. 1998;6:15-23.[PubMed]

Lindenhovius AL; Buijze GA; Kloen P; Ring DC. Correspondence between perceived disability and objective physical impairment after elbow trauma. J Bone Joint Surg Am. 2008;90:2090-7.[PubMed][CrossRef]

Bream E; Black N. What is the relationship between patients’ and clinicians’ reports of the outcomes of elective surgery?J Health Serv Res Policy. 2009;14:174-82.[PubMed][CrossRef]

Hildebrand KA; Patterson SD; King GJ. Acute elbow dislocations: simple and complex. Orthop Clin North Am. 1999;30:63-79.[PubMed][CrossRef]

O'Driscoll SW. Classification and evaluation of recurrent instability of the elbow. Clin Orthop Relat Res. 2000;370:34-43.[PubMed][CrossRef]

Cheung EV. Chronic lateral elbow instability. Orthop Clin North Am. 2008;39:221-8.[PubMed][CrossRef]

Hudak PL; Amadio PC; Bombardier C. Development of an upper extremity outcome measure: the DASH (disabilities of the arm, shoulder and hand) [corrected]. The Upper Extremity Collaborative Group (UECG). Am J Ind Med. 1996;29:602-8.[PubMed][CrossRef]

Dawson J; Doll H; Boller I; Fitzpatrick R; Little C; Rees J; Jenkinson C; Carr AJ. The development and validation of a patient-reported questionnaire to assess outcomes of elbow surgery. J Bone Joint Surg Br. 2008;90:466-73.[PubMed][CrossRef]

Anakwe RE; Jenkins PJ; Moran M. Predicting dissatisfaction after total hip arthroplasty: a study of 850 patients. J Arthroplasty. 2011;26:209-13.[PubMed][CrossRef]

Anakwe RE; Huntley JS; McEachan JE. Grip strength and forearm circumference in a healthy population. J Hand Surg Eur Vol. 2007;32:203-9.[PubMed][CrossRef]

O'Driscoll SW; Bell DF; Morrey BF. Posterolateral rotatory instability of the elbow. J Bone Joint Surg Am. 1991;73:440-6.[PubMed]

Mid-2007 Population estimates for Scotland. Population estimates by age, sex and administrative area. Edinburgh: General Register Office for Scotland; 2008.

King GJ; Richards RR; Zuckerman JD; Blasier R; Dillman C; Friedman RJ; Gartsman GM; Iannotti JP; Murnahan JP; Mow VC; Woo SL. A standardized method for assessment of elbow function. Research Committee, American Shoulder and Elbow Surgeons. J Shoulder Elbow Surg. 1999;8:351-4.[PubMed][CrossRef]

Ring D; Kadzielski J; Fabian L; Zurakowski D; Malhotra LR; Jupiter JB. Self-reported upper extremity health status correlates with depression. J Bone Joint Surg Am. 2006;88:1983-8.[PubMed] [CrossRef]

Josefsson PO; Johnell O; Wendeberg B. Ligamentous injuries in dislocations of the elbow joint. Clin Orthop Relat Res. 1987;221:221-5.[PubMed]

O'Driscoll SW; Jupiter JB; King GJ; Hotchkiss RN; Morrey BF. The unstable elbow. Instr Course Lect. 2001;50:89-102.[PubMed]

Topics

elbow region ; pain ; range of motion ; arm ; elbow dislocations ; motion of elbow

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Raymond E. Anakwe, Scott D. Middleton, Paul J. Jenkins, Margaret M. McQueen, Charles M. Court-Brown; Patient-Reported Outcomes After Simple Dislocation of the Elbow. The Journal of Bone & Joint Surgery. 2011 Jul;93(13):1220-1226.

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