Intervention Review

You have free access to this content

Interventions for treating acute elbow dislocations in adults

  1. Fraser Taylor1,*,
  2. Martyn Sims1,
  3. Jean-Claude Theis2,
  4. G Peter Herbison3

Editorial Group: Cochrane Bone, Joint and Muscle Trauma Group

Published Online: 18 APR 2012

Assessed as up-to-date: 1 JUL 2011

DOI: 10.1002/14651858.CD007908.pub2


How to Cite

Taylor F, Sims M, Theis JC, Herbison GP. Interventions for treating acute elbow dislocations in adults. Cochrane Database of Systematic Reviews 2012, Issue 4. Art. No.: CD007908. DOI: 10.1002/14651858.CD007908.pub2.

Author Information

  1. 1

    Dunedin Hospital, Department of Orthopaedics, Dunedin, Otago, New Zealand

  2. 2

    Dunedin School of Medicine, Department of Medical and Surgical Sciences, Dunedin, New Zealand

  3. 3

    Dunedin School of Medicine, University of Otago, Department of Preventive & Social Medicine, Dunedin, New Zealand

*Fraser Taylor, Department of Orthopaedics, Dunedin Hospital, Private Bag 1921, Dunedin, Otago, New Zealand. fj_taylor@hotmail.com.

Publication History

  1. Publication Status: New
  2. Published Online: 18 APR 2012

SEARCH

 
Characteristics of included studies [ordered by study ID]
Josefsson 1987

MethodsRandomisation method: pooled sealed envelopes
Assessor blinding: not stated
Loss to follow-up: 2 participants (7%)


ParticipantsEmergency Room, Malmo General Hospital, Sweden
Period of study: not stated
30 participants
Inclusion criteria: acute elbow dislocation, 16 years old or older, previously symptom free elbow
Exclusion criteria: dislocation with concomitant fracture (unless small avulsed fracture)
Diagnosis: not stated, presume clinical and radiological.
Presentation: acute
Sex: 10 male (33%)
Age: mean 35 years; range 16 to 70 years


InterventionsDislocations were initially reduced and immobilised in the emergency department. Elbows were then re-examined under general anaesthetic (mean 4 days later, range 1 to 7 days).
1. Surgery. Both the medial and lateral sides of the joint were explored by two separate lengthwise incisions. The muscles originating from the epicondyles were inspected as were the medial and lateral collateral ligaments and anterior capsule and brachialis muscle. Ligamentous and muscular injuries were sutured in their substance or via epicondylar drill holes using absorbable polyglycolic acid sutures. The elbows were then immobilised for a planned two weeks in plaster cast at 90 degrees of flexion. After removal of the cast active motion of the elbow was encouraged.
2. Conservative treatment. The elbows were then immobilised for a planned two weeks in plaster cast at 90 degrees of flexion. After removal of the cast active motion of the elbow was encouraged.
Assigned: 15/15
Analysed: 14/14 at follow-up


OutcomesLength of follow-up: mean 27.5 months, 12 to 59 months (also, 5 and 10 weeks)
Elbow range of motion: extension, flexion, pronation and supination
Varus and valgus stability
Neurological evaluation, including grip strength
Flexion and extension strength
Patient 'complaints': limited motion, weakness, discomfort, pain, instability, subluxation, recurrent dislocation
X-ray at follow-up: myositis ossificans


Notes


Risk of bias

BiasAuthors' judgementSupport for judgement

Random sequence generation (selection bias)Unclear risk"... random selection from a pool of thirty sealed envelopes." "Thirty consecutive patients..."

Allocation concealment (selection bias)Unclear risk"... random selection from a pool of thirty sealed envelopes. Fifteen of the envelopes indicated surgical and 15 indicated non-surgical treatment." Potential lack of allocation concealment once group size of 15 reached. Adequate safeguards not apparent.

Blinding (performance bias and detection bias)
All outcomes
High riskParticipants or clinicians unable to be blinded. No mention of blinding of outcome assessors.

Incomplete outcome data (attrition bias)
All outcomes
Unclear riskOne patient in each group unable to attend follow-up. Unlikely to affect conclusions. However, variable timing of follow-up (mean follow-up was 31 months in the surgical group versus 24 months in the conservative treatment group.

Selective reporting (reporting bias)Unclear riskInsufficient information available.

Other biasUnclear riskStudy appears to be free of other sources of bias.

Rafai 1999

MethodsRandomisation method: drawing of lots
Assessor blinding: not stated
Loss to follow-up: not reported


ParticipantsCentre Hospitaliare Universitaire Ibn Rochd, Casablanca, Morocco
Period of study: over 2 years
50 consecutive participants.
Inclusion criteria: young person, normal psychological profile, posterior dislocation of elbow, stable reduction of the elbow, no previous elbow problems
Exclusion criteria: unstable reduction of elbow
Diagnosis: posterior dislocation of the elbow in adults
Presentation: acute, within 24 hours of injury
Sex: 43 male (86%)
Age: mean 25 years; range 16 to 67 years


InterventionsReduction under general anaesthesia, and stability checks before:
1. Early mobilisation: mobilisation started after 3 days (if appropriate). Self-rehabilitation at 3 times a day for 10 minutes increasing range of mobilisation over time. For the first 3 weeks, the arm was kept in a sling when not exercising.
2. Immobilisation: plaster cast immobilisation at 90 degrees for 3 weeks, followed by rehabilitation.

Assigned: 26/24
Analysed: 26/24 at follow-up


OutcomesLength of follow up: 12 months (also at 7, 15, 21, 36 and 51 days, and 2, 3 and 6 months for group 1 and 21, 36 and 51 days, and 2, 3 and 6 months for group 2). Thus, 9 visits for group 1 and 7 visits for group 2

Elbow range of motion: extension, flexion, pronation and supination (second pair were reported together)
Pain
Instability and recurrence


Notes


Risk of bias

BiasAuthors' judgementSupport for judgement

Random sequence generation (selection bias)Unclear risk"Nous avons mené une étude prospective randomisée". "La méthode thérapeutique a été choisie par tirage au sort .." Translated as "drawing of lots"; but still unclear.

Allocation concealment (selection bias)Unclear risk"La méthode thérapeutique a été choisie par tirage au sort ..". Translated as "drawing of lots". Adequate safeguards not apparent.

Blinding (performance bias and detection bias)
All outcomes
High riskParticipants and personnel unable to be blinded. No mention of blinding of outcome assessors.

Incomplete outcome data (attrition bias)
All outcomes
Unclear riskBased on calculated percentages in the text, all participants were accounted for. However, the figures in the trial report gave a different answer.

Selective reporting (reporting bias)Unclear riskInsufficient information available.

Other biasUnclear riskStudy appears to be free of other sources of bias. However, baseline characteristics were not split by treatment group.

 
Characteristics of excluded studies [ordered by study ID]

StudyReason for exclusion

Bek 2009Pulled elbow rather than dislocated elbow. Paediatric population.

Fan 1995We were unable to obtain a copy of this Chinese trial, nor its abstract. It may not be randomised.

Josefsson 1984aWhile the allocation of surgery and non-surgery in 14 patients was randomised, this was a study of the use of arthrography for diagnosing ligament injury.

Maripuri 2007Retrospective non-randomised study.

Taha 2000Pulled elbow rather than dislocated elbow. Paediatric population.

 
Characteristics of ongoing studies [ordered by study ID]
NTR2025

Trial name or titleFunctional treatment versus plaster for simple elbow dislocations (FuncSiE): a randomised trial

MethodsMulti-centre randomised clinical trial

ParticipantsPatients aged 18 years or older with a simple elbow dislocation that can be reduced. Target sample size: 100

Interventions1. Functional treatment group: The affected arm will be put in a pressure bandage for up to three weeks. Early active movements within the limits of pain are allowed. Usually by the second day the patients are instructed to do two exercises by a physical therapist, which are gradually expanded if tolerated.
2. Plaster group: The affected arm will be put in plaster of Paris for three weeks. At three weeks after dislocation the plaster will be removed and full mobilisation (flexion, extension, pronation and supination) will be initiated by practicing under supervision of a physical therapist. Physical therapy sessions will be held at regular intervals, preferably 2 times a week during 12 weeks.

OutcomesPrimary outcome (Quick-DASH) and secondary outcomes (MEPI, Oxford Elbow Score, pain, range of motion, secondary intervention rates, complication rates, SF-36, and EQ-5D) will be compared at baseline, at 1, 3 and 6 weeks, and at 3, 6, and 12 months after start of treatment, using both univariate and multivariable analyses. Costs for (in)formal healthcare consumption will be determined for both interventions. Cost-effectiveness will be expressed as cost per quality of life year (QALY) gained.

Starting date26 Aug 2009; planned closing date: 31 Dec 2012

Contact informationD den Hartog, MD
Erasmus MC, Dept of Surgery-Traumatology Mailbox H-822k 's-Gravendijkwal 230, 3015 CE Rotterdam P.O. Box 2040, 3000 CA Rotterdam, The Netherlands
Tel: +31-10 7031050
Fax: +31-10 7032396
d.denhartog@erasmusmc.nl

NotesA protocol for this trial is available.

 
Comparison 1. Early mobilisation versus cast immobilisation

Outcome or subgroup titleNo. of studiesNo. of participantsStatistical methodEffect size

 1 Range of motion deficiencies1Risk Ratio (M-H, Fixed, 95% CI)Totals not selected

    1.1 Incomplete recovery of extension at 12 months
1Risk Ratio (M-H, Fixed, 95% CI)0.0 [0.0, 0.0]

    1.2 Incomplete recovery of flexion at 12 months
1Risk Ratio (M-H, Fixed, 95% CI)0.0 [0.0, 0.0]

    1.3 Incomplete recovery of pronosupination at 12 months
1Risk Ratio (M-H, Fixed, 95% CI)0.0 [0.0, 0.0]

 2 Pain and instability1Risk Ratio (M-H, Fixed, 95% CI)Totals not selected

    2.1 Residual pain
1Risk Ratio (M-H, Fixed, 95% CI)0.0 [0.0, 0.0]

    2.2 Instability / recurrence
1Risk Ratio (M-H, Fixed, 95% CI)0.0 [0.0, 0.0]

 
Comparison 2. Surgery versus conservative treatment

Outcome or subgroup titleNo. of studiesNo. of participantsStatistical methodEffect size

 1 Patient complaints1Risk Ratio (M-H, Fixed, 95% CI)Totals not selected

    1.1 Injured elbow inferior to non-injured elbow
1Risk Ratio (M-H, Fixed, 95% CI)0.0 [0.0, 0.0]

    1.2 Limited motion (extension)
1Risk Ratio (M-H, Fixed, 95% CI)0.0 [0.0, 0.0]

    1.3 Weakness
1Risk Ratio (M-H, Fixed, 95% CI)0.0 [0.0, 0.0]

    1.4 Weather-related discomfort
1Risk Ratio (M-H, Fixed, 95% CI)0.0 [0.0, 0.0]

    1.5 Pain on effort
1Risk Ratio (M-H, Fixed, 95% CI)0.0 [0.0, 0.0]

    1.6 Tenderness
1Risk Ratio (M-H, Fixed, 95% CI)0.0 [0.0, 0.0]

    1.7 Pain at rest
1Risk Ratio (M-H, Fixed, 95% CI)0.0 [0.0, 0.0]

    1.8 Feeling of instability
1Risk Ratio (M-H, Fixed, 95% CI)0.0 [0.0, 0.0]

 2 Range of motion (compared with contralateral side)1Mean Difference (IV, Fixed, 95% CI)Totals not selected

    2.1 Extension (degrees) at 10 weeks
1Mean Difference (IV, Fixed, 95% CI)0.0 [0.0, 0.0]

    2.2 Extension (degrees) at > 1 year
1Mean Difference (IV, Fixed, 95% CI)0.0 [0.0, 0.0]

    2.3 Flexion (degrees) at 10 weeks
1Mean Difference (IV, Fixed, 95% CI)0.0 [0.0, 0.0]

    2.4 Flexion (degrees) at > 1 year
1Mean Difference (IV, Fixed, 95% CI)0.0 [0.0, 0.0]

 3 Complications1Risk Ratio (M-H, Fixed, 95% CI)Totals not selected

    3.1 Recurrent dislocation of ulnar nerve
1Risk Ratio (M-H, Fixed, 95% CI)0.0 [0.0, 0.0]

    3.2 Myositis ossificans
1Risk Ratio (M-H, Fixed, 95% CI)0.0 [0.0, 0.0]