ORIGINAL ARTICLE
Primary Ligament Repair for Elbow Dislocation
In-Ho Jeon, Shin-Yoon Kim, and Poong-Taek Kim

Department of Orthopaedic Surgery, School of Medicine,
Kyungpook National University, Daegu, Korea(Received for publication on September 14, 2007)(Revised for publication on November 28, 2007)(Accepted for publication on January 17, 2008)

Abstract: Few have been reported on the role of early primary ligament repair for acuteunstable elbow dislocation. The purpose of this study is to evaluate the clinical outcome ofearly primary ligament repair for unstable elbow dislocation followed by protected earlyjoint mobilization exercise.
Thirteen patients who underwent operative treatment due to unstable elbow dislocation
without associated fracture were retrospectively reviewed. There were 11 male and 2 female with average age of 37 years (range; 18-72 years). Surgical indications of the unstableelbow were subluxation or non-congruent elbow joint on the radiographs following closed
reduction. Elbow dislocation which required extension block splint over 45 degrees to maintain reduction was considered as unstable elbow dislocation.
In ten patients, full stability was restored only after both medial and lateral structures
were re-attached. In two patients, only lateral structure (LCLC and common extensor tendon) was repaired and in one patient, only medial structure (MCL and flexor pronator tendon) was repaired for stability. Overall mean functional Mayo Elbow Performance Score was
93.5 (range; 70-100). No elbow was dislocated or subluxated after operation. All ten patients
returned to previous work level in average of 3.5 months. Heterotopic calcification was noted in six patients and three had mild ulnar nerve symptoms after operation.
In conclusion, primary ligament repair in acute unstable elbow dislocation were successful, because surgery achieved sufficient stability to allow early exercise (Keio J Med 57 (2) :99－104, June 2008)
Key words: Unstable Elbow, Ligament Repair

Introductionof fractures, and lateral column, radiocapitellar joint andthen to repair collateral ligament complex.3 A hinged external fixator is advised in certain circumstances inwhich it is desirable to protect fractures or ligament repair.4, 5 Because of contracture after prolonged immobilization or instability after poor healing of fracture or soft
tissue damage, early joint mobilization with sufficientsurgical stability is crucial for successful outcome.
There have been a few reports on complex elbow dislocations with associated fractures in the literature,
which reported acceptable functional outcome withhinged external fixator.2, 6, 7 However, few have been reported on the role of early primary ligament repair for
acute unstable elbow dislocation.7, 8 The purpose of thisComplex instability of the elbow joint which is defined
as an injury that destabilizes the elbow joint because ofdamage to the articular surface and the ligamentous
structures is a challenging problem.1 This injury compromises around 49% of elbow dislocations and most ofthese fractures are inherently unstable and require surgery.2 Because prolonged elbow immobilization after
this complex injury produces poor results, surgery mustachieve sufficient stability to allow early range of motion
exercise. Thus, the primary goal of the treatment for thecomplex instability of the elbow joint is to restore the essential elements, the ulnohumeral joint by osteosynthesis

Presented at the 1515th Meeting of the Keio Medical Society in Tokyo, April 12, 2007
Corresponding Author: Prof. Poong-Taek kim M.D., Department of Orthopaedic Surgery, Kyungpook National University Hospital, Daegu, Korea TEL:
82-53-420-5632, FAX: 82-53-422-6605, E-mail: ptkim@knu.ac.kr
99Jeon IH, et al: Primary Ligament Repair For Elbow Dislocation

100
Table 1 Details of the patients with unstable elbow dislocation
No

GenderAge

Cause of
Injury

Side

1

M

37

Fall

2

F

50

3

M

4
5

AssociatedinjurySoft tissue

SurgicalapproachL

MCL/FP+LCLC/CE

M+L

Fall

L

MCL/FP+LCLC/CE

M+L

46

RTA

L

MCL/FP+LCLC/CE

M+L

M

27

Fall

L

MCL/FP+LCLC/CE

M+L

M

18

Judo

R

MCL/FP

M

LCLC/CE+MCL/PF repair
LCLC/CE+MCL/PF repair
LCLC/CE+MCL/PF repair
LCLC/CE+MCL/PF repair
MCL/FP repair

LCLC/CEL

LCLC+CE repair

LCLC/CEL

LCLC+CE repair

MCL/FP+LCLC/CE

M+L

ICH

Distal radiusfx
Brachial a
rupture

6

F

72

Fall

L

7

M

46

Fall

R

8

M

43

Fall

R

9

M

22

Triathlon

R

MCL/FP+LCLC/CE

M+L

10

M

23

Fall

L

MCL/FP+LCLC/CE

M+L

11

M

35

Fall

R

Distal radius
MCL/FP+LCLC/CE
fx

M+L

12

M

40

RTA

R

13

M

21

Judo

L

Ave

11:2

36.9

Spine fxICH

MCL/FP+LCLC/CE

M+L

Mandicule fx MCL/FP+LCLC/CE

M+L

Operation

LCLC/CE+MCL/PF repair
LCLC/CE+MCL/PF repair
LCLC/CE+MCL/PF repair
LCLC/CE+MCL/PF repair
LCLC/CE+MCL/PF repair
LCLC/CE+MCL/PF repair

Complication

MEPS9

FU

Ulnar nerve Sx

100

12

100

36

100

34

85

32

100

28

75

16

85

18

100

26

100

28

100

35

70

37

100

32

100

18

93.5

27

HO-M

Stiffness
HO-M/L
HO-M/L
Ulnar nerve Sx
HO-M

Stiffness
Ulnar nerve Sx
Massive
HO-M/L/A/P
HO-M(M: male, F: female, RTA: road traffic accident, R: right, L: left, ICH: intra-cranial hemorrhage, MCL:medial collateral ligament, FP: flexor
pronator tendon, LCLC: lateral collateral ligament complex, CE: common extensor tendon, M: medial, L: lateral, HO: heterotopic ossification,
Ulnar nerve Sx: ulnar nerve symptoms, MEPS: Mayo Elbow Performance Score, FU: follow up)

study is to analyze and report the clinical outcome ofearly primary ligament repair for unstable elbow dislocation followed by protected early joint mobilization exercise.
Methods
From January 2004 to January 2006, 13 patients who
underwent operative treatment due to unstable elbow
dislocation without associated fracture in the elbow joint
were retrospectively reviewed in one tertiary trauma center. Patients presenting over 3 weeks from the original
injury or with dislocation associated with coronoid, olecranon or radial head fractures were excluded. There were
11 male and 2 female with average age of 37 (range
18-72 years). There were 6 right elbows and 7 left elbows.
Cause of injury was fall from a height in eight, sports
injury in three (two from Judo, one from triathlon), roadtraffic accident in two. Mean time from injury to operation was 3.5 days (range; 1-14 days).
Surgical indications of the unstable elbow were subluxation or non-congruent elbow joint on the radiographs

following closed reduction. Elbow dislocation which required extension block splint over 45 degrees to maintainreduction was considered as unstable elbow dislocation(Figure 1). MRI was taken in 10 patients to evaluate soft
tissue injuries and associated intra-articular damage.
Data of pain scale, range of motion using goniometer,stability using manual stress test, and activity of dailyliving were collected for functional evaluation of Mayo
Elbow Performance Score (MEPS).
Surgical technique
When dislocation is identified, reduction of the dislocation should be carried out first. Gentle closed reduction of elbow is recommended usually under general anesthesia. Repeated manipulation is not recommended to
avoid further soft tissue and cartilage damage. Plain radiographs and MRI provide valuable information onwhich sides of soft tissue were damaged.
Examination under anesthesia should be carried out toconfirm collateral ligament injuries. Valgus, varus andposterolateral rotatory instability testing were carriedout. Valgus stability at forearm pronation, varus pivot

Keio J Med 2008; 57 (2): 99－104

101

Fig. 1 A 23 year old man (Case number 10) sustained left elbow
dislocation after a fall during mountain hiking. After closed
reduction, plain radiographs of the elbow anteroposterior (A) andlateral (B) view show wide gap in the radiocapitellar joint andpersistent subluxation.

Fig. 2 At surgical exploration, common extensor tendons were
torn apart from the lateral epicondyle and lateral collateral
ligament complex (arrow) was avulsed from lateral epicondyle(asterisk), which were reattached using anchor screw and bonetunnel method.

shift testing confirmed unstable ulno-humeral joint. All
test signifies the disruption of medial and lateral soft tissue structures.
Lateral collateral ligament complex was exposed using
modified Kocher’s posterolateral approach. In most cases, common extensor tendon together with lateral collateral ligament complex was torn and retracted from thelateral epicondyle (Figure 2). Torn posterolateral cornerof the joint capsule and intra-articular fracture was carefully inspected. Torn edge of lateral collateral ligamentcomplex was tagged and re-attached the anatomic attachsite of the lateral epicondyle using metal suture anchor(Twinfix, Smith & Nephew, Memphis, TN). Non-absorbable suture using bone tunnel method was used to repair
the common extensor tendons.
Extensile medial approach was used to expose the medial collateral ligament together with flexor pronator tendon. Mostly, the medial collateral ligament and capsule
was avulsed from medial epicondyle, and flexor pronatortendon was torn at musculotendinous junction. Medialcollateral ligament was re-attached using anchor screw
and for flexor/pronator tendons, non-absorbable sutures(5-0 Ethibond, Ethicon, Johnson & Johnson, Somercille,
NJ) through bone tunnel in the medial epicondyle wasused, because the anatomic attachment site was easily
identified in the acute setting.
After re-attachment of medial collateral ligament,
valgus/varus stress and pivot shift test were carried out
to check integrity of lateral stabilizers. After re-attachment, concentric and congruent elbow joint during flexion and extension must be identified under the image intensifier. Trans-articular pin fixation was not recommended in any series.

Postoperative rehabilitation
Posterior splint is applied at 30 degrees of extension
and arm was elevated to reduce postoperative swelling.
Early active assisted range of motion exercise could startfrom 7 to 10 days after operation depending on the soft
tissue condition. Posterior splint was applied during thistime. Hinged plastic brace was applied afterwards andprotected active flexion and extension were allowedfrom 2 weeks after operation.
Case presentation
A 43 year old male carpenter fell from a height in theconstruction filed. He had lumbar spine bursting fracture, which was stabilized with pedicle screw system.
Right elbow dislocation was reduced manually before
being transferred. The patient complained severe pain in
the right elbow and physical examination showed extensive ecchymosis and subcutaneous hematoma along medial side of the elbow (Figure 3 A,B). No neurologic deficit was found at examination.
Plain radiographs at arrival showed non-congruent ulnotrochlear joint with radial shift of proximal radio-ulnar
joint. Lateral radiograph showed complete dislocation ofproximal radioulnar joint from distal humerus (Figure 3C, D). There was no fracture in the distal humerus, coronoid or radial head. MRI demonstrated non-congruent
elbow joint with persistent subluxation. High signal intensity on both medial and lateral sides of the elbow implied extensive soft tissue damage (Figure 4 A,B).
Examination under anesthesia showed unstable elbow
joint medially, laterally and posteriorly. Medial approach

102

Fig. 3 A 43 year old carpenter injured his right elbow after a fallin the construction field. At physical examination, right elbow
was very unstable at valgus (A) and varus (B). Plain radiographof anteroposterior (C) and lateral (D) views demonstrated highly
unstable elbow without congruent joint reduction. Concentric
reduction was unable to achieve.

Jeon IH, et al: Primary Ligament Repair For Elbow Dislocation

Fig. 4 T2 weighted coronal MR images showed extensive soft
tissue damage on both medial and lateral side with persistentsubluxation. (A,B). At exploration, flexor/pronator tendon (arrow)
was torn at musculotendinous junction and medial collateral
ligament and capsule were avulsed from medial epicondyle(asterisk) (C,D). Both medial and lateral structures together withanterior capsule were repaired using anchor screws and bonetunnel method.

exposed all flexor/pronator tendons were torn at musculotendinous junction or avulsed from medial epicondyle.
Medial collateral ligament was usually torn from humeral side, Re-attachment using non-absorbable suture andanchor screws (Figure 4 C,D). Anterior capsule and coronoid process could be exposed and examined frommedical side. After reattachment, there was significant
varus and posterolateral rotatory instability persisted.
Lateral ligament complex and capsule was torn from lateral epicondyle was retracted distally. After re-attachment, stable congruent elbow joint was achieved which
was confirmed under image intensifier.
After the rehabilitation protocol, functional range of
motion was achieved in three months, and no instabilityor traumatic arthrosis was noted at latest follow up (Figure 5).
Results

Fig. 5 After primary repair, early rehabilitation was possible
and near full range of motion was regained at three months
after operation (A,B). The patient reported minimal pain withno disturbance in activity of daily living. Functional score of
Mayo Elbow Performance Score was 100 at last follow up. Plain
radiographs (C,D) at latest follow up showed concentric reductionof the joint with no sign of instability, arthrosis or heterotopic
ossification.

All patients were followed up clinically and radiologically at a mean time of 27 months (range, 12-37 months)
after operation.
In ten patients, full stability was restored only after
both medial and lateral ligaments were re-attached. In
two patients, only lateral structure (LCLC and common
extensor tendon) was repaired and in one patient, only
medial structure (MCL and flexor pronator tendon) wasKeio J Med 2008; 57 (2): 99－104

repaired for stability. In ten patients, flexor/pronator tendon was torn in musculotendious junction and in threepatients, there was small flake of bone avulsed from epicondyle. In one patient, persistent posterior subluxation
was identified after medial and lateral structure repair,and repair of the torn anterior capsule and brachialis
from the coronoid process was performed. Preoperative
MRI showed soft tissue injuries and capsular tear withhigh signal intensity lesions. These have been identified
during the operation.
Overall mean functional Mayo Elbow Performance
Score9 was 93.5 (range 70-100).
Mean extension lag was 15 degrees (range; 10-30 degrees) and mean flexion was 130 degrees (range;
100-140 degrees). Mean prono/supination was 70/80 degrees (range; 50-90 pronation, 75-90 supination). No elbow was dislocated or subluxated during the operationand follow up period. Minor paresthesia or scar tenderness was reported by three patients but no further surgery
was performed.
All patients returned to previous work level except one
patient who had worker’s compensation. Otherwise allten patients returned to previous work level in average of
3.5 months.
Complications
Functional range of motion was not achieved in twopatients. One had traumatic subdural hematoma which
delayed the operative treatment and rehabilitation complicated. The other one patient had severe chest injury
which delayed the rehabilitation program until 8 weeks.
Both patients required open arthrolysis for the stiffness
and achieved near functional range of motion at last follow up.
Three patients had mild ulnar nerve symptoms after
operation. One of them required cubital tunnel decompression for the ulnar nerve. There was fibrous scar adhesion between the nerve and flexor pronator muscle below the medial epicondyle. Ulnar nerve symptoms of theother two patients resolved spontaneously in threemonths.
Heterotopic calcification was noted in 6 patients at last
follow up. Massive heterotopic ossification in the brachialis muscle was identified in one patient who sustained traumatic subdural hematoma. This has been resolved in six months postoperatively and the patient refused further surgery, because the range of motion at last
follow up was 30-110 degrees with no instability. Spotty
calcification around the lateral epicondyle and along thelateral collateral ligament complex in five patients andcalcification around the medial epicndyle in four andboth in two.

103

Discussion
The elbow is the second most commonly dislocatedjoint next to the shoulder in the adults.1 0 Dislocation or
subluxation typically occurs as a result of falls on theoutstretched hand. Axial compressive force during flexion together with valgus moment results posterior dislocation.11 Hyperextension injury to the elbow can produce
elbow dislocation.2 O’Driscoll introduced circle concept
to the soft tissue disruption from lateral to medial inthree stages and dislocation is the final of three sequential stages of elbow instability.1 0 Based on this concept,
anterior band of MCL is the most important structure
which becomes the centre of pivot for posterior dislocation. A study of anatomy, mechanism of injury and clinical features suggested that there were soft tissue injuries
around the elbow joint. Although the roles of the flexor/
pronator and common extensor origins are not fully understood, however they are probably crucial secondary
stabilizers of the elbow. 1 1 In our series, all flexor/
pronator and common extensors were disrupted in unstable elbow dislocations.
Acute simple dislocation of the elbow can be reduced
under regional or general anesthesia. After stability assessment, early mobilization based on severity of soft
tissue is recommended. Usually a total of 3 to 6 weeks ofprotected motion is adequate. (Hand Clinics)Reported
clinical results in simple dislocation with early mobilization were mostly successful. Uncomplicated dislocations
generally have very satisfactory results. Excellent resultswith full range of motion, normal strength, absent pain
and good stability may expected in half of uncomplicated dislocations. However, complex fracture dislocationof the elbow showed somewhat different clinical resultswith various complications, such as instability, painful
stiff elbow, etc.
According to Ring and Jupiter, instability of the elbow
joint presents in two basic patterns: One is the olecranon
and coronoid are fractured and inadequate fixation creates12 an inadequate trochlear notch and the other one is
the trochlear notch is either intact or repaired and there isdislocation or subluxation of the ulnohumeral joint. In
the first pattern, stability can often be restored by achieving secure realignment of the fractured bones. In the second pattern restoration of stability depends on management of the radial head, coronoid process, and capsuloligamentous structures. In our study, we focused mainly
on capsuloligamentous structure in complex instability
without fracture.
Indication for acute ligament repair or reconstruction is
instability that does not permit early protected motion ina cast brace. This usually occurs only when there are associated fractures. In such cases, the ligaments may havebeen avulsed and can be repaired directly to the bonewith heavy sutures. If they are torn and can not be re-Jeon IH, et al: Primary Ligament Repair For Elbow Dislocation

104

paired, reconstruction of the ligament using palmaris
longus tendon is recommended.13 In our experience, primary stabilization is preferred than late reconstruction
procedure, because primary repair immediate after injury
can avoid complicated reconstruction procedure withearly return to previous work activities.
The ligamentous contributors included are the medial
and lateral collateral ligament complex, and dynamic
stabilizers are flexor/pronator group and common
extensor/supinator group. 1 4 The primary goal of thetreatment for the unstable dislocation is to restore the essential element, the ulnohumeral joint by primary repairof disrupted collateral ligaments. The next step is to restore dynamic stability by repairing musculotendinous
structure. Third step is to repair collateral ligament complex. A hinged external fixator is advised in certain circumstances in which it is desirable to protect a fracture
or a ligament repair.
Josefsson and associates reviewed the long term sequelae of simple dislocation in 52 patients.7 Half of thepatients had normal elbows; one third had some loss of
motion, mainly extension. This related to the duration of
post-reduction immobilization. Those immobilized longer than 3 weeks were likely to develop contractures,
whereas those immobilized for shorter periods were not.
In this series, all patients were advised to follow protected early rehabilitation within ten postoperative days.
There have been few reports on recurrent dislocationof the elbow in the literature.1 5 Previous operations can
be classified into four groups. 1) Reichheim’s operation
which is transplantation of biceps tendon through thecoronoid process, 2) Milch’s and Wainwright’s boneblock procedure, which has mechanical effect on thecoronoid process to prevent its disengagement under thetrochlear through anterior approach, 3) Intra tendinous
sling procedure using artificial ligament described by
Kapel, 4) Knoflach and Spring’s reinforcement of collateral ligaments. More recently, Nester and O’Driscoll1 6
reported free palmaris longus tendon graft using bonetunnel method. Primary ligament repair and ligament reconstruction have been reviewed and compared by Mayogroup. They reported the clinical results were better inreconstruction group than primary repair group. None ofthe patients in this series, however, required late reconstruction and all achieved functional return to work.
Neurologic problems occur in approximately 20 percent of dislocation. The ulnar nerve is the most susceptible major nerve. Symptoms vary from transient paresthesia in the ulnar distribution to rare permanent ulnar nerve
palsy.
Pugh et al.17 reported surgical outcome of 36 patientswith elbow dislocation associated with both radial andcoronoid fracture. They repaired collateral ligament withor without hinged external fixation. Overall average rangeof motion was 112° ± 11° at a mean follow up of 36

months. Functional score using Mayo Elbow Performance Score was 88 points.
In conclusion, primary ligament repair for unstable elbow dislocations avoids late ligament reconstruction andprevents the poor results which are commonly found following non-operative treatment. An external fixator is
not usually required in the acute setting. Clinical resultsfrom primary ligament repair in unstable elbow havebeen successful, because immediate motion was possible
and stability has been achieved. The current approaches
to start immediate motion in all injured and operated elbow; those for which this is not possible are reconstructed to permit such early motion. Further studies are required to validate our clinical results
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