The elbow is the second most common dislocated joint after the shoulder joint1. An elbow dislocation can be classified as simple or complex. A simple elbow dislocation (SED) is a dislocation without associated fractures2. In many SEDs, small avulsions of the medial and/or collateral lateral ligaments or the capsule are seen; these avulsions are not classified as fractures1. The elbow dislocation has an incidence of 5 to 6 per 100,000 per year, of which 74% are SEDs3,4.

The trends concerning the therapy of a SED have changed over time. Previously, nonoperative therapy consisted mainly of immobilization and casting the elbow, with relatively good long-term outcomes5. Approximately 8% of patients with SEDs may experience persistent instability after nonoperative treatment or stiffness. The latter led to a focus on short-term immobilization (<7 days) or no immobilization at all, with active movement initiated immediately after closed reduction6,7. In addition to nonoperative therapy, there is a trend toward surgical intervention for elbows with gross instability after SED8. Optimizing the treatment strategy is important as suboptimal treatment may result in pain, persistent or recurrent instability, stiffness, posttraumatic arthritis, and the need for additional surgical intervention9.

The primary aim of this study was to systematically review the literature and analyze the outcomes and complications of different treatment options for acute and persistent elbow dislocations (PEDs), including operative and nonoperative treatments with varying immobilization periods. In addition, the secondary aims were to assess the outcomes of PED and SEDs in pediatric patients. By providing a comprehensive overview of the available evidence, this systematic review offers a new perspective on treating SEDs and can assist in shared decision-making regarding treatment options.

Methods

A systematic literature review was conducted according to the Preferred Reporting Items for Systematic Meta-Analyses guidelines10. The review was registered in an international prospective register of systematic reviews (PROSPERO). The protocol is registered under the following number CRD42021287756 and can be accessed electronically at http://www.crd.york.ac.uk/prospero.

Literature Search and Study Selection

A literature search was performed with the help of a clinical librarian (S.P.-V.) based on the online medical databases MEDLINE, Embase, and the Cochrane Central Register of Controlled Trials. The search strategy is presented in Appendix 1. Title, abstract, and full-text screening were performed by 2 independent reviewers (C.M.J.M.P. and H.H.d.K.) to identify potentially relevant articles. The authors independently selected articles. Studies were not blinded for author, affiliation, or source. Any disagreements were resolved by a third author (M.P.J.v.d.B.).

Inclusion and Exclusion Criteria

Articles presenting patients with a SED were eligible for inclusion. Patients with an acute or persistent total SED, without associated injuries, preexisting elbow pathology, or previous surgery in the ipsilateral elbow were included. Patients with an isolated radius dislocation were excluded. Studies were included if they were written in English, German, or Dutch; had at least 12 months of follow-up; and reported on a minimum of 5 patients. Studies had to contain at least one of the outcome parameters (patient-reported outcome measures [PROMs], range of motion [ROM], or complications) to be included. Reviews, biomechanical and cadaveric studies, expert opinions, and surgical technique articles were excluded.

Data Extraction

When available, the following baseline parameters were recorded: number of patients and elbows, sex, age, dominant side, and laterality of injury. Furthermore, the following intervention parameters were recorded: type of nonoperative treatment (the type of immobilization, duration of immobilization, and duration of early motion) or surgical treatment (medial collateral ligament repair and/or lateral collateral ligament repair). Relevant outcome parameters included the months of follow-up; pain score measured using the visual analog scale; continuous satisfaction rate; ROM of the elbow in flexion-extension and pronation-supination; Mayo Elbow Performance Score (MEPS); Quick Disabilities of the Arm, Shoulder, and Hand (qDASH) score; rate of return to sport; complications; and information about revision surgery or surgery after initial nonoperative treatment. The MEPS is an elbow outcome score used to test the limitations in the elbow during activities of daily living. A total score between 90 and 100 points can be considered excellent; between 75 and 89 points, good; between 60 and 74 points, fair; and <60 points, poor11. The Disabilities of the Arm, Shoulder, and Hand (DASH) score is a well-recognized instrument for measuring upper-limb function and symptoms. The qDASH score represents the disability/symptom score, which includes 11 items from the original DASH's 30 questions. This tool is performing well with strong evidence supporting reliability12. Each item of the qDASH has 5 response options (scored 1-5) used to create a summative score ranging from 0 (no disability or symptoms) to 100 (greater disability or symptoms).

Because there were many different options for the duration of immobilization and mobilization, we categorized them under treatment groups. Treatment groups consisted of early mobilization (<7 days), 1- to 3-week immobilization, ≥3-week immobilization, and surgery. The surgery group included 2 subheadings: patients who underwent surgery as their first choice of treatment or after failed nonoperative treatment and patients with PEDs. An elbow dislocation is defined as persistent when it persists for >3 weeks13. Some studies compared different groups; therefore, the different groups were collected separately when possible. The ROM flexion-extension arc was determined by subtracting ROM extension values from the ROM flexion values. Pediatric patients were also presented in Tables I and II, but Table III presents a subgroup analysis. Pediatric patients are defined as patients younger than 18 years.

TABLE I - Outcomes of Nonoperative Treatment in SED* Study Total Adults No. of Elbows Mean Age (yr) Mean Functional Outcome by Study† Complications, n (%) Mean Follow-up (mo) No. of Elbows Mean Age (yr) Mean Functional Outcome by Study† Complications, n (%) Mean Follow-up (mo) Early mobilization  Hopf et al., 201519 22 53.1 MEPS 94.1
qDASH 6.1
ROM F/E 146°
ROM P/S 165° 0 (0) minor
3 (4) major 59.6 22 53.1 MEPS 94.1
qDASH 6.1
ROM F/E 146°
ROM P/S 165° 0 (0) minor
3 (4) major 59.6  Krticka et al., 201820 28 48 MEPS 97
OES 46.2
qDASH 2.5
ROM F/E 132° 14 (50) minor
0 (0) major 32 28 48 MEPS 97
OES 46.2
qDASH 2.5
ROM F/E 132° 14 (50) minor
0 (0) major 32  Van Lieshout, 202018 48 43 EQ-5D 0.88
OES 93
qDASH 4
SF-36 PCS 53 25 (52) minor
3 (6) major 12 48 43 EQ-5D 0.88
OES 93
qDASH 4
SF-36 PCS 53 25 (52) minor
3 (6) major 12  Schnetzke et al., 20178 68 37.2 MEPS 94.2
ROM F/E 135°
Flexion 138°
Extension 3°
VAS 0.8 0 (0) minor
4 (6) major 40.8 68 37.2 MEPS 94.2
ROM F/E 135°
Flexion 138°
Extension 3°
VAS 0.8 0 (0) minor
4 (6) major 40.8  Beirer et al., 201821 10 44 ESAS 91.8
ROM F/E 140°
ROM P/S 176 0 (0) minor
1 (10) major 44 10 44 ESAS 91.8
ROM F/E 140°
ROM P/S 176 0 (0) minor
1 (10) major 44  Maripuri et al., 200738 22 41 DASH 2.7
MEPS 96.5 0 (0) minor
0 (0) major 1-3 wk immobilization  Ataoglu et al., 201722 14 OES 91
qDASH 5
ROM F/E 118
Flexion 132°
Extension 14° 2 (14) minor
0 (0) major 12 14 OES 91
qDASH 5
ROM F/E 118
Flexion 132°
Extension 14° 2 (14) minor
0 (0) major 12  Calderazzi et al., 20205 26 43 DASH 12.8
MEPS 93.8 6 (23) minor
0 (0) major 40 26 43 DASH 12.8
MEPS 93.8 6 (23) minor
0 (0) major 40  Maripuri et al., 200738 20 44.4 DASH 7.5
MEPS 90.5 0 (0) minor
1 (2) major  Cho et al., 201823 3 61.7 MEPS 81.7
qDASH 22
ROM F/E 130°
Flexion 133°
Extension 3°
ROM P/S 146°
Pronation 73°
Supination 73° 1 (33) minor
0 (0) major 48 3 61.7 MEPS 81.7
qDASH 22
ROM F/E 130
Flexion 133°
Extension 3°
ROM P/S 146
Pronation 73°
Supination 73° 1 (33) minor
0 (0) major 48  Kerschbaum et al., 201724 10 38 DASH 2
MEPS 90
OES 45
ROM F/E 145°
Flexion 145°
Extension 0° 0 (0) minor
7 (70) major 54  Willin et al., 202039 5 46.4 Bromberg-Morrey 94
MEPS 90
OES 55.8
qDASH 20.9
SEV 82 1 (20) minor
2 (40) major 27 5 46.4 Bromberg-Morrey 94
MEPS 90
OES 55.8
qDASH 20.9
SEV 82 1 (20) minor
2 (40) major 27  Panteli et al., 201543 27 41.4 1 (4) minor
0 (0) major 12  Borris et al., 198744 63 22.2 52 (83) minor
17 (27) major 84  Josefsson et al., 198745 34 39 3 (9) minor
5 (15) major 84  Bettuzzi et al., 202347 5 11 2 (40) minor
2 (40) major 67.2  Bua et al., 202241 10 11 Kim 87.5 0 (0) minor
1 (10) major >3 wk immobilization  Sofu et al., 201625 12 8 MEPS 91.6
ROM: F/E 120°
ROM P/S 146°
Pronation 67°
Supination 79° 0 (0) minor
4 (33) major 46  Adaş et al., 201426 11 9.8 MEPS 96.8
ROM F/E 129°
Flexion 137°
Extension 8°
ROM P/S 150°
Pronation 73°
Supination 77° 0 (0) minor
0 (0) major 24.3  Van Lieshout, 202018 52 47 EQ-5D 0.89
OES 95
qDASH 4
SF36-PCS 53 29 (56)
2 (4) major 12 52 47 EQ-5D 0.89
OES 95
qDASH 4
SF36-PCS 53 29 (56)
2 (4) major 12  Panteli et al., 201543 14 35.4 0 (0) minor
0 (0) major 12  Eygendaal et al., 200046 31 33 25 (80) minor
45 (145) major 108 31 33 25 (80) minor
45 (145) major 108  Geyer et al., 202237 21 37.4 ESAS 99.4
MEPS 97.3
qDASH 7.8
ROM F/E 139
ROM P/S 180 2 (10) minor
5 (24) major 72.8 21 37.4 ESAS 99.4
MEPS 97.3
qDASH 7.8
ROM F/E 139
ROM P/S 180 2 (10) minor
5 (24) major 72.8  Pincin et al., 202242 18 MEPS 100
OES 47.8
qDASH 0.25

*DASH = Disabilities of the Arm, Shoulder, and Hand, EQ-5D = EuroQol-5 Dimensions, ESAS = Elbow Self-assessment Score, Kim = Kim's elbow performance score, MEPS = Mayo Elbow Performance Score, OES = Oxford Elbow Score, qDASH = Quick Disabilities of the Arm, Shoulder, and Hand, ROM F/E = range of motion flexion-extension arc, ROM P/S = range of motion pronation-supination arc, SEV = subjective elbow value, SF-36 PCS = Short Form 36 physical component summary, and VAS = Visual Analog Scale.

†Posttherapy values are presented.

TABLE II - Outcomes of Surgical Treatment in SED* Study Total Adults No. of Elbows Mean Age (yr) Mean Functional Outcome by Study† Complications, n (%) Mean Follow-up (mo) No. of Elbows Mean Age (yr) Mean Functional Outcome by Study† Complications, n (%) Mean Follow-up (mo) Surgery  Krticka et al., 201820 26 50 MEPS 87.7
OES 42.5
qDASH 8.3
ROM F/E 117° 29 (112) minor
0 (0) major 26 26 50 MEPS 87.7
OES 42.5
qDASH 8.3
ROM F/E 117° 29 (112) minor
0 (0) major 26  Micic et al., 200927 14 34.1 MEPS 95.4
ROM F/E 116
Flexion 130°
Extension 14° 8 (57) minor
4 (29) major 32.6 14 34.1 MEPS 95.4
ROM F/E 116
Flexion 130°
Extension 14° 8 (57) minor
4 (29) major 32.6  Adolfsson et al., 201728 8 54 ROM F/E 130°
Flexion 136°
Extension 6° 4 (50) minor
0 (0) major 8 54 ROM F/E 130°
Flexion 136°
Extension 6° 4 (50) minor
0 (0) major  Lee et al., 201929 21 45.1 qDASH 4.3
ROM F/E 134
Flexion 138°
Extension 4°
ROM P/S 163
Pronation 73°
Supination 90° 1 (5) minor
16 (76) major 43.3 21 45.1 qDASH 4.3
ROM F/E 134°
Flexion 138°
Extension 4°
ROM P/S 163°
Pronation 73°
Supination 90° 1 (5) minor
16 (76) major 43.3  Cho et al., 201823 17 49.5 MEPS 86.5
qDASH 8.4
ROM F/E 121
Flexion 130°
Extension 9°
ROM P/S 153°
Pronation 71°
Supination 82° 5 (29) minor
0 (0) major 57.5 17 49.5 MEPS 86.5
qDASH 8.4
ROM F/E 121°
Flexion 130°
Extension 9°
ROM P/S 153°
Pronation 71°
Supination 82° 5 (29) minor
0 (0) major 57.5  Schnetzke et al., 20178 50 44.4 MEPS 93.4
ROM F/E 134°
Flexion 139°
Extension 5°
VAS 1 1 (2) minor
5 (10) major 40.8 50 44.4 MEPS 93.4
ROM F/E 134°
Flexion 139°
Extension 5°
VAS 1 1 (2) minor
5 (10) major 40.8  Jung et al., 201930 10 30.5 MEPS 85
NRS 2
qDASH 11.4
ROM F/E 130°
ROM P/S 161° 29 10 30.5 MEPS 85
NRS 2
qDASH 11.4
ROM F/E 130°
ROM P/S 161° 29  Beirer et al., 201821 10 43 ESAS 91.6
ROM F/E 131°
ROM P/S 173° 0 (0) minor
3 (30) major 44 10 43 ESAS 91.6
ROM F/E 131°
ROM P/S 173° 0 (0) minor
3 (30) major 44  Jeon et al., 200840 12 36.2 MEPS 94.2 27.8 12 36.2 MEPS 94.2 27.8  Willin et al., 202039 9 57.3 Bromberg-Morrey 94
MEPS 91
OES 54.7
qDASH 9.8
SEV 85 0 (0) minor
1 (11) major 36 9 57.3 Bromberg-Morrey 94
MEPS 91
OES 54.7
qDASH 9.8
SEV 85 0 (0) minor
1 (11) major 36  Josefsson et al., 198745 28 36 4 (14) minor
2 (7) major 36  Geyer et al., 202237 23 21 ESAS 99.8
MEPS 98.7
qDASH 6.3
ROM F/E 135
ROM P/S 177 4 (17) minor
6 (26) major 58.7 23 21 ESAS 99.8
MEPS 98.7
qDASH 6.3
ROM F/E 135
ROM P/S 177 4 (17) minor
6 (26) major 58.7 Persistent  Devnani, 200431 7 30.1 ROM F/E 83°
Flexion 110°
Extension 27° 7 (100) minor
2 (29) major 51.4 6 39.1 ROM F/E 100°
Flexion 120°
Extension 20° 43  Mahaisavariya et al., 200532 21 25.9 ROM F/E 84° 1 (5) minor
0 (0) major 50.3 16 31.1 ROM F/E 87°  Salihu et al., 202133 49 31.9 MEPS 92.6
PSFS 9.1
ROM F/E 87° 1 (2) minor
43 (89) major 12 49 31.9 MEPS 92.6
PSFS 9.1
ROM F/E 87° 12  Kapukaya et al., 201313 20 20 MEPS 79.3
ROM F/E 85° 0 (0) minor
10 (50) major 39.1 4 51.8 ROM F/E 51° 46.3  Anderson et al., 201834 32 25 MEPS 93
ROM F/E 101°
Flexion 132°
Extension 31°
ROM P/S 121°
Pronation 71°
Supination 150°
SOD 9 1 (3) minor
0 (0) major 22 24 30.6 MEPS 91.9
ROM F/E 83°
ROM P/S 120°
SOD 9 (8.6) 20.9  Mehta et al., 200735 6 25.2 MEPS 81.7
ROM F/E 92°
ROM P/S 150° 18 4 30.5 ROM F/E 83°
ROM P/S 150° 21  Krishnamoorthy et al., 197636 8 27.5 ROM F/E 93°
Flexion 124°
Extension 31° 31.5 7 36.7 ROM F/E 103°
Flexion 135°
Extension 32° 40.3

*ESAS = Elbow Self-assessment Score, MEPS = Mayo Elbow Performance Score, NRS = numeric rating scale, OES = Oxford Elbow Score, PSFS = Patient-Specific Functional Scale, qDASH = Quick Disabilities of the Arm, Shoulder, and Hand, ROM F/E = range of motion flexion-extension arc, ROM P/S = range of motion pronation-supination arc, SEV = subjective elbow value, SOD = Summary Outcomes Determination score, and VAS = Visual Analog Scale.

†Posttherapy values are presented.

TABLE III - Outcomes of Children with SED* Study No. of Elbows Mean Age (yr) Mean Functional Outcome by Study† Complications, n (%) Mean Follow-up (mo) 1-3 wk immobilization  Borris et al., 198744 43 10 16 (37) minor
11 (26) major 84  Subasi et al., 201548 22 11.6