Does Sonography Allow an Objective and Reproducible Distinction Between Stable, Hypermobile and Unstable Elbow Joints?

Kirschbaum Stephanie, Plachel Fabian, Kerschbaum Maximillian, Gerhard Christian, Thiele Kathi
Journal of Shoulder and Elbow Surgery 2021 January 19

INTRODUCTION: The diagnosis of residual or chronic elbow instability is often challenging. Sonography therefore allows a dynamic examination of the elbow joint without any radiation exposure. The purpose of this prospective single-center study was to investigate the application of sonography for the evaluation of ligamentous instabilities of the elbow joint. Therefore, asymptomatic (stable) and acute dislocated (unstable) elbows were examined by sonography.

METHODS: A total of 72 elbows in 36 participants (23 females, 13 male, 40 years ± 17 [range, 18-82]) were examined. Group 1 (G1 (normal)) included 40 unaffected, asymptomatic elbow joints. Twenty-eight elbows belonged to 14 voluntary participants (bilateral), 12 asymptomatic elbows belong to the patients who suffered from an acute elbow dislocation (contralateral elbow). Group 2 (G2 (hypermobile)) included 20 hypermobile elbow joints in 10 participants (bilateral) and group 3 (G3 (unstable)) included 12 acute unstable elbow joints without bony lesion. Radiographic assessment included sonography of both elbow joints with standardized measurements of the neutral and stressed radiocapitellar and ulnohumeral distances (as delta-values (Δ)). Two investigators independently performed all measurements. Additionally plain radiographs and MRI of the affected elbow joints were carried out within G3 (unstable).

RESULTS: At the radial side, the mean radiocapitellar -Δ was statistically higher in G3 - unstable (2.2 ± 1.6 mm) than in G1 (normal) (0.5 ± 0.4 mm; p<0.01) or G2 (hypermobile) (0.8 ± 0.6 mm; p<0.01). G3 (unstable) showed also an increased ulnohumeral-Δ (2.7 ± 0.7 mm) compared to G1 (normal) (1.0 ± 0.7 mm; p<0.01) or G2 (hypermobile) (0.9 ± 0.3 mm; p<0.01). No significant differences in the mean radiocapitellar -Δ (p=0.06) and ulnohumeral-Δ (p=0.26) were found between G1 (normal) and G2 (hypermobile). Within G3 (unstable), there was a significant higher Δ at the affected elbow joint compared to the contralateral unaffected elbow joint (radial: p=0.04; ulnar: p=0.04). The interrater correlation coefficient (ICC) was 0.82 for the radial side and 0.74 for the ulnar side. Patient with collateral ligament injury, diagnosed in MRI, showed higher Δ to those with intact collateral ligaments although no significant difference was found.

CONCLUSION: Sonography of the elbow joint is a valuable imaging tool for the assessment of ligamentous instability. Nevertheless, a distinction between healthy and hypermobile elbow joints is not possible and therefore, obtaining a complete clinical history and examination is vital. We further recommend comparing the affected elbow joint with the contralateral side in order to access intraindividual differences.

LEVEL OF EVIDENCE: Level III; Case-Control Design; Diagnostic Study.

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