The inter-individual anatomical variation of the trochlear notch as a predisposition for simple elbow dislocation

Abstract

Purpose: Besides the multi-layered capsule-ligamentous complex of the elbow joint the high bony congruence in the ulnohumeral joint contributes to elbow stability. Therefore, we assume that specific anatomical configurations of the trochlear notch predispose to dislocation. In case of ligamentous elbow dislocation both conservative and surgical treatment is possible without a clear treatment algorithm. Findings of constitutional bony configurations could help deciding for the best treatment option.

Methods: In this retrospective matched-pair analysis we compared MRI imaging from patients sustaining a primary traumatic elbow dislocation (instability group) with patients suffering from chronic lateral epicondylitis (control group), treated between 2009 and 2019. Two independent observers measured different anatomical landmarks of the trochlear notch in a multiplanar reconstructed standardized sagittal trochlear plane (SSTP). Primarily, opening angle and relative depth of the trochlear notch were determined. After adjustment to the proximal ulnar rim in the SSTP, coronoid and olecranon angle, the articular angle as well as the ratio of the tip heights of the trochlear notch were measured.

Results: We compared 34 patients in the instability group (age 48 +/- 14 years, f/m 19/15) with 34 patients in the control group (age 47 +/- 16 years, f/m 19/15). Instability group showed a significantly larger opening angle (94.1 degrees +/- 6.9 degrees vs. 88.5 degrees +/- 6.9 degrees, p = 0.0002), olecranon angle (60.9 degrees +/- 5.3 degrees vs. 56.1 degrees +/- 5.1 degrees, p < 0.0001) and articular angle (24.7 degrees +/- 6.4 degrees vs. 22.3 degrees +/- 5.8 degrees, p = 0.02) compared to the control group. Measuring the height from the coronoid (ch) and olecranon (oh) tip also revealed a significantly larger tip ratio (tr = ch/oh) in the instability group (2.7 +/- 0.8 vs. 2.2 +/- 0.5, p < 0.0001). The relative depth (61.0% +/- 8.3% vs. 62.7% +/- 6.0%, p = 0.21) of the trochlear notch as well as the coronoid angle (32.8 degrees +/- 4.5 degrees vs. 31.7 degrees +/- 5.2 degrees, p = 0.30) showed no significant difference in the instability group compared to the control group. The interrater reliability of all measurements was between 0.83 and 0.94.

Conclusion: MRI of patients with elbow dislocation show that there seems to be a bony anatomical predisposition. According to the results, it seems reasonable to include predisposing bony factors in the decision-making process when surgical stabilization and conservative treatment is possible. Further biomechanical studies should prove these assumptions to generate critical bony values helping surgeons with decision making.