In Dogs With Traumatic Elbow Luxation, Does Treatment Using Closed Reduction and Conservative Management Have a Better Prognosis Than Those Treated With Open Reduction and Surgery?

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Appraisal, application and reflection

All relevant studies identified and reported above are retrospective case series, which sit low on the hierarchy of evidence. Further to this, they all report on a small number of cases, ranging from just two to 44 (mean 13.8) cases; multiple single case reports were identified during the literature search, but were excluded. Of the nine studies reported, only five have been published since 2000, and only two have been published in the last five years. Since veterinary medicine and surgery is a rapidly developing branch of the medical industry, older studies are sometimes less relevant to the modern practitioner, however it appears that a lot of techniques used in the older reports are still employed today.

Five of the studies report cases that had presented as referrals from primary care veterinary surgeons (the remaining four studies do not state whether they are a referral hospital), which may introduce bias as, it appears, more difficult to manage cases (i.e. more severe injuries/comorbidities) that are inevitably over-represented at referral centres tend to require surgical management. Because different presentations appear to require different management, it is difficult to compare the success of open reduction (with or without surgical stabilisation) and closed reduction. Overall, the quality of evidence is poor. This limits the ability to generalise the results. However, trends in case management and a rough consensus among authors can be identified, allowing an evidence-based approach to be formulated. Until higher quality evidence (i.e. randomised, controlled, blinded) is available, it is difficult to draw more definitive conclusions. In the available literature, cases of traumatic elbow luxation managed by closed reduction appear to have a better long-term prognosis than cases managed by open reduction and surgical stabilisation. That being said, it is important to consider that the poorer outcome in surgically-managed cases could reflect the severity or chronicity of the injury rather than the treatment method itself, or indeed could reflect a combination of the two.

When considering all the studies listed above, there appears to be a step-by-step approach to management of traumatic canine elbow luxation, outlined most completely by Sajik et al. (2016). Closed reduction should be attempted in all cases as it seems that early, successful closed reduction provides the best long-term prognosis. Stability of the elbow should then be assessed using Campbell’s method – this should also help identify which collateral ligaments are injured. Should closed reduction not be possible, or should the elbow continue to be unstable or reluxate after closed reduction, surgical management is indicated. There are multiple surgical techniques described, though the most commonly employed appears to be primary ligament repair with non-absorbable suture, with concurrent placement of bone anchor screws and a figure-of-eight wire on the injured aspect(s) of the elbow – a comparison of the efficacy of individual surgical methods was considered beyond the scope of this Knowledge Summary and further research in this area is warranted. Joint immobilisation is widely recommended and commonly employed, however this is quite variable amongst studies with no clear consensus on the type or duration of immobilisation.

In conclusion, in cases of traumatic canine elbow luxation, closed reduction should be attempted in all cases. Surgical intervention is indicated in cases where closed reduction is not possible, or where reluxation or persistent joint instability follows closed reduction. A period of joint immobilisation should follow treatment. A significant proportion of cases in both treatment groups will suffer varying degrees of continued morbidity in the future. When cases can be treated successfully with early closed reduction, prognosis appears to be better than those cases requiring surgical management.

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