Basics
Description
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Dislocation of the elbow mostly results from trauma.
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Posterior dislocation is most common.
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It most frequently involves people <20 years of age.
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Rarely, elbow dislocation can occur in elderly patients after a fall.
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Most elbow dislocations occur at the ulnohumeral joint.
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Classification: Usually refers to the position of the ulna relative to the humerus after injury:
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Dislocations can be classified as posterior, anterior, medial, lateral, and divergent.
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Fracture dislocations of the elbow are associated with radial head and coronoid fractures: the terrible triad of the elbow.
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Classification of coronoid fractures:
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I: Avulsion of the tip
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II: <50% of the coronoid
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III: >50% of the coronoid
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Large coronoid fractures are thought to be associated with anterior and posterior fracture dislocations, whereas small transverse fractures are associated with the terrible triad.
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Epidemiology
Incidence
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The highest incidence is in persons <20 years old.
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It represents 3-6% of all children’s fractures and dislocations.
Risk Factors
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Snowboarders have a higher risk of elbow dislocation than do skiers.
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Sports activities
Pathophysiology
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Posterior dislocations are most common and thought to be secondary to a fall on an outstretched hand.
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The collateral ligaments usually are ruptured, with injury to the brachialis muscle and coronoid.
Associated Conditions
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Fracture of the radius
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Fracture of the ulna
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Fracture of the humerus
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Ulnar and median nerve injury
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Brachial artery injury
Diagnosis
Signs and Symptoms
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Elbow dislocation occurs mostly after trauma.
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The patient presents with pain, swelling, elbow deformity, and inability to move the elbow.
Physical Exam
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Assess the patient’s neurovascular status.
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Examine the functions of the radial, median, and ulnar nerves before reduction.
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The median nerve can be injured at the time of reduction by becoming entrapped in the joint.
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It is crucial to check nerve function before and after reduction.
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Evaluate the patient for brachial artery injury before reduction.
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The brachial artery may be trapped in the joint along with the median nerve.
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Vascular injury is an indication for immediate surgery.
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The upper extremity should be inspected for other injuries, such as Monteggia fracture-dislocation.
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Palpate the forearm for increased swelling or signs of compartment syndrome.
Tests
Imaging
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Radiography:
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AP and lateral views of the elbow are sufficient for diagnosis.
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They should be obtained with the elbow out of the splint, to rule out subtle intra-articular fractures and dislocations.
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CT is used for fracture dislocation of the elbow to determine the precise fracture pattern.
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MRI scan is useful for diagnosing ligamentous injury.
Differential Diagnosis
The main differential diagnosis is associated fracture.
Elbow Dislocation Treatment
General Measures
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The injured arm should be immobilized and elevated, with ice packs applied to the elbow.
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The patient should be sent to the emergency department immediately.
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The patient’s neurovascular status must be evaluated before and after reduction.
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The examiner rules out associated fractures.
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Most dislocations can be treated with closed reduction, with the patient under sedation.
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Open reduction is indicated in irreducible dislocation, i.e., one caused by soft-tissue entrapment and free fragment in the joint, or changes in neurovascular status.
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Longitudinal traction, with gradual flexion and downward pressure on the forearm, usually reduces posterior or posterolateral dislocations.
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After reduction, elbow ROM and stability should be checked with gentle ROM and valgus and varus stress.
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Neurovascular function also should be examined.
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Immobilization of the elbow in 90° of flexion with a posterior splint is recommended.
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Duration of immobilization varies, depending on elbow stability, but generally is 1 week.
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>3 weeks of immobilization should be avoided to prevent stiffness.
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If any neurovascular injury is detected, a vascular or orthopaedic surgeon should be notified.
Activity
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Gradual passive and active ROM and strengthening physical therapy should be started as soon as the immobilization device is removed.
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No lifting is allowed for 2 weeks.
Special Therapy
Physical Therapy
Therapy involves ROM and muscle strengthening.
Surgery
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Surgery is indicated for:
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Irreducible dislocation
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Open dislocation
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Neurovascular entrapment
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Certain types of associated fractures
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Complex fracture dislocations
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Open reduction and internal fixation are recommended for:
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Displaced radial head fractures
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Olecranon fractures
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Supracondylar humerus fractures
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Repair of complex fracture dislocations should be based on restoring stability to the elbow.
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Should be accomplished by repair of the coronoid (if possible), restoration of the radial head or radial head replacement, or repair of the collateral ligaments
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Total elbow arthroplasty has been used for severe fracture dislocation or missed injuries.
Follow-up
Prognosis
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Most patients do well after closed reduction.
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The most common residual condition after dislocation is decreased ROM (loss of 10-15° of extension).
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Medial instability leads to late arthritis and persistent pain.
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Surgery has not been shown to be beneficial for dislocations without fracture.
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Complex fracture dislocations have a worse prognosis but benefit from an aggressive surgical approach.
Complications
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Decreased ROM
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Neurovascular injury
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Persistent pain
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Arthritis
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Instability
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Heterotopic ossification
Patient Monitoring
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The follow-up frequency varies with the individual surgeon.
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In general, immobilization should continue for ~1 week, depending on the stability of elbow.
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Immobilization should be no longer than 3 weeks.
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Clinical monitoring of compartment status and of neurovascular function is recommended for the first 12-24 hours.
Miscellaneous
Codes
ICD9-CM
832.0 Elbow dislocation
Patient Teaching
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Monitor for signs of compartment syndrome.
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Emphasize ROM exercises at home.
Prevention
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Snowboarding is a risky sport for complex elbow fracture dislocations.
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No methods are available to lessen this risk.
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FAQ
Q: What is the long-term outcome of elbow dislocation?
A: Outcomes of dislocations without fracture are generally good. Some patients will develop arthritis symptoms and medial instability of the elbow. Outcomes of complex fracture dislocations are not as good.