Elbow Dislocation Treatment in Singapore

Description

• Dislocation of the elbow mostly results from trauma.
• Posterior dislocation is most common.
• It most frequently involves people <20 years of age.
• Rarely, elbow dislocation can occur in elderly patients after a fall.
• Most elbow dislocations occur at the ulnohumeral joint.
• Classification: Usually refers to the position of the ulna relative to the humerus after injury:
  • Dislocations can be classified as posterior, anterior, medial, lateral, and divergent.
  • Fracture dislocations of the elbow are associated with radial head and coronoid fractures: the terrible triad of the elbow.
  • Classification of coronoid fractures:
    • I: Avulsion of the tip
    • II: <50% of the coronoid
    • III: >50% of the coronoid
    • Large coronoid fractures are thought to be associated with anterior and posterior fracture dislocations, whereas small transverse fractures are associated with the terrible triad.

Epidemiology

Risk Factors

• Snowboarders have a higher risk of elbow dislocation than do skiers.
• Sports activities

Pathophysiology

• Posterior dislocations are most common and thought to be secondary to a fall on an outstretched hand.
• The collateral ligaments usually are ruptured, with injury to the brachialis muscle and coronoid.

Associated Conditions

• Fracture of the radius
• Fracture of the ulna
• Fracture of the humerus
• Ulnar and median nerve injury
• Brachial artery injury

Signs and Symptoms

• Elbow dislocation occurs mostly after trauma.
• The patient presents with pain, swelling, elbow deformity, and inability to move the elbow.

Tests

Differential Diagnosis

General Measures

• The injured arm should be immobilized and elevated, with ice packs applied to the elbow.
• The patient should be sent to the emergency department immediately.
• The patient’s neurovascular status must be evaluated before and after reduction.
• The examiner rules out associated fractures.
• Most dislocations can be treated with closed reduction, with the patient under sedation.
• 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.
• Longitudinal traction, with gradual flexion and downward pressure on the forearm, usually reduces posterior or posterolateral dislocations.
• After reduction, elbow ROM and stability should be checked with gentle ROM and valgus and varus stress.
  • Neurovascular function also should be examined.
• Immobilization of the elbow in 90° of flexion with a posterior splint is recommended.
• Duration of immobilization varies, depending on elbow stability, but generally is 1 week.
• >3 weeks of immobilization should be avoided to prevent stiffness.
• If any neurovascular injury is detected, a vascular or orthopaedic surgeon should be notified.

Special Therapy

Surgery

• Surgery is indicated for:
  • Irreducible dislocation
  • Open dislocation
  • Neurovascular entrapment
  • Certain types of associated fractures
  • Complex fracture dislocations
• Open reduction and internal fixation are recommended for:
  • Displaced radial head fractures
  • Olecranon fractures
  • Supracondylar humerus fractures
• Repair of complex fracture dislocations should be based on restoring stability to the elbow.
  • 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
• Total elbow arthroplasty has been used for severe fracture dislocation or missed injuries.

Prognosis

• Most patients do well after closed reduction.
• The most common residual condition after dislocation is decreased ROM (loss of 10-15° of extension).
• Medial instability leads to late arthritis and persistent pain.
• Surgery has not been shown to be beneficial for dislocations without fracture.
• Complex fracture dislocations have a worse prognosis but benefit from an aggressive surgical approach.

Complications

• Decreased ROM
• Neurovascular injury
• Persistent pain
• Arthritis
• Instability
• Heterotopic ossification

Patient Monitoring

• The follow-up frequency varies with the individual surgeon.
• In general, immobilization should continue for ~1 week, depending on the stability of elbow.
• Immobilization should be no longer than 3 weeks.
• Clinical monitoring of compartment status and of neurovascular function is recommended for the first 12-24 hours.

Miscellaneous

Codes

Patient Teaching

• Monitor for signs of compartment syndrome.
• Emphasize ROM exercises at home.

FAQ