Basics
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
Incidence
-
The highest incidence is in persons <20 years old.
-
It represents 3-6% of all children’s fractures and dislocations.
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
Diagnosis
Signs and Symptoms
-
Elbow dislocation occurs mostly after trauma.
-
The patient presents with pain, swelling, elbow deformity, and inability to move the elbow.
Physical Exam
-
Assess the patient’s neurovascular status.
-
Examine the functions of the radial, median, and ulnar nerves before reduction.
-
The median nerve can be injured at the time of reduction by becoming entrapped in the joint.
-
It is crucial to check nerve function before and after reduction.
-
-
Evaluate the patient for brachial artery injury before reduction.
-
The brachial artery may be trapped in the joint along with the median nerve.
-
Vascular injury is an indication for immediate surgery.
-
-
-
The upper extremity should be inspected for other injuries, such as Monteggia fracture-dislocation.
-
Palpate the forearm for increased swelling or signs of compartment syndrome.
Tests
Imaging
-
Radiography:
-
AP and lateral views of the elbow are sufficient for diagnosis.
-
They should be obtained with the elbow out of the splint, to rule out subtle intra-articular fractures and dislocations.
-
-
CT is used for fracture dislocation of the elbow to determine the precise fracture pattern.
-
MRI scan is useful for diagnosing ligamentous injury.
Differential Diagnosis
The main differential diagnosis is associated fracture.
Treatment
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.
Activity
-
Gradual passive and active ROM and strengthening physical therapy should be started as soon as the immobilization device is removed.
-
No lifting is allowed for 2 weeks.
Special Therapy
Physical Therapy
Therapy involves ROM and muscle strengthening.
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.
Follow-up
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
ICD9-CM
832.0 Elbow dislocation
Patient Teaching
-
Monitor for signs of compartment syndrome.
-
Emphasize ROM exercises at home.
Prevention
-
Snowboarding is a risky sport for complex elbow fracture dislocations.
-
No methods are available to lessen this risk.
-
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.