Elbow Dislocation Treatment in Singapore

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.
 

Elbow Dislocation 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.
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