Elbow Dislocation

By admin On Dec 11, 2023

Ovid: 5-Minute Sports Medicine Consult, The

Elbow Dislocation

John Munyak

Robert Bramante

Basics

Description

Separation/disruption of the articulations between distal humerus, proximal radius, and proximal ulna. Typically resulting from trauma and injury to the supporting soft tissue structures.
Subtypes: Anterior (rare) vs posterior (common) and simple (soft tissue injury) vs complex (fracture-dislocation)
Complete (dislocation) or partial (subluxation)
System(s) affected: Musculoskeletal

Epidemiology

The elbow is the second most frequently dislocated major joint after the shoulder.
Comprises 10–25% of all elbow injuries
More frequently seen in wrestling, gymnastics, football, falls, and motor vehicle accidents

Incidence

Adults: 6–8/100,000
10–50% sports-related
Usually on the nondominant side

Prevalence

Predominate age:
- Mean 30 yrs old
- 2nd most common dislocation in adults
Predominate sex: Males > Females

Risk Factors

Anatomical risk factors include a shallow olecranon fossa and a prominent olecranon tip.
Age and sports activity
Fall on an outstretched hand

General Prevention

Sport protective padding may provide a benefit.
Avoidance of falls

Etiology

Progression of injury from lateral collateral ligament to capsule to medial collateral ligament in posterior dislocation
Anterior dislocation from trauma to the posterior portion of a flexed elbow
Fall on outstretched hand
Axial loading and rotation upon impact

Commonly Associated Conditions

Common: Radial head/neck fracture, epicondyle avulsion fracture, soft tissue edema, coronoid process fracture
Rare: Neurovascular injury (brachial artery and median nerve), compartment syndrome

Diagnosis

History

Mechanism of fall
Type of activity leading to injury (sports, fall, work, accident)
Time since injury
Reduction attempts

Physical Exam

An obvious visual deformity usually is present.
Note the condition of the skin: Look for wounds indicating an open dislocation.
Palpation of deformity and effusion:
- Prominent olecranon: Posterior
- Long extended forearm: Anterior
Neurovascular evaluation, especially brachial artery and ulnar, interosseous and median nerve function
Consult orthopedics/vascular surgery urgently for any signs of neurovascular injury.
Rule out additional injuries, especially in contiguous musculoskeletal structures.
In reduced elbows: Lateral pivot-shift apprehension test is highly sensitive (1)[C]
- Sensation of dislocation is a positive test.

Diagnostic Tests & Interpretation

Imaging

Initial anteroposterior and lateral radiographs: Evaluate relationship between distal humerus and radio-ulnar complex. Identify associated fracture (2)[C].
Maintain a high index of suspicion for additional injuries and obtain radiographs of the humerus, forearm, or wrist as indicated.
Exception: On-field reduction by a medical professional can precede initial films (3)[C].
Postreduction radiographs: All dislocations (3)[C]
CT: Reserved for complex fracture dislocations or reconstruction planning

Diagnostic Procedures/Surgery

Angiography for suspected arterial injury

Differential Diagnosis

Elbow subluxation
Spontaneous elbow dislocation and reduction
Be especially cautious in the pediatric age group, as supracondylar humerus fractures are common in 5–10-yr-olds.
Nursemaid's elbow (pediatrics)
Other elbow joint/forearm fracture

Treatment

In experienced hands, reduction may be performed on the field without analgesia. Otherwise, transport patient to a medical facility that can treat this injury.
Appropriate monitoring is required, and proper resuscitation equipment should be available.
In rare instances, general anesthesia in the operating room may be required.
Postreduction, check elbow stability with range of motion.
Obtain postreduction radiographs.
Immobilize the elbow in a posterior splint as close to 90 degrees of flexion as possible using avoidance of a diminishing radial pulse as a guide.
Perform a postreduction neurovascular examination.
Duration of elbow immobilization is a controversial issue. Recommendations vary from 1 day to 2 wks.
Closed reduction of dislocation: Goal is atraumatic reduction with minimal attempts. There are several techniques:
- Option #1: Supine patient, forearm traction, humeral counter traction, anterior force on olecranon, and forearm supination (2) [C]
- Option #2: Prone patient, apply counter traction while extending the arm at the elbow, manipulate the coronoid process past the trochlea (3)[C]
- Option #3: (1-person reduction) Patient's arm across the chest, 1 hand braces the injured distal arm, the other holds the elbow and olecranon while providing traction to allow the coronoid to pass the trochlea (4)[C]
- Full passive range of motion will signify a successful reduction.
Postreduction evaluation:
- Postreduction radiographs to confirm position of radial head and ulna in relation to the capitate and distal humerus. Also to exclude iatrogenic fracture.
- Neurovascular reassessment to confirm no nerve impingement
- Assess joint stability:
  - Range of motion (ROM): No locking or crepitation
  - Joint should be examined under gentle stresses (valgus stress/laxity most common following dislocation) (3)[C]
  - Lateral pivot-shift apprehension test for joint stability (1)[C]
- Stable joint: Arm sling for comfort and early mobilization
- Unstable joint that stabilizes with pronation: Splint in pronation/flexion (2)[C]
- Joint unstable needs >45 degrees of flexion: Consider surgery (2)[C]
Issues for referral: Initial follow-up with orthopedics/sports medicine for splint removal and early mobilization

P.137

Additional therapies:
- ROM exercises after initial immobilization for comfort if joint is stable (2)[C]
- Unstable joints should have a splint that blocks full extension with encouragement of flexion as tolerated (2)[C]
- Extended therapy required if ROM not improved by 6–8 wks post injury (3)[C]
- Stability should be confirmed prior to full ROM therapy (5)[C].

Medication

Analgesia:
- Reduction can be attempted without analgesia (4)[C].
- Narcotics:
  - Morphine 0.1 mg/kg IVP usually ∼10 mg/dose (pediatric 0.1 mg/kg/dose)
  - Fentanyl 25–50 mcg IVP initially, shorter-acting, preferred narcotic for conscious sedation (pediatric 2 mcg/kg/dose)
  - Reversible with naloxone
  - Multiple oral narcotics available for use
Postreduction NSAIDs are recommended, as they also decrease risk of heterotopic ossification (2)[C].
Anxiolysis:
- Benzodiazepines:
  - Midazolam 1 mg/dose (pediatric 0.05 mg/kg/dose), short acting, rapid onset, preferred for conscious sedation
  - Lorazepam 0.05 mg/kg/dose (pediatrics 0.05 mg/kg/dose), longer duration not ideal for procedural sedation use
Conscious/procedural sedation (multiple options): Goal of adequate pain control and muscle relaxation:
- Versed/Fentanyl: As above
- Ketamine: Pediatric >3 mos 1.5 mg/kg IV with 0.5 mg/kg repeat doses. (Rarely used in adults due to emergence reactions and agitation.)
- Multiple other options, including propofol, barbiturates, and nitrous oxide
General sedation:
- Occasionally required for difficult/painful reductions
Local anesthesia by joint infiltration can reduce needed analgesic doses (2)[C].
Precautions:
- Be aware of respiratory and airway reflex depression with narcotics and benzodiazepines.
- Thorough preparation required for procedural sedation, including airway management devices, bag-valve mask for ventilation, reversal agents (naloxone/flumazenil) as appropriate, cardiovascular monitoring equipment

Additional Treatment

Additional Therapies

A follow-up radiograph should be obtained 1 and 2 wks after injury. A small percentage of patients will develop recurrent instability, which can be due to insufficiency of the lateral ulnar collateral ligament. These patients may require surgical reconstruction to restore stability.
Rehabilitation after simple elbow dislocation requires 1–3 mos to return to preinjury status. Typically, the outcome is good, with most athletes experiencing little morbidity or loss of function. The most common problem is loss of extension, which is minimized with an active, aggressive, early rehabilitation program.

Surgery/Other Procedures

Surgery is limited to select cases, as conservative management is preferred (5)[C].
Open dislocation, compartment syndrome, nerve injury/impingement, unstable fractures, and unstable reductions require operative intervention (2)[C].
Grossly unstable elbows may require acute ligament repair to confer early stability to allow for range of motion and enhanced rehabilitation.
Complex dislocations with fractures, including significant radial head, olecranon, and coronoid fractures, may require surgical stabilization via open reduction internal fixation (ORIF) of fracture segments (2)[C].
Isolated lateral collateral ligament repair in recurrent dislocation has shown success (1)[B]. Chronically unstable elbows may require reconstruction of the lateral ulnar collateral ligament.

In-Patient Considerations

Admission Criteria

Fracture dislocation requiring operative intervention
Nonreducible dislocation
Neurovascular injury
Edema with concern for compartment syndrome development

Nursing

Providing ordered medications for patient comfort or sedation as necessary
Monitoring of vitals for sedation procedures if needed
Reinforcing discharge instructions/plan

Discharge Criteria

Elbow dislocation confirmed by postreduction radiograph
Normal postreduction neurovascular exam documented
Supply orthopedic follow-up
Reduced elbow splinted for comfort or to maintain stability as needed

Ongoing Care

Follow-Up Recommendations

Consultation with an orthopedic surgeon should be obtained in most cases.

Patient Education

Avoid activities that specifically stress the elbow joint (eg, throwing) until ready upon re-evaluation.

Prognosis

Generally full recovery
Poor outcome related to stiffness/decreased ROM:
- Early physical therapy/ROM exercises decrease stiffness.

Complications

Neurovascular compromise
Stiffness
Compartment syndrome
Recurrent dislocation
Heterotopic ossification

References

1. Burra G, Andrews J. Acute elbow and shoulder dislocations in the athlete. Orthop Clin N Am. 2002;33:479–495.

2. Kuhn MA, Ross G. Acute elbow dislocations. Orthop Clin North Am. 2008;39(2):155–161.

3. O' Driscoll SW. Classification and evaluation of recurrent instability of the elbow. Clin Orthop Relat Res. 2007;370:34–43.

4. Mehta JA, Bain GI. Elbow dislocations in adults and children. Clin Sports Med. 2004;23(4):609–627.

5. Kumar A, Ahmed M. Closed reduction of posterior dislocation of the elbow: a simple technique. J Orthop Trauma. 1999;13(1):58–59.

Additional Reading

Krul M, van der Wouden JC, et al. Manipulative interventions for reducing pulled elbow in young children. Cochrane Database of Systemic Reviews. 2009;2.

Ristic S, Strauch R, Rosenwasser M. The assessment and treatment of nerve dysfunction after trauma around the elbow. Clin Orthop Relat Res. 2000;370:138–153.

Ross G, Chronister R, Ove P, et al. Treatment of elbow dislocation utilizing an immediate motion protocol. Am J Sports Med. 1999;3:308–311.

Taylor F, Sims M, et al. Interventions for treating acute elbow dislocations in adults. Cochrane Database of Systemic Reviews. 2009;3.

Work Loss Data Institute. Elbow (acute & chronic). Corpus Christi, TX: Work Loss Data Institute; 2008.

Codes

ICD9

832.00 Closed dislocation of elbow, unspecified site
832.01 Closed anterior dislocation of elbow
832.10 Open dislocation of elbow, unspecified site