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Elbow Dislocation
From WikiSM
Contents
Other Names
- Slipped elbow
- Simple elbow dislocation
- Complex elbow dislocation
- Elbow fracture-dislocation
Background
- Traumatic injury that typically involves fall on an extended elbow
- May involve dislocation only, may be fracture-dislocation
- Anterior, posterior, lateral or medial
Epidemiology
- Posterior much more common at around 80% (need citation)
- Semilunar notch of the ulna is dislocated posteriorly from the distal humerus
Pathophysiology
- Posterior dislocation caused by shearing forces, axial loading, supination of forearm or valgus posteolateral force
- Can be associated with radial head, radial neck or coronoid process fractures
- Medial collateral and lateral collateral ligaments provide support and the LCL is often disrupted first
- LCL ruptured most often by avulsion of the lateral epicondylar origin
- Flexor-pronator mass, brachialis and medial collateral ligament may be injured
- Medial collateral ligament often the last soft tissue structure injured as ulna is displaced
- Anterior compartment of elbow, which encompasses the brachial artery, ulnar and medial nerves are vulnerable to injury
- Ulnar nerve can become entrapped as it crosses medial epicondyle
- Anterior dislocations often associated with olecranon fractures
- May disrupt posterior compartment, which contains the radial nerve and insertion of the triceps muscle
Associated Injuries
- Radial Head & Neck Fracture
- Coronoid Fracture
- Radial Collateral Ligament Injury
- Distal Radial Ulnar Joint Instability
- Olecranon Fracture
Risk Factors
- Age > 65 (Increased fall risk)
- Overtraining in sports, especially overhead athletes
- Inherited joint disorders (Ehlers-Danlos syndrome, Marfan Syndrome)
Differential Diagnosis
- Fractures
- Adult
- Pediatric
- Dislocations & Instability
- Tendinopathies
- Bursopathies
- Ligament Injuries
- Neuropathies
- Arthropathies
- Other
- Pediatric Considerations
- Little League Elbow
- Panners Disease (Avascular Necrosis of the Capitellum)
- Nursemaids Elbow (Radial Head Subluxation)
Clinical Features
- General: Physical Exam Elbow
- History
- Patient should describe history of trauma
- Typically report pain, swelling, bruising, loss of range of motion
- Physical
- Inspection of elbow joint looking for swelling, deformity, open wounds or ecchymosis
- Posterior elbow dislocation often present with upper extremity that is flexed and appears shortened
- Anterior dislocation held in extension and upper extremity elongated
- Distal radioulnar joint for tenderness can indicate disruption of the intraosseus ligament referred to as an Essex-Lopresti lesion
- Most common neurovascular structures injures include brachial artery, ulnar and medial nerves
- Perfusion assessed by pulses and brisk capillary refill
- Neurovascular status of median and ulnar nerves should be assessed
- Compartment syndrome may need rules out if there are historical or physical findings concerning for neurovascular compromise
Evaluation
- Radiographs
- 3 views (AP, lateral and oblique)
- Typically sufficient to make diagnosis
- Assess joint congruency before and after reduction, fracture
- CT
- Useful if suspicious for complex injury pattern, periarticular fractures, surgical planning
Classification
- Simple
- No associated fracture
- 50-60 % of elbow dislocations
- Complex
- Dislocation with associated fracture
- R adial head fracture also in up to 10% of elbow dislocations
- Includes terrible triad injury
- Dislocation with LUCL tear, radial head fracture and coronoid tip fracture
- Dislocation with associated fracture
Management
Acute Management
- Closed reduction for simple dislocations
- Inline traction to improve coronal displacement, forearm supination and elbow flexion while placing direct pressure on tip of olecranon
- Any dislocation with signs of neurovascular compromise requires immediate closed reduction
- Some complex elbow dislocations may initially be treated with closed reductions
- Associated fracture implies significant soft tissue damage and possible persistent instability
- Open dislocation will require extensive washout during an open reduction
- Neurovascular exam and place in posterior mold splint in flexion of at least 90 degrees
- If LCL is disrupted, elbow more stable in pronation
- If MCL is disrupted, elbow more stable in supination
- Splint: Posterior Long Arm Splint
Nonoperative
- Immobilize for 5-10 days with repeat radiographs at 3-5 days and 10-14 days
- Start early therapy with early ROM shown to have better outcomes [1]
- Dislocations that appear more unstable may require up to 3 weeks of splinting and a specific range of motion plan
Operative
- ORIF of coronoid, radial head with repair of LCL and MCL if affected
- Approach depends on structures involved
- Kocher approach (ECU/anconeus) to address LCL complex, common extensor tendon origin
- Extensor origin avulsion common and may need repaired
- Must be careful to avoid injury to posterior interosseus nerve (PIN)
- Medial approach if MCL, flexor/pronator mass or coronoid involvement
- Must identify and protect ulnar nerve
- Typically only attempted if LCL fixation fails and elbow remains unstable
Return to Play
- Limited data on return to play protocols following elbow dislocation
- Recent study showing NFL players from 2000-2011 returned after nonoperative management on average 25 days
- Average return to play in players undergoing operative management was 46 days [2]
Complications
- Early stiffness with loss of terminal extension
- Early, active ROM can help prevent this
- Varus Posteromedial instability
- Due to LCL injury and fracture of coronoid
- Neurovascular injuries
- Brachial artery and median nerve associated with open dislocations, but rare
- Ulnar nerve can be stretched
- Recurrent instability
- Heterotopic Ossification
- Contracture
- Acute Compartment Syndrome
See Also
- Internal
- External
- Sports Med Review Elbow Pain: https://www.sportsmedreview.com/by-joint/elbow/
References
Created by:
John Kiel on 18 June 2019 01:12:32
Authors:
Last edited:
13 October 2022 13:28:16
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