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Elbow Dislocation

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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


Risk Factors

  • Age > 65 (Increased fall risk)
  • Overtraining in sports, especially overhead athletes
  • Inherited joint disorders (Ehlers-Danlos syndrome, Marfan Syndrome)

Differential Diagnosis


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

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


References


  1. Mehlhoff, TL, Noble, PC, Bennett, JB, Tullos, HS. Simple dislocation of the elbow in the adult: results after closed treatment. J Bone Joint Surg Am. 1988;70(2):244–249.
  2. Chang, E. S. et al. Management of Elbow Dislocations in the National Football League. Orthop. J. Sports Med. 6, (2018).
Created by:
John Kiel on 18 June 2019 01:12:32
Last edited:
11 November 2020 14:43:29
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