Elbow Dislocation

Aka: Elbow Dislocation, Posterior Elbow, Anterior Elbow Dislocation

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II. Epidemiology

  1. Elbow Dislocation is the third most common joint dislocation (after Shoulders and fingers)
  2. Incidence: 6 to 13 per 100,000 persons in U.S.

III. Types

  1. Dislocation directions (ulna relative to Humerus)
    1. Posterior Elbow Dislocation (80-90%, typically posteolateral dislocation)
    2. Anterior Dislocation (uncomon)
    3. Pure lateral or medial dislocations (rare)
  2. Complexity
    1. Simple Elbow Dislocations
      1. No significant Fracture (other than periarticular avulsion Fractures)
    2. Complex Elbow Dislocations
      1. Concurrent Fracture at radial head, olecranon, ulna coronoid process or Humerus epicondyles

IV. Mechanism

  1. Posterior Elbow Dislocation
    1. Fall on Outstretched Hand with elbow hyperextended
    2. Most common in sporting events
  2. Anterior Elbow Dislocation (uncommon)
    1. Direct impact to posterior olecranon in a flexed elbow

V. Exam

  1. In addition to elbow, evaluate Shoulder and wrist for concurrent injury
  2. Evaluate Hand Neurovascular Exam (before and after reduction)
    1. Ask about coolness, numbness or Paresthesias of the hand
    2. Evaluate radial pulse, distal coloration and Capillary Refill
      1. Brachial artery injury is the key vascular injury risk (occurs in 5-13% of cases)
    3. Evaluate median (ok sign), ulnar (finger abduction) and Radial Nerve (wrist dorsiflexion) function
      1. Median and Ulnar Nerve injury are the key neurologic risks

VI. Signs

  1. Obvious elbow deformity
    1. Posterior Dislocation
      1. Flexed Elbow
      2. Forearm shortened
      3. Olecranon prominent at posterior aspect
    2. Anterior Dislocation
      1. Extended elbow
      2. Forearm lengthened
      3. Distal Humerus prominent at posterior aspect
  2. Abnormal alignment of olecranon and both epicondyles
    1. Elbow flexed to 90 degrees
    2. Assess alignment of these 3 points at elbow
      1. Normal: equilateral triangle
      2. Dislocated: straight line
  3. Radial Head Fracture easy to feel at lateral epicondyle
    1. Vascular compromise unlikely if present

VII. Differential Diagnosis

  1. Supracondylar Fracture
  2. Medial Epicondyle avulsion Fracture
  3. Radial Head Fracture

VIII. Imaging

  1. Elbow XRay (AP and Lateral)
  2. Elbow CT
    1. Consider in complex Fracture dislocations requiring operative repair

IX. Precautions: Emergent Orthopedic Consultation Indications (Complex Dislocation)

  1. Open Fracture Dislocation
  2. Vascular Compromise or Disruption (esp. Brachial Artery)
  3. Entrapped soft tissue and non-reducible dislocation
  4. Compartment Syndrome

X. Technique: Reduction

  1. Anesthesia
    1. Consider pre-procedure analgesia
    2. Consider Joint Injection of Anesthetic
    3. Usually performed under Procedural Sedation
    4. Consider under Regional Anesthesia
      1. Supraclavicular Brachial Plexus Block
        1. Risk of phrenic nerve injury
      2. Interscalene Brachial Plexus Block
      3. Infraclavicular Brachial PlexusNerve Block
        1. https://www.nysora.com/topics/regional-anesthesia-for-specific-surgical-procedures/upper-extremity-regional-anesthesia-for-specific-surgical-procedures/anesthesia-and-analgesia-for-elbow-and-forearm-procedures/ultrasound-guided-infraclavicular-brachial-plexus-block/
        2. May be safer and more effective than the more traditional, older blocks
        3. Avoid in underlying lung disease
        4. Heflin (2015) Am J Emerg Med 33(9):1324.e1-4 +PMID: 26231527 [PubMed]
  2. Background
    1. Posterior dislocation (90% of cases) reduction is described
    2. Anterior reductions require reverse of pressure applied at olecranon (posterior)
      1. Backward pressure on proximal Forearm
  3. Parvin's Method for Posterior Elbow Dislocation (prone, often first maneuver)
    1. Position
      1. Patient prone on gurney
      2. Patient's arm abducted at Shoulder
      3. Elbow flexed 90 degrees
      4. Elbow at edge of gurney and arm hanging loosely over the side with fingers pointing toward floor
    2. Technique 1
      1. Examiner grasps the patient's wrist, slightly supinates the Forearm, and applies downward traction at wrist
      2. Examiner, with other hand, applies downward pressure at olecranon process
        1. Also disengage the coronoid process from olecranon fossa by applying downward pressure
        2. Gently extend elbow to 25-30 degrees
    3. Technique 2 (if technique 1 fails)
      1. Place pillow under distal Humerus (just proximal to elbow)
      2. Attach 5-10 pound weight at the wrist and wait several minutes
    4. Completion
      1. Anticipate a "clunk" as the elbow relocates
      2. Confirm relocation with gentle range of motion
  4. Straight Traction for Posterior Elbow Dislocation (two person technique)
    1. Position
      1. Patient lies supine on gurney
      2. Patient's arm abducted at Shoulder
      3. Forearm supinated
      4. Elbow flexed to 25-30 degrees
    2. Technique
      1. One examiner braces mid-shaft Humerus against gurney with both hands
        1. Applies downward force to olecranon
      2. Second examiner
        1. One hand grasps wrist, supinates Forearm and flexes elbow with downward traction
        2. Second hand applies inline traction at volar Forearm
    3. Completion
      1. Anticipate a "clunk" as the elbow relocates
      2. Confirm relocation with gentle range of motion

XI. Management: Post-Reduction

  1. Obtain post-reduction Elbow XRay (AP and Lateral)
  2. Evaluate Hand Neurovascular Exam after reduction
    1. See exam above
    2. Check gentle range of motion of elbow for instability
    3. Perform gentle varus and valgus testing for stability
  3. Immobilize elbow in molded posterior plaster or fiberglass splint
    1. Splint elbow at 90 degrees flexion
      1. Allows ligament and capsular healing
    2. Splint for 3-5 days (or until orthopedic or sports medicine follow-up)
      1. Avoid prolonged immobilization (esp. >2-3 weeks)
      2. Improved outcomes with early range of motion
  4. Gentle Range of motion after Splinting
    1. Never force range of motion (worsens injury)
    2. Temporary stiffness is common
  5. Discharge Instructions
    1. Ice on for 20 min/hour for first few days
    2. Elevation
    3. Sling with splint until follow-up
    4. Return immediately for numb, cold, pale or immobile hand
    5. Follow-up with orthopedics or sports medicine in next few days
  6. Surgical Indications
    1. See emergent Consultation indications above under precautions (esp. neurovascular injury)
    2. Elbow Dislocation not able to be reduced under Procedural Sedation
    3. Chronic dislocation
    4. Locked Elbow Dislocation due to interposed tissue
    5. Unstable elbow Fracture dislocations
    6. Elbow Terrible Triad (Elbow Dislocation with both Radial Head Fracture and Coronoid Process Fracture)

XII. Prognosis

  1. Full elbow Range of motion may take months
  2. May have some residual restriction in range of motion
    1. Often minor restriction
    2. Does not interfere with function

XIII. Complications

  1. Elbow Instability
    1. Medial or lateral collateral ligaments are frequently disrupted
    2. Interosseous ligament injury (Essex-Lopresti lesion) may also occur
  2. Brachial Artery Injury (5-13% of cases)
  3. Median Nerve Injury
  4. Ulnar Nerve Injury
  5. Elbow Posterolateral Fracture Dislocation (Terrible Triad of the Elbow)

XIV. References

  1. Chapman (2019) Crit Dec Emerg Med 33(10):12-3
  2. Eiff (2018) Fracture Management for Primary Care, Elsevier, Philadelphia, p. 151-3
  3. Huang (2021) Crit Dec Emerg Med 35(1): 12-3

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