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Elbow Dislocation
Aka: Elbow Dislocation, Posterior Elbow, Anterior Elbow Dislocation
- See Also
- Supracondylar Fracture
- Radial Head Fracture
- Nursemaid's Elbow (Radial Head Subluxation)
- Radial Head Dislocation
- Monteggia Fracture
- Elbow Posterolateral Fracture Dislocation
- Epidemiology
- Elbow Dislocation is the third most common joint dislocation (after Shoulders and fingers)
- Incidence: 6 to 13 per 100,000 persons in U.S.
- Mechanism
- Posterior Elbow Dislocation
- Fall on Outstretched Hand with elbow hyperextended
- Anterior Elbow Dislocation (uncommon)
- Direct impact to posterior olecranon in a flexed elbow
- Types
- Dislocation directions (ulna relative to Humerus)
- Posterior Elbow Dislocation (80-90%, typically posteolateral dislocation)
- Anterior Dislocation (uncomon)
- Pure lateral and medial dislocations (rare)
- Complexity
- Simple Elbow Dislocations
- No significant Fracture (other than periarticular avulsion Fractures)
- Complex Elbow Dislocations
- Concurrent Fracture at radial head, olecranon, ulna coronoid process or Humerus epicondyles
- Exam
- In addition to elbow, evaluate Shoulder and wrist for concurrent injury
- Evaluate Hand Neurovascular Exam
- Evaluate radial pulse, distal coloration and Capillary Refill
- Brachial artery injury is the key vascular injury risk (occurs in 5-13a% of cases)
- Evaluate median (ok sign), ulnar (finger abduction) and Radial Nerve (wrist dorsiflexion) function
- Median and Ulnar Nerve injury are the key neurologic risks
- Signs
- Obvious elbow deformity
- Posterior Dislocation
- Flexed Elbow
- Forearm shortened
- Olecranon prominent at posterior aspect
- Anterior Dislocation
- Extended elbow
- Forearm lengthened
- Distal Humerus prominent at posterior aspect
- Abnormal alignment of olecranon and both epicondyles
- Elbow flexed to 90 degrees
- Assess alignment of these 3 points at elbow
- Normal: equilateral triangle
- Dislocated: straight line
- Radial Head Fracture easy to feel at lateral epicondyle
- Vascular compromise unlikely if present
- Differential Diagnosis
- Supracondylar Fracture
- Medial Epicondyle avulsion Fracture
- Radial Head Fracture
- Imaging
- Elbow XRay (AP and Lateral)
- Elbow CT
- Consider in complex Fracture dislocations requiring operative repair
- Precautions: Emergent Orthopedic Consultation Indications (Complex Dislocation)
- Open Fracture Dislocation
- Vascular Compromise or Disruption (esp. Brachial Artery)
- Entrapped soft tissue and non-reducible dislocation
- Compartment Syndrome
- Technique: Reduction
- Anesthesia
- Consider pre-procedure analgesia
- Consider Joint Injection of Anesthetic
- Usually performed under Procedural Sedation
- Background
- Posterior dislocation (90% of cases) reduction is described
- Anterior reductions require reverse of pressure applied at olecranon (posterior)
- Backward pressure on proximal Forearm
- Parvin's Method for Posterior Elbow Dislocation (prone, often first maneuver)
- Position
- Patient prone on gurney
- Patient's arm abducted at Shoulder
- Elbow flexed 90 degrees
- Elbow at edge of gurney and arm hanging loosely over the side with fingers pointing toward floor
- Technique 1
- Examiner grasps the patient's wrist, slightly supinates the Forearm, and applies downward traction at wrist
- Examiner, with other hand, applies downward pressure at olecranon process
- Also disengage the coronoid process from olecranon fossa by applying downward pressure
- Gently extend elbow to 25-30 degrees
- Technique 2 (if technique 1 fails)
- Place pillow under distal Humerus (just proximal to elbow)
- Attach 5-10 pound weight at the wrist and wait several minutes
- Completion
- Anticipate a "clunk" as the elbow relocates
- Confirm relocation with gentle range of motion
- Straight Traction for Posterior Elbow Dislocation (two person technique)
- Position
- Patient lies supine on gurney
- Patient's arm abducted at Shoulder
- Forearm supinated
- Elbow flexed to 25-30 degrees
- Technique
- One examiner braces mid-shaft Humerus against gurney with both hands
- Applies downward force to olecranon
- Second examiner
- One hand grasps wrist, supinates Forearm and flexes elbow with downward traction
- Second hand applies inline traction at volar Forearm
- Completion
- Anticipate a "clunk" as the elbow relocates
- Confirm relocation with gentle range of motion
- Management: Post-Reduction
- Obtain post-reduction Elbow XRay (AP and Lateral)
- Evaluate Hand Neurovascular Exam after reduction
- See exam above
- Check gentle range of motion of elbow for instability
- Perform gentle varus and valgus testing for stability
- Immobilize elbow in molded posterior plaster or fiberglass splint
- Splint elbow at 90 degrees flexion
- Allows ligament and capsular healing
- Splint for 3-5 days (or until orthopedic or sports medicine follow-up)
- Avoid prolonged immobilization (esp. >2-3 weeks)
- Improved outcomes with early range of motion
- Gentle Range of motion after Splinting
- Never force range of motion (worsens injury)
- Temporary stiffness is common
- Discharge Instructions
- Ice on for 20 min/hour for first few days
- Elevation
- Sling with splint until follow-up
- Return immediately for numb, cold, pale or immobile hand
- Follow-up with orthopedics or sports medicine in next few days
- Surgical Indications
- See emergent Consultation indications above under precautions (esp. neurovascular injury)
- Elbow Dislocation not able to be reduced under Procedural Sedation
- Chronic dislocation
- Locked Elbow Dislocation due to interposed tissue
- Unstable elbow Fracture dislocations
- Elbow Terrible Triad (Elbow Dislocation with both Radial Head Fracture and Coronoid Process Fracture)
- Prognosis
- Full elbow Range of motion may take months
- May have some residual restriction in range of motion
- Often minor restriction
- Does not interfere with function
- Complications
- Elbow Instability
- Brachial Artery Injury (5-13% of cases)
- Median Nerve Injury
- Ulnar Nerve Injury
- Elbow Posterolateral Fracture Dislocation (Terrible Triad of the Elbow)
- References
- Chapman (2019) Crit Dec Emerg Med 33(10):12-3
- Eiff (2018) Fracture Management for Primary Care, Elsevier, Philadelphia, p. 151-3
- Huang (2021) Crit Dec Emerg Med 35(1): 12-3