Elbow Dislocation

Aka: Elbow Dislocation

1. See Also
   1. Supracondylar Fracture
   2. Radial Head Fracture
   3. Nursemaid's Elbow (Radial Head Subluxation)
   4. Radial Head Dislocation
   5. Monteggia Fracture
2. Epidemiology
   1. Third most common joint dislocation (after Shoulders and fingers)
3. Causes
   1. Fall on Outstretched Hand with elbow hyperextended
4. Pathophysiology
   1. Dislocation directions (ulna relative to Humerus)
      1. Posterior Elbow Dislocation (90%)
      2. Anterior Dislocation
      3. Pure lateral and medial dislocations (rare)
5. Exam
   1. In addition to elbow, evaluate Shoulder and wrist for concurrent injury
   2. Evaluate Hand Neurovascular Exam
      1. Evaluate radial pulse, distal coloration and Capillary Refill
      2. Evaluate median (ok sign), ulnar (finger abduction) and Radial Nerve (wrist dorsiflexion) function
6. Signs
   1. Obvious elbow deformity
   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
7. Differential Diagnosis
   1. Supracondylar Fracture
   2. Medial Epicondyle avulsion Fracture
   3. Radial Head Fracture
8. Precautions: Emergent Orthopedic Consultation Indications (Complex Dislocation)
   1. Open Fracture
   2. Entrapped soft tissue and non-reducible dislocation
9. Management: Reduction
   1. Anesthesia
      1. Consider pre-procedure analgesia
      2. Consider Joint Injection of anesthetic
      3. Consider Procedural Sedation
   2. Background
      1. Posterior dislocation (90% of cases) reduction is desccribed
      2. Anterior reductions require reverse of pressure applied at olecranon (posterior)
   3. Parvin's Method (prone, often first maneuver)
      1. Position
         1. Patient prone on gurney
         2. Patient's arm abducted at Shoulder and flexed 90 degrees at elbow
         3. 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. May also gently extend elbow
      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 (two person technique)
      1. Position
         1. Patient lies supine on gurney
         2. Patient's arm abducted at Shoulder
      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
10. Management: Post-Reduction
    1. Obtain post-reduction XRay
    2. Evaluate Hand Neurovascular Exam after reduction
       1. See exam above
       2. Check gentle range of motion of elbow
    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 5-10 days (or until orthopedic or sports medicine follow-up)
    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
11. 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
12. Complications
    1. Elbow Instability
    2. Brachial Artery Injury
    3. Median Nerve Injury
    4. Ulnar Nerve Injury
13. 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