Elbow Dislocation

Author: Derek Moore

Topic updated on 04/18/13 2:56pm

Introduction

Elbow dislocations are the most common joint dislocation second to the shoulder
Pathoanatomy
- associated with complete or near complete disruption of capsuloligamentous stabilizers
- progression of injury is from lateral to medial
  - LCL fails first by avulsion of lateral epicondylar origin
    - midsubstance LCL tears are less common but do occur
  - MCL fails last depending on degree of energy

Classification

Anatomic description
- based on anatomic location of olecranon relative to humerus
  - posterolateral most common (80%)
Simple vs. complex
- simple
  - no associated fracture
- complex
  - associated fracture present

Treatment of Acute Dislocation

Nonoperative
- reduction and splinting at 90° for 7-10 days followed by early therapy
  - indications
    - simple stable dislocations
  - technique
    - early therapy
      - supervised (therapist) active and active assist range-of-motion exercises after 1 to 2 weeks
      - initial range of motion is the stable arc found on postreduction examination
    - rehabilitation
      - proceed with light duty use 2 weeks from injury
- reduction splinting in hinged brace at 90° for 2-3 weeks
  - indications
    - simple unstable elbow dislocations (dislocations with extension)
  - technique
    - early range of motion exercises with arm in pronation
Operative
- ORIF (coronoid, radial head, olecranon) , LCL repair, +/- MCL repair
  - indications
    - complex dislocations with fractures and instability
  - technique
    - approach
      - posterior utility approach used
    - radial head
      - when placing fixation on the proximal radius, one must be aware of the "safe zone" for fixation
      - 90° arc in the radial head that DOES NOT articulate with the proximal ulna
      - the "safe zone" can be identified by its relationship to Lister's tubercle and the radial styloid

Treatment of Chronic Dislocation

Operative
- open reduction, capsular release, and dynamic hinged elbow fixator
  - indications
    - hinged external fixator indicated in chronic dislocation to protect the reconstruction and allow early range of motion, but it does not maintain the reduction
  - approach
    - posterior utility approach used
  - technique
    - concomitant radial head fracture
    - fix first
    - ORIF for radial head that can be reconstructed
    - radial head arthroplasty is indicated for a radial head fracture that cannot be reconstructed

Complications

Varus Posteromedial instability
- injury to the LCL and fracture of the anteromedial facet of the coronoid
- solid fixation of the anteromedial facet is critical for functional outcome and prevention of arthrosis
Loss of motion
- loss of terminal extension is the most common sequelae after closed treatment of a simple elbow dislocation

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Qbank (5 Questions)

TAG

(OBQ10.69) A 26-year-old male wrestler suffers the elbow injury shown in Figure A. On physical exam he is neurologically intact and has a palpable radial pulse. He is treated with closed reduction in the emergency room. In order to optimize his clinical outcomes, which of the following treatment and rehabilitation protocols should be avoided? Topic

Review Topic

FIGURES: A

1. Immediate active and active-assist range of motion through a stable arc
2. Initial splinting and immobilization for 4 weeks followed by physical therapy
3. Initial splinting in 90 degrees of flexion with neutral forearm rotation
4. A range of motion protocol that limits full extension in the early phases of rehab
5. Light duty use of the affect arm immediately following immobilization

PREFERRED RESPONSE ▶

DISCUSSION: Prolonged splinting following simple elbow dislocations of greater than 2 weeks after reduction can lead to chronic stiffness and poor outcomes and should be avoided. All of the remaining answers are appropriate in the rehabilitation of these injuries.

Simple elbow dislocations are second only to the shoulder in rates of joint dislocation. Closed reduction with early rehabilitation has proven the most effective treatment for these injuries when the elbow is stable. Rehabilitation for a simple elbow dislocations should include initial splinting in 90 degrees of flexion with neutral forearm rotation and immediate active and active-assist range of motion through a stable arc. Full extension should be avoided initially in rehab. The patient should be encouraged to use the affected arm for light duty immediately following immobilization.

Mehloff et al. determined that elbows splinted longer than 2 weeks had decreased ROM at 1 year. They further describe the benefits of using the affected arm for light duty after 2 weeks of rest.

Smith et al. describe the effectiveness of immediate active and active-assist ROM exercises after reduction.

O'Driscoll et al. describe how to test an elbow for posterolateral instability, which can occur after an elbow dislocation. They emphasize the elbow is most unstable in extension immediately after injury. Therefore, the elbow should be splinted in 90 degrees of flexion with neutral forearm rotation until therapy begins.

Figure A is a lateral radiograph of the elbow which shows a simple posterior elbow dislocation. The anatomic description is based on the anatomic location of olecranon relative to humerus.

REFERENCES:

1. O'Driscoll SW, Bell DF, Morrey BF. Posterolateral rotatory instability of the elbow. J Bone Joint Surg Am. 1991 Mar;73(3):440-6. PMID:2002081 (Link to Abstract)

2. 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 Feb;70(2):244-9. PMID:3343270 (Link to Abstract)

3. Smith J, Morrey BF. Principles of elbow rehabilitation. In: Morrey BF, Sanchez-Sotelo J, eds. The Elbow and Its Disorders, 4th ed. Philadelphia, PA: Elsevier Saunders; 2009:152-159.

Question Authors:

Joshua Blomberg MD, Ben Taylor MD, Derek Moore,

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TAG

(OBQ10.252) A 34-year-old male falls from a roof and sustains a right elbow dislocation that is closed reduced in the emergency room. An AP radiograph is shown in Figure A. This injury pattern is at highest risk for which of the following? Topic

Review Topic

FIGURES: A

1. Anterior interosseous nerve palsy
2. Varus posteromedial rotatory instability
3. Posterior interosseous nerve palsy
4. Valgus posterolateral rotatory instability
5. Elbow instability when pushing oneself up from a seated position in a chair

PREFERRED RESPONSE ▶

DISCUSSION: Anteromedial coronoid facet fracture and LCL injury following an elbow dislocation is commonly associated with varus posteromedial rotatory instability. Varus and posteromedial rotation force on the forearm results in rupture of the LCL from its humeral origin. As the LCL ruptures, the medial coronoid process is fractured as it impacts against and under the medial trochlea. Fracture involvement of the sublime tubercle, where the MCL attaches, can lead to more instability. The lateral pivot shift test is similar to pushing oneself up from a seated position in a chair is an indication of valgus posterolateral rotatory instability. Ulnar neuropathy can be seen following this injury pattern but AIN and PIN nerve palsy do not commonly characterize this injury pattern.

The review article by O'Driscoll highlights key points in diagnosis and management of capitellum, distal humerus, coronoid, and terrible triad injuries.

The article by Doornberg and Ring is a Level 4 study of 18 patients that sustained varus posteromedial rotational injuries resulting in anteromedial facet coronoid fractures. They found that lack of fixation at injury or malunion of the anteromedial facet were significant predictors of suboptimal functional outcome and development of arthrosis.

The anteromedial facet is highlighted in yellow as displayed in Illustration A. Illustration B depicts the lateral collateral ligament injury evident during varus stress fluroscopic examination.

Illustrations: A

REFERENCES:

1. O’Driscoll SW, Jupiter JB, Cohen MS, Ring D, McKee MD. Difficult elbow fractures: pearls and pitfalls. Instr Course Lect. 2003;52:113-34. Review. PMID:12690844 (Link to Abstract)

2. Doornberg JN, Ring DC. Fracture of the anteromedial facet of the coronoid process. J Bone Joint Surg Am. 2006 Oct;88(10):2216-24. PMID:17015599 (Link to Abstract)

Question Authors:

Michael Hughes MD, Ben Taylor MD,

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TAG

(OBQ08.149) What is the most common mode of failure of the lateral ulnar collateral ligament associated with an elbow dislocation? Topic

Review Topic

1. ligament avulsion off the humeral origin
2. ligament avulsion off the ulnar insertion
3. midsubstance rupture
4. bony avulsion of the humeral origin
5. combined proximal and distal ligament avulsions

PREFERRED RESPONSE ▶

DISCUSSION: The lateral ulnar collateral ligament (LUCL) is often injured with elbow dislocations, and is most commonly injured at the proximal origin. McKee noted that in 62 consecutive operative elbow dislocations and fracture/dislocations, the LUCL was ruptured in all of the patients, proximally in 32, bony avulsion proximally in 5, midsubstance rupture in 18, ulnar detachment in 3, ulnar bony avulsion in only 1, and combined patterns in 3. Pugh et al established a standard protocol to treat elbow fracture dislocations (terrible triad) which includes coronoid repair, radial head repair/replacement, LUCL repair, and MCL and/or external fixation as needed.

REFERENCES:

1. McKee MD, Schemitsch EH, Sala MJ, O'driscoll SW. Pathoanatomy of lateral ligamentous disruption in elbow instability. JSES 2003;12:391-396 PMID:12934037 (Link to Abstract)

2. Pugh DM, Wild LM, Schemitsch EH, King GJ, McKee MD. Standard surgical protocol to treat elbow dislocations with radial head and coronoid fractures. J Bone Joint Surg Am. 2004 Jun;86-A(6):1122-30. PMID:15173283 (Link to Abstract)

Question Authors:

Greg Galano MD, Derek Moore, Patrick McCulloch MD,

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TAG

(OBQ08.192) You are planning open reduction and internal fixation for a comminuted radial head fracture. To avoid impingement with the proximal ulna, you need to carefully place your fixation. What percent of the proximal radial head does not articulate with the proximal ulna? Topic

Review Topic

1. 0%
2. 25%
3. 50%
4. 75%
5. 100%

PREFERRED RESPONSE ▶

DISCUSSION: Only 25% of the radial head (or a 90 degree arc) does not articulate with the ulna and is the "safe zone" for placement of fixation.

Caputo et al looked at 24 cadevaric arms and found the average arc of the nonarticulating radial head was 113 degrees (range, 106 degrees to 120 degrees; standard deviation, 4 degrees).

Smith et al found the nonarticulating portion of the radial head (or safe zone for prominent fixation) consistently encompassed a 90 degree angle localized by palpation of the radial styloid and Lister's tubercle.

Cohen et al reviewed the classification, diagnosis, and management of acute elbow dislocations and specifically discuss treatment of associated proximal radial fracture where fixation needs to be applied in the "safe zone."

Illustration A depicts the radial head safe zone during forearm pronation, supination, and neutral positions.

Illustrations: A

REFERENCES:

1. Caputo AE, Mazzocca AD, Santoro VM. The nonarticulating portion of the radial head: anatomic and clinical correlations for internal fixation. J Hand Surg Am. 1998 Nov;23(6):1082-90. PMID:9848563 (Link to Abstract)

2. Smith GR, Hotchkiss RN. Radial head and neck fractures: anatomic guidelines for proper placement of internal fixation. J Shoulder Elbow Surg. 1996 Mar-Apr;5(2 Pt 1):113-7. PMID:8742874 (Link to Abstract)

3. Cohen MS, Hastings H 2nd. Acute elbow dislocation: evaluation and management. J Am Acad Orthop Surg. 1998 Jan-Feb;6(1):15-23. Review. PMID:9692937 (Link to Abstract)

Question Authors:

Patrick O'Donnell MD/PhD, Michael Hughes MD,

Please Rate Educational Value!

4.0

Average 4.0 of 12 Ratings

TAG

(OBQ05.6) Which component is most common to both simple and complex elbow dislocations? Topic

Review Topic

1. radial head fracture
2. radial neck fracture
3. loss of terminal extension
4. coronoid tip fracture
5. coronoid base fracture

PREFERRED RESPONSE ▶

DISCUSSION: Elbow dislocations are classified as either simple (no associated fracture) or complex (associated fracture). The goal of treatment is a stable joint that tolerates early motion. The initial range of motion is the stable arc found on postreduction examination. Studies have demonstrated a better outcome when simple elbow dislocations are treated non-surgically rather than with surgical repair. Simple elbow dislocations usually have an excellent outcome (return of functional range of motion with normal strength). A loss of terminal extension is the most common sequelae.

REFERENCES:

1. Orthopaedic Knowledge Update 7. Koval KJ (Editor). Published by the American Academy of Orthopaedic Surgeons. Rosemont, IL. Copyright. 2007

2. Ross G, McDevitt ER, Chronister R, Ove PN. Treatment of simple elbow dislocation using immediate motion protocol. 1999. AJSM. 27:308-11. PMID:10352765 (Link to Abstract)

Question Authors:

Greg Galano MD, Patrick McCulloch MD,

Please Rate Educational Value!

2.0

Average 2.0 of 15 Ratings

Cases

	closed elbow dislocation, and proximal radius fracture (C1459) Trauma - Treatment Consult - Elbow Dislocation HPI - fall from bike, immediate reduction and cast temporary How would you treat this?	3/20/2013 216 responses 5
	Chronic elbow dislocation (C1309) Trauma - Treatment Consult - Elbow Dislocation HPI - Dislocated his elbow 8 years ago in the Honduras after a fall from a tree. No o... What would you do with this injury?	11/2/2012 127 responses

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Posts

Standard surgical protocol to treat elbow dislocations with radial head and coronoid fractures. Includes Poll

Pugh DM, Wild LM, Schemitsch EH, King GJ, McKee MD
J Bone Joint Surg Am. 2004 Jun;86-A(6):1122-30. PMID: 15173283 (Link to Pubmed)

Trauma - Journal Club - Elbow Dislocation

2 weeks ago

42 responses

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ABOS II: Elbow Dislocation

General - Oral Boards Review

7/29/2011

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Evidence & References Show References

Level of Evidence 5 and Other Journal Articles (includes Case Reports, Expert Opinions, Personal Observations, and Biomechanic Studies)

Caputo AE, Mazzocca AD, Santoro VM. The nonarticulating portion of the radial head: anatomic and clinical correlations for internal fixation. J Hand Surg Am. 1998 Nov;23(6):1082-90. PMID:9848563 (Link to Abstract)
Cohen MS, Hastings H 2nd. Acute elbow dislocation: evaluation and management. J Am Acad Orthop Surg. 1998 Jan-Feb;6(1):15-23. Review. PMID:9692937 (Link to Abstract)
Smith GR, Hotchkiss RN. Radial head and neck fractures: anatomic guidelines for proper placement of internal fixation. J Shoulder Elbow Surg. 1996 Mar-Apr;5(2 Pt 1):113-7. PMID:8742874 (Link to Abstract)

Textbooks

Review of Orthopaedics, 6th Edition, Mark D. Miller MD, Stephen R. Thompson MBBS MEd FRCSC, Jennifer Hart MPAS PA-C ATC, an imprint of Elsevier, Philadelphia, Copyright 2012
AAOS Comprehensive Orthopaedic Review, Jay R. Leiberman. Published by American Academy of Orthopaedic Surgeons, Rosemont IL. Copyright 2009
Orthopaedic Knowledge Update 10, John M Flyn. Published by American Academy of Orthopaedic Surgeons, Rosemont IL. Copyright 2011
Hoppenfeld SP. Surgical Exposures in Orthopaedics: The Anatomic Approach. Lipponcott, Williams, and Wilkins, Philadelphia, PA, Copyright 2009
Orthopaedic In-training Examination (OITE) Questions 2004-2012, American Academy of Orthopaedic Surgeons, Rosemont IL. Copyright 2004-2012
Self-Assessment Examination (SAE) Questions 2004-2012, American Academy of Orthopaedic Surgeons, Rosemont IL. Copyright 2004-2012

Undefined

Doornberg JN, Ring DC. Fracture of the anteromedial facet of the coronoid process. J Bone Joint Surg Am. 2006 Oct;88(10):2216-24. PMID:17015599 (Link to Abstract)
McKee MD, Schemitsch EH, Sala MJ, O'driscoll SW. Pathoanatomy of lateral ligamentous disruption in elbow instability. JSES 2003;12:391-396 PMID:12934037 (Link to Abstract)
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 Feb;70(2):244-9. PMID:3343270 (Link to Abstract)
O’Driscoll SW, Jupiter JB, Cohen MS, Ring D, McKee MD. Difficult elbow fractures: pearls and pitfalls. Instr Course Lect. 2003;52:113-34. Review. PMID:12690844 (Link to Abstract)
O'Driscoll SW, Bell DF, Morrey BF. Posterolateral rotatory instability of the elbow. J Bone Joint Surg Am. 1991 Mar;73(3):440-6. PMID:2002081 (Link to Abstract)
Orthopaedic Knowledge Update 7. Koval KJ (Editor). Published by the American Academy of Orthopaedic Surgeons. Rosemont, IL. Copyright. 2007
Pugh DM, Wild LM, Schemitsch EH, King GJ, McKee MD. Standard surgical protocol to treat elbow dislocations with radial head and coronoid fractures. J Bone Joint Surg Am. 2004 Jun;86-A(6):1122-30. PMID:15173283 (Link to Abstract)
Ross G, McDevitt ER, Chronister R, Ove PN. Treatment of simple elbow dislocation using immediate motion protocol. 1999. AJSM. 27:308-11. PMID:10352765 (Link to Abstract)
Smith J, Morrey BF. Principles of elbow rehabilitation. In: Morrey BF, Sanchez-Sotelo J, eds. The Elbow and Its Disorders, 4th ed. Philadelphia, PA: Elsevier Saunders; 2009:152-159.

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Elbow Dislocation

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