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Updated: Aug 21 2022

Elbow Dislocation - Pediatric

Images elbow dislocation and medial epicpondyle fracture.jpg fracture.jpg
  • Summary
    • Elbow Dislocations in the pediatric population usually occur in older children (10-15 years) and can be associated with elbow fractures such as medial epicondyle fractures.
    • Diagnosis can be made with plain radiographs of the elbow. 
    • Treatment is usually closed reduction followed by brief immobilization. Open reduction is indicated for dislocations associated with a medial epicondyle fracture with an incarcerated fragment.
  • Epidemiology
    • Incidence
      • 3-6% of all pediatric elbow injuries
    • Dffemographics
      • male:female = 3:1
      • most common in 10-15 year olds
      • very rare in younger children < 3 years old
  • Etiology
    • Pathophysiology
      • mechanism of injury
        • fall onto an outstretched hand
      • pathoanatomy
        • posterior dislocation
          • hyperextension, valgus stress, and supination
        • anterior dislocation
          • a direct posterior to anterior force on a flexed elbow
        • relatively small coronoid process in children cannot resist distal and posterior displacement of ulna
    • Associated conditions
      • traumatic
        • avulsion of the medial epicondyle
          • medial epicondyle fractures are the most common associated fracture
          • incarcerated intra-articular bone fragment may block reduction
        • fractures of proximal radius, olecranon and coronoid process
        • neurovascular injury
          • brachial artery and median nerve
            • may be stretched over displaced proximal fragment
          • ulnar nerve
            • at risk with associated medial epicondyle avulsions
            • most common neuropraxia
      • congenital
        • dislocation of radial head
  • Classification
    • Anatomic classification
      • based on the position of the proximal radio-ulnar joint in relation to the distal humerus
      • includes
        • posterolateral (most common)
        • posteromedial
        • anterior (rare)
        • divergent
  • Presentation
    • Symptoms
      • painful and swollen elbow
      • attempts at motion are painful and restricted
    • Physical exam
      • inspection
        • elbow held in flexion
        • forearm appears to be shortened from the anterior and posterior view
      • palpation
        • distal humerus creates a fullness within the antecubital fossa
      • essential to perform neurovascular examination
        • assess for brachial artery and median/ulnar nerve injury
  • Imaging
    • Radiographs
      • required views
        • AP and lateral radiograph of elbow
        • comparison radiographs of the contralateral elbow may be helpful
      • findings
        • loss or radiocapitellar and ulnohumeral relationship but maintained radial and ulnar relationship
        • look for fractures of medial epicondyle, coronoid, proximal radius
        • "elbow dislocation" in very young (<3 years old) most likely represents a distal humerus physeal separation and raises concern for nonaccidental trauma
  • Treatment
    • Nonoperative
      • closed reduction, brief immobilization with early range of motion
        • indications
          • dislocation that remains stable following reduction
            • indicated in the majority of cases
        • reduction technique (see below)
          • should be addressed promptly as reduction should not be delayed
        • brief immobilization
          • immobilization should be minimized to 1- 2 weeks to minimize risk of stiffness
        • early therapy
          • encourage early active range of motion
    • Operative
      • open reduction
        • indications
          • open dislocation
          • incarcerated medial epicondyle or coronoid process in the joint
          • failure to obtain or maintain an adequate closed reduction
          • significant joint instability (rare)
  • Technique
    • Closed reduction technique
      • posterior dislocations
        • supine
          • closed reduction performed with the elbow flexed in forearm supination using gradual traction
        • prone
          • forearm hanging from table and anterior directed force on olecranon
      • anterior dislocations
        • inline traction to distal forearm with a posteriorly directed force on the forearm and an anteriorly directed force on the distal humerus
      • post-reduction films should be reviewed to rule out presence of entrapped bone fragment
        • must locate medial epicondyle on post-reduction radiographs to ensure it is not within the joint
    • Open reduction
      • approach
        • depends on reason for blocked reduction
          • elbow medial approach
            • indicated if medial epicondyle avulsion with incarcerated fragment is blocking reduction
  • Complications
    • Stiffness
      • most commonly loss of terminal extension
        • due to prolonged immobilization
    • Heterotopic ossification
      • vigorous reduction increases risk
    • Neurologic injuries
      • usually transient
      • median nerve injury may occur due to nerve entrapment
      • ulnar nerve most commonly affected if associated medial epicondyle fracture occurs
    • Vascular injury
      • brachial artery may be injured (rare)
    • Compartment syndrome
      • excessive swelling and immobilization in hyperflexion
    • Chronic instability (recurrent dislocations)
      • associated with coronoid and radial head fractures
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