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  • summary
    • Elbow Dislocations are common elbow injuries which can be characterized as simple or complex depending on associated injury to nearby structures. 
    • Diagnosis can be made with plain radiographs. CT studies can be helpful to evaluate for loose bodies or for surgical planning.
    • Treatment is closed reduction followed by a short period of immobilization for stable simple elbow dislocations. Surgical management is indicated for complex elbow dislocations associated with fractures or persistent instability.
  • Epidemiology
    • Incidence
      • elbow dislocations are the most common major joint dislocation second to the shoulder
        • most common dislocated joint in children
      • account for 10-25% of injuries to the elbow
      • posterolateral is the most common type of dislocation (80%)
    • Demographics
      • predominantly affects patients between age 10-20 years old
  • Etiology
    • Pathophysiology
      • mechanism for posterolateral dislocation
        • usually a combination of
          • axial loading
          • supination/external rotation of the forearm
          • valgus posterolateral force
        • a varus posteromedial mechanism (combined with axial load and forearm external rotation) has also been reported
        • posterior dislocations may involve more than one injury mechanism
      • pathoanatomy
        • associated with complete or near complete circular disruption of capsuloligamentous stabilizers
        • pathoanatomic cascade
          • progression of injury is from lateral to medial
            • LCL fails first (primary lesion)
              • by avulsion of the lateral epicondylar origin
              • midsubstance LCL tears are less common but do occur
            • MCL fails last depending on degree of energy
    • Associated injuries
      • shoulder and wrist injuries
        • concomitant shoulder and wrist injuries occur in 10-15% of elbow dislocations
  • Anatomy
    • Osteology
      • static and dynamic stabilizers confer stability to the elbow
        • static stabilizers (primary)
          • ulnohumeral joint
          • anterior bundle of the MCL
          • LCL complex (includes the LUCL)
        • static stabilizers (secondary)
          • radiocapitellar joint
          • joint capsule
          • origins of the common flexor and extensor tendons
        • dynamic stabilizers
          • muscles that cross the elbow joint, which apply compressive (stabilizing) force
            • anconeus
            • brachialis
            • triceps
    • See complete Anatomy and Biomechanics of Elbow
  • Classification
    • Anatomic
      • based on anatomic location of olecranon relative to humerus
        • posterolateral
          • most common
    • Simple vs. complex
      • simple
        • elbow dislocation with no associated fracture
        • accounts for 50-60% of elbow dislocations
      • complex
        • elbow dislocation with associated fracture
        • may take form of
          • terrible triad injury
            • elbow dislocation associated with a LUCL tear, radial head fracture, and coronoid tip fracture
              • radial head fractures occur in up to 10% of elbow dislocations
          • varus posteromedial rotatory instability
            • elbow injury associated with an LCL tear and a coronoid fracture
            • radial head fracture unlikely 
            • coronoid fracture characterisitics
              • medial facet fracture
              • comminuted
  • Presentation
    • Symptoms
      • pain and swelling
    • Physical exam
      • inspection
        • the status of the skin - evaluate for open injuries
      • palpation
        • presence of compartment syndrome
        • status of wrist and shoulder
          • concomitant injuries occur in 10-15% of elbow dislocations
      • neurovascular status
  • Imaging
    • Radiographs
      • recommended views
        • AP and lateral views
          • assess joint congruency, especially after attempted reduction
        • oblique views
          • assess for associated periarticular fractures
    • CT scan
      • indications
        • suspicion of complex injury pattern
        • useful to identify associated periarticular fractures
  • Treatment
    • Nonoperative
      • closed reduction and immobilization with early motion 
        • indications
          • acute simple stable dislocations
          • recurrent instability after simple dislocations is rare (<1-2% of dislocations)
      • techniques
        • splint in at least 90° of flexion for 5-10 days
        • begin early supervised physical therapy
    • Operative
      • open reduction internal fixation (ORIF) with ligament repair
        • indications
          • closed reduction cannot be performed
            • often due to entrapped soft tissue or osteochondral fragments
          • persistent instability after reduction
          • acute complex elbow dislocations
            • presence of coronoid, radial head, olecranon fractures
        • technique
          • ORIF of coronoid, radial head, olecranon fracture if present
          • ligament repair
            • perform LCL repair +/- MCL repair depending on intraoperative stability
          • postoperative
            • elbow requires >50-60° to maintain reduction
      • open reduction, capsular release, and dynamic hinged elbow fixator
        • indications
          • chronic dislocations
        • postoperative
          • hinged external fixator indicated in chronic dislocation to protect the reconstruction and allow early range of motion
  • Technique
    • Closed reduction and immobilization with early motion 
      • closed reduction
        • technique
          • ensure patient has sufficient analgesia to allow for adequate muscle relaxation
          • reduction maneuver requires a combination of:
            • inline traction to improve coronal displacement
            • forearm supination to shift the coronoid under the trochlea
            • elbow flexion while placing direct pressure on tip of olecranon
          • a palpable "clunk" can be appreciated after most reductions
          • assess post reduction stability
            • elbow is often unstable in extension
            • elbow is often unstable to valgus stress
              • test by stressing elbow with forearm in pronation to lock the lateral side
      • immobilization
        • place post-reduction posterior mold splint in flexion and appropriate forearm rotation
          • splint in at least 90° of elbow flexion
          • if LCL is disrupted - elbow will be more stable in pronation
          • if MCL is disrupted - elbow will be more stable in supination
      • post-reduction radiographs
        • obtain following reduction in immobilization
          • if joint is concentric, immobilize (5-10 days) and start early therapy
          • obtain repeat radiographs at 3-5 days and 10-14 days to confirm reduction
      • rehabilitation
        • initial
          • immobilize for 5-10 days
          • immobilization for >3 weeks results in poor final ROM outcomes
        • early
          • supervised (therapist) active and active assist range-of-motion exercises within stable arc
          • extension block brace is used for 3-4 weeks
          • proceed with light duty use 2 weeks from injury
        • late rehabilitation
          • extension block is decreased such that by 6-8 weeks after the injury full stable extension is achieved
    • Open reduction internal fixation (ORIF) with ligament repair
      • approach
        • approach depends on the location of the pathology
          • Kocher approach (ECU/anconeus)
            • used to address the LCL complex, common extensor tendon origin, coronoid, capitellum, and/or radial head fractures
            • when approaching joint (ie, for radial head fractures) during deep dissection, make incision slightly anterior to midline of the radial head to protect the posterior fibers of the LCL complex
            • take care with retractor placement to avoid injury to the PIN
          • medial approach
            • used to address the MCL, flexor/pronator mass origin, and/or comminuted coronoid fractures
            • identify and protect the ulnar nerve
        • posterior approach
      • internal fixation with ligament repair
        • coronoid fractures
          • ORIF
            • rarely needed, as most fractures involve only the coronoid tip (proximal to insertion of brachialis)
            • typically approached laterally, but can also be addressed via a medial approach, especially if comminuted
        • radial head fractures
          • ORIF
            • when placing fixation on the proximal radius, one must be aware of the "safe zone" (a 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
          • radial head arthroplasty
            • indicated if radial head can not be reconstructed
            • if radial head is replaced the replacement should be anatomic and restore normal length/size
              • this improves the varus and external rotatory stability of the elbow, but stability isn't restored until LCL is addressed
              • excision of the radial head leads to varus/external rotatory instability when the LCL function is absent
        • LCL
          • repaired or reconstructed
          • extensor origin avulsion is common and may be repaired
        • MCL
          • if instability persists following LCL repair, the MCL is repaired or reconstructed
      • postoperative
        • elbow requires >50-60° to maintain reduction
        • depending on stability of the elbow, active ROM exercises may commence while using a brace
        • an extension block may or may not be used
    • Hinged external fixator
      • only necessary if elbow remains unstable after attempt at fixation as described above
  • Complications
    • Early stiffness
      • loss of terminal extension is the most common complication after closed treatment of a simple elbow dislocation
      • early, active ROM can help prevent this from occurring
      • static, progressive splinting can be helpful after inflammation has decreased
        • often between 6-8 weeks after surgery
    • 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
    • Neurovascular injuries
      • brachial artery injuries (rare) typically associated with open dislocations
      • ulnar nerve injury typically results from stretch
      • median nerve injury (rate) typcially associated with brachial artery injury
    • Compartment syndrome
    • Damage to articular surface
    • Recurrent instability
    • Heterotopic ossification
      • may require excision to improve elbow range of motion
    • Contracture/stiffness
      • correlated with immobilization beyond 3 weeks
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