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 Anatomy 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 description 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 important to assess the status of the skin - evaluate for open injuries presence of compartment syndrome neurovascular status status of wrist and shoulder concomitant injuries occur in 10-15% of elbow dislocations 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 splinting at least 90° for 5-10 days, early therapy indications acute simple stable dislocations recurrent instability after simple dislocations is rare (<1-2% of dislocations) Operative ORIF (coronoid, radial head, olecranon), LCL repair, +/- MCL repair indications acute complex elbow dislocations persistent instability after reduction elbow requires >50-60° to maintain reduction reduction cannot be performed closed often due to entrapped soft tissue or osteochondral fragments 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 with splinting 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 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 obtain post-reduction radiographs 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 ORIF of coronoid, radial head, repair of LCL +/- MCL approach depends on 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 reconstruction 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 hinged external fixator only necessary if elbow remains unstable after attempt at fixation as described above postoperative care depending on stability of the elbow, active ROM exercises may commence while using a brace an extension block may or may not be used 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
Technique Guide Technique guides are not considered high yield topics for orthopaedic standardized exams including ABOS, EBOT and RC. Hinged Elbow External Fixator Orthobullets Team Trauma - Distal Humerus Fractures
QUESTIONS 1 of 17 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 Previous Next (OBQ19.222) 47-year-old female falls while mountain biking and presents to the emergency department with the injury shown in Figures A and B. She has no other injuries besides superficial abrasions. Closed reduction is performed but the elbow is highly unstable and will not stay reduced. What is the most appropriate next step in management? QID: 214124 FIGURES: A B Type & Select Correct Answer 1 6 weeks immobilizaiton in a splint then gentle progressive physical therapy 1% (13/1106) 2 Arthroscopic-assisted reduction follow external fixator placement 1% (12/1106) 3 Open reduction with isolated internal joint stabilizer placement 3% (37/1106) 4 Open reduction with lateral collateral ligament repair with or without medial collateral ligament repair 91% (1001/1106) 5 Open reduction with lateral collateral ligment reconstruction followed by 6 weeks of immobilization 3% (35/1106) L 1 Question Complexity E Question Importance Select Answer to see Preferred Response SUBMIT RESPONSE 4 Review Tested Concept Review Full Topic Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK (OBQ12.183) A 30-year-old woman falls onto an outstretched arm while rollerblading. She presents to the emergency room with the elbow deformity shown in Figure A. On physical examination she is unable to range her elbow. She is distally neurovascularly intact. Her radiograph is shown in Figure B. What is the next step in management of this patient? QID: 4543 FIGURES: A B Type & Select Correct Answer 1 Closed reduction, hinged external fixator 1% (81/7376) 2 Closed reduction, acute surgical repair of the lateral collateral ligament complex 2% (183/7376) 3 Open reduction and surgical repair of the lateral collateral ligament complex 2% (115/7376) 4 Closed reduction, splinting & early passive ROM 25% (1815/7376) 5 Closed reduction, splinting & early active ROM 70% (5141/7376) L 3 Question Complexity B Question Importance Select Answer to see Preferred Response SUBMIT RESPONSE 5 Review Tested Concept Review Full Topic (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? QID: 3350 FIGURES: A Type & Select Correct Answer 1 Anterior interosseous nerve palsy 2% (72/3560) 2 Varus posteromedial rotatory instability 62% (2199/3560) 3 Posterior interosseous nerve palsy 3% (92/3560) 4 Valgus posterolateral rotatory instability 24% (854/3560) 5 Elbow instability when pushing oneself up from a seated position in a chair 9% (310/3560) L 1 Question Complexity B Question Importance Select Answer to see Preferred Response SUBMIT RESPONSE 2 Review Tested Concept Review Full Topic (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? QID: 3155 FIGURES: A Type & Select Correct Answer 1 Immediate active and active-assist range of motion through a stable arc 15% (550/3788) 2 Initial splinting and immobilization for 4 weeks followed by physical therapy 71% (2700/3788) 3 Initial splinting in 90 degrees of flexion with neutral forearm rotation 4% (162/3788) 4 A range of motion protocol that limits full extension in the early phases of rehab 7% (271/3788) 5 Light duty use of the affected arm immediately following immobilization 2% (89/3788) L 2 Question Complexity B Question Importance Select Answer to see Preferred Response SUBMIT RESPONSE 2 Review Tested Concept Review Full Topic Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK (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 articulates with the proximal ulna? QID: 578 Type & Select Correct Answer 1 0% 2% (32/1622) 2 75% 66% (1071/1622) 3 50% 12% (191/1622) 4 25% 19% (306/1622) 5 100% 1% (19/1622) L 1 Question Complexity C Question Importance Select Answer to see Preferred Response SUBMIT RESPONSE 2 Review Tested Concept Review Full Topic (OBQ08.149) What is the most common mode of failure of the lateral ulnar collateral ligament associated with an elbow dislocation? QID: 535 Type & Select Correct Answer 1 ligament avulsion off the humeral origin 64% (688/1081) 2 ligament avulsion off the ulnar insertion 20% (217/1081) 3 midsubstance rupture 10% (106/1081) 4 bony avulsion of the humeral origin 5% (54/1081) 5 combined proximal and distal ligament avulsions 1% (11/1081) L 1 Question Complexity B Question Importance Select Answer to see Preferred Response SUBMIT RESPONSE 1 Review Tested Concept Review Full Topic (OBQ05.6) Which of the following is most commonly associated with both simple and complex elbow dislocations? QID: 43 Type & Select Correct Answer 1 radial head fracture 7% (150/2136) 2 radial neck fracture 1% (17/2136) 3 loss of terminal extension 76% (1626/2136) 4 repeat dislocation 11% (228/2136) 5 coronoid base fracture 5% (102/2136) L 2 Question Complexity D Question Importance Select Answer to see Preferred Response SUBMIT RESPONSE 3 Review Tested Concept Review Full Topic
All Videos (11) Podcasts (2) Login to View Community Videos Login to View Community Videos 7th Annual Frontiers in Upper Extremity Surgery Case Review: Elbow Dislocation in a 39 Years Old Male Who Fell from Roof with Prior Injury - Peter Evans, MD Peter J. Evans Trauma - Elbow Dislocation 10/4/2022 216 views 4.0 (1) Login to View Community Videos Login to View Community Videos Cleveland Combined Hand Fellowship Lecture Series 2021-2022 Elbow Dislocations - Robert Walker, MD Robert Walker Trauma - Elbow Dislocation C 12/28/2021 135 views 5.0 (1) Login to View Community Videos Login to View Community Videos Cleveland Combined Hand Fellowship Lecture Series 2021-2022 Elbow Fractures - Jack Reynolds, MD JacK Reynolds Trauma - Elbow Dislocation C 12/28/2021 30 views 5.0 (1) Trauma⎜Elbow Dislocations (ft. Dr. Mark S. Cohen) Team Orthobullets (AF) Trauma - Elbow Dislocation Listen Now 31:52 min 12/3/2019 354 plays 5.0 (1) Trauma⎪Elbow Dislocation Orthobullets Team Trauma - Elbow Dislocation Listen Now 17:5 min 12/11/2019 440 plays 4.0 (4) See More See Less
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