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https://upload.orthobullets.com/topic/1018/images/posteriorelbowdislocation.jpg
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Introduction 
  • 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
  • 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
          • 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
Nonoperative 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 pronatino 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
Operative Technique
  • 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
 

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(OBQ05.6) Which of the following is most commonly associated with both simple and complex elbow dislocations? Review Topic

QID: 43
1

radial head fracture

5%

(54/1068)

2

radial neck fracture

1%

(10/1068)

3

loss of terminal extension

79%

(844/1068)

4

repeat dislocation

11%

(119/1068)

5

coronoid base fracture

3%

(32/1068)

Select Answer to see Preferred Response

PREFERRED RESPONSE 3

(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? Review Topic

QID: 578
1

0%

3%

(19/723)

2

75%

66%

(475/723)

3

50%

13%

(96/723)

4

25%

18%

(127/723)

5

100%

1%

(6/723)

Select Answer to see Preferred Response

PREFERRED RESPONSE 2

(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? Review Topic

QID: 3350
FIGURES:
1

Anterior interosseous nerve palsy

2%

(29/1202)

2

Varus posteromedial rotatory instability

61%

(739/1202)

3

Posterior interosseous nerve palsy

2%

(30/1202)

4

Valgus posterolateral rotatory instability

23%

(279/1202)

5

Elbow instability when pushing oneself up from a seated position in a chair

10%

(119/1202)

Select Answer to see Preferred Response

PREFERRED RESPONSE 2

(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? Review Topic

QID: 4543
FIGURES:
1

Closed reduction, hinged external fixator

1%

(69/5870)

2

Closed reduction, acute surgical repair of the lateral collateral ligament complex

2%

(146/5870)

3

Open reduction and surgical repair of the lateral collateral ligament complex

1%

(84/5870)

4

Closed reduction, splinting & early passive ROM

25%

(1473/5870)

5

Closed reduction, splinting & early active ROM

69%

(4070/5870)

Select Answer to see Preferred Response

PREFERRED RESPONSE 5

(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? Review Topic

QID: 3155
FIGURES:
1

Immediate active and active-assist range of motion through a stable arc

15%

(406/2663)

2

Initial splinting and immobilization for 4 weeks followed by physical therapy

71%

(1893/2663)

3

Initial splinting in 90 degrees of flexion with neutral forearm rotation

4%

(107/2663)

4

A range of motion protocol that limits full extension in the early phases of rehab

7%

(191/2663)

5

Light duty use of the affected arm immediately following immobilization

2%

(59/2663)

Select Answer to see Preferred Response

PREFERRED RESPONSE 2

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

QID: 535
1

ligament avulsion off the humeral origin

60%

(314/523)

2

ligament avulsion off the ulnar insertion

22%

(117/523)

3

midsubstance rupture

10%

(53/523)

4

bony avulsion of the humeral origin

5%

(28/523)

5

combined proximal and distal ligament avulsions

1%

(6/523)

Select Answer to see Preferred Response

PREFERRED RESPONSE 1
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