November 6, 2024

Elbow Dislocations

Written by Stephen Hongach, DO
REBEL Core
Medical Category: Trauma

Elbow Dislocation

Definition:

Disarticulation of the proximal radius & ulna bones from the humerus
Epidemiology:
- Incidence
  - Second most common joint dislocation (after shoulder) in adults
  - Most commonly dislocated joint in children
  - Accounts for 10-25% of all injuries to the elbow (Cohen 1998)
  - Posterolateral is the most common type of dislocation (80%)

- Demographics
  - Most commonly affects patients between ages 10-20 years old
  - As age increases, elbow dislocation rates tend to decrease
  - More common in men than women (53% vs. 47%) (Layson 2023)
  - Most common sports: football, roller-blading or skateboarding, & wrestling

Elbow Dislocations (D1)

Classification:
- Differentiate by the direction of the olecranon relative to the humerus (Layson 2023) (e.g. posterolateral, posteromedial, posterior, anterior, medial or lateral) (D1)
  - Complete: The coronoid is completely dissociated from the trochlea
  - Subluxated (Perched): The coronoid rests on the trochlea
  - Simple: Dislocation with injury to only capsular or ligamentous structures
  - Complex: Dislocation with injury involving fracture
    - Radial head (36%) (F3), coronoid process (13%), olecranon (4%) (F2), distal humerus, medial (F4) or lateral epicondyles (Josefsson 1986)
    - Radial head most common associated fracture in adults
    - Medial epicondyle fracture most common associated fracture in children
    - Up to 60% of medial epicondyle fractures are associated with elbow dislocations in children (Gottschalk 2012)
  - Terrible Triad (F5)
    - Elbow dislocation associated with a LCL tear, radial head & coronoid process fracture
    - Associated with poor outcomes (Mathew 2009)
  - Varus Posteromedial Rotatory Instability
    - Elbow injury associated with LCL tear & coronoid fracture
  - Trans-Olecranon Fracture Dislocation

Posterior Dislocation (F1)

Olecranon Fracture (F2)

Radial Head Fracture (F3)

Medial Epicondyle Fracture (F4)

Terrible Triad (F5)

Etiology:
- Pathophysiology
  - Mechanism of Posterior Dislocation (F1) (Taylor 2012)
    - Falling onto an outstretched hand is the most common mechanism
    - Forces involved: valgus stress, axial compression & forearm supination
    - Less common: axial load, supination & varus posteromedial stress

- - Mechanism of Anterior Dislocation (Saouti 2003)
    - Fall on a flexed elbow with an anterior-directed force on the proximal ulna

- Pathoanatomy
  - Associated with disruption of capsuloligamentous stabilizers
  - Disruption occurs from lateral to medial called the “Horii Circle” (O’Driscoll 2018)
  - LCL (fails first), followed by anterior capsule, posterior capsule, & MCL depending on the degree of energy

Physical Exam:
- General
  - Pain & swelling
  - Inability to move the affected extremity
  - ROM will be decreased

- Inspection
  - Look for any obvious deformity or malposition of the extremity
  - Inspect skin for any ecchymosis
  - Posterior dislocation: elbow often held in mid-flexion
  - Anterior dislocation: elbow often held in extension with forearm supination
  - Prominent olecranon posteriorly may be seen
  - Ipsilateral forearm may appear “shortened”

Elbow Anatomy (A1)

- Palpation
  - Assessment for any palpable effusion
  - Elbow to evaluate for any tenderness and/or crepitus
  - Cautious ROM of elbow to evaluate articulations involved in a dislocation
  - Make sure to examine the shoulder & wrist thoroughly to look for additional injuries

- Neurovascular Status
  - Concomitant injuries occur in 10-15% of elbow dislocations (Abutalib 2016)
  - Crucial to document due to potential changes post reduction attempt
  - Motor Nerve Function Testing (Murphy 2023), (Akhondi 2023 ), (Glover 2023), (Wheeler 2023), ( Lleva 2023)
    - Median Nerve: check flexor digitorum superficialis by having pt make fist
    - Anterior Interosseus Nerve: check flexor pollicis longus by having pt make an “OK” sign
    - Radial Nerve: check extensor digitorum muscles by having pt extend wrist
    - Posterior Interosseous Nerve: check extensor pollicis longus by having pt make a “thumbs up” gesture
    - Ulnar Nerve: check palmar & dorsal interossei muscles by having pt abduct & adduct pt’s fingers

Imaging Modalities:
- Plain Radiographs
  - AP, Lateral, Oblique
- CT Scan
  - Useful in pts with suspicion of complex dislocation (i.e. terrible triad)
  - Aids in identifying associated periarticular fractures
Management:
- Orthopedic Consultation
  - Indications
    - Open dislocation, vascular disruption or compartment syndrome (Decker 2022)
    - Irreducible & chronic dislocations (dislocation > 2 weeks)
    - Incarcerated tissue with a locked elbow dislocation
    - Grossly unstable elbow

- - Intervention ( Robinson 2013)
- Open Reduction
  - ORIF with ligament repair in the OR
  - Indications
    - If the elbow is unstable with extension during ROM, exhibited by dislocation once the elbow reaches 50-60° of extension
    - Any associated unstable fractures with a complex elbow dislocation
  - Complications
    - Early Stiffness
      - Loss of terminal extension is the most common complication after closed elbow reduction in a simple dislocation
      - Early active ROM can help prevent from occurring
    - Neurovascular Injuries
      - Rare, typically associated with open dislocations
      - Brachial Artery Injury: most serious injury, associated with anterior & open dislocations
      - Median Nerve Injury: anterior interosseous branch typically involved
        
        Associated with entrapment in fracture site or posterior to a displaced medial epicondyle in children (Layson 2023)
      - Radial Nerve Injury
      - Ulnar Nerve Injury: most common neuropraxia associated with posterior dislocations
    - Compartment Syndrome
    - Volkmann Contracture: (claw hand) can develop in presence of large tissue swelling
    - Recurrent Instability
    - Contracture/Stiffness
      - Associated with immobilization beyond 3 weeks
      - Children generally have lower rates of contracture & loss of motion (Donohue 2016)
- Closed Reduction
  - Indications
    - Acute simple stable dislocations
    - Recurrent instability post-reduction is rare (<2% of dislocations)
    - Techniques (Gottlieb 2018)

General Principles of Reduction:
- Requires sufficient analgesia to allow for adequate muscle relaxation
- Displacement of elbow in medial or lateral direction first gets translated before the application of longitudinal traction of the forearm (Layson 2023)
- Posterolateral Dislocation:
  - Techniques
    - Traction-Countertraction Technique (E1)
      - Two-person Traction-Countertraction Technique (2)
        
        A case series of 6 pts reported 100% reduction success (Skelley 2015)

Elbow Reduction (E1)

- - - Kumar Technique
      - Single-person Traction-Counteraction Technique (1)
      - 95% reduction success rate among 21 patients (Kumar 1999)

- - - Leverage Technique
      - Single-person Leverage Technique (3)
      - 77 cases successfully reduced without complications (Hankin 1984)

- - - Hanging-arm Technique (C1)
      - Single-person Hanging-arm Technique (4)
      - 20 cases successfully reduced without complications (Parvin 1957)

Hanging-arm Techniques (C1)

- Anterior Dislocation:
  - Technique
    - Modified Traction-Counteraction Technique (B1)
      - Posterior directed force applied on pt’s proximal forearm guides olecranon past distal humerus

Anterior Elbow Reduction (B1)

Immobilization:
- Assess post reduction elbow stability
- Perform gentle ROM in flexion/extension, valgus/varus, pronation/ supination (Mathew 2009)
- Place in a posterior long arm splint in at least 90° of elbow flexion that prevents extension of elbow
- If LCL is disrupted, elbow is more stable in pronation
- If MCL is disrupted, elbow is more stable in supination
- Repeat neuromuscular assessment post-reduction –
  - Brachial artery injury or median nerve entrapment may lead to operative management
- Post-reduction plain radiographs
- Repeat plain radiographs to confirm reduction after 3-5 days post-reduction
- Initiate physical therapy utilizing ROM exercises to avoid loss of terminal extension
- Immobilization >3 weeks results in poor ROM outcomes

Take Home Points:
- Early identification & reduction is key to prevent complications
- Simple dislocations may be treated with closed reduction, splinting & orthopedic follow-up in 1-2 weeks
- Orthopedic consultation if open dislocation, vascular disruption or compartment syndrome

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References:

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Post Peer Reviewed By: Anand Swaminathan MD, MPH (Insta @EMSwami)

Cite this article as: Stephen Hongach, DO, "Elbow Dislocations", REBEL EM blog, November 6, 2024. Available at: https://rebelem.com/elbow-dislocations/.