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7

Elbow Dislocation

Topic updated on 08/31/16 11:47pm
Introduction 
  • Epidemiology
    • incidence
      • elbow dislocations are the most common major joint dislocation second to the shoulder
      • 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
      • usually a combination of
        • axial loading
        • supination/external rotation of the forearm
        • posterolateral based valgus force 
      • a varus posteromedial mechanism 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
      • capsule
      • origins of the flexor and extensor tendons
    • dynamic stabilizers
      • includes muscles crossing elbow joint
        • 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  
      • no associated fracture 
      • account for 50-60% of elbow dislocations
    • complex  
      • associated fracture present
      • may take form of
        • terrible triad injury  
          • involves a disruption of the LUCL, a radial head fracture, a coronoid tip fracture and a dislocation of the elbow
        • varus posteromedial rotatory instability
          • the coronoid fracture may be comminuted
          • medial facet of the coronoid is usually involved
Presentation
  • Symptoms
    • pain may be the primary symptom
  • Physical exam 
    • important to assess
      • the status of the skin
      • presence of compartment syndrome
      • neurovascular status
Imaging
  • Radiographs
    • recommended views
      • AP and lateral films 
        • need to check the status of the congruency of the joint
    • optional views
      • oblique views
        • may give clearer sense of periarticular bony involvement
  • CT scan
    • indications
      • suspicion of complex injury pattern
      • useful to identify osseous involvement
Treatment 
  • Nonoperative
    • reduction and splinting at 90° for 7-10 days, early therapy 
      • indications
        • acute simple stable dislocations
    • reduction splinting in hinged brace at 90° for 2-3 weeks
      • indications
        • acute simple unstable elbow dislocations (unstable with extension following reduction)
  • Operative
    • ORIF (coronoid, radial head, olecranon) , LCL repair, +/- MCL repair
      • indications
        • acute complex elbow dislocations
        • persistent instability after reduction 
        • reduction blocked by entrapped soft tissue or osteochondral fragments
      • outcomes
        • improved with use of this systematic algorithm
    • 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
    • reduction maneuver 
      • inline traction to correct coronal displacement
      • supination to clear the coronoid beneath trochlea
      • flexion of elbow while placing pressure on tip of olecranon
    • assess post reduction stability 
      • elbow is often unstable in extension 
        • if LCL is disrupted then usually more stable in pronation
        • if MCL is disrupted then usually more stable in supination
    • immobilize and obtain post-reduction radiographs
      • check for concentric reduction of joint 
      • if concentric then immobilize (5-7 days) and start early therapy
  • Rehabilitation
    • initial
      • immobilize for 5-7 days
    • 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
      • posterior utility approach used
      • Kocher interval laterally (ECU/anconeus)
    • reconstruction
      • coronoid
        • fixation can usually be completed laterally via radial head fracture
        • severe comminution may necessitate medial approach
      • radial head
        • 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
        • reconstructed or repaired relative to the anatomic axis of rotation
        • extensor origin avulsion is common and may be repaired
      • MCL
        • if instability persists following LCL repair, the MCL is repaired or reconstructed
    • 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
  • 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
  • Loss of motion
    • loss of terminal extension is the most common sequelae after closed treatment of a simple elbow dislocation 
    • early active ROM can help prevent this from occurring 
    • static, progressive splinting can be utilized after inflammation has diminished
  • Neurovascular injuries (ulnar/median nerves)
  • Compartment syndrome
  • Damage to articular surface
  • Chronic instability
  • Heterotopic ossification
    • may require excision to improve elbow range of motion 
  • Contracture/stiffness
    • correlated with immobilization beyond 3 weeks

 

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Qbank (7 Questions)

TAG
(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? Topic Review Topic
FIGURES: A   B        

1. Closed reduction, hinged external fixator
2. Closed reduction, acute surgical repair of the lateral collateral ligament complex
3. Open reduction and surgical repair of the lateral collateral ligament complex
4. Closed reduction, splinting & early passive ROM
5. Closed reduction, splinting & early active ROM

PREFERRED RESPONSE ▶
TAG
(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? Topic Review Topic
FIGURES: A          

1. Immediate active and active-assist range of motion through a stable arc
2. Initial splinting and immobilization for 4 weeks followed by physical therapy
3. Initial splinting in 90 degrees of flexion with neutral forearm rotation
4. A range of motion protocol that limits full extension in the early phases of rehab
5. Light duty use of the affected arm immediately following immobilization

PREFERRED RESPONSE ▶
TAG
(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? Topic Review Topic
FIGURES: A          

1. Anterior interosseous nerve palsy
2. Varus posteromedial rotatory instability
3. Posterior interosseous nerve palsy
4. Valgus posterolateral rotatory instability
5. Elbow instability when pushing oneself up from a seated position in a chair

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

1. ligament avulsion off the humeral origin
2. ligament avulsion off the ulnar insertion
3. midsubstance rupture
4. bony avulsion of the humeral origin
5. combined proximal and distal ligament avulsions

PREFERRED RESPONSE ▶
TAG
(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? Topic Review Topic

1. 0%
2. 75%
3. 50%
4. 25%
5. 100%

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

1. radial head fracture
2. radial neck fracture
3. loss of terminal extension
4. repeat dislocation
5. coronoid base fracture

PREFERRED RESPONSE ▶
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