AUTHOR AND EDITOR INFORMATION

Section 1 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

INTRODUCTION

Section 2 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

Background

The elbow joint displays an elegant balance between stability and mobility. While allowing a wide range of motion, the joint has an inherent stability that requires a considerable force to dislocate. As a result, a significant percentage—approximately one third of elbow dislocations—are associated with fractures of bony components of the elbow. Dislocations without associated fracture are termed simple, while dislocations with accompanying fracture are termed complex.

Dislocations of the elbow fall in frequency just behind dislocations of the finger and shoulder. Most commonly, the elbow dislocates posteriorly. Immediate reduction is essential to reduce the risk of neurovascular or cartilaginous complications.

Pathophysiology

Both posterior dislocations and anterior dislocations can occur.

Posterior dislocations

A fall onto an extended abducted arm is the mechanism of injury seen in posterior dislocations of the elbow. An example of this is someone rollerblading who, falling backward, extends an arm behind to break the fall. Posterior dislocations account for most elbow dislocations. Closed posterior dislocations are not commonly associated with neurovascular injury.

Anterior dislocations

A strong blow to the posterior aspect of a flexed elbow may result in anterior dislocation of the elbow. This force drives the olecranon forward in relation to the humerus. Anterior dislocations and any open fracture are commonly associated with disruption of the brachial artery and/or injury to the median nerve.

Sex

Elbow dislocation injuries occur more often in males than in females.

Age

Dislocations occur more commonly in adults, since the same force in children more often results in a supracondylar fracture of the distal humerus.

CLINICAL

Section 3 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

History

Obtain history that includes the mechanism of injury, type and location of pain, amount of immediate dysfunction, treatment prior to arrival in the emergency department, timing of effusion appearance, and history of prior elbow injury.

• Mechanisms - A fall onto an extended, abducted arm (posterior) or a direct blow to a flexed elbow (anterior)
• Pain - Intense, focused around the elbow joint
• Extremely limited range of motion
• Effusion

Physical

• Posterior dislocations: Elbow is flexed, with an exaggerated prominence of the olecranon. On palpation, the olecranon is displaced from the plane of the epicondyles (as opposed to a supracondylar fracture, in which the epicondyles are palpable in the same plane as the olecranon).
• Anterior dislocations: The elbow is held in full extension. The upper arm appears shortened, while the forearm is elongated and held in supination.
• Neurovascular function should be documented in detail before and after reduction. Continued repeated examination is essential.

DIFFERENTIALS

Section 4 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

WORKUP

Section 5 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

Imaging Studies

• Radiography
• • Plain radiographs are essential prior to reduction of the suspected dislocation.
  • Postreduction films should confirm opposition of the joint surfaces and should rule out previously unidentified fractures or entrapment of bony fragments within the joint space.

Other Tests

• Arteriography should be performed for cases of suspected vascular injury.

TREATMENT

Section 6 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

Prehospital Care

Prehospital personnel should splint the limb in the position found. Because of the risk of neurovascular injury, field reduction is not recommended. Successful reduction is usually unsuccessful without adequate analgesia and sedation. Patients with neurovascular compromise should be transported rapidly to the closest facility.

Emergency Department Care

• Early reduction is essential, since delay may increase risk of neurovascular compromise or damage to articular cartilage.
• The emergency physician should attempt reduction after obtaining appropriate radiologic studies if evidence of vascular compromise is noted or if orthopedic consultation is delayed significantly.
• The following 2 methods commonly are used for posterior elbow reductions. Be certain that the patient has received adequate analgesic and sedative medications before beginning either procedure.
• • With the elbow flexed to 90 degrees and supinated, apply posterior pressure to the humerus while a second operator applies downward pressure on the proximal forearm. A coupling is felt and heard as the capitellum slides over the coronoid process and the joint realigns.
  • The second method (the Parvin method) involves placing the patient in the prone position with the humerus resting on the table and the forearm hanging perpendicular to the plane of the table. The humerus should be supported by the table, with padding, just proximal to the elbow joint. Apply 5-10 lb of weight to the wrist or gently pull down at the wrist. Reduction should occur over a period of minutes as the muscles relax. The physician may guide the olecranon into place if necessary.
• Anterior dislocation reduction is performed with distal traction on the wrist and backward pressure on the forearm. Take care to avoid hyperextension at the elbow, which may cause traction and potential injury to neurovascular structures around the elbow.
• Postreduction neurovascular check should always be performed as the brachial artery and the median and ulnar nerves can become entrapped with manipulation.
• A failed closed reduction is indicative of an entrapped medial epicondyle or an inverted cartilaginous flap.

Consultations

• Emergent orthopedic consultation should be sought for all patients with elbow dislocations.
• Vascular surgery consultation may be needed in patients with possible vascular injury.

MEDICATION

Section 7 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

Analgesics and anxiolytics are used to treat the pain associated with dislocations.

Drug Category: Analgesics

Pain control is essential to quality patient care. It ensures patient comfort, promotes pulmonary toilet, and aids physical therapy regimens. Many analgesics have sedating properties that benefit patients who have sustained injuries.

Drug Category: Anxiolytics

Patients with painful injuries usually experience significant anxiety. Anxiolytics allow the clinician to administer a smaller analgesic dose to achieve the same effect.

FOLLOW-UP

Section 8 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

Further Inpatient Care

• Indications for admission with frequent neurovascular assessment include the following:
• • Children
  • Unreliable patients
  • Extensive edema
  • Evidence of neurovascular compromise either before or after reduction

Further Outpatient Care

• Following reduction, splint elbow in at least 90 degrees of flexion using a posterior molded splint.
• Arrange close follow-up care with the orthopedic surgeon.

Transfer

• Patients with dislocations of the elbow should not be transferred until the elbow has been reduced.
• In hospitals without access to an orthopedic surgeon, reduction should be performed by the emergency physician prior to transfer.

Complications

• Brachial artery injury
• Medial nerve injury
• Ulnar nerve injury
• Concomitant fractures
• Avulsion of the triceps mechanism insertion (anterior dislocation only)
• Entrapment of bone fragments within the joint space
• Joint stiffness with decreased range of motion (particularly in extension)
• Myositis ossificans
• Compartment syndrome

Prognosis

• Up to 10 degrees limitation in full extension and some limitation in flexion are common, unless an intensive rehabilitation program is instituted.

Patient Education

• For excellent patient education resources, visit eMedicine's Breaks, Fractures, and Dislocations Center. Also, see eMedicine's patient education articles, Elbow Dislocation and Broken Elbow.

MISCELLANEOUS

Section 9 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

Medical/Legal Pitfalls

• Failure to find vascular injury: Presence of a distal pulse does not exclude arterial injury. Severe disruption of the joint results in brachial artery injury in 8% of patients. This complication should be suspected in cases of extreme force, massive swelling, or wide separation of the joint noted on physical or radiologic examination.
• Failure to find nerve entrapment: Loss of median nerve function after reduction should raise the concern of likely nerve entrapment. Immediate orthopedic consult is needed in these cases for operative intervention.
• Failure to detect spontaneous reduction: Elbow dislocations can reduce spontaneously, presenting a diagnostic dilemma to the emergency physician. A high degree of suspicion is necessary to avoid overlooking the complications associated with elbow dislocations.

REFERENCES

Section 10 of 10

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

• Ali FM, Krishnan S, Farhan MJ. A case of ipsilateral shoulder and elbow dislocation: an easily missed injury. J Accid Emerg Med. May 1998;15(3):198. [Medline].
• Bell S, Salmon J. The management of common dislocations in the upper limb. Aust Fam Physician. Sep 1996;25(9):1413-5, 1418-23, 1425, passim. [Medline].
• Cohen MS, Hastings H. Acute elbow dislocation: evaluation and management. J Am Acad Orthop Surg. Jan-Feb 1998;6(1):15-23. [Medline].
• Gillingham BL, Wright JG. Convergent dislocation of the elbow. Clin Orthop Relat Res. Jul 1997;(340):198-201. [Medline].
• Haddad FS, Cobiella CE. Isolated radial head dislocation in an adult: case report and review of the literature. J R Coll Surg Edinb. Jun 1997;42(3):207; author reply 208. [Medline].
• Hems TE. Isolated radial head dislocation in an adult: case report and review of the literature. J R Coll Surg Edinb. Jun 1997;42(3):207. [Medline].
• Maxwell AJ. Isolated radial head dislocation in an adult: case report and review of the literature. J R Coll Surg Edinb. Jun 1997;42(3):207-8. [Medline].
• Noyez JF. Isolated traumatic posterior dislocation of the radial head: a report on two cases. Acta Orthop Belg. Sep 1996;62(3):148-50. [Medline].
• Rettig AC. Elbow, forearm and wrist injuries in the athlete. Sports Med. Feb 1998;25(2):115-30. [Medline].
• Ring D, Jupiter JB. Fracture-dislocation of the elbow. J Bone Joint Surg Am. Apr 1998;80(4):566-80. [Medline].
• Sachar K, Mih AD. Congenital radial head dislocations. Hand Clin. Feb 1998;14(1):39-47. [Medline].
• Shearman CM, el-Khoury GY. Pitfalls in the radiologic evaluation of extremity trauma: Part I. The upper extremity. Am Fam Physician. Mar 1 1998;57(5):995-1002. [Medline].
• Sugimoto M, Yoshida T, Kitano K, Hosoya T, Tada K. Voluntary dislocation of the radial head. J Shoulder Elbow Surg. May-Jun 1996;5(3):228-30. [Medline].

Article Last Updated: Aug 15, 2007