REVISTA MEDICINA LEGAL DE COSTA RICA Vol. 36 (2) Septiembre 2019

REVISTA MEDICINA LEGAL DE COSTA RICA

ISSN 2215-5287

166

A case of elbow dislocation

Un caso de dislocación de codo

Gurmeet Singh Sarla

1. Classified Specialist in Surgery, Military Hospital Devlali Cantt Nasik Maharashtra

India

Dr Gurmeet Singh Sarla --rijak1@gmail.com

Recibido: 20-02-2019 Aceptado:10-VII-2019

Abstract

The elbow joint is a stable joint and a significant force is required to disrupt the joint. The elbow joint is

the second most commonly dislocated joint. A 29 years old male sustained a fall on outstretched hand and

presented with pain, swelling , deformity and inability to move his Right elbow. Closed Reduction was done

followed by immobilisation for 3 weeks and thereafter range of movement exercises of the elbow joint.

Neurovascular complications , associated fracture around the elbow joint and instability of the joint should

be looked for. Associated fractures which are difficult to see on plain X Rays can go for Computerized

tomography and unstable fractures where damage to the ligamentous complex is suspected should undergo

an Magnetic Resonance imaging study of the involved joint.

Key words

Simple dislocation, elbow joint, elbow dislocation.

Introduction

The elbow joint is the second most commonly dislocated joint in adults after dislocation of the shoulder

joint. The annual incidence of simple and complex elbow dislocations is 6.1 per 100,000

. Elbow

dislocations are classified as simple or complex types

. The simple dislocation is characterised by the

absence of fractures, while the complex dislocation is associated with intra-articular fractures of the radial

head and coronoid process. This injury frequently occurs during sporting activities when a person falls on

an extended elbow. Elbow dislocation is usually posterior and the semilunar notch of the ulna is dislocated

posteriorly from the distal humerus. The elbow joint is a stable joint and a significant force is required to

disrupt the joint. Neurovascular complications are rare. The less encountered anterior elbow dislocation

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requires much more force. A dislocated elbow requires immediate closed reduction to prevent

complications.

Case report

A 29 years old male sustained a fall on outstretched hand from two wheeler and presented to the department

of General Surgery at a peripheral hospital in Nasik, Maharashtra, India with pain, swelling , deformity and

inability to move his Right elbow. Imaging in the form of X Ray Right elbow revealed a dislocated elbow.

Closed Reduction was done under General Anaesthesia and Congruity of the bones forming the elbow joint

was achieved which was confirmed on check X Ray Right elbow. He was offered immobilisation of the

elbow joint in the form of above elbow Posterior slab for 3 weeks followed by active and passive elbow

movements to achieve full range of movements at the elbow joint. He was advised to consult an

Orthopaedician after discharge from the hospital.

Figure 1. X-ray of right elbow dislocated and clinical appereance

Figure 2. X-ray and clinical appereance after closed reduction.

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Discussion

The elbow represents one of the most stable joints in the human body. Despite its name, simple elbow

dislocation is a complex injury of the capsule-ligamentous structures. Typically, simple elbow dislocations

occur when a person falls onto an outstretched hand. Complex dislocation is associated with intra-articular

fractures of the radial head and coronoid process. Elbow dislocations are classified by the direction of their

displacement. Most of the elbow dislocations are posterior dislocations and anterior elbow dislocations are

rare.

In 58% of patients, the simple elbow dislocations were on the non-dominant side3. Following reposition

and treatment in plaster of simple dislocations, recurrent dislocations and chronic instability are not or only

rarely seen2.

Etiology: A posterior elbow dislocation often occurs when a person falls on an outstretched hand. Anterior

elbow dislocations occur when the elbow is flexed, and there is a direct blow on the posterior aspect of the

elbow.

Epidemiology: Elbow dislocation is the most common joint dislocation in paediatric patients and the second

most common in adult patients. The injury more often occurs in adolescent male athletes. Footballers and

wrestlers are prone to this injury. Posterior elbow dislocations comprise 90% of all elbow dislocations4.

Anatomy: The elbow joint is a highly congruent articulation that confers substantial bony stability5. The

coronoid process enhances stability particularly in flexion and the contact area of the radio-capitellar joint

increases with flexion6.The medial collateral ligament and the lateral collateral ligament complex (including

the lateral ulna collateral ligament (LUCL)) are the primary stabilisers. These are complemented by the

secondary stabilisers; the radial head, the joint capsule and the common flexor and extensor origins. This is

also augmented by dynamic stability provided by the muscles crossing the elbow joint.

Pathophysiology: The brachial artery and ulnar and median nerves are particularly susceptible to injury

because the anterior compartment is often disrupted during posterior dislocation. The ulnar nerve may

become entrapped as it passes posteriorly around the medial epicondyle. Anterior dislocations are often

associated with olecranon fractures and may also disrupt the posterior elbow compartment which contains

the radial nerve.

History: History includes the details of mechanism of injury. The patient should be asked if there have been

previous elbow injuries in the past. The patient should be asked about the symptoms suggesting a

neurovascular compromise and inquire about numbness, tingling or coolness of the distal extremity.

Local Examination: The elbow joint should be inspected for swelling, deformity or bruising. Posterior

elbow dislocations often present with an upper extremity that is flexed and appears shortened. Anterior

elbow dislocations are held in extension, and the upper extremity appears elongated. Open wounds would

suggest a complex dislocation. The functionality of the elbow joint should be assessed by observing a range

of movements.

Neuro-vascular damage: The most common neurovascular structures injured during an elbow dislocation

include the brachial artery , ulnar nerve and median nerve. Radial and ulnar pulses should be palpated .

Median nerve sensation can be assessed by a light touch of the palmar aspect of the thumb and index finger.

Median motor function is tested by observing the strength of thumb opposition. A light touch on the palmar

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aspect of the ring and little fingers can assess ulnar sensation. The ulnar motor function is tested by observing

the strength of finger abduction and adduction.

Imaging: Plain Radiographs of elbow joint taking anterior-posterior , lateral and oblique views help

evaluate joint congruency and associated fractures. Computerized tomography may be considered to

identify periarticular fractures not easily seen on plain radiographs.

Treatment: Initial treatment of simple, closed posterior elbow dislocations is closed reduction. Complex

elbow dislocations require open reduction and internal fixation. Open dislocations require extensive

washout during an open reduction. Any dislocation with signs of neurovascular compromise requires

immediate closed reduction7.

There are two common approaches to the reduction of a posterior elbow dislocation. The first technique is

attempted with the patient lying down in the prone position. The affected arm is abducted with an elbow on

the edge of the cart. The wrist is then grasped and the forearm placed in slight supination while gentle

traction is applied. The coronoid process must be distracted and disengaged from the olecranon fossa. Once

this has been accomplished downward pressure with the other hand on the olecranon should reduce the

dislocation with the operator feeling a confirmatory clunk. A two-person technique is also described where

one operator applies downward traction at the wrist, and other applies the downward force onto the

olecranon with both their thumbs.

The alternative method is performed with the patient seated or lying supine on the cart. An assistant

stabilizes the affected humerus while the operator flexes the elbow, supinates the wrist slightly and applies

distal and downward traction at the wrist with one hand. The other hand is placed just distal to the elbow on

the volar aspect of the forearm applying slow, gentle inline traction until the confirmatory clunk is

appreciated.

Following reduction, a neurovascular examination should be performed to identify improvement in any

previous neurovascular symptom or a new symptom that may have manifested following the reduction. The

elbow should be held in 90 degrees of flexion for about 3 weeks of splinting and a specific range of motion

plan thereafter.

After reduction of the elbow joint, targeted clinical examination should be performed in order to ascertain

and record the severity of the injury and assess whether an MRI is needed for further diagnosis.

Conclusion

Simple elbow dislocations are a commonly seen injury within orthopaedic practice and expedient closed

reduction and early active mobilisation usually results in excellent or good long-term functional outcomes.

Elbow dislocation is usually posterior. Neurovascular complications are rare. A dislocated elbow requires

immediate closed reduction to prevent complications.MRI can identify those that may require surgical

intervention.

References

1. Josefsson PO, Nilsson BE (1986) Incidence of elbow dislocation. Acta Orthop Scand 57(6):537–

538

2. Hildebrand KA, Patterson SD, King GJ (1999) Acute elbow dislocations: simple and complex.

Orthop Clin North Am 30(1):63–79

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3. Josefsson PO, Johnell O, Gentz CF (1984) Long-term sequelae of simple dislocation of the elbow.

J Bone Joint Surg Am 66(6):927–930

4. Tomori Y, Nanno M, Takai S. Posteromedial elbow dislocation with lateral humeral condylar

fracture in children: Three case reports and a literature review. Medicine (Baltimore). 2018

Sep;97(36):e12182.

5. Miyasaka KC. Anatomy of the elbow. Orthop Clin North Am 1999; 30: 1–13.

6. Werner FW, An KN. Biomechanics of the elbow and forearm. Hand Clin 1994; 10: 357–373.

7. Cho CH, Kim BS, Rhyou IH, Park SG, Choi S, Yoon JP, Choi CH, Dan J. Posteromedial Elbow

Dislocations without Relevant Osseous Lesions: Clinical Characteristics, Soft-Tissue Injury

Patterns, Treatments, and Outcomes. J Bone Joint Surg Am. 2018 Dec 05;100(23):2066-207

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