Elbow Dislocation

Elbow dislocation is the displacement of either the radius or the ulna relative to the humerus. The most common mechanism of injury is falling on an outstretched hand Hand The hand constitutes the distal part of the upper limb and provides the fine, precise movements needed in activities of daily living. It consists of 5 metacarpal bones and 14 phalanges, as well as numerous muscles innervated by the median and ulnar nerves. Hand. Elbow dislocation presents with joint swelling, pain Pain Pain has accompanied humans since they first existed, first lamented as the curse of existence and later understood as an adaptive mechanism that ensures survival. Pain is the most common symptomatic complaint and the main reason why people seek medical care. Physiology of Pain, and restricted range of motion. Dislocation of the elbow can be classified into simple or complex depending on the absence or presence, respectively, of a concomitant fracture Fracture A fracture is a disruption of the cortex of any bone and periosteum and is commonly due to mechanical stress after an injury or accident. Open fractures due to trauma can be a medical emergency. Fractures are frequently associated with automobile accidents, workplace injuries, and trauma. Overview of Bone Fractures. Dislocations are diagnosed with an X-ray. Management depends on whether the dislocation is simple or complex. Simple dislocations are managed with joint immobilization and casting, while complex dislocations require open reduction and internal fixation. Elbow dislocations can be complicated by joint contractures, which are due to fibrotic changes in the joint capsule, or permanent joint instability, which are due to loose ligaments.

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Overview

Definition

Elbow dislocation is the displacement of either the radius or ulna relative to the humerus.

Anatomy

The elbow is a synovial hinge joint between the upper arm Arm The arm, or "upper arm" in common usage, is the region of the upper limb that extends from the shoulder to the elbow joint and connects inferiorly to the forearm through the cubital fossa. It is divided into 2 fascial compartments (anterior and posterior). Arm and the forearm Forearm The forearm is the region of the upper limb between the elbow and the wrist. The term "forearm" is used in anatomy to distinguish this area from the arm, a term that is commonly used to describe the entire upper limb. The forearm consists of 2 long bones (the radius and the ulna), the interosseous membrane, and multiple arteries, nerves, and muscles. Forearm

  • Articulation point between the humerus in the upper arm Arm The arm, or "upper arm" in common usage, is the region of the upper limb that extends from the shoulder to the elbow joint and connects inferiorly to the forearm through the cubital fossa. It is divided into 2 fascial compartments (anterior and posterior). Arm and the radius and ulna in the forearm Forearm The forearm is the region of the upper limb between the elbow and the wrist. The term "forearm" is used in anatomy to distinguish this area from the arm, a term that is commonly used to describe the entire upper limb. The forearm consists of 2 long bones (the radius and the ulna), the interosseous membrane, and multiple arteries, nerves, and muscles. Forearm
  • Consists of 3 joints, which form a functional unit enclosed within a single articular capsule:
    • Humeroulnar joint 
    • Humeroradial joint
    • Proximal radioulnar joint
  • Supported by the articular capsule as well as several ligaments:
    • Radial collateral ligament
    • Ulnar collateral ligament
    • Annular ligament of the radius
    • Interosseous membrane
  • The muscles of the elbow originate in the upper arm Arm The arm, or "upper arm" in common usage, is the region of the upper limb that extends from the shoulder to the elbow joint and connects inferiorly to the forearm through the cubital fossa. It is divided into 2 fascial compartments (anterior and posterior). Arm and insert into the forearm Forearm The forearm is the region of the upper limb between the elbow and the wrist. The term "forearm" is used in anatomy to distinguish this area from the arm, a term that is commonly used to describe the entire upper limb. The forearm consists of 2 long bones (the radius and the ulna), the interosseous membrane, and multiple arteries, nerves, and muscles. Forearm, producing flexion/extension of the elbow as well as supination/pronation of the forearm Forearm The forearm is the region of the upper limb between the elbow and the wrist. The term "forearm" is used in anatomy to distinguish this area from the arm, a term that is commonly used to describe the entire upper limb. The forearm consists of 2 long bones (the radius and the ulna), the interosseous membrane, and multiple arteries, nerves, and muscles. Forearm.

Epidemiology

  • More common in men
  • Peak incidence: 12–20 years
  • 2nd most commonly displaced joint after the shoulder

Etiology and Classification

Etiology

Trauma is the most common cause, and the direction of the force affecting the elbow joint Elbow joint The elbow is the synovial hinge joint between the humerus in the upper arm and the radius and ulna in the forearm. The elbow consists of 3 joints, which form a functional unit enclosed within a single articular capsule. The elbow is the link between the powerful motions of the shoulder and the intricate fine-motor function of the hand. Elbow Joint determines the direction of the dislocation.

  • A fall on an outstretched hand Hand The hand constitutes the distal part of the upper limb and provides the fine, precise movements needed in activities of daily living. It consists of 5 metacarpal bones and 14 phalanges, as well as numerous muscles innervated by the median and ulnar nerves. Hand (most common mechanism of injury) → elbow dislocated posteriorly
  • Medial trauma → elbow dislocated laterally
  • Lateral trauma → elbow dislocated medially
  • Posterior trauma → elbow displaced anteriorly

Classification

The classification of elbow dislocations can be anatomical or clinical.

  • The clinical classification focuses on the presence of a concomitant fracture Fracture A fracture is a disruption of the cortex of any bone and periosteum and is commonly due to mechanical stress after an injury or accident. Open fractures due to trauma can be a medical emergency. Fractures are frequently associated with automobile accidents, workplace injuries, and trauma. Overview of Bone Fractures
  • The anatomical classification focuses on the direction of the dislocation.

Clinical classification:

  • Simple elbow dislocation: no concomitant fracture Fracture A fracture is a disruption of the cortex of any bone and periosteum and is commonly due to mechanical stress after an injury or accident. Open fractures due to trauma can be a medical emergency. Fractures are frequently associated with automobile accidents, workplace injuries, and trauma. Overview of Bone Fractures
  • Complex elbow dislocation: concomitant fracture Fracture A fracture is a disruption of the cortex of any bone and periosteum and is commonly due to mechanical stress after an injury or accident. Open fractures due to trauma can be a medical emergency. Fractures are frequently associated with automobile accidents, workplace injuries, and trauma. Overview of Bone Fractures, commonly associated with “the terrible triad” of the elbow
    • Fracture of the coronoid process
    • Fracture of the radial head or neck
    • Posteriorly displaced elbow

Anatomical classification:

  • Posterior dislocation (most common)
  • Anterior dislocation
  • Medial dislocation
  • Lateral dislocation

Clinical Presentation

  • Restricted movement during elbow flexion and extension due to displaced bones
  • Swelling and pain Pain Pain has accompanied humans since they first existed, first lamented as the curse of existence and later understood as an adaptive mechanism that ensures survival. Pain is the most common symptomatic complaint and the main reason why people seek medical care. Physiology of Pain of the joint with possible erythema
  • Limb length discrepancy
    • If the elbow is displaced posteriorly, the affected extremity is shorter than the contralateral one.
    • In contrast, if the elbow is displaced anteriorly, the affected extremity is longer than the contralateral one.
  • Elbow deformity with prominent olecranon process
  • Damage to the brachial artery that can present with pain Pain Pain has accompanied humans since they first existed, first lamented as the curse of existence and later understood as an adaptive mechanism that ensures survival. Pain is the most common symptomatic complaint and the main reason why people seek medical care. Physiology of Pain, pallor, absence of pulse distal to the injury, paralysis, or paresthesia 
  • Neuropathy:
    • Which (if any) peripheral nerve is affected depends on the direction of the elbow dislocation and the presence of a concomitant fracture Fracture A fracture is a disruption of the cortex of any bone and periosteum and is commonly due to mechanical stress after an injury or accident. Open fractures due to trauma can be a medical emergency. Fractures are frequently associated with automobile accidents, workplace injuries, and trauma. Overview of Bone Fractures.
    • Nondisplaced fractures with medial elbow dislocations: associated with ulnar neuropathy with decreased sensation and strength of the 4th and 5th digits
    • Nondisplaced supracondylar fractures with anteromedial elbow dislocations: associated with median neuropathy with decreased sensation and strength of lateral 3½ digits
    • Anterolateral elbow dislocation: associated with radial neuropathy with finger drop, wrist drop, and decreased sensation on the posterior forearm Forearm The forearm is the region of the upper limb between the elbow and the wrist. The term "forearm" is used in anatomy to distinguish this area from the arm, a term that is commonly used to describe the entire upper limb. The forearm consists of 2 long bones (the radius and the ulna), the interosseous membrane, and multiple arteries, nerves, and muscles. Forearm and the dorsal hand Hand The hand constitutes the distal part of the upper limb and provides the fine, precise movements needed in activities of daily living. It consists of 5 metacarpal bones and 14 phalanges, as well as numerous muscles innervated by the median and ulnar nerves. Hand

Diagnosis

  • Physical assessment: characterized by signs and symptoms of fracture Fracture A fracture is a disruption of the cortex of any bone and periosteum and is commonly due to mechanical stress after an injury or accident. Open fractures due to trauma can be a medical emergency. Fractures are frequently associated with automobile accidents, workplace injuries, and trauma. Overview of Bone Fractures/dislocation
    • Pain on palpation
    • Visible swelling or disfigurement
    • Severely restricted motion 
    • Recent history of trauma to the elbow joint Elbow joint The elbow is the synovial hinge joint between the humerus in the upper arm and the radius and ulna in the forearm. The elbow consists of 3 joints, which form a functional unit enclosed within a single articular capsule. The elbow is the link between the powerful motions of the shoulder and the intricate fine-motor function of the hand. Elbow Joint
  • X-ray of the elbow joint Elbow joint The elbow is the synovial hinge joint between the humerus in the upper arm and the radius and ulna in the forearm. The elbow consists of 3 joints, which form a functional unit enclosed within a single articular capsule. The elbow is the link between the powerful motions of the shoulder and the intricate fine-motor function of the hand. Elbow Joint: Anteroposterior (AP) view and lateral view are obtained to confirm the dislocation.
  • CT of the elbow joint Elbow joint The elbow is the synovial hinge joint between the humerus in the upper arm and the radius and ulna in the forearm. The elbow consists of 3 joints, which form a functional unit enclosed within a single articular capsule. The elbow is the link between the powerful motions of the shoulder and the intricate fine-motor function of the hand. Elbow Joint:
    • Not always indicated when X-ray is definitive
    • Performed if a complex elbow dislocation with concomitant fracture Fracture A fracture is a disruption of the cortex of any bone and periosteum and is commonly due to mechanical stress after an injury or accident. Open fractures due to trauma can be a medical emergency. Fractures are frequently associated with automobile accidents, workplace injuries, and trauma. Overview of Bone Fractures(s) is suspected

Management

Nonsurgical management

  • Preferred for simple elbow dislocations with no concomitant fractures
  • IV analgesics 
  • Closed reduction:
    1. Elbow is first flexed at 90 degrees
    2. Elbow is then preferably pronated.
    3. Axial force is applied to the forearm Forearm The forearm is the region of the upper limb between the elbow and the wrist. The term "forearm" is used in anatomy to distinguish this area from the arm, a term that is commonly used to describe the entire upper limb. The forearm consists of 2 long bones (the radius and the ulna), the interosseous membrane, and multiple arteries, nerves, and muscles. Forearm, bringing the olecranon process into place.
  • Postreduction X-ray of the elbow joint Elbow joint The elbow is the synovial hinge joint between the humerus in the upper arm and the radius and ulna in the forearm. The elbow consists of 3 joints, which form a functional unit enclosed within a single articular capsule. The elbow is the link between the powerful motions of the shoulder and the intricate fine-motor function of the hand. Elbow Joint to ensure successful reduction and correct anatomical placement
  • Assessment of radial and ulnar pulses to exclude vascular compromise
  • Focused exam of sensation and motor strength of the affected extremity to exclude nerve entrapment
  • Immobilization of the elbow joint Elbow joint The elbow is the synovial hinge joint between the humerus in the upper arm and the radius and ulna in the forearm. The elbow consists of 3 joints, which form a functional unit enclosed within a single articular capsule. The elbow is the link between the powerful motions of the shoulder and the intricate fine-motor function of the hand. Elbow Joint with brace or splint after successful reduction

Surgical management

  • Preferred for complex elbow dislocations with concomitant fracture Fracture A fracture is a disruption of the cortex of any bone and periosteum and is commonly due to mechanical stress after an injury or accident. Open fractures due to trauma can be a medical emergency. Fractures are frequently associated with automobile accidents, workplace injuries, and trauma. Overview of Bone Fractures(s)
  • IV analgesics 
  • Open reduction internal fixation: open surgical procedure to stabilize the fractured bone Bone Bone is a compact type of hardened connective tissue composed of bone cells, membranes, an extracellular mineralized matrix, and central bone marrow. The 2 primary types of bone are compact and spongy. Structure of Bones segments and repair the collateral ligaments of the elbow
  • Postoperative X-ray of the elbow joint Elbow joint The elbow is the synovial hinge joint between the humerus in the upper arm and the radius and ulna in the forearm. The elbow consists of 3 joints, which form a functional unit enclosed within a single articular capsule. The elbow is the link between the powerful motions of the shoulder and the intricate fine-motor function of the hand. Elbow Joint to ensure successful reduction and correct anatomical placement
  • Assessment of intact radial and ulnar pulses to exclude vascular compromise
  • Focused exam of sensation and motor strength of the distal upper extremity to exclude nerve entrapment

Clinical Relevance

Elbow dislocation can commonly be observed in the following underlying conditions:

  • Radial head subluxation Radial Head Subluxation Radial head subluxation, also known as nursemaid’s elbow or babysitter’s elbow, is a frequent injury seen in children under 4 years of age and describes the subluxation of the radial head under the annular ligament at the elbow. Radial Head Subluxation (Nursemaid’s Elbow): displacement of the radial head from the annular ligament. Radial head subluxation Radial Head Subluxation Radial head subluxation, also known as nursemaid’s elbow or babysitter’s elbow, is a frequent injury seen in children under 4 years of age and describes the subluxation of the radial head under the annular ligament at the elbow. Radial Head Subluxation (Nursemaid’s Elbow) usually occurs in children when they are hung by their arms (“ nursemaid’s elbow Nursemaid’s Elbow Radial head subluxation, also known as nursemaid’s elbow or babysitter’s elbow, is a frequent injury seen in children under 4 years of age and describes the subluxation of the radial head under the annular ligament at the elbow. Radial Head Subluxation (Nursemaid’s Elbow)”). Excessive upward or outward traction on the radius will displace it from the annular ligament. Radial head subluxation Radial Head Subluxation Radial head subluxation, also known as nursemaid’s elbow or babysitter’s elbow, is a frequent injury seen in children under 4 years of age and describes the subluxation of the radial head under the annular ligament at the elbow. Radial Head Subluxation (Nursemaid’s Elbow) presents with severe pain Pain Pain has accompanied humans since they first existed, first lamented as the curse of existence and later understood as an adaptive mechanism that ensures survival. Pain is the most common symptomatic complaint and the main reason why people seek medical care. Physiology of Pain and a pronated forearm Forearm The forearm is the region of the upper limb between the elbow and the wrist. The term "forearm" is used in anatomy to distinguish this area from the arm, a term that is commonly used to describe the entire upper limb. The forearm consists of 2 long bones (the radius and the ulna), the interosseous membrane, and multiple arteries, nerves, and muscles. Forearm held close to the trunk. Management includes hyperpronation or supination until the radial head is returned into the annular ligament. 
  • Osteogenesis imperfecta Osteogenesis imperfecta Osteogenesis imperfecta (OI), or "brittle bone disease," is a rare genetic connective tissue disorder characterized by severe bone fragility. Although OI is considered a single disease, OI includes over 16 genotypes and clinical phenotypes with differing symptom severity. Osteogenesis Imperfecta: also known as “brittle bone Bone Bone is a compact type of hardened connective tissue composed of bone cells, membranes, an extracellular mineralized matrix, and central bone marrow. The 2 primary types of bone are compact and spongy. Structure of Bones disease.” Osteogenesis imperfecta Osteogenesis imperfecta Osteogenesis imperfecta (OI), or "brittle bone disease," is a rare genetic connective tissue disorder characterized by severe bone fragility. Although OI is considered a single disease, OI includes over 16 genotypes and clinical phenotypes with differing symptom severity. Osteogenesis Imperfecta is an autosomal dominant Autosomal dominant Autosomal inheritance, both dominant and recessive, refers to the transmission of genes from the 22 autosomal chromosomes. Autosomal dominant diseases are expressed when only 1 copy of the dominant allele is inherited. Autosomal Recessive and Autosomal Dominant Inheritance genetic condition caused by mutations in either the COL1A1 or COL1A2 gene. Osteogenesis imperfecta Osteogenesis imperfecta Osteogenesis imperfecta (OI), or "brittle bone disease," is a rare genetic connective tissue disorder characterized by severe bone fragility. Although OI is considered a single disease, OI includes over 16 genotypes and clinical phenotypes with differing symptom severity. Osteogenesis Imperfecta results in decreased production of otherwise normal type I collagen. Patients may present with bone Bone Bone is a compact type of hardened connective tissue composed of bone cells, membranes, an extracellular mineralized matrix, and central bone marrow. The 2 primary types of bone are compact and spongy. Structure of Bones fractures due to minimal trauma, blue sclerae due to thick choroidal connective tissue Connective tissue Connective tissues originate from embryonic mesenchyme and are present throughout the body except inside the brain and spinal cord. The main function of connective tissues is to provide structural support to organs. Connective tissues consist of cells and an extracellular matrix. Connective Tissue, teeth Teeth Normally, an adult has 32 teeth: 16 maxillary and 16 mandibular. These teeth are divided into 4 quadrants with 8 teeth each. Each quadrant consists of 2 incisors (dentes incisivi), 1 canine (dens caninus), 2 premolars (dentes premolares), and 3 molars (dentes molares). Teeth are composed of enamel, dentin, and dental cement. Teeth abnormalities due to lack of dentin, and hearing loss Hearing loss Hearing loss, also known as hearing impairment, is any degree of impairment in the ability to apprehend sound as determined by audiometry to be below normal hearing thresholds. Clinical presentation may occur at birth or as a gradual loss of hearing with age, including a short-term or sudden loss at any point. Hearing Loss due to ossicular defects. 
  • Ehlers-Danlos syndrome Ehlers-Danlos syndrome Ehlers-Danlos syndrome (EDS) is a heterogeneous group of inherited connective tissue disorders that are characterized by hyperextensible skin, hypermobile joints, and fragility of the skin and connective tissue. Ehlers-Danlos Syndrome: genetic condition with a variable Variable Variables represent information about something that can change. The design of the measurement scales, or of the methods for obtaining information, will determine the data gathered and the characteristics of that data. As a result, a variable can be qualitative or quantitative, and may be further classified into subgroups. Types of Variables mode of inheritance resulting in defective collagen. There are multiple types of Ehlers-Danlos syndrome Ehlers-Danlos syndrome Ehlers-Danlos syndrome (EDS) is a heterogeneous group of inherited connective tissue disorders that are characterized by hyperextensible skin, hypermobile joints, and fragility of the skin and connective tissue. Ehlers-Danlos Syndrome (EDS). The hypermobility type is the most common. The classic type affects type V collagen while the vascular type affects type III collagen. Patients present with hypermobile joints, hyperelastic skin Skin The skin, also referred to as the integumentary system, is the largest organ of the body. The skin is primarily composed of the epidermis (outer layer) and dermis (deep layer). The epidermis is primarily composed of keratinocytes that undergo rapid turnover, while the dermis contains dense layers of connective tissue. Structure and Function of the Skin, bleeding tendency due to vascular wall weakness, and possible organ rupture. 
  • Marfan syndrome Marfan syndrome Marfan syndrome is a genetic condition with autosomal dominant inheritance. Marfan syndrome affects the elasticity of connective tissues throughout the body, most notably in the cardiovascular, ocular, and musculoskeletal systems. Marfan Syndrome: autosomal dominant Autosomal dominant Autosomal inheritance, both dominant and recessive, refers to the transmission of genes from the 22 autosomal chromosomes. Autosomal dominant diseases are expressed when only 1 copy of the dominant allele is inherited. Autosomal Recessive and Autosomal Dominant Inheritance connective tissue Connective tissue Connective tissues originate from embryonic mesenchyme and are present throughout the body except inside the brain and spinal cord. The main function of connective tissues is to provide structural support to organs. Connective tissues consist of cells and an extracellular matrix. Connective Tissue disease caused by FBN1 gene mutation Mutation Genetic mutations are errors in DNA that can cause protein misfolding and dysfunction. There are various types of mutations, including chromosomal, point, frameshift, and expansion mutations. Types of Mutations on chromosome 15. Marfan syndrome Marfan syndrome Marfan syndrome is a genetic condition with autosomal dominant inheritance. Marfan syndrome affects the elasticity of connective tissues throughout the body, most notably in the cardiovascular, ocular, and musculoskeletal systems. Marfan Syndrome results in a defect in the fibrillin that is necessary for the normal function of elastin fibers. Patients present with tall stature, increased arm Arm The arm, or "upper arm" in common usage, is the region of the upper limb that extends from the shoulder to the elbow joint and connects inferiorly to the forearm through the cubital fossa. It is divided into 2 fascial compartments (anterior and posterior). Arm wingspan, decreased ratio of upper body to lower body, upward and temporal lens dislocation, aortic aneurysm Aneurysm An aneurysm is a bulging, weakened area of a blood vessel that causes an abnormal widening of its diameter > 1.5 times the size of the native vessel. Aneurysms occur more often in arteries than in veins and are at risk of dissection and rupture, which can be life-threatening. Extremity and Visceral Aneurysms, and chest abnormalities (e.g., pectus excavatum or pectus carinatum).

References

  1. Joseph Chorley, M.D. (2021). Elbow injuries in active children or skeletally immature adolescents: approach. UpToDate. Retrieved March 31, 2021, from https://www.uptodate.com/contents/elbow-injuries-in-active-children-or-skeletally-immature-adolescents-approach
  2. Brian R. Moore, M.D. & Joan Bothner, M.D. (2021). Radial head subluxation Radial Head Subluxation Radial head subluxation, also known as nursemaid’s elbow or babysitter’s elbow, is a frequent injury seen in children under 4 years of age and describes the subluxation of the radial head under the annular ligament at the elbow. Radial Head Subluxation (Nursemaid’s Elbow) (pulled elbow): evaluation and management. UpToDate. Retrieved March 31, 2021, from https://www.uptodate.com/contents/radial-head-subluxation-pulled-elbow-evaluation-and-management
  3. Mark E. Halstead, M.D. (2019). Elbow dislocation: Background, epidemiology, functional anatomy. Medscape. https://emedicine.medscape.com/article/96758-overview

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