1) Elbow dislocations are most commonly posterior dislocations, which occur due to a combination of hyperextension, valgus stress, arm abduction, and forearm supination. 2) Treatment depends on whether the dislocation is simple or complex, with associated fractures or ligament injuries requiring operative management like open reduction and repair of soft tissues. 3) The terrible triad of elbow injuries involves a dislocation with fractures of the radial head and coronoid process, requiring restoration of stability through fixation of the fractures and repair of collateral ligaments.

1. ELBOW DISLOCATION
Dr. HARSHA NANDINI TALASILA
M.S ORTHO

2. • Incidence :11 to 28%of elbow injuries
• POSTERIOR DISLOCATION is common

3. ANATOMY OF ELBOW JOINT
• Modified Hinge joint
• ULNOTROCHLEAR(HINGE)
• RADIOCAPITELLAR JOINT(ROTATION)
• PROXIMAL RADIOULNAR(ROTATION)

4. CAPSULOLIGAMENTOUS ANATOMY
The static soft tissue stabilizers
• the anterior and posterior joint capsule
• the medial and LCL complexes.
• The collateral ligament complexes are medial and lateral capsular
thickenings

5. MCL COMPLEX
3 components:
• the anterior bundle or anterior MCL,
• the posterior bundle,
• the transverse ligament
• The origin of the MCL is at the anteroinferior surface of the medial
epicondyle.

6. LCL COMPLEX
four components
• radial collateral ligament,
• the lateral ulnar collateral ligament,
• the annular ligament,
• the accessory collateral ligament
• The LCL complex originates along the inferior surface of the lateral
epicondyle.

7. STABILITY OF ELBOW JOINT
ANTERO-POSTERIOR
TROCHLEAR-OLECRANON PROCESS :during extension.
RADIO-CAPITELLAR,CORONOID FOSSA,BICEPS-TRICEPS-BRACHIALIS:
during flexion.

8. VALGUS:
MEDIAL COLLATERAL LIGAMENT
COMPLEX:
Anterior Band: in flexion and
extension
Anterior capsule in extension

9. VARUS:
The lateral ulnar collateral ligament is static stabilizer
Anconeus : dynamic stabilizer

10. NORMAL ROM
FLEXION:0-150 degrees
SUPINATION:80 degrees
PRONATION: 85 degrees

11. MECHANISM OF INJURY
• Fall on outstretched hand or elbow: levering force to unlock the
olecranon from the trochlea

12. POSTERIOR DISLOCATION
• Combination of Elbow
hyperextension, valgus stress, arm
abduction, forearm supination

13. ANTERIOR DISLOCATION
• A direct force strikes the
posterior forearm with the elbow
in a flexed position

14. HORI CIRCLE
• The capsuloligamentous injury
progresses from lateral to
medial

15. CLINICAL FEATURES
• Pain and Swelling of the elbow
• Careful neurovascular assessment must be done.
• 3 point bony relationship is lost.

16. ASSOSCIATED INJURIES
• Radial head
• Coronoid process of ulna
• Ulnar nerve
• Anterior interosseous branch of median nerve
• Brachial artery

17. RADIOGRAPHIC EVALUATION
• AP AND LATERAL VIEW
• VALGUS STRESS VIEW:30degrees elbow flexion,full forearm pronation
To see MCL ligamentous complex injury

18. CLASSIFICATION
• Simple: no assosciated fractures or ligamentous injuries
• Complex: assosciated with ligamentous injury

19. BASED ON DIRECTION
• POSTERIOR
• POSTERIOMEDIAL
• ANTERIOR
• LATERAL
• MEDIAL

21. FRACTURE-DISLOCATION
• Assosciated radial head fractures
• Medial and lateral epicondyle fractures
• Coronoid process

22. ELBOW INSTABILITY
• MORREY’S INSTABILITY SCALE:
1. Type 1:posterolateral rotational instability: lateral ulnar collateral
ligament disrupted.
2. Type 2: perched condyles, Varus instability, lateral ulnar collateral
ligament,anterior and posterior capsule disrupted
3. Type 3a: posterior dislocation : valgus instability; lateral ulnar
collateral, anterior and posterior capsule and posterior MCL
disrupted
4. Type 3b: posterior dislocation: lateral ulnar collateral, anterior and
posterior capsule and posterior MCL and anterior MCL disrupted

24. TREATMENT

25. PARVIN’S METHOD
• Patient in prone
• Gentle downward traction of the
wrist for few minutes
• As the olecranon fossa begins to
slip distally, physician lifts up gently
on arm.

26. MEYN and QUIGLEY’S Method
• Only forearm hangs from the
stretcher.
• Gentle downward traction of the wrist
with reduction of the olecranon with
the opposite hand.

27. • Elbows that are stable through out ROM : splint at 90degrees flexion
for 3 to 5 days followed by placement of hinged orthoses ,which
allows for a protected full ROM.
• Subluxation or impending dislocation at 30 degrees or more flexion
indicates instability and surgical stabilization is needed.

28. • If instability is present in less than 30 degrees of elbow flexion, one
should pronate the forearm and reassess the stability.
• If pronation confers elbow stability, the extremity should be splinted
with the elbow flexed 90degrees and the forearm pronated for 3 to 5
days followed by hinged orthoses that maintains forearm pronation.
• Elbows that sublux in less than 30 degrees of flexion and full forearm
pronation : splint the elbow in flexion at 90 degrees and forearm
pronated ,followed by placement of hinged orthoses with forearm
rotational control and an extension block

29. OPERATIVE MANAGEMENT
• INDICATIONS:
1. When the elbow cannot be held in a concentrically reduced
position, redislocates before post reduction x-rays, dislocates later
in spite of splint immobilization, the dislocation is deemed unstable.
2. A large displaced coronoid fragment.
3. Radial head fractures.

30. • Open reduction and repair of the soft tissues
• Lateral collateral ligament is reattached using suture anchors or bone
tunnels
• If instability is present after LCL repair then MCL repair must be
addressed.
• If persistent instability is present: HINGED EXTERNAL FIXATION is
done.

31. TERRIBLE TRIAD OF ELBOW

32. TREATMENT OF TERRIBLE TRIAD
PRINCIPLES OF TREATMENT:
1. Restore coronoid stability through fracture fixation of type 2 and
type 3 fractures, through anterior capsular repair of type 1 fracture
2. Restore radial head stability through fracture fixation or
replacement with a metal prosthesis.
3. Restore lateral stability through repair of the lateral collateral
ligament complex and associated secondary constrains such as
common extensor origin and or posterolateral capsule.

33. 4. Repair the medial collateral ligament in patients with posterior
instability
5. Apply a hinged external fixator when the conventional repair does
not establish sufficient joint stability to allow early motion.

34. FIXATION STRATEGY
• From deep to superficial
1. Fixation of coronoid
2. Anterior capsule repair
3. Radial head fixation or replacement
4. Lateral collateral ligament repair
5. Common extensor origin
reattachment.

36. COMPLICATIONS
• Loss of motion(stiffness of elbow)
• Neurologic compromise: ulnar nerve
Exploration is done if there is no recovery after 3months
• Vascular injury: brachial artery
• Compartment syndrome( Volkmann contracture )
• Persistent instability/ redislocation
• Arthrosis

37. Heterotopic bone/ Myositis ossificans
• SITE:
Anteriorly :between brachialis muscle
and anterior capsule
Posteriorly: between triceps and
posterior capsule
• CAUSE:
Due to multiple reduction attempts
A greater degree of soft tissue
trauma
Associated fractures

38. • REFERENCES:
• Kenneth A Egol, Kenneth J Koval,Joseph D Zuckerman Handbook of
fractures.
• Campbell’s Operative Orthopaedics,volume 3,13th edition

39. THANK YOU