Elbow dislocations occur commonly in young and can be managed conservatively

1. ELBOW
DISLOCATION
DR AJITH JOHN K

2. ▶ Simple elbow dislocation is one in which there are no associated fractures
▶ The elbow joint is the second most commonly dislocated joint in the adult
population
▶ Adolescent males are the highest-risk group

3. GROSS ANATOMY
▶ Articulations
The elbow joint is made up of three articulations
▶ Radiohumeral: capitellum of the humerus with the radial head
▶ Ulnohumeral: trochlea of the humerus with the trochlear notch (with
separate olecranon and coronoid process articular facets) of the ulna
▶ Radioulnar: radial head with the radial notch of the ulna (proximal
radioulnar joint)

4. MOVEMENTS
▶ The elbow is a trochoginglymoid (combination hinge and pivot) joint
▶ the hinge component (allowing flexion-extension) is formed by the
ulnohumeral articulation
▶ the pivot component (allowing pronation-supination) is formed by the
radiohumeral articulation and the proximal radioulnar joint

5. LIGAMENTS
▶ medial (ulnar) collateral ligament complex
▶ lateral (radial) collateral ligament complex
▶ oblique cord
▶ inconstant thickening of supinator muscle fascia and functionally insignificant
▶ runs from tuberosity of the ulna to just distal to radial tuberosity
▶ quadrate ligament (of Denuce)
▶ thickening of the inferior aspect of the joint capsule
▶ runs from just inferior to the radial notch of the ulna to insert to the medial
surface of the radial neck

6. PATHOANATOMY AND APPLIED
ANATOMY
▶ soft tissue restraints can be divided into both static and dynamic stabilizers
▶ static stabilizers
joint capsule and the LCLs and MCLs

7. LCL
▶ Primary varus and posterolateral rotational stabilizer
▶ LCL has three components-
The radial collateral ligament
annular ligament
The lateral ulnar collateral ligament

8. ▶ The radial head is surrounded by the annular ligament which attaches to
the anterior and posterior margins of the radial notch of the proximal ulna
▶ The radial collateral ligament arises from the lateral epicondyle and blends
with the annular ligament
▶ The lateral ulnar collateral ligament is posterior to the radial collateral
ligament

9. ▶ MCL consists of the anterior and posterior bundles
▶ The anterior bundle is the key valgus stabilizer of the elbow, arising from
the anteriorinferior aspect of the medial epicondyle to insert on the
sublime tubercle of the proximal ulna
▶ The posterior bundle provides a secondary restraint to valgus load and
also resists ulnar rotation

11. Dynamic restraints
▶ Biceps, brachialis, and triceps

12. ▶ Patients with simple elbow dislocations routinely have disruption of both
the MCL and LCL and the elbow capsule
▶ The muscular origins may be disrupted as well; typically the injury to the
lateral common extensor origin is more extensive than the medial common
flexor origin
▶ Most activities of daily living exert a varus force on the elbow than a valgus
force, residual instability is usually due to incompetence of the LCL in the
majority of patients

13. ▶ The radial head causes an impression fracture of the posterior capitellum
which can contribute to recurrent instability

14. Mechanisms of Injury
▶ Fall on an outstretched hand
▶ The soft tissue injury is thought to begin on the lateral side of the elbow
with disruption of the lateral collateral ligament (LCL) and then proceeds
through the capsule to the medial side with the medial collateral ligament
(MCL) being injured last

16. Associated Injuries
▶ Simple elbow dislocations are not associated with fractures
▶ Disruption of the collateral ligaments, elbow capsule, and forearm flexor
and extensor muscle origins
▶ Injury to the brachial artery has been described in closed simple
dislocations and nerve palsies are possible
▶ The ulnar nerve is the most commonly injured nerve following elbow
dislocation

17. Signs and Symptoms
▶ Obvious deformity and pain about the affected elbow
▶ Elbow flexed to 90 degrees, the medial and lateral epicondyles and the
olecranon process should form an isosceles triangle
▶ Complete peripheral neurologic examination should be performed

18. Imaging and Other Diagnostic Studies
▶ Anteroposterior, lateral, and oblique radiographs are used to diagnose
elbow dislocation and help to rule out associated fractures
▶ Although rarely required in practice, a line drawn along the anterior
margin of the humerus (anterior humeral line) and one along the long axis
of the radius should intersect near the centre of the capitellum

19. ▶ Computed tomography (CT) scanning is rarely needed but can be useful if
there is a questionable associated fracture

20. ▶ MRI is not needed unless there is concern for ulnar nerve entrapment in
the joint since the pathology of the soft tissue injury associated with elbow
dislocations has been well established

21. CLASSIFICATION
▶ Based on the direction of dislocation
▶ Simple versus complex
displacement of the ulna relative to the humerus
Posterior ■ Posterolateral ■ Posteromedial ■ Lateral ■ Medial ■ Anterior

23. Post

24. Medial

25. Outcome Measures
▶ DASH and the Oxford Elbow Questionnaire

26. Fracture-Dislocations
▶ Associated radial head fracture
▶ Medial or lateral epicondyle fracture
▶ Coronoid process fracture

27. INJURY PATTERNS
▶ Posterior dislocation with a fracture of the radial head
▶ Posterior dislocation with fractures of the radial head and coronoid
process—the so-called “terrible triad” injury
▶ Varus posteromedial rotational instability pattern injuries associated with
anteromedial facet of the coronoid fractures
▶ Anterior olecranon fracture-dislocations
▶ Posterior olecranon fracture-dislocations

28. TYPES OF ELBOW INSTABILITY
Posterolateral rotatory instability (elbow dislocations with or without
associated fractures)
Varus posteromedial rotational instability (anteromedial coronoid facet
fractures)
Olecranon fracture-dislocations

29. TREATMENT

30. NONOPERATIVE TREATMENT
▶ The majority of simple elbow dislocations can be treated nonoperatively
with closed manipulative reduction evaluation of stability and an early
rehabilitation program

31. TECHNIQUES-PARVINS METHOD
▶ The medial and lateral epicondyles are palpated and their relationship to
the olecranon is determined in order to first correct and medial/lateral
displacement in the coronal plane
▶ The elbow is typically flexed to approximately 30 degrees, and traction is
placed through the forearm while stabilizing the humerus
▶ Direct pressure over the olecranon may help to guide it over the distal
humerus and into joint
▶ Supination of the forearm may be helpful to gain the reduction

33. ▶ After reduction-the elbow is taken through an arc of flexion– extension in
pronation, neutral, and supination in order to evaluate for residual
instability
▶ The elbow redislocates when flexed to less than 30 degrees, operative
treatment should be considered
▶ Most patients will have varus–valgus instability

34. ▶ The elbow is then immobilized in a light plaster splint with the forearm in
st
pronation, neutral, or supination (depending on the position of maximal
ability) and the elbow at 90 degrees of flexion
Radiographs are performed to ensure a congruous reduction has been
achieved and to evaluate for the presence of fractures not visualized on the
prereduction radiographs

35. ▶ Immobilization greater than 3 weeks should be avoided as this has been
demonstrated to cause an increased incidence of stiffness and poorer
functional outcomes

36. OUTCOMES
▶ Several studies have reported good to excellent outcomes in the majority
of patients after simple elbow dislocation
▶ Prolonged immobilization after injury was associated with a worse result
with increasing duration of immobilization leading to increased flexion
contracture and more severe residual pain: In general, prolonged
immobilization is to be avoided in this setting

37. OPERATIVE TREATMENT
▶ The main indication for operative management of simple elbow
dislocations is an inability to maintain a concentric elbow joint after closed
reduction or a recurrent dislocation
▶ irreducible dislocations are also indications for operative treatment but
these are rare injuries

38. SURGICAL PROCEDURE
▶ Patient is placed supine on the operating table with a radiolucent arm
table on the affected side
▶ Preoperative examination of the shoulder should be performed to be sure
that there is adequate external rotation of the shoulder in order to
approach the medial side of the elbow

39. ▶ Surgical Approach-posterior midline incision is employed and a full
thickness lateral flap is elevated on the deep fascia
▶ If the medial structures require repair, full thickness elevation of the medial
flap is performed

40. Soft Tissue Repair
▶ Vast majority of cases, a medial ligament repair is not required and the
surgery is complete
▶ The lcl can be repaired using transosseous bone tunnels or suture anchors
▶ Locking krackow stitches are placed in the lcl while a second suture is
placed in the extensor fascia

42. ▶ In the unusual setting that the elbow remains unstable in spite of repair of
the lateral structures, the medial side of the elbow is approached with care
taken to protect the ulnar nerve
▶ The flexor–pronator muscles are also repaired if they have been avulsed
▶ elbow is still unstable, then a static or hinged external fixator should be
placed or, as a last resort, the elbow should be transfixed with a screw or
robust Steinman pin

43. EXTERNAL FIXATION
▶ A hinged fixator will allow for range of motion exercises to be performed
while the external fixator is in place and should be considered if the
surgeon has access to this and the experience to apply it
▶ Static fixators are easier to apply and are more widely available
▶ The key to all hinged devices is an understanding of the axis of elbow
rotation
▶ Two pins are placed in the humeral shaft laterally and two pins are placed
in the ulnar shaft laterally in a position that allows for forearm rotation

44. ▶ Open pin placement is recommended to avoid injury to the radial nerve
▶ A static frame is assembled with the elbow joint reduced
▶ The external fixator is left in place for approximately 4 weeks and then a
range of motion protocol is initiated as outlined above for closed
treatment

46. ▶ Bridge Plate
Indications are conditions where maintenance of reduction is challenging
such as morbid obesity and patients with neurologic injuries such as spasticity
or flaccid paralysis
triceps-splitting approach
Three to four locking screws are placed in the ulna and the distal humerus
avoiding the articulation and fossae

47. ▶ The plate is removed at 4 weeks, and a posterior capsulectomy and an
elbow manipulation can be considered at the time of plate removal to
increase the recovery of motion

48. ADVERSE OUTCOMES

50. COMPLICATIONS
▶ Loss of motion (stiffness): Stiffness following complicated or
uncomplicated elbow dislocation is usually the rule. Immobilization of the
elbow should generally not go beyond 2 weeks

51. ▶ Compartment syndrome (Volkmann contracture): This may result from
massive swelling due to soft tissue injury

52. ▶ Persistent instability/redislocation: This is rare after isolated,
traumatic posterior elbow dislocation; the incidence is increased in the
presence of an associated coronoid process and radial head fracture
(terrible triad of the elbow)

53. THANK U