7. elbow dislocations

8/9/2019 7. Elbow Dislocations

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Anatomy

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The Elbow Jointy The elbow joint, although a single

synovial cavity, is made up of threedistinct articulations, which are:

y 1.humero-ulnar : between the

trochlea of the humerus and thetrochlear notch of the ulna (a hinge-joint);

y 2.the humeroradial: between thecapitulum and the upper concavesurface of the radial head (a ball andsocket joint);

y 3.superior radio-ulnar between

the head of the radius and the radialnotch of the ulna, the head beingheld in place by the tough annularligament (a pivot joint).

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MovementsTwo sets of movements take

place at the elbow:

1. Flexion and extension:at the humero-ulnar and

humero-radial joints

2. Pronation and supination:at the proximal radio- ulnarand distal radio-ulnar joint.

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Rang

eof

Mov

em

ents

(ROM)y FLEXION/EXTENSION:

Normal ROM: 0-145 degrees

Functional ROM: 30-130 degrees

y SUPINATION/PRONATION:

Normal-80 degrees each way

Functional ROM is 50 degrees each way

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Dislocation Elbow

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Incidencey 20% of all dislocations

y Essentially a Humero-ulnar dislocation

y Second most commonly dislocated major joint of thebody after the shoulder

y Associated fractures

y Radial head/neck 50-60%

y Medial/lateral epicondyle 10%

y Coronoid 10%

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Mechanismy Usually indirect voilence (Posterior dislocation).

y Less commonly its direct voilence (Anterior Dislocation).

y Apatient of any age can dislocate his elbow if he falls onhis outstretched hand.

y In this common injury a force travels up his forearm andpushes his radius and ulna posteriorly, or his humerus

posteriorly and laterally.

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MorbidAnatomyy Patient cannot move his elbow, and usually holds it at

about 45.

y The posterior outline of his elbow, instead of beingnormally rounded, shows a prominent pointedprojection backwards .

y The three bony points of the elbow are not in theirnormal places.

y There may be other injuries also:

y (1) A child may fracture his medial epicondyle whichmay become trapped inside his dislocated elbow.

y (2) His lateral condyle may also fracture.

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MorbidAnatomy

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ClassificationClassified according to the position of the radius and ulna in relationto the distal humerus after injury.Five types:

y Posterior (most common)y Anteriory Medialy Lateraly Divergent (radius and ulna are dislocated in different directions in

relation to humerus).

All these varieties may be complex or simple. Complex dislocationsare associated with fractures whereas simple ones are puredislocations without fractures.

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Classification

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Diagnosisy The patient presents with swelling, pain and deformityaround the

elbow. The affected extremity is supported with the opposite hand dueto pain.

y The forearm appears shortened and the olecranon is prominenton the posterior aspect of the elbow.

y The normal (isosceles) triangular relationship between theepicondyles of the humerus and the olecranon is disturbed.

y A careful examination of the brachial artery and the peripheral nervesis essential to rule out a neurovascular injury.

y Elbow stability should be assessed after a successful reduction has

been achieved.

y Proper X-rays (AP and lateral) should be requested to confirm thediagnosis and to identify associated injuries.

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Associated injuriesy Fracture of the radial head,

y Fracture of the coronoid process

yFracture of the ulna

y Fracture the medial epicondyle.

y Rupture ofMedial collateral ligament

y Rupture of lateral collateral ligament

yAssociated Monteggia fracture type IV

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UrgentManagementy ATLS

y Injury specific treatment

y Rest and supporty Reassure

y Relief of pain

y Investigations

y Proper management

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Closedreductiony The sooner you do this, the easier it will be, and the fewer the

complications

y Good general relaxation is essential in adults, but is lessnecessary in children.

y

XRAYS

Check: (1) that reduction is satisfactory, and (2

) thatthere is no bony fragment trapped in the joint. If there is, it willhave to be removed by opening the joint.

y CAUTION! if you neglect to Xray a patient after trying to reducehis dislocated elbow, you may fail to diagnose that reduction is

incomplete, until after the swelling has gone. Reduction willthen be possible only at open operation with irepairabledamabge been done to the elbow articular surface already

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Reductionmenouvrey The patient lies on his back with his upper arm vertical, andhis forearm flexed across his chest.

y Assistant will exert traction on the patients hand from theother side of the table .While he does this, grasp the patientselbow in both hands, with your fingers round the front of hishumerus, and your thumbs behind his olecranon.

y The patients olecranon should lie in the centre of his armmidway between his two epicondyles . If it is shifted sideways,first move it into the midline with your thumbs as you reduceit, then push it forwards over the lower end of thehumerus,and at the same flex the elbow gradually .

y The dislocation will reduce with a scrunch.When you thinkthat you have succeeded, move the patients elbow through itsnormal range. Unless you can get full flexion, you have notreduced it. If it feels stable, apply a plaster back slab

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REMEMBERAlways remember after reduction:

y Check Radial pulse

y Check full regaining of normal ROM

y Check re-establishment of Bony triangularconfiguration

y Radiological evaluation

y Plaster support.

y As soon as a patient recovers from the anesthetic, re-examine his median, ulnar, and radial nerves to makesure that you have not injured them during reduction

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Postoperative careIf reduction is stable:

y rest his arm in a sling for 3 weeks in the hope of avoiding posttraumatic ossification. While it is in the sling he should move it as muchas possible.

y Start shoulder, finger, and wrist exercises within the sling immediately.y

If there are no complications, his elbow will recover slowly, but he mayalways have some limitation of full extension.y Never perform passive stretching exercises. These encourage post

traumatic ossification.

If reduction is unstable:y

f lex his elbow as far as it will go in a collar and cuff sling, or with aposterior slab, for 3 weeks.y Then start active movements.

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Complicationsy Loss ofROM

y Recurrent dislocations.

y Heterotopic ossification.(Myositis Ossificans)y Post-traumatic osteoarthritis.

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7. elbow dislocations

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