Elbow Dislocation

A dislocated elbow occurs when the bones that make up the elbow joint (the humerus, radius, and ulna) are forced out of alignment, either partially (subluxation) or completely. It is usually caused by high-energy impacts resulting from an athletic sport, a motor vehicle accident, or a fall from a substantial height. The elbow is the second most commonly dislocated joint after the shoulder in adults, and the most commonly dislocated joint in children and adolescents.

Toddlers may experience a dislocated elbow, sometimes known as nursemaid’s elbow, if they are lifted or swung by their forearms.

The elbow is stable because of the combined stabilizing effects of bone surfaces, ligaments, and muscles. When an elbow dislocates, any or all of these structures can be injured to different degrees:

• A simple dislocation does not have any major bone injury.

• A complex dislocation can have severe bone and ligament injuries.

• In the most severe dislocations, the blood vessels and nerves that travel across the elbow may be injured. If this happens, there is a risk of losing the arm.

A dislocated elbow can usually be realigned without surgery. However, if the elbow is also fractured, surgery might be needed.

Cause

A few causes of an Elbow Dislocation include:

• Direct trauma to the elbow, due to an automobile accident
• Taking part in any rough or high-impact sport
• Falling from a significant height; especially landing on the elbow/arm (or the injury occurring since the individual is overweight)
• Improper lifting of a child

Some people are born with greater laxity or looseness in their ligaments. These people are at greater risk for dislocating their elbows. Some people are born with an ulna bone that has a shallow groove for the elbow hinge joint. They have a slightly higher risk for dislocation.

Signs & Symptoms

Signs and symptoms of an Elbow Dislocation include:

• Excruciating pain in the elbow
• Visible elbow joint deformity
• Pain and bruising at the site of the injury

A partial elbow dislocation or subluxation can be harder to detect. Typically, it happens after an accident. Because the elbow is only partially dislocated, the bones can spontaneously relocate and the joint may appear fairly normal. The elbow will usually move fairly well, but there may be pain. There may be bruising on the inside and outside of the elbow where ligaments may have been stretched or torn. Partial dislocations can continue to recur over time if the ligaments never heal.

Toddlers with nursemaid’s elbow might experience pain only when the affected elbow is moved. A child often avoids using the arm and holds it slightly flexed next to the body.

Sometimes, the elbow is only partially dislocated. Partial dislocation can cause bruising and pain where the ligaments were stretched or torn.

Diagnosis

Diagnostic methods that may help to diagnose an Elbow Dislocation include:

• Physical examination – The doctor will check for tenderness, swelling, and deformity. He/she will evaluate the skin and circulation to the arm. Pulses at the wrist will be checked. If the artery is injured at the time of dislocation, the hand will be cool to touch and may have a white or purple hue. This is caused by the lack of warm blood reaching the hand. It is also important to check the nerve supply to the hand. If nerves have been injured during the dislocation, some or all of the hand may be numb and not able to move.

• X-ray of elbow joint – An X-ray is necessary to determine if there is a bone injury. X-rays can also help show the direction of the dislocation. X-rays are the best way to confirm that the elbow is dislocated.

• Computerized tomography (CT) scan – If bone detail is difficult to identify on an X-ray, a CT scan may be done.

• Magnetic resonance imaging (MRI) – If it is important to evaluate the ligaments, an MRI can be helpful.

First, however, the doctor will set the elbow, without waiting for the CT scan or MRI. These studies are usually taken after the dislocated elbow has been put back in place.

Treatment

A high percentage of Elbow Dislocation injuries do not a require surgical correction. Some, however, need a doctor to manipulate the bones back into their proper alignment (called a reduction) and/or repair any damaged ligaments.

Non-surgical Treatment

The normal alignment of the elbow can usually be restored in an emergency department at the hospital. Before this is done, sedatives and pain medications usually will be given. The act of restoring alignment to the elbow is called a reduction maneuver. It is done gently and slowly. Two people are usually required to perform this maneuver.

Additional measures may include:

• Applying ice to the elbow to help reduce pain and swelling
• Complete immobilization of the elbow with a cast to restrict movement
• Non-steroidal anti-inflammatory oral medications, such as indomethacin and naproxen, to help decrease the pain and swelling
• Physical therapy exercises, to help strengthen the muscles, increase stability, and decrease stiffness

Surgical Treatment

Surgery might be needed if:

• Any of the dislocated bones have also been broken
• Torn ligaments need to be reattached
• Damaged nerves or blood vessels need repair

Closed reduction:
Closed reduction is a surgical treatment method that is used to realign the elbow joint, back to its original position without making an incision. This procedure can be performed under general anesthesia, spinal anesthesia, or through conscious sedation with muscle relaxants.

Open reduction and internal fixation (ORIF):
Open reduction is a surgical procedure to realign the fractured bone, to its original position. Surgical hardware (such as plates, screws, or rods) is then used to stabilize the fractured bone under the skin. This procedure is only required, if any bones are also broken.

After surgery, the elbow may be protected with an external hinge. This device protects the elbow from dislocating again. If blood vessel or nerve injuries are associated with the elbow dislocation, additional surgery may be needed to repair the blood vessels and nerves and repair bone and ligament injuries.

Late reconstructive surgery can successfully restore motion to some stiff elbows. This surgery removes scar tissue and extra bone growth. It also removes obstacles to movement.

Over time, there is an increased risk for arthritis in the elbow joint if the alignment of the bones is not good; the elbow does not move and rotate normally; or the elbow continues to dislocate.

Lateral Ulnar Collateral Ligament (LUCL) Reconstruction

The main ligament stabilizer on the outside of the elbow is the lateral ulnar collateral ligament (LUCL). This ligament is frequently stretched or torn after an elbow dislocation. When the elbow is put back in place, the LUCL usually heals enough that it does not need to be fixed with surgery.

On occasion, the LUCL remains loose resulting in an elbow that won’t stay in place throughout its entire range of motion. If this happens, patients may feel like their elbow slides out of place or “clunks” during activities like pushing themselves out of a chair. Recurrent elbow dislocations are also possible.

If the LUCL remains loose after an injury, physical therapy aimed at strengthening the muscles around the elbow may be beneficial. However, the most reliable way to treat a loose LUCL is to repair the ligament or to reconstruct the ligament with a tendon from another part of the body (usually the forearm).

Ligament repair is more effective if it is done within the first 2-3 weeks after the injury. Ligament reconstruction is usually better to treat an injury that is more than 3 weeks old.

The ligament is reconstructed through an incision on the outside of the elbow. After surgery, patients are usually put into a splint for 7-10 days and then controlled motion is started. At 6 weeks, unrestricted motion is allowed. Return to full activity is allowed after 4-6 months depending on the type of activities the person is trying to get back to.