Elbow dislocation

What is an elbow dislocation?

When the joint surfaces of an elbow are forced apart, the elbow is dislocated. The elbow is the second most commonly dislocated joint in adults. Elbow dislocations can be complete or partial. A partial dislocation is referred to as a subluxation. The amount of force needed to cause an elbow dislocation is enough to cause a bone fracture at the same time. These two injuries (dislocation and fracture) often occur together.

What structures are involved?

The bones of the elbow are the humerus (the upper arm bone), the ulna (the larger bone of the forearm, on the opposite side of the thumb), and the radius (the smaller bone of the forearm on the same side as the thumb). The elbow itself is essentially a hinge joint, meaning it bends and straightens like a hinge. But there is a second joint where the end of the radius (the radial head) meets the humerus. This joint is complicated because the radius has to rotate so that you can turn your hand palm up and palm down.

In the elbow, two of the most important ligaments are the medial collateral ligament and the lateral collateral ligament. The medial collateral is on the inside edge of the elbow, and the lateral collateral is on the outside edge. Together these two ligaments connect the humerus to the ulna and keep it tightly in place as it slides through the groove at the end of the humerus. These ligaments are the main source of stability for the elbow. They can be torn when there is an injury to or dislocation of the elbow. If they do not heal correctly the elbow can be too loose, or unstable.

What causes an elbow dislocation?

Elbow dislocation is often the result of trauma. The most common trauma resulting in an elbow dislocation is a fall onto an outstretched hand and arm. When the hand hits the ground, the force is transmitted through the forearm to the elbow. This force pushes the elbow out of its socket. This can also result in a fracture/dislocation.

About half of all elbow dislocations in teens and young adults occur as a result of a sports activity. The most common elbow dislocations are associated with sports such as gymnastics, cycling, roller-blading, or skateboarding.

What are the symptoms?

If the elbow is fully dislocated, it will look out of joint. There may be dimples or indentations of the skin over the dislocation where the bones have shifted position. Pain can be intense until the arm is relocated. The pain is often relieved immediately after the joint is put back in place. There may be some residual tenderness around the joint. If ligaments or other soft tissues are torn, there can be swelling and bruising around the elbow. Bruising is not immediately obvious but appears several days after the injury. Injury to any of the three nerves that cross the elbow (median, ulnar, radial nerves) can cause neurologic symptoms such as numbness, tingling, and/or weakness of the forearm, wrist, and hand.

If a bone fracture is also involved the fracture can cut or damage a nerve causing temporary or permanent paralysis. Pain and an inability to straighten the elbow or pain when turning the hand the palm up (supination) is typical. There is often tenderness along the lateral aspect of the elbow (side of the elbow away from the body).

How is it diagnosed?

The history and physical examination are probably the most important tools the doctor uses to guide his or her diagnosis. Moving the elbow passively is painful, especially extension and supination. The doctor will check for any signs of injury to the nerves or blood vessels. X-ray is the best way to look for dislocation or fracture-dislocation. After the joint is relocated, other imaging studies may be ordered to look for damage to the joint cartilage, bone, ligaments, and other soft tissues. If bone detail is difficult to identify on an X-ray, a computed tomography (CT) scan may be done. If it is important to evaluate the ligaments, a magnetic resonance image (MRI) can be helpful.

What is the treatment?

Nonsurgical treatment:
It is possible for the elbow to relocate by itself. This is more likely when there is a subluxation, rather than a complete dislocation. Sometimes the elbow can be reduced or put back in place by a trained medical person applying a quick motion to the forearm. There are several different methods used for manual (closed) reduction. Closed reduction refers to the fact that the elbow can be put back in joint without surgery. An open incision is not needed. Manual reduction can be done in an emergency on site (e.g., at an athletic event or car accident) by a trained medical person but usually the procedure is done in a clinic or hospital setting. You would be given medications first to help with the pain.

X-rays may be taken while the elbow heals. This will show if the bones of the elbow joint are healing in a reduced position with good alignment. The arm may be immobilized for 10 to 14 days to allow the ligament to heal. Gentle range of motion may be allowed during that time but you should rely on your physician to advise you.

Physiotherapy may begin after the period of immobilization, The goal is to restore normal motion, joint proprioception (sense of position), and motor control.

Surgical treatment:
If there is too much swelling, it may be necessary to delay surgery for a few days up to a week. The elbow will be reduced right away and the arm immobilized while waiting for the swelling to subside. If there has been damage to the bones and/or ligaments, surgery may be needed to restore alignment and function. The type of surgery depends on the extent of the damage. Wires, pins, or even an external fixation device may be needed to hold everything together until healing occurs.

Post-operative immobilization is often required, especially for complex injuries. This could be a cast, dynamic splint, or postoperative range-of-motion (ROM) brace. The adjustable ROM brace is used to improve elbow motion gradually while allowing soft tissue healing. It helps minimize scar tissue formation and may contribute to fewer complications (such as arthritis) later on. After immobilization, physical therapy may begin. The goal is to restore normal motion, joint proprioception (sense of position), and motor control.

What is the prognosis?

Simple elbow dislocations heal well with few (if any) problems. You may notice a slight loss of elbow motion, especially when trying to straighten the arm. This should not affect your overall motion and function.

More complex fracture-dislocations take longer to recover and may cause residual pain and stiffness. Recurrent dislocation is also possible and additional reconstructive surgery may be needed. For some patients, arthritis is a long-term result of elbow injury. This is more likely if there is a history of recurrent elbow dislocations.