Elbow Dislocation

What is Elbow Dislocation?

Elbow dislocation is the common condition of the elbow in which the forearm bones (radius or ulna) get displaced from their positions as compared with the upper arm bone (humerus).  Elbow joint is formed by three bones humerus (upper arm bone), radius and ulna (forearm bones) supported by ligaments to keep them in proper alignment. The elbow joint is the second most mobile joint of our body after shoulder joint. Partial or complete dislocation of the elbow can happen due to a traumatic injury to elbow by fall or an accident.  Falling onto an outstretched hand is a common cause of elbow dislocations.

Elbow dislocation accounts for 10-25% of the injuries related to the elbow. The most common type of elbow dislocation is posterolateral (back side) about 80 %. Children of age 10-20 years of age are commonly affected by elbow dislocation. Around 50% of elbow dislocations are following sports injuries. Simple elbow dislocation with no fractures in the involved bones accounts for 50-60% of elbow dislocations. Complex elbow dislocation is associated with other fractures and injuries to ligaments with damage to nerves and blood vessels in severe cases.

 

What are the symptoms of Elbow Dislocation?

Pain, tenderness, swelling, deformity and bruising in the elbow are its common symptoms. You will not be able to bend or twist your arm. You may feel looseness in the elbow. There can be a loss of pulse in the wrist. Numbness can be present if nerve injury is present.

 

How is it diagnosed?

Your surgeon will inquire about the history of your injury or accident and other medical histories. He will examine your hand and check your pulse. He will ask you to have an x-ray to confirm the diagnosis. Ct scan or MRI scan may be done to detect injuries to ligaments.

 

What happens if nothing is done?

If it is left untreated or neglected, it may lead to stiffness and weakness in the affected elbow. It may also result in damage to ligaments, nerves or blood vessels as they are pinched by dislocated bones. It may also lead to osteoarthritis.

 

How is it treated?

Elbow dislocation is considered a serious injury that demands emergency treatment. The main goal of its treatment is the realignment of the bones to their normal position and restoration of the normal function of the elbow joint. It can be treated conservatively or surgically. Conservative treatment includes closed reduction, rest, immobilization by a sling, physical therapy and painkillers.

Surgery is indicated in

  • Irreducible dislocation
  • Acute complex elbow dislocation
  • Chronic instability after closed reduction
  • Soft tissue involvements – ligament injury
  • Chronic dislocation
  • Fractures of the forearm bones
  • Open fractures
  • Nerve injury
  • Brachial artery injury

 

What are the non-operative treatments?

Most cases are treated non-operatively. The bones of the elbow joint are realigned through conservative methods that involve-

  1. Closed reduction- your surgeon will realign your bones of the elbow by pulling down your wrist and pushing your elbow back into its position. This process is also called reduction manoeuvre or closed reduction. This mechanical pulling is performed gently and slowly but still, it is painful. You might need anaesthesia and painkillers like codeine or paracetamol before this procedure so that you don’t feel pain.
  2. Rest– the elbow of the patient is rested in a polysling for 1-2 weeks.
  3. Ice packs (frozen peas bag)– you can also apply ice on the joint for 20 -30 minutes in every 2 to 3 hours in first two days of the injury as it can relieve pain and swelling.
  4. Medications– anti-inflammatory medicines like ibuprofen or aspirin may be given to regulate swelling in the elbow for few days as long-term consumption of these medicines may cause damage to your kidneys and stomach.
  5. Physical therapy- early motion exercises are started after 1 to 2 weeks of immobilization to prevent stiffness and maintain the good mobility in your elbow. Your elbow is prone for getting stiff and extra bone formation. Early physiotherapy under the supervision of your surgeon and physiotherapist is paramount for optimal outcome.

 

What does the operation involve?

The main purpose of the surgery is the realignment of the elbow joint and repair of the damaged ligaments, blood vessels and nerves with the rejoining the bone fragments if present.  It is usually performed in complex dislocations.

  • The operation is performed under general anesthetic and the skin is cut over the affected site. The bones are repositioned to their normal position.
  • Fractured bone fragments are reattached with plates, pins or screws to keep them in position while healing. Sometimes, bone substitutes may be used to bridge the gap and accelerate healing. Ligaments, blood vessels, and nerves are repaired if they are found damaged.
  • The skin is closed by absorbable sutures. The whole operation ends in 1-2 hours and most patients are discharged on the same day.
  • After the surgery, a device called external hinged splint may be used to protect the joint from dislocation again.

 

What happens after surgery?

  • The local anaesthetic wears off 4-10 hrs after surgery; the patient is encouraged to start taking painkillers before the pain starts i.e. on return home and for at least 48 hours from there. This way most of our patients report little or any pain.
  • Initially, the aims are the comfort and rest to the elbow in a sling for 1 to 3 weeks.
  • Before discharge, you may see a physiotherapist, who will teach you gentle exercises of your fingers, wrist, and elbow. You may be able to start these gentle exercises on the day of your operation and they are essential to reduce stiffness and pain.
  • You can use your arm to do light activities (writing, using keyboard etc) that don’t cause excessive pain or discomfort.
  • The patient is reviewed in clinic around 2 weeks following the operation for wound check and physiotherapy.
  • The wound should be massaged (typically after 2 weeks) using the moisturizing cream by the patient 3 times a day for 3 months once the wound is well healed. This reduces the scar sensitivity and scar-related complications (tenderness; helps scar to mature).
  • You could start a gentle range of movement (ROM) exercises after surgery and progress to more strenuous activities around six weeks. This will be guided by your surgeon and is based on radiographic (X-ray) and clinical union of the fracture. The duration may increase or decrease based on the personality of dislocation, fracture, quality of bone and method of fixation.

 

Are there any risks?

  • Infection
  • Nerve injury
  • Vascular injury (uncommon, brachial artery)
  • Delayed union
  • Non-union
  • Mal-union
  • Myositis ossificans
  • Compartment syndrome
  • Damage to articular surface
  • Recurrent instability
  • Hardware failure
  • Anaesthetic complications

 

What are the results of the operation?

The results of the operation in elbow dislocation are excellent without long-lasting complications. The elbow heals fast. Recovery depends on the age of the patient, clinical nature of the injury, rehabilitation and program, and type of surgery performed.

 

When can I return to driving and work?

You can get back to work in 2-4 weeks if you have a desk job, however might take upto 3 months if your job involves physical work. Regarding return to contact sports, it usually takes 3-6 months and depends on the severity of injury.  You should be able to resume driving in 6-12 weeks. The above time line could vary based on the severity of injury and the treatment modality.  Your physician will be able to advise you.

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