A 70-year-old female presents with left elbow pain and deformity after falling on an outstretched hand. You obtain shoulder x-rays and see the above images. What is the most likely diagnosis, likely mechanism of injury, expected physical exam findings, and management plan?  (Image 1: AP and lateral views of the left elbow. Author’s own images)

Posterior elbow dislocation with tiny avulsion fractures from the posterior distal humerus.

  • Pearl: Posterior dislocations are the most common type of elbow dislocations –  80% of cases [1-6].
  • Pearl: Simple elbow dislocations are characterized by the absence of a major associated fracture, aside from small periarticular avulsion fractures [2,5]. Meanwhile, complex dislocations can have significant fractures of the radial head, olecranon, coronoid, humeral condyles, or epicondyles [1-6].

 

The typical mechanism of injury for posterior dislocations is a fall on outstretched hands resulting in axial loading on an extended elbow combined with a valgus force [1-6].

The elbow is often held in 45 degrees of flexion, with shortening of the forearm and prominence of the olecranon posteriorly [1,2,4]. A careful neurovascular examination should be performed to assess for brachial artery, median nerve, and ulnar nerve injuries [1-6]. Brachial artery disruption is the most serious complication and it occurs in 5 to 13% of cases [1-4].

  • Plain radiographs with anteroposterior and lateral views of the elbow to assess the type of dislocation and look for associated fractures [1-6].
  • Reduction under procedural sedation [1-4].
    • Apply longitudinal traction of the supinated forearm with the elbow flexed at 25 to 30 degrees, with countertraction of the upper arm [1-3]. Apply downward pressure at the proximal forearm and anterior pressure behind the olecranon [1-4].
  • Post-reduction neurovascular examination and radiographs [1-6]. Assess for stability of the elbow through its normal range of motion and perform varus and valgus stress testing [1-6]. Stable reductions should be immobilized in a posterior splint with 90 degrees of elbow flexion for 3 to 5 days [1-6].
  • Outpatient follow-up should be arranged with orthopedics for progressive mobilization. Early active mobilization has shown improved outcomes compared to plaster immobilization, and immobilization for longer than 2 to 3 weeks should be avoided [2,3,5].

Figure 2. Post-reduction images that demonstrate reduction of the elbow joint. Author’s own images.

Emergent consultation is required for open dislocations, vascular disruption, and compartment syndrome [1-3]. Orthopedic intervention is indicated for irreducible and chronic dislocations, incarcerated tissue resulting in a locked elbow dislocation, and grossly unstable elbows [2,3,5].

  • Pearl: Operative treatment is usually recommended for the “terrible triad,” which is an elbow dislocation with associated fractures of the radial head and coronoid process, because it can be complicated by recurrent instability and post-traumatic arthrosis [3,6].

References and Resources:

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  1. Geiderman J, Torbati S, Mayer T. Humerus and elbow. In: Marx J, ed. Rosen’s Emergency Medicine Concepts and Clinical Practice. 8th ed. Philadelphia, PA: Elsevier, Saunders; 2014: 596-617.e1
  2. Grazette AJ, Aquilina A. The assessment and management of simple elbow dislocations. The Open Orthopaedics Journal. 2017;11:1373–1379. PMID: 29290877
  3. Khan SO, Field LD. Elbow dislocations in the adult athlete and pediatric patient. In: DeLee & Drez’s Orthopaedic Sports Medicine: Principles and Practice. 3rd ed. Philadelphia, PA: Elsevier Saunders; 2009: 1300-1310.
  4. Horn AE, Ufberg JW. Management of common dislocations. In: Roberts & Hedges’ Clinical Procedures in Emergency Medicine. 6th ed. Philadelphia, PA: Elsevier Saunders; 2014: 973-978.
  5. Robinson PM, Griffiths E, Watts AC. Simple elbow dislocation. Shoulder & Elbow. 2017;9(3):195–204. PMID: 26498542
  6. Smith WR, Stahel PF, Suzuki T, Gabrielle P. Musculoskeletal trauma surgery. In: Current Diagnosis & Treatment in Orthopedics, 5th ed. New York, NY: McGraw-Hill; 2014. Accessed April 06, 2020.
Victor Huang, MD

Victor Huang, MD

Department of Emergency Medicine
New York-Presbyterian Queens
Weill Cornell Medical College
Victor Huang, MD

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Tabitha Ford, MD

Tabitha Ford, MD

Medical Education Fellow
Emergency Medicine
University of Vermont Medical Center
Tabitha Ford, MD

@tabeduford

Emergency doc, medical education fellow, part-time adventurer. #FOAMus #MedEd
Tabitha Ford, MD

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William Denq, MD CAQ-SM

William Denq, MD CAQ-SM

Assistant Professor
Department of Emergency Medicine
University of Arizona
William Denq, MD CAQ-SM

@willdenq

Clinical Assistant Professor Emergency Medicine and Sports Medicine University of Arizona George Washington University '18 University of Pittsburgh '14 and '10
William Denq, MD CAQ-SM

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