Elbow sprains in adults and children

What is elbow dislocation and how is it treated? We are talking about a violation of the anatomical articulation of the elbow joint bones, such as the humerus, ulna and radius. The injury is accompanied by a capsular rupture, damage to the ligamentous apparatus, and a hematoma.

The elbow joint is a relatively complex, specific and easily injured musculoskeletal mechanism, which is prone to damage and, in particular, to dislocations. Such an injury most often results from a person falling with an emphasis on the upper limb. In childhood, injury is possible due to a weak ligamentous apparatus and insufficient physical development of the child. [ 1 ]

Epidemiology

Elbow dislocation in the practice of a traumatologist is a fairly common injury for which patients seek medical help. According to statistics, it is much more common than shoulder dislocation. In 90% of cases, posterior dislocation of the forearms or displacement of one radius is diagnosed. The annual incidence of complex elbow dislocations in children and adults is 1.6 per 100,000, or 26% of all elbow dislocations. [ 2 ], [ 3 ] Most elbow dislocations without fractures occur in patients under 30 years of age [ 4 ] and non-surgical treatment with good clinical results.

The posterior type of elbow dislocation occurs when a person falls on a straightened upper limb, and the anterior type is a consequence of a blow to the elbow while the arm is bent.

The injury most often occurs in childhood and adolescence, particularly during sports activities. Subluxation of the elbow or radial head is common in young children under four years of age. This type of injury occurs when the child is pulled hard by the arm.

Elbow dislocations can occur both at home and at work. More rare cases are associated with the so-called "habitual" dislocation, indicating a congenital or acquired weakening of the joint ligaments.

Causes elbow dislocation

Traumatologists have voiced the following reasons that contribute to the formation of elbow dislocation:

• direct blow to the joint area;
• indirect force impact on the hand;
• arm extension (typical for children 3-4 years old);
• sudden lifting of a too heavy object or pushing it away;
• performing a movement from a position that is uncomfortable for the hand;
• twisting of the arm (rotational-axial overload).

Most often, such an injury occurs in people with insufficient physical development - for example, if they decide to suddenly lift an unbearably heavy object. Often, the injury occurs during arm wrestling or wrestling (in people without the appropriate training). [ 5 ], [ 6 ]

Risk factors

The most common cause of elbow dislocation is landing on an outstretched limb. The reason why the bones in the joint are displaced is a fall associated with strong extension of the arm, or excessive load on the elbow joint, which is in a bent position. In some people, the injury is associated with a direct blow to the elbow. [ 7 ]

Often dislocations occur in accidents or careless behavior in transport, at home, etc. Less often, a weakened muscular-ligamentous mechanism becomes a risk factor.

If we talk about the so-called habitual elbow dislocation, its occurrence is also associated with weakening of the ligamentous apparatus. Weakness of the ligaments, in turn, occurs as a result of long-term inflammatory reactions, previous injuries that negatively affected the quality and condition of the joint capsule.

The risk group includes:

• athletes;
• small children;
• people leading an active lifestyle;
• overweight patients;
• elderly people.

Pathogenesis

The elbow is a specific joint that includes three bones, such as the humerus, radius, and ulna. The joint is a complex structure, as it is combined from three parts: the humeroulnar, humeroradial, and proximal radioulnar parts. The joint is united by a common capsule and bursa, inside which a special liquid lubricant is produced for smooth sliding of the articular surfaces and maintaining trophism. The surfaces of the joint are covered with cartilaginous tissue. The elbow is strengthened by the ligamentous apparatus and muscular framework. [ 8 ]

Elbow dislocation is an injury caused by the anatomical and biomechanical features of the elbow joint, which is associated with several muscle groups at once: the shoulder and flexor-forearm. Elbow dislocation is said to occur if there is a displacement of two base bones of the forearm from the articulation node with the humerus bone. In addition, the other above-mentioned bones may also move out of the node relative to each other.

During the displacement, damage to blood vessels and nerves occurs. The severity of these injuries also affects the extent of further treatment.

The elbow joint has a complex structure and consists of several articular surfaces. It has a rich vegetative innervation, so the elbow usually reacts painfully to any injury, and with a significant injury, there is a sharp limitation of motor activity. As a result of prolonged immobility, stiffness can easily develop. To prevent this from happening, special attention should be paid to the restoration and maintenance of the functionality of the upper injured limb during treatment. Particular attention should be paid to a short period of immobilization and early rehabilitation, started at the stage of unstable contracture. [ 9 ]

Symptoms elbow dislocation

Elbow injuries are varied and differ in their manifestations. How can you recognize that you have a dislocation? Of course, it is better to see a doctor. However, it is equally important to know the set of symptoms characteristic of an elbow dislocation.

These symptoms include:

• sharp or increasing pain in the elbow area;
• increasing swelling in the area of injury;
• loss of sensation in the injured arm;
• inability to feel the pulse below the area of injury;
• inability to move the damaged joint;
• change in elbow configuration;
• when palpated, the radial head is determined from the anterior or posterior side;
• inability to bend or straighten the arm (or severe limitation of flexion-extension);
• change in body temperature;
• impaired motor activity of the fingers and wrist joint.

The atypical position of the injured arm often attracts attention. When attempting to return the limb to its physiological position, some springy resistance is noted.

Most often, traumatic displacements occur due to excessive load on the joint. This happens, for example, with a sharp fall on the joint, a jerk or a blow. Symptoms may be supplemented by other signs if the dislocation is complicated by a fracture - in such cases they talk about a fracture-dislocation. [ 10 ]

What does a dislocated elbow look like?

It is usually not difficult for an experienced specialist to determine a dislocated elbow: a traumatologist will make a diagnosis almost immediately, based on the corresponding signs. The victim, as a rule, holds the injured arm in an unnatural position, often trying to support it with the healthy arm.

An injured elbow looks like a deformed, swollen joint. Any attempt to move the arm causes pain – and quite severe pain.

In the case of a posterior dislocation, a recession of the skin above the olecranon is usually detected, and in the case of an anterior displacement, the tip of the olecranon is “lost”.

To clarify the type of displacement and the location of the bones, the doctor will carefully palpate the joint and try to assess the condition of the muscle-tendon mechanism. To exclude possible bone damage, additional diagnostic tests will be prescribed - in particular, X-rays.

The primary symptoms of an elbow dislocation are quite specific and allow one to suspect a displacement in the joint almost immediately after the injury.

The main features are:

• severe pain in the elbow area;
• loss of ability to move the elbow;
• forced position of the hand (the position of least pain);
• external curvature, abnormal shape of the joint.

If the victim notices unnatural mobility of the hand, crunching is felt when pressing, pain appears under axial load, then in such cases a fracture can be suspected. A dislocation is characterized by almost complete motor blockade.

Elbow dislocation in a child

A dislocated elbow is not as dangerous for an adult as it is for a growing child. The child's musculoskeletal system is still developing, so any disruption in the joints can cause negative changes in the overall bone and joint structure.

Any injuries in children should never be ignored: medical help should be sought as soon as possible. The doctor will conduct the necessary diagnostics, and the treatment and rehabilitation period will be prescribed in the same way as the complex measures carried out for adults.

Why is a thorough diagnosis necessary? In childhood, it is often not a dislocation, but a subluxation of the elbow. Such an injury is especially typical for children aged 3-4 years. A child can receive such an injury, for example, if he is pulled hard by the arm. At the moment of stretching, the head of the radius is removed from the fossa, the child feels severe pain, the motor function of the joint becomes sharply limited. In this situation, it is important for parents to quickly orient themselves and perform the following actions:

• place the baby's hand on a sling to relieve muscle tension and ensure immobility;
• urgently take the child to a medical facility (emergency room).

If everything is done quickly and consistently, then further adverse consequences can be avoided. [ 11 ]

Forms

Elbow dislocation is differentiated depending on the following signs:

• completeness of dislocation (incomplete damage is said to occur if there is a displacement of the articular surface without it going beyond the capsule, whereas with a complete dislocation the joint comes out of the damaged capsular-ligamentous node);
• the number of bones involved in the dislocation (one or two forearm bones);
• the presence of only a dislocation, or its combination with a bone fracture.

In addition, dislocation is classified depending on the time interval that has passed since the injury. Thus, elbow dislocation can be:

• fresh (no more than three days after injury);
• stale (up to 14 days);
• old (more than 14 days).

Patients who have had equivalent elbow dislocations three or more times are diagnosed with a "habitual" dislocation. This type of injury is usually associated with individual features of the joint anatomy - congenital or acquired (for example, as a result of primary trauma to the upper limb). [ 12 ]

Complications and consequences

Pain and swelling of the elbow after a dislocation is only the least adverse effect of such an injury. The main problem is that improper treatment or lack of reduction of the dislocation often leads to motor problems - in particular, the patient loses the ability to straighten the affected limb, even against the background of visible healing of the painful process.

In addition, the pain during a dislocation can be very strong, even to the point of the victim losing consciousness. The pain syndrome during a dislocation is quite specific: immediately after receiving an injury, a person may feel almost nothing, since the pain occurs with some delay. The intensity of the pain depends on many factors - for example, the age of the victim, the state of his nervous system, concomitant injuries, etc. [ 13 ]

With a complex elbow dislocation, damage to the vessels that run along the upper limb or injury to the nerve fibers may occur.

Correct reduction and treatment of dislocation is the key to rapid recovery and restoration of the affected arm. In complex cases, dystrophic processes and muscle dysfunction often develop. [ 14 ]

If immobilization of the injured arm after dislocation was insufficient, then difficulties with full restoration of the ligament mechanism arise. As a result, a defect is formed in the capsule, due to which a repeated displacement of the bone may occur. Subsequently, a habitual dislocation is formed, which is more difficult to treat and requires a surgical solution to the problem.

After a dislocated elbow, the hand swells up a lot

Swelling of the hand after an elbow dislocation is caused by circulatory problems in the limb. The intensity of the swelling varies depending on the severity of the injury:

1. Mild swelling with pain when attempting to move and when palpating the damaged area.
2. Swelling of the entire arm from the forearm to the hand, combined with severe pain and problems when trying to move the limb.
3. Internal bleeding in the tissue, including in the area of the hand, deformed and swollen joint. Motor activity of the affected limb is impossible.

In order for the swelling to disappear faster, it is necessary to ensure rest for the injured arm (with its position elevated), use an elastic bandage, and immediately after the injury apply ice or a cold compress.

As a rule, swelling decreases within about 1-1.5 weeks after elbow dislocation. If this does not happen, or the condition worsens, then you should definitely consult a doctor to prevent complications of the injury.

The elbow does not straighten after dislocation

Reduced motor amplitude, impaired joint mobility after dislocation occurs as a result of contraction of soft structures that participate in the formation of the joint. We are talking about ligaments, tendons, which are tightened due to injury to the elbow, cicatricial changes occur. The problem occurs especially often if the damaged area was immobilized for a long time, fixed with a plaster cast, which could lead to impaired motor range, muscle atrophy.

To avoid impairment of the elbow's motor ability after dislocation, it is recommended to start rehabilitation procedures in a timely manner, perform exercises to develop the limb and prevent atrophic processes, to stimulate metabolism and accelerate tissue healing.

Diagnostics elbow dislocation

Diagnosis of elbow dislocation begins with a local examination. The doctor pays attention to the following points:

• forced position of the injured limb;
• the presence of deformed areas, swelling, hemorrhages, external tissue damage;
• the presence of areas that are painful upon palpation.

During the examination, the doctor will determine the range of motion (both active and passive), the degree of sensitivity, and also assess the state of peripheral circulation (color of the hands, skin temperature, pulsation). [ 15 ]

Laboratory tests are not indicative in all cases. Changes in the blood picture will be observed only in inflammatory processes or other joint pathologies not related to trauma. Thus, during a biochemical study, the doctor will pay attention to the C-reactive protein in the serum, the content of total protein. The presence of inflammation will be indicated by an increase in ESR. The presence of arthritis will be “given away” by a sharp increase in the level of uric acid, and rheumatological inflammatory diseases will manifest themselves as antinuclear antibodies in an immunological blood test.

Urine analysis for elbow dislocation usually shows no changes.

Instrumental diagnostics play the main role in diagnosing elbow dislocation. The most commonly used are X-ray examination, computed tomography, MRI, and arthrography. In the vast majority of cases, X-ray imaging is sufficient to determine elbow dislocation. This procedure takes only a few minutes, and the results can be seen within fifteen minutes (depending on the device).

To clarify some points, as well as in complex cases, you can seek help from arthrography or tomography (CT or MRI). These are more precise methods that allow you to examine joint pathology or injury in detail.

Less frequently, ultrasound of the joint is prescribed for elbow dislocation. This diagnostic procedure may be indicated for women during pregnancy, whereas X-ray examination is contraindicated during this period. [ 16 ]

Differential diagnosis

The most appropriate diagnostic method for each specific patient is determined by the attending physician. He takes into account the complaints of the victim, his general well-being, etc. However, sometimes it becomes difficult to immediately make a diagnosis, since the pathology can be combined or accompanied by other additional symptoms. In such cases, differential diagnostics of elbow dislocation with other clinically similar diseases or injuries is carried out:

• contusions of the olecranon, periarticular area, humeral condyles and ulnar nerve;
• sprain;
• intra-articular, periarticular, closed bone fractures;
• epicondylitis (a degenerative inflammatory pathology affecting the tendon apparatus in the elbow area);
• styloiditis (inflammatory-dystrophic process in the area of attachment of the tendon to the olecranon);
• bursitis (inflammatory reaction in the joint capsule in the area of the back of the elbow);
• neuritis of the ulnar nerve (neuropathy);
• elbow tendinitis (inflammatory reaction in the tendon of the elbow end of the triceps muscle);
• arthritis (inflammation affecting the articular cartilage and capsule);
• osteoarthritis (degenerative-dystrophic disorder in the cartilage and bone of the joint).

Treatment elbow dislocation

In case of elbow dislocation, the victim must undergo emergency first aid measures:

• immobilize the injured arm using suitable improvised means (the easiest way to immobilize is a sling with additional rigid fixation);
• apply cold (ice) to the elbow area;
• take an analgesic (for example, Analgin, Ortofen, etc.).

After this, the victim should be transported to the nearest medical facility, and ideally to the emergency room.

If your elbow is dislocated, you must not:

• massage, rub the injured area;
• do warming procedures;
• treat with warming ointments and creams.

For more information on how to reset the elbow joint, read this article.

Prevention

Basic preventive measures are attentiveness and caution. To prevent injury – in particular, a dislocated elbow – it is necessary to be careful when performing any movements.

• Shoes should be as comfortable as possible, without high unstable heels and narrow toes, which significantly increase the risk of falls and bruises. The best options are a flat sole or a wide heel up to 4 cm high. The sole material should not slip.
• When walking, avoid slippery areas, as well as places uncleared of snow or covered with stones. It is preferable to walk on clean sidewalks, and in winter – on cleared, sprinkled paths. Elderly people are advised to use a cane when walking. Pregnant women should only walk with an escort.
• When performing any movements, or simply while walking, you should not rush or fuss. You cannot be distracted when going up or down stairs.
• When carrying bags and other items, it is necessary to distribute the load evenly between the right and left sides.
• The habit of keeping your hands in your pockets increases the risk of losing balance and falling.
• It is important to abstain from drinking alcohol, as it is easier to get not only a dislocated elbow, but also more serious injuries when intoxicated. In addition, alcohol reduces sensitivity to pain, which entails a later visit to the doctor and, as a result, an increased likelihood of complications.
• If you lose your balance, you should group yourself and relax. You should not put your hand in the direction of the fall, or land on your elbow. If a fall is inevitable, you should try to roll to the side, as if distributing the blow.

An additional method of preventing any damage to the musculoskeletal system is strengthening the bones. The diet should include foods with a high content of calcium, iodine, vitamin D: seafood, milk, cottage cheese, cheese, eggs.

Forecast

In general, the prognosis for elbow dislocation can be called favorable. However, there is a risk of complications: it lies in the fact that nerve fibers and blood vessels run near the joint. If the reduction is not performed correctly or if there is no treatment at all, the victim may develop complications:

• movement restrictions caused by damage to nerves and tendons;
• tactile disturbances;
• displacement and instability of the joint, weakening of the ligaments.

In case of unfavorable development of events, the recovery period increases significantly, and various negative consequences of the injury may arise. [ 17 ]

Most patients experience adequate recovery. The main factor in recovery is timely medical attention within the first two days after an elbow dislocation. An attempt to self-reduce the injury or the lack of necessary therapy significantly worsens the prognosis. In these cases, it is often necessary to resort to a surgical solution to the problem.