Elbow dislocation in adults and children

What is elbow dislocation and how is it treated? It is a violation of the anatomical articulation of the ulnar articular bones, such as the humerus, ulna and radius. Trauma is accompanied by capsular rupture, damage to the ligamentous apparatus, hematoma.

The elbow joint is a relatively complex, specific and easily traumatized musculoskeletal mechanism that is prone to injury and, in particular, to dislocation. Such an injury most often becomes the result of 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 frequent injury with which patients seek medical help. According to statistics, it is much more common than a dislocation of the shoulder joint. In 90% of cases, a posterior dislocation of the forearm bones 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 of the elbow dislocation without fracture occurs in patients younger than 30 years old  [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 an elbow strike in a bent arm state.

Trauma occurs more often in childhood and adolescence, particularly during sports activities. Subluxation of the elbow or radial head is not uncommon in young children under four. Similar damage occurs if the baby is pulled strongly by the hand.

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

Causes dislocated elbow

Traumatologists have voiced the following reasons contributing to the formation of a dislocated elbow:

• direct blow to the articular area;
• indirect force on the hand;
• stretching the arm (typical for babies 3-4 years old);
• a sharp rise of a too heavy object, or its repulsion;
• performing a movement from an uncomfortable position for the hand;
• twisting of the arm (rotary axial overload).

Most often, such an injury occurs in persons with insufficient physical development - for example, if they decide to sharply raise an unbearable heavy object. Often, damage occurs during armwrestling or wrestling (in people with a lack of appropriate training). [5], [6]

Risk factors

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

Dislocations often occur during accidents or inaccurate behavior in transport, in domestic conditions, etc. Less often, a weakened musculo-ligamentous mechanism becomes a risk factor.

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

The risk group includes:

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

Pathogenesis

The elbow is a specific connection that includes three bones such as the humerus, radius and ulna. The joint belongs to complex structures, since it is combined of three parts: the brachioral, brachioradial and proximal radioulnar parts. The joint is united by a common capsule and bursa, inside of 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 cartilage. The elbow is strengthened by a ligamentous apparatus and a muscular frame. [8]

Dislocation of the elbow is damage caused by the anatomical and biomechanical features of the elbow joint, which is associated with several muscle groups at once: the shoulder and flexion-forearm. A dislocation of the elbow is said to be if there is a displacement of the two basic bones of the forearm from the articulation node with the shoulder bone. In addition, it is possible to exit from the node and other above-mentioned bones 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 contains rich autonomic innervation, so the elbow usually reacts painfully to any injury, and in case of significant injury, there is a sharp limitation of motor activity. As a consequence of prolonged immobility, stiffness can easily form. To prevent this from happening, during treatment, special attention should be paid to the restoration and maintenance of the functionality of the injured upper limb. Particular attention should be paid to the short period of immobilization and early rehabilitation, which began at the stage of unstable contracture. [9]

Symptoms dislocated elbow

Elbow injuries are varied and manifest. How to recognize that there is a dislocation? Of course, for this it is better to see a doctor. However, it is equally important to know the set of symptoms inherent in elbow dislocation.

These symptoms include:

• sharp or growing pain in the elbow area;
• an increase in swelling in the area of damage;
• loss of sensation in the injured hand;
• inability to feel the pulse below the area of damage;
• inability to move the damaged joint;
• change in the configuration of the elbow;
• when probing, the radial head is determined from the front or back side;
• inability to bend or straighten the arm (or severe limitation of flexion-extension);
• changes in body temperature;
• violation of motor activity of the fingers on the hand, wrist joint.

The atypical position of the injured hand is often noteworthy. When trying to return a limb to its physiological position, some springy resistance is noted.

Most often, traumatic displacements associated with excessive stress on the joint occur. This happens, for example, with a sharp fall on a joint, jerk or impact. Symptoms can be supplemented by other signs if the dislocation is complicated by a fracture - in such cases, they talk about 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, focusing on the corresponding signs. The victim, as a rule, holds the injured arm in an unnatural position, often tries to support it with the healthy arm.

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

In posterior dislocation, the skin is usually retracted above the olecranon, and with anterior displacement, the apex of the olecranon is "lost".

To clarify the type of displacement and location of the bones, the doctor gently feels the joint, tries to assess the condition of the muscle-tendon mechanism. To exclude possible damage to the bones, additional diagnostic tests will be prescribed - in particular, radiography.

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

The main features are:

• severe soreness in the elbow region;
• loss of the ability to make movements in the elbow;
• forced position of the hand (position of the least pain);
• external curvature, irregular shape of the joint.

If the victim pays attention to the unnatural mobility of the hand, a crunch is felt when pressed, pain appears during axial load, then in such cases a fracture can be suspected. The dislocation is characterized by an almost complete motor block.

Dislocated elbow in a child

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

Any trauma to children should never be ignored: seeking medical attention should follow as soon as possible. The doctor will carry out the necessary diagnostics, and the treatment and rehabilitation period will be prescribed in the same way as for the complex measures 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 3-4 years old. A child can get such damage, for example, if he is pulled strongly by the hand. At the moment of stretching, the head of the radius is removed from the fossa, the baby feels severe pain, the motor function of the joint becomes sharply limited. In this situation, it is important for parents to quickly navigate and perform the following actions:

• put the baby's hand on the kerchief 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 distinguished, depending on the following symptoms:

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

In addition, dislocation is subdivided, depending on the time interval after the injury. So, dislocation of the elbow happens:

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

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

Complications and consequences

Pain and swelling (swelling) of the elbow after a dislocation is only the smallest adverse effect of such an injury. The main trouble is that improper treatment or lack of repositioning of the dislocation often leads to movement problems - in particular, the patient loses the ability to unbend the affected limb, even against the background of visible healing of the painful process.

In addition, the pain during dislocation is very strong, up to the loss of consciousness to the victim. The pain syndrome with dislocation is quite specific: immediately after receiving an injury, a person can practically not bother anything, since the pain occurs with some delay. The intensity of 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 dislocation of the elbow, damage to the vessels that run along the upper limb, or injury to nerve fibers can occur.

Competent reduction and treatment of a dislocation is the key to a quick recovery and restoration of the affected arm. In difficult cases, dystrophic processes and muscle dysfunction often develop. [14]

If the immobilization of the injured arm after receiving the dislocation was insufficient, then difficulties arise with the complete restoration of the ligamentous mechanism. As a result, a defect forms in the capsule, due to which a repeated displacement of the bone can occur. In the future, a habitual dislocation is formed, which is already more difficult to treat and requires a surgical solution to the problem.

After a dislocation of the elbow, the hand swells greatly

Swelling of the hand after a dislocation of the elbow is caused by impaired blood circulation in the limb. The intensity of the edema varies, depending on the severity of the injury:

1. Slight swelling with pain when trying to move and when feeling 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 hemorrhage in 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 the rest of the injured arm (with its elevated position), use an elastic bandage, and immediately after the injury apply ice or a cold compress.

Typically, the swelling diminishes within about 1-1.5 weeks after elbow dislocation. If this did not happen, or the condition worsened even more, then you should definitely consult a doctor in order to prevent the development of complications of the injury.

Elbow after dislocation does not unbend

Decreased motor amplitude, impaired articular mobility after dislocation occurs as a result of contraction of soft structures that are involved in the formation of the joint. We are talking about ligaments, tendons, which are pulled together due to damage to the elbow, and cicatricial changes occur. Especially often, the problem arises if the damaged area was immobilized for a long time, was fixed with a plaster splint, which could lead to impaired motor volume, muscle atrophy.

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

Diagnostics dislocated elbow

Diagnosis of a dislocated elbow begins with a local examination. The doctor pays attention to such moments:

• forced position of the injured limb;
• the presence of deformed areas, edema, hemorrhage, external tissue damage;
• the presence of zones that are painful to palpation.

During the examination, the doctor necessarily determines the range of movements (both active and passive), the degree of sensitivity, and also assesses the state of the peripheral circulation (color of the hands, skin temperature, pulsation). [15]

Laboratory tests are not useful in all cases. Changes in the blood picture will be observed only in inflammatory processes, or other articular pathologies that are not related to injury. So, in a biochemical study, the doctor will pay attention to the C-reactive protein in the serum, to the content of total protein. An increase in ESR will indicate the presence of inflammation. The presence of arthritis will "give out" a sharp increase in the level of uric acid, and rheumatological inflammatory diseases will manifest themselves as antinuclear antibodies in an immunological blood test.

Analysis of urine with a dislocated elbow, as a rule, does not show changes.

Instrumental diagnostics play the main role in the diagnosis of elbow dislocation. The most commonly used are X-ray examination, computed tomography, MRI, arthrography. In the overwhelming majority of cases, X-ray 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 difficult cases, you can seek help for arthrography or tomography (CT or MRI). These are more highly accurate methods that allow a detailed examination of articular pathology or injury.

Somewhat less often, with an elbow dislocation, an ultrasound of the joint is prescribed. This diagnostic procedure can be indicated for women during pregnancy, while X-ray examination is contraindicated in this period. [16]

Differential diagnosis

The most appropriate diagnostic method for each individual patient is determined by the attending physician. It takes into account the complaints of the victim, his general state of health, etc. However, sometimes it becomes difficult to immediately diagnose, since the pathology is combined, or is accompanied by other additional symptoms. In such cases, differential diagnosis of elbow dislocation with other clinically similar diseases or injuries is carried out:

• bruises of the olecranon, periarticular zone, brachial condyles and ulnar nerve;
• sprain;
• intraarticular, periarticular, closed bone fractures;
• epicondylitis (degenerative-inflammatory pathology that affects the tendon apparatus in the elbow region);
• styloiditis (inflammatory-dystrophic process in the area of attachment of the tendon to the olecranon);
• bursitis (an inflammatory reaction in the joint capsule in the posterior elbow area);
• ulnar nerve neuritis (neuropathy);
• ulnar tendonitis (an 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 dislocated elbow

In case of dislocation of the elbow, the victim needs to carry out emergency pre-medical measures:

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

After that, the victim should be transported to the nearest medical facility, and optimally to the emergency room.

With a dislocated elbow, you cannot:

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

Read more about how to adjust the elbow joint in this article .

Prevention

Basic preventive measures are attentiveness and caution. To prevent injury - in particular, elbow dislocation - you must be careful when performing any movement.

• Shoes should be as comfortable as possible, without high, unstable heels and narrow capes, which significantly increase the risk of falls and bruises. The best options are a flat sole or a wide heel up to 4 cm in height. The sole material should not slip.
• When walking, avoid slippery areas, as well as places that are not cleared of snow or covered with stones. It is preferable to walk on a clean sidewalk, and in winter - on cleared scrubbed paths. Elderly people are advised to use a cane while walking. Pregnant women should only walk when accompanied.
• Performing any movements, or just while walking, one should not rush, fuss. Do not be distracted by going up or down stairs.
• When carrying bags and other items, it is necessary to evenly distribute the load on the right and left sides.
• The habit of keeping your hands in your pockets increases the risk of losing your balance and falling.
• It is important to give up the use of alcoholic beverages, since in a state of intoxication it is easier to get not only a dislocation of the elbow, but also more severe injuries. In addition, alcohol decreases the sensitivity to pain, which entails a later visit to the doctor and, as a result, an increase in the likelihood of complications.
• If you lose your balance, you should group and relax. You can not put your hand in the direction of the fall, or land on your elbow. If the fall is inevitable, you need to try to roll to the side, as if distributing the blow.

An additional method of preventing any damage to the musculoskeletal system is to strengthen the bones. The diet should include foods high in 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 danger of complications: it lies in the fact that nerve fibers and blood vessels lie next to the joint. With an illiterate reduction or in the absence of treatment at all, the victim may develop complications:

• motor restrictions due to damage to nerves and tendons;
• tactile disturbances;
• displacement and instability of the joint, weakening of the ligaments.

With an unfavorable development of events, the recovery period is significantly increased, various negative consequences of the injury may occur. [17]

Most patients show adequate recovery. The main factor of recovery is timely seeking medical help within the first two days after elbow dislocation. An attempt to self-repair the damage, or the absence of the necessary therapy, significantly worsens the prognosis. In these cases, it is often necessary to resort to a surgical solution to the problem.