A Posterior Elbow Dislocation is a type of injury in the elbow joint often occurs when a person falls on an outstretched hand, posteriorly directed force, trauma, gunshot wound, motorbike accident, playing cricket, athlete at the elbow joint causes dislocation at the ulnohumeral and radiocapitellar articulations. Valgus force may commonly see posterolateral elbow dislocation. [rx][rx][rx] Anterior elbow dislocations also occur when the elbow is flexed position, and there is a direct blow on the posterior aspect of the elbow.
Pathophysiology
Considering elbow anatomy and therefore the likely mechanism of injury-causing an elbow dislocation can help one understand the pathophysiology related to this particular injury. During a posterior elbow dislocation, the shearing forces causing the injury may cause associated radial head, radial neck or processus coronoideus fractures. The medial collateral and lateral collateral ligaments provide support to the elbow additionally to its bony anatomy. The LCL is usually disrupted when an elbow dislocation occurs; the MCL is the last soft tissue structure injured because the ulna is displaced. Often, the flexor-pronator mass could also be ruptured, and infrequently the brachialis could also be injured.
The anterior compartment of the elbow encompasses the arteria brachialis and ulnar and median nerves. These structures are particularly susceptible to injury because the anterior compartment is usually disrupted during posterior dislocation. The cubital nerve may become entrapped because it passes posteriorly around the medial epicondyle. The arteria brachialis and median nerve travel closely to at least one another and injuries are often seen in both these structures simultaneously.
Anterior dislocations are often related to olecranon fractures. These dislocations can also disrupt the posterior elbow compartment which contains the nervus radialis and insertion of the triceps muscle.
Causes Of Posterior Elbow Dislocation
In general, elbow trauma, and dislocation can subdivide into the following categories:
Traumatic injuries
- Soft tissue injuries range from mild, moderate, superficial soft tissue injuries (e.g., simple contusions, strains, or sprains) to traumatic arthrotomies such as gunshot wounds or penetrating lacerations
- The osseoligamentous spectrum of injury compasses fractures, fracture-dislocations, ligamentous injuries, cartilage degeneration, and simple versus complex dislocation patterns
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Simply refers to no major, and associated fracture accompanying the dislocation
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“Complex” refers to an associated fracture in the tendon, cartilage, ligament, bursa, synovium accompanying the dislocation.
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Terrible triad elbow injuries
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Elbow dislocation is typically posterolateral direction with associated LCL ligament complex injury. Elbow dislocation is the two most common dislocated joint after the shoulder and the most are posterior dislocations
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A radial head/neck fracture
- Coronoid fracture
- Attritional injuries – Encompasses acute, subacute, or chronic presentations following various repetitive motion mechanisms
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Often seen in athletes, cricket players, involved in any upper extremity sport-related activity requiring repetitive motions (e.g., overhead throwers/baseball pitchers, tennis)
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Manual laborers with analogous occupational repetitive injury, demands.
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Direct Traumatic injuries
- Direct traumatic injuries range from simple contusions to more complex osseoligamentous injury, fracture-dislocation patterns. The latter is often seen following a fall on an outstretched hand, during the accident while the forearm is supinated and the elbow is either partially flexed or fully extended position
Attritional injuries
- Another form of dislocation and elbow injury consists of the subacute-to-chronic variety that occurs secondary to repetitive motions, eventually leading to various tendinosis injury conditions. These can include but are not limited to, lateral epicondylitis (tennis elbow), and chronic partial UCL injuries or strains, sprain.[rx][rx]
Pediatric considerations
- Elbow trauma in children most commonly occurs via sport or following falls, in cricket-playing, athletes. Moreover, careful attention during the dislocation is necessary, given the characteristic sequence of ossification of bone center appearance and fusion, which can make the radiographic assessment become challenging and encountered pediatric elbow fractures include (but are not limited to)[rx]
Supracondylar fractures
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Most common in children peak ages 5 to 10 years old, rarely occurs at greater than 15 years
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Extension type (98%) – fall on an outstretched hand with fully extended or hyperextended arm position Type 1: minimal or no displacement type 2: slightly displaced fracture, dislocation posterior cortex intact type 3: totally displaced fracture, the posterior cortex is broken permanently.
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Flexion type – blow directly to a flexed elbowType 1: minimal or no displacement type 2: slightly displaced fracture, anterior cortex intact type 3: totally displaced fracture, the anterior cortex is broken
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Lateral condyle fractures
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Medial epicondyle fractures
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Radial head and neck fractures – Usually indirect mechanism such as fall on an outstretched hand, and the radial head being driven into capitalism directly.
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Olecranon fractures
Another common elbow injury in children
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Subluxated radial head (nursemaid’s elbow dislocation) and accounts for 20% of all upper extremity injuries in children
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Peak age 1 to 4 years; occurs more frequently in females than males
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Mechanism of injury: sudden longitudinal pull on the forearm with forearm pronated position
Signs And Symptoms Of Posterior Elbow Dislocation
Symptoms include:
- The child stops using the arm due to dislocation, which is held in extension (or slightly bent) and palms down.[rx]
- Minimal swelling, edema, and symptoms include pain and tenderness on the inside of the elbow.
- All movements can be done except supination.
- Intense pain on the outer part of the elbow (lateral epicondyle)
- Tenderness is found over the lateral epicondyle—a prominent part of the bone on the outside of the elbow joint
- Pain from gripping strongly and movements of the wrist limited, especially wrist extension (e.g. turning a screwdriver) and lifting movements[rx]
- Sudden intense pain at the back of the elbow joint will be felt at the time of injury.
- The patient will in most cases not straighten the elbow.
- Rapid swelling and bruising may start to appear after posterior elbow dislocation. Trying to move the elbow will be painful and the back of the elbow will be intense tender to touch.
- Caused pain by longitudinal traction with the wrist in pronation, above all in a series, only 51% of people were reported to have this mechanism, with 22% reporting falls, and patients less than 6 months of age indicate to have the injury after rolling over in bed.
- Bruising and swelling may be present for more severe posterior elbow dislocation injuries.
- Impact injuries in posterior elbow dislocation causing damage to the medial ligament usually involve a lateral force (towards the outside) being applied to the forearm, placing the medial (inner) joint under stress.
- The patient presents with swelling, tenderness over the lateral elbow with a limited range of motion, particularly forearm rotation and elbow extension ± elbow effusion and bruising, and pain is increased with passive rotation.
- The most reliable and accurate clinical sign is point tenderness over the radial head.
- Needs careful assessment for nerve and vascular involvement, especially with brachial artery, median and ulnar nerves.
- It is important to detect crepitation or a mechanical blockage of motion in older age people from displaced fracture fragments. This often requires aspiration of fluid a haemarthrosis with the installation of a local anesthetic for pain relief.
- If there is significant wrist pain, central forearm pain, and there may be acute longitudinal radioulnar dissociation with disruption of the distal radioulnar joint.
- Overuse injuries of the MCL may occur. Repetitive motions types movement that places a lot of stress on the inner elbow can cause damage to the ligament. For example, throwers types (track and field and ball sports such as baseball) are prone to this injury.
Diagnosis Of Posterior Elbow Dislocation
History
All patients experiencing a traumatic injury, dislocation should first be assessed head to toe, if any life or limb-threatening injuries first. Obvious bony deformities in previous time injury, dislocation may distract both the patient and the practitioner from more serious traumatic injuries.
The initial history of posterior elbow dislocation should consist of the mechanism of injury and the duration of the injury until the initial presentation to your doctor. The patient should be asked if this is a first-time occurrence or if there have been previous elbow injuries recorded in the past. A physician should also want to know symptoms suggesting a neurovascular compromise in posterior elbow dislocation and inquire about numbness, tingling, or coolness of the distal extremity.
Physical Examination
The physical examination should begin with an inspection of the elbow joint looking for swelling, deformity, or bruising. Posterior elbow dislocations often present with an upper extremity that is flexed and appears shortened. The motor function of the elbow joint in should be assessed by observing a range of motion. Particular attention should be given to the distal radioulnar joint for tenderness, swelling which can indicate disruption of the intraosseous ligament, eponymously referred to as an Essex-Lopresti lesion.
The examiner should also perform and document relevant findings, including:
- Skin integrity is normal or critical when assessing for the presence of an open fracture and/or traumatic arthrotomy
- Presence of swelling or effusion, tenderness.
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Comprehensive neurovascular examination to investigate more complex or not
How the patient carries their arm may give clues to the diagnosis.
Bony Injuries
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Supracondylar fracture
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Flexion type
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Patient supports injured forearm with other arm and elbow in 90º flexion
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Loss of olecranon prominence
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Extension type
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Patient hold arm at side in S-type configuration
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Soft Tissue Injuries
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Elbow dislocations:
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Posterior: abnormal prominence of olecranon
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Anterior: loss of olecranon prominence
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Radial head subluxation
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Elbow slightly flexed and forearm pronated resists moving the arm at the elbow
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Sensory And Motor Testing Of The Median And Ulnar Nerves
Median
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Test for sensory function
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Two-point discrimination over the tip of the index finger.
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Test for motor function
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“OK” sign with thumb and index finger and abduction of the thumb (recurrent branch)
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Ulnar
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Test for sensory function
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Two-point discrimination of the little finger
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Test for motor function
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Abduct index finger against resistance
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Radiological Test
Radiographic tests that is necessary for all patients presenting with varying degrees of posterior elbow dislocation include:
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Anteroposterior (AP) elbow
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Lateral elbow
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Oblique views (optional, depending on fracture/injury)
- Traction view (optional, can facilitate the assessment of comminuted types fracture patterns)
- Ipsilateral shoulder to wrist orthogonal views should be assessed
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Especially in the setting of high energy trauma in posterior elbow dislocation or when exam and evaluation are limited
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Fat pad sign
- Seen with intra-articular or extra-articular injuries
- Normally, the anterior fat pad is seen a narrow radiolucent strip anterior to the humerus
- The posterior fat pad is normally not visible in most cases
- Anterior fat pad sign indicates joint effusion, edema injury when raised and becomes more perpendicular to the anterior humeral cortex (sail sign)
- Posterior fat pad sign indicates effusion/injury in posterior elbow dislocation adults, posterior fat pad sign without other obvious fracture in radial head fracture, In children, it saw the supracondylar fracture
Pediatric Considerations
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Fractures in children often occur in unossified cartilage, tendon making radiographic interpretation confusing
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A line of unsaturation drawn down in the anterior surface of the humerus should always be seen the capitellum in lateral view.
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If any bony relationship appears on radiographs, obtain a comparison view of the uninvolved elbow joint.
- Suspect nonaccidental trauma if history does not tip injury.
- Ossification centers: 1 appear: (CRITOE)
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Capitellum 3 to 6 months
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Radial head 3 to 5 years
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Medial (Internal) epicondyle 5 to 7 years
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Trochlea 9 to 10 years
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Olecranon 9 to 10 years
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Lateral Epicondyle
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It is essential for bilateral radiographic imaging in pediatric cases.
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A nurse’s elbow may reduce spontaneously when the patient supinates the arm.
Advanced Imaging Sequences
Computerized tomography (CT) scans are the confirmed test of comminuted fracture patterns for pre-operative surgical planning. Magnetic resonance imaging (MRI) can be an option type of test that is done when soft tissue and ligamentous injury evaluation, or when suspecting stress or occult fractures.[rx][rx][rx]
Treatment of Posterior Elbow Dislocation
Initial treatment of simple, closed posterior elbow dislocations is a closed reduction types treatment. Some complex elbow dislocations may initially be treated with closed reductions; however, associated fracture or complex fractures implies significant soft tissue damage and likely persistent instability for a long time which may require open reduction and internal fixation to improve outcomes. Open dislocations will require extensive washout and cleaning during an open reduction. Any dislocation or posterior elbow dislocation with signs of neurovascular compromise requires immediate closed reduction.[rx][rx]
Your doctors sometimes recommend very different treatments for both dislocation or posterior dislocation. According to the studies done so far, the following treatments can help:
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Rest, ice, protection, elevation to prevent fluid accumulation
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Physical therapy when appropriate – Eccentric exercises for lateral epicondylitis, dislocation or posterior dislocation
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Braces/bandages – These are worn around the elbow or on the forearm to take the strain off the muscles in dislocation or posterior elbow dislocation.
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Extracorporeal shockwave therapy (ESWT) – A device that generates shock or pressure waves dislocation or posterior elbow dislocation that are transferred to the tissue through the skin. This is help to improve the circulation of blood in the tissue and speed up the healing process.
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Laser therapy – The tissue is treated with concentrated beams of light in laser types treatment. This is supposed to stimulate the circulation of blood and the body’s cell metabolism that help to heal.
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Stretching and strengthening exercises – Special exercises that stretch and strengthen the muscles of the arm and wrist to keep the original range of motion, movement.
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Manual therapy – This includes active and passive exercises, as well as massages therapy with various types of gliding movement, deep transverse friction, PNF, Mulligan concept, etc.
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Ultrasound therapy – The arm is exposed to high-frequency sound waves therapy to heal up quickly. This warms the tissue, which improves the circulation of blood in the elbow joint.
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Transcutaneous electrical nerve stimulation (TENS) – TENS devices transfer electrical impulses to the nervous system through the skin to activate the nervous system and superficial muscle. These are stopped to keep the pain signals from reaching the brain.
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Acupuncture – The acupuncture needles are inserted into certain types of pain points on the surface of the arm. Here, too, the aim is to erase the perception of pain.
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Cold – The elbow is regularly cooled with ice packs.
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Massages –A massage technique called transverse friction massage is often used to treat tennis elbow and golfer’s elbow and posterior elbow dislocation. It is applied to certain tendons and muscles, using the tips of one or two fingers.
Do no HARM for 72 hours after injury
- Heat—hot baths, electric heat, saunas, heat packs, etc has the opposite effect on the blood flow. Heat may cause more fluid accumulation in the fracture joints by encouraging blood flow. Heat should be avoided when inflammation is developing in the acute stage. However, after about 72 hours, no further inflammation is likely to develop and heat can be soothing.
- Alcohol stimulates the central nervous system that can increase bleeding and swelling and decrease healing.
- Running, and walking may cause further damage, and causes healing delay.
- Massage also may increase bleeding and swelling. However, after 72 hours of your fracture, you can take a simple message, and applying heat may be soothing the pain.
Medication
The following medications may be considered by your doctor to relieve acute and immediate pain, long term treatment
- Antibiotic – Cefuroxime or Azithromycin, or Flucloxacillin or any other cephalosporin/quinolone, meropenem antibiotic must be used to prevent infection or clotted blood removal to prevent further swelling, inflammation, and edema.
- NSAIDs – Prescription-strength drugs that reduce both pain and inflammation. Pain medicines and anti-inflammatory drugs help to relieve pain and stiffness, allowing for increased mobility and exercise. There are many common over-the-counter medicines called non-steroidal anti-inflammatory drugs (NSAIDs). They include first choice NSAIDs is Ketorolac, then Etoricoxib, then Aceclofenac, naproxen.
- Muscle Relaxants – These medications provide relief from spinal muscle spasms, spasticity. Muscle relaxants, such as baclofen, tolperisone, eperisone, methocarbamol, carisoprodol, and cyclobenzaprine, may be prescribed to control postoperative muscle spasms, spasticity, stiffness, contracture.
- Calcium & vitamin D3 – To improve bone health, blood clotting, helping muscles to contract, regulating heart rhythms, nerve functions, and healing fractures. As a general rule, too absorbed more minerals for men and women age 50 and older should consume 1,200 milligrams of calcium a day, and 600 international units of vitamin D a day to heal back pain, fractures, osteoarthritis.
- Neuropathic Agents – Drugs(pregabalin & gabapentin) that address neuropathic—or nerve-related—pain. This includes burning, numbness, tingling sensation, and paresthesia.
- Glucosamine & Diacerein, Chondroitin sulfate – can be used to tighten the loose tendon, cartilage, ligament, and cartilage, ligament regenerates cartilage or inhabits the further degeneration of cartilage, ligament. The dosage of glucosamine is 15oo mg per day in divided dosage and chondroitin sulfate approximately 500mg per day in different dosages, and diacerein minimum of 50 mg per day may be taken if the patient suffers from osteoarthritis, rheumatoid arthritis, and any degenerative joint disease.[rx]
- Topical Medications and essential oil – These prescription-strength creams, gels, ointments, patches, and sprays help relieve pain and inflammation in acute trauma, pain, swelling, tenderness through the skin. If the fracture is closed and not open fracture then you can use this item.
- Antidepressants – A drug that blocks pain messages from your brain and boosts the effects of endorphins in your body’s natural painkillers. It also helps in neuropathic pain, anxiety, tension, and proper sleep.
- Corticosteroids – Also known as oral steroids, these medications reduce inflammation. To heal the nerve inflammation and clotted blood in the joints.
- Dietary supplement – To eradicate the healing process from fracture your body needs a huge amount of vitamin C, and vitamin E. From your dietary supplement, you can get it, and also need to remove general weaknesses & improved health.
- Cough Syrup – If your doctor finds any chest congestion or fracture-related injury in your chest, dyspnoea, post-surgical breathing problem, then advice you to take bronchodilator cough syrup.
What To Eat and What to avoid
Eat Nutritiously During Your Recovery
All bones and tissues in the body need certain micronutrients in order to heal properly and in a timely manner. Eating a nutritious and balanced diet that includes lots of minerals and vitamins is proven to help heal broken bones and all types of fractures. Therefore, focus on eating lots of fresh food produce (fruits and veggies), whole grains, cereal, beans, lean meats, seafood, and fish to give your body the building blocks needed to properly repair your fracture. In addition, drink plenty of purified mineral water, milk, and other dairy-based beverages to augment what you eat.
- Broken bones or fractures bones need ample minerals (calcium, phosphorus, magnesium, boron, selenium, omega-3) and protein to become strong and healthy again.
- Excellent sources of minerals/protein include dairy products, tofu, beans, broccoli, nuts and seeds, sardines, sea fish, and salmon.
- Important vitamins that are needed for bone healing include vitamin C (needed to make collagen that your body essential element), vitamin D (crucial for mineral absorption, or machine for mineral absorber from your food), and vitamin K (binds calcium to bones and triggers more quickly collagen formation).
- Conversely, don’t consume food or drink that is known to impair bone/tissue healing, such as alcoholic beverages, sodas, fried fast food, most fast food items, and foods made with lots of refined sugars and preservatives.
Attritional injuries management modalities
Injections into the elbow with various substances, such as Botox, hyaluronic acid, or autologous blood (the body’s own blood) to prevent accumulation of blood in the elbow joint and prevent contracture, muscle spasm.
Most of these injections contain one of the following active ingredients. These include but are not limited to[rx][rx][rx]:
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Platelet-rich plasma (PRP) considerations – 2016 study noted efficacy in managing dislocation or posterior elbow dislocation insufficiency but effective.
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Hyaluronic acid – A substance made by the body, found in tissue and joints. it’s typically wont to treat osteoarthritis. One study suggests that mucopolysaccharide could be effective within the treatment of lateral epicondylitis. But further research is required to assess its pros and cons.
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Botox – inhibits the sending of signals between the nerve cells. This features a paralyzing effect on the muscles. consistent with studies done on this thus far, Botox can relieve the pain just a touch at the most. Also, Botox injections can have side effects like partial paralysis within the fingers which will last several weeks.
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Autologous blood injections – Blood is taken from a vein within the arm then injected into the elbow. This blood could also be treated in several ways before it’s injected. One common sort of treatment with autologous blood is named platelet-rich plasma (PRP) therapy. It involves separating the blood into its various elements during a centrifuge. Then a concentrated solution of blood platelets is injected into the elbow. there’s no evidence that treatment using autologous blood is effective.
Surgery Technique or Approaches to the Reduction
There are two common approaches to the reduction of a posterior elbow dislocation. it’s recommended the primary technique is attempted within the prone position. With the patient laying down the affected arm is abducted with an elbow on the sting of the cart. The wrist is then grasped and therefore the forearm is placed in slight supination while gentle traction is applied. The processus coronoideus must be distracted and disengaged from the olecranon fossa. Once this has been accomplished downward pressure with the opposite hand on the olecranon should reduce the dislocation with the operator feeling a confirmatory clunk. A two-person technique is additionally described where one operator applies downward traction at the wrist, and the other applies the downward force onto the olecranon with both their thumbs.
The alternative method is performed with the patient seated or lying supine on the cart. An assistant stabilizes the affected humerus while the operator flexes the elbow, supinates the wrist slightly, and applies distal and downward traction at the wrist with one hand. the opposite hand is placed just distal to the elbow on the volar aspect of the forearm applying slow, gentle inline traction until the confirmatory clunk is appreciated.
Following a reduction of the dislocation, a neurovascular examination should be performed to spot improvement in any previous neurovascular symptom or a replacement symptom that will have manifested following the reduction. The elbow should be held in 90 degrees of flexion for five to 10 days followed by a lively range of motion. Earlier range of motion has demonstrated better physical outcomes. Dislocations that appear more unstable may require up to three weeks of splinting and a selected range of motion plan. Post-reduction films should be obtained.
References
