Posterior Elbow Dislocation
- 1 Definition/Description
- 2 Epidemiology /Etiology
- 3 Classification
- 4 Characteristics/Clinical Presentation
- 5 Differential Diagnosis
- 6 Examination
- 7 Medical Management
- 8 Physiotherapy Management
- 9 Complications post reduction
- 10 Resources
- 11 Clinical Bottom Line
- 12 References
Specifically, the olecranon process of the ulna moves into the olecranon fossa of the humerus and the trochlea of the humerus is displaced over the coronoid process of the ulna. PED is classified as simple or complex and staged according to severity.
In children under 10 years, PEDs are the most common type of joint dislocation.
Elbow dislocations annually affect between 6 and 7 people per 100,000. Approximately 90% of all elbow dislocations are directionally classified as posterior or posterolateral and are more commonly seen in the non-dominant upper limb.
Typically, elbow dislocation is caused by a traumatic fall onto an outstretched hand resulting in an hyper-extension injury. However, more recent research has suggested that axial compression, elbow flexion, valgus stress, and forearm supination lead to a rotational displacement of the ulna on the distal humerus. If there is not sufficient valgus/varus distraction on the joint at the time of trauma it is likely a coronoid fracture will also occur.
PED can be classified as simple or complex.
- A simple dislocation is classified as a dislocation without the presence of a fracture.
- A complex dislocation has related fractures.
- Fractures may exist on the radial head, coronoid process, olecranon, humeral condyles, or capitellum.
- These fractures may lead to disruption of the medial collateral ligament (MCL), lateral collateral ligament (LCL), or interosseous membrane.
- 'Terrible triad' is a term used to describe a severe complex dislocation with intra-articular fractures of the radial head and coronoid process. Elbow dislocations are staged depending on the disruption of the following stabilizers: the ulnohumeral articulation, MCL, and LCL.
The clinical presentation may include:
- Popping sensation on immediate injury
- Reduced AROM
- Swelling - the olecranon may be prominent creating a divot over distal triceps
- Joint line tenderness on palpation
- Recurrent dislocations can occur if a ligament injury is also sustained
To diagnose PED, radiographs in the anterior, posterior, and lateral views with valgus stress are obtained.
|Insufficiency of the ulnar LCL||
Traumatic forces through radial head, humeral condyles, coronoid process, olecranon, or capitellum
|Compartment Syndrome||Fractures, swelling, casting, trauma||
|Complex Regional Pain Syndrome (CRPS)||Unknown||
Physical therapy examination should include:
- Observation - specifically deformities
- Vascular screen - palpation of brachial, radial and ulnar arteries
- Neuromuscular screen - dermatomes, myotomes and reflexes including upper limb neuro-tension tests (if tolerated by patient)
- Palpation - It is essential to palpate for associated fractures in the elbow complex. The elbow extension sign can be used to rule out a fracture.
- Muscle testing
- Ligament integrity tests - varus and valgus stress test, the lateral pivot-shift test/ apprehension test (Posterolateral Rotational Instability Test).
Radiographs are indicated when there is no response to care after four weeks of conservative treatment, significant activity restriction for more than four weeks, or non-mechanical pain is present.
- Irreducible dislocation
- Instability (recurrent instability may indicate a ligamentus repair
- Elbow stiffness
- Neuro-vascular injury
- Ulnar nerve release,
- Humeroulnar reduction
- Humeroradial reduction,
- Triceps lengthening using Speed's procedure
- Wires and/or screws placed in the olecranon for stabilising the joint.
- Ligamentus repairs with sutures
Once surgery is complete, the patient is typically immobilised with time frames varying based on the individual and the surgeon's protocol. Some patients may be allowed to actively move the elbow immediately post op, however this will depend on the surgeon.
Hinged braces, fixators, plaster casts, and slings are utilised to keep the elbow in a position of approximately 70-80o of flexion and slight pronation.
While conservative treatment approaches to PED can vary depending on the level of tissue involvement, there are key elements to consider throughout the clinical decision-making process. PED can occur on a continuum of severity; therefore, the treatment must be diverse as well.
Treatment can vary from aggressive immediate AROM to traditional plaster immobilisation for several days depending on orthopaedic intervention. If a fracture occurs secondary to dislocation, intra-articular bone fragments and fracture position may dictate treatment.
Following a typical reduction with no fracture:
- Immobilisation: typically involves the use of a posterior splint at 45-90o of elbow flexion for three days to three weeks.Throughout the immobilisation phase, wrist and shoulder function should be maintained through ROM and strengthening exercises. Inflammation is a common following PED and can be addressed using PRICE protocols.
- After the immobilisation phase physiotherapy begins with gentle AROM and PROM exercises in a pain-free range targeting the entire upper limb.
- When pain is no longer a barrier to treatment, functional progressive resistance exercises should be implemented to improve total upper limb muscle strength and endurance.
- Therapeutic goals in the later phase of rehabilitation include attaining full ROM and strength capabilities of the entire affected arm, suppression of pain, and restoration of functional abilities to pre-injury level.
- A patient is able to return to functional activities around twelve weeks and sports around six months.
Complications post reduction
There can be detrimental effects of prolonged immobilisation including flexion contractures, enhanced perception of pain, and increased duration of disability, all of which prolong the rehabilitation process.
When treating a post-surgical PED patient, physical therapists should be cautious of pin site infection.
Although full extension should be a goal of rehabilitation, care must be taken to protect the vulnerable elbow and avoid hyperextension. It is important to be cautious during passive mobilisation and ROM.
Clinical Bottom Line
It is important to explore the level of severity and degree of complication associated with each PED since this dictates the patients' prognoses. Patients who have had simple PED with early reduction usually have good outcomes.
In most cases, there is potential for developing instability and degenerative joint disease.
Overall the best treatment for PED is initial short term restricted ROM (usually two weeks or less) followed by early mobilisation including PROM, progressing to AROM and functional strengthening. This can allow for more rapid return to work and or sport.
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