closed reduction techniques for elbow dislocations cover

Closed Reduction Techniques for Elbow Dislocations

The elbow is the second most commonly dislocated adult joint and the most commonly dislocated joint in children.  Elbow dislocations are classified as simple or complex. Simple implies a pure dislocation, although small avulsion fractures may be present up to 2 mm in diameter [1]. Complex dislocations are associated with fractures of the olecranon, radial head, or coronoid process. The goal of treatment in all dislocations is to obtain a concentric and stable reduction to allow early movement of the elbow joint and to restore function. The best available literature on this topic consists of weak epidemiologic data and small case series [2].

The elbow joint is generally very stable and requires a fairly significant amount of force to dislocate, with the most common mechanism being a fall on an outstretched arm.  Posterior or posterolateral dislocations are most common (80%) [2].  The mechanism is most commonly having the elbow hyperextend, arm abduct and forearm supinate together, which causes movement of the olecranon posteriorly.  The elbow dislocates after the ring of soft tissues surrounding the joint are compromised, including the lateral collateral ligament, anterior capsule, and medial collateral ligament. The structures are usually disrupted in that order with progressive translation from stable to perched and, finally, complete dislocation[1].

Case Vignette

While you are covering a wrestling event, a 17 year old is returned to the mat by an opposing wrestler and you observe him fall on an outstretched arm. He screamed out in pain and the match was stopped. You are called over by the athletic trainer with what seems to be an obvious elbow deformity and you have concern for an elbow dislocation. What is the age range with the highest incidence and what is the most common type of dislocation?

A) Males ages 20-30; posteromedial
B) Females ages 10-20; posteromedial
C) Males ages 10-20; posterolateral
D) Males ages 10-20; posteromedial

Epidemiology

The highest incidence occurs in males between 10 and 20 years old and has a high incidence with certain sporting events such as wrestling, snowboarding, weightlifting and football.  In a study using the National Electronic Injury Surveillance System database, approximately 44.5% of elbow dislocations were found to be sustained during sports [3].   In high school athletes, 91.3% of dislocations are found in boys, most commonly in wrestling (46.1% of dislocations) and football (37.4% of dislocations).  More than half (52%) of elbow dislocations in high school football players occur on running plays, with running backs being the most frequently the injured player (23.8%) [3]. In girls, gymnastics and skating are the most common sports resulting in elbow dislocations.

PRESENTATION AND INITIAL MANAGEMENT

In the sports medicine field, it is very possible one will encounter an elbow dislocation.  Deformity is usually obvious in the acute setting. Neurovascular examination is important before and after reduction. The ulnar nerve is the most frequently injured nerve, though there are reports of both median and radial nerve injuries.  Arterial injuries occur in 0.3% to 6% of closed elbow dislocations and in up to 33% of open elbow dislocations [4].  There is debate on whether it is appropriate to attempt reduction before any type of radiograph.  Some institutions may have x-ray available on site and it is recommended to have AP, oblique and lateral views performed.  

elbow xray lateral radiograph elbow dislocation

Image 1. Lateral radiograph of elbow demonstrating dislocation (courtesy of radiopaedia.org)

On the lateral radiograph, an ulnohumeral distance (measured from the trochlear sulcus to the olecranon) of greater than or equal to 4 mm is referred to as a positive “drop sign,” and suggests instability and may require surgical stabilization [5]. An oblique lateral view (Greenspan view) can provide better visualization of the radial head detect minimally displaced radial head, coronoid, or capitellum fractures. If these are not available and there is an experienced provider, one to two attempts are sometimes performed on site at the event and done as quickly as possible.

Closed reduction techniques

For the first technique, the reduction is performed with gentle supination and valgus stress (Figure 1). The clinician supports the hand or wrist and applies traction and flexion while the other hand is placed on the humerus to provide countertraction. The clinician’s left fingertips are placed over the tip of the dislocated ulna to guide the reduction.This maneuver re-creates the injury mechanism and replicates the deformity. Once the elbow begins to shift, longitudinal traction is applied with a varus stress and simultaneous pronation [6]. Once the elbow reduces, the forearm is held in pronation to stabilize the joint. The elbow is typically immobilized at 90° of elbow flexion, with the forearm in pronation for a posterolateral dislocation (Image 1). 

Elbow dislocation reduction 1 example

Image 2: The clinician supports the hand or wrist and applies traction and flexion while the other hand is placed on the humerus to provide countertraction. The clinician’s left fingertips are placed over the tip of the dislocated ulna to guide the reduction. Image adopted from [11].

The second technique requires a training table or elevated surface.  The patient is prone on a table with the affected extremity hanging over the side of the table. Gentle downward traction is applied at the wrist and the necessary time is taken for reduction to occur (usually between 1 and 10 minutes; forceful traction results in spasm and failure). When the olecranon is felt to perch on the humerus, the operator maintains traction on the wrist with one hand while gently lifting the humerus to flex the elbow about 20, completing the reduction (Image 2) [7].

Elbow dislocation reduction parson's technique

Image 3: Parson’s technique. Image adopted from [7].

A third technique has been described that also requires an exam table, training table or elevated surface (Image 3).  It can be used for both posteromedial and posterolateral dislocations.  The patient is placed supine, with the humerus supported by the bed and only the forearm hanging free over the table.  For a posterolateral dislocation, the provider stands on the affected side lateral to the limb.  For the posteromedial dislocation, the provider will be medial to the limb.  The wrist is held with one hand to suspend the semiflexed elbow while the other hand is positioned behind the elbow in such a way that the olecranon and the head of the radius rests on the palm, and the fingers and thumb on the sides of the prominent lower end of the humerus. 

Reduction is achieved by shifting the olecranon towards the trochlea, while the fingers and thumb stabilize the distal humerus [8]. Traction is not typically needed. In one case series, 22 out of 24 underwent a successful reduction without anesthesia if they presented within 6 hours from injury. Three of four patients underwent a successful reduction between 6 and 24 hours, but this was done with sedation [8].
Elbow dislocation reduction example 3

Image 4: Photograph showing reduction of posteromedial dislocation of the elbow by the method described. Image adopted from [8].

A fourth technique is similar in some ways to the second technique described (Figure 4).  The patient is positioned in the prone position with the affected limb dangling over the edge of the bed towards the floor.  The wrist is grasped and gentle traction is applied in the direction of the long axis of the forearm.  After muscular relaxation occurs (usually within ten mins), the olecranon is grasped with the operator’s other hand with the thumb and index finger and the olecranon is guided into a reduced position without force.  This has been referred to as the Meyn-Quigley method (named after the authors) [9].

Elbow dislocation reduction Meyn-Quigley

Image 5.  Meyn-Quigley method. Image adopted from [9].

A fifth technique is also described by Parsons and Ramsey [10].  This was described with conscious sedation with the patient in the supine position with the arm overhead.  For posterior dislocations, the elbow is hypersupinated to clear the coronoid from the distal humerus and then extended with a valgus stress applied. Pushing the olecranon distally then reduces the joint. Reduction is often noticed by a palpable clunk. Once reduction is achieved, the elbow is flexed and the forearm pronated.

Aftercare and management

Regardless of the method used, there are steps needed after a closed reduction of the elbow.  After initial reduction, the neurovascular status of the limb is reevaluated. Although the loss of neurologic function after closed reduction is rare, its presence can be an indication for surgical exploration to rule out nerve entrapment.  It can be difficult to assess the stability of the elbow without sedation, but this may be attempted depending on the athlete or patient with the forearm in pronation.  If this is not possible due to tolerance, it should be done within 3-5 days [11].  

Stability is usually compromised in full extension and with valgus stress. If the elbow is stable throughout the arc of motion when the stability examination is performed, the elbow should be splinted posteriorly for comfort at 90 degrees or slightly more. It should be splinted in pronation if it is suspected the LCL is disrupted and supination of the MCL is suspected to be disrupted. Historically, plaster splinting for 3 weeks was accepted as the method of treatment of simple elbow dislocation; however, this is associated with significant limitations in elbow range of motion [11].

Depending on the setting, it is ideal to get radiographs once the patient is splinted for post reduction films and may be repeated 3-5 days after the injury.  This is to rule out fractures and assess stability.  Careful review of post reduction radiographs should demonstrate a concentrically reduced joint. Occasionally, there is slight widening of the joint noted on post reduction radiographs without frank dislocation.  If no fracture is present and the elbow is stable on examination, early range of motion and therapy is typically started after 5 to 10 days.  If there is instability with extension, some may benefit from an extension block splint or brace for an additional 1-2 weeks.  

If instability persists or if an unstable fracture is present, surgical intervention may be needed. Many patients have an extension deficit after treatment or splinting and you will need to ensure the physical therapists are comfortable working with this injury. No clear rules exist for return to sport after an elbow dislocation. Existing publications related to return to play are case series or expert opinions. Each athlete must be treated individually based on his or her symptoms and examination. 

Return to sport should be delayed until the elbow is comfortable and has pain free near-normal range of motion with symmetric strength to the contralateral upper extremity. Valgus and posterolateral rotatory instability tests should not cause pain or apprehension before return. Most athletes can return to sport in a hinged brace within 2 to 5 weeks of a simple dislocation. In cases that require surgery, the timing of return to sport is variable in the literature, ranging from 3 to 12 months after surgery [11].

Summary

In summary, the elbow is the most commonly dislocated joint in children and second most dislocated major joint.  Most will occur in males and sports such as wrestling, football, snowboarding and weightlifting have a higher incidence.  In females, gymnastics and skating are the most high risk in regards to elbow dislocations.  Acute deformity is usually easily identified and closed reduction is sometimes attempted depending on the comfort of the provider.  

Many techniques can be used but it is very important to assess neurovascular status both before and after attempted reduction. Splinting will most cases be a posterior splint in 90 degrees in either neutral of pronation and post reduction radiographs should be performed afterwards and after 3 to 5 days. Management depends on stability of the elbow but most will begin therapy and motion 5 to 10 days after injury and most can regain full motion and strength between 2 and 5 weeks from injury for simple dislocations.

Case Conclusion

Answer C. The majority of elbow dislocations occur in males that are between the ages of 10-20 and is the most commonly dislocated joint in pediatric patients and the overall second most common dislocated joint. Males have a much higher incidence when compared to females and high risk sports include football, wrestling and snowboarding. Around 80 percent of elbow dislocations are posterolateral.

– More Elbow Pain from Sports Medicine Review: https://www.sportsmedreview.com/by-joint/elbow/

– Parsons BO, Ramsey ML. Acute elbow dislocations in athletes. Clin Sports Med. 2010 Oct;29(4):599-609.

References

 

  1. Robinson PM, Griffiths E, Watts AC. Simple elbow dislocation. Shoulder Elbow. 2017;9(3):195-204. doi:10.1177/1758573217694163
  2. Mayne IP, Wasserstein D, Modi CS, Henry PD, Mahomed N, Veillette C. The epidemiology of closed reduction for simple elbow dislocations and the incidence of early subsequent open reduction. J Shoulder Elbow Surg. 2015 Jan;24(1):83-90. doi: 10.1016/j.jse.2014.08.027. Epub 2014 Oct 29. PMID: 25440518.
  3. Dizdarevic I, Low S, Currie DW, et al. Epidemiology of elbow dislocations in high school athletes. Am J Sports Med 2015;44(1):202–8.
  4. Marcheix B, Chaufour X, Ayel J, et al. Transection of the brachial artery after closed posterior elbow dislocation. J Vasc Surg 2005;42(6):1230–2.
  5. . Coonrad RW, Roush TF, Major NM, et al. The drop sign, a radiographic warning sign of elbow instability. J Shoulder Elbow Surg 2005;14(3):312–7

6.Skelley NW, McCormick JJ, Smith MV. In-game Management of Common Joint Dislocations. Sports Health. 2014;6(3):246-255. doi:10.1177/1941738113499721

  1. PARVIN RW. Closed Reduction of Common Shoulder and Elbow Dislocations Without Anesthesia. AMA Arch Surg. 1957;75(6):972–975. 
  2. Bhan, S., Mehara, A.K. A method of closed reduction of posterior dislocation of the elbow. International Orthopaedics 18, 271–272 (1994).
  3. Meyn, Malcolm A. Jr. M.D.*; Quigley, Thomas B. M.D.** Reduction of Posterior Dislocation of the Elbow by Traction on the Dangling Arm, Clinical Orthopaedics and Related Research: September 1974 – Volume 103 – Issue – p 106-108
  4. Parsons BO, Ramsey ML. Acute elbow dislocations in athletes. Clin Sports Med. 2010 Oct;29(4):599-609.
  5. Morris MS, Ozer K. Elbow Dislocations in Contact Sports. Hand Clin. 2017 Feb;33(1):63-72.
  6. Skelley NW, McCormick JJ, Smith MV. In-game Management of Common Joint Dislocations. Sports Health. 2014;6(3):246-255.