Elbow Dislocation and Reduction

imagesClinical suspicion of acute anterior, posterior, lateral, medial, or divergent dislocation with or without neurovascular compromise


   imagesThe clinical presentation depends on the type of dislocation


   imagesSuspected dislocation is clinically confirmed by disruption of the relationship between the tip of the olecranon and the distal epicondyles of the humerus in comparison with the unaffected elbow


imagesRadiographic evidence of anterior, posterior, lateral, medial, or divergent dislocation (FIGURE 65.1)


CONTRAINDICATIONS



imagesOpen dislocations require emergent consultations with an orthopedic surgeon


imagesMultiple failed reduction attempts with adequate sedation should prompt consultation with an orthopedic surgeon


imagesIrreducible elbow dislocations may require operative management


imagesAn elbow that has been unreduced for 7 or more days will likely require open reduction with an orthopedic surgeon


RISKS/CONSENT ISSUES



imagesProcedural sedation may be associated with loss of airway reflexes and respiratory arrest (these risks are extremely rare)


imagesSoft-tissue injury may occur with reduction attempts


imagesFractures and neurovascular injury may occur with reduction attempts



imagesGeneral Basic Steps


   imagesObtain necessary x-rays


   imagesSedation/Analgesia


   imagesPosition patient


   imagesReduction


   imagesPostprocedure exam/x-rays



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FIGURE 65.1 Posterior dislocation of the olecranon. (From Campbell C. Elbow dislocation. In: Greenberg MI, ed. Greenberg’s Text-Atlas of Emergency Medicine. Philadelphia, PA: Lippincott Williams & Wilkins; 2005:492, with permission.)



images


FIGURE 65.2 Elbow anatomy. (From McCue FC III, Sweeney T, Urch S. The elbow, wrist, and hand. In: Perrin DH, ed. The Injured Athlete. 3rd ed. Philadelphia, PA: Lippincott Williams & Wilkins; 1999, with permission.)


TECHNIQUE



imagesPerform a complete neurovascular check before any reduction attempt


imagesObtain radiographs of the affected joint and consider radiographs of one joint above and below the injury (shoulder and wrist)


   imagesComplex dislocations (those with associated fractures) may require consultation with orthopedic surgery


   imagesDislocations with neurovascular compromise should be reduced without prior imaging


imagesAnesthesia/analgesia: Consider parenteral analgesics. Reduction may also be attempted with injection of local anesthetic alone into the elbow joint or an ultrasound-guided brachial plexus block


imagesReduction technique is determined by the type of dislocation


TECHNIQUE: POSTERIOR DISLOCATION



images80% to 90% of all elbow dislocations


imagesMechanism of injury: Most commonly caused by a fall on an outstretched hand with the arm in extension


imagesClinical presentation: Shortened forearm that is held in flexion with a prominent olecranon posteriorly. In addition, a defect may be palpable above the olecranon (FIGURE 65.2).


imagesAssociated injuries:


   imagesFractures including radial head and coronoid process are common


   imagesSmall fractures of the coronoid process may be treated as simple posterior dislocations


   imagesNeurologic symptoms accompany 15% to 22% of dislocations


      imagesUlnar nerve injury is most common followed by median nerve injury


      imagesRadial nerve injury commonly occurs when the dislocation is complicated by radial head fracture


      imagesTraction leading to stretch injury, local swelling, and entrapment during reduction are common causes of nerve injury


   imagesBrachial artery injury occurs in 5% to 13% of posterior dislocations


imagesReduction Techniques


   imagesSupine Technique


      imagesPlace patient in supine position


      imagesAn assistant stabilizes the humerus by wrapping both hands around arm just distal to axilla


      imagesThe physician grasps the wrist with one hand and places the other hand just above the antecubital fossa with the thumb on the olecranon (FIGURE 65.3)


      imagesThe physician applies slow, steady in-line traction while the assistant applies steady countertraction


      imagesTo minimize additional trauma to the coronoid process, the elbow is held in slight flexion and the wrist is held in supination as traction is applied


      imagesAvoid hyperextension as this may cause injury to the median nerve or brachial artery


      imagesReduction is accompanied by a “clunk” that is heard or felt


      imagesAlternatively, the forearm may be gently flexed in an effort to reduce the joint


   imagesSeated Technique


      imagesPatient is seated in a high backed chair with arm hanging over the back of the chair in a flexed position


      imagesThe physician applies traction by gently pulling down on the patient’s hand while guiding the olecranon into place using the other hand


      imagesThe physician may also elect to simply apply downward pressure onto the olecranon to reduce the elbow


      imagesReduction is once again signaled by a “clunk”


      imagesThis method has the advantage of requiring only a single physician



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FIGURE 65.3 Technique for reduction of posterior dislocation of the elbow. (From Perron AD, Germann CA. Elbow injuries. In: Wolfson AB. Harwood-Nuss’ Clinical Practice of Emergency Medicine. 6th ed. Philadelphia, PA: Lippincott Williams & Wilkins; 2015:260, with permission.)

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Aug 9, 2016 | Posted by in EMERGENCY MEDICINE | Comments Off on Elbow Dislocation and Reduction
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