How does a dislocation occur?
The elbow joint is formed by three bones and is held in place by strong collateral ligaments and a capsule. When falling on an outstretched and slightly abducted arm, the force is transmitted along the forearm, the elbow hyperextends, and the bones of the forearm slide back. The ligaments are torn and the capsule is stretched. If the trauma energy is high, the radial head and coronoid process fracture simultaneously—this combination is called an unstable triad and is treated differently than a simple dislocation. In young children, a special variant occurs - subluxation of the head of the radial bone when sharply pulling the arm.
- Posterior forearm dislocation is the most common variant
- Anterior and lateral dislocations are rare
- Rupture of the collateral ligaments and joint capsule
- Combination with a fracture of the radial head and coronoid process
- Subluxation of the radial head in children under 5 years of age
- Possible damage to nerves and blood vessels
Symptoms
The pain occurs instantly and is very intense. The hand is in a forced position - slightly bent, the victim supports it with his healthy hand and does not allow him to touch it. The elbow appears deformed: the olecranon process protrudes from behind, and the usual bony landmarks are displaced. Active movements are impossible, passive ones are sharply painful and springy. The swelling increases quickly. Be sure to check the pulse in the wrist, the color and temperature of the hand, as well as the movements and sensitivity of the fingers - this is done before and after reduction.
- Sharp pain and inability to move
- Visible elbow deformity
- Forced half-bent position of the arm
- Spring resistance when trying to move
- Rapidly increasing swelling
- Numbness of fingers due to nerve damage
First aid
The main rule is not to try to straighten the joint yourself and not to jerk your hand. Inept attempts can damage blood vessels and nerves or turn a non-displaced fracture into a displaced one. The hand needs to be fixed in the position in which it is located with a handy scarf or splint, cold applied through the fabric and the person taken to the emergency room as quickly as possible. Rings and bracelets are removed immediately before swelling increases. You should not eat or drink before the examination: pain relief or anesthesia may be required.
- Do not adjust the joint yourself
- Secure your hand with a scarf in a comfortable position
- Apply cold through the cloth
- Remove rings and bracelets
- Do not eat or drink until examined by a doctor
- Go to the emergency room immediately
Diagnosis and reduction
Before reduction, an x-ray of the elbow joint is required in two projections so as not to miss fractures. The reduction is performed by a doctor under sufficient anesthesia, often intravenous, with gentle axial traction followed by flexion. After reduction, the image is repeated, the stability of the joint and the condition of the nerves and blood vessels are checked. If the images reveal fractures of the head of the radius or coronoid process, a computed tomography scan is additionally prescribed to plan the operation. MRI and ultrasound are used if significant ligament damage is suspected.
- X-ray before reduction in two projections
- Reduction under anesthesia by a doctor
- Control image after reduction
- Checking joint stability
- CT scan for associated fractures
- Assessing the condition of the nerves and pulse before and after the procedure
Treatment after reduction and rehabilitation
In case of a simple stable dislocation, the arm is fixed in flexion with an orthosis or splint for only a few days, a maximum of 1–2 weeks: prolonged immobility is the main cause of persistent stiffness. Then active movements begin in a safe range, gradually increasing extension. Passive forced stretching and massage of the joint are contraindicated; they provoke the formation of bone tissue in the muscles. In case of instability, fractures and repeated dislocations, an operation is performed: the ligaments are restored, the head of the radial bone is fixed or replaced, and sometimes a hinged external fixation device is used.
- Short fixation with an orthosis for several days
- Early start of active movements
- Gradual increase in extension without violence
- Refusal of rough massage and passive stretching of the joint
- Surgery for instability and associated fractures
- Dynamic range of motion control