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Dislocations, Elbow
Last Updated: April 25, 2005 Synonyms and related keywords: dislocations o the el!o", posterior el!o" dislocations, anterior el!o" dislocations

AUTHOR I !OR"ATIO
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Author: #ames E $eany, "D, !A%E& , %irector o Emergency Medical Education, %epartment o Em Medicine, Mission +ospital ,egional Medical $enter and $hildren-s +ospital at Miss .ames E /eany, M%, (A$E0, is a mem!er o the ollo"ing medical societies: $ali ornia Medical Ass Editor1s2: #osep' # Sac'ter, "D, !A%E& , $onsulting Sta , %epartment o Emergency Medicine, M ,egional Medical $enter3 !rancisco Tala(era, &'armD, &'D, Senior 0harmacy Editor, eMedicine3 DO, Medical %irector, $hairman, %epartment o Emergency Medicine, 4ancaster ,egional Medical $ Halamka, "D, $hie #n ormation O icer, $are5roup +ealthcare System, Assistant 0ro essor o Med %epartment o Emergency Medicine, *eth #srael %eaconess Medical $enter3 Assistant 0ro essor o +ar6ard Medical School3 and )arry )renner, "D, &'D, !A%E& , 0ro essor o Emergency Medicine #nternal Medicine, and 0ro essor o Anatomy and 7euro!iology, $hairman, %epartment o Emergenc 8ni6ersity o Ar'ansas or Medical Sciences %isclosure

I TRODU%TIO
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)ack*ro+nd: The el!o" 9oint displays an elegant !alance !et"een sta!ility and mo!ility: &hile allo" o motion, the 9oint has an inherent sta!ility that re;uires a considera!le orce to dislocate: (or this re appro<imately one third o el!o" dislocations are associated "ith ractures o !ony components o th

%islocations o the el!o" all in re;uency 9ust !ehind dislocations o the inger and shoulder: Most c el!o" dislocates posteriorly: #mmediate reduction is essential to reduce the ris' o neuro6ascular or complications: &at'op'ysiolo*y: *oth posterior and anterior dislocations occur: &osterior dislocations

A all on an e<tended a!ducted arm is the mechanism o in9ury seen in posterior dislocations o the e e<ample o this is someone roller!lading "ho, alling !ac'"ard, e<tends an arm !ehind to !rea' the

dislocations account or the ma9ority o el!o" dislocations: Anterior dislocations

A strong !lo" to the posterior aspect o a le<ed el!o" may result in anterior dislocation o the el!o" dri6es the olecranon or"ard in relation to the humerus: Se,: These in9uries occur more o ten in males than in emales:

A*e: %islocations occur more commonly in adults, since the same orce in children more o ten resul supracondylar racture:

%LI I%AL
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History: O!tain history that includes the mechanism o in9ury, type and location o pain, amount o im dys unction, treatment prior to arri6al in the emergency department, timing o e usion appearance, a el!o" in9ury:

Mechanisms ) A all on an e<tended, a!ducted arm 1posterior2 or a direct !lo" to a le<ed el!o 0ain ) #ntense, ocused around the el!o" 9oint E<tremely limited range o motion E usion

&'ysical:

0osterior dislocations: El!o" is le<ed, "ith an e<aggerated prominence o the olecranon: On olecranon is displaced rom the plane o the epicondyles 1as opposed to a supracondylar rac epicondyles are palpa!le in the same plane as the olecranon2:

Anterior dislocations: The el!o" is held in ull e<tension: The upper arm appears shortened " is elongated and held in supination:

7euro6ascular unction should !e documented in detail !e ore and a ter reduction: $ontinued essential: DI!!ERE TIALS

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(ractures, El!o" (ractures, (orearm 0ediatrics, 7ursemaid El!o" Trauma, 0eripheral =ascular #n9uries

-OR$U&
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Ima*in* St+dies:

,adiography
o o

0lain radiographs are essential prior to reduction o the suspected dislocation: 0ostreduction ilms should con irm opposition o the 9oint sur aces and should rule out unidenti ied ractures or entrapment o !ony ragments "ithin the 9oint space:

Ot'er Tests:

Arteriography or cases o suspected 6ascular in9ury TREAT"E T

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&re'ospital %are: 0rehospital personnel should splint the lim! in the position ound: *ecause o the neuro6ascular in9ury, ield reduction is not indicated: Success ul reduction is unli'ely "ithout ade;ua sedation: 0atients "ith neuro6ascular compromise should !e transported rapidly to the closest acilit Emer*ency Department %are:

Early reduction is essential, since delay may increase ris' o neuro6ascular compromise or da cartilage:

The emergency physician should attempt reduction a ter o!taining appropriate radiologic stud 6ascular compromise is noted or i orthopedic consultation is delayed signi icantly:

The ollo"ing 2 methods commonly are employed or posterior el!o" reductions: *e certain th recei6ed ade;uate analgesic and sedati6e medications !e ore !eginning either procedure:
o

&ith the el!o" le<ed to >0 degrees and supinated, apply posterior pressure to the hum

second operator applies do"n"ard pressure on the pro<imal orearm: A coupling is el capitellum slides o6er the coronoid process and the 9oint realigns:
o

The second method in6ol6es placing the patient in the prone position "ith the humerus ta!le and the orearm hanging perpendicular to the plane o the ta!le: The humerus sh !y the ta!le, "ith padding, 9ust pro<imal to the el!o" 9oint: Apply 5)?0 pounds o "eigh ,eduction should occur o6er a period o minutes as the muscles rela<:

Anterior dislocation reduction is per ormed "ith distal traction on the "rist and !ac'"ard pres orearm: Ta'e care to a6oid hypere<tension at the el!o", "hich may cause traction and poten neuro6ascular structures around the el!o":

%ons+ltations:

Emergent orthopedic consultation should !e sought or all patients "ith el!o" dislocations: =ascular surgery consultation may !e needed in patients "ith possi!le 6ascular in9ury:

"EDI%ATIO
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Section . o/ 01

Analgesics and an<iolytics are used to treat the pain associated "ith dislocations:

%rug $ategory: Analgesics )) 0ain control is essential to ;uality patient care: #t ensures patient co

pulmonary toilet, and aids physical therapy regimens: Many analgesics ha6e sedating properties tha "ho ha6e sustained in9uries:

Dr+*

ame

(entanyl citrate 1%uragesic, Su!lima@e2 )) 7arcotic analgesic "ith potency and much shorter hal )li e than morphine sul ate: %O$ o conscious sedation analgesia: &ith short duration 1A0)B0 min2 an titration, an e<cellent choice or pain management and sedation: E ;uic'ly re6ersed !y nalo<one: A ter initial dose, su!se;uent dose not !e titrated more re;uently than ;Ah or ;Bh: 0:5)? mcgC'gCdose #=C#M ;A0)B0min D2 years: 2)A mcgC'gCdose #=C#M ;A0)B0min 2)?2 years: ?)2 mcgC'gCdose #=C#M ;B0min >?2 years: Administer as in adults

Ad+lt Dose &ediatric Dose %ontraindications Interactions &re*nancy &reca+tions

%ocumented hypersensiti6ity3 hypotension3 potentially compromis in "hich esta!lishing rapid air"ay control "ould !e di icult

0henothia@ines may antagoni@e analgesic e ects3 tricyclic antide may potentiate ad6erse e ects $ ) Sa ety or use during pregnancy has not !een esta!lished:

$aution in hypotension, respiratory depression, constipation, nau emesis, and urinary retention3 idiosyncratic reaction, 'no"n as ch rigidity syndrome, may re;uire neuromuscular !loc'ade to increas 6entilation

Dr+*

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O<ycodone and acetaminophen 10ercocet2 )) %rug com!ination in or relie o moderately se6ere to se6ere pain: %O$ or aspirin) hypersensiti6e patients: ?)2 ta! or cap 0O ;E)Bh prn 0:05)0:?5 mgC'gCdose o<ycodone 0O ;E)Bh prn3 not to e<ceed 5 o o<ycodone %ocumented hypersensiti6ity

Ad+lt Dose &ediatric Dose %ontraindications Interactions &re*nancy &reca+tions Dr+* ame

0henothia@ines may decrease analgesic e ects3 $7S depressan tricyclic antidepressants may increase to<icity $ ) Sa ety or use during pregnancy has not !een esta!lished: %uration o action may increase in elderly3 !e a"are o total daily acetaminophen patient is recei6ing3 do not e<ceed E,000 mgC2Eh acetaminophen3 higher doses may cause li6er to<icity

O<ycodone and aspirin 10ercodan2 )) %rug com!ination indicated

o moderately se6ere to se6ere pain: Ad+lt Dose &ediatric Dose %ontraindications ?)2 ta! or cap 0O ;E)Bh prn 0:05)0:?5 mgC'gCdose o<ycodone 0O ;E)Bh prn3 not to e<ceed 5 o o<ycodone

%ocumented hypersensiti6ity3 li6er damage3 hypoprothrom!inemi / de iciency3 !leeding disorders3 asthma3 due to association o as ,eye syndrome do not use in children 1D?B y2 "ho ha6e lu

Interactions &re*nancy &reca+tions Dr+* ame

0henothia@ines may decrease analgesic e ects3 $7S depressan tricyclic antidepressants may increase to<icity3 may potentiate ant e ects o "ar arin % ) 8nsa e in pregnancy

%uration o action may increase in elderly3 caution in renal or li6er impairment, peptic ulcer disease, and erosi6e gastritis

+ydrocodone !itartrate and acetaminophen 1=icodin ES2 )) %rug com!ination indicated or relie o moderately se6ere to se6ere pa ?)2 ta! or cap 0O ;E)Bh prn

Ad+lt Dose &ediatric Dose

D?2 years: ?0)?5 mgC'gCdose acetaminophen 0O ;E)Bh prn3 not t 2:B gCd acetaminophen or 5 mg o hydrocodone !itartrateCdose >?2 years: F50 mg acetaminophen 0O ;Eh3 not to e<ceed ?0 mg hydrocodone !itartrate in a single dose3 not to e<ceed 5 doses pe

%ontraindications Interactions &re*nancy &reca+tions

%ocumented hypersensiti6ity3 high)altitude cere!ral edema3 ele6a intracranial pressure

0henothia@ines may decrease analgesic e ects3 $7S depressan tricyclic antidepressants may increase to<icity $ ) Sa ety or use during pregnancy has not !een esta!lished:

Ta!lets contain meta!isul ite, "hich may cause hypersensiti6ity3 c patients dependent on opiates since this su!stitution may result in opiate)"ithdra"al symptoms3 caution in se6ere renal or hepatic d

%rug $ategory: Anxiolytics )) 0atients "ith pain ul in9uries usually e<perience signi icant an<iety:
the clinician to administer a smaller analgesic dose to achie6e the same e ect:

Dr+*

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4ora@epam 1Ati6an2 )) Sedati6e hypnotic in !en@odia@epine class onset o e ect and relati6ely long hal )li e: *y increasing acti6ity o ma9or inhi!itory neurotransmitter, may depress all le6els o $7S, lim!ic and reticular ormation: E<cellent medication "hen patient !e sedated or >? d: Monitor patient-s *0 a ter administering dose ad9ust as necessary: ?)?0 mgCd di6ided #= !idCtid3 not to e<ceed E mgCdose

Ad+lt Dose &ediatric Dose

0:05)0:? mgC'g #= slo"ly o6er 2)5 min3 may repeat dose o 0:05 m

slo"ly3 not e<ceed E mgCdose %ontraindications Interactions &re*nancy &reca+tions

%ocumented hypersensiti6ity3 pree<isting $7S depression3 hypot narro")angle glaucoma % ) 8nsa e in pregnancy

Alcohol, phenothia@ines, !ar!iturates, or MAO#s may increase $7

$aution in renal or hepatic impairment, myasthenia gra6is, organi syndrome, or 0ar'inson disease

Dr+*

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%ia@epam 1=alium2 )) #ndi6iduali@e dosage and increase cautious ad6erse e ects: *y increasing acti6ity o 5A*A, a ma9or inhi!itory neurotransmitter, depresses all le6els o $7S, including lim!ic an ormation:

Ad+lt Dose &ediatric Dose %ontraindications Interactions &re*nancy &reca+tions !OLLO-2U&

5)?0 mg 0OC#=C#M ;A)Eh3 repeat ;2)Eh prn3 not to e<ceed A0 mg i period

0:05)0:A mgC'gCdose #=C#M o6er 2)A min3 repeat in 2)E h prn3 0:?2 mgC'gCd 0O di6ided ;B)Gh3 not to e<ceed ?0 mgCdose %ocumented hypersensiti6ity3 narro")angle glaucoma

0henothia@ines, !ar!iturates, alcohols, or MAO#s may increase $ to<icity % ) 8nsa e in pregnancy

$aution "ith other $7S depressants, lo" al!umin le6els, or hepa 1may increase to<icity2

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!+rt'er Inpatient %are:

#ndications or admission "ith re;uent neuro6ascular assessment include the ollo"ing:

o o o o

$hildren 8nrelia!le patients E<tensi6e edema E6idence o neuro6ascular compromise

!+rt'er O+tpatient %are:

(ollo"ing reduction, splint el!o" in at least >0 degrees o le<ion using a posterior molded sp

Arrange close ollo")up care "ith the orthopedic surgeon:

Trans/er:

0atients "ith dislocations o the el!o" should not !e trans erred until the el!o" has !een redu

#n hospitals "ithout access to an orthopedic surgeon, reduction should !e per ormed !y the e physician prior to trans er:

%omplications:

*rachial artery in9ury Medial ner6e in9ury 8lnar ner6e in9ury $oncomitant ractures A6ulsion o the triceps mechanism insertion 1anterior dislocation only2 Entrapment o !one ragments "ithin the 9oint space .oint sti ness "ith decreased range o motion 1particularly in e<tension2 Myositis ossi icans

&ro*nosis:

8p to ?0 degrees limitation in ull e<tension and some limitation in le<ion are common, unless reha!ilitation program is instituted:

&atient Ed+cation:

(or e<cellent patient education resources, 6isit eMedicine-s *rea's, (ractures, and %islocatio see eMedicine-s patient education articles, El!o" %islocation and *ro'en El!o": "IS%ELLA EOUS

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"edical3Le*al &it/alls:

(ailure to ind 6ascular in9ury: 0resence o a distal pulse does not e<clude arterial in9ury: Se6e 9oint results in !rachial artery in9ury in GH o patients: This complication should !e suspected orce, massi6e s"elling, or "ide separation o the 9oint noted on physical or radiologic e<amin

(ailure to ind ner6e entrapment: 4oss o postreduction median ner6e unction should raise th ner6e entrapment: #mmediate orthopedic consult is needed in these cases or operati6e inter6

(ailure to detect spontaneous reduction: El!o" dislocations can reduce spontaneously, prese dilemma to the emergency physician: A high degree o suspicion is necessary to a6oid o6erlo complications associated "ith el!o" dislocations: )I)LIO4RA&H5

Section 01 o/ 01

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Ali (M, /rishnan S, (arhan M.: A case o ipsilateral shoulder and el!o" dislocation: an easily Accid Emerg Med ?>>G May3 ?51A2: ?>GIMedlineJ: *ell S, Salmon .: The management o common dislocations in the upper lim!: Aust (am 0hys 251>2: ?E?A)5, ?E?G)2A, ?E25, passimIMedlineJ: $ohen MS, +astings +: Acute el!o" dislocation: e6aluation and management: . Am Acad Or .an)(e!3 B1?2: ?5)2AIMedlineJ: 5illingham *4, &right .5: $on6ergent dislocation o the el!o": $lin Orthop ?>>F .ul3 1AE02: ? +addad (S, $o!iella $E: #solated radial head dislocation in an adult: case report and re6ie" o $oll Surg Edin! ?>>F .un3 E21A2: 20F3 author reply 20GIMedlineJ: +ems TE.: #solated radial head dislocation in an adult: case report and re6ie" o the literature Edin! ?>>F .un3 E21A2: 20FIMedlineJ: Ma<"ell A.: #solated radial head dislocation in an adult: case report and re6ie" o the literatur Edin! ?>>F .un3 E21A2: 20F)GIMedlineJ: 7oye@ .(: #solated traumatic posterior dislocation o the radial head: a report on t"o cases: A ?>>B Sep3 B21A2: ?EG)50IMedlineJ: ,ettig A$: El!o", orearm and "rist in9uries in the athlete: Sports Med ?>>G (e!3 25122: ??5)A ,ing %, .upiter .*: (racture)dislocation o the el!o": . *one .oint Surg Am ?>>G Apr3 G01E2: Sachar /, Mih A%: $ongenital radial head dislocations: +and $lin ?>>G (e!3 ?E1?2: A>)EFIMe Shearman $M, el)/houry 5Y: 0it alls in the radiologic e6aluation o e<tremity trauma: 0art #: T e<tremity: Am (am 0hysician ?>>G Mar ?3 5F152: >>5)?002IMedlineJ: Sugimoto M, Yoshida T, /itano /, et al: =oluntary dislocation o the radial head: . Shoulder E May).un3 51A2: 22G)A0IMedlineJ:
OTE:

Medicine is a constantly changing science and not all therapies are clearly esta!lished: 7e" research changes drug and treatment therapies daily: The authors, this 9ournal ha6e used their !est e orts to pro6ide in ormation that is up)to)date and accurate and is generally accepted "ithin medical standards at the time o p medical science is constantly changing and human error is al"ays possi!le, the authors, editors, and pu!lisher or any other party in6ol6ed "ith the pu!lication o the in ormation in this article is accurate or complete, nor are they responsi!le or omissions or errors in the article or or the results o using this in ormation: The in ormation in this article rom other sources prior to use: #n particular, all drug doses, indications, and contraindications should !e con irmed in the pac'age inse %islocations, El!o" e<cerpt