Elbow Case #1

History & Physical

A 17yo wrestler presents to the ED c/o elbow pain sustained during a match. Pt holding in fixed position with exaggerated prominence of the olecranon

Image

Diagnosis: Posterior Elbow Dislocation

Disarticulation at the elbow joint, which is usually obvious

Associated fractures can be more difficult to find, but become more visible in post reduction views

Must identify entrapped fragmentsChildren: medical epicondylar ossification centerAdults: fracture of the coronoid process

ED Management and Prognosis

Closed reduction and castingObtain post reduction film and

reexamineOrtho follow upOperative repair indications

Complex dislocation with associated fractures

Severe instability with rupture of both medial collateral ligament and flexor forearm muscles

Prognosis50% have full recovery1/3 will have limited ROM, usually <10°Remaining 15% have more range of

motion limitations

History classically from hyperextension, usually a fall on an extended, abducted arm

Collateral ligaments commonly avulse at their humeral attachments, which can lead to chronic instability

Associated with fractures 60% of the timeLook closely for coronoid process, olecranon

process, medial epicondyle, radial head, articular surfaces, distal radius and wrist fractures

A pre- and post-reduction neurovascular exam (as always) is crucial!Watch out for brachial artery injury, medial and

ulnar nerve injury, and myositis ossificans

Pearls

Additional Images

Additional ImagesAnterior

elbow dislocationOnly 10-

15% of elbow dislocations

Pt will hold elbow in full extension

ReferencesE-radiography

http://www.e-radiography.net/technique/elbow/elbowap.htm

Marx J MD; Hockberger R MD; Walls R MD. Rosen’s emergency medicine. 7th ed.

Simon R; Sherman S; Koenigsknecht S. Emergency orthopedics: the extremities. 5th ed. McGraw Hill Publishing.

Wheeless C R III MD. Wheeless textbook of orthopedics. www.wheelessonline.com.